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PubMed2006

The influence of an enhanced recovery programme on clinical outcomes, costs and quality of life after surgery for colorectal cancer.

OBJECTIVE: Optimizing peri-operative care using an enhanced recovery programme improves short-term outcomes following colonic resection. This study compared a prospective group of patients undergoing resection of colorectal cancer within an enhanced recovery programme, with a prospectively studied historic cohort receiving conventional care. PATIENTS AND METHODS: Sixty patients underwent elective resection within an enhanced recovery programme (ERP). This incorporated pre-operative counselling, epidural analgesia, early feeding and mobilization. Clinical outcomes were compared with 86 prospectively studied historic control patients receiving conventional care (CC). All patients completed EORTC QLQ-C30, QLQ-CR38 and health economics questionnaires up to three months after surgery. RESULTS: Baseline clinical data were similar in both groups. Postoperative hospital stay was significantly reduced in the ERP, with patients staying 49% as long as those in the CC group including convalescent hospital stay (95% CI 39% to 61%P < 0.001). There were no differences in the number of complications, readmissions or re-operations. There were no significant differences in quality of life or health economic outcomes. CONCLUSION: Patients undergoing colorectal resection within an ERP stay in hospital half as long as those receiving conventional care, with no increased morbidity, deterioration in quality of life or increased cost.

Aged↗
PubMed1995

Cost-benefit analysis of laparoscopic versus laparotomy salpingo-oophorectomy for benign tubo-ovarian disease.

STUDY OBJECTIVE: To compare laparoscopy and laparotomy adnexectomy with respect to operating time, complications, length of hospitalization, convalescence, effectiveness, and surgical and equipment cost. DESIGN: A comparison of 30 consecutive patients undergoing laparoscopic adnexectomy from January 1990 to July 1991, and 27 consecutive patients who underwent adnexectomy by laparotomy from January 1985 to December 1990. SETTING: Private practice of one surgeon (GAV), and Department of Obstetrics and Gynecology, Lawson Research Institute, St. Joseph's Health Care Center, London, Ontario, Canada. PATIENTS: All patients had had a hysterectomy with preservation of at least one adnexa. The indications for adnexectomy were chronic pelvic pain or adnexal mass less than 6 cm diameter, with benign characteristics defined by sonography and tumor markers. INTERVENTIONS: Laparoscopic adnexectomy was performed by three-puncture technique with bipolar coagulation and endoloop ligation of the pedicle. Dissection and resection were performed with the carbon dioxide laser or scissors. RESULTS: Differences were noted between laparoscopy and laparotomy (mean +/- SD) in operating time (90 +/- 40 vs 65 + 20 min, p < 0.01), complications (11% vs 18.5%, p < 0.05), effectiveness (72% vs 72%), length of hospitalization (1.7 +/- 1.0 vs 7.1 +/- 1.2 days, p < 0.05), convalescence (2.2 +/- 1.7 vs 9.5 +/- 5.2 wks, p < 0.05), surgical cost ($1603 vs $5158), and equipment cost ($198,048 vs $17,345). CONCLUSIONS: Operating time, complications, safety, efficiency, and effectiveness were comparable for the two procedures. Markedly reduced hospitalization in the laparoscopy group resulted in a mean saving per patient of $3555. These women also had shorter convalescence and earlier return to normal activities and employment. The cost of laparoscopic equipment appears prohibitive, but it pays for itself after 50 surgical procedures.

Adult↗
PubMed1990

Dietary supplementation in elderly patients with fractured neck of the femur.

59 elderly patients (mean age 82) with femoral neck fractures were randomised into two groups. 27 patients received daily an oral nutrition supplement (250 ml, 20 g protein, 254 kcal) for a mean of 32 days; 32 patients acted as controls. On admission most patients had nutritional deficiencies. Despite being offered adequate quantities, nutritional requirements were not met during the hospital stay. Clinical outcome was significantly better in the supplemented group (56% favourable course vs 13% in controls) during the stay in the convalescent hospital. The rates of complications and deaths were also significantly lower in supplemented patients (44% vs 87%). 6 months after the fracture the rates of complications and mortality were significantly lower in supplemented patients (40% vs 74%). The median duration of hospital stay was significantly shorter in the supplemented group (24 vs 40 days). Thus the clinical outcome of elderly patients with femoral neck fracture can be improved by once daily dietary oral supplementation.

25-Hydroxyvitamin D 2↗
PubMed1978

Hospital and community mortality rates among the retarded.

