Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study

OBJECTIVES: (a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV. DESIGN: A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished. SETTING: A 16 bed surgical intensive care unit. SUBJECTS: All 267 men and 135 women admitted to the unit during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality. RESULTS: No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital. CONCLUSIONS: Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.     

Pretreatment with antithrombotic agents during radiofrequency catheter ablation: a randomized comparison of aspirin versus ticlopidine

OBJECTIVES: To compare the variations in intensive care (ICU) outcome in relation to variations in resources utilization and costs between a developed and a developing country with different medical and economical conditions. DESIGN AND SETTING: Prospective comparison between a 26-bed French ICU and an 8-bed Tunisian ICU, both in university hospitals. PATIENTS: Four hundred thirty and 534 consecutive admissions, respectively, in the French and Tunisian ICUs. MEASUREMENTS: We prospectively recorded demographic, physiologic, and treatment information for all patients, and collected data on the two ICU structures and facilities. Costs and ICU outcome were compared in the overall population, in three groups of severity indexes and among selected diagnostic groups. RESULTS: Tunisian patients were significantly younger, were in better health previously and were less severely ill at ICU admission (p < 0.01). French patients had a lower overall mortality rate (17.2 vs 22.5%; p < 0.01) and received more treatment (p < 0.01). In the low severity range, the outcome and costs were similar in the two countries. In the highest severity range, Tunisian and French patients had similar mortality rates, while the former received less therapy throughout their ICU stays (p < 0.05). Conversely, in the mid-range of severity, mortality was higher among Tunisian patients, and a difference in management was identified in COPD patients. CONCLUSION: Although the Tunisian ICU might appear more cost-effective than the French one in the highest severity group of patients, most of this difference appeared in relation to shorter lengths of ICU stay, and a poorer efficiency and cost-effectiveness was suggested in the mid-range severity group. Differences in economical constraints may partly explain differences in ICU performances. These results indicate where resource allocation could be directed to improve the efficiency of ICU care.     

Deciding about cardiopulmonary resuscitation. The contributions of decision analysis

BACKGROUND: Patients have the right to decide whether to authorize cardiopulmonary resuscitation (CPR). Physicians should provide adequate information and help clarify preferences. METHODS: The usefulness of decision analysis was investigated in two convenience samples: 20 healthy outpatient volunteers and 35 audience members at medical ethics grand rounds. Subjects quantified their relative preferences (utilities) for the outcomes of cardiac arrest. First, they rated them on a linear scale. Second, they participated in hypothetical gambles in which they indicated how much they would risk to avoid each outcome. The investigator then calculated the overall expected utilities of the CPR and no-CPR strategies. RESULTS: Subjects were able to complete both the gambles and the rating scale. Utilities derived by the two methods differed greatly. Subjects had strong aversions to an outcome of severe long-term brain damage and widely varying ratings of an outcome of a short period of intensive care followed by death (intensive care unit death). Because intensive care unit death is far more likely than long-term brain damage, its utility was the prime determinant of whether CPR or no-CPR had the higher calculated expected utility. CONCLUSIONS: The methods of decision analysis showed promise as a means not only of informing patients about CPR but of helping them make rational choices. They also revealed the inadequacy of current data on the key outcome of intensive care unit death.     

Toward a medical approach to the evaluation of activity in a physician-staffed mobile intensive care unit

OBJECTIVE: To test the ability of various medical criteria for classifying the patients in a physician-staffed mobile intensive care unit (MICU) by referring to intervention times. STUDY DESIGN: Prospective, open study. PATIENTS AND METHODS: For all the on-scene interventions of the MICUs over a 10-month period, the following data were prospectively collected: pre-hospital diagnosis, initial severity score, medical care score, immediate outcome and three intervention times: on-scene time (OS), time spent with the patient by the MICU team (MT), total duration of intervention (TD). RESULTS: A total of 3,672 MICU interventions were included. Median times were 45 min (32-59) for OS, 66 min (41-91) for MT and 85 min (61-116) for TD. The amount of interventions in a city was correlated with the population (R = 0.95; P < 0.001). The medical care score was greater than one in more than half of the patients. It defined five groups of patients which were different for the three intervention times (P < or = 0.001). A third of the patients were directly transported by the MICU to an ICU. For the median test, immediate outcome groups were different for the three intervention times (P < 0.001). After exclusion of patients with initial cardiac arrest, initial severity score defined five groups of patients which were different for the three intervention times (P < 0.002). Initial severity score and medical care score were correlated (R = 0.37; P < 0.001). CONCLUSION: A classification of the patients based on immediate outcome would be a more accurate indicator of the variability in medical care and consumption of resources in a physician-staffed MICU. In addition, a medical intervention score should be developed to better characterise this medical activity.     

