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Biomedical subjects

W H Edwards

Publications and source records attributed to W H Edwards.

At least 19 recordsLinked to original sources
PubMed2001

Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Patient demographic and clinical information for infants with birth weight 501 to 1500 g was collected using the Vermont Oxford Network Database for January 1, 1994 to December 31, 1997. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Sixty-six other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (n = 3063) and the 66 comparison NICUs (n = 21 509); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (n = 738). INTERVENTIONS: NICUs formed multidisciplinary teams that worked together under the direction of a trained facilitator over a 3-year period beginning in January 1995. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: The rates of infection after the third day of life with coagulase-negative staphylococcal or other bacterial pathogens for infants with birth weight 501 to 1500 g, and the rates of oxygen supplementation or death at 36 weeks' adjusted gestational age for infants with birth weight 501 to 1000 g. RESULTS: Between 1994 and 1996, the rate of infection with coagulase-negative staphylococcus decreased from 22.0% to 16.6% at the 6 project NICUs in the infection group; the rate of supplemental oxygen at 36 weeks' adjusted gestational age decreased from 43.5% to 31.5% at the 4 NICUs in the chronic lung disease group. There was heterogeneity in the effects among the NICUs in both project groups. The changes observed at the project NICUs for these outcomes were significantly larger than those observed at the 66 comparison NICUs over the 4-year period from 1994 to 1997. CONCLUSION: We conclude that multidisciplinary collaborative quality improvement has the potential to improve the outcomes of neonatal intensive care.

Chronic Disease↗
PubMed2001

Economic implications of neonatal intensive care unit collaborative quality improvement.

OBJECTIVE: To make measurable improvements in the quality and cost of neonatal intensive care using a multidisciplinary collaborative quality improvement model. DESIGN: Interventional study. Data on treatment costs were collected for infants with birth weight 501 to 1500 g for the period of January 1, 1994 to December 31, 1997. Data on resources expended by hospitals to conduct this project were collected in a survey for the period January 1, 1995 to December 31, 1996. SETTING: Ten self-selected neonatal intensive care units (NICUs) received the intervention. They formed 2 subgroups (6 NICUs working on infection, 4 NICUs working on chronic lung disease). Nine other NICUs served as a contemporaneous comparison group. PATIENTS: Infants with birth weight 501 to 1500 g born at or admitted within 28 days of birth between 1994 and 1997 to the 6 study NICUs in the infection group (N = 2993) and the 9 comparison NICUs (N = 2203); infants with birth weight 501 to 1000 g at the 4 study NICUs in the chronic lung disease group (N = 663) and the 9 comparison NICUs (N = 1007). INTERVENTIONS: NICUs formed multidisciplinary teams which worked together to undertake a collaborative quality improvement effort between January 1995 and December 1996. They received instruction in quality improvement, reviewed performance data, identified common improvement goals, and implemented "potentially better practices" developed through analysis of the processes of care, literature review, and site visits. MAIN OUTCOME MEASURES: Treatment cost per infant is the primary economic outcome measure. In addition, the resources spent by hospitals in undertaking the collaborative quality improvement effort were determined. RESULTS: Between 1994 and 1996, the median treatment cost per infant with birth weight 501 to 1500 g at the 6 project NICUs in the infection group decreased from $57 606 to $46 674 (a statistical decline); at the 4 chronic lung disease hospitals, for infants with birth weights 501 to 1000 g, it decreased from $85 959 to $77 250. Treatment costs at hospitals in the control group rose over the same period. There was heterogeneity in the effects among the NICUs in both project groups. Cost savings were maintained in the year following the intervention. On average, hospitals spent $68 206 in resources to undertake the collaborative quality improvement effort between 1995 and 1996. Two thirds of these costs were incurred in the first year, with the remaining third in the second year. The average savings per hospital in patient care costs for very low birth weight infants in the infection group was $2.3 million in the post-intervention year (1996). There was considerable heterogeneity in the cost savings across hospitals associated with participation in the collaborative quality improvement project. CONCLUSION: Cost savings may be achieved as a result of collaborative quality improvement efforts and when they occur, they appear to be sustainable, at least in the short run. In high-cost patient populations, such as infants with very low birth weights, cost savings can quickly offset institutional expenditures for quality improvement efforts.

