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Biomedical subjects

A W Wojner

Publications and source records attributed to A W Wojner.

18 recordsLinked to original sources
PubMed2000

Predictors of tube feeding in acute stroke patients with dysphagia.

Stroke is the third leading cause of death and the leading cause of disability in adults. Dysphagia, or difficulty with swallowing, is an untoward outcome of stroke occurring in as many as 71% of stroke survivors. This study sought to identify characteristics in stroke patients predictive of tube feeding dependency during acute care secondary to neurogenic oropharyngeal dysphagia. Significant differences in age, stroke severity scores, length of stay, and cost per case were measured between the tube feeding and control group patients. Univariate analysis identified the existence of seven dependent risk factors, of which four were found to be independent risk factors for the outcome of interest: wet voice after swallowing water, hypoglossal nerve dysfunction, National Institutes of Health Stroke Scale score, and incomplete oral labial closure. Findings from this study may assist healthcare providers in the early identification of stroke patients at risk for clinically significant neurogenic oropharyngeal dysphagia, facilitating reduction of untoward outcomes.

Acute Disease↗
PubMed2000

High rate of complete recanalization and dramatic clinical recovery during tPA infusion when continuously monitored with 2-MHz transcranial doppler monitoring.

BACKGROUND AND PURPOSE: Clot dissolution with tissue plasminogen activator (tPA) can lead to early clinical recovery after stroke. Transcranial Doppler (TCD) with low MHz frequency can determine arterial occlusion and monitor recanalization and may potentiate thrombolysis. METHODS: Stroke patients receiving intravenous tPA were monitored during infusion with portable TCD (Multigon 500M; DWL MultiDop-T) and headframe (Marc series; Spencer Technologies). Residual flow signals were obtained from the clot location identified by TCD. National Institutes of Health Stroke Scale (NIHSS) scores were obtained before and after tPA infusion. RESULTS: Forty patients were studied (mean age 70+/-16 years, baseline NIHSS score 18.6+/-6.2, tPA bolus at 132+/-54 minutes from symptom onset). TCD monitoring started at 125+/-52 minutes and continued for the duration of tPA infusion. The middle cerebral artery was occluded in 30 patients, the internal carotid artery was occluded in 11 patients, the basilar artery was occluded in 3 patients, and occlusions were multiple in 7 patients; 4 patients had no windows; and 1 patient had a normal TCD. Recanalization on TCD was found at 45+/-20 minutes after tPA bolus: recanalization was complete in 12 (30%) and partial in 16 (40%) patients. Dramatic recovery during tPA infusion (total NIHSS score <3) occurred in 8 (20%) of all patients (baseline NIHSS range 6 to 22; all 8 had complete recanalization). Lack of improvement or worsening was associated with no recanalization, late recanalization, or reocclusion on TCD (C=0.811, P< or =0.01). Improvement by > or =10 NIHSS points or complete recovery was found in 30% of all patients at the end of tPA infusion and in 40% at 24 hours. Improvement by > or =4 NIHSS points was found in 62.5% of patients at 24 hours. CONCLUSIONS: Dramatic recovery during tPA therapy occurred in 20% of all patients when infusion was continuously monitored with TCD. Recovery was associated with recanalization on TCD, whereas no early improvement indicated persistent occlusion or reocclusion. At 24 hours, 40% of all patients improved by > or =10 NIHSS points or recovered completely. Ultrasonic energy transmission by TCD monitoring may expose more clot surface to tPA and facilitate thrombolysis and deserves a controlled trial as a way to potentiate the effect of tPA therapy.

Adult↗
PubMed2000

Deterioration following spontaneous improvement : sonographic findings in patients with acutely resolving symptoms of cerebral ischemia.

