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PubMed1995

Geographic variation in rates of selected surgical procedures within Los Angeles County.

OBJECTIVE: We explore the contribution of income and ethnicity to geographic variation in utilization of surgical procedures. DATA SOURCES/STUDY SETTING: We assessed the use of eight procedures from 1986 through 1988 among residents of Los Angeles County using data from the California Discharge Dataset, the 1980 census, and other secondary sources. Procedures chosen for evaluation were coronary artery bypass grafting (CABG), coronary artery angioplasty, permanent pacemaker insertion, mastectomy, simple hysterectomy, transurethral prostate resection (TURP), carotid endarterectomy, and appendectomy. STUDY DESIGN: The amount of inter-zip code variation for each procedure was first measured using various estimates including the analysis of variance coefficient of variation (CVA). Population-weighted multivariate regression analysis was used to model variation in age- and gender-adjusted rates of procedure use among 236 residential zip codes. PRINCIPAL FINDINGS: Highest-variation procedures were coronary artery angioplasty (CVA = .392) and carotid endarterectomy (CVA = .374). The procedures with the lowest degree of variation were cardiac pacemaker implantation (CVA = .194) and hysterectomy (CVA = .195). Variation was significantly related to income (carotid endarterectomy) and either African American or Latino zip code ethnicity for all procedures except pacemaker implantation. For all procedures except appendectomy, the direction of the effect was toward fewer procedures with lower income. However, the effect of African American or Latino population ethnicity varied. CONCLUSIONS: In this large urban area both population ethnicity and socioeconomic status are significantly associated with the geographic utilization of selected surgical procedures.

Age Factors↗

PubMed2003

Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates.

BACKGROUND: Despite an increasing awareness regarding pain management in neonates and the availability of published guidelines for the treatment of procedural pain, preterm neonates experience pain leading to short- and long-term detrimental effects. OBJECTIVE: To assess the frequency of use of analgesics in invasive procedures in neonates and the associated pain burden in this population. METHODS: For 151 neonates, we prospectively recorded all painful procedures, including the number of attempts required, and analgesic therapy used during the first 14 days of neonatal intensive care unit admission. These data were linked to estimates of the pain of each procedure, obtained from the opinions of experienced clinicians. RESULTS: On average, each neonate was subjected to a mean +/- SD of 14 +/- 4 procedures per day. The highest exposure to painful procedures occurred during the first day of admission, and most procedures (63.6%) consisted of suctioning. Many procedures (26 of 31 listed on a questionnaire) were estimated to be painful (pain scores >4 on a 10-point scale). Preemptive analgesic therapy was provided to fewer than 35% of neonates per study day, while 39.7% of the neonates did not receive any analgesic therapy in the neonatal intensive care unit. CONCLUSIONS: Clinicians estimated that most neonatal intensive care unit procedures are painful, but only a third of the neonates received appropriate analgesic therapy. Despite the accumulating evidence that neonatal procedural pain is harmful, analgesic treatment for painful procedures is limited. Systematic approaches are required to reduce the occurrence of pain and to improve the analgesic treatment of repetitive pain in neonates.

Analgesics↗

PubMed1999

Cerebellar contribution to spatial event processing: characterization of procedural learning.

Recently, we demonstrated the prevalent role of cerebellar networks in the acquisition of the procedural components of spatial information by testing hemicerebellectomized (HCbed) rats in a classical spatial task, the Morris water maze (MWM). As procedures used in the water maze are a mixture of different components (that is, general procedures, exploration procedures, direct reaching procedures), for optimally solving a spatial task all procedural components must be opportunely managed. Thus, severely impaired procedural learning of cerebellar origin can be better comprehended by fractionating the procedural facets. To this aim, a two-step water-maze paradigm was employed. Normal rats were first trained to search for a hidden platform moved to a different position in each trial, utilizing a water maze setting in which visual cues were abolished by heavy black curtains surrounding the tank. In this paradigm, normal animals solved the task by using general and exploration procedures, but they could not use direct reaching skills. A subgroup of these pretrained animals was then HCbed and, after recovery from cerebellar lesion, was tested in a water maze with normal environmental cues available, a paradigm in which normal animals develop abilities for reaching the target with very direct trajectories. Pretrained HCbed animals, however, did not display the typical spatial deficits of naive HCbed rats, persisted in exhibiting the scanning strategy learned during pretraining, and never displayed direct reaching skills. In conclusion, cerebellar networks appear to be involved in the acquisition of all procedural facets necessary for shifting behavior within the maze until direct reaching of the platform. The lack of flexibility in changing exploration strategies displayed by pretrained HCbed rats is interpreted by taking into account the well-known cerebellar frontal interplay sculpting a specific cerebellar role in the acquisition of spatial procedural steps.

