Improved postoperative outcomes with stentless aortic valve: a community hospital experience.
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Aortic Valve↗
Biomedical subjects
J F Reed
Publications and source records attributed to J F Reed.
Computerized assessment of complications after colorectal surgery: is it valid?
PURPOSE: Historically, complication rates after colorectal surgery have been stratified by disease process, type of operation, or anesthesia risk derived after an intensive review of the medical record. Newer computer applications purport to shorten this process and predict the probability of postoperative complications by distinguishing them from comorbidities that are commingled on uniform discharge codes. We analyzed CaduCIS software, which uses discharge codes, to determine whether its predictions of comorbidity and complications were comparable to what was interpreted on the medical record. METHODS: Two-hundred seventy patients were analyzed according to the principal and secondary diagnoses coded on discharge. Coding inaccuracies of clinical occurrences were identified by physician review of each medical record. The actual incidences of 17 common preoperative comorbidities and 11 postoperative complications were compared with those predicted by CaduCIS. RESULTS: The CaduCIS-predicted distribution of comorbidities was similar to the actual occurrences in 15 of 17 categories. The overall incidence of complications obtained by physician (actual) review was 47 percent, compared with 46 percent predicted by CaduCIS. However, there was a statistical difference between the CaduCIS-predicted and the actual complication rates in 5 of the 11 categories. The most common preoperative comorbidity and complication was cardiopulmonary (47 percent and 28 percent, respectively). CONCLUSION: The overall complication rate interpreted from the medical record (47 percent) was accurately predicted by CaduCIS (46 percent). Predictions of 5 of 11 individual complications were underestimated because of charting and coding inaccuracies, not because of computerized errors. Because uniform discharge coding of commingled comorbidity and complications is increasingly used to rapidly compute surgical outcomes, colon and rectal surgeons need to ensure compatibility of the actual and coded medical records.
Comorbidity↗
Readmissions after colorectal surgery cannot be predicted.
INTRODUCTION: Readmission after discharge from the hospital is an undesirable outcome. In an attempt to prevent unplanned readmissions after abdominal or perineal colon resection, we proposed to identify risk factors associated with return to the hospital. METHODS: Study participants consisted of 249 patients who were operated on from July 1, 1996, to March 30, 1998. All patients who were readmitted within 90 days of discharge from the hospital after surgery were evaluated for the study. A retrospective review of charts was performed to assess whether readmission within 90 days was a direct consequence of the recent operation (unplanned related readmission). These patients were compared with a control group consisting of patients who were never readmitted or who were readmitted with an unrelated problem. RESULTS: Of the 249 patients, 59 (24 percent) were readmitted within 90 days of discharge from the hospital. Twenty-two (9 percent) were unplanned related readmissions. Ten patients were readmitted with unrelated emergencies, and 27 patients were readmitted electively. In the unplanned related group, there was no correlation between age, gender, admission diagnosis, activity status, or postoperative length of stay and the likelihood of readmission. Patients with multiple chronic medical problems or those who developed postoperative complications did not have a higher readmission rate. Patients with ulcerative colitis or those who underwent abdominoperineal resection or total/subtotal colectomy had a higher incidence of readmissions, although the difference was not significant. The mean interval between discharge from the hospital and readmission with a related complication was 19 days. Small-bowel obstruction was the most common reason for readmission, and all cases resolved with conservative management. Mean length of stay during all readmissions was 8 days. CONCLUSION: The incidence of unplanned related readmissions 90 days after abdominal or perineal colon resection is 9 percent, and these readmissions could not be predicted from the postoperative course. Because 82 percent of unplanned readmissions occurred within 30 days, this time frame is suitable for computerized comparative analysis.
Adult↗
Upregulation of G protein-linked receptor kinases with advancing age in rat aorta.
