Pyloric stenosis: the Christchurch experience

OBJECT

Evaluation of the performance of a general paediatric unit in diagnosis and treatment of infantile hypertrophic pyloric stenosis, including morbidity and measurable outcomes in relationship to changing management.

METHODS

Retrospective case note audit.

RESULTS

In the 11 year period 1980-91, 103 infants underwent surgical correction of pyloric stenosis, after correction of metabolic disturbance. There was a predominance of males (82.5%), but the incidence of first born infants affected was no greater than the population birth order. While the clinical diagnosis was firm in the majority of infants, over 75% had at least one radiologic imaging procedure. On objective criteria, 80% of patients were less than 5% dehydrated, despite having electrolyte and acid-base derangement. The relatively high incidence of mucosal perforation (31.1%) did not lead to further morbidity. The incidence of postoperative vomiting (19.4%) was significantly less than in previously reported series. There were no deaths, one patient suffered longterm neurologic deficit following profound hypoglycaemia. A change in preoperative management to aggressive rehydration did not reduce morbidity, and was associated with an increased median postoperative stay.

CONCLUSIONS

Pyloric stenosis remains a relatively common surgical problem of infancy. The cornerstone of diagnosis remains a clinical one; however there is a place for radiology. Operative repair is elective, following correction of metabolic derangement. In a general paediatric unit, long term sequelae of initial morbidity are rare.

Associations between intramucosal acidosis in the gut and organ failure

OBJECTIVE

To alert health professionals to the need for early detection and prevention of shock in critically ill patients. By describing the associations between intramucosal acidosis in the gut and multiple system organ failure, the author demonstrates how noninvasive measurement of gut intramucosal pH can be used to monitor the adequacy of tissue oxygenation in the splanchnic organs and predict splanchnic ischemia within minutes of its onset.

DATA SOURCES

Review and analysis of current medical literature on shock and organ failure, combined with the author's prior research and expertise in the areas of tissue oxygenation and tonometric monitoring in the critically ill.

CONCLUSIONS

The presence of defective tissue oxygenation in splanchnic organs and in gut ischemia may be detected within minutes of its occurrence via measurements of intramucosal pH in the gut. Measurement of intramucosal pH, obtained noninvasively with an intraluminally located gastrointestinal tonometer, provides an absolute metabolic measure of the adequacy of mucosal oxygenation. The putative consequences of intramucosal acidosis and associated mucosal injury include nosocomial pneumonia, myocardial depression, sepsis from enteric organisms, multiple system organ failure, and death. Through the use of routine monitoring of the adequacy of gut mucosal oxygenation, ischemic mucosal injury and its putative consequences can be prevented, resulting in reduced frequency of multiple organ failure and improved outcome.

The role of secondary brain injury in determining outcome from severe head injury

As triage and resuscitation protocols evolve, it is critical to determine the major extracranial variables influencing outcome in the setting of severe head injury. We prospectively studied the outcome from severe head injury (GCS score < or = 8) in 717 cases in the Traumatic Coma Data Bank. We investigated the impact on outcome of hypotension (SBP < 90 mm Hg) and hypoxia (Pao2 < or = 60 mm Hg or apnea or cyanosis in the field) as secondary brain insults, occurring from injury through resuscitation. Hypoxia and hypotension were independently associated with significant increases in morbidity and mortality from severe head injury. Hypotension was profoundly detrimental, occurring in 34.6% of these patients and associated with a 150% increase in mortality. The increased morbidity and mortality related to severe trauma to an extracranial organ system appeared primarily attributable to associated hypotension. Improvements in trauma care delivery over the past decade have not markedly altered the adverse influence of hypotension. Hypoxia and hypotension are common and detrimental secondary brain insults. Hypotension, particularly, is a major determinant of outcome from severe head injury. Resuscitation protocols for brain injured patients should assiduously avoid hypovolemic shock on an absolute basis.

