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Biomedical subjects

Kevin Major

Publications and source records attributed to Kevin Major.

7 recordsLinked to original sources
PubMed2006

Technology penetration of endovascular aortic aneurysm repair in southern California.

Our objective was to investigate the penetration of endovascular abdominal aortic aneurysm repair (EVAR) in the large, diverse health-care market of southern California over 3 years and to study variability in the pattern of distribution of EVAR in southern California counties by analyzing available demographic, geographic, and socioeconomic data from California state health-care databases. Information abstracted from the inpatient hospital discharge data for patients undergoing AAA repair for the years 2001, 2002, and 2003, derived from the Office of Statewide Health Planning and Development, included age, gender, race, hospitals performing EVAR, and payors for the service. Per-capita income (PCI) for the year 1999 and the population size of each county for the respective years were obtained from the U.S. Census Bureau. Data pertaining to members of the Southern California Vascular Surgical Society (SCVSS) serving the southern California region were obtained from the SCVSS membership directory. Data were categorized based on 10 counties in southern California. All the above variables were analyzed using the chi-squared test, with p < 0.05 considered significant. The proportions of EVAR for the years 2001, 2002, and 2003 were 15.4% (n = 409), 20.2% (n = 492), and 25.9% (n = 566), respectively. This is a 67.8% (p < 0.0001) increase in EVAR application in southern California since 2001. However, the proportion of EVAR varied among counties (p < 0.0001), with 457 EVARs performed in Los Angeles County and eight in Imperial County during the study period. EVAR proportion was higher in patients aged > or =65 years (p < 0.0001) and male patients (p < 0.0001). The proportion of EVAR was significantly higher in counties with more than 20 vascular surgeons available (p < 0.0001) and PCI >21,000 US$ (p < 0.0001) and in Medicare, health maintenance organization, preferred provider organization, and private insurance holders (p < 0.0001). There was a trend toward increased EVARs in counties with more than eight hospitals that performed EVAR (p = 0.0545). However, no significant difference in EVAR proportion was observed among subgroups based on race (p = 0.535) and population size (p = 0.84). Although the number and proportion of EVAR increased significantly in southern California over 3 years, the penetration of the procedure varied among counties. County affluence, payor mix, and the number of vascular surgeons/county influenced the variability. These observations suggest that economic barriers may limit access to new biomedical technology. This has implications for health-care public policy directed toward providing equal access to medical care without regard to economic status.

Age Distribution↗
PubMed2005

Attitudes regarding surgeons' attire.

BACKGROUND: No studies to date exist regarding the attire of physicians on a surgical service. The objective of this study was to determine patient, surgeon, and nonhospitalized public (NHP) attitudes and preferences regarding surgeons' attire and mannerisms. METHODS: A questionnaire was developed to survey each group. The Internet was used as a novel avenue to survey the NHP. Eight questions were presented to each group, and each question had three possible responses: agree, disagree, or no opinion. Total responses and percentages were determined for each group's answers, and statistical analysis was performed using chi-square test. RESULTS: Thirty-eight surgical inpatients, 38 surgeons, and 334 NHP participated in the study. All groups agreed that surgeons should wear nametags while they are seeing patients. Inpatients agreed with surgeons that surgeons should wear white coats while seeing patients (P > .05). Surgeons considered scrubs and clogs to be acceptable attire, which differed from all other groups (P < .05). Although 31% of the NHP considered blue jeans acceptable, only 10% of surgeons (P < .05) and 22% of patients (P > .05) considered them acceptable. All groups believed that a surgeon's appearance influences their perceptions and impressions regarding the quality of medical care they received (P < .05). CONCLUSIONS: Based on the agreement of all groups that a surgeon's appearance and mannerisms affects perceptions of the quality of medical care received, surgeons should respond to these perceptions and dress accordingly while seeing surgical patients.

Attitude of Health Personnel↗
PubMed2003

Cryopreserved saphenous vein allografts in infrainguinal revascularization: analysis of 240 grafts.

