The unequal clinical profile, quality of life and hospital mortality in patients undergoing aortocoronary bypass in the public and private centers of Catalonia. The CIRCORCA Study

INTRODUCTION AND AIMS: The influence of the type of health care funding and management of hospital centres on hospital mortality in coronary artery bypass surgery (CABG) has not been analyzed in detail. We therefore assessed clinical and quality of life preoperative profiles and in-hospital mortality in public and private patients undergoing coronary bypass surgery in Catalonia. METHODS: Clinical questionnaires, Duke Activity Status Index (DASI) and SF-36 were preoperatively administered to all patients undergoing first coronary bypass surgery without associated procedures in Catalonia between November 1996-June 1997. In-hospital morbidity and mortality were recorded. RESULTS: Predictors of in-hospital death, including DASI, SF-36 and comorbidity scores, were significantly worse in public than in private patients. In-hospital mortality rate was more than ten times greater in public than in private patients (8.2% vs 0.7%; p < 0.001). Multivariate analysis identified private funding of health care, among others, as an independent predictor of in-hospital survival. Non evidence-based indications for surgery were significantly more common in private than in public patients (6% vs 0.7%, p < 0.001). CONCLUSIONS: a) In catalonia, the risk profile of public patients undergoing coronary bypass surgery was significantly higher than that of private patients, accounting, at least in part, for a remarkable mortality difference; b) non evidence-based indications for surgery were more common in private than in public patients; c) these unequal patterns raise questions about the adequacy of care and referral patterns in both private and public sectors.     

Gastrointestinal complications following cardiac surgery

This study sought to determine which factors influence the mortality rate in patients developing gastrointestinal complications following cardiac surgery. Between July 1988 and January 1992, 2054 patients underwent cardiac surgical procedures at the Boston University Medical Center. Of these, 29 (1.4%) developed postoperative gastrointestinal complications. The overall mortality rate among these patients was 27% (8/29). Those who died following such complications had a higher incidence of New York Heart Association (NYHA) class IV and unstable symptoms (8/8, 100% versus 3/21, 14%; P < 0.0001), and an increased need for preoperative intra-aortic balloon pump support (4/8, 50% versus 1/21, 5%; P < 0.004). The need for gastrointestinal surgical intervention increased the mortality rate significantly compared with patients managed medically (8/18, 44% versus 0/11, 0%; P < 0.01). Patients with ischemic bowel also had a significantly higher mortality (5/5, 100% versus 3/24, 12%; P < 0.001). It is concluded that most patients with gastrointestinal complications following cardiac surgery can be treated, and with acceptable mortality rates. The presence of unstable symptoms, preoperative intra-aortic balloon pump support, ischemic bowel and the need for gastrointestinal surgical intervention adversely affect mortality.     

Factors influencing selected lengths of ICU stay for coronary artery bypass patients

This study examines factors influencing the length of intensive care unit stay for patients after coronary artery bypass surgery. Profiles of patients with selected lengths of ICU stay were identified for Group 1 (< or =1 day) and Group 2 (> or =2 days). Medical records of 175 patients who had undergone this procedure at an urban teaching hospital were reviewed. Patients who had a 1-day ICU length of stay were younger (mean=62.39, SD=10.88) and had comorbidities such as hypertension. Those patients with an ICU length of stay 2 days or longer were older (mean=68.18, SD=11.84) and had preoperative comorbidities such as congestive heart failure, chronic obstructive pulmonary disease, ejection fraction <50%, and need for an intra-aortic balloon pump. Atrial dysrhythmias, low cardiac output syndrome, renal insufficiency, and respiratory insufficiency were the postoperative complications associated with a prolonged ICU length of stay. Knowledge of the factors influencing selected lengths of ICU stay will enable nurses to choose patients for critical pathways and to anticipate postoperative problems in high-risk patients.     

Intraoperative endovascular angioplasty and stenting of iliac artery: an adjunct to femoro-popliteal bypass