Who goes to after-hours clinics? Demographic analysis of an after-hours clinic

This study examines an after-hours clinic developed by family physicians of a major community hospital. The physicians have notable linkages with the hospital, and most of the patients come from the practices of the physicians on staff. Hospital-linked clinics of this type could have an increasingly important role as mechanisms of health care delivery continue to evolve.

The impact of a diabetes education program on children and mothers

To investigate the effect of a diabetes education program for school-age diabetic children and their mothers, an evaluative research approach was used in this exploratory study. Significant gains were made and maintained for 3 months for both the children and their mothers on most of the primary goals of the education program that focused on improving diabetes knowledge and skills. Recommendations are included for improving program effectiveness and research designs.

Using patient reports to assess health-related quality of life after total hip replacement

Data on disease severity, co-morbidity, and process of care were obtained from the medical records of 356 patients without rheumatoid arthritis undergoing a first unilateral total hip replacement at four teaching hospitals in California and Massachusetts. Socio-demographic characteristics, functional status prior and subsequent to hospitalization, and improvement in health status were measured with a patient questionnaire 12 months after discharge. Completed questionnaires were received from 284 patients, a response rate of 79.8%. The questionnaire was acceptable to patients, reliable, and had good construct validity. The data indicate substantial benefits from hip arthroplasty. As expected, pre-surgical functioning was a strong predictor of outcomes 1 year after surgery. Controlling for pre-surgical functioning, age was not related to outcomes.

Infection control monitoring in the ambulatory surgery unit

This article shares a plan for infection control monitoring in an ambulatory surgery unit. Simple, efficient, and effective, the plan meets the unique needs of nurses working in a high-volume unit with rapid turnover of patients where virtually no contact occurs nor is information received about patients after the first 24 hours. The success of the plan depends on the surgeons assuming responsibility for identifying and reporting their patients' postoperative infections. We have found that surgeons will respond if provided with a simple reporting system that requires minimal completion time.

Influenza and pneumococcal vaccination of HIV-infected patients: a policy analysis

OBJECTIVE

To analyze the policy of vaccinating human immunodeficiency virus (HIV)-infected young adults against influenza and pneumococcal infections.

METHODS

Transition state model of clinical immune deterioration of HIV infection, published data, and experts' estimates for the uncertain variables. Outcome measures are the number of influenza and pneumococcal infection hospitalizations and deaths prevented over 10 years and cost-effectiveness ratios.

PATIENTS

Hypothetical cohort of HIV-infected 30-year-old patients.

RESULTS

Although pneumococcal vaccine effectiveness diminishes with advanced HIV disease, the risks of pneumococcal infection rise substantially. Pneumococcal vaccination was therefore found to be a reasonable prevention strategy at all HIV disease stages: few vaccinations are needed to prevent hospitalizations and deaths, and the vaccination strategy is cost-effective. By contrast, influenza incidence is low among young adults, and HIV-related immunodeficiency increases influenza risks only minimally. Because the vaccine is administered yearly, many more vaccinations must be administered and fewer hospitalizations and deaths are prevented than with pneumococcal vaccination. The costs to extend life expectancy are high, and beyond the costs of other prevention strategies for persons with moderate to severe immunodeficiency.

CONCLUSIONS

Pneumococcal vaccination is a reasonable prevention strategy for HIV-infected patients at all stages of immunodeficiency. Fewer hospitalizations and deaths are prevented by influenza vaccination, making it a far less cost-effective prevention strategy than pneumococcal vaccination.

A comparison of outcome measures for use with back pain patients: results of a feasibility study

OBJECTIVE

To compare the reliability, validity and change in patient clinical status over time with treatment for six potential outcome questionnaires in a defined population of patients.

SETTING

Physician based, multidoctor teaching practice.

PATIENTS

Three hundred thirty-five consecutive patients presenting with new complaints were solicited. One hundred eighty-six agreed to participate.

INTERVENTIONS

The six questionnaires being studied were administered to each of the participants on three separate occasions. They were: a) prior to clinical evaluation for their chief complaint, b) immediately after clinical evaluation and before treatment and c) 6 wk later.

