The learning curve for laparoscopic colorectal surgery. Preliminary results from a prospective analysis of 1194 laparoscopic-assisted colectomies

BACKGROUND: Laparoscopic-assisted colectomy is an emerging technology for patients with cancer, polyps, inflammation, and other types of pathologic conditions. While previous studies have shown better outcomes for laparoscopic cholecystectomies when surgeons perform more procedures, there is no information on the relationship between surgeon volume and outcomes for laparoscopic-assisted colectomy. OBJECTIVE: To evaluate whether better clinical outcomes are found for surgeons who perform higher numbers of laparoscopic-assisted colectomies and whether such a relationship, if it exists, applies to both intraoperative and postoperative outcomes. DESIGN: Analysis of a data set of 1194 patients, operated on by 114 surgeons, from a prospective registry sponsored by the American Society of Colon and Rectal Surgeons, from May 1991 to October 1994. MAIN OUTCOME MEASURES: Completion rate, intraoperative and postoperative complications, and length of hospital stay. RESULTS: In 75% of cases, surgery was completed laparoscopically, with no difference between high-volume surgeons (> or = 40 cases) and low-volume surgeons. Length of stay (average, 6 days) did not vary according to surgeon volume. Postoperative complications occurred in 15% of cases, with a significantly lower rate for high-volume surgeons (10% vs 19%; P < .001). Intraoperative complications occurred in 5% of cases, with a nonsignificant trend toward a lower rate for high-volume surgeons (3.7% vs 6.3%). A multivariate regression analysis, adjusting for type of disease (cancer vs inflammation vs polyps) and for level of difficulty of the procedure (high vs low) showed that for high-volume surgeons there is a lower probability of both intraoperative complications (adjusted odds ratio, 0.56; 95% confidence interval, 0.32-0.97; P = .04) and postoperative complications (adjusted odds ratio, 0.48; 95% confidence interval, 0.34-0.68; P < .001). CONCLUSIONS: There is a learning curve for laparoscopic-assisted colectomy with respect to intraoperative and postoperative outcomes. As with other laparoscopic procedures, surgeons who perform higher volumes of laparoscopic-assisted colectomy have lower rates of intraoperative and postoperative complications.     

Parathyroidectomy in Maryland: effects of an endocrine center

BACKGROUND: Surgery for hyperparathyroidism is associated with high cure rates and low morbidity and mortality when performed by experienced surgeons. We wanted to determine whether referral of patients with hyperparathyroidism to an endocrine surgery center has an impact on patient outcomes and costs. METHODS: Data from 901 patients who underwent parathyroidectomy recorded in the Maryland inpatient discharge database between 1990 and 1994 at 52 hospitals were compared with 169 consecutive patients who underwent surgical exploration by one surgeon (R.U.) at the Johns Hopkins Hospital. RESULTS: Although in 47 of 52 hospitals fewer than 10 parathyroidectomies were performed each year, in these hospitals four of five related deaths occurred before patient discharge. The percentage of parathyroidectomies in Maryland performed by one endocrine surgeon has increased from 8% in 1990 to 21% in 1994 and is associated with a 97% cure rate and no mortality. Moreover, while hospital length of stay (LOS) in the state has decreased from 7 to 3.1 days, LOS for the high-volume provider has declined to a mean of 1.3 days. CONCLUSIONS: Patients with hyperparathyroidism are increasingly referred to an endocrine surgery center, which results in a high cure rate, low morbidity, no mortality, and a shorter LOS. Improved surgical outcomes and lower costs depend on an experienced surgeon and argue for the referral of these patients to endocrine surgery centers.     