BACKGROUND: With the rapid development of endovascular techniques, the management strategy of patients with multilevel atherosclerotic arterial occlusive disease is also evolving. Iliac artery stenting is a means whereby multiple bypass operations can be avoided in such patients. The early results of preoperative iliac artery stenting seem promising but the role of intraoperative iliac artery angioplasty and stenting is less clear. STUDY DESIGN: This study was undertaken to evaluate our early results of a combined endovascular and operative approach to patients with multilevel atherosclerotic arterial occlusive disease. Between June 1995 and March 1997, primary intraoperative iliac artery balloon angioplasty and stent placement were performed on 13 affected limbs of 12 patients undergoing an infrainguinal bypass operation. Indications for operation, patient demographics, and risk factors were noted. The outcome of surgery and the patency rates of bypass graft and stent were also recorded. RESULTS: The initial technical success of primary iliac artery angioplasty and stenting was 93%. An improvement of the ankle-brachial index by a mean value of 0.38 was attained after operation (p < 0.001). Clinical success, based on the criteria suggested by the Society for Vascular Surgery/International Society for Cardiovascular Surgery, was achieved in all patients. There was no operative or hospital mortality. Postoperative morbidity rate was 8% (n = 1). The cumulative 1-year patency rates of iliac stent and infra-inguinal bypass grafts were 100% and 85%, respectively. The limb loss rate was 7%. CONCLUSIONS: The technique of intraoperative angioplasty and stenting can be easily mastered by an experienced and skilled vascular surgeon, using a portable C-arm fluoroscopic unit, in the operation theater. A combined endovascular and operative approach optimizes the therapeutic option to this selected group of patients.     

The use of prosthetic meshes in the surgical treatment of inguinal hernia: the costs and profits for the local health screening unit]

BACKGROUND: The appropriate timing of elective coronary artery bypass surgery (CABG) following acute myocardial infarction (AMI) remains uncertain. It is hypothesized that a waiting period allows the myocardium to recover prior to revascularization, thus decreasing morbidity and mortality. This study was designed to determine if a waiting strategy is justified following AMI in patients requiring elective CABG. METHODS: Between 1994 and 1996, 214 patients underwent isolated, nonrepeat, elective CABG. Three groups were evaluated: group I, control, 155 patients with no AMI; group 11, 39 patients with nontransmural AMI; and Group III, 20 patients with transmural AMI. Demographics, intraoperative, and postoperative variables were collected and compared among all groups. RESULTS: Groups were well-matched demographically: group I, patients waited an average of 2.3 days in hospital prior to operation; group II, an average of 4.2 days; and group III, an average of 5.2 days. Except for the use of inotropes, group I 34%, group 11 39%, and group III 70% (P = 0.007), and the intra-aortic balloon pump, group I 0%, group 11 8%, and group III 25% (P = 0.001). There were no differences in complications. Importantly, there was no difference in mortality or postoperative length of stay. The mortality in group I was 2.6%, in group 11 2.6%, and in group III 0%. The length of stay in groups I and II was 8.5 days, and in group III, 8.1 days. CONCLUSION: A waiting period of 3 to 5 days after a nontransmural AMI and 5 to 7 days after a transmural AMI can produce similar postoperative results to non-AMI patients undergoing CABG. Thus, a waiting strategy to allow the myocardium to recover is justified.     

Clinical and hemodynamic criteria for use of the intra-aortic balloon pump in patients requiring cardiac surgery

In order to establish criteria for elective use of the intra-aortic balloon pump (IABP) in patients having cardiac surgery, we conducted a retrospective study of 43 patients who required counterpulsation, because of inability to be weaned from cardiopulmonary bypass, between May, 1972, and June, 1974. Patients in cardiogenic shock preoperatively were excluded. The 43 patients included 23 (Group A) who had severe preoperative left ventricular dysfunction with a mean cardiac index less than 1.8 L. per minute per square meter, ejection fraction less than 30 per cent, and end-diastolic pressure greater than 22 mm. Hg; 20 patients (Group B) had a combination of moderate cardiac dysfunction (cardiac index less than 2.2, ejection fraction less than 40, end-diastolic pressure less than 18) in the presence of acute infarction or severe aortic stenosis (gradient greater than 80 mm. Hg) with or without coronary disease. An inverse relationship was noted between survival and delay from completion of operation to the use of 1ABP. Thirty-two of 43 patients were weaned off bypass and were balloon assisted for 12 to 96 hours postoperatively; 25 patients were discharged (58 per cent). In Subgroup A, 14 of 23 (60 per cent) and, in Subgroup B, 9 of 20 (45 per cent) were long-term survivors. Based on these findings, 45 patients were operated upon between June, 1974, and December, 1975, with elective use of 1ABP and were assessed by serial hemodynamic studies. Sixteen had severe preoperative left ventricular dysfunction similar to Subgroup A and 29 had moderate dysfunction in combination with pathology similar to Subgroup B. Fifteen of these patients were hemodynamically unstable at time of arrival in the operating room; 1ABP was inserted under local anesthesia. Thirty-nine patients (87 per cent) were weaned off bypass and were hospital survivors. In Subgroup A, 13 of 16 (81 per cent) and, in Group B, 21 of 29 (72 per cent) were long-term survivors. Criteria for elective use of 1ABP in cardiac surgery should include severe preoperative left ventricular dysfunction or a combination of moderate dysfunction with coronary or valvular pathology. Elective 1ABP improves the survival with trivial iatrogenic morbidity.     