MEASUREMENTS

Each instrument was scored following the prescribed methods of interpretation from the original literature describing it. Results were submitted for analysis by Pearson correlation and two-way analysis of variance as appropriate.

MAIN RESULTS

Differences were found in the mean value of the modified Zung with respect to both gender and time. An unexpected drop in patients' somatic perceptions in association with the process of clinical evaluation was found for the Modified Somatic Pain Questionnaire. Overall, the Oswestry and Visual Analogue Pain Scale were the most reliable and responsive to clinical change for musculoskeletal disorders.

CONCLUSIONS

This investigation demonstrated substantial differences in the validity and reliability of commonly referenced self-administered instruments for quantifying patient perceptions of pain and disability. The Oswestry and Visual Analogue Pain Scale were both more reliable and valid than other instruments.

Modified condylotomy for treatment of the painful temporomandibular joint with a reducing disc

Data from a pool of approximately 400 patients operated on with modified condylotomy during a 9-year period are presented. The chief findings were good relief of pain and dysfunction, and reversal of the internal derangement in a high percentage of patients. There was low morbidity and remarkably few complications. Comparison of these findings with published results of alternative surgical and nonsurgical procedures seems to favor modified condylotomy.

The importance of co-existent disease in the occurrence of postoperative complications and one-year recovery in patients undergoing total hip replacement. Comorbidity and outcomes after hip replacement

Co-existent or comorbid diseases are appreciated as prognostic factors in studies of quality and effectiveness of care when mortality is the end point. The need to measure and adjust for comorbidity in studies of postoperative hospital complications or long-term recovery from surgery has not been documented. In this study, we determined the impact of co-existent disease on post-operative complications and 1-year health-related quality of life in patients hospitalized for a total hip replacement. The study population consisted of a cohort of 356 patients who were hospitalized in four teaching hospitals in California and Massachusetts for a total hip replacement. Patients' medical records were reviewed to collect information regarding severity of illness, co-existent disease, and postoperative complications. The kind and amount of baseline preoperative co-existent disease was measured from medical record information at admission using a four level Index of co-existent Disease (ICED). Approximately 12 months after hospital discharge, 283 (80%) of the patients were surveyed by questionnaire. The presence and amount of co-existent disease were significant predictors of postoperative complications. The complication rates ranged from 3% to 41% between the lowest and highest levels of the ICED. Patients treated at the four study hospitals differed in functional outcomes 1 year after surgery. Functional outcomes were strongly related to ICED scores: patients in Level 4 ICED scored 26.8 points lower in instrumental activities of daily living than patients in Level 1. After controlling for gender, age, education, and marital status, ICED remained a significant predictor of functional status at 1 year. Furthermore, differences among hospitals in functional outcomes disappeared when the ICED was included in the model to adjust for patient characteristics at the time of surgery. A measure of co-existent disease was crucial in explaining differences among hospitals in recovery from total hip replacement patients.

Audit of intensive care unit admissions from the operating room

An audit of 265 intensive care unit (ICU) admissions from the operating room was performed for the year 1991. In a quality assurance exercise we identified 34 unanticipated ICU admissions (UIAs) by a retrospective peer review of the medical charts. Of these UIAs, 16 were deemed predictable and seven preventable. Five of the seven potentially preventable UIAs were judged to have had inappropriate intravenous fluid management. This has prompted changes in our education programme. In an assessment of our resource management, we evaluated prospectively collected data on the Apache II scores on the day of admission, the incidence of ICU-specific interventions, length of stay in ICU, and outcomes. ICU-specific interventions were not initially required in 36% of admissions and these patients had a low risk (1.1%) of eventually requiring ICU-specific interventions. In comparison with patients requiring ICU-specific interventions, they had lower Apache II scores (10.2 vs 13.1), shorter ICU stays (medians of one vs two days), lower ICU mortality (0 vs 8.2%), P < 0.05, but hospital mortality was not different (7.4 vs 15.3%). This audit has prompted reorganisation of our intensive care services, so that patients not requiring ICU-specific interventions will be managed in an intermediate care area with nurse:patient ratios of 1:3 or 4, in comparison with 1:1 or 2 ratios in the intensive care area.