Thyroid surgery in children and teenagers

From 1961 to 1976 62 patients under age 20 underwent thyroidectomy for various thyroid disorders. Twenty-four thyroid lobectomies and eight subtotal or near-total thyroidectomies were performed for benign nodular goiter. Eight near-total thyroidectomies and two thyroid lobectomies were performed for carcinoma. Two patients also had a radical neck dissection. Twenty patients with hyperthyroidism underwent near-total thyroidectomy. Postoperative complications occurred in six patients-all with hyperthyroidism. Operative mortality was zero. Two indications for thyroidectomy in our series were nodular goiter (to rule out carcinoma), and hyperthyroidism (that was not well-controlled medically or where surgery was chosen as primary therapy). In patients with nodular goiters that required surgery, a minimal complication rate occurred. By contrast, surgery for hyperthyroidism was associated with a high postoperative complication rate, six of 20 patients or 30%, which must be anticipated by the surgeon.     

Can total thyroidectomy be performed as safely by general surgeons in provincial centers as by surgeons in specialized endocrine surgical units? Making the case for surgical training

OBJECTIVE: To determine whether surgeons who had received appropriate training in the technique of total thyroidectomy could continue to perform the procedure with minimal morbidity after moving to a provincial surgical practice. DESIGN: Comparison of the complication rates from total thyroidectomy between a specialized endocrine surgical unit and provincial centers. SETTING AND PATIENTS: Six hundred fifty patients undergoing total thyroidectomy by two surgeons over a 5-year period in the endocrine surgical unit at Royal North Shore Hospital, St Leonards, Australia, were compared with 120 patients undergoing total thyroidectomy by seven provincial surgeons who were former trainees in the unit. MAIN OUTCOME MEASURES: Indications for surgery and specific complications of thyroidectomy including recurrent laryngeal nerve palsy, permanent hypoparathyroidism, and postoperative bleeding. RESULTS: Each of the seven surgeons in provincial practice performed only between two and 16 thyroidectomies annually. The percentage of total thyroidectomies for benign and malignant disease was identical for both the endocrine surgical unit and provincial center groups (44%). There was no difference in the incidence of recurrent laryngeal nerve palsy, permanent hypoparathyroidism, or postoperative bleeding between the two groups. CONCLUSION: Total thyroidectomy is an operation that always engenders controversy relating to the morbidity of recurrent laryngeal nerve and parathyroid injury. Surgeons who have completed a well-designed training program and who have become proficient at total thyroidectomy as trainees will remain proficient at the procedure despite practicing in a provincial center. Achieving a low morbidity rate demands meticulous attention to operative technique and anatomical detail.     

Profile of a clinical practice: Thresholds for surgery and surgical outcomes for patients with primary hyperparathyroidism: a national survey of endocrine surgeons

A 1991 NIH Consensus Development Conference statement provided recommendations for the management of patients with asymptomatic and minimally symptomatic primary hyperparathyroidism (primary HPT), but adherence to these guidelines has not been documented. We conducted a cross-sectional survey of North American members of the American Association of Endocrine Surgeons inquiring about surgeon and primary HPT patient characteristics, thresholds for surgery, and clinical outcomes. Multivariate regression was used to assess the relationship of physician characteristics to practice patterns and outcomes. Of 190 surgeons surveyed, 147 (77%) responded; 109 provided complete responses (57%). These surgeons spend 66% of their time in patient care and perform an average of 33 (range, 1-130) parathyroidectomies/yr. More than 72% of primary HPT patients who underwent surgery were asymptomatic or minimally symptomatic. High volume surgeons (>50 cases/yr) had significantly lower thresholds for surgery with respect to abnormalities in preoperative creatinine clearance, bone densitometry changes, and levels of intact PTH and urinary calcium compared to their low volume colleagues (1-15 cases/yr). Overall reported surgical cure rates were 95.2% after primary operation and 82.7% after reoperation. Compared to high volume surgeons, low volume endocrine surgeons had significantly higher complication rates after primary operation (1.9% vs. 1.0% respectively; P < 0.01) and reoperation (3.8% vs. 1.5%; P < 0.001) as well as higher in-hospital mortality rates (1.0% vs. 0.04%; P < 0.05). Endocrine surgeons operate on a large number of asymptomatic or minimally symptomatic primary HPT patients. Even among a group of highly experienced surgeons who typically see patients after referral from endocrinologists, clinical outcomes and criteria for surgery vary widely and appear to be associated with surgeon experience. Their criteria for surgery diverge from NIH guidelines. These results implore the endocrine community to examine the evidential basis for decisions made in the management of primary HPT.     