Coronary angioplasty volume-outcome relationships for hospitals and cardiologists

OBJECTIVE: To assess the relationship between each of 2 provider volume measures (annual hospital volume and annual cardiologist volume) for percutaneous transluminal coronary angioplasty (PTCA) and 2 outcomes of PTCA (in-hospital mortality and same-stay coronary artery bypass graft [CABG] surgery). DESIGN: Cohort study, using data from January 1, 1991, through December 31, 1994, from the Coronary Angioplasty Reporting System of the New York State Department of Health. SETTING: Thirty-one hospitals in New York State in which PTCA was performed during 1991-1994. PATIENTS: All 62670 patients discharged after undergoing PTCA in these hospitals during 1991-1994. MAIN OUTCOME MEASURES: Rates of in-hospital mortality and CABG surgery during the same stay as the PTCA. RESULTS: The overall in-hospital mortality rate for patients undergoing PTCA in New York during 1991-1994 was 0.90%, and the same-stay CABG surgery rate was 3.43%. Patients undergoing PTCA in hospitals with annual PTCA volumes less than 600 experienced a significantly higher risk-adjusted in-hospital mortality rate of 0.96% (95% confidence interval [CI], 0.91%-1.01%) and risk-adjusted same-stay CABG surgery rate of 3.92% (95% CI, 3.76%-4.08%). Patients undergoing PTCA by cardiologists with annual PTCA volumes less than 75 had mortality rates of 1.03% (95% CI, 0.91%-1.17%) and same-stay CABG surgery rates of 3.93% (95% CI, 3.65%-4.24%); both of these rates were also significantly higher than the rates for all patients. Also, same-stay CABG surgery rates for patients undergoing PTCA in hospitals with annual volumes of 600 to 999 performed by cardiologists with annual volumes of 75 to 174 (2.99%; 95% CI, 2.69%-3.31 %) and 175 or more (2.84%; 95% CI, 2.57%-3.14%) were significantly lower than the overall statewide rate (3.43%). CONCLUSIONS: In New York State, both hospital PTCA volume and cardiologist PTCA volume are significantly inversely related to in-hospital mortality rate and same-stay CABG surgery rate for patients undergoing PTCA.     

Identification of human and rabbit cytochromes P450 1A2 as major isoforms involved in thiabendazole 5-hydroxylation

OBJECTIVE: To determine perioperative predictors of morbidity and mortality in patients > or =75 yrs of age after cardiac surgery. DESIGN: Inception cohort study. SETTING: A tertiary care, 54-bed cardiothoracic intensive care unit (ICU). PATIENTS: All patients aged > or =75 yrs admitted over a 30-month period for cardiac surgery. INTERVENTION: Collection of data on preoperative factors, operative factors, postoperative hemodynamics, and laboratory data obtained on admission and during the ICU stay. MEASUREMENTS AND MAIN RESULTS: Postoperative death, frequency rate of organ dysfunction, nosocomial infections, length of mechanical ventilation, and ICU stay were recorded. During the study period, 1,157 (14%) of 8,501 patients > or =75 yrs of age had a morbidity rate of 54% (625 of 1,157 patients) and a mortality rate of 8% (90 of 1,157 patients) after cardiac surgery. Predictors of postoperative morbidity included preoperative intraaortic balloon counterpulsation, preoperative serum bilirubin of >1.0 mg/dL, blood transfusion requirement of >10 units of red blood cells, cardiopulmonary bypass time of >120 mins (aortic cross-clamp time of >80 mins), return to operating room for surgical exploration, heart rate of >120 beats/min, requirement for inotropes and vasopressors after surgery and on admission to the ICU, and anemia beyond the second postoperative day. Predictors of postoperative mortality included preoperative cardiac shock, serum albumin of <4.0 g/dL, systemic oxygen delivery of <320 mL/ min/m2 before surgery, blood transfusion requirement of >10 units of red blood cells, cardiopulmonary bypass time of >140 mins (aortic cross-clamp time of >120 mins), subsequent return to the operating room for surgical exploration, mean arterial pressure of <60 mm Hg, heart rate of >120 beats/min, central venous pressure of >15 mm Hg, stroke volume index of <30 mL/min/m2, requirement for inotropes, arterial bicarbonate of <20 mmol/L, plasma glucose of >300 mg/dL after surgery, and anemia beyond the second postoperative day. During the study period, the study cohort used 6,859 (21.5%) ICU patient-days out of a total 31,867 ICU patient-days. Nonsurvivors used 2,023 (30%) ICU patient-days and patients with morbidity used 5,903 (86%) ICU patient-days. CONCLUSIONS: Severe underlying cardiac disease (including shock, requirement for mechanical circulatory support, hypoalbuminemia, and hepatic dysfunction), intraoperative blood loss, surgical reexploration, long ischemic times, immediate postoperative cardiovascular dysfunction, global ischemia and metabolic dysfunction, and anemia beyond the second postoperative day predicted poor outcome in the elderly after cardiac surgery. Postoperative morbidity and mortality disproportionately increased the utilization of intensive care resources in elderly patients. Future efforts should focus on preoperative selection criteria, improvement in surgical techniques, perioperative therapy to ameliorate splanchnic and global ischemia, and avoidance of anemia to improve the outcome in the elderly after cardiac surgery.     

