Use of inferior vena cava filters in the Medicare population

To examine the use of inferior vena cava (IVC) filters, we performed a population-based study using a 5% random sample of the United States Medicare population (1.25 million persons). Filter placement and its timing relative to diagnosis of venous thromboembolism (VTE) were determined using both hospital and physician Medicare billing codes after detailed review of large samples of complete individual claims records. Comorbid conditions and mortality were also noted. From July 1986 through June 1989, a total of 806 patients in the sample population received IVC filters. Mortality rates after filter placement were high: 16% during initial hospitalization, 32% within 6 months of filter placement, and 48% after 2 years. However, only 3 (1%) of 423 patients who underwent filter placement without the diagnosis of pulmonary embolism (PE) suffered PE within 1 year of filter placement. Use of IVC filters increased significantly over the study period (p <0.001).Rates of filter placement among the nine census divisions of the United States differed significantly (p<0.001).An East-West trend was notable with the highest rate (37 filters/100,000 enrollees/yr) in New England, as compared with 14 filters/100,000 enrollees/yr in the Pacific Division. No explanation for these regional-differences was evident after patient demographics and comorbidity were examined. Vena cava filters prevent PE for at least 1 year after placement. The frequency of IVC filter use in elderly patients is increasing and varies substantially by region. Although reasons for these trends are unclear, these findings suggest the need for uniform practice guidelines for IVC filter placement.Supported in part by the National Institutes of Aging, grant R0 1 AG 07-146, and by a training grant from the National Library of Medicine (NIH 5 T15 LM07044) to Dr. Birkmeyer.     

Sound-Tissue Interaction: The Physical Basis of Bone Ultrasonometry and Limitations of Existing Methods

Ultrasound measurements of bone are generally obtained using transmission rather than pulse-echo techniques because of its highly attenuating nature. Ultrasound velocity and attenuation measurements are utilized. For velocity, there are well-defined fundamental relationships describing the dependence on the elasticity and density of bone. However, the practical implementation and signal processing of velocity measurements has led to a significant variability in results from different commercial systems. We may measure either phase of group velocity, for the latter, adopting a range of pulse arrival definitions. We are offered bone velocity, heel velocity, time of flight, and amplitude-dependent velocity. For attenuation measurements, however, the reverse is true. We generally record the increase in attenuation with frequency (0.2-0.6 MHz), termed broadband ultrasound attenuation (BUA). Although first described in 1984, because of the complex interplay of attenuation mechanisms, there still lacks a fundamental understanding of the dependence of BUA on the material and structural properties of cancellous bone. With the increasing number of commercial systems available, there is an urgent need to understand the intrinsic (artefact free) and system estimation of ultrasound velocity and attenuation parameters that may be implemented to characterise bone and provide clinical information.     

Snakes and ladders: the immediate future of nurse education?

This paper considers the recent increase in proposals to merge colleges of nursing and midwifery with higher education institutions. It reviews the differing natures of proposed mergers. It considers some major challenges posed by such mergers: the academic, the cultural, the professional, personal and identity, and the epistomological. It reflects on some ways in which these challenges might be met by the application of management theory, and enlightened practice. It concludes by suggesting that the opportunities afforded colleges by individual mergers are so divergent as to risk fragmenting nurse education within the higher education sector, rather than uniting it into a coherent whole, and compromising the development of nursing, midwifery and health visiting as learned practice professions.     

Competency-based learning applied to nursing management

The ability to manage change has become an essential skill for all managers, particularly those employed within the Health and Social Services. It is recognized that managers may have received an introduction to management concepts and skills within their professional education but require more specific management development. The government approach to adult education with an increased emphasis on vocational training as opposed to professional education (Hyland 1991) has had an important impact upon the theory and practice of nurse management. Nurses are now required to demonstrate, not only the appropriate knowledge and theory of management, but also the competencies necessary to fulfil their role. This is becoming an important dimension of management development programmes. This paper discusses aspects of competency based learning and considers how these concepts are applied to a higher education nurse management programme on 'Managing Change'. The difficulties experienced in applying vocational standards to professional education within the culture of a higher education will be explored, difficulties identified and some alternatives offered.     

Developing the sociology of health in nurse education: towards a more critical curriculum — Part 2: linking methodology and epistemology

In Part Two of the paper a model forcurriculum development is proposed which derives from the teaching experience of the authors. This is intended to provide a methodological and conceptual framework for studying the problem of human consciousness and action in relation to health in a way that is consistent with both the values and purposes of student-centred learning and the claims of critical theory. It is suggested that such a critical curriculum of health is needed in order to ensure that the ‘knowledgeable doer’ Project 2000 aims to produce is indeed a qualitatively different kind of professional nurse practitioner.     

Scoliosis in Elderly and Age-Related Bone Loss: A Population-Based Study

Osteoporosis, a common metabolic condition resulting in reduced bone mass, causes significant morbidity in affected individuals by predisposing them to osteoporotic fractures. To determine the relationship of scoliosis and osteoporosis, dual-energy X-ray absorptiometry (DXA) scans of 493 men and 762 women were analyzed according to their scoliotic status. No association was observed in the few scoliotic men without osteoarthritis of the spine compared to nonscoliotic men. Without osteoarthritis, scoliotic women had significantly decreased bone mass of the total hip and the femoral neck (p < 0.05) compared to nonscoliotic women, whereas in spine, bone mass was also decreased compared to nonscoliotic women, but not statistically significant. This suggests that scoliosis associates with bone loss, and affected women may benefit from early institution of therapeutic measures.     

Preparing for Trust status–an investigation into the morale of nurses undergoing change

The morale of nurses is a phenomenon often open to public comment without substantiated evidence. This study objectively explored the morale of nurses in a large district general hospital preparing for transition to National Health (NHS) Trust status. Information was sought using a 72-item questionnaire. The investigation was firmly centred around a structured theory which construes morale in terms of nine dimensions. The notion of morale being a construct synthesized of nine dimensions adds to the uniqueness of the study. Other studies fail to differentiate between the dynamic morale construct and the more complacent attitudes of job satisfaction.