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PubMed2005

Free internet access, the digital divide, and health information.

BACKGROUND: The Internet has emerged as a valuable tool for health information. Half of the U.S. population lacked Internet access in 2001, creating concerns about those without access. Starting in 1999, a survey firm randomly invited individuals to join their research panel in return for free Internet access. This provides a unique setting to study the ways that people who had not previously obtained Internet access use the Internet when it becomes available to them. METHODS: In 2001-2002, we surveyed 12,878 individuals 21 years of age and older on the research panel regarding use of the Internet for health; 8935 (69%) responded. We analyzed respondents who had no prior Internet access, and then compared this group to those who had prior Internet access. RESULTS: Among those newly provided free Internet access, 24% had used the Internet for health information in the past year, and users reported notable benefits, such as improved knowledge and self-care abilities. Not surprisingly, the no-prior-Internet group reported lower rates of using the Internet (24%) than the group that had obtained Internet access prior to joining the research panel (40%), but the 2 groups reported similar perceptions of the Internet and self-reported effects. CONCLUSIONS: Those who obtained Internet access for the first time by joining the panel used the Internet for health and appeared to benefit from it. Access helps explain the digital divide, although most people given free access do not use the Internet for health information.

Access to Information↗

PubMed1994

Access to health care. A conceptual framework and its relevance to health care planning.

Despite some serious past efforts to clarify its multiple dimensions and meanings, access to health care has remained a rather elusive concept, hampering the work of health care policymakers and professionals as they endeavor to effect meaningful health care reform. This article provides perhaps the most detailed clarification of the access concept, especially the crucial linkages among the various access dimensions, and presents a comprehensive conceptual framework for evaluation and planning activities as they relate to people's access to health care services. The proposed conceptual model recognizes access as the outcome of a process involving the interplay between the characteristics of the health care service system and of potential users in a specified area, and moderated by health care related public policy and planning efforts. An elaborate typology of access, incorporating four pairs of access dimensions, is also derived. This atomization of the concept allows us to focus on specific aspects of the access to health care problem, and to develop precise outcome indicators of health system performance for evaluative purposes. Further, it enables the access concept and its pertinent dimensions to be put into proper perspective when assessing the health care access situation in a specific national or regional context. The relevance of the proposed access model and the typology to health care planning in general, and to spatial planning of health care service systems in particular, is also discussed.

Demography↗

PubMed2002

Evaluation of accessibility and use of new communication technologies in patients with type 1 diabetes mellitus.

BACKGROUND: The role of patients in the management and control of type 1 diabetes mellitus, a chronic disease, is well established. The advent of new communication technologies is expected to improve patients' access to health information. However, little is known about the extent to which patients with type 1 diabetes mellitus use the Internet to retrieve medical information and about the impact, if any, this retrieval has on their health status. OBJECTIVE: To evaluate the accessibility and use of new communication technologies in a population of patients with type 1 diabetes mellitus. METHODS: Patients with type 1 diabetes mellitus attending the Diabetes Clinic of the Hospital de Sabadell, Sabadell, Spain, in a 6-month period were asked to answer a structured questionnaire about education level, Internet accessibility, use of health-related Web sites, and mobile-phone ownership and use. RESULTS: Of 302 patients with type 1 diabetes mellitus attending the Diabetes Clinic on a regular basis, 244 (115 men, 129 women) were interviewed (response rate 80.8%). Personal computers were owned by 58.2% of patients. Fifty-nine percent had access to the Internet, 39.3% had access to the Internet at home; however, only 36.5% were regular Internet users. Internet users were younger, more frequently men, and of higher education level. Among Internet users only 49.4% had ever accessed a health-related Web site. Internet users who had ever accessed a health-related Web site had a higher level of education, presented severe hypoglycemia more frequently, and were more likely to have access to the Internet at home. No differences were found in metabolic control between Internet users and nonusers or between Internet users who had ever accessed a health-related Web site and Internet users who had never accessed a health-related Web site. Of the 76.6% of the patients that owned a mobile phone, 96% used it more than once a week. CONCLUSIONS: The impact of new communication technologies might be jeopardized by the low rate of access and utilization of the Internet for health-related purposes. Because of their high rate of ownership and use, mobile phones show promise as a tool in health care communication technologies.

Adult↗

PubMed2002

Family structure, socioeconomic status, and access to health care for children.

