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Biomedical subjects

M S Riedinger

Publications and source records attributed to M S Riedinger.

18 recordsLinked to original sources
PubMed1992

Implementing practice guidelines through a utilization management strategy: the potential and the challenges.

Although there is currently much enthusiasm for practice guidelines, far more energy and resources have been expended on their development than on their implementation. A prospective interventional trial was performed using a previously validated explicit practice guideline (decision aid) to decrease the hospital length of stay for selected "low-risk" patients with chest pain. Utilization management (UM) coordinators (RNs) and physicians were chosen to implement the guideline since these resource people are available in most hospitals, allowing for generalization of the experience. With explicit review criteria used for 624 patients, it was found that when the guideline was applied by UM coordinators, it had a sensitivity of 0.85, a specificity of 0.90, a positive predictive value of 0.76, and a negative predictive value of 0.94. The attending physicians failed to override falsely classified low-risk patient recommendations 51% of the time. Implicit review judged that outcome might have theoretically been worsened in two of these patients. Follow-up at 30 days after admission, however, revealed no untoward sequelae in falsely categorized patients discharged according to the guideline. Utilization management appears to be a promising mechanism for guideline implementation that is available in most institutions. However, the accuracy with which UM coordinators implement guidelines should be assessed rigorously. Guidelines should be implemented in an environment of checks and balances in which physicians have the ultimate responsibility for their patients' care.

Adult↗
PubMed1990

Early "step-down" transfer of low-risk patients with chest pain. A controlled interventional trial.

OBJECTIVE: To determine whether providing private practitioners with triage criteria for their low-risk chest pain patients would safely enhance bed utilization efficiency in coronary and intermediate care units. DESIGN: Prospective, controlled, interventional trial using an alternate month study design. SETTING: A large teaching community hospital. PATIENTS: Cohort of 404 low-risk patients with chest pain for whom a diagnosis of myocardial infarction has been excluded and who have not sustained complications, required interventions, or developed unstable comorbidity. INTERVENTIONS: During intervention months, private practitioners caring for low-risk patients in the coronary and intermediate care units were contacted 24 hours after admission. Physicians were informed that the transfer of low-risk patients to nonmonitored beds could probably be done safely, based on the results of a pilot study. The practitioner had the option of agreeing to or deferring patient transfer. During control months, physicians were not contacted in this way. MEASUREMENTS AND MAIN RESULTS: Use of the triage criteria by private practitioners reduced lengths of stay in the intermediate and coronary care units by 36% and 53%, respectively. Bed availability increased by 744 intermediate and 372 coronary care unit bed-days per year. Charges decreased by $2.6 million per year and profits improved by $390,000 per year. There were not significant differences in complications between control and intervention patients and in no case (95% CI, 0% to 1.6%) did the triage criteria adversely affect quality of care. CONCLUSIONS: The early transfer triage criteria may be a safe and efficacious decision aid for improving bed utilization in intermediate and coronary care units. In addition, this study shows the feasibility of and potential benefits from applying practice guidelines at a community hospital.

Aged↗
PubMed1990

The principle of parsimony: Glasgow Coma Scale score predicts mortality as well as the APACHE II score for stroke patients.

Although the development and use of severity-of-illness measures has gained widespread enthusiasm, uncertainty remains as to the optimal measure for stroke patients. The Health Care Financing Administration recently derived a severity-of-illness measure based on the APACHE II system to explain differences in Medicare mortality rates among hospitals treating stroke patients. We hypothesized that the Glasgow Coma Scale score provides prognostic information of accuracy comparable to that of the APACHE II score for stroke patients, yet is simpler and cheaper to abstract from the medical record. We therefore studied 246 patients hospitalized with stroke, including 49 oversampled mortalities. The Glasgow Coma Scale score was as accurate as the APACHE II score in predicting stroke mortality both before (r = -0.50 and r = 0.50, respectively) and after (r = -0.40 and r = 0.38, respectively) the oversampled mortalities were excluded. The APACHE II score required abstraction of 16 variables from the medical record compared with three for the Glasgow Coma Scale score and required more than three times the time to abstract from the medical record. Therefore, in the interest of parsimonious data collection, the Glasgow Coma Scale may be a preferable severity-of-illness measure for patients with stroke.

Aged↗
PubMed1989

Selecting the best triage rule for patients hospitalized with chest pain.