Expression of the POU transcription factor Brn-5 is an early event in the terminal differentiation of CNS neurons

OBJECTIVE: To evaluate transesophageal echocardiography (TEE) as an intraoperative monitoring modality and to assess its safety, reliability, and overall utility in real-time use during cardiac surgery. DESIGN: Prospective, observational cohort study performed from January 1993 to June 1997. SETTING: Operating room of a tertiary care hospital for cardiology and cardiovascular surgery. PARTICIPANTS: Five thousand and sixteen adult patients with acquired heart disease, who underwent 1,356 valve procedures and 3,660 coronary artery bypass graftings (CABGs). INTERVENTIONS: All patients were monitored with radial artery and pulmonary artery catheters, along with continuous TEE monitoring with a multiplane transducer. MEASUREMENTS AND MAIN RESULTS: Prebypass imaging yielded unsuspected findings that either helped or modified the surgical plan in 158 of 1,356 valve procedures (11.65%) and in 993 of 3,660 CABGs (27.13%). There were 3,217 TEE-guided hemodynamic interventions in 944 patients (25.79%) in the CABG group and 629 in 142 patients (10.47%) in the valve group. TEE was the sole guiding factor in initiating therapy in 23.53% of events, whereas it was supportive to other monitoring modalities in 76.46% of events. Postbypass TEE identified the need for graft revision in 29 patients (0.8%), intra-aortic balloon pump (IABP) requirement in 29 patients (0.8%), and inadequate valve repair in 28 patients (2.08%). For the entire series, 38.78% of patients benefited from prebypass and 39.16% from postbypass use of TEE. There were no complications attributable to the use of TEE in the entire series. There was 87% concordance between online interpretation by a trained anesthesiologist and offline analysis by a cardiologist. CONCLUSION: Intraoperative TEE is useful in formulating the surgical plan, guiding various hemodynamic interventions, and assessing the immediate results of surgery. It is safe and the results are reliable in the hands of trained anesthesiologists.     

Factors influencing elementary school teachers'' ratings of ADHD and ODD behaviors

Oligo-elements such as zinc (Zn), selenium (Se) and copper (Cu) have a significant influence on the function of the immune system. Various immunological and inflammatory changes are known to occur in patients undergoing cardiopulmonary bypass. The aim of this study was to evaluate changes in serum oligo-elements levels during and following cardiopulmonary bypass. The serum levels of Zn, Se and Cu were determined in 67 consecutive patients, with coronary artery disease admitted for coronary artery bypass grafting. Blood samples for oligo-elements, analysis were withdrawn into metal-free tubes just prior to the start of cardiopulmonary bypass; at 30, 60 and 90 min into cardiopulmonary bypass; following weaning from cardiopulmonary bypass; 30 min after termination of cardiopulmonary bypass; at 24 h; and on the 5th postoperative day. Trace elements analyses were performed using atomic absorption spectrophotometry. Interleukin 6 and 8, as well as serum albumin, creatine phosphokinase, lactate dehydrogenase and creatine phosphokinase-MB fractions were also analyzed. The mean age was 63 +/- 9 years and 91% (61) were men. The mean preoperative left ventricular function was 52 +/- 12%, Canadian Cardiovascular Society (CCS) angina class was 3.7 +/- 0.5 and 30% (20) of the operations were re-do's. All patients had normothermic cardiopulmonary bypass. Mean cardiopulmonary bypass-time was 85 +/- 31 min. One patient was lost for the recovery sampling (hospital mortality, 1.5%). Nine patients had a postoperative cardiac index < 2.0 liter/min per m2, which required pharmacological support and additional intra-aortic balloon pump in two of them. Other postoperative complications were few. There was a rapid depletion of S-selenium and S-Zn levels, which were halved at 30 min after cardiopulmonary bypass and remained low throughout the study period. The Cu/Zn ratio increased significantly at the start of cardiopulmonary bypass, which indicated an inflammatory reaction and was not normalized until the 5th postoperative day. Length of ischemia time, presence of diabetes. hypertension and hyperlipidemia did not influence the results, while a prolonged cardiopulmonary bypass-time > 120 min resulted in a higher Cu/Zn ratio than observed for shorter cardiopulmonary bypass-times. This indicates a more profound inflammatory response. Inflammatory parameters responded in the same manner as described earlier by others. These data indicate that severe loss of various oligo elements occur in patients undergoing coronary artery bypass grafting and suggests that a supplementary administration of zinc and perhaps also selenium could be appropriate during cardiopulmonary bypass.     

