Factors related to rehospitalization within thirty days of discharge after coronary artery bypass grafting

BACKGROUND: Early rehospitalization after coronary artery bypass grafting (CABG) is an expensive and frequently adverse outcome. Rehospitalization rates after various surgical procedures have been used as an indicator of quality of care. Determining the extent to which rehospitalization rates reflect patient case mix and severity of illness rather than quality of care requires detailed information regarding the patients, the care they received, and the reasons for their rehospitalization. METHODS: We conducted a nested case control study comparing 110 CABG patients who were rehospitalized within 30 days after discharge with 224 control patients. Control patients were randomly selected from patients undergoing CABG during the same time frame as the cases and were matched on age, gender, and priority of surgery. A detailed chart review provided information regarding treatment in the postsurgical period, in addition to the preoperative information collected on all CABG patients as part of an ongoing regional prospective study. RESULTS: The overall rehospitalization rate was 13.8%. The most common reasons for rehospitalization included: wound infection (19%), atrial fibrillation (13%), pleural effusion (11%), and thromboembolic event (10%). Preoperative severity of illness and comorbidity accounted for 24% of the total variance. After adjustment for these factors, discharge hematocrit less than 30% (OR = 2.01, p = 0.018) and several discharge medications including: antiarrhythmics (OR = 3.26, p = 0.047), diuretics (OR = 2.18, p = 0.055), beta blockers (OR = 0.44, p = 0.036), and long length of stay (more than 7 days; OR = 2.09, p = 0.029) were the most important predictors of rehospitalization risk. CONCLUSIONS: Although the reasons for rehospitalization after CABG are heterogeneous and related to patient severity of illness as well as comorbid status, several of the most common are potentially preventable and related to quality of care. Rehospitalization was not related to early discharge.     

The use of controlled-release oxycodone for the treatment of chronic cancer pain: a randomized, double-blind study

1. We have studied the effects of muscarinic cholinoceptor agonists and subtype-preferring antagonists on the isometric contraction of smooth muscle strips from dog prostate. 2. Acetylcholine and carbachol induced contraction of prostate strips from the peripheral zone, ('the capsule'). Bethanechol contracted the tissue but not at lower doses. McN-A-343 and oxotremorine-M showed the same effects. 3. Blocking alpha- and beta-adrenoceptors with phentolamine and propranolol, respectively, did not modify carbachol-induced contractions. 4. The nicotinic receptor blocker, hexamethonium (10(-6)-10(-4) M) did not affect the contractile response evoked by a single dose of carbachol (10(-5) M), whilst the muscarinic receptor antagonist, atropine (10(-11)-10(-9) M), inhibited it in a competitive manner. 5. The muscarinic M1 (pirenzepine), M2 [AF-DX 116, himbacine (M2/M4) and methoctramine], M3 (HHSID and f-F-HHSID), and putative M4 (tropicamide) antagonists reduced significantly the carbachol-induced contractions. The pIC50 values were: atropine (10.01) > himbacine (8.3) > methoctramine (7.85) > AF-DX 116 (7.60) > HHSID (7.21) > p-F-HHSID (7.10) > pirenzepine (7.30) > tropicamide (7.00). 6. The antagonist profile indicates that an predominant M2 receptor subtype could mediate the muscarinic contraction in the canine prostate.     

Intracranial hemorrhage associated with idiopathic thrombocytopenic purpura: report of seven patients and a meta-analysis

We present the results of a meta-analysis using clinical data obtained from seven of our patients and 24 previously reported patients with idiopathic thrombocytopenic purpura complicated by intracranial hemorrhage. Twenty-four had an intracerebral hemorrhage (ICH) and seven had a subdural hematoma (SDH). Mean age of the patients with ICH was significantly younger than those with SDH. The mortality rate of ICH associated with ITP was similar to that of spontaneous ICH. All seven patients with SDH improved without sequelae.     

Differential expression and distribution of focal adhesion and cell adhesion molecules in rat hepatocyte differentiation