The findings of McCurley et al. are generally replicated by this study. Community rates are usually lower than those of comparable institutional residents, except for convalescent hospitals used for the care of the profoundly retarded in the United States. Attention is drawn to the sharp mortality difference between ambulatory and non-ambulatory retarded individuals and the affect of the ability to walk can have on the estimation of mortality rates. The ambulation factor should be considered more routinely in future studies. Finally, a revision of the usual method of estimation of age at death was attempted. The utility of the method, similar to standardisation procedures widely used in demography, provides estimates which are more directly comparable between studies.

Adolescent↗
PubMed1989

[Comparative study of arthroscopy and arthrotomy (economic aspects)].

On the Traumatological Orthopaedic Surgery Department of the Hungarian National Institute of Physical Education and Sports Hygiene 1629 arthroscopic operations of the knee joint were made between 1984-87. From these arthroscopic meniscectomy was made in 543 cases. A follow up study was performed in 302 arthroscopic meniscectomised and in 326 traditionally operated patients from the point of view of objective therapeutic results, hospitalization, convalescence and economic efficacy as well. The average follow up period was 8.2 months. The objective estimation of the therapeutic result was made by Lysholm score and Tapper-Hoover's functional classification. The mean hospitalization was 2 days after arthroscopic meniscectomy and 7 days following the traditional meniscectomy respectively. Twenty days shorter convalescence was observed in the arthroscopic meniscectomy cases. The patients were able to start regular physical activity 43 days earlier than traditionally operated athletes. The difference in Lysholm scores was 12 in favour of arthroscopic operations. On basis of the above considerable several millions reduction of expenses could be revealed what evidently proved the economic efficacy of arthroscopy.

Arthroscopy↗
PubMed2000

Patients' interpretation of symptoms as a cause of delay in reaching hospital during acute myocardial infarction.

OBJECTIVE: To examine whether the association between expected symptoms of acute myocardial infarction and actual symptoms predicted delay in reaching hospital and help seeking behaviour. DESIGN: During hospital convalescence, participants completed a structured interview designed to measure symptom experience and help seeking behaviour following the onset of symptoms of acute myocardial infarction. PATIENTS: 88 patients admitted to hospital with their first myocardial infarction MAIN OUTCOME MEASURES: Delay in reaching hospital from onset of worst symptoms, obtained from ambulance and hospital records. RESULTS: The most common symptoms expected by patients with myocardial infarction were central chest pain (76%), radiating arm or shoulder pain (34%), and collapse (26%). The most common symptoms experienced were sweats or feeling feverish (78%), chest pain (64%), and arm, shoulder, or radiating pain (66%). A mismatch between symptoms experienced and those expected occurred in 58% of patients, and was associated with delay. Patients who experienced a mismatch between expectation and actual symptoms also were more likely to have a third party decide to call for help. CONCLUSIONS: The experience and interpretation of symptoms is an important source of delay and help seeking following onset of myocardial infarction symptoms.

Aged↗
PubMed1996

Preperitoneal bilateral inguinal herniorrhaphy evolution of a technique from conventional to laparoscopic.

BACKGROUND: Simultaneous repair of bilateral inguinal hernia remains controversial. METHODS: Seventy-two consecutive patients underwent a preperitoneal prosthetic repair of bilateral groin hernia; 25 via laparoscopy. ASA classification, Nyhus type, hospitalization, convalescence time, and cost were examined. Mean follow-up was 36 and 12 months for the conventional and laparoscopic group respectively. RESULTS: Sixty-nine patients were available for long-term follow-up. Average hospital stay, recurrence rate, perioperative urinary retention, transient thigh neuralgia, and return to normal activities were 48 hours, 5%, 9%, 6%, and 22 days as compared to 4 hours, 6%, 20%, 12%, and 9 days for the conventional and laparoscopic group respectively. The cost for laparoscopic repair was $500 greater. CONCLUSIONS: The preperitoneal approach to repair of bilateral hernias demonstrates an acceptable recurrence rate with low long-term morbidity. Experience with conventional preperitoneal technique greatly facilitates transition to laparoscopic repair.

Costs and Cost Analysis↗
PubMed1999

Geriatric screening in acute care wards--a novel method of providing care to elderly patients.