Outcome of palliative biliary and gastric bypass surgery for pancreatic head carcinoma in 126 patients

BACKGROUND: Recent reports of decreased morbidity and mortality following palliative surgery for patients with irresectable pancreatic head carcinoma prompted a review of the results in 126 patients (median age 64 (range 39-90) years) who had undergone palliative biliary and gastric bypass surgery. METHODS: The indication for surgical palliation was the finding of an irresectable tumour at laparotomy (n = 44), failure of endoscopic treatment (n = 43), clinical symptoms of gastric outlet obstruction (n = 28) and miscellaneous (n = 11). Biliary and gastric bypass was performed in 118 patients, biliary bypass alone in six and gastrojejunostomy alone in two. The indication for gastrojejunostomy was symptoms in 28 patients (23 per cent) and prophylaxis in 92 patients (77 per cent). RESULTS: Postoperative local complications occurred in 17 per cent of patients, general complications in 10 per cent and delayed gastric emptying in 14 per cent of patients. The 30-day mortality rate was 1 per cent and overall hospital mortality rate 2 per cent. Median hospital stay was 17 (range 5-80) days. Median overall postoperative survival was 190 (range 14-830) days. Late obstructive gastrointestinal symptoms occurred in 14 patients (11 per cent) after a median of 141 (range 21-356) days. CONCLUSION: Roux-en-Y hepaticojejunostomy combined with gastrojejunostomy offers effective palliation for irresectable pancreatic head cancer and can be performed with low mortality and acceptable morbidity rates.     

The impact of nosocomial infections on patient outcomes following cardiac surgery

STUDY OBJECTIVE: To evaluate the relationship between nosocomial infections and clinical outcomes following cardiac surgery, and to identify risk factors for the development of nosocomial infections in this patient population. DESIGN: Prospective cohort study. SETTING: Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS: Six hundred five consecutive patients undergoing cardiac surgery. INTERVENTIONS: Prospective patient surveillance and data collection. MAIN OUTCOME MEASURES: Occurrence of nosocomial infections, multiorgan dysfunction, hospital mortality, and risk factors for the acquisition of nosocomial infections. RESULTS: One hundred thirty-one (21.7%) patients acquired at least one nosocomial infection following cardiac surgery. Four independent risk factors for the development of a nosocomial infection were identified: the duration of mechanical ventilation, postoperative empiric antibiotic administration, the duration of urinary tract catheterization, and female gender. Thirty (5.0%) patients died during their hospitalization. The mortality rate of patients acquiring a nosocomial infection (11.5%) was significantly greater than the mortality rate of patients without a nosocomial infection (3.2%) (odds ratio [OR]=4.0; 95% confidence interval [CI]=2.7 to 5.8; p<0.001). Multiorgan dysfunction was found to be the most important independent determinant of hospital mortality (adjusted OR=23.8; 95% CI=13.5 to 42.1; p<0.001) along with the aortic cross-clamp time (adjusted OR=2.3; 95% CI=1.7 to 3.0; p=0.002) and severity of illness as measured by APACHE II (acute physiology and chronic health evaluation) (adjusted OR=1.1; 95% CI=1.1 to 1.2; p=0.019). Ventilator-associated pneumonia, clinical sepsis, female gender, the cardiopulmonary bypass time, and severity of illness were identified as independent risk factors for the development of multiorgan dysfunction. Among hospital survivors, patients acquiring a nosocomial infection had longer hospital lengths of stay compared to patients without a nosocomial infection (20.1+/-13.0 days vs 9.7+/-4.5 days; p<0.001). CONCLUSIONS: Nosocomial infections, which are common following cardiac surgery, are associated with prolonged lengths of hospitalization, the development of multiorgan dysfunction, and increased hospital mortality. These data suggest potential interventions for the prevention of nosocomial infections following cardiac surgery that could substantially improve patient outcomes and decrease medical care costs.     