OBJECTIVE: To test the hypothesis that among children of lower socioeconomic status (SES), children of single mothers would have relatively worse access to care than children in two-parent families, but there would be no access difference by family structure among children in higher SES families. DATA SOURCES: The National Health Interview Surveys of 1993-95, including 63,054 children. STUDY DESIGN: Logistic regression was used to examine the relationship between the child's family structure (single-mother or two-parent family) and three measures of health care access and utilization: having no physician visits in the past year, having no usual source of health care, and having unmet health care needs. To examine how these relationships varied at different levels of SES, the models were stratified on maternal education level as the SES variable. The stratified models adjusted for maternal employment, child's health status, race and ethnicity, and child's age. Models were fit to examine the additional effects of health insurance coverage on the relationships between family structure, access to care, and SES. PRINCIPAL FINDINGS: Children of single mothers, compared with children living with two parents, were as likely to have had no physician visit in the past year; were slightly more likely to have no usual source of health care; and were more likely to have an unmet health care need. These relationships differed by mother's education. As expected, children of single mothers had similar access to care as children in two-parent families at high levels of maternal education, for the access measures of no physician visits in the past year and no usual source of care. However, at low levels of maternal education, children of single mothers appeared to have better access to care than children in two-parent families. Once health insurance was added to adjusted models, there was no significant socioeconomic variation in the relationships between family structure and physician visits or usual source of care, and there were no significant disparities by family structure at the highest levels of maternal education. There were no family structure differences in unmet needs at low maternal education, whereas children of single mothers had more unmet needs at high levels of maternal education, even after adjustment for insurance coverage. CONCLUSIONS: At high levels of maternal education, family structure did not influence physician visits or having a usual source of care, as expected. However, at low levels of maternal education, single mothers appeared to be better at accessing care for their children. Health insurance coverage explained some of the access differences by family structure. Medicaid is important for children of single mothers, but children in two-parent families whose mothers are less educated do not always have access to that resource. Public health insurance coverage is critical to ensure adequate health care access and utilization among children of less educated mothers, regardless of family structure.

Adolescent↗

PubMed2005

Household computer and Internet access: The digital divide in a pediatric clinic population.

Past studies have noted a digital divide, or inequality in computer and Internet access related to socio-economic class. This study sought to measure how many households in a pediatric primary care outpatient clinic had household access to computers and the Internet, and whether this access differed by socio-economic status or other demographic information. We conducted a phone survey of a population-based sample of parents with children ages 0 to 11 years old. Analyses assessed predictors of having home access to a computer, the Internet, and high-speed Internet service. Overall, 88.9% of all households owned a personal computer, and 81.4% of all households had Internet access. Among households with Internet access, 48.3% had high speed Internet at home. There were significant associations between home computer ownership or Internet access and parental income or education. There was no relationship these factors and high speed Internet access. Over 60% of families with annual household income of $10,000-$25,000, and nearly 70% of families with only a high-school education had Internet access at home. While income and education remain significant predictors of household computer and internet access, many patients and families at all economic levels have access, and might benefit from health promotion interventions using these modalities.

Computers↗

PubMed2005

Primary access-related complications with laparoscopy: comparison of blind and open techniques.

BACKGROUND: Severe or fatal complications attributable to gas embolus, major vascular injury, or visceral injury are rare but have been reported after blind access to the abdominal cavity in laparoscopy. The open access technique has been introduced with the aim to reduce these injuries. This report evaluates access-related complications with both blind and open access techniques in a teaching hospital using standardized techniques for both methods. METHODS: Two groups of patients at different times from a prospective database were compared. A retrospective analysis of 2,297 patients treated using blind access between 1992 and 1996 were compared with 2,066 patients treated using open step-by-step access between 1999 and 2001 regarding access-related complications. An accreditation program for both techniques was mandatory for the 67 surgeons involved. RESULTS: No case of gas embolus or major vascular injury was seen in either group. Four cases of visceral injuries (0.17%) in the blind access group and one case (0.05%) in the open group were seen (p = 0.337). All the injuries were recognized and repaired intraoperatively with no further postoperative complications. CONCLUSION: Our educational efforts to make both techniques as safe as possible were successful, as evidenced by a minimum of access-related complications. Because no evidence exists to show that the blind access technique is superior in any aspect, the open technique is recommended for access to the abdominal cavity in laparoscopy.

