Search

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2004.12.043 Byline: Joseph S. Carey (a), Beate Danielsen (b), Jeffrey P. Gold (c), Stephen J. Rossiter (a) Abstract: Background data were obtained on all California hospitals performing coronary artery bypass grafting and percutaneous coronary intervention procedures and compared with reports published by the state of New York to develop a collaborative quality improvement program for cardiac surgery programs. Author Affiliation: (a) California Society of Thoracic Surgeons, Torrance, Calif (b) Health Information Solutions, Rocklin, Calif (c) Albert Einstein College of Medicine, Bronx, NY Article History: Received 23 June 2004; Revised 1 December 2004; Accepted 17 December 2004 Article Note: (footnote) Supported by a grant from the California Healthcare Foundation.

Study objectives: Patients with HIV-1 infection or AIDS may present with abnormal chest radiograph (CXR) findings in the absence of symptoms specific to the lung. The objective was to determine [...]

Byline: Hermann Reichenspurner (a), Jose A. Navia (b), Gerald Berry (c), Robert C. Robbins (c), Denise Barbut (d), Jeffrey P. Gold (d), Bruno Reichart (a) Abstract: Objective: Particulate embolization is associated with neurologic morbidity after cardiac surgery. Crossclamp manipulation has been identified as the single most significant cause of particulate emboli release during cardiac surgery. A new intra-aortic filtration method has been assessed with regard to its safety and its ability to capture particulate emboli before they enter the central circulation. Methods: Patients undergoing cardiac surgery with cardiopulmonary bypass through standard median sternotomy were selected for emboli management by means of intra-aortic filtration. A novel intra-aortic filter device was inserted through a modified 24F arterial cannula immediately before releasing the crossclamp in 77 patients. Filters remained in the aorta until cardiopulmonary bypass was discontinued and the heart was fully ejecting. The procedure was assessed for facility, safety, and effect on routine cardiopulmonary bypass operation and function. Results: The insertion and removal of the intra-aortic filter were safe, easy, and uneventful in most patients. Patient hemodynamics and bypass flow rates remained normal throughout the filter dwell period. No strokes or gross neurologic defects were noted. Electron microscopic analysis of 12 filters revealed an insignificant degree of platelet adhesion on filter surfaces. Histology samples (n = 44) were examined, and 66% (n = 29) showed evidence of atheromatous material, 36% (n = 16) with platelet-fibrin, 25% (n = 11) with true thrombus and/or blood clot, 7% (n = 3) with normal vessel wall, and 2% (n = 1) with aggregates of cholesterol or grumous portion of atheromatous plaque. Conclusion: The intra-aortic filter can be safely deployed and captures particulate emboli, the predominant origin of which is atheromatous. The beneficial effects of this device on neurologic outcomes have yet to be determined. (J Thorac Cardiovasc Surg 2000;119:233-41) Author Affiliation: (a) University Hospital Munich-Grosshadern, Munich, Germany (b) Italian Hospital of Buenos Aires, Buenos Aires, Argentina (c) Stanford University Medical Center, Stanford, Calif (d) Cornell University Medical College, New York, NY. Article History: Received 22 April 1999; Revised 7 July 1999; Revised 14 October 1999; Accepted 14 October 1999 Article Note: (footnote) [star] Drs Reichenspurner, Navia, Robbins, Gold, and Barbut serve as clinical consultants to Embol-X, Inc., [star][star] Read at the Seventy-ninth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La, April 18-21, 1999., a Address for reprints: Hermann Reichenspurner, MD, PhD, Department of Cardiac Surgery, University Hospital Grosshadern, Marchioninistrasse 15, Munich, Germany D-81377 (E-mail: hcr@hch.med.uni-muenchen.de) ., aa 0022-5223/2000 $12.00 + 0 12/6/103733

The child tax credit has proved to be more complex than originally thought upon its enactment in the Taxpayer Relief Act of 1997 due to its interaction with other Tax Code provisions. The credit interacts with the alternative minimum tax, and tax credits such as the earned income, dependent care, and adoption credits in such a way as to require tax planning and additional tax return administration time. The intended tax benefit to lower-income taxpayers is reduced by the likely need to employ professional tax preparers or purchase tax software.