Outcome of treatment of 686 gunshot wounds of the trunk at Los Angeles County-USC Medical Center: implications for the community

The Los Angeles County-University of Southern California (LAC-USC) Medical Center, a level I trauma center, has experienced a rapidly increasing incidence of gunshot wounds (GSWs). We sought to enumerate the annual monetary costs and medical consequences of thoracoabdominal gunshot wounds in the epicenter of urban violence. A consecutive series of patients admitted from September 1, 1989 to August 31, 1990 was studied. Their records were coded by trauma nurse reviewers and held in the Trauma Emergency Medical Information System (TEMIS) and Automated Medical Record Abstracting and Reporting System (AMRARS). Diagnoses, procedures, and complications were verified by chart review. An estimate of disability 3 months after discharge was made from the record and reported on a functional activity scale. The total number of patients with GSWs admitted to all of the level I Los Angeles County trauma centers was 2771 during the study period. The total number of patients with major gunshot injuries admitted to LAC-USC Medical Center was 1007. Thoracoabdominal wounds without any head wound component occurred in 686 gunshot patients. Three quarters of the injured patients with truncal gunshot injuries were Hispanic. Total length of stay at the LAC-USC Medical Center for those with truncal wounds was 4666 hospital bed days including 432 ICU bed days, representing a minimum estimated total medical cost of $5,441,334. Annual medical cost of all admissions including rehabilitation, however, could be as great as $12 million for the Medical Center and $53 million for the County of Los Angeles. Thirty percent of patients had MediCal insurance. Payment could not be recovered from another 57% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Outcome of patients hospitalized for complications after outpatient liver biopsy

OBJECTIVE

To determine the safety of outpatient liver biopsies by analyzing the outcome of patients hospitalized for complications.

DESIGN

Retrospective review.

SETTING

Large clinic referral center.

PATIENTS

All patients admitted after outpatient liver biopsy at the Mayo Clinic from 1 April 1989 to 1 April 1991.

RESULTS

During this period, 405 outpatients underwent biopsy. Of the 405 patients, 13 (3.2%) were admitted with complications after biopsy. Five patients (38%) were admitted with persistent localized pain, five (38%) with orthostatic hypotension, one (8%) with both pain and hypotension, one (8%) with peritoneal signs, and one (8%) with lightheadedness but no orthostatic changes. All complications were noted within 3 hours after the biopsy. Bleeding, potentially the most serious complication, was radiographically defined in 5 of the 13 patients (38%) admitted. Only two patients, however, required blood transfusions. No patient required invasive management such as surgery or chest tube placement. The average length of the hospital stay was 1.5 days.

CONCLUSION

Complications after outpatient liver biopsy occur early and rarely require invasive management. Outpatient liver biopsy is safe when done on carefully selected patients in a setting that provides close observation for at least 3 hours after liver biopsy.

Outcome of missed diagnosis of HIV infection

The potential benefits of early intervention in HIV infection with antiretroviral therapy and prophylaxis for opportunistic infections are well recognised. In contrast, data on the consequences of a missed diagnosis of HIV infection are limited. Two recently published studies address this issue.

[Lethal outcomes analysis (status, problems, methods)]

The role of a lethal issues analysis in improving the level of public health is discussed. The significance of autopsy results and their analysis, with the development of medical science, not only did not decrease but, on the contrary, considerably increased. Real possibility of computer analysis of the lethal issues appeared with the introduction of International classification of diseases. The requirements to the unified reports of the departments of pathology are considered, the latter being the most important information about the activity of the pathology service and the quality of the therapeutical and diagnostic process at its different levels.

Nurse-managed postpartum home care

In 1989, Professional Nurse Associates, Inc., and Kaiser Permanente of Ohio collaborated to provide a home-centered postpartum recovery program to meet the postdelivery health-care needs of mothers, neonates, and families after a shortened hospital stay. This article reviews the history, process, and outcomes of that joint effort. The authors describe outcomes in terms of type and frequency of nursing diagnoses found on home visits, readmission rates, cost savings, and consumer satisfaction.