PURPOSE: During an observational study, we investigated the potential benefits and risks of the use of admission and early transfer triage rules in 498 patients hospitalized with chest pain. PATIENTS AND METHODS: Appropriateness of triage decisions was measured using explicit and implicit judgments. RESULTS: Application of an admission triage rule (partially based on the Brush electrocardiographic criteria) would have increased coronary care unit (CCU) admissions by 3%, whereas application of a triage rule 24 hours after admission would have reduced bed utilization by 860 intermediate care and 82 CCU bed-days per year when compared with actual patient triage. Although 9.5% of patients who underwent triage according to the early transfer triage rule would have experienced a minor complication after transfer, the medical care of none would have been adversely affected. CONCLUSION: Our results show that application of a triage rule 24 hours after admission may have the potential to shorten length of stay in the CCU and intermediate care unit without significantly compromising patient care. However, use of the admission triage rule would have increased CCU bed utilization. The failure of the admission triage rule to improve bed utilization illustrates the potential hazards of ignoring patient complications, interventions, and co-morbidity when predicting the efficacy of a triage rule.

Aged↗
PubMed1986

Brown adipose tissue in cancer patients: possible cause of cancer-induced cachexia.

Cachexia is a common manifestation of advanced cancer and frequently contributes to physical disability and mortality. An increased metabolic rate has been suggested to be one of the causes of cancer-induced cachexia, although the mechanisms producing this hypermetabolism remain unclear. The presence and activation of brown adipose tissue, a highly thermogenic tissue, may result in a hypermetabolic state and be partially responsible for weight loss in cancer patients. To investigate this hypothesis, we examined necropsy samples of peri-adrenal tissues using light microscopy to identify the prevalence of brown adipose tissue in 25 cachectic patients who died from cancer and 15 age-matched subjects who died from other illnesses. Brown adipose tissue was observed in 20 of the cancer patients (80%) compared to 2 of the age-matched subjects (13%). Therefore, our preliminary results indicate that a high prevalence of brown adipose tissue is associated with cancer-induced cachexia and may reflect an abnormal mechanism responsible for profound energy expenditure and weight loss.

Adipose Tissue, Brown↗
PubMed1985

Efficacy and safety of sublingual nifedipine in hypertensive emergencies.

Hypertensive emergencies are a diverse group of disorders characterized by a marked elevation of systemic arterial pressure that is associated with acute end-organ dysfunction. The efficacy and safety of sublingual nifedipine were evaluated in 16 men and 14 women (mean age 65 +/- 14 years) who had hypertensive emergencies. Before treatment, mean systolic blood pressure was 224 +/- 23 mm Hg, mean diastolic blood pressure was 125 +/- 18 mm Hg, and the average mean arterial pressure was 158 +/- 16 mm Hg. Administration of 10 or 20 mg of sublingual nifedipine initiated a smooth and predictable decline in blood pressure values within five minutes and produced a peak effect between 30 and 60 minutes. At 30 minutes, the decreases in the systolic blood pressure, diastolic blood pressure, and mean arterial pressure for the group were 49 +/- 24 mm Hg, 31 +/- 17 mm Hg, and 39 +/- 20 mm Hg, respectively, all of which were highly significant (p less than 0.001). By 60 minutes, nifedipine had decreased the diastolic blood pressure to less than 120 mm Hg in 97 percent of patients, less than 110 mm Hg in 93 percent, and less than 100 mm Hg in 67 percent. Fourteen patients required other antihypertensive medications within the first 12 hours for the antihypertensive effect to be maintained. In this group, the systolic, diastolic, and mean arterial pressures were significantly lower than baseline values (p less than 0.001) at the time that the other drugs were started (which occurred at a mean of 4.3 +/- 3.2 hours after entry into the study). The response to nifedipine correlated with the blood pressure value prior to treatment, but did not correlate with age, gender, value prior to treatment, but did not correlate with age, gender, or the type of hypertensive emergency. Twenty mg of nifedipine produced a significantly greater antihypertensive effect than did 10 mg during the first 20 minutes (176 +/- 15 mm Hg versus 201 +/- 18 mm Hg systolic; p = 0.009) and appeared to be more efficacious clinically. In only two of 30 patients (7 percent) was the blood pressure response considered inadequate, and all 10 patients with pulmonary edema or myocardial ischemia showed clinical improvement within 60 minutes of treatment. In one patient, flushing and another symptom suggestive of transient symptomatic hypotension developed after treatment with nifedipine. These results suggest that sublingual nifedipine is a safe, effective, and practical agent for treating patients with hypertensive emergencies.

Administration, Oral↗
PubMed1985

Left ventricular performance in septic shock: reversible segmental and global abnormalities.