The Soft Systems Methodology (SSM) can considerably improve career management by applying systems analysis to people-based organizational problems that involve multiple solutions. Such human resource management (HRM) problems typically involve difficult to define issues. SSM is a seven-phase learning process through which the individual 'soft' viewpoint can be integrated with 'hard' issues of organizational systems and processes. The application of SSM to the HRM problems of the Nationwide Building Society (NBS) is described to illustrate the formulation of an integrated career management system. The process began with the formulation of a Rich Picture in which the components of the existing system are depicted along with their interrelationships. The Rich Picture identified the core problem as a lack of a career management system that would help key and regular personnel develop their potentials. A step-by-step description of SSM and its implications for NBS are discussed.

* To identify predictors of postoperative pulmonary complications, a population of 278 patients, mainly hypertensive and diabetic patients undergoing elective general surgery was studied; 60% of the patients underwent abdominal surgery. Of the 278 patients, 6% had postoperative pulmonary complications: 3% had radiographic evidence of infiltrates or segmental atelectasis and 3% had clinical evidence of atelectasis. Among the two thirds of patients undergoing abdominal surgery, only patients with underlying asthma or chronic bronchitis were at increased risk. Generally, patients with better exercise tolerance by self-report, walking distance, or cardiovascular classification had lower rates. Pulmonary function tests did not help to delineate patients at higher risk of postoperative pulmonary complications. Simple clinical information provided as much data about the patients' risk as pulmonary function tests. Many of these complications occurred in patients who sustained other types of postoperative morbidity, suggesting that predicting and preventing postoperative cardiac morbidity may be the best approach to reducing postoperative pulmonary morbidity.

During surgery, patient blood pressure is closely monitored. It has been suggested that characteristics of the blood pressure pattern may be used to predict the development of postoperative complications. One of the characteristics used in previous studies has been mean arterial pressure (MAP), the average blood pressure in the arterial portion of the circulatory system. A study was undertaken to explore how changes in blood pressure during surgery should be measured to predict postoperative complications, and to provide a framework for standardizing assessment of a patient's hemodynamic course. A prospective study was undertaken of 254 high-risk patients, patients with high blood pressure or diabetes, who underwent elective surgery. Postoperative complications occurred in 54 patients (21 percent); these complications involved the heart or kidney. Patients with the highest risk of postoperative complications were those with more than one hour of decreased MAP, and patients with less than an hour of decreased and more than 15 minutes of increased MAP. These two patterns showed a 46 percent sensitivity (true-positive) and a 70 percent specificity (true negative) in predicting complications. Prolonged changes of more than 20 percent of normal MAP (preoperative level) were significantly related to the development of postoperative complications. This study provides an analytic framework for further research. (Consumer Summary produced by Reliance Medical Information, Inc.)

Simultaneous primary malignancy of the lung and kidney has been rarely recognized during life. Three patients with synchronous primary pulmonary and renal cancer are described. The pulmonary tumors were asymptomatic [...]