Is there a duty to die?

OBJECTIVE: To review appendectomy cases in children at a small community hospital and to compare with experience at larger centers. DESIGN: A five-year retrospective study. SETTING: Bartlett Regional Hospital, Juneau, Alaska. PATIENTS AND METHODS: Records of children age 14 and younger who underwent appendectomy from 1991 through 1996 were reviewed; 79 charts were found. Cases were grouped as simple appendicitis, advanced appendicitis, and appendectomy without appendicitis. Variables considered included: length of symptoms at first contact, time from onset until surgery, presence or absence of classical symptoms, post-operative complications, length of hospital stay. RESULTS AND CONCLUSION: 51 cases (64.6%) of simple appendicitis, 22 cases (27.9%) of advanced disease, and 6 cases (7.6%) of normal appendix occurred. Advanced disease was high (66.7%) in children less than 5, and low (22.7%) in ages 10-14. Parental delay > 48 hours in seeking care was a significant factor in advanced disease, professional delay (time from first exam until surgery) was not. Post-surgical complications occurred in 7 (31.8%) cases of advanced disease and in none of the cases with simple appendicitis. Advanced disease cases had an average hospital stay of 8.59 days (+/-2.92) vs. 3.86 days (+/-1.46) for simple appendicitis. Review of appendicitis in children at this hospital compared favorably with the experience at larger medical centers.     

What changes drug metabolism in critically ill patients--III? Effect of pre-existing disease on the metabolism of midazolam

OBJECTIVE: To determine the number and duration of hospital admissions due to diabetes in children aged 0-19 years between 1980-1991. RESEARCH DESIGN AND METHODS: Secondary analysis of data collected by the SIG Health Care Information was based on the 9th revision of the International Classification of Diseases. The subjects were all children in The Netherlands, aged 0-19 years. The main outcome measures were number and duration of hospital admissions due to type I diabetes (ICD 9 code 250.0-250.9). RESULTS: The hospital admission rate due to diabetes decreased > 30%. This decrease was statistically significant in all age subgroups. The total number of days in hospital due to diabetes decreased dramatically: from 24,961 in 1980 to 11,305 in 1991. The average duration of hospital stay length due to diabetes decreased as well from 14.5 days in 1980 to 11.9 days in 1991. CONCLUSIONS: The hospital admission rate and the length of hospital stay for diabetes in children aged 0-19 years have decreased, in spite of an increasing incidence. The hospital admission rate may decrease still further if more children with newly diagnosed diabetes can be adequately managed by team management at home in the initial phase.     

Influence of age and hospital volume on the results of carotid endarterectomy: a statewide analysis of 9918 cases

PURPOSE: This study evaluated the impact of patient age and hospital volume on the results of carotid endarterectomy (CEA) in contemporary practice. METHODS: The Maryland Health Services Cost Review Commission (MHSCRC) database was reviewed to identify all patients who underwent elective CEA as the primary procedure in all acute care hospitals in the state over the past 6 years. RESULTS: From January 1990 through December 1995, 9918 elective CEAs were performed in 48 hospitals at a total charge of $68.9 million. Postoperative death and neurologic complications occurred in 90 (0.9%) and 166 (1.7%) cases, including 0.8% and 1.7%, 0.9% and 1.6%, 0.9% and 1.8%, and 1.4% and 1.3% of patients < 65 years, 65 to 69 years, 70 to 79 years, and > or = 80 years old, respectively. The mean length of stay and hospital charges increased linearly with increasing age: 4.2 days/$6550, 4.4 days/$6834, 4.8 days/$7059, and 5.6 days (p < 0.0001 vs others)/$7756 (p < 0.005 vs 70 to 79 years and p < 0.0003 vs < 70 years old), respectively, for patients < 65, 65 to 69, 70 to 79, and > or = 80 years old. The mortality rate was 1.9% in low-volume hospitals, 1.1% in moderate-volume hospitals, and 0.8% in high-volume hospitals. The neurologic complication rate was significantly higher (6.1%; p < 0.0001) in low-volume when compared with moderate-volume (1.3%) and high-volume (1.8%) hospitals. CONCLUSIONS: CEA is a safe procedure in the majority of hospitals in contemporary practice, even among the very elderly, who may experience a longer length of stay and higher charges correlating with their documented greater medical complexity.     