Temporal changes in the care and outcomes of elderly patients with acute myocardial infarction, 1987 through 1990

OBJECTIVE: To investigate changes between 1987 and 1990 in the care and outcomes associated with acute myocardial infarction (AMI) in elderly patients. DESIGN: Retrospective cohort study using a longitudinal database created from Medicare administrative files. PATIENTS: Cohorts comprising a total of 856,847 AMI patients insured by Medicare between 1987 and 1990. MAIN OUTCOME MEASURES: Annual rates of mortality at 30 days and 1 year following AMI, and the use of coronary angiography, coronary artery bypass graft surgery, and percutaneous transluminal coronary angioplasty during the first 90 days after a new AMI. RESULTS: Between 1987 and 1990, mortality rates decreased 10% overall from 26% to 23% at 30 days (P < .001) and from 40% to 36% at 1 year following AMI (P < .001). Declines in mortality and adjusted risks of 1-year mortality were similar in men and women and in blacks and whites, but mortality declines were more evident in those younger than 85 years. Meanwhile, the proportion of elderly AMI patients having angiography within the first 90 days after their index admission increased from 24% to 33% (P < .001); proportions increased for both genders and all races. The proportion of patients undergoing revascularization procedures increased from 13% to 21%; while rates of bypass surgery increased from 8% to 11%, rates of angioplasty doubled from 5% to 10% (all P < .001). CONCLUSIONS: Between 1987 and 1990, survival of elderly patients following AMI improved significantly. While changes in patient treatment may be responsible, the increased use of thrombolytic therapy appears to be only a partial explanation. Also, while the use of coronary angiography and revascularization procedures increased dramatically, the degree to which it caused the improvement in survival could not be determined.     

The untranslated first exon ''exon 0S'' of the rat estrogen receptor (ER) gene

Occasionally, ipsilateral ischemia develops following the groin insertion of an intra-aortic balloon catheter. Various treatment options have evolved, and include replacing the catheter in the opposite groin, removing it completely, or performing a femorofemoral bypass to deliver blood flow below the catheter. Outlined in this paper is a simple method to restore blood flow to a threatened limb, during femoral artery exploration, in the presence of an intra-aortic balloon. This method is also appropriate for optimal positioning of the balloon catheter prior to femorofemoral bypass.     

Hospital vascular surgery volume and procedure mortality rates in California, 1982-1994

PURPOSE: Little is known about the long-term growth and outcomes of vascular surgery procedures over time. Trends in the use of three major vascular surgery procedures by a general population-lower extremity arterial bypass (LEAB), carotid endarterectomy (CEA), and abdominal aortic aneurysm repair (AAA)-are described. The extent to which these procedures are being performed in low-, moderate-, and high-volume hospitals is examined. METHODS: California hospital discharge records for LEAB, CEA, AAA, lower extremity angioplasty, coronary angioplasty, and coronary bypass surgery (CABG) were studied in all non-federal hospitals between 1982 and 1994. The data were age- and sex-adjusted to describe procedure growth. In-hospital mortality rates for LEAB, CEA, and AAA are related to overall hospital procedure volume, using logistic regression to control for risk factors and time trends. RESULTS: Growth in the number of vascular procedures performed in California was modest between 1982 and 1994, with no age-adjusted growth. Lower extremity angioplasty grew considerably in the 1980s and has since plateaued. Annual in-hospital death rates declined for all procedures except ruptured AAA. Comparing the two 5-year periods of 1982-1986 and 1990-1994, in-hospital death rates decreased from 4.2% to 3.3% for LEAB, from 9.2% to 6.2% for unruptured AAA, and from 1.6% to 1.0% for CEA (p < 0.0001). The odds of dying for patients treated in high-volume hospitals for LEAB and CEA procedures compared with patients treated in hospitals performing fewer than 20 procedures in a year were 66.7% (p = < 0.0001) and 66.1% (p < 0.0001), respectively. For patients with ruptured and unruptured AAA procedures, the odds of dying in hospitals with at least 50 AAA procedures in a year were 49.1% (p < 0.0001) and 83.8% (p = 0.016), respectively, compared with the odds of dying in low-volume hospitals. CONCLUSIONS: In-hospital mortality rates for CEA, LEAB, and unruptured AAA have been significantly decreasing over time. Mortality is inversely related to hospital volume and directly related to patient age and emergency status. Mortality trends over time for ruptured AAA remains unchanged; however, mortality is less in high-volume hospitals. Coronary angioplasty (PTCA) has not had an impact on rates for LEAB.     