ObjectiveProlonged continuous video-electroencephalography (cEEG) is recommended for neonates at risk of seizures. The cost and expertise required to provide a real-time response to detected seizures often limits its utility. We hypothesised that the first hour of cEEG could predict subsequent seizures.Design and settingRetrospective multicentre diagnostic accuracy study.Patients266 term neonates at risk of seizure or with suspected seizures.InterventionThe first hour of cEEG was graded by expert and novice interpreters as normal, mildly, moderately or severely abnormal; seizures were identified.Main outcome measuresAssociation between abnormalities in the first hour of cEEG and the presence of seizures during total cEEG monitoring.Results50/98 (51%) of neonates who developed seizures had their first seizure in the first hour of cEEG monitoring. The ‘time-to-event’ risk of seizure from 0 to 96 hours was 0.38 (95% CI 0.32 to 0.44) while the risk in the first hour was 0.19 (95% CI 0.15 to 0.24). cEEG background was normal in 48% of neonates, mildly abnormal in 30%, moderately abnormal in 13% and severely abnormal in 9%. Inter-rater agreement for determination of background was very good (weighted kappa=0.81, 95% CI 0.72 to 0.91). When neonates with seizures during the first hour were excluded, an abnormal background resulted in 2.4 times increased risk of seizures during the subsequent monitoring period (95% CI 1.3 to 4.4, p<0.003) while a severely abnormal background resulted in a sevenfold increased risk (95% CI 3.4 to 14.3, p<0.0001).ConclusionsThe first hour of cEEG in at-risk neonates is useful in identifying and predicting whether seizures occur during cEEG monitoring up to 96 hours. This finding enables identification of high-risk neonates who require closer observation.

The proposed electronic filing agreement between the IRS and tax preparers would likely victimize, rather than help, low-income taxpayers. It is a bad idea and should not be instituted.

The federal government should continue to fund tax preparation services for low-income taxpayers. This would help avoid expensive tax controversies and aid taxpayers in dealing with extremely complicated federal tax requirements.

To investigate prenatal imaging findings supporting a diagnosis of suspected septo‐optic dysplasia (SOD) by fetal ultrasound (US), magnetic resonance imaging (MRI), or both. A retrospective review identified 11 patients with SOD: 9 had a clinical diagnosis of SOD postnatally, and 2 were terminated on the basis of suspicious prenatal imaging. Prenatal and neonatal imaging of the cavum septi pellucidi (CSP), frontal horns (FHs), and lateral ventricles was evaluated. The appearance of the CSP varied on US and MRI. Complete (“fused”) FHs or partial absence of the CSP was reported in 6 of 11 patients by fetal US and 7 of 8 patients by fetal MRI. The diagnosis of SOD was prospectively suspected prenatally in 6 of 11 and in an additional 5 of 11 cases retrospectively. Fetal MRI incorrectly initially reported normal morphologic abnormalities for 2 cases with partial absence of the CSP, whereas US accurately identified the morphologic abnormalities in 1 of these cases before MRI. Imaging features were first suggested at anatomic US (4 patients) and follow‐up prenatal US (2 patients). Neonatal imaging was concordant in all 9 live births: 5 completely absent CSP, 3 partially absent CSP, and 1 completely present CSP. Clinical manifestations included optic nerve hypoplasia (9 of 9), panhypopituitarism (5 of 9), and neurodevelopmental delays. Primary imaging features of SOD are “continuous” FHs with complete or partial absence of the CSP. Septo‐optic dysplasia can be suspected in utero and can appear isolated but has substantial associated central nervous system anomalies identified on fetal MRI or after birth. Partial absence of the CSP can be a prenatal sign of suspected SOD, although fetal MRI lacked the spatial resolution to identify it accurately in all cases.

Supplemental Digital Content is available in the text.

Familial arrhythmogenic right ventricular dysplasia is a rare cardiomyopathy that is usually diagnosed on postmortem examination or on presentation with progressive congestive heart failure. We present a patient in whom [...]

Supplemental Digital Content is available in the text.

In 2010, severe storms, flooding, and winter weather wreaked havoc--including water damage to buildings, downed trees, and beach erosion--throughout the New York, New Jersey, and Connecticut tristate area. A temporary [...]