Effect of surgical panel composition on patient outcome at a level I trauma center

OBJECTIVE: To compare the effect of staffing with general surgeons vs trauma specialists on patient outcome at a trauma center. DESIGN: The care of injured patients at a level I urban trauma center serving a population of 2.5 million was the responsibility of 12 surgeons (10 general surgeons and 2 trauma specialists) between January 1 and June 30, 1996 (group 1). Between July 1 and December 31, 1996 (group 2), trauma was the responsibility solely of 4 trauma specialists. An additional comparison was made with those patients in group 1 who were admitted to the general surgeons (group 1A). The outcomes and quality of care for these periods, as determined by the quality assurance screens, were retrospectively analyzed and compared. SETTING: Urban, tertiary care, level I trauma center. PARTICIPANTS: Each trauma and burn patient admitted during the study periods is included in this study. Upon the patient's discharge from the hospital, specially trained nurses completed a review of the patient's stay and entered it into the TraumaOne database (Lancet Technology Inc, Cambridge, Mass). There were 693 trauma patients in group 1 (472 in group 1A) and 734 patients in group 2. MAIN OUTCOME MEASURES: Mortality, length of stay, and 16 quality assurance screens were quantified and compared using chi(2) analyses and t tests. RESULTS: The age and sex of the 2 groups were similar. The mortality rate was 6.2% (43/693) in group 1, 6.1% (29/472) in group 1A, and 6.5% (48/734) in group 2 (P = .80 and P = .78, respectively). When stratified by injury severity score (ISS), lengths of stay were statistically similar, except for patients with an ISS of 0 to 7. Patients with an ISS of 0 to 7 in groups 1 and 1A stayed a mean of 2.6 days, compared with 3.2 days for group 2 (P = .01 and P = .02, respectively). The results of quality assurance screens (missed injury, wound infection, readmission, and 13 others) were similar in the 2 groups. CONCLUSIONS: Transitions in staffing afforded the opportunity to examine patient outcomes by surgeon specialization and frequency of call. In our sample, 12 well-trained surgeons taking call less frequently managed a trauma service as efficiently as a group of 4 trauma specialists, without any differences in morbidity and mortality.     

Effects of metal ions on the rates and enantioselectivities of reactions catalyzed by a series of semisynthetic transaminases created by site directed mutagenesis

BACKGROUND: Early discharge after childbirth is widely reported. In this study the authors examined trends in maternal length of hospital stay in Canada from fiscal year 1984-85 through fiscal year 1994-95. They also examined variations in length of stay in 1994-95 in most of the Canadian provinces and the territories. METHODS: Epidemiologic analyses of the temporal and geographic variations in maternal length of hospital stay in Canada from 1984-85 to 1994-95 (even years only), based on hospital discharge data collected by the Canadian Institute for Health Information, with a total of 1,456,800 women for the 6 study years. RESULTS: Mean length of hospital stay decreased during the decade, from 5.3 days in 1984-85 to 3.0 days in 1994-95, with similar trends for both cesarean and vaginal delivery. The decrease resulted from both increasing rates of short stay (less than 2 days) and decreasing rates of long stay (more than 4 days). Substantial temporal and interprovincial variations in several medical and obstetric complications were also observed but did not explain the corresponding variations in length of stay. The reduction in length of hospital stay was not restricted to uncomplicated cases: there was an equivalent decrease in cases with complications. In 1994-95 the average length of hospital stay in Alberta was 2.6 days, 0.3 to 1.7 days shorter than in the other provinces and the territories. INTERPRETATION: Length of hospital stay for childbirth has decreased substantially in Canada in recent years, but there remain important interprovincial variations. These trends and variations are not likely due to changes or differences in patient-specific factors.     