Animals↗

PubMed2006

Long-term single procedure efficacy of catheter ablation of atrial fibrillation.

BACKGROUND: Two important limitations of the data regarding the outcomes of catheter ablation of atrial fibrillation (AF) are the short-term follow-up used in most published studies and the lack of single-procedure outcomes. OBJECTIVE: The objective was to report the long-term single-procedure outcomes at our center. MATERIALS AND METHODS: The patient population was comprised of 200 consecutive patients who underwent ablation (133 men; age 56 +/- 11 years). Atrial fibrillation was paroxysmal in 92 (46%). Success was defined as absence of symptomatic AF, off antiarrhythmic drug (AAD) after a single procedure. RESULTS: After a follow-up of 26 +/- 11 months, the single-procedure long-term success rate was 28% with an additional 7% of patients demonstrating improvement. After including repeat procedures in 64 patients, the overall long-term success rate was 41% with 11% demonstrating improvement. Further subgroup analysis of 48 paroxysmal AF patients considered to be optimal candidates for the procedure, revealed a long-term success rate of 69% with an additional 4% demonstrating improvement. A major complication occurred in 7.9% of patients. CONCLUSION: The results reveal that the long-term single-procedure success rate of catheter ablation of AF in a cohort of patients with predominantly non-paroxysmal AF is less than 40%. The inclusion of redo procedures resulted in an improvement in outcomes. A much higher success rate of 69% was achieved in patients with paroxysmal AF considered to be optimal candidates for this procedure. These results make it clear that further advances in the technique of catheter ablation of AF are needed to improve the safety and efficacy of this procedure. In order to be able to compare outcomes of various techniques in differing patient populations, we urge investigators to report long-term single procedure outcomes.

Atrial Fibrillation↗

PubMed2004

Waiting for urgent procedures on the weekend among emergently hospitalized patients.

PURPOSE: Many hospital departments tend to have lower staffing levels on weekends. We evaluated the use of selected urgent procedures for emergently hospitalized patients and measured the time until procedure based upon the day of hospital admission. METHODS: We analyzed all acute care admissions from all 190 emergency departments in Ontario, Canada, between 1988 and 1997. We selected patients (n = 126,754) who underwent one of six prespecified procedures as their most responsible procedure: fiberoptic bronchoscopy, esophageal gastroduodenoscopy, magnetic resonance imaging, echocardiography, ventilation-perfusion scanning, or coronary angiography. We noted each patient's day of procedure and day of hospital admission. For waits of less than 8 days, we analyzed the time to procedure based upon the day of admission. RESULTS: Only 5% (n = 5903) of the urgent procedures were performed on the weekend. Of the six selected procedures, coronary angiography showed the most skewed pattern of performance (1.5% performed on the weekend) and esophageal gastroduodenoscopy showed the least skewed pattern (8% performed on the weekend). Patients admitted on Fridays or Saturdays had the longest waits for procedures. For all six procedures, patients with relatively longer waits had relatively longer total in-hospital stays (P <0.001 for each). CONCLUSION: Relatively few urgent procedures are performed in emergently hospitalized patients on the weekend, suggesting that greater attention to weekend care might result in more timely interventions and shorter lengths of stay.

Adolescent↗

PubMed1999

The novel-response procedure in humans.

The novel-response drug discrimination procedure is one of several three-choice procedures developed to address interpretational difficulties that can occur under standard two-response procedures. The novel-response procedure is unique among three-choice discrimination procedures by using instructions, rather than explicit training procedures. With the novel-response procedure, participants are trained under a standard two-response (drug vs. placebo) discrimination, and then instructed that in the presence of a drug stimulus unlike either of the training drugs, responses should be made on the novel-response alternative. Several studies have assessed the utility of the novel-response procedure by comparing effects under a standard two-response and the novel-response procedure in participants trained to discriminate triazolam from placebo. Results indicate that the novel-response procedure can increase the selectivity of both placebo- and drug-appropriate responding, and in this way, allows for finer distinctions to be made among sedatives than a standard two-response procedure.

