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Biomedical subjects

T Dorman

Publications and source records attributed to T Dorman.

At least 19 recordsLinked to original sources
PubMed2002

[Short stature treatment by lower limb lengthening--multicenter study from five centers].

MATERIAL: 26 patients (17 female, 9 male) from 5 centers were evaluated. The age at the beginning of treatment ranged from 6 to 29 years (mean 13.8). The cause of short stature in 19 patients was achondroplasia or pseudoachondroplasia, in next 2--other bone dysplasias. The other 5 patients had not bone pathology and were treated because of cosmetic indications. Preoperative body height ranged from 90 to 149 cm (mean 120). Axial deviations of the lower extremities were noted in 11 patients. Mean follow-up was 3.7 years. METHOD OF TREATMENT: Most of patients were treated with Ilizarov device using cross lengthening strategy (2 stages--opposite femur and tibia lengthening). Mean duration of treatment including interval between two stages (mean 12 months) was 29 months. Planned increase of body height ranged from 10 to 26 cm (mean 16.4). RESULTS: Planned or greater lengthening (mean 14.8 cm) was achieved in 14 patients. Partial planned lengthening (mean 65% of planned lengthening) was achieved in 8 patients (mean 11.8 cm) including two patients who resigned the second stage of treatment. In two patients lengthening was stopped during first month of treatment because of great complications. In 2 patients treatment was not completed (interval between first and second stage). Mean increase of body height of patients with complete treatment was 13.1 cm (from 2 to 28). Problems, obstacles and complications were analyzed according to Paley classification. PROBLEMS: There were 24 problems in 15 patient (inflammation process around K wires--15 patients, bone healing disturbances--3, regenerate fracture--2, transient foot equinus--2 and axial deviation of the lower extremity--1). OBSTACLES: There were 31 obstacles in 19 patients (regenerate's defect--7 patients, premature bone consolidation--6, foot equinus--4 and other--14). COMPLICATIONS: There were 26 complications in 18 patients (axial deviation of the lengthened segment--8, foot equinus--6, paresis of the peroneal nerve--3, fractures--2 and other--5). The most serious complication was hemiparesis after cerebral embolism (1 patient) and damaging of the femoral artery (1 patient) both disrupting bone lengthening. CONCLUSION: The risk of complication in surgical treatment of short stature patients is high. Qualification for short stature treatment because of cosmetic indication should be made very careful and after precise psychological and/or psychiatric investigation.

Adolescent↗
PubMed2001

Assessing the effectiveness of critical pathways on reducing resource utilization in the surgical intensive care unit.

OBJECTIVES: To evaluate the effectiveness of procedure-specific surgical critical pathways on reducing resource utilization in a university surgical intensive care unit (ICU). DESIGN AND SETTING: Prospective cohort study in a university surgical ICU. PATIENTS: 194 patients, accounting for 255 patient days, sampled on randomly selected days over a 12-month period of time. MEASUREMENTS AND RESULTS: The primary outcomes of this study were pathway eligibility and laboratory utilization. Patients were eligible for a procedure-specific pathway in 34% of patient days identified, and the patient's clinical course was "on" pathway in 22% of patient days. Of those "on" the pathway, 54% had a pathway present in the chart and 32% of these included documentation of the patient's clinical course. Thus in 78% of the patient days the patient was either not eligible for a critical pathway or the patient's clinical course was "off" pathway. In those patients "on" the pathway 46 % did not have a pathway present in the chart. Being on a critical pathway did not reduce laboratory utilization. Laboratory utilization did not vary between patients "on" and "off" the pathway (19.1 +/- 11.3 laboratory tests/patient day versus 20.4 +/- 5.7 laboratory tests/patient day). Predicted laboratory utilization by the pathway was 5.6 laboratory tests/patient day. By reducing actual laboratory utilization to that predicted by the critical pathway we would reduce laboratory utilization at our institution by $1.2 million per year. CONCLUSIONS: Procedure-specific surgical critical pathways are not an effective tool for reducing resource utilization in our ICU. Most of our patients were not eligible for an available pathway, and those who were eligible and were "on" the pathway did not appear to have laboratory utilization guided by the pathway. Future initiatives need to explore other means such as ICU-specific care processes to reduce resource utilization in the ICU.