Adolescent↗

PubMed2005

Experience with autogenous arteriovenous access for hemodialysis in children and adolescents.

The National Kidney Foundation's DOQI-NKF recommendation to construct an autogenous arteriovenous access (AAVA) for chronic hemodialysis whenever possible can be a challenge in the pediatric population. This report reviews recent surgical experience in this patient subgroup. From March 1999 to April 2004, 47 consecutive children requiring permanent vascular access had construction of AAVA. There were 16 girls and 31 boys, with a mean age of 14.6 years (range 5-20). The surgeon preoperatively mapped veins with ultrasound in all patients. Access sites were radial-cephalic (n = 16), upper arm brachial-cephalic (n = 15), transposed upper arm brachial-basilic (n = 7), and transposed femoral vein (n = 9). An operating microscope was used to construct three radial-cephalic accesses in individuals with small arteries. Three forearm cephalic veins were transposed (one at the original surgical procedure and two postoperatively). Five upper arm cephalic veins were transposed (three at the original surgical procedure and two postoperatively). Femoral vein accesses were constructed for either exhausted access in the upper extremities (n = 7) or patient preference (n = 2). Primary patency at 1 and 2 years was 100% and 96%, respectively. Secondary patency at 1 and 2 years was 100%. One individual with a radial-cephalic AAVA and severe radial artery calcification required an inflow procedure. Thirty-five accesses are currently in use (functionally patent), eight are in individuals with successful renal transplants, and two are maturing; one individual declines using the access. Two accesses are secondarily patent (thrombosed and repaired 12 and 29 months after construction, respectively), and one access thrombosed after 27 months (abandoned). Construction of an AAVA is possible in virtually all pediatric age individuals if attention is given to preoperative vein mapping, selective use of an operating microscope, and creation of a transposed femoral vein when upper extremity access is neither possible nor desired.

Adolescent↗

PubMed2007

Perceptions and behaviour of access of the Internet: a study of women attending a breast screening service in Sydney, Australia.

OBJECTIVES: To describe the perceptions and behaviour in accessing health information from the Internet by women attending a BreastScreen, New South Wales (NSW) Service in Northern Sydney. DESIGN: Cross-sectional study. SETTING: A BreastScreen NSW Service in Northern Sydney. MAIN OUTCOME MEASURES: Behaviour and perceptions of accessing of the Internet for breast health and screening information and other related health information. PARTICIPANTS: Four hundred and fifteen women aged > or =40 years who had a screening mammogram at a BreastScreen NSW Service in Northern Sydney. Data were collected from 1 October to 22 December 2004 (study interval). RESULTS: Four hundred and sixty-one eligible women were invited to participate in the study and of these 415 women agreed to participate in the study (participation rate=90%). Of the 415 women enrolled in the cohort, 80% (333/415) of women accessed the Internet in general and 62% (205/333) of the women who accessed the Internet also accessed health related information from the Internet, but only 7% of the total women accessed breast health and screening information from the Internet. Two hundred and eighty (70%) women in the cohort expressed their intention to access the Internet if they were diagnosed with breast cancer. Age (OR=0.94; 95% CI=0.91-0.97), marital status (OR=2.65; 95% CI=1.45-4.83), educational status (OR=3.26; 95% CI=1.77-6.02) and behavioural intention of accessing the Internet if diagnosed with breast cancer (OR=3.31; 95% CI=1.83-5.98) were found to be associated with access of Internet for general information. Furthermore, behavioural intention (OR=2.43; 95% CI=1.30-4.55), rating of computer skills as 'average' (OR=0.42; 95% CI=0.22-0.79) and 'not good to poor' (OR=0.23; 95% CI=0.11-0.49) were found to be associated with access of health related information from the Internet. CONCLUSIONS: Information searching from the Internet is common among women having a screening mammogram. There is potential to provide guidance to women regarding accessing the BreastScreen NSW website and other reliable sources of Internet information on breast health, breast screening and cancer-related information.

Aged↗

PubMed1998

Mitral valve operation via Port Access versus median sternotomy.