AbstractObjectives:The SARS-CoV-2 pandemic has highlighted the need for rapid creation and management of ICU field hospitals with effective remote monitoring which is dependent on the rapid deployment and integration of an Electronic Health Record (EHR). We describe the use of simulation to evaluate a rapidly scalable hub-and-spoke model for EHR deployment and monitoring using asynchronous training.Methods:We adapted existing commercial EHR products to serve as the point of entry from a simulated hospital and a separate system for tele-ICU support and monitoring of the interfaced data. To train our users we created a modular video-based curriculum to facilitate asynchronous training. Effectiveness of the curriculum was assessed through completion of common ICU documentation tasks in a high-fidelity simulation. Additional endpoints include assessment of EHR navigation, user satisfaction (Net Promoter), system usability (System Usability Scale-SUS), and cognitive load (NASA-TLX).Results:A total of 5 participants achieved a 100% task completion on all domains except ventilator data (91%). Systems demonstrated high degrees of satisfaction (Net Promoter = 65.2), acceptable usability (SUS = 66.5), and acceptable cognitive load (NASA-TLX = 41.5); with higher levels of cognitive load correlating with the number of screens employed.Conclusions:Clinical usability of a comprehensive and rapidly deployable EHR was acceptable in an intensive care simulation which was preceded by < 1 hour of video education about the EHR. This model should be considered in plans for integrated clinical response with remote and accessory facilities.

This article describes the presentations and discussions at a conference co-convened by the Council on Medical Education of the American Medical Association (AMA) and by the American Board of Medical Specialties (ABMS). The conference focused on the ABMS Maintenance of Certification (MOC) Part III Examination. This article, reflecting the conference agenda, covers the value of and evidence supporting the examination, as well as concerns about the cost of the examination, and—given the current format—its relevance. In addition, the article outlines alternative formats for the examination that four ABMS member boards are currently developing or implementing. Lastly, the article presents contrasting views on the approach to professional self-regulation. One view operationalizes MOC as a high-stakes, pass–fail process while the other perspective holds MOC as an organized approach to support continuing professional development and improvement. The authors hope to begin a conversation among the AMA, the ABMS, and other professional stakeholders about how knowledge assessment in MOC might align with the MOC program’s educational and quality improvement elements and best meet the future needs of both the public and the physician community.

The usual method of measuring heart function in critically ill children is thermodilution. This procedure requires that a very sensitive thermometer be placed within the child's pulmonary artery. which is done with the use of a catheter. A specific amount of a solution of known temperature is added to the blood stream. The resulting lowering of the blood's temperature is measured by the internal thermometer. The change in temperature is used to evaluate how well the heart is functioning. The procedure has measurable risks of increased sickness and death associated with its use. If a simpler technique could be developed that did not require entering the patient's body, it would be very beneficial. Pulsed Doppler (sonographic) measurements have been proposed as an alternative to thermodilution. This study evaluated the paired thermodilution and Doppler measurements taken on 17 patients. The results showed a discrepancy of 15 percent or more in 45 percent of the readings taken. The conclusion was that as studied, pulsed Doppler determination cannot replace thermodilution in measuring cardiac output of critically ill children.

ABSTRACTBackground With the widespread adoption of electronic health records (EHRs), there is a growing awareness of problems in EHR training for new users and subsequent problems with the quality of information present in EHR-generated progress notes. By standardizing the case, simulation allows for the discovery of EHR patterns of use as well as a modality to aid in EHR training.Objective To develop a high-fidelity EHR training exercise for internal medicine interns to understand patterns of EHR utilization in the generation of daily progress notes.Methods Three months after beginning their internship, 32 interns participated in an EHR simulation designed to assess patterns in note writing and generation. Each intern was given a simulated chart and instructed to create a daily progress note. Notes were graded for use of copy-paste, macros, and accuracy of presented data.Results A total of 31 out of 32 interns (97) completed the exercise. There was wide variance in use of macros to populate data, with multiple macro types used for the same data category. Three-quarters of notes contained either copy-paste elements or the elimination of active medical problems from the prior days' notes. This was associated with a significant number of quality issues, including failure to recognize a lack of deep vein thrombosis prophylaxis, medications stopped on admission, and issues in prior discharge summary.Conclusions Interns displayed wide variation in the process of creating progress notes. Additional studies are being conducted to determine the impact EHR-based simulation has on standardization of note content.