Anti-Anxiety Agents↗

PubMed2000

Avoidance of radiation injuries from medical interventional procedures.

Interventional radiology (fluoroscopically-guided) techniques are being used by an increasing number of clinicians not adequately trained in radiation safety or radiobiology. Many of these interventionists are not aware of the potential for injury from these procedures or the simple methods for decreasing their incidence. Many patients are not being counselled on the radiation risks, nor followed up when radiation doses from difficult procedures may lead to injury. Some patients are suffering radiation-induced skin injuries and younger patients may face an increased risk of future cancer. Interventionists are having their practice limited or suffering injury, and are exposing their staff to high doses. In some interventional procedures, skin doses to patients approach those experienced in some cancer radiotherapy fractions. Radiation-induced skin injuries are occurring in patients due to the use of inappropriate equipment and, more often, poor operational technique. Injuries to physicians and staff performing interventional procedures have also been observed. Acute radiation doses (to patients) may cause erythema at 2 Gy, cataract at 2 Gy, permanent epilation at 7 Gy, and delayed skin necrosis at 12 Gy. Protracted (occupational) exposures to the eye may cause cataract at 4 Gy if the dose is received in less than 3 months, at 5.5 Gy if received over a period exceeding 3 months. Practical actions to control dose to the patient and to the staff are listed. The absorbed dose to the patient in the area of skin that receives the maximum dose is of priority concern. Each local clinical protocol should include, for each type of interventional procedure, a statement on the cumulative skin doses and skin sites associated with the various parts of the procedure. Interventionists should be trained to use information on skin dose and on practical techniques to control dose. Maximum cumulative absorbed doses that appear to approach or exceed 1 Gy (for procedures that may be repeated) or 3 Gy (for any procedure) should be recorded in the patient record, and there should be a patient follow-up procedure for such cases. Patients should be counselled if there is a significant risk of radiation-induced injury, and the patient's personal physician should be informed of the possibility of radiation effects. Training in radiological protection for patients and staff should be an integral part of the education for those using interventional techniques. All interventionists should audit and review the outcomes of their procedures for radiation injury. Risks and benefits, including radiation risks, should be taken into account when new interventional techniques are introduced.A concluding list of recommendations is given. Annexes list procedures, patient and staff doses, a sample local clinical protocol, dose quantities used, and a procurement checklist.

Adult↗

PubMed1998

Arthroscopic or open Bankart procedures: what are the costs?

The cost implications and resource utilization of arthroscopic and open Bankart procedures were evaluated to determine if differences exist between these procedures when performed in a community setting. Billing and hospital records of consecutive patients who underwent either open or arthroscopic Bankart procedures at the three facilities in our city during an 18-month period were analyzed. Procedure type (open or arthroscopic), location (hospital or surgicenter), operation time, operating room time, postanesthesia care unit time, step-down area time, charges for each of these, and anesthesiologist charges were analyzed for 11 open and 13 arthroscopic Bankart procedures. Open procedures took longer and required more operating room time than arthroscopic procedures regardless of location (P < .01). Open procedures required longer postanesthesia care unit time than arthroscopic procedures (P < .01). Facility made no difference. Anesthesia fees were less for arthroscopic ($882) than open Bankarts ($1,075) (P = .002). Total facility and anesthesia fees were less for arthroscopic ($4,747) than for open Bankarts ($6,062) (P = .05). The arthroscopic Bankart repair was performed more quickly than the open Bankart procedure, regardless of facility choice, and resulted in lower total charges. A surgicenter is less expensive whether these procedures are performed arthroscopically or open.

Adolescent↗

PubMedDate not supplied

Value of CT fluoroscopy for percutaneous biopsy procedures.

PURPOSE: To assess the clinical impact of computed tomographic (CT) fluoroscopy (CTF) with regard to procedure time and success rate for CT image-guided biopsy procedures. MATERIALS AND METHODS: One hundred ninety consecutive patients referred to the same radiologist underwent biopsy procedures performed with use of a CT scanner equipped with fluoroscopic capabilities during a 15-month period. CTF procedures were performed predominantly by means of a continuous fluoroscopic technique, with typical exposure factors of 50 mA at 120 kV and a slice thickness of 10 mm. The total procedure time, fluoroscopy time, and complication and procedure success rates were documented prospectively in this group. A control group consisted of retrospective analysis of 93 consecutive patients who had undergone a classic CT-guided procedure performed by the same radiologist. RESULTS: Procedure success rate was increased in the CTF group (93.7 versus 88.2%), although the difference was not statistically significant (P > .05: Fisher exact test). A statistically significant difference was noted when comparing mean procedure times (CTF, 27.56 minutes; range, 20-60 minutes versus control, 43.17 minutes; range, 35-80 minutes; P < .0001; Welch unpaired t test). CONCLUSION: CT fluoroscopy facilitates CT-guided biopsy procedures by allowing visualization of the needle trajectory from skin entry to the target point, allowing procedures to be performed more rapidly and efficiently.