OBJECTIVE: The advantages and disadvantages of minimally invasive Port Access mitral valve operation have not been defined relative to standard median sternotomy. A study was therefore designed to delineate differences in outcome from mitral operation via Port Access versus sternotomy in comparable patients. METHODS: The records of 41 consecutive patients undergoing isolated mitral valve replacement (n = 14) or repair (n = 27) were examined. All operations were performed using cardioplegic arrest through either median sternotomy (n = 20) or a small right anterolateral thoracotomy using an endoaortic clamp and catheter system (Heartport, Redwood City, CA) to arrest and decompress the heart (Port Access, n = 21). RESULTS: Both groups were well matched for age, mitral pathology, ejection fraction, and comorbidity. except that Port Access patients were less likely to be female. Three patients had undergone previous cardiac operations. Surgical procedure time was longer for Port Access patients (384+/-80 vs. 263+/-41 min, P < 0.05). Port Access provided significantly smaller incision length (8+/-2 vs. 26+/-2 cm, P < 0.01) and similar or shorter hospital stay (6+/-4 vs. 7+/-3 days). Port Access provided excellent visualization of the mitral valve and subvalvular apparatus, generally better than sternotomy, to allow complex mitral valve repairs. The greatest advantage of Port Access mitral operation was that Port Access patients returned to normal activity more rapidly (4+/-2 vs. 9+/-1 weeks, P = 0.01) than did patients undergoing standard median sternotomy. CONCLUSIONS: By avoiding a sternotomy, Port Access mitral valve operation provided a smaller incision and a dramatically more rapid return to normal activity than did median sternotomy. Port Access cardioplegic arrest with the Heartport system allowed visualization of the mitral valve superior to median sternotomy and has become the standard approach at this institution.

Case-Control Studies↗

PubMed2000

Prevalence of youth access to alcohol, guns, illegal drugs, or cigarettes in the home and association with health-risk behaviors.

PURPOSE: To describe the prevalence of access to alcohol, guns, drugs, or cigarettes in the home and its association with related health-risk behaviors among adolescents.METHODS: We analyzed cross-sectional data from the 1995 in-home survey of the National Longitudinal Study on Adolescent Health which used a nationally representative school-based sample (N = 6,504) of adolescents in grades 7-12. We used logistic regression analysis, adjusted for gender, race/ethnicity and age, to examine the associations between access to alcohol, guns, drugs, and cigarettes in the home and the practice of risk behaviors involving those variables.RESULTS: Overall, 1,817 (28%) adolescents reported having easy access to alcohol in the home, 1,616 (25%) had access to a gun, 189 (3%) had access to drugs, and 2,067 (32%) had access to cigarettes. Associations were found between easy home access to alcohol and drinking during the past 12 months (Adj. OR = 2.16, 95% CI = 1.89-2.47), ever being drunk at school (Adj. OR = 2.33, 95% CI = 1.85-2.95, and ever driving drunk (Adj. OR = 1.64, 95% CI = 1.29-2.09). Access to a gun at home was associated with carrying a gun to school (Adj. OR = 2.54, 95% CI = 1.40-4.64). Associations were also found between access to drugs and cigarettes in the home and ever using drugs and smoking regularly.CONCLUSIONS: Easy access to alcohol, guns, and cigarettes in the home is prevalent among adolescents and may increase involvement in risky behaviors. Limiting access therefore is important in order to reduce the occurrence of health-risk behaviors associated with substance use, deliquency and injury among adolescents.

Journal Article↗

PubMed2001

Effect of access cavity location and design on degree and distribution of instrumented root canal surface in maxillary anterior teeth.

AIM: The null hypothesis tested in this study was that in single-rooted anterior teeth with simple root canal anatomy, different access cavity designs ('lingual cingulum', 'lingual conventional', 'incisal straight-line') do not influence the ability of endodontic files to plane the walls of the root canals. METHODOLOGY: Thirty extracted human maxillary anterior teeth were divided randomly into three groups for each access cavity. The access cavities were prepared according to predefined criteria and the roots embedded in individual polyvinyl-siloxane putty matrices. The matrices allowed these teeth to be split into buccal and palatal halves and to be reassembled. The split teeth enabled removal of pulpal remnants from the root canal system and the walls to be stained with an even layer of permanent black ink. Once dried, the split roots were reassembled in the putty matrices and a step-back filing technique was used to prepare the canals with water irrigation. The canal walls were examined for residual ink staining and scored by three independent assessors using an index devised for the purpose. RESULTS: There was good agreement between the assessors. None of the access cavities allowed file contact with the entire root canal wall. The overall (palatal and buccal sections) scores showed significant differences (P < 0.01) between the access cavity groups in the extent to which the canal walls could be filed. The straight-line incisal access cavity had the greatest proportion of instrumented root canal surface. The lingual cingulum access cavity was the worst in this respect. The differences in residual ink scores between the access cavity types were significant for the buccal halves (P < 0.01) but not for the palatal halves (P > 0.05). CONCLUSIONS: The null hypothesis was proven. Regardless of access cavity design, mechanical preparation did not allow instrumentation of the entire root canal wall. Straight-line access allowed the greatest proportion of the root canal wall to be instrumented and the lingual cingulum access the least.