The age-related decline in beta-adrenergic receptor (beta-AR)-mediated vasorelaxation is associated with desensitization of beta-ARs without significant downregulation. The primary mode of this homologous beta-AR desensitization, in general, is via G protein receptor kinases (GRK). Therefore, we hypothesize that age-related changes in GRKs are causative to this etiology in rat aorta. Herein, we investigate the activity and cellular distribution (cytoplasmic vs. membrane) of several GRK isoforms and beta-arrestin proteins. GRK activity was assessed in extracts from aortic tissue of 6-wk, 6-mo, 12-mo, and 24-mo-old male Fischer-344 rats using a rhodopsin phosphorylation assay. We also performed immunoblots on lysates from aorta with specific antibodies to GRK-2, -3, -5, and beta-arrestin-1. Results show an age-related increase in GRK activity. Furthermore, expression of GRK-2 (cytoplasmic and membrane), GRK-3 (cytoplasmic and membrane), and beta-arrestin (soluble) increased with advancing age, whereas GRK-5 (membrane) expression remained unchanged. These results suggest that age is associated with increased activity and expression of specific GRKs. This increase likely results in enhanced phosphorylation and desensitization of beta-ARs. These biochemical changes are consistent with observed aging physiology.
Aging↗
Immunohistochemical and functional correlations of renal cyclooxygenase-2 in experimental diabetes.
Prostaglandins (PGs) generated by the enzyme cyclooxygenase (COX) have been implicated in the pathological renal hemodynamics and structural alterations in diabetes mellitus, but the role of individual COX isoenzymes in diabetic nephropathy remains unknown. We explored COX-1 and COX-2 expression and hemodynamic responses to the COX-1 inhibitor valeryl salicylate (VS) or the COX-2 inhibitor NS398 in moderately hyperglycemic, streptozotocin-diabetic (D) and control (C) rats. Immunoreactive COX-2 was increased in D rats compared with C rats and normalized by improved glycemic control. Acute systemic administration of NS398 induced no significant changes in mean arterial pressure and renal plasma flow in either C or D rats but reduced glomerular filtration rate in D rats, resulting in a decrease in filtration fraction. VS had no effect on renal hemodynamics in D rats. Both inhibitors decreased urinary excretion of PGE(2). However, only NS398 reduced excretion of thromboxane A(2). In conclusion, we documented an increase in renal cortical COX-2 protein expression associated with a different renal hemodynamic response to selective systemic COX-2 inhibition in D as compared with C animals, indicating a role of COX-2-derived PG in pathological renal hemodynamic changes in diabetes.
Animals↗
Rectal prolapse: a search for the "best" operation.
There is a lack of consensus regarding the optimal operative treatment for full-thickness rectal prolapse. We describe our experience in the management of procidentia and evaluate our current practice for improvement of results. The medical records of patients undergoing surgery for rectal prolapse between 1989 to 1999 were retrospectively reviewed. A total of 36 perineal proctosigmoidectomies (PPSs) and 29 abdominal procedures [17 anterior resections (ARs) and 12 Ripstein procedures (RPs)] were performed during the 10-year period. Patients undergoing PPS were significantly older and had more comorbidities. Mean operating time and length of hospital stay were shorter for the PPS group. Early and late postoperative complication rates were also significantly lower in the PPS group. Six patients (16%) in the PPS group developed recurrence at a mean follow-up of 50 months. Operation under general anesthesia or removal of a longer segment of prolapsed bowel did not reduce recurrence after PPS. No full-thickness recurrence was noted after AR or RP. We conclude that abdominal procedures (AR and RP) have the lowest recurrence but at a significantly higher cost in terms of complications. PPS is a valuable option in selected patients and can be performed with minimal morbidity and a relatively low recurrence rate.
Abdominal Muscles↗
Homogeneity of kappa statistics in multiple samples.