Aged↗
PubMed2001

Variations in complication rates and opportunities for improvement in quality of care for patients having abdominal aortic surgery.

BACKGROUND: The purpose was to assess the current variation in complication rates and evaluate the association between specific types of complications and in-hospital mortality and total hospital charges for patients having abdominal aortic surgery. PATIENTS/METHODS: We studied 2987 patients for abdominal aortic surgery in Maryland from 1994 to 1996 and used discharge diagnoses and procedure codes to identify diagnoses that most likely represent major surgery complications. We evaluated how in-hospital mortality and total hospital charges related to specific complications, adjusting for patient demographics, severity of illness, comorbidity, and hospital and surgeon volumes. Discharge data was obtained from the hospital marketing departments. RESULTS: Complication rates varied widely among hospitals. Complications independently associated with increased risk of in-hospital death include cardiac arrest with an odds ratio (OR) of 90 and a 95% confidence interval (CI) of 32-251, septicemia (OR 6.1, CI 3.3-11.3), acute myocardial infarction (OR 5.7, CI 2.3-14.3), acute renal failure (OR 5.0, CI 2.3-11.0), surgical complications after a procedure (OR 3.1, CI 2.0-4.9), and reoperation for bleeding (OR 2.2, CI 1.1-4.8). The population-attributable risk for in-hospital mortality was 47% for cardiac arrest and 27% for acute renal failure. CONCLUSIONS: In abdominal aortic surgery on patients in Maryland, the rates of some complications vary widely and are independently associated with increased in-hospital mortality and hospital charges (charges differ from costs). Efforts to reduce these complications should help to decrease both levels.

Aortic Aneurysm, Abdominal↗
PubMed2001

Telecardiology and the intensive care unit.

Technology continues to advance at a pace that produces a new innovation daily. To move forward, clinicians must assess these potential technological solutions adequately for their clinical, financial, and customer satisfaction efficacies. Whether the payers, the patients, or health care will find these systems acceptable has yet to be established completely. The preliminary data in the literature seem to point to physicians' trepidations as the limiting factor. More work is needed on the legal and ethical issues surrounding telemedicine. Telemedicine is progressing quickly from a strange rare subtype of medicine into something that is part and parcel of the practice of medicine in general. Cardiology and intensivist practices have been impacted directly by this technology. As it matures it will be intertwined with daily practice.

Cardiology↗
PubMed2001

Nicardipine versus nitroprusside for breakthrough hypertension following carotid endarterectomy.

STUDY OBJECTIVE: To evaluate the effectiveness of nicardipine and nitroprusside for breakthrough hypertension following carotid endarterectomy. DESIGN: Prospective, randomized, double-blind, controlled effectiveness trial. SETTING: University-based surgical intensive care unit. PATIENTS: 60 ASA physical status I, II, III, and IV patients experiencing breakthrough hypertension at the time of admission to the intensive care unit (ICU). INTERVENTIONS: Patients received either nicardipine (n = 29) and placebo or nitroprusside (n = 31) and placebo for up to 6 hours postoperatively. Loading doses of nicardipine were provided, but placebo was used as a load for patients randomized to nitroprusside. MEASUREMENTS AND MAIN RESULTS: Rapidity and variability of blood pressure (BP) control were assessed. During the first 10 minutes, 83% of nicardipine patients compared to 23% of nitroprusside-treated patients, achieved BP control (p < 0.01). Following initial control, 12 nicardipine- and 24 nitroprusside-treated patients required additional titration of their infusions to maintain blood pressure within the targeted range (p < 0.05). No patient suffered a stroke, myocardial infarction, or was returned to the operating room (OR) for bleeding. CONCLUSIONS: Nicardipine administration produced more rapid BP control, most likely related to the administration of a loading dose. In addition to more rapid control, nicardipine-treated patients had less variability in BP and required significantly fewer additional interventions. Although no patient suffered a major event during this study, this study was not powered sufficiently to assess safety.