Chi-Square Distribution↗

PubMed1999

Hyperhomocysteinemia, anticardiolipin antibody status, and risk for vascular access thrombosis in hemodialysis patients.

BACKGROUND: Vascular access failure is an important cause of morbidity in end-stage renal failure patients on hemodialysis. Currently, little is known about risk factors that predispose certain hemodialysis patients to recurrent access thrombosis. Hyperhomocysteinemia (common in patients with renal failure) predisposes people with normal renal function to recurrent and early-onset venous thrombosis, although the effect on vascular access thrombosis is currently unknown. Previous studies have suggested that high titers of IgG anticardiolipin antibody (IgG-ACA) predispose hemodialysis patients to access thrombosis. This cross sectional study was designed to assess for an association between two predictive variables, hyperhomocysteinemia and elevated titers of IgG-ACA, and vascular access thrombosis in patients undergoing chronic hemodialysis. METHODS: Risk factors for vascular access thrombosis were documented, and the number of episodes of access thrombosis was recorded for the previous three years in patients undergoing hemodialysis. Midweek predialysis total homocysteine and IgG-ACA levels were measured in all subjects. RESULTS: Of the 118 patients who were enrolled, 75.4% had a native arteriovenous fistula. Episodes of vascular access thrombosis were recorded for the previous three years; 34 (28.8%, 95% CI 20.9 to 37.9%) patients had 72 episodes of access thrombosis over the period of risk. Mean homocysteine levels were not significantly different between these 34 patients (28.6 micromol/liter, 95% CI 24.5 to 32.7) and the patients who had no episodes of graft thrombosis (29.8 micromol/liter, 95% CI 26.7 to 32.9). Sixty-seven unselected patients had IgG-ACA levels drawn for analysis, and all assays were negative. The only variable that was associated with a higher risk for graft thrombosis was the type of vascular access placed (odds ratio 4.0, 95% CI 1.6 to 9.6 for patients with a synthetic graft compared with those with an arteriovenous fistula). CONCLUSIONS: No association was found between homocysteine levels or anticardiolipin antibody and vascular access thrombosis in our patient population.

Antibodies, Anticardiolipin↗

PubMed2001

Infectious complications of the hemodialysis access.

Infectious complications of the vascular access are a major source of morbidity and mortality among hemodialysis (HD) patients. Numerous reports implicate the vascular access in up to 48 to 73% of all bacteremias in HD patients. The incidence of vascular access-related infection is highest when central venous dialysis catheters are employed. Native arteriovenous fistulas carry the lowest risk of infection. Unfortunately, prosthetic arteriovenous grafts, which represent the most common type of HD access in the United States, have been repeatedly shown to be a risk factor for bacteremic and nonbacteremic infections. Silent infection in old nonfunctional clotted prosthetic arteriovenous grafts has recently been recognized as a frequent cause of bacteremia and morbidity among HD patients. High proportions of infections related to the vascular access are caused by staphylococcal organisms, which carry high rates of mortality, recurrence, and metastatic complications. Management of vascular access-related infection has two aspects: The first relates to the choice, duration, and mode of administration of antibiotic therapy. Empiric antibiotic therapy, guided by demographic data and severity of illness, should be employed when the causative organisms are unknown. Prolonged administration of specific parenteral antibiotics is crucial in decreasing complications of infection, especially in cases of staphylococcal bacteremia. The second aspect relates to management of the vascular access. Efforts directed toward bacteriological cure should be concurrent with efforts to preserve native venous access sites whenever possible. Efforts to prevent vascular access-related infection should focus on increasing placement of arteriovenous fistulas and minimizing insertion of central venous dialysis catheters. Careful inspection and monitoring of the vascular access is of paramount importance in early detection of vascular access site-related infections. Several new approaches aimed at preventing catheter and prosthetic graft-related infection are being explored.