Chronic Disease↗
PubMed2000

Emollient ointment for preventing infection in preterm infants.

BACKGROUND: This section is under preparation and will be included in the next issue. OBJECTIVES: To assess the effect of prophylactic application of emollient ointment in preterm infants. SEARCH STRATEGY: Searches were made of the Oxford Database of Perinatal Trials, Medline (MeSH terms: ointment; limits: age groups, newborn infant; publication types, clinical trial), previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, and journal handsearching in the English language. SELECTION CRITERIA: Randomized controlled trials which compared the effect of prophylactic application of emollient ointment to routine care or as needed topical therapy in preterm infants are included in this review. DATA COLLECTION AND ANALYSIS: Data regarding clinical outcomes including transepidermal water loss, skin condition, fluid intake, suspect infection and proven nosocomial infection were excerpted from the reports of the clinical trials by the reviewers. Data analysis was done in accordance with the standards of the Cochrane Neonatal Review Group. MAIN RESULTS: Two randomized trials which compared prophylactic application of ointment to routine skin care or as needed topical ointment therapy were identified. Lane (1993) noted improved skin condition in infants receiving topical application of emollient ointment. In the study of Nopper and coworkers (1996), prophylactic application of ointment significantly decreased transepidermal water loss during the first six hours after initial application. Skin condition was noted to be improved during the first 1-2 weeks. Surveillance cultures demonstrated less bacterial colonization during the two week study. A significant decrease in suspect and proven infection was noted. Fewer infants were evaluated for sepsis among the group who received prophylactic application of ointment (relative risk 0. 50, 95% CI 0.27, 0.93; risk difference -0.30, 95% CI -0.54, -0.06). Both studies reported on the incidence of proven nosocomial infection. A trend towards a decrease in the risk of proven nosocomial infection was noted in infants who received prophylactic application of emollient ointment (typical relative risk 0.29, 95% CI 0.07, 1.16, typical risk difference -0.13, 95% CI -0.25, -0.01). REVIEWER'S CONCLUSIONS: In two small studies, prophylactic application of emollient ointment decreased transepidermal water loss, decreased the severity of dermatitis, and decreased the risk of suspect sepsis and proven sepsis. Further clinical studies are warranted to validate these results.

Cross Infection↗
PubMed2000

Vertebral-carotid transposition.

In the early years of evaluating patients with cerebral disease, the origins of the vertebral and subclavian arteries were not routinely visualized. Surgical intervention was more formidable then, and most symptoms were thought to be relieved by corrective carotid surgery. The continued occurrence of nonhemispheric symptoms in some patients, coupled with better techniques of diagnosis and improved surgical techniques, prompted the complete angiographic evaluation of total cerebral flow in all patients evaluated for cerebral symptoms. When carotid endarterectomy did not relieve hind brain symptoms, whether there was significant decreased vertebral flow, and whether surgical was indicated, could then be determined. Most vertebral artery occlusive disease is located near its origin and can be relieved by vertebral carotid transposition. The operative technique is described in this article along with pertinent anatomy and historical perspectives.

Anastomosis, Surgical↗
PubMed1999

An assessment of the current applicability of the EVT endovascular graft for treatment of patients with an infrarenal abdominal aortic aneurysm.