Perioperative risk factors affecting hospital stay and hospital costs in open heart surgery for patients > or = 65 years old

OBJECTIVE: Demographic changes, associated with increased demands for open heart surgery in the elderly, place increased burden on financial resources. To evaluate perioperative risk factors affecting incidence of hospital events and estimation of hospital charges, 2577 patients > or = 65 years (range 65-91), operated on from January 1991 to December 1994, were compared with a concurrent cohort of 2642 younger patients. METHODS: Statistical analysis, by surgical procedure, focused on hospital mortality, key postoperative complications affecting length of hospital stay and hospital charges. RESULTS: Overall hospital mortality was 4.7%, 3.5% in younger patients versus 6.1% in the older group (P < 0.01). Mortality was significantly lower in patients less than 65 years undergoing coronary artery bypass grafting (3% versus 5%, P < 0.01) and valve replacement (4% versus 9%, P = 0.01). Significant risk factors for hospital death in the elderly: diabetes (P < 0.01), hypertension (P < 0.01), myocardial infarction (P < 0.01) and congestive heart failure (P < 0.01). Significant postoperative events, more common in older patients, included prolonged ventilation (P < 0.01), congestive heart failure (P < 0.01), infection (P < 0.01), cerebrovascular accident (P < 0.01), and intra aortic balloon pump (P < 0.01). Incremental risk factors for morbidity in the elderly were: higher New York Heart Association class, congestive heart failure, emergent operation, and female gender. Mean length of hospital stay for the < 65 group was 15.3 versus > 19.5 days for the > 65 group (P < 0.01). Length of stay over 18 days positively correlated with increased morbidity in both age groups. For patients > or = 65 years of age, the average hospital charge for open heart surgery was 172% higher for patients with a length of stay greater than 18 days compared with 165% for patients less than 65 years of age. CONCLUSIONS: Higher operative mortality and longer length of stay in elderly patients, resulting in increased health care costs, was associated with more co-morbidities. These results suggest interventions designed to reduce congestive heart failure and other co-morbidities may improve patient's recovery and reduce costs.     

Bacterial leakage into and from prefabricated screw-retained implant-borne crowns in vitro

PURPOSE: To analyze the results of the valve cardiac surgery in pregnant women and cardiopulmonary bypass consequences to the patients and their fetuses. METHODS: Study of 8 pregnant women who underwent cardiac surgery between January of 1986 and December of 1996. Patients' average age was 31.4 +/- 8.9 years and the gestation age ranged from 12 to 31 (average of 26.6 +/- 7.1) weeks. Fetus monitorization was performed in all patients. The temperature was always higher than 34 degrees C, as well as high flow rates during the cardiopulmonary bypass. Four surgeries of aortic valve and four of mitral valve were performed, in which two were reoperations. RESULTS: There was no mortality. There were two premature births and in one child there was neurological damage. The other children did not have growth problems. CONCLUSION: Valve cardiac surgery in pregnant women may have good results as long as care in the cardiopulmonary bypass and fetus monitorization are undertaken.     

Referral selection bias in the Medicare hospital mortality prediction model: are centers of referral for Medicare beneficiaries necessarily centers of excellence?

OBJECTIVE: Although the Health Care Financing Administration (HCFA) uses Medicare hospital mortality data as a measure of hospital quality of care, concerns have been raised regarding the validity of this concept. A problem that has not been fully evaluated in these data is the potential confounding effect of illness severity factors associated with referral selection and hospital mortality on comparisons of risk-adjusted hospital mortality. We address this issue. DATA SOURCES AND STUDY SETTING: We analyzed the 1988 Medicare hospitalization data file (MEDPAR). We selected data on patients treated at the two Mayo Clinic-associated hospitals in Rochester, Minnesota, and a group of seven other hospitals that treat many patients from large geographic areas. These hospitals have had observed mortality rates substantially lower than those predicted by the HCFA model for the period 1987-1990. STUDY DESIGN: Using the multiple logistic regression model applied by HCFA to the 1988 data, we evaluated the relationship between distance from patient residence to the admitting hospital and risk-adjusted hospital mortality. PRINCIPAL FINDINGS: Among patients admitted to Mayo Rochester-affiliated hospitals, residence outside Olmsted County, Minnesota was independently associated with a 33 percent lower 30-day mortality rate (p < .001) than that associated with residence in Olmsted County. When patients at Mayo hospitals were stratified by residence (Olmsted County versus non-Olmsted County), the observed mortality was similar to that predicted for community patients (9.6 percent versus 10.2 percent, p = .26), whereas hospital mortality for referral patients was substantially lower than predicted (5.0 percent versus 7.5 percent, p = < .001). After incorporation of the HCFA risk adjustment methods, distance from patient residence to the hospitals was also independently associated with mortality among the Mayo Rochester-affiliated hospitals and seven other referral center hospitals. CONCLUSIONS: The HCFA Medicare hospital mortality model should be used with extreme caution to evaluate hospital quality of care for national referral centers because of residual confounding due to severity of illness factors associated with geographic referral that are inadequately captured in the extant prediction model.     