Assessment of patient function after limb-sparing surgery

Cancer rehabilitation is becoming more of a focus for the field of physiatry due to increased longevity and the side effects of treatment. In order to investigate the rehabilitation needs of patients undergoing limb-sparing procedures, chart analysis was conducted on 17 children treated for primary bone tumors by resection and an expandable endoprosthetic replacement. Each patient underwent a course of postoperative inpatient and outpatient physical therapy and was followed over an average of 2.5 years. Gait training was relatively straightforward and in seven patients required neither orthosis nor ambulatory aid. The other ten patients walked with a knee orthosis, axillary crutches, or both. Until the time came for reoperation to lengthen the implant, a shoe lift of 1in maximum was added to compensate for the limb length discrepancy. These findings compare favorably with the more complex requirements of high proximal amputees with external prostheses, including more difficult gait training and the need for frequent adjustments, as well as prosthetic replacement as the children grow. It is clear that children undergoing limb-sparing surgery have special needs that should be addressed, including early mobilization, gait training, adjustment to repeated brief hospitalizations for lengthening, and continued follow-up to monitor their activity restriction.

Scabies outbreak in an extended care unit--a positive outcome

A recent outbreak of scabies occurred in an extended care unit attached to an acute care hospital. Seventy-eight residents and over 100 staff and family members were treated at a cost of more than $20,000. The protocol in use at that time was found to be inadequate for an outbreak situation because it was based on the assumption that all staff would have previous experience of this type of problem. Close liaison with the head nurse of the affected unit, the occupational health and safety department, the medical microbiologist and the infection control department has resulted in the development of a procedure that reflects all of the concerns that were raised during the outbreak. In addition, a policy was formulated to cover problems associated with contacting medical personnel in a timely manner. This outbreak has resulted in positive changes in procedures as well as improved communication in a wide variety of departments within the hospital.

Health care in China: a rural-urban comparison after the socioeconomic reforms

This article provides an overview of the current Chinese health care system with particular emphasis on rural-urban differences. China's post-1978 economic reforms, although they improved general living standards, created some unintended consequences, as evidenced by the disintegration of the rural cooperative medical system and the sharp reduction in the number of "barefoot doctors", both of which were essential elements in the improvement of health status in rural China. The increase in the elderly population and their lack of health insurance and pensions will also place enormous pressure on services for their care. These changes have disproportionately affected the rural health care system, leaving the urban system basically intact, and have contributed to the rural-urban disparity in health care. Based on recent data the article compares current rural-urban differences in health care policy, systems, resources, and outcomes, and proposes potential solutions to reduce them.

Problem-based learning: a review of literature on its outcomes and implementation issues

The effects of problem-based learning (PBL) were examined by conducting a meta-analysis-type review of the English-language international literature from 1972 to 1992. Compared with conventional instruction, PBL, as suggested by the findings, is more nurturing and enjoyable; PBL graduates perform as well, and sometimes better, on clinical examinations and faculty evaluations; and they are more likely to enter family medicine. Further, faculty tend to enjoy teaching using PBL. However, PBL students in a few instances scored lower on basic sciences examinations and viewed themselves as less well prepared in the basic sciences than were their conventionally trained counterparts. PBL graduates tended to engage in backward reasoning rather than the forward reasoning experts engage in, and there appeared to be gaps in their cognitive knowledge base that could affect practice outcomes. The costs of PBL may slow its implementation in schools with class sizes larger than 100. While weaknesses in the criteria used to assess the outcomes of PBL and general weaknesses in study design limit the confidence one can give conclusions drawn from the literature, the authors recommend that caution be exercised in making comprehensive, curriculum-wide conversions to PBL until more is learned about (1) the extent to which faculty should direct students throughout medical training, (2) PBL methods that are less costly, (3) cognitive-processing weaknesses shown by PBL students, and (4) the apparent high resource utilization by PBL graduates.