Outcome and cost of trauma among the elderly: a real-life model of a single-payer reimbursement system

BACKGROUND: As our population ages, the number of elderly trauma patients (age > or = 65 years) increases. Studies have demonstrated increased mortality and cost for a given injury severity in the elderly compared with younger patients. The financial viability of trauma centers in the United States has been an area of concern for many years. As reimbursement diminishes for privately insured patients, the ability to finance the care of the indigent is jeopardized. Medicare, the single-payer insurance plan for the elderly, reimburses at a lower rate than standard private insurance carriers. We examined the differences in outcome and cost between the elderly and younger patients and the financial burden imposed by care for elderly trauma. Our hypothesis was that elderly trauma patients would have poorer outcomes, higher cost, and generate greater financial losses than younger patients. METHODS: All patients admitted to the University of Virginia Trauma Service from July 1, 1994, to July 1, 1997 were included. Trauma registry and patients records were examined. Patients with incomplete financial data (cost, reimbursement, and payer source) were excluded. Patients were grouped by age (18-64 and > or =65 years), Injury Severity Score, and payer source. RESULTS: One thousand one hundred twenty-seven patients met the entry criteria. One hundred forty patients had incomplete financial or patient data and were excluded. Nine hundred eighty-seven patients were included in the study, of which 159 were elderly and 828 were 18 to 64 years of age. Injury Severity Scores were significantly higher in the elderly group. Only 2% of elderly patients were uninsured (76% were insured by Medicare), whereas 25% of younger patients were uninsured. Medicare reimbursement rates actually exceeded those of all other carriers (114% of costs). Elderly patients had a higher mortality rate, but the z score did not reach significance. The W score, however, indicated that there were more unexpected, negative outcomes among elderly patients. As injury severity increased, profit per case increased in the elderly and decreased in the younger group. CONCLUSION: Despite higher injury severity and lower survival probability for the elderly, the length of hospital and intensive care unit stays, as well as the percentage of admissions to the intensive care unit, were similar. The per capita cost of hospital care for the elderly was lower than for younger patients, whereas reimbursement was higher, primarily because 98% of elderly patients were insured. Medicare, the single-payer insurance plan for the elderly, adequately reimburses for elderly trauma care. This implies that universal insurance coverage for all trauma patients would be desirable, even if reimbursement rates decreased significantly. The increased mortality in the elderly requires continued study and diligence.     

Endotoxin exposure and symptoms in asthmatic children

Osteoporosis is not an inevitable accompaniment of aging. Rather, it evolves silently over a lifetime, with its attendant morbidities occurring late in life. It is no longer the standard of care to wait until the primary morbidity strikes to begin therapy. A better outcome is always achieved when the individuals at risk are identified early, lessening or even preventing morbidity such as osteoporotic fractures. Recent surveys show a reluctance on the part of many physicians to diagnose or treat osteoporosis in their patients. A second level of resistance is often seen even after fractures occur. Either scenario is particularly unfortunate as therapies currently exist that can significantly reduce future morbidity and probably mortality. Physicians must recognize that patients who have had one fracture are at significantly greater risk to sustain more fractures and are more likely to suffer chronic debilitating musculoskeletal failure. Therefore, in the elderly fracturing patient, even more intensive intervention (fracture prevention) is required.     

Outcome after polytrauma

BACKGROUND AND AIMS: Outcome refers to the different facets of consequences resulting from an event or intervention. These consequences may be relevant for an individual patient, but also for society. There is a growing recognition that clinical research needs to define and focus on the outcomes of medical care. Outcome research should help health care professionals to better evaluate the effectiveness of specific interventions or a therapeutic concept. This broader base of evidence should then benefit the patients. METHODS: The literature was reviewed with respect to concepts of outcome research as well as results of outcome research after major trauma. RESULTS: Measuring outcome might be relevant for research purposes as well as in daily surgical practice. In the past, clinical research in trauma care has tended to focus on survival. Mortality rates are not out, complication rates are not out, but their value is limited and restricted to given scenarios with high mortality rates. New outcomes have to be added: such a functional status, emotional health, social interaction, cognitive function, degree of disability and other indicators of health. CONCLUSION: Despite differences in injury pattern and severity of injury, there is strong evidence from the literature that the quality of life is significantly impaired after major trauma. This is true for functional outcome as well as for psycho-social outcome in up to 70% of patients.     