OBJECTIVE: To determine the percentage of elective abdominal aortic aneurysms (AAAs)/aortoiliac aneurysms that currently can be repaired with endovascular grafts (EVGs), the reasons for rejection of EVGs, and the future role of EVG in the treatment of AAA. METHODS: From January 1997 to May 1998, patients at three hospitals (a university hospital, a university-affiliated teaching hospital, and a Veterans Administration hospital with university faculty and residents) were evaluated for EVGs as part of a national clinical trial with grafts manufactured by Endovascular Technologies (EVT, Menlo Park, Calif). All patients at two hospitals and patients treated by the participating surgeons at the third hospital were screened for EVG. Patients with AAAs that were ruptured, symptomatic, or involved renal or mesenteric arteries and patients who declined treatment were excluded from the study. Evaluation included clinical examination, computed tomography scan, and selective arteriography. The decision to proceed with EVG was made by the vascular surgeon, with input and concurrence of medical personnel from a company with extensive experience in endograft repair. The main outcome measures were the determination of the percentage of elective AAAs currently being treated with an EVG and the reasons for exclusion of patients from EVG placement. RESULTS: A total of 162 patients underwent elective treatment of an AAA, 22 (14%) with an EVG (14 bifurcated, eight tube) and 140 (86%) with traditional resection. Indications for not proceeding with an EVG included insufficient proximal cuff in 29 patients (21%), distal common iliac aneurysm or insufficient distal iliac neck in 29 patients (21%), proximal neck too large for an EVG in 24 patients (17%), symptomatic iliac stenosis in 23 patients (16%), iliac stenosis precluding introducer passage in 17 patients (12%), patient preference in 11 patients (8%), and calcification, kink, or extensive thrombus involving the proximal neck precluding safe graft attachment in seven patients (5%). Of the 22 patients treated with an EVG, three were converted to open resection, because of iliac stenosis in two patients and premature stent deployment in one patient (initial technical success rate, 86%). CONCLUSION: Based on currently available technology, 80% of patients were not candidates for an EVG because of proximal calcification, short aortic or distal cuff, coexisting distal iliac aneurysm, and stenotic iliac disease. Even with the use of adjunctive procedures, most patients still require open repair. Significant changes in design will be necessary to apply these devices to most patients with an AAA.

Aortic Aneurysm, Abdominal↗
PubMed1999

The New Hampshire Perinatal Program: twenty years of perinatal outreach education.

OBJECTIVE: To describe 20 years of regional outreach education by the New Hampshire Perinatal Program, its interaction with all 26 community hospitals in the state with maternity services and an additional four in adjoining Vermont. STUDY DESIGN: This paper describes educational initiatives responsive to the needs of perinatal physicians and nurses. The core of the program is the transport conference held annually at each referring hospital in which maternal-fetal and infant referrals are discussed. There are additional community hospital-based programs, programs at convenient locations in the region and medical center conferences and skills programs. RESULTS: The program annually awards 10,000 continuing medical education credits (CME) and nursing contact hours. Evaluation and feedback from all participants is encouraged. New Hampshire has one of the lowest perinatal mortality rates in the county, which reflects in part the accomplishments of the program. CONCLUSION: Perinatal outreach education is a shared responsibility of providers in both the academic center and community hospitals and is necessary to ensure optimal care for mothers and infants.

Community-Institutional Relations↗
PubMed1999

Management of neuropathic fractures in the foot and ankle.

Neuroarthropathy, a rapid, painless destructive process, has become increasingly prevalent among long-lived diabetic patients. It is characterized by warm, swollen joints with a grossly disorganized radiographic appearance, in spite of which the patient is often pain-free. Neglect of this condition results in progressive deformity or instability, often complicated by ulceration and infection, which can ultimately result in loss of independent mobility, loss of the affected limb, and even death. In most cases, a plantigrade, stable, and functional foot can be achieved with simple nonoperative techniques, such as the use of a total-contact cast or shoe modification. A few patients in whom uncontrolled instability or major osseous prominences cause recurrent ulceration will require reconstructive surgery (either exostectomy or osteotomy/arthrodesis). Although some patients will have an improvement in function, ongoing vigilance is necessary.

Amputation, Surgical↗
PubMed1999

Bifurcated devices in the treatment of abdominal aortic aneurysms: limitations and advantages of a single-component bifurcated prosthesis.