Measuring and predicting outcomes in ESRD patients

To test the feasibility of using general health status as a practical dialysis outcome measure, in a longitudinal pilot study, two well-validated instruments were administered to patients from our dialysis unit or clinic. The instruments were administered three times, at eight-week intervals for seven months to 41 hemodialysis (HD) patients. Forty-five transplant (Tx) patients were surveyed once as a validating control. Sociodemographic, imaging and biochemical data were tested as outcome predictors. Unexpected hospitalizations and adverse intercurrent events were used as additional outcome measures. Preliminary analysis shows HD patients scoring low, while Tx patients scored higher (healthier). These preliminary results suggest that assessment of general health status is a valid and practical outcome measure.

A systematic overview (meta-analysis) of outcome measures in Helicobacter pylori gastritis trials and functional dyspepsia

STUDY AIM

To critically appraise the use of outcome measures in treatment trials of Helicobacter pylori positive non-ulcer dyspepsia patients.

METHODS

Meta-analysis of published randomized placebo-controlled clinical trials.

RESULTS

Significant methodological problems were detected in all seven retrieved studies. There is marked variation in measurement of: symptoms, scales used to assess severity of dyspepsia, use of global assessments and methods used to determine whether a change occurred in symptom severity.

CONCLUSION

Much more attention needs to be paid to outcome measures in non-ulcer dyspepsia trials and consensus on this should be reached by investigators in this area.

New wine in old bottles: certificate of need enters the 1990s

Although state certificate-of-need (CON) programs have been the subject of intense criticism over the past decade, recent evidence suggests that CON programs may be more effective than commonly believed. While many state programs have yielded disappointing results, the CON process can also be used to achieve other important policy objectives, such as increasing access to care for the uninsured and increasing lay participation in health policy planning. In sum, rather than fading away after the termination of federal support for health planning in 1986, state CON programs are poised to assume new roles during the 1990s.

Hybrid total knee arthroplasty. Two- to five-year results using the Miller-Galante prosthesis

Forty-one "hybrid" Miller-Galante total knee prostheses having porous-coated femoral and patellar components and a tibial component without a keel, cemented using low-viscosity technique, were implanted and prospectively evaluated for two to five years. The surgical technique was accurate, restoring the mechanical axis of the lower extremity to an average of 1.6 degrees varus. The average postoperative knee score was 90 points with 88% good or excellent results and 88% completely painless. Range of motion improved from a mean 88 degrees to a mean 108 degrees. Nonprogressive, incomplete radiolucent lines were present at the bone prosthesis interface in 27% of patellar, 15% of femoral, and 20% of tibial components. There were six patellar component fractures, four of which have been revised. These clinical and roentgenographic results support the "hybrid" technique for total knee arthroplasty. However, the use of the porous-coated, metal-backed patellar component is not recommended.

Quality of care in nursing homes: from the resident's perspective

This paper derives from a study conducted by the Deakin Institute of Nursing Research between 1988 and 1990, whose major objective was to determine the impact of staffing mix on nursing resident's quality of care and life. Resident satisfaction with life in the nursing home is a key element in determining the quality of care and quality of life provided. Both the literature review and the study objectives supported the view that resident outcome can be collected through assessing the quality of care and the quality of life, through assessment by informed observers using instruments derived from explicitly stated standards, and through eliciting the perceptions of residents themselves. A schedule designed to measure satisfaction with care was developed and resident interviews were undertaken using this measure and the Life Satisfaction Index (A). The majority of responses to the resident satisfaction schedule were positive. The high percentage of positive responses did not correlate with the observations of the research assistants and there was some concern that while residents were able to assess care they were reluctant to criticize the staff or their behaviour.

Quality control in fatally injured patients: the value of the necropsy

OBJECTIVE

To identify the contribution of necropsy results to the audit care of severely injured patients.

DESIGN

Retrospective study.

SETTING

University Hospital in The Netherlands.

SUBJECTS

56 patients who died of severe trauma or its complications during the 10 year period, 1977 to 1987.