Long-term survival after retransplantation of the liver

OBJECTIVE: The authors determined the long-term outcome of patients undergoing hepatic retransplantation at their institution. Donor, operative, and recipient factors impacting on outcome as well as parameters of patient resource utilization were examined. SUMMARY BACKGROUND DATA: Hepatic retransplantation provides the only available option for liver transplant recipients in whom an existing graft has failed. However, such patients are known to exhibit patient and graft survival after retransplantation that is inferior to that expected using the same organs in naiive recipients. The critical shortage of donor organs and resultant prolonged patient waiting periods before transplantation prompted the authors to evaluate the results of a liberal policy of retransplantation and to examine the factors contributing to the inferior outcome observed in retransplanted patients. METHODS: A total of 2053 liver transplants were performed at the UCLA Medical Center during a 13-year period from February 1, 1984, to October 1, 1996. A total of 356 retransplants were performed in 299 patients (retransplant rate = 17%). Multivariate regression analysis was performed to identify variables associated with survival. Additionally, a case-control comparison was performed between the last 150 retransplanted patients and 150 primarily transplanted patients who were matched for age and United Network of Organ Sharing (UNOS) status. Differences between these groups in donor, operative, and recipient variables were studied for their correlation with patient survival. Days of hospital and intensive care unit stay, and hospital charges incurred during the transplant admissions were compared for retransplanted patients and control patients. RESULTS: Survival of retransplanted patients at 1, 5, and 10 years was 62%, 47%, and 45%, respectively. This survival is significantly less than that seen in patients undergoing primary hepatic transplantation at the authors' center during the same period (83%, 74%, and 68%). A number of variables proved to have a significant impact on outcome including recipient age group, interval to retransplantation, total number of grafts, and recipient UNOS status. Recipient primary diagnosis, cause for retransplantation, and whether the patient was retransplanted before or after June 1, 1992, did not reach statistical significance as factors influencing survival. In the case-control comparison, the authors found that of the more than 25 variables studied, only preoperative ventilator status showed both a significant difference between control patients and retransplanted patients and also was a factor predictive of survival in retransplanted patients. Retransplant patients had significantly longer hospital and intensive care unit stays and accumulated total hospitalization charges more than 170% of those by control patients. CONCLUSIONS: Hepatic retransplantation, although life-saving in almost 50% of patients with a failing liver allograft, is costly and uses scarce donor organs inefficiently. The data presented define patient characteristics and preoperative variables that impact patient outcome and should assist in the rational application of retransplantation.     

Insurance coverage of patients with breast cancer in the 1991 commission on cancer patient care evaluation study

BACKGROUND: Trends in the care of patients with cancer are monitored annually by the Commission on Cancer of the American College of Surgeons. In 1991 a patient care evaluation study of breast cancer was conducted, which among other questions examined the correlation of health insurance with type or quality of care delivered for breast cancer on a national basis. METHODS: The tumor registry system of the American College of Surgeons was used to obtain data on patients with breast cancer diagnosed in 1983 and 1990. Trends in diagnosis and treatment were correlated with the type of insurance or lack of insurance. RESULTS: Data were obtained from hospitals in 50 states on a total of 41,651 patients. The largest number of patients were covered by Medicare. Fewer than 5% were considered medically indigent. Medically indigent patients presented with higher stage disease and did not participate in a trend toward downstaging, which occurred between the two study years. The treatment of medically indigent patients appeared to be appropriate and comparable with better insured patients. Insurance type (health maintenance organization vs. private) did not affect stage, treatment, or outcome. Decisions to use controversial therapies, such as chemotherapy for stage I disease, did not appear to be financially driven. CONCLUSION: A nationwide pattern of care study for breast cancer indicates that medically indigent patients present with more advanced disease compared with better insured patients, but once the diagnosis is made, treatment and outcome have little to do with insurance type.     