Anti-Bacterial Agents↗

PubMed2001

Analysis of variable flow Doppler hemodialysis access flow measurements and comparison with ultrasound dilution.

The variable flow (VF) Doppler method determines access blood flow from the pump speed-induced change in Doppler signal between the arterial and venous needles. This study evaluated 35 patients in two analyses to assess VF Doppler measurement reproducibility (54 paired measurements) and compared VF Doppler and ultrasound dilution flow measurements (24 paired measurements). VF Doppler measurement variations were 4% for access flow less than 800 mL/min (n = 17), 6% for access flow of 801 to 1,600 mL/min (n = 22), and 11% for access flow greater than 1,600 mL/min (n = 15). The mean measurement coefficient of variation was 7% for VF Doppler compared with 5% for ultrasound dilution. Correlation coefficients (r) between VF Doppler and ultrasound dilution access flow measurements were 0.79 (n = 24; P < 0.0001), 0.84 for access flow less than 2,000 mL/min (n = 20; P < 0.0001), and 0.91 for access flow less than 1,600 mL/min (n = 18, P < 0.0001). VF Doppler measurements using indicated versus measured pump flow rates correlated highly (r = 0.99; P < 0.0001). VF Doppler therefore yields reproducible access volume flow measurements that correlate with ultrasound dilution measurements. The VF Doppler method is dependent on the pump-induced change in access Doppler signal and therefore is inherently most accurate and reproducible at lower access blood flow rates. This method appears capable of determining access flow rates in the clinically useful range.

Blood Flow Velocity↗

PubMed2002

Hemodialysis vascular access survival: upper-arm native arteriovenous fistula.

Achieving Dialysis Outcomes Quality Initiative guidelines for native arteriovenous fistulae using the radiocephalic forearm fistula (lower-arm fistula [LAF]) is difficult. This study reports results using the upper-arm native arteriovenous fistula (UAF). From a prospective access database (1992 to 1998), this study was based on 204 patients (322 accesses). Average patient age was 56 +/- 1 years, 63% were men, and 47% had diabetes. A native fistula was the first access in 73% of patients (36%, LAFs; 37%, UAFs) and accounted for 48% of subsequent accesses (13%, LAFs; 35%, UAFs). Younger men were more likely to receive an LAF, but there was no demographic difference between patients receiving a UAF or arteriovenous graft (AVG). Both primary unassisted and cumulative access patencies were significantly better for UAFs than either LAFs or AVGs. For first accesses, cumulative access patency rates at 1, 3, and 5 years were 71%, 57%, and 57% for UAFs; 54%, 46%, and 36% for LAFs; and 54%, 28%, and 0% for AVGs (P < 0.01). Despite shorter access survival, AVGs required more total access procedures than either UAFs or LAFs (procedures per access: 2.5, 1.0, and 0.6 for AVGs, UAFs, and LAFs, respectively). When used, catheters were required for dialysis for a longer time for UAFs (median catheter days, 36, 53, and 56 for AVGs, LAFs, and UAFs, respectively; P < 0.05). Access flow rates were greater in UAFs (1,247 mL/min; n = 48; P < 0.01) than AVGs (851 mL/min; n = 30) or LAFs (938 mL/min; n = 31). There was no evidence that UAFs were banded or ligated for steal syndromes or heart failure more often than AVGs or LAFs. These results show that the UAF is a good alternative to an AVG for achieving Dialysis Outcomes Quality Initiative guidelines.

Analysis of Variance↗

PubMed2002

Recommended standards for reports dealing with arteriovenous hemodialysis accesses.

The incidence rate of treated end-stage renal disease in the united states is 180 per million and continues to rise at a rate of 7.8% per year. Arteriovenous hemodialysis access (AV access) creation and maintenance are two of the most difficult issues associated with the management of patients on hemodialysis. The 1-year complication rate of a primary prosthetic AV access for hemodialysis ranges from 33% to 99%. Various investigators report on patency and complications of AV access. However, it is rather difficult to compare outcomes because of the wide variety of access materials, configurations, locations, risk factors, and quality of inflow and outflow vessels. Although there have been reporting standards for dialysis access endovascular interventions and for central venous access placement, standards regarding surgical access placement and its revision are lacking. The "Dialysis Outcome Quality Initiative," published by the National Kidney Foundation, provides recommendations for optimal clinical practices aimed at improving dialysis outcome and patient survival. This reporting standards document is not meant to be a "practice guidelines" or "best practices" document. Rather, the purpose of this document is to provide standardized definitions related to AV access procedures and to recommend reporting standards for patency and complications, to be used by surgeons, nephrologists, and interventional radiologists, that will permit meaningful comparisons among AV access procedures. The terms, definitions, and categories featured in this article have been approved by the Committee on Reporting Standards of the Society for Vascular Surgery and the American Association for Vascular Surgery and should be observed in preparing manuscripts on AV accesses for submission to the Journal Of Vascular Surgery.