Adolescent↗

PubMed1999

Averaging dependent effect sizes in meta-analysis: a cautionary note about procedures.

When a primary study includes several indicators of the same construct, the usual strategy to meta-analytically integrate the multiple effect sizes is to average them within the study. In this paper, the numerical and conceptual differences among three procedures for averaging dependent effect sizes are shown. The procedures are the simple arithmetic mean, the Hedges and Olkin (1985) procedure, and the Rosenthal and Rubin (1986) procedure. Whereas the simple arithmetic mean ignores the dependence among effect sizes, both the procedures by Hedges and Olkin and Rosenthal and Rubin take into account the correlational structure of the effect sizes, although in a different way. Rosenthal and Rubin's procedure provides the effect size for a single composite variable made up of the multiple effect sizes, whereas Hedges and Olkin's procedure presents an effect size estimate of the standard variable. The three procedures were applied to 54 conditions, where the magnitude and homogeneity of both effect sizes and correlation matrix among effect sizes were manipulated. Rosenthal and Rubin's procedure showed the highest estimates, followed by the simple mean, and the Hedges and Olkin procedure, this last having the lowest estimates. These differences are not trivial in a meta-analysis, where the aims must guide the selection of one of the procedures.

Data Interpretation, Statistical↗

PubMed1999

Development of an international standard for the determination of metals and metalloids in workplace air using ICP-AES: evaluation of sample dissolution procedures through an interlaboratory trial.

Inductively coupled plasma atomic emission spectrometry (ICP-AES) is rapidly overtaking atomic absorption spectrometry (AAS) as the method of choice for the determination of toxic metals in workplace air. However, the few ICP-AES methods that have been published are not well characterised in terms of the effectiveness of the sample dissolution procedures described and their validation status. The International Standards Organization (ISO) is currently engaged in developing ISO 15202, which will describe a generic method for the determination of metals and metalloids in airborne particulate matter by ICP-AES. One part of the proposed standard deals with dissolution procedures. The ISO work has been supported by a project carried out in the authors' laboratory to identify, develop and validate sample dissolution procedures for inclusion in the proposed standard. This paper describes an interlaboratory comparison carried out to assess the performance of selected procedures using samples of airborne particulate matter collected on filters with a multiport sampler. Five dissolution procedures were tested. These included an ultrasonic agitation procedure, two hot-plate procedures (based upon NIOSH 7300 and OSHA ID 125G) and two microwave-assisted procedures (based upon EPA 3052). It was shown that the dissolution procedures selected for use in the trial and used internally at HSL generally gave equivalent performance. As expected, a wider spread of results was obtained by participants in the trial. More specifically, there exists some reservation regarding the ability of the ultrasonic and hot-plate procedures to attack fully on a consistent basis some resistant materials, e.g., chromium containing particulate matter. Above all, the trial demonstrated the usefulness of microwave-assisted dissolution procedures in a modern laboratory.

Calibration↗

PubMed1998

What differentiates declarative and procedural memories: reply to Cohen, Poldrack, and Eichenbaum (1997)