BACKGROUND AND PURPOSE: Some stroke patients will deteriorate following improvement (DFI), but the cause of such fluctuation is often unclear. While resolution of neurological deficits is usually related to spontaneous recanalization or restoration of collateral flow, vascular imaging in patients with DFI has not been well characterized. METHODS: We prospectively studied patients who presented with a focal neurological deficit that resolved spontaneously within 6 hours of symptom onset. Patients were evaluated with bedside transcranial Doppler (TCD). Digital subtraction angiography (DSA), computed tomographic angiography (CTA), or magnetic resonance angiography (MRA) were performed when feasible. DFI was defined as subsequent worsening of the neurological deficit by >/=4 National Institutes of Health Stroke Scale points within 24 hours of the initial symptom onset. RESULTS: We studied 50 consecutive patients presenting at 165+/-96 minutes from symptom onset. Mean age was 61+/-14 years; 50% were females. All patients had TCD at the time of presentation, and 68% had subsequent angiographic examinations (DSA 10%, CTA 4%, and MRA 44%). Overall, large-vessel occlusion on TCD was found in 16% of patients (n=8); stenosis was found in 18% (n=9); 54% (n=27) had normal studies; and 6 patients (12%) had no temporal windows. DFI occurred in 16% (n=8) of the 50 patients: in 62% of patients with TCD and angiographic evidence of occlusion, in 22% with stenosis, and in 4% with normal vascular studies (P<0.001, Phi=0.523, chi(2)=12.05). DFI occurred in 31% of patients with large-vessel atherosclerosis, 23% with cardioembolism, and 9% with small-vessel disease when stroke mechanisms were determined within 2 to 3 days after admission (P=0.2, NS). CONCLUSIONS: DFI is strongly associated with the presence of large-vessel occlusion or stenosis of either atherosclerotic or embolic origin. Normal vascular studies and lacunar events were associated with stable spontaneous resolution without subsequent fluctuation. Urgent vascular evaluation may help identify patients with resolving deficits and vascular lesions who may be candidates for new therapies to prevent subsequent deterioration.

Acute Disease↗
PubMed2000

Timing of recanalization after tissue plasminogen activator therapy determined by transcranial doppler correlates with clinical recovery from ischemic stroke.

BACKGROUND: The duration of cerebral blood flow impairment correlates with irreversibility of brain damage in animal models of cerebral ischemia. Our aim was to correlate clinical recovery from stroke with the timing of arterial recanalization after therapy with intravenous tissue plasminogen activator (tPA). METHODS: Patients with symptoms of cerebral ischemia were treated with 0.9 mg/kg tPA IV within 3 hours after stroke onset (standard protocol) or with 0.6 mg/kg at 3 to 6 hours (an experimental institutional review board-approved protocol). National Institutes of Health Stroke Scale (NIHSS) scores were obtained before treatment, at the end of tPA infusion, and at 24 hours; Rankin Scores were obtained at long-term follow-up. Transcranial Doppler (TCD) was used to locate arterial occlusion before tPA and to monitor recanalization (Marc head frame, Spencer Technologies; Multigon 500M, DWL MultiDop-T). Recanalization on TCD was determined according to previously developed criteria. RESULTS: Forty patients were studied (age 70+/-16 years, baseline NIHSS score 18.6+/-6.2). A tPA bolus was administered at 132+/-54 minutes from symptom onset. Recanalization on TCD was found at the mean time of 251+/-171 minutes after stroke onset: complete recanalization occurred in 12 (30%) patients and partial recanalization occurred in 16 (40%) patients (maximum observation time 360 minutes). Recanalization occurred within 60 minutes of tPA bolus in 75% of patients who recanalized. The timing of recanalization inversely correlated with early improvement in the NIHSS scores within the next hour (polynomial curve, third order r(2)=0.429, P<0.01) as well as at 24 hours. Complete recanalization was common in patients who had follow-up Rankin Scores if 0 to 1 (P=0.006). No patients had early complete recovery if an occlusion persisted for >300 minutes. CONCLUSIONS: The timing of arterial recanalization after tPA therapy as determined with TCD correlates with clinical recovery from stroke and demonstrates a 300-minute window to achieve early complete recovery. These data parallel findings in animal models of cerebral ischemia and confirm the relevance of these models in the prediction of response to reperfusion therapy.

Aged↗
PubMed1998

Longitudinal outcomes measurement and management. Standardized practices across the continuum of care.

Longitudinal outcomes measurement involves collection of outcomes data across a continuum of care services in a patient cohort. Measurement and management of intermediate outcomes, within the varied care settings represented by the continuum, must precede measurement of long-term outcomes to provide meaningful information to providers. Once connected across a continuum of services, longitudinal outcomes measures produce powerful findings that may be used to successfully optimize the health care experience for patients and their families. The postacute continuum is ripe with research opportunities and should be pursued with vigor by outcomes researchers interested in understanding the contributions of this segment of the continuum to the production of patient outcomes.

Continuity of Patient Care↗
PubMed1997

Outcomes management: from theory to practice.

Providers and consumers currently are challenged to move the payer-driven health care system toward a patient-driven model. Described as disease management, this system would be based on prevention and the natural course of disease, providing care across the continuum. Creating the new system will demand the measurement and management of health outcomes to facilitate practice delivery within a scientific framework. Outcomes management provides this framework, enabling the development of best clinical practices, informed consumer decision making, prediction of resource consumption, identification of consumer expectations, and reduction of financial risk.