Left ventricular dysfunction has been implicated in the pathogenesis of septic shock, but little is known about its natural history, cause, and prognostic significance. Left ventricular performance was assessed by serial radionuclide and hemodynamic studies in 35 patients with culture-proven septic shock. The mean age (+/- S.D.) of the group was 64 +/- 18 years; 16 of the subjects were women, and 15 had antecedent heart disease. On the first study, the left ventricular stroke work index was depressed in 33 (94%) patients, and nineteen (54%) had a left ventricular ejection fraction less than 0.48. Twenty-two (63%) of the patients had segmental and four had generalized wall motion abnormalities. Conventional hemodynamic parameters were of no value in predicting the patients who had a depressed left ventricular ejection fraction or segmental abnormalities. Patients with underlying heart disease had a much higher frequency (87%) of segmental dysfunction than those without underlying heart disease (45%; p = 0.016), but no differences were noted in the left ventricular ejection fraction or left ventricular stroke work index of these two groups. Segmental abnormalities and low ejection fractions were seen more often in patients with a large left ventricular end-diastolic volume index. Only five subjects had a systemic vascular resistance index greater than 2580 dynes X sec X cm-5 per m2, and the correlation between systemic vascular resistance index and left ventricular ejection fraction was poor. No difference was found in the mean coronary perfusion pressure of those with segmental abnormalities and those with normal wall motion.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1984

Right ventricular performance in septic shock: a combined radionuclide and hemodynamic study.

Twenty-five patients with septic shock underwent simultaneous radionuclide ventriculography and right heart catheterization to clarify the role of the right ventricle in this syndrome. A depressed right ventricular ejection fraction (less than 38%) was present in 13 patients and was found in patients with elevated cardiac output (4 of 6 patients) and with normal or low cardiac output (9 of 19 patients). Right ventricular dysfunction was seen with or without acute respiratory failure. In eight patients, a depressed right ventricular ejection fraction was seen in combination with an abnormal left ventricular ejection fraction (less than 48%), but in five patients, right ventricular ejection fraction impairment occurred with normal left ventricular ejection fraction. There was no significant correlation between abnormal right ventricular afterload and depressed right ventricular ejection fraction. No clinical or hemodynamic finding could be used to identify patients with diminished right ventricular ejection fraction. On follow-up study in 17 surviving patients, right ventricular ejection fraction improved in 6 and was unchanged in 11. Improvement in right ventricular ejection fraction occurred more frequently in patients without pulmonary hypertension or respiratory distress. The results suggest that right ventricular dysfunction in septic shock may be more common than previously suspected. It may be caused by abnormalities in right ventricular afterload in some patients and depressed myocardial contractility in others. The findings are of therapeutic importance since interventions that diminish right ventricular afterload and increase right ventricular contractility would be appropriate in patients with septic shock and right ventricular dysfunction.

Adult↗
PubMed1984

Severe neutropenia associated with sustained-release procainamide.

Neutropenia is a rare complication of procainamide therapy. However, over a period of 20 months, 8 patients developed severe neutropenia while taking a sustained-release preparation of the drug. Seven patients presented with fever and constitutional symptoms and one patient was asymptomatic. Bone marrow examinations showed myeloid aplasia or maturation arrest in 5 patients and myeloid hyperplasia in 1. Neutropenia resolved within 30 days of drug withdrawal, and all patients survived. A case-control study showed a significant association between sustained-release procainamide therapy and severe neutropenia in 5 of 114 patients (4.4%) recovering from open-heart surgery (Mantel-Haenszel chi square = 13.84; p less than 0.001). Thus, life-threatening neutropenia may be common with sustained-release procainamide preparations.

Aged↗
PubMed1983

Thermodilution cardiac output determination in hypothermic postcardiac surgery patients: room vs ice temperature injectate.

In normothermic patients, room temperature and ice temperature injectate have been shown to result in comparable thermodilution cardiac output measurements. However, room temperature injectate may give inaccurate results in hypothermic patients, particularly if the injectate volume is small, because of the lower injectate-to-blood temperature differential. We compared determinations of cardiac output using 10- and 5-ml volumes of room temperature (19-25 degrees C) injectate to those using 10-ml volumes of ice temperature (0-5 degrees C) injectate in 26 hypothermic (32.7 +/- 1.2 degrees C) postcardiac surgery patients. The cardiac outputs ranged from 1.8 to 5.3 L/min. Regression analysis demonstrated a close relationship between the cardiac outputs measured using room temperature injectate compared to those using ice temperature injectate (0.951 for the 10-ml volumes, 0.925 for the 5-ml volumes). We conclude that the room temperature injectate method is acceptable for determining thermodilution cardiac outputs in moderately hypothermic patients.

Adult↗
PubMedDate not supplied

Reading pulmonary artery and pulmonary capillary wedge pressure waveforms with respiratory variations.

Various techniques for reading pulmonary artery and pulmonary capillary wedge pressures have been described. We feel that the most easily obtained and accurate method for reading pressures with respiratory variations should be with reference to end expiration. This is a relatively constant period of intrathoracic pressure and allows for a stable pressure waveform, which can be measured easily. No matter which technique is utilized, a standard procedure should be adopted by those reading the pressures and understood by those who must interpret them. Consistency in the method of pressure waveform reading is important to ensure meaningful measurements and subsequent appropriate treatment of the patient.

Blood Pressure Determination↗