The measurement of intra-observer agreement when the data are categorical has been the subject of several investigators since Cohen first proposed the kappa (kappa) as a chance-corrected coefficient of agreement for nominal scales. Subsequent procedures have been developed to assess the agreement of several raters using a dichotomous classification scheme, assess majority agreement among several raters using a polytomous classification scheme, and the use of kappa as an indicator of the quality of a measurement. Further developments include inference procedures for testing the homogeneity of k>/=2 independent kappa statistics. An executable FORTRAN code for testing the homogeneity of kappa statistics (kappa(h)) across multiple sites or studies is given. The FORTRAN program listing and/or executable programs are available from the author on request.
Analysis of Variance↗
Eliminating bias in randomized cluster trials with correlated binomial outcomes.
Clustered or correlated samples with binary data are frequently encountered in biomedical studies. The clustering may be due to repeated measurements of individuals over time or may be due to subsampling of the primary sampling units. Individuals in the same cluster tend to behave more alike than individuals who belong to different clusters. This exhibition of intracluster correlation decreases the amount of information about the effect of the intervention. In the analysis of randomized cluster trials one must adjust the variance of estimator of the mean for the effect of the positive intraclass correlation p;. We review selected alternative methods to the typical Pearson's chi2 analysis, illustrate these alternatives, and out line an alternative analysis algorithm. We have written and tested a FORTRAN program that produces the statistics outlined in this paper. The program is available in an executable format and is available from the author on request.
Algorithms↗
Carotid endarterectomy outcomes research: reduced resource utilization using a clinical protocol.
BACKGROUND AND PURPOSE: The purpose of this study was to examine the necessity of intensive care unit (ICU) utilization following carotid endarterectomy (CEA) and to identify patients who can be managed postoperatively on a vascular unit using a clinical protocol. METHODS: Medical records of 50 patients admitted to the ICU following elective CEA were reviewed retrospectively for patient characteristics, morbidity, mortality, length of stay (LOS), and ICU intervention. Prospectively, the next 200 patients were routed to either a vascular unit or ICU, based on a clinical protocol. Endpoints were mortality, stroke, myocardial infarction, total hospital LOS, ICU LOS, and ICU intervention. RESULTS: There were no significant differences in morbidity or mortality between patients admitted to the vascular unit and those admitted to the ICU. Of patients evaluated prospectively, 129 (63%) were admitted directly to the vascular unit. Of the 73 patients admitted to the ICU, 63% required direct intervention compared with only 54% of patients in the retrospective series (P=0.001). In addition, after institution of the protocol, ICU LOS decreased significantly from 1.4 to 0.6 days (P<0.001). The hospital cost savings using this protocol averaged $1043 per patient. CONCLUSIONS: A clinical protocol can select patients for admission to the ICU or the vascular unit following CEA without increase in morbidity or mortality. Selective use of the ICU conserved resources, decreased ICU LOS, and provided substantial cost savings.
Aged↗
Using a SANE interdisciplinary approach to care of sexual assault victims.
BACKGROUND: Many hospitals have recognized the need to develop policies and procedures for female sexual assault victims' prompt access to emergency medical care and for collecting law enforcement evidence. At Lehigh Valley Hospital (Allentown, Penn), care in the emergency department (ED) for sexual assault victims was covered by oncall obstetricians and gynecologists. Although many aspects of rape management were in place, a busy ED with varying levels of physician response and exposure to the process of rape management contributed to a lack of standardized, objective, timely, and compassionate medical management of sexual assault victims. DEVELOPING THE PROGRAM: The Sexual Assault Nurse Examiner (SANE) interdisciplinary approach to care of sexual assault victims was implemented in May 1998. Community education and awareness projects emphasized prevention of sexual assault and domestic violence, as well as minimization of trauma for victims by promoting services that provide a supportive, caring, and healing environment. RESULTS: Comparing a baseline group of 130 sexual assault victims with 39 patients who were evaluated after the SANE approach was implemented indicated increased clinical interaction and significant improvements in quality indicators, such as completeness of evaluation and information gathered relevant to medical-legal issues. DISCUSSION: Law enforcement staff developed a more collaborative relationship with SANE examiners through the interdisciplinary team approach. Collaborative relationships were initiated with several other hospitals in the hospital's integrated delivery system to help offset some of the program's training, continuing education, and on-call costs and to allow for joint outcomes collection. The SANE program became a core ED service in July 1999.