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis

BACKGROUND: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially in cases where surgeons are not limited by technical constraints. METHODS: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July 1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy was performed using a three-trocar technique and the endoscopic stapler. Results: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669; p = ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom had perforated appendicitis. CONCLUSIONS: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis.     

High incidence of adeno- and polyomavirus-induced hemorrhagic cystitis in bone marrow allotransplantation for hematological malignancy following T cell depletion and cyclosporine

Retrosternal goiter is defined as any goiter in which at least 50 per cent of the thyroid resides below the level of the thoracic inlet. The incidence of retrosternal goiter varies from 3 to 20 per cent with respect to thyroidectomy patients. A retrospective chart review from June 1991 to December 1997 found 232 thyroidectomies performed at our institution. Sixteen patients were found to have retrosternal goiters (6.9%). The mean age was 57.8 years (range, 34-92). All were of benign pathology. Symptoms included shortness of breath (68.8%), hoarseness (37.5%), dysphagia (31.3%), and superior vena cava obstruction (6.25%). Thirteen patients were female (81.3%). Fifteen patients had surgical intervention (93.8%). Total thyroidectomy was performed in nine cases (60%), whereas lobectomy was performed in six cases (40%). All treated patients had complete resolution of symptoms. A cervical incision alone was used in 13 cases (86.7%). Complications consisted of one postoperative pleural effusion and in one case a traumatic C5 nerve root compression occurred. There were no instances of long-term vocal cord paralysis or hypoparathyroidism. There was no perioperative mortality. In the majority of patients with retrosternal goiter, surgery can be done expeditiously through a cervical incision with minimal morbidity and mortality.     

Does practice make perfect? Examining the relationship between hospital surgical volume and outcomes for hip fracture patients in Quebec

OBJECTIVES: Most tests of the practice-makes-perfect hypothesis have used cross-sectional data, which reveal that patients receiving surgery in high-volume hospitals tend to experience better postsurgery outcomes. This study uses longitudinal data to explicitly examine whether any given hospital's patient outcomes change as its surgery volume varies with time. METHODS: Longitudinal data from all hospitals conducting hip fracture surgery in Quebec between 1990 and 1993 were used to examine the relationship between surgery volume and outcomes. The longitudinal data allowed volume to be measured using the actual number of surgeries performed by the admitting hospital in the 12 months before a patient's surgery. Determinants of postsurgery length of stay were assessed using ordinary least squares regression, and the explanators of inpatient mortality were identified using logistic regression. The regressions included fixed effects (hospital-specific dummy variables) to control for systematic differences in outcomes across hospitals that persist with time. Therefore, the coefficient on hip fracture surgery volume in the regression models captured differences in outcomes that were attributable to changes in surgery volume within hospitals with time. RESULTS: The fixed effects were significant explanators of both postsurgery length of stay and inpatient mortality, indicating that there were significant differences in outcomes across hospitals that persisted with time. In regressions that excluded the fixed effects, the coefficient on surgery volume was significant. In contrast, the coefficient on surgery volume was insignificant when the fixed effects were included. CONCLUSIONS: Longitudinal data revealed that after controlling for differences in hospital outcomes that were fixed with time, hospitals performing more surgeries in one period than in another experienced no significant improvement in outcomes. These results do not support the "practice makes perfect" hypothesis. The volume-outcome relationship for hip fracture patients thus appears to reflect fixed differences in quality between high-volume and low-volume hospitals.     