OBJECTIVE: To assess a nurse-implemented geriatric screening system. DESIGN: Descriptive study. SETTING: University teaching hospital, Hong Kong. PATIENTS: All (5080) elderly patients admitted between 1 January 1996 and 31 December 1996. MAIN OUTCOME MEASURES: Patient characteristics such as disease, prior admission, living quarters, and regular medications; interventions taken; and morbidity and mortality. RESULTS: The most common interventions were referral to a convalescent hospital, patient education, and carer contact. The overall death rate was 8.5% and the diseases with the highest mortality rates were renal failure, liver cirrhosis, and cancer. Approximately one quarter of patients had been admitted to hospital in the previous month. The death rate was higher among women than men (10.8% versus 6.7%, P<0.001; odds ratio=1.68; 95% confidence interval, 1.38-2.05), as was the percentage of those with a history of admission in the previous month (32.8% versus 20.0%, P<0.001; odds ratio=1.95; 95% confidence interval, 1.71-2.21). Patients with multiple pathologies and polypharmacy had a greater frequency of previous 1-month admission compared with those who did not have these features (37.5% versus 20.0%, P<0.001; odds ratio=2.37; 95% confidence interval 2.0-2.7). Patients living in old-age homes had a higher death rate and more previous 1-month admissions than home dwellers, and patients living in private old-age homes had a higher death rate but lower number of previous 1-month admissions than those living in subsidised old-age homes. CONCLUSIONS: This study has collected important data from one form of integrated geriatric practice, which can be used for future service provision.

Journal Article↗
PubMed1995

Laparoscopic drainage of lymphoceles after kidney transplantation: indications and limitations.

BACKGROUND: Symptomatic lymphoceles are not uncommon after kidney transplantations. Surgical marsupialization with internal drainage is the treatment of choice. However, laparoscopic drainage is reportedly as effective, with only minimal trauma. METHODS: We attempted 14 laparoscopic lymphocele drainages during a 3-year period and studied the indications and limitations, using intraoperative ultrasonography in all cases. RESULTS: Laparoscopic drainage was successful in only 9 (64%) of 14 patients. A conversion to open laparotomy was necessary in five patients; their lymphoceles were lateral and either posterior or inferior to the kidney. Two patients with initially successful laparoscopic drainage required conversion to open laparotomy 21 and 83 days later; their lymphoceles were inferior to the kidney. Laparoscopic drainage shortened the median hospital stay by 4 days versus open surgical drainage and by 7 days versus conversion. Hospital costs for laparoscopic drainage averaged $7400 less versus open drainage and $10,300 less versus conversion. CONCLUSIONS: In patients with symptomatic lymphoceles medial and either superior or anterior to the kidney, laparoscopic drainage under intraoperative ultrasonographic guidance is easy, safe, and effective. It decreases hospitalization, convalescence, and costs. In patients with symptomatic lymphoceles lateral and either posterior or inferior to the kidney, laparoscopic drainage may fail because of anatomic inaccessibility and technical impracticability.

Adolescent↗
PubMed1976

A geriatric medical residency program. A four-year experience.

Geriatricians are needed to further improve the health care of elderly Americans. The first formalized geriatric residency program in the United States was developed at the Mount Sinai City Hospital Center in New York, and this has produced a second program at the Jewish Institute for Geriatric Care at Long Island Jewish-Hillside Medical Center, New Hyde Park, New York. The goals of this training are to develop special clinical skills to deal with the medical and psychosocial problems of the elderly, and to achieve the ability to develop health care systems for the elderly. Emphasis is on a multileveled system, including home, outpatient, acute hospital, convalescent unit, and long-term institution care. The training period is 12 to 24 months, after an initial 24 to 36 months of standard internal medicine, thus fulfilling the requirements for board eligibility in internal medicine.

Aged↗
PubMed1991

Clinical and demographic characteristics of 13,911 medical emergency patients.

In order to provide better quality of care at Taipei Veterans General Hospital, 13,911 emergency patients coming into the medical emergency room were studied using the computer to key in all demographic data including registration time, time to be seen, desposition time, impression, triage category, discipline as well as daily dynamic status in the observation room from August through December 1989. The study showed that 8.6% were triage category 1 (life-threatening cases) and 22.08% were triage 4 (pseudo-emergency patients). Of the average 101 studied patients seen per day, 20 (20.27%) should have been theoretically admitted, but only 14.7% were admitted, and 18 (18.08%) were sent to the observation room. In general, the daily dynamic status of the patients in the observation room were: (1) Out of 45 overnight patients, 12 (27%) were waiting for admission; and (2) 9 (20.14%) were waiting for a transfer to other convalescent hospitals. We conclude that less than one-tenth of the emergency patients were really emergencies in such a large and busy emergency department, and there was enormous patients stasis in the observation room causing overcrowding of the emergency department, which is the main issue we have to resolve if the quality assurance of the emergency department is to be improved.

Computers↗
PubMed2005

Prevalence of malnutrition and risk factors in geriatric patients of a convalescent and rehabilitation hospital.

