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Biomedical subjects

J H Sanders

Publications and source records attributed to J H Sanders.

At least 19 recordsLinked to original sources
PubMed2001

Improved in-hospital mortality in women undergoing coronary artery bypass grafting. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: Few studies have examined the changes in in-hospital mortality for women over time. We describe the changing case mix and mortality for women undergoing coronary artery bypass grafting (CABG) from 1987 to 1997 in northern New England. METHODS: Data were collected on 8,029 women and 21,139 men undergoing isolated CABG. The study consisted of three time periods (1987 to 1989, 1990 to 1992, and 1993 to 1997) to account for regional efforts to improve quality of care that occurred during 1990 to 1992. RESULTS: Compared with 1987 to 1989, women undergoing CABG in 1993 to 1997 were older, had poorer ventricular function, and more often required urgent or emergency operations. The crude and adjusted mortality rates for both women and men decreased significantly over time. The absolute magnitude of the change in adjusted rates was greater for women (3.1%) than for men (1.5%). Although women represented only 28% of the study population, the decrease in their mortality accounted for 44% of the total decrease in adjusted mortality during the study period. CONCLUSIONS: Over the last decade there has been a marked decrease in CABG mortality for women, despite a worsening case mix.

Aged↗
PubMed2001

Pitfalls in surgical decision-making during mitral valve repair.

Mitral valve repair has become the mainstay of surgical treatment for mitral valvular regurgitation. Surgeons in North America were relatively slow to adopt the various repair techniques, perhaps because rheumatic heart disease was less common, and the initial experiences with large numbers of repairs in Europe dealt largely with rheumatic disease. Subsequent experience, however, has clearly shown that patients with degenerative mitral valve disease can expect very durable repairs, and that most such patients have relatively simple pathologic conditions. The potential for repair, with a lack of need for long-term anticoagulation, has led to earlier surgical intervention. Still, mitral valve repair is far more complex than mitral valve replacement and must be accompanied by careful intraoperative decision making. Pitfalls exist that are different from those that accompany replacement. In this article, we examine some of the more common problems, their identification, and, hopefully, ways to avoid them.

Decision Making↗
PubMed2000

Risks of morbidity and mortality in dialysis patients undergoing coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: Although dialysis patients are undergoing CABG with increasing frequency, large studies specifically comparing patient characteristics and procedure-related risks in this population have not been performed. METHODS AND RESULTS: We conducted a regional prospective cohort study of 15,500 consecutive patients undergoing CABG in northern New England from 1992 to 1997. We used multiple logistic regression analysis to examine associations between preoperative dialysis-dependent renal failure and postoperative events and to adjust for potentially confounding variables. The 279 dialysis-dependent renal failure patients (1.8%) were 4.4 times more likely to experience in-hospital mortality than were other CABG patients (12.2% versus 3.0%, respectively; P:<0.001). Dialysis-dependent renal failure patients were older and had more comorbidities and more severe cardiac disease than did other CABG patients. After adjusting for these factors in multivariate analysis, however, dialysis-dependent renal failure patients remained 3.1 times more likely to die after CABG (adjusted odds ratio [OR] 3.1, 95% CI 2.1 to 4.7; P:<0.001). Dialysis-dependent renal failure patients compared with other CABG patients also had a substantially increased risk of postoperative mediastinitis (3.6% versus 1.2%, respectively; adjusted OR 2.4, 95% CI 1.2 to 4.7; P:=0.011) and postoperative stroke (4.3% versus 1.7%, respectively; adjusted OR 2. 1, 95% CI 1.1 to 3.9; P:=0.016), even after controlling for potentially confounding variables. Risks of reexploration for bleeding were similar for patients with and without dialysis-dependent renal failure. CONCLUSIONS: Preoperative dialysis-dependent renal failure is a strong independent risk factor for in-hospital mortality and mediastinitis after CABG.

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PubMed1998

Telemedicine: where it is and where it's going.

The term telemedicine encompasses a wide range of telecommunications and information technologies and many clinical applications, although interactive video may be the most common medium. The first telemedicine programs were established almost 40 years ago, but the technology has grown considerably in the past decade. Despite the expansion of telemedicine, the volume of patients receiving services that use the technology remains relatively low (about 21000 in 1996). In part, this reflects the lack of a consistent coverage and payment policy and concerns about licensure, liability, and other issues. A considerable amount of federal funding has supported telemedicine in recent years, and legislators and federal, regional, and state policymakers are struggling with several crucial policy matters. Research on the effectiveness of telemedicine is somewhat limited, although the work that has been done thus far supports the hypothesis that, in general, the technology is medically effective. The cost-effectiveness of specific telemedicine applications has not yet been rigorously demonstrated.

Humans↗
PubMed1998

Hybrid myocardial revascularization after previous left pneumonectomy.

Previous intrapericardial left pneumonectomy and irradiation necessitated an unorthodox, staged approach to myocardial revascularization in a patient with unstable angina pectoris, left main artery, and three-vessel coronary artery disease. A saphenous vein bypass graft was constructed from the descending thoracic aorta to the left anterior descending coronary artery via left thoracotomy, without cardiopulmonary bypass. Two days later the patient underwent stenting of the left main and circumflex coronary arteries. Recovery was uneventful.

Aged↗
PubMed1998

A proposed framework for economic evaluation of telemedicine.