Currently, prostheses for endovascular repair of abdominal aortic aneurysms are divided into 2 device categories. Endoprostheses based on the first approach arise from the concept that endovascular grafting should ideally mimic standard surgical repair of abdominal aortic aneurysms. The second category of devices developed from a design strategy that was a conceptual outgrowth of transcathete-based techniques in which an endovascular graft is constructed de novo within the abdominal aorta from modular components. Both grafts are dependent on the successful exclusion of blood flow from the aneurysm sac. Ongoing clinical trials of these 2 categories of devices have yet to be completed with long-term data, but it is apparent even at this early stage that there exist both advantages and limitations to each system. In this review, these issues are discussed for single-component bifurcated endografts within the context of our 5-year experience gained through the use of a bifurcated device produced by Endovascular Technologies, Inc (EVT). Overall, present limitations of the single-component bifurcated prosthesis are related to graft size and the somewhat cumbersome maneuvers required for implantation. Nonetheless, the inherent advantages of these prostheses, including their durability and capacity to respond to aneurysm remodeling without late device failure, may ultimately provide the patient with a prosthesis with superior long-term clinical performance characteristics.

Aged↗
PubMed1997

Technical complications of endovascular abdominal aortic aneurysm repair.

PURPOSE: Results from 34 endovascular repairs of abdominal aortic aneurysms are reviewed to identify technical complications and relate them to anatomic and technical features of the operation. METHODS: Twenty-one patients underwent attempted tube graft repair (mean follow-up, 13 months). Thirteen patients underwent placement of a bifurcated graft (mean follow-up, 7.2 months). RESULTS: Twenty-five patients (74%) underwent repair without technical complication (16 tube graft and nine bifurcated graft). Of five patients who had tube graft complications, two involved small iliac arteries and resulted in arterial injury. One of these patients needed a femorofemoral bypass procedure, and the other required conversion to standard operation. Two patients had distal leaks associated with the attachment system, and one patient had misplacement of the distal attachment system. The two patients who had leaks were followed-up; one required operation after 7 months, whereas the other leak sealed. The patient who had distal attachment system misplacement had a second endograft placed within the first to provide a distal seal. The four patients who had bifurcated graft complications involved two graft limb stenoses, one managed with a Palmaz stent and the other with balloon angioplasty. The patient treated with balloon angioplasty had graft thrombosis 1 week after the operation, which resulted in the need for a femorofemoral bypass procedure. Another bifurcated graft patient had a graft limb twist, which has resulted in chronic claudication. One patient had placement of a limb too proximal in the common iliac artery with chronic leak, and an open operation was performed 18 months later. CONCLUSIONS: Technical complications in this series seem to be associated with short distal necks, small iliac arteries, tortuous iliac arteries, and atherosclerosis at the aortic bifurcation. We believe that experience and understanding of these issues will reduce the risk of these complications in the future.

Aged↗
PubMed1997

Limb ischemia: surgical therapy in acute arterial occlusion.

Mortality and amputation rates from acute arterial occlusion are reported from 7 to 37 per cent and 10 to 30 per cent, respectively. Recent data from thrombolysis or peripheral arterial surgery suggest no significant differences between initial management with surgical or thrombolytic therapy. Mortality and amputation rates were in the above ranges. The last 230 procedures (216 patients) over 10 years were reviewed. All graft occlusions, cardiac catheterization injuries, and aortic balloon-related thromboses were excluded. Immediate and delayed amputation rates were 6.5 and 0.9 per cent. Death occurred in 21 patients (9.7%), with only 6 deaths over the last 6 years (3.8%). Except for transesophageal echocardiography, perioperative studies were of limited value. Long-term anticoagulation was also not effective in preventing recurrent episodes. A mortality rate of 9.7 per cent and amputation rate of 7.4 per cent justifies an early aggressive surgical approach. Limited perioperative studies and less prolonged anticoagulation may also improve cost containment.