Closed humeral shaft fractures: a prospective evaluation of surgical treatment

OBJECTIVE: We tried to define the roles of the rigid dynamic compression plate (DCP) and the semi-rigid Ender nail (EN) in the treatment of closed humeral shaft fractures. DESIGN: A prospective, randomized clinical study was performed with detailed comparison parameters. MATERIALS AND METHODS: Ninety-one closed humeral shaft fractures were treated. Randomly, 30 humeri were treated with open reduction and internal fixation with DCP and no bone grafting (BG), 29 were treated with the same procedure but with BG, and 32 were treated with closed reduction and internal fixation with Ender nails. The average follow-up period was 32 months (range, 13-54 months). MEASUREMENTS AND MAIN RESULTS: In the group with DCP without BG, the average blood loss was 270 mL, operation time was 92 minutes, hospital length of stay was 6.5 days, and union time was 12.5 weeks. In the group with DCP with BG, the average blood loss was 325 mL, operation time was 108 minutes, hospital length of stay was 6.9 days, and union time was 9.4 weeks. In the EN group, the average blood loss was 114 mL, operation time was 54 minutes, hospital length of stay was 5.6 days, and union time was 9.9 weeks. Analysis of variance and Fisher's exact test were used to evaluate the statistical significance. CONCLUSION: In our experience, for humeral shaft fractures fixed surgically, EN is better than DCP without BG. When DCP is chosen for the means of fixation, prophylactic BG is recommended, especially in cases with more comminution.     

Ultrasonically activated shears in thyroid surgery

BACKGROUND: Ultrasonically activated shears (UAS) have been documented to be both safe and fast devices in laparoscopic surgery. We studied whether the use of UAS would have some advantage in thyroid surgery. METHODS: Thyroidectomies, performed by one senior endocrine surgeon between December 1996 and February 1997, were retrospectively matched, with patients operated on by the same surgeon using the conventional method. RESULTS: Six pairs of total thyroidectomies and one pair of lobectomies could be matched. Mean operating time was 100 minutes for the patients operated on with the UAS and 154 minutes for the patients operated on with the conventional method. The mean operating time with the UAS was thus on average 64.6% of the operation time with the conventional method, with a 95% confidence interval from 50.1% to 83.5% (t = 4.00, 6 df, P = 0.007). CONCLUSIONS: In this material the use of UAS reduced significantly operating time in thyroidectomies.     

Patients in Norwegian hospitals. Length of stay and patterns of use

All 633,987 periods of admission to Norwegian general hospitals in 1991 were analyzed. The length of stay increases considerably with the patient's age. 80-year old patients stay three times as long in hospital as five-year old patients. The typical surgical patient requires 56% more resources than the typical medical patient. For surgical patients, the mean length of stay was 7.2 days, and for medical patients it was 6.8 days. Patients in the age group 70-79 years require almost twice as much resources as the youngest patients. Patients up to the age of 65 who live in a municipality where there is a hospital stay in hospital just as long as corresponding patients from municipalities without a hospital. For older patients there are significant differences in length of stay for these two categories of patients. The discharge rate for men of 70 years and older is significantly higher than the rate for women in the same age group, but the women stay longer in hospital.     

Patient comorbidity: relationship to outcomes of total knee arthroplasty

One hundred six patients treated consecutively with total knee arthroplasty were evaluated to determine whether preoperative comorbidity (as measured by patient class, knee score, short form, anesthesia severity assessment, and number of medical comorbidities) correlated with perioperative and postoperative outcomes, including length of stay, total (and specific) hospital charges, and validated outcome scores. The length of stay for total knee arthroplasty was longer in patients who had lower preoperative knee scores and for patients with greater medical and musculoskeletal morbidity. Greater total hospital costs were associated with Class C patients and patients with poor anesthesia morbidity ratings. Patients who were debilitated medically and had four or more risk factors had decreased postoperative outcome scores. Preoperative medical and musculoskeletal morbidity influence the results of total knee arthroplasty. These findings may be useful to surgeons for optimizing resource utilization and outcomes in patients undergoing total knee arthroplasty. These data must be accounted for when contrasting total knee arthroplasty results between different surgeons and institutions.     