Arteriovenous Shunt, Surgical↗

PubMed2004

Prospective randomized trial comparing high lumbotomic with laparotomic access in renal cell carcinoma surgery.

OBJECTIVE: We compared laparotomic with lumbotomic access in renal cell carcinoma (RCC) surgery by means of a prospective randomized trial, in order to evaluate differences in surgical time, blood loss, number of lymph nodes removed, duration of postoperative ileus and hospitalization, perioperative complications and progression-free and cancer-specific survival rates. MATERIAL AND METHODS: Between November 1991 and November 1996, 94 patients with RCC were recruited and randomly assigned to undergo surgery by lumbotomic (n = 50) or laparotomic (n = 44) access. All patients underwent radical nephrectomy and lymph node dissection. RESULTS: The mean surgical time was 59.1 min (range 20-140 min) and 84.4 min (range 40-180 min) for lumbotomic and laparotomic access, respectively (p < 0.01). Blood loss was 502 ml (range 200-1800 ml) for lumbotomic and 648 ml (range 200-2000 ml) for laparotomic access (p < 0.005). Mean hospital stay was 6.8 days (range 3-13 days) for lumbotomic and 8.2 days (range 5-15 days) for laparotomic access (p < 0.001). The perioperative complication rates were 6.1% and 13.6% for lumbotomic and laparotomic access, respectively. After a mean follow-up period of 7.5 years, cancer-specific and progression-free survival rates were 88% and 75%, respectively for lumbotomic and 88% and 72.7%, respectively for laparotomic access (p = NS). Multivariate analysis of risk factors showed that pathological stage was the best prognostic indicator of tumor progression, while other variables (age, tumor grade, surgical access, tumor size and incidental diagnosis of tumor) were not predictive of the prognosis of patients with RCC. CONCLUSIONS: During radical nephrectomy, control of the renal vessels is easier and faster with high lumbotomic access. The suggested risk of tumor cell spread due to manipulation of the kidney before vessel ligature was not confirmed in our study. Because of the shorter surgical time, lower blood loss, lower perioperative and late complication rates and shorter hospital stay involved, lumbotomic access should be preferred to laparotomic access in radical nephrectomy for RCC.

Adult↗

PubMed2005

The effects of the spread of hatch and interaction with delayed feed access after hatch on broiler performance until seven days of age.

Delay in access to feed for 1-d-old chicks impairs posthatch growth. It is a standard practice that 1-d-old chicks are deprived of feed for about 48 h before they are placed on farms. During incubation, there is a spread of 24 to 48 h for late versus early hatching. As spread of hatch increases, number of chicks that are feed-deprived for a longer time before free access (IA) to feed and water increases. In this current study, we investigated the effects of time delay in feed access on chick juvenile relative growth (RG: a measure of speed of growth) up to d 7, taking into consideration the duration of egg storage and spread of hatch. Our results confirmed that delay in feed access caused weight loss during holding time and depressed growth rate after access to feed. The magnitude of the effect depended on the hatching period within the hatching window. It also depended on whether the biological age (BA) or the chronological age (CA) of the chick was considered. Immediate access to feed produced significantly different results depending on CA or BA. Both ways, the method seemed to benefit the late hatchers. This finding contrasts with the effect of delayed feeding in which early hatchers benefited more. Long duration of egg storage depressed RG not only of chicks with immediate access to feed but also in those denied access after hatch. Delay in feed access significantly aggravated the effects of long egg storage duration on RG. Triiodothyronine levels were lower in feed-deprived chicks, and the effect was greater in late hatchers. It is concluded that the beginning of delay in feed access should be determined from the time of hatch not at the end of hatch. It is suggested that the adverse effects of delay in feed access can be reduced by providing a source of energy in hatching baskets or during transportation.

Aging↗