Acute Disease↗
PubMed1996

Endovascular grafting of abdominal aortic aneurysms. A preliminary study.

OBJECTIVE: The authors report the experience of a single investigational center involving two Phase I and a Phase II clinical trials approved by the Food and Drug Administration (FDA) for the transfemoral implantation of woven Dacron grafts for abdominal aortic aneurysms. SUMMARY BACKGROUND DATA: In 1993, EndoVascular Technologies, Inc. ([EVT]; Menlo Park, CA), began an FDA-approved clinical trial of repair of abdominal aortic aneurysms by transfemoral placement of a tube endograft. Subsequently, a bifurcated endograft trial was started. This the first single institution report using the EVT endograft for both tube and bifurcated aortic replacement. METHODS: Seventeen patients were enrolled in two Phase I and one Phase II clinical trials. The Phase I tube graft trial and the Phase I bifurcated graft trial were nonrandomized studies. The Phase II tube graft trial consisted of a randomized prospective control trial of open endoaneurysmorrhaphy versus transfemoral placement of an endograft. RESULTS: Seventeen patients were enrolled in the trial. The graft was placed successfully in all but one patient. Five patients randomized to open procedure and one declined to participate. Eleven patients with endografts are available for follow-up. One graft has been explanted for attachment system migration. One patient is a late failure because of persistent filling of the aneurysm sac. CONCLUSION: Transfemoral placement of an endovascular graft is a viable and effective treatment of abdominal aortic aneurysms in the short term. Use of a bifurcated endograft will open the procedure to more patients. The ideal attachment system and graft material await long-term implantation follow-up.

Adult↗
PubMed1996

Resource utilization and pathways: meeting the challenge of cost containment.

The 1990s will bring sweeping changes with managed care and capitation. To address this cost/quality paradox, selective intensive care utilization is coupled with clinical pathways as an innovative change for all patients having cerebral revascularization (CVR) or femoral revascularization (FR). From January 1, 1991 through June 30, 1995, data were accumulated on 2023 procedures in 1524 patients. The study was based on 848 CVRs and 1175 FRs. Intensive care unit (ICU) observation was necessary in 73 patients (3.6%) for cardiac or hypertensive management. Twenty-six patients (1.2%) transported to a vascular surgical floor from the postanesthesia recovery room required return to an ICU for complications during hospitalization. There were nine strokes or transient ischemic attacks (0.4%) in the CVR group, four myocardial infarctions (0.2%), and five perioperative deaths (0.3%). In the FR group, there were 14 deaths (0.9%). Readmission during the perioperative period, 30 days, was necessary in 46 patients (3.1%). Financial cost analysis revealed the mean adjusted cost for CVR in 1990 adjusted to 1995 dollars was $7223. The institution of case management reduced this to $4490 (37.8 per cent reduction in total hospital costs). The cost for FR in 1990 dollars adjusted to 1995 was $14,332 reduced to $5541 (a 59 per cent reduction in total hospital costs). This study suggests the use of clinical pathways does not impair quality of care, leads to no higher morbidity or mortality, and can produce significant cost savings to a hospital.

Aged↗
PubMed1996

Evaluation of the neonatal nurse practitioner role: the next frontier.

The neonatal nurse practitioner (NNP) role at Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, has been in place since 1989. As part of the professional growth and development of this NNP group, the necessity for a useful evaluation instrument emerged. This instrument needed to be congruent with the job description, practice philosophy, and strong commitment to peer review. The literature search and institutional survey failed to uncover an acceptable option, so an evaluation instrument was developed, tested, and refined. This instrument captures the diverse scope of NNP practice and incorporates a continuum of novice to expert competencies based on the work of Patricia Benner. This evaluation mechanism has had a profound effect on our group, encouraging the development of a shared vision of the NNP role and stimulating professional growth.

Clinical Competence↗
PubMed1995

Preliminary experience with the Endovascular Technologies bifurcated endovascular aortic prosthesis in a calf model.