Effects of an intervention by a diabetes team in hospitalized patients with diabetes

OBJECTIVE: Hospitalized patients with diabetes have a prolonged length of stay in the hospital. We conducted a controlled prospective randomized feasibility study of the effects of a diabetes team (a diabetes nurse educator and an endocrinologist) on the length of stay and other outcomes of hospitalization in these patients. RESEARCH DESIGN AND METHODS: A total of 179 hospitalized patients with diabetes were randomly assigned to receive usual care supplemented with (85 patients) or without (94 control patients) a diabetes team intervention. Outcome measures included the length of stay, blood glucose control, and rates of readmission. RESULTS: For the primary diagnosis of diabetes, the median length of stay was 5.5 days (95% CI 4-8 days) for patients who received diabetes team intervention and 7.5 days (5-11 days) for the control patients (NS). For the secondary diagnosis of diabetes, the median length of stay was 10.0 days (8-13 days) in the intervention group and 10.5 days (8-13 days) in the control group (NS). One month after the team intervention was initiated, 75% of patients in the intervention group were in good glycemic control, compared with 46% in the control group. Readmissions at 3 months after discharge included 13 (15%) patients from the intervention group and 30 (32%) patients in the control group (P = 0.01). CONCLUSIONS: Randomized controlled prospective trials of clinical interventions in hospitalized patients with diabetes are feasible. Diabetes team intervention appears to reduce the hospital length of stay and to improve glycemic control. Team intervention significantly reduces the rate of recurrent hospitalization.     

Prognostic significance of the expressions of metallothionein, glutathione-S-transferase-pi, and P-glycoprotein in curatively resected gastric cancer

OBJECTIVE: To determine the effect of adding a trained intensivist on patient care and educational outcomes in a community teaching hospital. MATERIAL AND METHODS: We retrospectively reviewed outcomes for patients admitted to the medical intensive-care unit (MICU) of a 270-bed community teaching hospital between July 1992 and June 1994. Mortality rates and durations of stay were determined for the year before (BD, 1992 through 1993) and the first year after (AD, 1993 through 1994) introduction of a full-time director of critical care. Performance of resident trainees on a standardized critical-care examination was measured for the same periods. RESULTS: Overall, 459 patients in the BD period were compared with 471 patients in the AD period. The mix of cases and severity of illness (acute physiology and chronic health evaluation or APACHE II scores) on admission were similar for the BD and AD periods. MICU mortality decreased from 20.9% during the BD to 14.9% during the AD period (P = 0.02), and in-hospital mortality decreased from 34.0% to 24.6% (P = 0.002). Disease-specific mortalities were lower during the AD period for most categories of illness. Detailed analysis of a subgroup of patients (those with pneumonia) demonstrated no differences in distribution of patients by gender, race, or acuity of illness (APACHE II scores). The mortality rate due to pneumonia decreased from 46% during the BD period to 31% during the AD period. This decrease was consistent across categories of APACHE II scores. From BD to AD periods, mean durations of total hospital stay decreased from 22.6 +/- 1.4 days to 17.7 +/- 1.0 days, and mean MICU stay decreased from 5.0 +/- 0.3 days to 3.9 +/- 0.3 days (P < 0.05). Critical-care in-service examination scores for 22 residents increased from 53.8 +/- 1.7% to 67.5 +/- 2.2% (P < 0.01), and AD scores were significantly higher than BD scores for residents at similar levels of training. CONCLUSION: Addition of a medical intensivist was temporally associated with improved clinical and educational outcomes in our community teaching hospital.