Bariatric analysis and reporting outcome system (BAROS)

BACKGROUND: The lack of standards for comparison of results was identified by the NIH Consensus Conference panelists as one of the key problems in evaluating reports in the surgical treatment of severe obesity. The analysis of outcomes after bariatric surgery should include weight loss, improvement in comorbidities related to obesity, and quality-of-life (QOL) assessment. Definitions of success and failure should be established and the presentation of results standardized. METHODS: A survey among experienced bariatric surgeons was conducted to study the reporting of results. The concept of evaluating outcomes by using a scoring system was introduced in 1997 and has now been refined further. Psychologists with expertise in bariatrics were asked to recommend a disease-specific instrument to analyze QOL after surgery. RESULTS: The system defines five outcome groups (failure, fair, good, very good, and excellent), based on a scoring table that adds or subtracts points while evaluating three main areas: percentage of excess weight loss, changes in medical conditions, and QOL. To assess changes in QOL after treatment, this method incorporates a specifically designed patient questionnaire that addresses self-esteem and four daily activities. Complications and reoperative surgery deduct points, thus avoiding the controversy of considering reoperations as failures. CONCLUSIONS: The Bariatric Analysis and Reporting Outcome System (BAROS) analyzes outcomes in a simple, objective, unbiased, and evidence-based fashion. It can be adapted to evaluate other forms of medical intervention for the control of obesity. This method should be considered by international organizations for the adoption of standards for the outcome assessment of bariatric treatments, and for the comparison of results among surgical series. These standards could also be used to compare the long-term effects of surgery with nonoperative weight loss methods.     

Hematologic emergencies in the intensive care unit

Hematologic emergencies in the oncology population may require an admission to the intensive care unit (ICU). Syndrome of inappropriate antidiuretic hormone, hypercalcemia, tumor lysis syndrome, and disseminated intravascular coagulation are diseases defined in this article. These are common conditions in oncology patients that are reduced or prevented with close monitoring and accurate assessments. The purpose of this article is to introduce intensive care nurses to these disease entities so they will have a better understanding of the care involved with an oncology patient in the ICU unit.     

Stepped care treatment for eating disorders.

A stepped care approach would link different patient needs to therapeutic modalities that range from simple advice to intensive inpatient care. Brief methods, including self-help and psychoeducation, may be effective for a subset of patients with bulimia nervosa and binge eating disorder. Identifying this subset remains a challenge. It is unclear how patients who fail to respond to evidence-based, first-line treatments should be treated. Given the absence of data on effective treatment of anorexia nervosa (AN), discussion of a stepped care approach is speculative. Because AN typically demands expert and sustained treatment, the lower levels of stepped care models are inapplicable for these patients. A stepped care approach poses methodological challenges for clinical research and raises important clinical issues, such as when to switch from 1 level of treatment to another. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Splitting hairs: dissecting roles of signaling systems in epidermal development

A case of hepatic portal venous gas following intestinal ileus in a critically ill patient in the intensive care unit, who went on to have a successful outcome, is described. Although hepatic portal venous gas (HPVG) is usually associated with an abdominal catastrophe and portends a poor clinical outcome, there are a number of benign causes of HPVG. The pathophysiological processes such as gut bacterial translocation and altered intestinal permeability that may occur as a paraphenomenon in the setting of HPVG are discussed.     

Memory function in aging and Parkinson''s disease--an event-related potential study]

PURPOSE: Though case management has been recommended to improve the outcomes of patients with costly or morbid conditions, it has seldom been studied in controlled trials. We performed a randomized, controlled clinical trial of an intensive, multidisciplinary case management program for patients with chronic renal insufficiency and followed patients for 5 years. PATIENTS AND METHODS: We enrolled 437 primary-care patients (73% of those eligible) with chronic renal insufficiency (estimated creatinine clearance consistently < 50 mL/min with the last serum creatinine level > 1.4 mg/dL) who were attending an urban academic general internal medicine practice. The intensive case management, administered during the first 2 years after enrollment, consisted of mandatory repeated consultations in a nephrology case management clinic staffed by two nephrologists, a renal nurse, a renal dietitian, and a social worker. Control patients received usual care. Primary outcome measurements included serum creatinine level, estimated creatinine clearance, health services use, and mortality in the 5 years after enrollment. Secondary measures included use of renal sparing and potentially nephrotoxic drugs. RESULTS: There were no differences in renal function, health services use, or mortality in the first, second, or third through fifth years after enrollment. There were significantly more outpatient visits among intervention patients, mainly because of the added visits to the nephrology case management clinic. There were also no significant differences in the use of renal sparing or selected potentially nephrotoxic drugs. The annual direct costs of the intervention were $89,355 ($484 per intervention patient). CONCLUSION: This intensive, multidisciplinary case-management intervention had no effect on the outcomes of care among primary-care patients with established chronic renal insufficiency. Such expensive and intrusive interventions, despite representing state-of-the-art care, should be tested prospectively before being widely introduced into practice.     