Emergency Service, Hospital↗
Angiotensin II enhances beta-adrenergic receptor-mediated vasorelaxation in aortas from young but not old rats.
beta-Adrenergic receptor (beta-AR)-mediated (cAMP-dependent) vasorelaxation declines with advancing age. It has been shown that angiotensin II (ANG II), a potent vasoconstrictor, enhances cAMP-mediated vasorelaxation. Therefore, we questioned whether ANG II could reverse age-related, impaired beta-AR-mediated vasorelaxation and cAMP production. Pretreatment of aortic rings from 6-wk-old or 6-mo-old male Fischer 344 rats with ANG II significantly enhanced vasorelaxation induced by isoproterenol (Iso), a beta-AR agonist, and forskolin, a direct activator of adenylyl cyclase, but not dibutyryl-cAMP or isobutylmethylxanthine. The ANG II effect was blocked by losartan but not PD-123319 and was not observed in the aortas from 12- and 24-mo-old animals. Iso-stimulated cAMP production in the aorta was enhanced in the presence of ANG II in the 6-wk-old and 6-mo-old age groups only. Results suggest ANG II cannot reverse the age-related impairment in beta-AR-dependent vasorelaxation. We conclude aging may affect a factor common to both ANG II-receptors and beta-AR signaling pathways or aging may impair cross-talk between these two receptor pathways.
1-Methyl-3-isobutylxanthine↗
Transanal endoscopic microsurgery for excision of rectal lesions: technique and initial results.
The aim of this study was to review experience with transanal endoscopic microsurgery (TEM) and to assess its applicability to an existing practice of colorectal surgeons. Patients undergoing TEM excision of rectal lesions from March 1997 through May 1999 were selected for this study. Medical records were reviewed retrospectively to obtain pertinent data, including indications for TEM, tumor size, distance from anal verge, duration of operation, completeness of tumor resection, postoperative complications, duration of stay and follow-up, and recurrence. Thirty-one patients underwent TEM during the 2-year period. Indications for TEM included benign disease in eight patients and cancer in 23 patients. Mean distance of the tumor from the anal verge was 8.3 cm. Mean size of the lesion was 2.8 cm, and mean specimen size was 4.5 cm. Larger specimen sizes allowed for tumors to be removed with negative margins (97%) in all cases but one. Mean duration of operation was 140 minutes (including set-up time), and mean duration of hospital stay was 1.2 days. Major postoperative complications occurred in one patient. Mean duration of follow-up was 15 months, and recurrence developed in two patients during this period. Transanal endoscopic microsurgery excision of rectal lesions with negative margins was possible in 97% of cases with minimal morbidity and a short-duration hospital stay. Follow-up was too brief to evaluate recurrence, but the thoroughness of resection of tumor in a high proportion of cases is promising.
Aged↗
Usefulness of a state-legislated, comparative database to evaluate quality in colorectal surgery.