MAIN OUTCOME MEASURES

Correlation between clinical and necropsy findings.

RESULTS

The clinical and necropsy findings corresponded in 31 patients (55%). The necropsy brought to light errors in diagnosis or treatment that might have affected survival in eight cases (14%). The most common missed diagnoses were bronchopneumonia and severe haemorrhage, and the most common cause of death was sepsis. Age, length of stay in hospital, and time between admission and operation were not correlated with accuracy of diagnosis or adequacy of treatment.

CONCLUSION

Necropsies in patients who die after severe injuries make a useful contribution to the audit of the care of patients admitted with such injuries.

The side effects of antipsychotic drugs and patients' quality of life: patient education and preference assessment with computers and multimedia

Determining the relative value of novel antipsychotics such as clozapine requires measures of the utility of their different side-effect profiles. Many of these side effects (SE) are complex and difficult to describe adequately. Schizophrenic patients are also difficult to interview reliably. Even in normal subjects, utility assessment can be tedious, inconsistent, and difficult for subjects to understand. We addressed these challenges by developing a multimedia patient education and utility assessment tool. SE were described using short video sequences accompanied by digitized voice descriptions. Patients' preferences were assessed using visual analog scales, pairwise comparisons, and standard gambles. These assessment techniques were carefully explained and logically integrated. Instructions were presented both by digitized voice and in print, and, if necessary, were clarified by a moderator. Animated displays were used to graphically display probability. Reminder pictures, comprehension tests and validation questions were used throughout the survey. Thirty-three patients from VA and public clinic inpatient and outpatient settings took the survey. Five psychiatrists were surveyed as a reference group. Patients understood the SE and the survey (92% mean comprehension) and their answers were internally valid and consistent (74% internal consistency). The standard gamble disutilities for the SE were substantial, ranging from 12-20% decrease in their quality of life. Computer-based, multimedia techniques are useful in conducting utility assessment and evaluating its validity. They allow effective patient education and elicitation of useful values, even in subjects with cognitive impairments.

Patient outcomes with co-managed post-operative care after cataract surgery

This study examined the practice of co-managed post-operative care and the visual acuity outcomes and complications associated with co-managed services. Data on service utilization and medical outcomes were collected for 2822 cataract surgery procedures performed in 5 ambulatory eye centers between January and July 1988. Average age of patients was 72.8 (SD = 10.4) and 63% were female. Eighty-seven percent of eyes were co-managed. Average number of post-operative visits within 90 days was 4.7 and 6.2 for co-managed cases with and without complications, respectively. Successful visual acuity outcomes (< 20/40) were experienced by 86% of all co-managed patients. There was evidence that patients with pre-existing ocular conditions (e.g. glaucoma, macular degeneration) and serious post-surgical complications were not referred for co-management. For co-managed patients without pre-existing medical or ocular conditions, 92% had successful vision outcomes, while 77-90% with these conditions had successful outcomes. Ninety-three percent of co-managed cases had no post-operative complications, and the rate of specific types of complications ranged from 0.04 to 2.0%. Using physician evaluations as the standard, sensitivity of optometrist detection of complications was 59% and specificity was 99.6%. Optometrists located in separate offices demonstrated 95.8% accuracy in assessing patients for post-operative complications.

Missed opportunities for childhood vaccinations in office practices and the effect on vaccination status

To determine the rate of childhood under-vaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a group-model health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever > 60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness.(ABSTRACT TRUNCATED AT 250 WORDS)

Foreign body ingestions in children: risk of complication varies with site of initial health care contact. Pediatric Practice Research Group

Current recommendations for the management of pediatric foreign body ingestions are based on studies of patients cared for at tertiary care hospitals; they call for aggressive evaluation because of a high incidence of complications. Two hundred forty-four children with suspected foreign body ingestions were prospectively followed to analyze adverse outcomes, ie, procedures, complications, and hospitalizations. Patient enrollment into the study was from three sources: (1) patients who referred themselves to a tertiary pediatric emergency department, (2) patients referred to the same tertiary pediatric emergency department after an initial evaluation by another hospital or physician, and (3) patients who reported their foreign body ingestions to a private pediatric practitioner participating in the study. Most children were well toddlers in normal circumstances, under parent supervision at the time of ingestion. Coins were the most common item ingested (46%). Procedures were done in 53 (24%) of 221 patients and complications occurred in 48 (22%) of 221. Complications were higher in patients referred to the emergency department (63%) than in emergency department self-referred patients (13%) or private practice patients (7%) (chi 2, P < .01). These findings demonstrate the risk of drawing conclusions regarding a universal standard of care from studies involving only hospital-based patients.