Aged↗
PubMed2001

Evidence-based medicine in anesthesiology.

By making the clinical decision making process explicit, conscious, and science based, we may avoid confusing opinion with evidence. EBM may help sharpen our critical appraisal skills and thus improve the way we practice, teach, and conduct research. Nevertheless, EBM will need to supplement rather than substitute for other approaches to patient care and teaching. EBM may better incorporate patients' values into clinical decision making, and this may be especially important in anesthesiology, where we are in need of valid evidence about important clinical issues such as preoperative testing and postoperative analgesia. By incorporating valid scientific evidence and patients' values into clinical decision making, we may improve patient outcomes. Outside of internal medicine, the literature suggesting that the practice of EBM improves outcomes is sparse, though increasing. Future studies to critically evaluate the practice of EBM in anesthesiology and critical care would be helpful.

Anesthesiology↗
PubMed2001

Leukocytes can enhance platelet-mediated aggregation and thromboxane release via interaction of P-selectin glycoprotein ligand 1 with P-selectin.

BACKGROUND: Platelet--leukocyte conjugates have been observed in patients with unstable coronary syndromes and after cardiopulmonary bypass. In vitro, the binding of platelet P-selectin to leukocyte P-selectin glycoprotein ligand-1 (PSGL1) mediates conjugate formation; however, the hemostatic implications of these cell--cell interactions are unknown. The aims of this study were to determine the ability of leukocytes to modulate platelet agonist--induced aggregation and secretion in the blood milieu, and to investigate the role of P-selectin and PSGL-1 in mediating these responses. METHODS: Blood was drawn from healthy volunteers for in vitro analysis of platelet agonist--induced aggregation, secretion (adenosine triphosphate, beta-thromboglobulin, and thromboxane), and platelet-leukocyte conjugate formation. Experiments were performed on live cells in whole blood or plasma to simulate physiologic conditions. Whole-blood impedance and optical aggregometry, flow cytometry, and enzyme-linked immunosorbent assays were performed in the presence and absence of blocking antibodies to P-selectin and PSGL1. The platelet-specific agonists, thrombin receptor activating peptide and adenosine diphosphate, were used to elicit platelet activation responses. RESULTS: Inhibition of platelet--leukocyte adherence by P- selectin and PSGL1 antibodies decreased agonist--induced aggregation in whole blood. The presence of leukocytes in platelet-rich plasma increased aggregation, and this increase was attenuated by P-selectin blocking antibodies. Data from flow cytometry confirmed that platelet-leukocyte conjugate formation contributed to aggregation responses. Blocking antibodies reduced platelet agonist--induced thromboxane release but had no impact on adenosine triphosphate and beta-thomboglobulin secretion. CONCLUSIONS: Leukocytes can enhance platelet agonist--induced aggregation and thromboxane release in whole blood and platelet-rich plasma under shear conditions in vitro. Interaction of platelet P-selectin with leukocyte PSGL1 contributes substantially to these effects.

Adult↗
PubMed2001

Herbal medicine and anesthesia.

Complementary and alternative medicine is one of the fastest growing areas in health care. Many patients worldwide utilize these additional health care strategies in conjunction with standard medical therapies. Unfortunately little is understood about many of the interactions that can occur and as many as 50% of the patients do not inform their health care providers about these complementary and alternative therapies. The interactions that are most important in the perioperative period include sympathomimetic, sedative, and coagulopathic effects. Given the overall paucity of information regarding herbal medicines and their potential pertinent perioperative implications this domain requires a significant amount of further study and in my opinion would be fertile ground for federally funded requested projects.

Editorial↗
PubMed2001

Developing and implementing measures of quality of care in the intensive care unit.