Geriatric assessment in oncology

With the anticipated growth in the numbers of elderly persons, a higher prevalence of cancers among older persons is expected; as a result, oncologists will treat larger numbers of older persons in their practices. Clinicians caring for older persons with cancer must recognize the heterogeneity of the elderly population and focus their assessments and care plans accordingly. The author reviewed literature and drew conclusions regarding geriatric assessment in several key areas: the medical, cognitive, affective, functional economic, and environmental status of patients; social support for patients; and advance directives. They concluded that for younger and healthier seniors, simple probes for the presence of common geriatric problems may suffice, but traditional means of medical assessment should be supplemented by brief screening for common geriatric conditions and nonmedical issues that are of particular relevance to the health of older persons. Assessment instruments can be used to guide these brief evaluations, but results must be interpreted in the context of the limitations of the instruments used. Patients who are frail or at high risk for functional decline or nursing home placement should receive more extensive evaluation by individual practitioners or by a multidisciplinary team of health care professionals who can provide comprehensive geriatric assessment. By broadening their assessment skills to include domains that are beyond traditional internal medicine and oncology training, oncologists can better serve their older cancer patients.     

A quantitative study of the emotional outcome of people caring for stroke survivors

BACKGROUND AND PURPOSE: Although the physical and, to a lesser extent, emotional outcome of stroke survivors has been well documented, there are far fewer data relating to the outcomes of those who care for them. We aimed to describe the outcome of those caring for stroke patients and to identify both patient and caregiver factors that are associated with poor caregiver outcomes. METHODS: As part of a randomized trial to evaluate a stroke family care worker, we identified 417 patients (67% of all referrals to our institution). We followed up 376 survivors of whom 246 identified a caregiver at a 6-month follow-up interview. The patients and caregivers were asked to complete 2 measures of emotional distress ( 30-item General Health Questionnaire [GHQ-30] and Hospital Anxiety and Depression [HAD] Scale). A regression analysis was used to identify factors that were independently associated with poor caregiver outcomes. RESULTS: Fifty-five percent of responding caregivers scored more than 4 on the GHQ-30, indicating that emotional distress is common in this group. Caregivers were more likely to be depressed if the patients were severely dependent (P<0.01) or emotionally distressed themselves (P<0.01). Female caregivers reported more anxiety (median HAD=8) than male caregivers (median HAD=5; P<0.01) but caregivers' levels of anxiety were not so clearly related to the patients' degree of physical disability as their levels of depression. Caregivers suffered more emotional distress if the patients had been dependent before their strokes. CONCLUSIONS: These data may help to identify those caregivers at greatest risk of poor emotional outcomes and thus help in the planning of trials and delivery of interventions aimed at preventing or treating distress among caregivers.     

Measures and meanings: outcome measures in the management of sexually transmitted infections

Applicable outcome measures in genitourinary medicine (GUM) include compliance with clinical standards of care, symptom control, cure rates of infections, decreased incidence of infections, lack of complications, increase in patients' knowledge or satisfaction, and number of partners treated. Measuring these may be easy in the short-term but result in information of limited usefulness. Longer-term outcomes may be more meaningful, but harder--or impossible--to obtain. Some outcome measures are affected by case mix, so differences between patients may be as much as or more relevant than the care received. Quantitative and qualitative measurements of patient satisfaction are straightforward to obtain and essential in examining care delivery, but may be unrelated to desired clinical outcomes for individuals or populations. Compliance with clinical standards is easy to measure, relatively independent of case mix, and useful if standards are evidence-based and validated. The role and applicability of outcome measures are discussed.     

Missing quality of life data in cancer clinical trials: serious problems and challenges

Measurement of quality of life (QOL) in cancer clinical trials has increased in recent years as more groups realize the importance of such endpoints. A key problem has been missing data. Some QOL data may unavoidably be missing, as for example when patients are too ill to complete forms. Other important sources are potentially avoidable and can broadly be divided into three categories: (i) methodological factors; (ii) logistic and administrative factors; (iii) patient-related factors. Logistic and administrative factors, for example, staff oversights, have proven to be most important. Since most QOL measurements require patient self-report, it is usually not possible to rectify the failure to collect baseline data or any follow-up assessments. There is strong evidence that such data are not 'missing at random', and cannot be ignored without introducing bias. Although several approaches to the analysis of partly missing data have been described, none is entirely satisfactory. Prevention of avoidable missing data is better than attempted cure. In July 1996, an international conference on missing QOL data in cancer clinical trials reported the experience of most major groups involved. This paper will serve as an introduction to the problem and provide an estimation of its magnitude, and approaches to its prevention and solution.