OBJECTIVES: To investigate the prevalence and risk factors of malnutrition in geriatric patients admitted to a convalescent and rehabilitation hospital. DESIGN: Cross-sectional study. SETTING: Regional hospital, Hong Kong. PATIENTS: A total of 120 patients (aged 60 years or older) referred to Tung Wah Eastern Hospital. MAIN OUTCOME MEASURES: Anthropometric, biochemical, and haematological parameters were measured for nutritional assessment. Malnutrition was defined as a body mass index of lower than 18.5 kg/m(2) and serum albumin level of lower than 35 g/L. The clinical outcomes of patients were also recorded. The predictive value of the Chinese Mini Nutritional Assessment as a nutritional screening tool was assessed. Potential risk factors associated with malnutrition were evaluated according to established protocols. RESULTS: The mean age of patients was 80.3 years (standard deviation, 7.4 years), and the mean body mass index was 21.9 kg/m(2) (standard deviation, 4.4 kg/m(2)). The prevalence of malnutrition was 16.7%. The age distribution of malnourished patients (mean, 86.2 years; standard deviation, 7.0 years; n=20) was significantly different to those nourished (mean, 79.1 years; standard deviation, 6.9 years; n=100) [P=0.0001]. Mortality was also higher in malnourished patients (25%) than nourished patients (4%) [P=0.001]. Based on the Chinese Mini Nutritional Assessment, 16.9% of patients were classified as malnourished (cut-off value, 18.5). The Chinese Mini Nutritional Assessment was useful as a screening tool to exclude patients who were not malnourished, ie it had a high negative predictive value (95%). Being totally dependent for the performance of activities of daily living, living in a home for the elderly, and being chair- or bed-bound posed a significantly increased risk of malnutrition. The presence of mental depression (geriatric depression scale score of 8 or higher), moderately or severely impaired cognitive function (abbreviated mental test score of lower than 7), or polypharmacy (five medications or more) did not significantly affect risk of malnutrition. CONCLUSIONS: Malnutrition was common in the geriatric patients studied and was associated with an increased mortality. The Chinese Mini Nutritional Assessment was a useful screening tool to exclude malnutrition. Significant risk factors of malnutrition were total dependence, living in a home for the elderly, and being chair- or bed-bound.

Age Factors↗
PubMed1984

Motor disorders of voice and speech in Reye's syndrome survivors.

Disorders of voice and speech were studied in 43 survivors of Reye's syndrome (RS). During hospital convalescence 26 (60%) of 43 were aphonic, hoarse, or had other alterations of speech production. These disorders occurred in those patients with the worst severity of RS. Four patients (9% of survivors) had a persistent motor voice or speech disorder at follow-up examination 1 1/2 to five years after recovery. All of the patients have breathy, low-intensity voice quality, whereas three of the four exhibit rapid and slurred speech. These four children have no difficulty with the symbolic aspects of language and their motor voice and speech impairment cannot be ascribed to global intellectual deficit. Although other neurologic deficits are present in three of these four children, the disorders of voice and speech are the major permanent disabling handicap in our RS survivors.

Adolescent↗
PubMed1976

Surgical treatment of hepatic metastases from colorectal cancers.

Follow-up data covering periods of two to 23 years have been collected on 60 patients who had resection of hepatic metastases for colorectal cancer. Multiple lesions were removed from 20 patients, and solitary lesions were excised from the other 40 patients. Only one patient died during hospital convalescence. No patient who had multiple lesions excised lived for five years. In contrast, 15 of the 36 patients eligible for five-year survival study who had resection of apparent solitary lesions lived for five years or more, and eight patients were alive without evidence of recurrence ten years or more after operation. These surprisingly favorable results of surgical treatment were analyzed in relation to results in patients who had biopsy specimens taken of lesions of comparable size and number, but no removal at the time of colonic resection. No patient in this control group lived for five years. Aggressive surgical treatment of apparent solitary hepatic metastatic lesions from colorectal cancer seems to be justified by the survival rate of surgically treated patients.

Adult↗
PubMed1992

Patterns of recurrent colorectal cancer and recovery surgery.

In only two areas of colorectal cancer recurrence does surgery provide benefit. For a minority of patients with liver metastases that can be resected completely, cure is possible. Recent data from a prospective liver surgery protocol provide a perspective on the outcome, morbidity, and mortality of the procedure and confirm many of the suggestions in previous retrospective reviews. For patients with isolated pelvic or perineal recurrence, surgical removal of recurrent tumor provides palliation, but only if in-hospital convalescence is minimal and if recently introduced reconstructive techniques allow early rehabilitation.

Colorectal Neoplasms↗