CPE claim that procedural and declarative representations differ on two important dimensions: flexibility and compositionality. I have proposed that the apparent flexibility of a memory depends entirely on the transfer conditions. Any retest is, in some sense, a test of flexibility, because something has changed since the original encoding episodic. I have argued that if one changes something that does not provide support to memory performance, the memory will appear flexible, and resistant to changes in the environment. If one changes the very thing that the representation codes, the memory will appear inflexible and easily disrupted by changes in the environment. This principle is equally true for procedural and declarative memory. CPE contend that procedural representations lack compositionality. An ideal test of this claim would examine the representation of a task that is widely agreed to be procedural (e.g. that has been demonstrated to be learned normally by amnesic patients, and in the absence of awareness by neurologically intact subjects). Such experiments appear not to have been conducted, and the fact is that many tasks that are widely agreed to be procedural probably are not compositional. They appear to be, as CPE contend, biases in a processing system; it is hard to imagine how repetition priming could be compositional. Nevertheless, this is not true of all procedural memories. There is a good deal of evidence that motor behaviour is organised hierarchically and has compositionality. There is every reason to think that most if not all motor behaviour is procedural; motor behaviour might be driven by goals that are declarative, but the low-level operations that actually manipulate effectors are closed to consciousness, do not depend on the medial temporal lobe or diencephalon, and would therefore be classified as procedural. CPE framed their theory of differences between procedural and declarative memory systems as an account of the deficit in amnesic patients. They therefore predict that the learning of amnesic patients should not show flexibility or compositionality. There is already at least one study showing learning in amnesic patients that is as flexible as that of control participants (Knowlton & Squire, 1996). There are not, to my knowledge, data on whether the motor skill learning of amnesic patients shows compositionality, but one might expect that it would, given that it does in neurologically intact participants, and given that motor skill learning appears unimpaired in amnesic patients. Thus, the conception of declarative and procedural memory provided by CPE may not provide a complete account of amnesic performance. The anatomic distinction between procedural and declarative memory systems appears quite strong, and there is therefore reason to believe that there are accompanying computational differences. There does not, however, appear to be sufficient evidence to support those differences proposed by CPE.

Amnesia↗

PubMed2006

Estimated risk of endocarditis in adults with predisposing cardiac conditions undergoing dental procedures with or without antibiotic prophylaxis.

BACKGROUND: Although antibiotic prophylaxis for infective endocarditis (IE) has been recommended for persons with predisposing cardiac conditions (PCCs) for many years, its efficacy, which has not been demonstrated, has been recently challenged. To assess its usefulness, we estimated the risk of developing IE after undergoing a dental procedure for which subjects would be eligible for prophylaxis, both in subjects having (protected procedure) or not having (unprotected procedure) received antibiotic prophylaxis. METHODS: The number of French persons with PCCs, the annual number of dental procedures in which subjects would be eligible for antibiotic prophylaxis, and the number of procedures that were unprotected were estimated on the basis of a survey performed on a sample of 2805 subjects aged 25-84 years. The annual number of IE cases possibly due to an unprotected procedure was estimated on the basis of a 1-year epidemiological study of IE conducted in an area inhabited by 16 million people. RESULTS: After standardization, extrapolation of results to the age-equivalent general population (39 millions subjects) indicated the following: first, 3.3% (95% confidence interval [CI], 2.6%-4%) of the subjects had PCC, 2.7 million (95% CI, 2.3-3.2 million) of whom had undergone at least 1 at-risk dental procedures within the survey year, and the procedures were unprotected in 62% of cases; second, 37 (95% CI, 18-68; 2.7%) of the 1370 annual IE cases in France were possibly related to unprotected procedures. Thus, the risks of developing IE were estimated to be 1 in 46,000 for unprotected procedures (1 in 10,700 and 1 in 54,300 for subjects with prosthetic and native valve PCC, respectively) and 1 in 150,000 for protected procedures. CONCLUSIONS: A huge number of prophylaxis doses would be necessary to prevent a very low number of IE cases.

Adult↗

PubMed2000

What is the quality of the implemented meta-analytic procedures in chronic pain treatment meta-analyses?