As consumers, payers, and regulatory agencies require evidence regarding quality of care, the demand for intensive care unit (ICU) quality measures will likely grow. ICU providers and professional societies may need to partner with experts in quality measurement to develop and implement quality measures. This essay outlines the steps for developing and implementing quality measures and provides examples of potential ICU quality indicators. Outcome measures, in particular mortality rates, require risk adjustment, making data collection burdensome and broad implementation unlikely. On the other hand, structure and process measures may be feasible to implement broadly. Given the steps for developing quality measures outlined in this essay and the growing evidence in the literature regarding the impact of ICU care, the future should realize the development and implementation of ICU quality indicators that are rigorously developed and provide insights into opportunities to improve the quality of ICU care.

Humans↗
PubMed2001

Impact of critical care physician workforce for intensive care unit physician staffing.

The Society for Critical Care Medicine has advocated for intensivist lead multi-disciplinary critical care for our 30 years; growing evidence supports their assertion. It is estimated that if intensive care unit (ICU) physician staffing (IPS) was implemented in non-rural United States hospitals, 53,000 lives and $5.4 billion would be saved annually. Despite the benefits of hiring physicians specialized in the treatment of critically ill patients, many hospitals worry about their ability to hire critical care physicians to staff their ICUs. In this essay, we discuss issues regarding the future supply of and demand for critical care physicians beginning with an overview of how to evaluate physician supply and demand in general. We then discuss supply and demand for critical care physicians considering emerging issues such as the Leapfrog standard that may impact estimates of the supply and demand for critical care physicians.

Critical Care↗
PubMed2000

Bundle-branch block as a risk factor in noncardiac surgery.

BACKGROUND: Despite extensive data examining perioperative risk in patients with coronary artery disease, little attention has been devoted to the implications of conduction system abnormalities. OBJECTIVE: To define the clinical significance of bundle-branch block (BBB) as a perioperative risk factor. METHODS: Retrospective, cohort-controlled study of all noncardiac, nonophthalmologic, adult patients with BBB seen in our preoperative evaluation center. Medical charts were reviewed for data regarding cardiovascular disease, surgical procedure, type of anesthesia, intravascular monitoring, and perioperative complications. RESULTS: Bundle-branch block was present in 455 patients. Right BBB (RBBB) was more common than left BBB (LBBB) (73.8% vs 26.2%). Three patients with LBBB and 1 patient with RBBB died; 1 patient had a supraventricular tachyarrhythmia. Three of the 4 deaths were sepsis related. There were 2 (0.4%) deaths in the control group. There was no difference in mortality between BBB and control groups (P = .32). Subgroup analysis suggested an increased risk for death in patients with LBBB vs controls (P = .06; odds ratio, 6.0; 95% confidence interval, 1.2-100.0) and vs RBBB (P = .06; odds ratio, 8.7; 95% confidence interval, 1.2-100.0). CONCLUSIONS: The presence of BBB is not associated with a high incidence of postoperative cardiac complications. Perioperative mortality is not increased in patients with RBBB and not directly attributable to cardiac complications in patients with LBBB. These data suggest that the presence of BBB does not significantly increase the likelihood of cardiac complications following surgery, but that patients with LBBB may not tolerate the stress of perioperative noncardiac complications.

Adult↗
PubMed2000

Telemedicine.

Telemedicine began from the humble beginnings of the first telephone call from Alexander Graham Bell to his associate, Watson. These systems already have been used for educational programs, consultative care, image transfer, second opinions, and direct acute patient care. Most of the original programs failed because of several reasons, primarily because of lack of funding when a grant ended. The major lesson of these programs is that a solid business plan is needed initially for long-term survival. The reliability of telemedical examinations has been demonstrated superficially, but more conclusive work in this area is needed. Studies that evaluate clinical, financial, and satisfaction outcomes are required simultaneously. Further integration of medical informatics into telemedicine systems is needed before these systems can achieve more acceptance. Twenty years ago, few people predicted this technologic revolution. Innovations arise almost daily. The future seems promising for telemedical systems, but much work is required. Partnerships with industry must move beyond niche projects, and regulatory and medicolegal issues must be resolved. Anesthesiologists can expect their practice to be affected directly by technology, and should embrace it, evaluate it, and help lead its use in this millennium.

Humans↗
PubMed2000

Survival and functional outcome after prolonged intensive care unit stay.