PURPOSE: Colorectal surgery, a high-volume procedure, has been targeted for performance improvement to reduce length of stay. Specific postoperative quality indicators and readmission rates should be analyzed concomitantly to assure that adverse events are not associated with earlier discharge. METHODS: From July 1, 1990, to June 30, 1997, 1,218 consecutive patients who underwent transabdominal colorectal surgery were analyzed for length of stay, mortality, morbidity, and discharge disposition. Each patient was assigned an Admission Severity Group rating 0 to 4 using a hospital-based state-legislated software system (Atlas) to validate comparative performance internally and externally. Readmission data within 120 days of discharge were available for the last 678 consecutive patients from July 1, 1993, to June 30, 1997, using Lastword (computerized medical records). RESULTS: The annual frequencies of the 1,218 procedures were 173, 183, 175, 146, 167, 189, and 185, respectively, from July 1990 through June 1997. Severity distribution was 32 for Admission Severity Group 0, 517 for Admission Severity Group 1, 540 for Admission Severity Group 2, 128 for Admission Severity Group 3, and 1 for Admission Severity Group 4, with no annual difference (P = 0.012). There was a significant reduction in total length of stay of 3.1 (12.9-9.8) days during the seven years (P = 0.001). The overall operative mortality rate was 1.4 percent, and the morbidity was 2.6 percent, with no annual differences (P = 0.655 and P = 0.033, respectively). The disposition to home did not change (P = 0.21). Of the 678 patients followed up for readmission, 100 (14.7 percent) were readmitted within 120 days, with no annual difference (P = ().302). CONCLUSION: Mortality, morbidity, disposition, and readmission rates were not affected by a decreased length of stay after colorectal surgery.
Colonic Diseases↗
Relation between myocardial infarction, depression, hostility, and death.
OBJECTIVE: To examine the independent impact of major depression and hostility on mortality rate at 6 months and 12 months after discharge from the hospital in patients with a myocardial infarction. METHOD: Three hundred thirty-one patients were prospectively evaluated for depression with a modified version of the National Institute of Mental Health Diagnostic Interview Schedule for major depressive episode. The Cook Medley Hostility Scale data were analyzed by chi(2) procedures for nominal and categoric data, and Student t test was used for continuous data types. RESULTS: Depression was a significant predictor of death at 12 months (P =. 04) but not at 6 months (P =.08). Hostility was not found to be a predictor of death at 6 months or 12 months. CONCLUSIONS: Major depression in patients hospitalized after myocardial infarction is a significant univariable predictor of death at 12 months, although it was not a statistically significant predictor after adjusting for other variables. Hostility is not a predictor of death. Prospective studies are needed to determine the impact of aggressive treatment of depression on post-myocardial infarction survival.
Adult↗
Ocular volume change per minute with ocular pneumoplethysmography.
Ocular pneumoplethysmography was performed before and after 1,737 carotid endarterectomies, 82% of which were performed for carotid lesions of hemodynamic consequence. Preoperative ocular hypoperfusion without ischemia was associated with at least transient postoperative ocular hyperemia. A difference in ocular volume change per minute of 14.0%, female greater than male, was explained by sex differences in heart rate, brachial pulse pressure and eye size. These observations may have a direct application in the management of diabetic retinopathy with panretinal photocoagulation.
Blood Pressure↗
Sensory symptoms of multiple sclerosis: a hidden reservoir of morbidity.
OBJECTIVE: To assess the frequency and quality of sensory symptoms in a population of patients with Multiple Sclerosis (MS) and compare them with controls. DESIGN: Survey to target population and control group evaluating demographic data, data on disease course, presence of various symptoms of MS. SETTING: Neurological practices affiliated with a tertiary community hospital. PARTICIPANTS: 224 patients with MS, 93 controls of similar age and sex. RESULTS: Sensory symptoms were more common in MS patients than in controls, and differed in severity and quality. Fifty per cent described brief (seconds to hours) episodes of neurological dysfunction, significantly more often than in controls (P = 0.001). Pain was present at some time in similar percentages in patients and controls, but active pain problems were present more often in MS patients (P = 0.001). The qualitative description of pain in MS patients was more often neuropathic, with burning, itching, electric and formicatory pain, as opposed to throbbing, sharp or muscular pain. Pain was localized to arms, legs, trunk, hands, feet and face more often in the MS group. Lhermitte's phenomenon was present in two-thirds of patients at some time in their disease course. Twenty per cent of the patients identified themselves as having respiratory problems (Controls 7.5%, P = 0.005). Fatigue limited activity in 78% of patients, but only in 17% of controls (P = 0.001). Dizziness, memory dysfunction, and restless legs symptoms were all more frequent in patients. The self-rated 'worst' symptoms of MS was pain in 12%, fatigue in 17% and dizziness in 5%, a total of 34% of 'worst' symptoms. Sensory symptoms were present in patients with early disease and without disability as often as in disabled patients and in those with longer disease duration. There was however a strong correlation between the total number of sensory symptoms reported and the presence of disability in the MS patients. CONCLUSIONS: Sensory symptoms are common in MS patients. Pain syndromes, transient neurologic events, Lhermitte's phenomenon, fatigue, respiratory symptoms and vertigo were present significantly more frequently in patients with MS than in a control population and contributed to subjective morbidity. Future clinical trials assessing therapy in MS might include sensory symptoms as secondary endpoints to capture this 'hidden reservoir' of disease morbidity.