Traumatic death in urban children, revisited

OBJECTIVE

Trauma is the leading cause of death in children older than 1 year in the United States. We performed an analysis of the causes of death due to trauma in children in a large urban community to suggest means of prevention in such communities. We also examined data obtained before and after the designation of pediatric trauma centers to determine whether this has made a difference.

DATA SOURCES

Records of the Medical Examiner, Cook County, Illinois, from 1983 through 1988.

STUDY SELECTION

The admitting log was reviewed for all children before their 16th birthday. During the 6-year study period, 3121 autopsies were performed on children, 36.1% of whom died due to traumatic injuries. We reviewed the records of those children who died secondary to these injuries.

DATA EXTRACTION

Record review on pediatric trauma deaths as to cause of death, time of death, age, sex, and any other pertinent information.

RESULTS

Of all trauma deaths, fire was the most common cause of death, followed by motor vehicle-related injuries, homicides, drownings, and falls. These findings differ from national statistics. Improvement in outcome was seen following the designation of general trauma centers, with further improvement seen following the designation of specific pediatric trauma centers.

CONCLUSIONS

Identification of causes of pediatric trauma death enables us to suggest methods of prevention. The centralized care of seriously injured children through the establishment of trauma centers and, specifically, pediatric trauma centers might help to prevent these deaths. Further study of pediatric trauma deaths, including hospital and ambulance records, is needed to improve medical care.

Replantation of the thumb: survival rate and functional recovery in correlation with type of injury

During a period of 4 years, we attempted replantation of an amputated thumb in 21 patients. We present the survival rate as well as the functional recovery in correlation with type of injury. In 21 thumbs, 16 survived surgery (76.2%); 2 out of 5 losses belonged to the guillotine category and 3 belonged to the crush-avulsion category. Out of the 11 thumbs that belonged to the crush-avulsion type, 8 survived, which is a 72.7% success rate. Eight out of 10 thumbs of the guillotine type survived, an 80% success rate. The cosmetic and functional result was satisfactory.

Chronic total obstruction and short-term outcome: the Excimer Laser Coronary Angioplasty Registry experience

Percutaneous transluminal coronary angioplasty for chronic total obstructions is associated with significantly decreased success rates in comparison with those for dilation of subtotal stenoses. Failure usually results from inability to cross the occlusive lesion with a guidewire, although it may result from inability to pass the balloon catheter after the guidewire has been passed. In the Excimer Laser Coronary Angioplasty Registry, 172 chronic total obstructions were treated in 162 patients (10.3% of the 1,569 patients entered). For chronic total obstructions, passage of a guidewire is a prerequisite for laser angioplasty. Once a guidewire crossed an occlusion, the overall laser success rate for treatment of chronic total obstructions was 83%; the extent of stenosis decreased from 100% to 55 +/- 26%. Success was independent of length of the occlusive lesion. In 74% of patients, adjunctive percutaneous transluminal coronary angioplasty was used after laser angioplasty. A final procedural success, defined as residual stenosis of less than 50% and no major complication (coronary artery bypass grafting, myocardial infarction, or death), was achieved in 90%. Major complications were infrequent; 1.2% of patients required coronary artery bypass grafting, and 1.9% had a Q-wave myocardial infarction. Only one death occurred. The use of laser angioplasty may be of particular value when chronic total obstructions can be crossed with a guidewire but not with a conventional balloon catheter or when the occlusion is confirmed to be extremely long.