The present study has examined the distribution of axons of differing sizes in the optic pathway of the ground squirrel. Axon diameters were measured from electron micrographs at various locations across sections of the optic nerve and tract, and total distributions and numbers were estimated. In both the nerve and tract, roughly 1.2 million optic axons were present. The population of optic axons had a unimodal size distribution, peaking at 0.9 microm in diameter and having an extended tail toward larger diameters. Local axon diameter distributions in the optic tract indicated distinct (though partially overlapping) axon diameter classes, including one of fine sizes peaking at 0.8-0.9 microm, a second of medium sizes peaking around 1.7-1.8 microm, and a third composed of the larger fibers with diameters up to 4.8 microm. The fine-caliber axons were found at all locations in the tract, and were the only axons present immediately adjacent to the pia, while the medium- and coarse-caliber axons were found at deeper locations. Curiously, the larger axons were found primarily in the medial parts of the tract, where axons from the dorsal retina normally course. A similarly restricted distribution of the larger axons was observed in the dorsotemporal parts of the optic nerve, suggesting that this difference in the tract may relate to an asymmetric distribution of ganglion cells on the retina giving rise to these axons. Measurements of axonal size taken within the optic fiber layer in dorsal and ventral parts of the retina confirmed this asymmetry, consistent with previous demonstrations of soma size differences in the dorsal versus ventral retina. The partial segregation of axons by size in the optic tract of the ground squirrel then reflects both the asymmetric distribution of retinal ganglion cell classes and the chronotopic reordering of optic axons that occurs within the chiasmatic region.     

Tennessee's failed managed care program for mental health and substance abuse services

In July 1996, Tennessee initiated a managed mental health and substance abuse program called TennCare Partners. This publicly funded "carve-out" experiment started chaotically and soon deteriorated into a crisis. Many patients did not receive care or lost continuity of care, and the traditional "safety net" mental health system nearly disintegrated. This qualitative case study sought to ascertain the impact of the TennCare Partners program. It points out that the program's difficulties stemmed directly from a flawed design that spread funds previously earmarked for severely mentally ill patients across the entire Medicaid population. States contemplating similar reforms should strive to protect vulnerable patients by risk-adjusting capitation payments and by focusing resources on care for severely mentally ill persons. States should also minimize program complexity and ensure the accountability of managed care networks for their patients' behavioral health care needs.     

Protein kinase C modulates estrogen receptors in differentiated osteoblastic cells in vitro

Ventriculo-peritoneal shunts (VPS) are the most frequent operative procedures used to treat hydrocephalic children. Abdominal complications of VPS are now a rare event; however, their frequency varies from 5% to 47% according to reports. Anything that causes an obstruction or impediment of the VP derivation system will lead to intracranial hypertension, which requires immediate surgery. From 1985 to 1995 at the Division of Pediatric Surgery of the Federico II University of Naples, ten laparoscopies were performed in ten children with VPS complications. Cerebrospinal fluid pseudocysts were found in four infants. There was one case of abdominal wall perforation by the tip of the catheter at the umbilical level, two bowel obstructions, and one catheter was lost in the abdominal cavity. Finally, two children had malfunctioning of the peritoneal limb of the catheter. The laparoscopic technique was curative in all ten cases, thus avoiding a conventional laparotomy and the consequent risk of adhesions, which could cause further complications.     

S-phase fractions of breast carcinomas. Relationships to morphology, estrogen and progesterone receptors, and early recurrence

Analysis of the S-phase fractions (SPF) measured by in vitro thymidine labeling, morphological appearances, and estrogen receptor (ER) assays of primary invasive breast carcinomas demonstrated several interrelationships. Lobular, mucinous, tubular, and adenocystic carcinomas consistently had low SPF and were usually positive for ER. The same was true for the carcinomas of no special histologic type [the not otherwise specified (NOS) group of E. R. Fisher including "infiltrating ductal" and undifferentiated carcinomas] with minimal anaplasia. Medullary, atypical medullary, and morphologically unclassifiable carcinomas with marked nuclear anaplasia nearly always had high SPF and were usually negative for ER. High SPF was associated with advanced stages of carcinoma initially or with early recurrence following mastectomy.     

Predictability of healing of ischemic leg ulcers by radioisotopic and Doppler ultrasonic examination

In a prospective study of twenty-six patients with ischemic ulcerations of the lower extremity, the predictive reliability with regard to spontaneous wound healing of diabetes, pedal pulses, ankle blood pressure (ABP) as measured by doppler ultrasound, and "leg ulcer scan" as performed by the intra-arterial injection of radioactive albumin was evaluated. The results suggest that only the leg ulcer scan is significantly reliable in predicting the likelihood of spontaneous healing. The following format for the evaluation of the ischemic leg ulcer is therefore suggested: (1) If pedal pulses are present, a three week trial of conservative therapy is indicated before further evaluation. (2) If the doppler ABP is 50 mm Hg or less, the ulcer will not heal spontaneously. (3) Leg ulcer scan is indicated: (a) in the absence of pedal pulses if ABP is less than 50 mm Hg; (b) in the presence of pedal pulses if there is no evidence of spontaneous healing after three weeks of conservative therapy.