Case Management↗
PubMed1997

Outcomes manager: a role for the advanced practice nurse.

Outcomes management offers the advanced practice nurse an opportunity to lead interdisciplinary providers in the restructuring of health care services across the continuum of care. Within an outcomes management framework, the advanced practice nurse functions as an attending nurse for a population of patients by overseeing interdisciplinary care delivery and outcomes measurement and refining standardized practices to achieve best practice.

Case Management↗
PubMed1997

Collaborative ventures in outcomes management: roles and responsibilities in a service line model.

Outcomes management is an interdisciplinary process that directs providers toward developing and implementing best practice. A service line framework complements an outcomes management effort, aligning business and clinical spheres toward achievement of defined population targets. Within each sphere, provider roles must relate directly to outcomes initiatives, creating a synergy that promotes outcomes achievement. This article highlights the roles of the service line manager, advanced practice nurse/outcomes manager, staff nurse, nurse manager, physician, and administrator. This group, complemented by other essential interdisciplinary providers, forms a collaborative practice team charged with continuous quality enhancement of an outcomes management program.

Case Management↗
PubMed1996

Optimizing ischemic stroke outcomes: an interdisciplinary approach to poststroke rehabilitation in acute care.

Stroke is the third leading cause of death and the leading producer of disability among adults in the United States. Despite the high incidence of stroke, the general public's understanding of stroke symptoms, risk factors, and the need for early assessment and treatment is poor contributing to delays in treatment and the potential for suboptimal outcomes. Ischemic stroke accounts for most stroke events. Treatment is expanding to include drug agents that lyse clots and medications that may interrupt the neuronal metabolic cascade occurring with ischemia. Rehabilitative strategies require synergistic, collaborative relations among providers to optimize outcomes.

Acute Disease↗
PubMed1996

Outcomes management: an interdisciplinary search for best practice.

Rising U.S. health-care costs have resulted in mandates to reform the health system. Payors are closely scrutinizing care delivery and have empowered themselves as gatekeepers for consumer health-care access. In the late 1980s, outcomes management emerged as an interdisciplinary process advocating the measurement of health outcomes among populations undergoing medical care. Outcomes management provides a mechanism to foster development of patient-driven health services aimed to impact clinical quality through intermediate and long-term outcome analysis. Outcomes measurement facilitates ongoing enhancement of interdisciplinary health-care delivery, enabling determination of "best" practice and identification of opportunities for practice improvement. The advanced practice nurse's unique educational preparation provides a framework for development of the prerequisite leadership qualities necessary to cultivate an outcomes management program.

Case Management↗
PubMed1996

Collaborative practice teams: the infrastructure of outcomes management.

Collaborative practice teams consist of interdisciplinary providers who are charged with the process of implementing and refining an outcomes management program within a targeted population. Collaborative practice teams work under the assumption that clinical quality enhancement through practice standardization decreases care fragmentation, resulting in improved physiologic, psychosocial, and financial outcomes. Collaborative practice team members identify best practice through the implementation and testing of interdisciplinary interventions. Represented on a critical pathway, these practices are evaluated toward achievement of defined population outcomes. In this article, the authors review the process of collaborative practice team formation, expected pitfalls and barriers to effective collaboration, and the work accomplished by a collaborative practice team.

Critical Pathways↗
PubMed1995

Stereotactic radiosurgery: new practice frontiers for the perioperative nurse.

Stereotactic radiosurgery (SR) is a technology that blends the skill and technology of several disciplines such as neurosurgery, radiation oncology, radiology, engineering, medical physics, and nursing. The improvement of neurological imaging that occurred in the 1970s and 1980s provided diagnosticians with the technical foundation necessary to support parallel advancement of SR. Today, SR is used to treat pituitary tumors, meningiomas, acoustic neuromas, arteriovenous malformations, metastatic tumors of the brain, craniopharyngiomas, and residual gliomas. Participation in SR procedures provides the perioperative nurse with an opportunity to move beyond the walls of the operating suite into the exciting world of neurological imaging and radiotherapy.

Humans↗
PubMed1994

Assessing the five points of the intra-aortic balloon pump waveform.

IABP timing challenges the nurse not only with a waveform analysis but also an understanding of complex physiologic concepts crucial to patient management. Optimizing timing through assessment of the five points of the IABP waveform permits the critical care nurse to increase the hemodynamic benefits of IABP therapy, potentially improving patient outcome.

Education, Nursing, Continuing↗