Economic evaluation of telemedicine compares the costs and other consequences of delivering specific services through telemedicine vs. alternative means. Cost-effectiveness analysis, the most common method used for health issues, helps to assess whether the expected health benefits are worth the investment. Telemedicine raises particular challenges for evaluators: a telemedicine system may have multiple uses and joint costs that are difficult to apportion to one service, the existence of a system may lead to expanded indications for use, and technological change may rapidly make an evaluation outdated. Public and private regulation and payment may affect the diffusion of telemedicine. Uncertainty surrounds the policy of the U.S. Food and Drug Administration, which is still formulating its position. Changes are underway in policies on licensure and credentialing of clinicians, which have traditionally been done by state and by site, to reflect the fact that telemedicine services may cross these regional boundaries. Lack of insurance coverage for telemedicine services has been considered an impediment to adoption with fee-for-service payment. Under capitation payment and fixed budgets, however, providers have financial incentives to use the most efficient method to deliver services, and these arrangements would favor telemedicine if it is the less costly alternative. If telemedicine were most costly and the health benefits worth the cost, monitoring might be needed to ensure the quality of care.

Capitation Fee↗
PubMed1996

Expanding indications for pediatric coronary artery bypass.

Pediatric coronary artery bypass has been done mostly for ischemic complications of Kawasaki disease. We reviewed our clinical experience between 1987 and 1994 with internal thoracic artery-coronary artery bypass in one infant and five children for varying indications. Indications for coronary bypass included Kawasaki disease (2), congenital left main coronary ostial stenosis, iatrogenic coronary cameral fistula, anomalous origin of the left coronary artery from the pulmonary artery, and single coronary artery traversing between the great arteries in a patient after cardiac transplantation. An additional cohort of 34 control patients of various ages and weights (1 day to 16.1 years, 2.6 kg to 62 kg) had angiographic measurements of the right coronary, left coronary, and left internal thoracic arteries with respect to the feasibility of performing coronary artery bypass. All six patients survived internal thoracic artery-left anterior descending coronary artery bypass without evidence of perioperative myocardial infarction. Postoperative angiographic studies in five and color Doppler echocardiography in one showed graft patency. Retrospective angiographic measurements in the 34 control patients showed that internal thoracic and coronary arteries are proportionately quite large in neonates and infants compared with those in older children and adolescents. Internal thoracic artery-coronary artery bypass should be considered for the expanding indications presented herein and when emergency intraoperative life-threatening situations present themselves. Long-term patency and reoperation rates have yet to be determined.

Case-Control Studies↗
PubMed1995

Telemedicine infrastructure development.

While there are significant technical and regulatory barriers to developing an adequate infrastructure for telemedicine, even more fundamental organizational and financial infrastructure issues must be addressed if this technology is to realize its potential. The lack of good evaluative data on telemedicine consultations has been a further major stumbling block to its acceptance by both practitioners and policy-makers. This paper discusses these issues and suggests approaches for overcoming many of the impediments to telemedicine.

Computer Communication Networks↗
PubMed1995

Challenges to the implementation of telemedicine.

In the United States, we are witnessing a renewed emphasis on the potential role of telemedicine in redressing issues of accessibility, cost, and quality of medical care. This paper describes several major problems confronting the current generation of telemedicine projects as they move toward maturity. In fact, it is argued here, the future development of telemedicine as an integral component of the health care system depends on the successful resolution of these concerns. Included for discussion are issues related to physicians, institutions, patients, and the general public. On the basis of the tenets of telemedicine and its capacity to transcend traditional boundaries of medical care via telecommunications, informed speculations are presented that are intended to stimulate discussion and provide direction for addressing a number of potential problems. Included are suggestions pertaining to restructuring the medical licensure system to accommodate telemedicine and the virtual regionalization of health care; implications for provider liability and reimbursement; patient privacy; system design; and diffusion of information.

Confidentiality↗
PubMed1995

Telemedicine.

Explore the source record for details and available documents.

Evaluation Studies as Topic↗
PubMed1992

Oblique transseptal left atriotomy for optimal mitral exposure.

Twenty patients underwent mitral valve replacement or other surgical procedures within the left atrium with Dubost's transseptal left atriotomy. The left atrium was grossly enlarged in six patients. Exposure was considered to be excellent in 13 patients and poor in only two. One patient (with a second aortic and mitral valve replacement) required a permanent pacemaker after operation, none had a residual shunt at the atrial level, and none required reoperation for bleeding. The Dubost transseptal left atriotomy affords excellent exposure of left atrial structures, is easy to close, and does not increase the prevalence of postoperative rhythm disturbances.

Adolescent↗
PubMed1990

Clinical experience with portable cardiopulmonary bypass in cardiac arrest patients.

To evaluate the use of portable cardiopulmonary bypass as a resuscitative tool and its impact on long-term survival of patients in cardiac arrest, we reviewed the results of 32 consecutive patients resuscitated by cardiopulmonary bypass for cardiac arrest or severe hemodynamic compromise at Northwestern Memorial Hospital over a 2-year period. Overall survival was 12.5%. Only 1 (3.4%) of the 29 patients who had cardiac arrest survived and left the hospital. All 3 patients who had severe hemodynamic compromise but not cardiac arrest were long-term survivors. Our study suggests that portable cardiopulmonary support systems used as a resuscitative tool do not prolong the survival of most cardiac arrest patients but may be useful for patients with shock due to mechanical causes and for those with profound hemodynamic compromise due to ischemia or myocardial infarction. Portable heart-lung machines can provide patients with excellent hemodynamic support; however, neurological or cardiac recovery is unlikely once cardiac arrest occurs.

Cardiopulmonary Bypass↗