PURPOSE: The purpose of this study was to develop a bifurcated endoluminal prosthesis for transfemoral placement in the aortoiliac position with a large-animal model that would simulate human implantation. METHODS: Fifteen calves (160 to 200 kg) underwent bilateral femoral artery exposure and transfemoral placement in the aortoiliac position of a bifurcated Dacron prosthesis, inserted through a 26F sheath with an over-the-bifurcation guide wire to retrieve the contralateral limb and secured proximally and distally with self-expanding attachment systems. The preferred location was determined before implantation and compared with final implant location by caliper measurements and angiography. Events during implantation, maneuvers used to accomplish accurate deployment, and final results, as judged by angiography and clinical evaluation, were recorded. Four animals survived and were used for chronic evaluation and healing by gross and microscopic studies. RESULTS: All grafts (n = 15) were patent at the end of the procedure. All (n = 7) noncrimped grafts had minor kinks in areas of curvature, whereas eight of eight crimped grafts (device modification) had none. Torque control of the body and individual limbs was necessary to correct twists before deployment in 10 of 15 grafts, with two greater than 30-degree twists remaining, which did not appear to affect flow. One implant was entirely deployed in the aorta because of parallax error, subsequently avoided by use of a marker board placed dorsally. Three premature deployments occurred, corrected by attachment system lock modification. The mean final implant position was within 2.9 +/- 1.4 mm (aortic), 1.6 +/- 1.1 mm, and 1.5 +/- 0.8 mm (contralateral and ipsilateral iliac limbs, respectively) of the intended position. Three of four animals intended for long-term evaluation were killed prematurely because of clinically evident spinal cord ischemia. Histologic sections at 2 weeks showed early wall repair without inflammatory cells and pannus ingrowth across the anastomosis. CONCLUSION: We conclude that implantation of a bifurcated endovascular prosthesis through the bilateral femoral approach is possible, provided the intended aortic implantation site (neck) is at least 12 mm in length (mean +/- 2 SD each direction). Torque control of each portion of the device will be needed in the majority of instances, with attention to parallax effect necessary for optimal placement. This animal model is not suitable for chronic graft evaluation because of its sensitivity for spinal cord ischemia. Healing data suggest graft incorporation similar to that of a surgically placed prosthesis.

Animals↗
PubMed1995

Effects of vesicocolic anastomosis on the proliferation of colonic mucosa in a rat model.

The effects of diverting the urinary stream into a defunctioned segment of the distal colon has been studied in a rat model. Distal rat colon was defunctioned using the Hartmann's procedure and a vesicocolic anastomosis was performed 14 days later. The distal colon was harvested after 10 days following the administration of a vinblastine mitotic block either 1 or 3 h before death. Both the mean crypt cell proliferation and the crypt length were increased significantly in the colonic mucosa exposed to urine when compared with the control defunctioned colon or to the functional unexposed proximal colon. An active fraction was obtained from human urine by elution from a diethylaminoethyl sepharose column using 1 mol/L NaCl. This fraction was administered intraluminally to defunctioned rat colons using Alzet minosmotic pumps. In these animals the crypt cell production rate was significantly increased compared with the control animals. Although the crypt length did not increase significantly in these animals the atrophy normally seen in defunctioned colonic mucosa did not occur. The identity of the active molecule in this urine fraction is still being determined.

Analysis of Variance↗
PubMed1995

An unsuspected cause for recurrent angina: subclavian artery stenosis.

The advantages of internal mammary artery (IMA) grafts over saphenous vein grafts (SVG) for coronary artery bypass grafting have been extensively recorded in the literature. Operative results and postoperative mortality in patients with IMA versus SVG are comparable. The relative risks of thrombosis, however, of an SVG are four to five times greater than an IMA graft, and the probability of recurrent angina or need for reoperation is significantly less in IMA grafted patients. Coltharp et al. also showed that the risks of reoperation for recurrent angina were decreased by a previously constructed IMA graft.

Adult↗