OBJECTIVE: Meta-analysis (MA) is the application of quantitative techniques for the purposes of summarizing data from individual studies. This type of review has many advantages over traditional reviews. However, different investigators performing MAs on the same data set have reached different conclusions. These reliability problems have been attributed to differences in the quality of the implemented meta-analytic procedures. We, therefore, examined the chronic pain treatment meta-analytic literature for MA procedure quality and for the consistency of conclusions. DESIGN, SETTING, PARTICIPANTS, OUTCOME MEASURES: Chronic pain treatment MAs were isolated according to inclusion/exclusion criteria. Data from these MAs were abstracted into structured tables. Table format reflected eight meta-analytic procedures identified previously as being important to MA implementation quality. These were: adequacy of retrieval, publication bias, inclusion/exclusion criteria, abstraction of data, quality, homogeneity/heterogeneity, independence, and statistical versus clinical interpretation. Each meta-analytic procedure was then independently rated by two raters. Rating results were then analyzed by procedure for each individual MA for percentage scores out of 100%, and mean scores. For MAs addressing the same topic area (pain facility treatment, antidepressant treatment, manipulation treatment) direction of effect size was noted. Mean effect sizes were calculated for these subgroups. RESULTS: Sixteen chronic pain treatment MAs fulfilled inclusion/exclusion criteria. Mean procedure ratings indicated that four procedures may not be implemented adequately. These were publication bias, abstraction of data, quality, and homogeneity/heterogeneity. There was wide MA implementation score variability, with 37.5% scoring less than 50%. The effect sizes of the MA subgroups demonstrated replicate nonvariability. CONCLUSIONS: Some meta-analytic procedures could be interpreted to be implemented inadequately in some chronic pain treatment MAs. There is wide variability between individual chronic pain treatment MAs on adequacy of implementation of these procedures. However, the effect sizes of the different MA subgroups demonstrated consistency. This finding indicates that for these MA subgroups, MA results are consistent between authors. In addition, chronic pain MAs, as compared with other groups of MAs, appear to address some of the procedures in a more adequate fashion. Future chronic pain MAs should concentrate on improving the quality of their methods with particular emphasis on the above four procedures. Because of potential validity problems with these results, these data cannot and should not be used to make administrative decisions about previous MAs.

Chronic Disease↗

PubMed2002

Integra as a dermal replacement in a meshed composite skin graft in a rat model: a one-step operative procedure.

BACKGROUND: Current use of Integra, the collagen-based dermal analogue, requires a two-step grafting procedure to achieve wound closure with an "ultrathin" autograft. METHODS: A one-step operative procedure of meshed composite skin graft (MCSG) using Integra as a dermal template for a meshed split thickness autograft was developed in rats. The silicon layer of Integra was removed, the resulting dermal analogue was meshed (1:1.5), expanded, and placed on excised full thickness wound and covered with a meshed (1:1.5 or 1:6) split thickness autograft. Grafted wounds were dressed with BioBrane, Vaseline gauze, silver-impregnated nylon, or silver-nylon and direct current (SNDC). At scheduled intervals up to 3 months postgrafting, wounds were examined for epithelialization, collagen deposition and fibrosis, hair growth, and contraction. The results of wound closure and healing following the one-step procedure were compared with the outcome of the two-step grafting procedure where application of meshed Integra (step one) was followed in 14 days by removal of the silicon layer and application of the meshed autograft (step two). RESULTS: The one-step procedure applied to meshed autograft/Integra (1:1.5/1:1.5) composite graft accelerated wound closure by 6-19 days when compared with the two-step procedure. At 3 months postgrafting, the contraction of the healed wound dressed with SNDC, BioBrane, or Vaseline gauze was reduced by 13-16% following the one-step procedure compared with the two-step procedure (p < 0.05). The one-step procedure allowed the expansion of the autograft layer to 1:6 while achieving wound healing results similar to grafting with 1:1.5 meshed autograft layer using the two-step grafting procedure. CONCLUSION: Single-step application of meshed, thin, split thickness autograft over meshed Integra-derived dermal substitute allows more rapid wound closure with less contraction and more efficient use of graft donor skin than can be obtained with the commonly used two-step grafting procedure.

Analysis of Variance↗

PubMed2000

Laparoscopic antegrade continence enema in situ appendix procedure for refractory constipation and overflow fecal incontinence in children with spina bifida.