Adult↗
Laparoscopic cholecystectomy alleviates pain in patients with acalculous biliary disease.
Our goal was to determine whether laparoscopic cholecystectomy is a safe and effective means of treatment for patients with acalculous cholecystitis. We reviewed the charts of 243 patients diagnosed with acalculous cholecystitis or biliary dyskinesia. Follow-up telephone interviews to measure degree of patient satisfaction and relief of preoperative symptoms were conducted. Hepatobiliary scanning results and postoperative symptom resolution were compared. One hundred seventy-one patients (94.5%) reported complete or partial resolution of symptoms postoperatively. Although 99 patients had symptoms reproduced with cholecystokinin injection during scanning, there was no significant correlation between these findings and alleviation of pain with cholecystectomy. There was no significant correlation between pain resolution after cholecystectomy and abnormal pathologic findings. Patients who suffered symptoms for a longer period of time preoperatively were more likely to be satisfied with the result of laparoscopic cholecystectomy. Laparoscopic cholecystectomy alleviates symptoms in many patients with acute or chronic acalculous cholecystitis or biliary dyskinesia with minimal morbidity.
Adolescent↗
The delay in reporting symptoms of carotid artery stenosis in an at-risk population. The Asymptomatic Carotid Atherosclerosis Study experience: a statement of concern regarding watchful waiting.
OBJECTIVE: To examine whether patients in the Asymptomatic Carotid Atherosclerosis Study reported symptoms of cerebral and retinal ischemia promptly to the investigating team. DESIGN: Cohort study within the Asymptomatic Carotid Atherosclerosis Study, a prospective, randomized, multicenter clinical trial, with a median follow-up time of 2.7 years. SETTING: Thirty-nine clinical sites across the United States and Canada. PATIENTS: Patients with asymptomatic carotid artery stenosis (> or = 60% reduction in diameter) who experienced either a transient ischemic attack (TIA) (n = 115) or stroke (n = 127) during the follow-up period, as verified by an external committee. MAIN OUTCOME MEASURE: Proportion of patients who reported cerebrovascular symptoms to a study nurse or physician within 3 days of occurrence. RESULTS: Thirty-seven patients (32.2%) experiencing TIA and 57 (44.9%) experiencing stroke reported symptoms to the study staff within 3 days of onset. For TIA, there was a statistically significant inverse association between prompt reporting and the amount of time a patient was enrolled in the study before the event occurred (48% with TIA occurring within 6 months vs 9% with TIA after year 3; P = .04). For stroke, there was a statistically significant association between prompt reporting and treatment arm (56% for the surgical vs 38% for the medical group; P = .05). For either TIA or stroke, none of the other factors examined were significantly associated with prompt reporting. CONCLUSIONS: Despite extensive education and reinforcement, fewer than 40% of all first events were reported within 3 days and fewer than 25% were reported in less than 24 hours. Frequent outpatient evaluation of high-risk patients and careful review of symptoms is necessary to determine when asymptomatic carotid artery stenosis has become symptomatic to offer appropriate forms of therapy.
Adult↗