OBJECTIVE: To examine the functional outcome and costs of a prolonged illness requiring a stay in the surgical intensive care unit (SICU) of 7 of more days. SUMMARY BACKGROUND DATA: The long-term benefits and costs after a prolonged SICU stay have not been well studied. METHODS: All patients with an SICU length of stay of 7 or more days from July 1, 1996, to June 30, 1997, were enrolled. One hundred twenty-eight patients met the entry criteria, and mortality status was known in 127. Functional outcome was determined at baseline and at 1, 3, 6, and 12 months using the Sickness Impact Profile score, which ranges from 0 to 100, with a score of 30 being severely disabled. Hospital costs for the index admission and for all readmissions to Johns Hopkins Hospital were obtained. All data are reported as median values. RESULTS: For the index admission, age was 57 and APACHE II score was 23. The initial length of stay in the ICU was 11 days; the hospital length of stay was 31 days. The Sickness Impact Profile score was 20.2 at baseline, 42.9 at 1 month, 36.2 at 3 months, and 20.3 at 6 months, and was lower than baseline at 1 year. The actual 1-year survival rate was 45.3%. The index admission median cost was $85,806, with 65 total subsequent admissions to this facility. The cost for a single 1-year survivor was $282,618 (1996). CONCLUSIONS: An acute surgical illness that results in a prolonged SICU stay has a substantial in-hospital death rate and is costly, but the functional outcome from both a physical and physiologic standpoint is compatible with a good quality of life.

APACHE↗
PubMed2000

Intensive care unit telemedicine: alternate paradigm for providing continuous intensivist care.

OBJECTIVE: Intensive care units (ICUs) account for an increasing percentage of hospital admissions and resource consumption. Adverse events are common in ICU patients and contribute to high mortality rates and costs. Although evidence demonstrates reduced complications and mortality when intensivists manage ICU patients, a dramatic national shortage of these specialists precludes most hospitals from implementing an around-the-clock, on-site intensivist care model. Alternate strategies are needed to bring expertise and proactive, continuous care to the critically ill. We evaluated the feasibility of using telemedicine as a means of achieving 24-hr intensivist oversight and improved clinical outcomes. DESIGN: Observational time series triple cohort study. SETTING: A ten-bed surgical ICU in an academic-affiliated community hospital. PATIENTS: All patients whose entire ICU stay occurred within the study periods. INTERVENTIONS: A 16-wk program of continuous intensivist oversight was instituted in a surgical ICU, where before the intervention, intensivist consultation was available but there were no on-site intensivists. Intensivists provided management during the intervention using remote monitoring methodologies (video conferencing and computer-based data transmission) to obtain clinical information and to communicate with on-site personnel. To assess the benefit of the remote management program, clinical and economic performance during the intervention were compared with two 16-wk periods within the year before the intervention. MEASUREMENTS AND MAIN RESULTS: ICU and hospital mortality (observed and Acute Physiology and Chronic Health Evaluation III, severity-adjusted), ICU complications, ICU and hospital length-of-stay, and ICU and hospital costs were measured during the 3 study periods. Severity-adjusted ICU mortality decreased during the intervention period by 68% and 46%, compared with baseline periods one and two, respectively. Severity-adjusted hospital mortality decreased by 33% and 30%, and the incidence of ICU complications was decreased by 44% and 50%. ICU length of stay decreased by 34% and 30%, and ICU costs decreased by 33% and 36%, respectively. The cost savings were associated with a lower incidence of complications. CONCLUSIONS: Technology-enabled remote care can be used to provide continuous ICU patient management and to achieve improved clinical and economic outcomes. This intervention's success suggests that remote care programs may provide a means of improving quality of care and reducing costs when on-site intensivist coverage is not available.

APACHE↗
PubMed2000

Automated information systems in anesthesiology.

The current state of the art of anesthesia information systems remains primitive. Currently, available commercial systems focus only at automating the charting process and not the care process. Until systems are available that integrate these two functions, anesthesiologists will not truly benefit from such systems.

Anesthesiology↗