PURPOSE: The antegrade continence enema procedure allows patients with neurogenic bowel to administer large volume enemas through a right lower quadrant stoma to flush the colon every other day. This procedure results in freedom from refractory constipation and diapers required by unexpected episodes of overflow fecal incontinence. We present a simplified laparoscopic technique using in situ appendix. MATERIALS AND METHODS: A total of 6 male and 10 female children with a mean age of 12 years (range 4 to 21) and neurogenic bowel secondary to myelomeningocele underwent the antegrade continence enema in situ appendix procedure. The procedure was done with laparoscopic assistance, and associated with other bladder and bladder outlet reconstructive surgery in 5 patients. In 3 patients, a purely laparoscopic antegrade continence enema in situ appendix procedure was performed. The appendix and cecum were mobilized, and the tip of the appendix was anastomosed directly to the skin of the right lower quadrant through 1 of the 5 mm. lower quadrant port sites. The continence mechanism is simply a function of the appendix length and the mucosal coaptation of the appendiceal lumen. A 6Fr silicone Foley catheter is used to stent the mucocutaneous anastomosis. Concomitant procedures included ileocystoplasty, ileovesicostomy, sigmoidovesicostomy or ureterovesicostomy, and/or pubovaginal sling done through a low Pfannenstiel incision after laparoscopic mobilization of the appendix and cecum. RESULTS: The 3 patients treated with the laparoscopic antegrade continence enema procedure ate the day of surgery and were discharged home the next morning. Constipation and fecal incontinence resolved in all cases. All antegrade continence enema stomas were catheterized easily with a 6 or 8Fr feeding tube and were continent. Complications in the 8 laparoscopic and laparoscopic assisted cases included stomal stenosis requiring dilation in the office and obstructive volvulus associated with malrotation requiring segmental resection. Patient mothers in particular were gratified by this procedure at a mean followup of 11/2 years. CONCLUSIONS: The simplified antegrade continence enema in situ appendix procedure works well for refractory constipation and overflow fecal incontinence in children with neurogenic bowel secondary to spina bifida. Coaptation of the appendiceal lumen and use of small catheters allow for persistent continence without a formal surgically constructed valve mechanism. The combined antegrade continence enema and either ileovesicostomy or sigmoidovesicostomy continent urinary diversion procedures allow children to control bowel and bladder evacuation programs. A laparoscopic approach is reasonable particularly in cases requiring no other procedures.

Adolescent↗

PubMed1994

Measuring the necessity of medical procedures.

This is a report on the extension of the concept of the appropriateness of a procedure to the necessity, or crucial importance, of that procedure. To state that a procedure is crucial means that withholding the procedure would be deleterious to the patient's health. Appropriateness and necessity ratings for six procedures were obtained using a modified Delphi panel process developed in earlier work. Panels were composed of practicing clinicians who were recognized leaders in their fields. The panels included both performers and nonperformers of the procedure under discussion. For most procedures and panelists, necessity was related to appropriateness, but was distinct from it. The proportion of indications for which the procedure was crucial varied in clinically consistent ways both among and within procedures. However, panelists did not achieve a consensus on necessity. Further research is suggested to refine the method to promote consensus and to validate further the ratings of necessity. In conclusion, necessity ratings can be used together with appropriateness ratings to address not only the overuse of procedures, but also to indicate limited access to care through underuse of procedures.

Angioplasty, Balloon, Coronary↗

PubMed2000

Relation of gender and health insurance to cardiovascular procedure use in persons with progression of chronic renal disease.

BACKGROUND: Women often are less likely than men to receive diagnostic and therapeutic invasive procedures for coronary disease. OBJECTIVE: To examine the relation between gender, health insurance, and access to cardiovascular procedures over time in persons with chronic illness. RESEARCH DESIGN: Seven-year longitudinal analyses in a cohort from the United States Renal Data System. SUBJECTS: National random sample of women and men who progressed to end-stage renal disease (ESRD) in 1986 to 1987 and were treated at 303 dialysis facilities (n = 4,987). MEASURES: Medical history and utilization records, physical examination, and laboratory data. MAIN OUTCOME MEASURES: Receipt of a coronary catheterization or revascularization procedure before (baseline) and after (follow-up) the development of ESRD and acquisition of Medicare, adjusted for clinical and socioeconomic variables. RESULTS: At baseline, 5.2% of women and 9.2% of men had undergone a cardiac procedure; the odds of women receiving a procedure were one third lower than for men (adjusted odds ratio 0.66 [95% CI 0.49-0.88]). During follow-up, women were just as likely as men to undergo a procedure (adjusted odds ratio 0.94 [95% CI 0.74-1.20]). Compared with men with baseline private insurance, men and women with other and no insurance had 34% to 81% lower odds of receiving procedures at baseline. Women with private insurance had 42% lower odds of having a procedure at baseline compared with men (adjusted odds ratio 0.58 [95% CI 0.42-0.78]) but had the same odds at follow-up (adjusted odds ratio 1.09 [95% CI 0.82-1.45]). At follow-up, gender differences in procedure use were eliminated for groups with baseline Medicaid or no insurance. CONCLUSIONS: Overall gender differences in cardiac procedure use were narrowed markedly after progression of a serious illness, the assurance of health insurance, and entry into a comprehensive care system. Gender disparities in procedure use for different baseline insurance groups were largely equalized in follow-up. These findings suggest that provision of insurance with disease-managed care for a chronic disease can provide equalized access to care for women.

Adult↗