Effect of aspirin in coronary artery bypass grafting

OBJECTIVES: To evaluate the effect of aspirin (ASA) therapy on postoperative blood loss, transfusion requirements, reoperation for bleeding, duration of stay in the intensive care unit and in the hospital in a selected population undergoing a first coronary artery bypass grafting (CABG) surgery. DESIGN: Prospective observational study in consecutive patients during a 3-month period. SETTING: A teaching cardiothoracic center. PARTICIPANTS: Two hundred forty consecutive patients undergoing elective coronary artery bypass grafting surgery for the first time. INTERVENTIONS: Two hundred forty consecutive patients admitted for a first CABG the day before surgery were visited. patients with an abnormal routine coagulation screen or taking drugs that might have affected their coagulation mechanisms were prospectively excluded (n = 96). The date of the last dose of ASA was recorded in the 144 remaining patients, and data were acquired prospectively. MEASUREMENTS AND MAIN RESULTS: Total mediastinal blood drainage, blood products usage, reopening, and duration of intensive care unit and hospital stay were recorded. Patients were grouped by days free of ASA. There were no significant differences detected between groups. CONCLUSIONS: In patients undergoing a first CABG and with no known factors affecting their coagulation, ASA therapy did not appear to increase blood loss, reopening for bleeding, or blood products usage requirements during the hospital stay. ASA therapy did not influence the duration of stay in intensive care or in the hospital.     

Benchmarking the perioperative process: III. Effects of regional anesthesia clinical pathway techniques on process efficiency and recovery profiles in ambulatory orthopedic surgery

STUDY OBJECTIVES: (1) To incorporate regional anesthesia options for common outpatient orthopedic surgery into clinical pathways; (2) to use the clinical pathway format and the Procedural Times Glossary published by the Association of Anesthesia Clinical Directors (AACD) as management tools to measure postoperative same-day surgery processes and discharge outcomes; and (3) to determine the effects of general, regional, and combined general-regional anesthesia on these processes and outcomes. DESIGN: Hospital database and patient chart review of consecutive patients undergoing anterior cruciate ligament reconstruction (ACLR) during academic years (AY) 1995-1996 and 1996-1997. Patient data from AY 1995-1996, during which no intraoperative anesthesia clinical pathway existed, served as historical controls. Data from AY 1996-1997, during which intraoperative anesthesia clinical pathways were used, served as the treatment group. SETTING: Ambulatory surgery center in a teaching hospital. MEASUREMENTS AND MAIN RESULTS: The records of 503 ASA physical status I and II patients were reviewed. 1996-1997 patients selected general anesthesia (+/- femoral nerve block) or epidural anesthesia, after which the remainder of the perioperative anesthesia process was standardized with respect to the drugs and equipment used. 1995-1996 patients did not necessarily have a choice in anesthesia technique and did not have a standardized perioperative anesthetic course with respect to specific drugs and supplies. Intervals described in the AACD Procedural Times Glossary, anesthesia drug and supply costs, and patient outcome variables (postoperative nursing interventions required and unexpected admissions), as influenced by anesthesia technique used, were measured. Combined general-regional anesthesia care for ACLR in 1996-1997, when compared with general anesthesia alone, led to increased pharmacy and materials costs and increased turnover time. However, patients with the combined technique showed improved recovery profiles and lower unexpected admission rates, and they required fewer nursing interventions for common postoperative symptoms. Patients receiving epidural anesthesia showed discharge outcomes similar to those patients receiving general anesthesia with femoral nerve block. Postanesthesia care unit bypass (fast-tracking) was more likely in clinical pathway regional anesthesia patients, when compared with the clinical pathway general anesthesia used. CONCLUSIONS: Clinical pathway regional anesthesia care for outpatient orthopedics may have a significant role in simultaneously containing costs and improving both process efficiency and patient outcomes.