INTRODUCTION: Cryopreserved saphenous vein allografts (Cryograft; CryoLife, Kennesaw, Ga) have been used as conduit in infrainguinal revascularization when autogenous vein is inadequate or unavailable. Although some studies of Cryografts report poor long-term patency, an anticoagulation protocol may improve outcome. We evaluated our experience with Cryografts to further define their role in lower extremity revascularization. Patients and methods Between March 1992 and March 2002, 240 infrainguinal revascularization procedures with Cryografts were performed in 199 limbs of 177 patients. Eighty-nine percent of procedures were performed because of ischemic rest pain or tissue loss, and 75% of vein grafts were implanted into infrapopliteal targets. Most patients received anticoagulation therapy with warfarin sodium or aspirin, or both, postoperatively. Mean age of the cohort was 78 years; 61% were women; 75% had hypertension, 58% had diabetes, and 38% had renal dysfunction; and 47% were current or past smokers. RESULTS: Mean follow-up was 7 months (range, 0-48 months). Primary patency rate was 83% at 1 month, 50% at 6 months, 30% at 12 months, and 18% at 24 months. Diabetes adversely affected graft patency. Warfarin sodium or antiplatelet therapy did not significantly improve graft patency. Limb salvage was 80% at 1 year and 71% at 2 years. CONCLUSIONS: Cryografts have low primary patency rates that are not affected by anticoagulation with warfarin sodium. Short-term patency of these grafts may be sufficient to heal ischemic wounds and thereby prevent limb loss. However, other less expensive alternatives, eg, prosthetic grafts with vein cuffs, are available and appear to have better patency. Accordingly, use of Cryografts should be limited to revascularization through infected fields in patients without autogenous conduit.

Aged↗
PubMed2003

The value of laparoscopy in management of abdominal trauma.

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOI), indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.

Abdominal Injuries↗
PubMed2002

Wireless clinical alerts and patient outcomes in the surgical intensive care unit.

Errors in medicine have gained public interest since the Institute of Medicine published its 1999 report on this subject. Although errors of commission are frequently cited, errors of omission can be equally serious. A computerized surgical intensive care unit (SICU) information system when coupled to an event-driven alerting engine has the potential to reduce errors of omission for critical intensive care unit events. Automated alerts and patient outcomes were prospectively collected for all patients admitted to a tertiary-care SICU for a 2-year period. During the study period 3,973 patients were admitted to the SICU and received 13,608 days of care. A total of 15,066 alert pages were sent including alerts for physiologic condition (6,163), laboratory data (4,951), blood gas (3,774), drug allergy (130), and toxic drug levels (48). Admission Simplified Acute Physiology Score and Acute Physiology and Chronic Health Evaluation II score, SICU lengths of stay, and overall mortality rates were significantly higher in patients who triggered the alerting system. Patients triggering the alert paging system were 49.4 times more likely to die in the SICU compared with patients who did not generate an alert. Even after transfer to floor care the patients who triggered the alerting system were 5.7 times more likely to die in the hospital. An alert page identifies patients who will stay in the SICU longer and have a significantly higher chance of death compared with patients who do not trigger the alerting system.

Critical Care↗
PubMedDate not supplied

Current trends in the management of iatrogenic cervical carotid artery injuries.

This study was undertaken to elicit the opinion of experts regarding the management of iatrogenic injury to the carotid artery. A text questionnaire was transmitted by electronic mail to members of the Western Vascular Society concerning management of iatrogenic injury to the cervical carotid artery. Participants were asked to submit information regarding practice status and their preferred choices for the management of different clinical scenarios. The scenarios were: (1) large bore sheath (> 8.5F) cannulation of the carotid artery in anesthetized patients, (2) large bore sheath cannulation of the carotid artery in an awake patient, (3) delayed recognition of a misplaced sheath by > 4 hours, and (4) arterial puncture was recognized after only the entry needle (16-gauge) was introduced but before sheath insertion. Finally, the members were asked to comment on the management of abnormal findings on duplex scanning, such as intimal flap or pseudoaneurysm. A response rate of 42% was obtained (45/106 active members). Eighty-two percent of respondents had been in practice for longer than 10 years. Eighty-nine percent had seen this complication and 29% had cared for patients in whom subsequent neurologic deficit developed. The institutional incidence of such injury was 1-5 cases per year for 82% of respondents. Sixteen-gauge needle injury was managed by immediate removal and applied pressure by 98% of respondents. When large-bore sheath injury is recognized within 1 hour of insertion, 62% of respondents would remove the sheath and hold pressure, with or without obtaining a duplex ultrasound examination. However, if injury recognition was delayed for > 4 hours, 82% would proceed to surgery. Only 26% operated on asymptomatic carotid flap found on ultrasound, while the remaining 74% would base their decision on size and flow characteristics on ultrasound. The management of pseudoaneurysm differed significantly. Whereas 31% of respondents would manage this finding expectantly, 69% would proceed to surgery regardless of size or symptoms. Despite awareness of iatrogenic injury to the cervical carotid artery, the institutional incidence remains high. Two thirds of respondents would manage a misplaced sheath in the carotid artery nonoperatively if the injury was recognized immediately. However, if injury recognition was delayed for > 4 hours, the majority of respondents would remove the sheath surgically. While the management of intimal flap largely depended on size and flow characteristics, 69% of respondents would operate on a pseudoaneurysm regardless of size or symptoms. The results of this survey may serve as a guideline for the management of this potentially devastating injury.

Carotid Arteries↗