Early unplanned Pediatric Intensive Care Unit (PICU) readmission is associated with greater length of stay and mortality. No tools exist to identify children at risk for PICU readmission. The Pediatric Early Warning Score (PEWS) currently identify children at risk for deterioration on the ward. Our primary objective was to evaluate the ability of PEWS to identify children at risk for unplanned PICU readmission.

As a geriatrician, I am a reader of Clinical Geriatrics, the American Geriatrics Society's monthly journal. Its peer-reviewed articles offer clinically relevant, updated medical information tailored to the older population. [...]

ELIZABETH, N.J. (AP) -- Even though Rosalee Jones considers herself in good health and able to live on her own, she takes four different pills each day, and sometimes a [...]

Funding for graduate medical education (GME) and undergraduate medical education (UME) in the United States is being debated and challenged at the national and state levels as policy makers and educators question whether the multibillion dollar investment in medical education is succeeding in meeting the nation’s health care needs. To address these concerns, the authors propose a novel all-payer system for GME and UME funding that equitably distributes medical education costs among all stakeholders, including those who benefit most from medical education. Through a “Medical Education Workforce (MEW) trust fund,” indirect and direct GME dollars would be replaced with a funds-flow mechanism using fees paid for services by all payers (Medicaid, Medicare, private insurers, others) while providing direct compensation to physicians and institutions that actively engage medical learners in providing clinical care. The accountability of those receiving MEW funds would be improved by linking their funding levels to their ability to meet predetermined institutional, program, faculty, and learner benchmarks. Additionally, the MEW fund would cover learners’ UME tuition, potentially eliminating their UME debt, in return for their provision of health care services (after completing GME training) in an underserved area or specialty. This proposed model attempts to increase transparency and enhance accountability in medical education by linking funding to the development of a physician workforce that is able to excel in the evolving health delivery system. Achieving this vision requires physician educators, leaders of academic health centers, policy makers, insurers, and patients to muster the courage to embrace transformational change.

Electronic Health Records (EHRs) have been shown to markedly alter clinical workflows and are associated with lower professional satisfaction scores among providers post-implementation. In light of these issues, questions exist regarding what barriers currently exist in EHRs to adequately meet the workflow needs of providers. The objective of this study was to describe what physicians perceive to be the current barriers to information gathering and overall workflow when using electronic health records (EHRs) to evaluate new patients. A web-based national survey was distributed to practicing physicians in primary care, general internal medicine, medicine subspecialties, general surgery, surgery subspecialties, general pediatrics, and pediatrics subspecialties from June to September 2014. Prominent themes pertaining to information gathering and overall workflow in the EHR were identified from narrative survey responses using constant comparison and axial coding to arrive at a grounded theory. Narrative responses from 327 physicians were obtained and analyzed from a total of 1385 respondents (24%). Major identified themes included: 1) Physicians struggle with unintuitive workflows and negative time impact; 2) EHR documentation was excessive and often of poor clinical value; 3) Provider-provider communication is negatively impacted by EHR challenges; and 4) Frustration with EHRs led to mistrust of vendors and clinical administration responsible for building and selecting the EHR software. Barriers such as inefficient workflows, increased time demands, and inconsistent documentation practices exist in EHRs that prevent ideal information gathering when evaluating a new patient. Results from this study could provide insights into new EHR interface redesign and development, and into new physician EHR training opportunities.

Blood conservation and the subsequent prevention of transfusion have assumed an increasingly important role in cardiac surgery. The concern is one of preventing transmission of transfusion related diseases and of conserving an extremely valuable resource (1,2). Cardiac surgery with cardiopulmonary bypass has become the most common operation performed, thus attracting much analysis of transfusion practices. It is estimated that of the approximately 250,000 cardiopulmonary bypass procedures done in the United States each year, the majority require transfusion of blood products (3). It has been calculated that the cardiac surgery services throughout the United States use somewhat over 10% of all the blood product resources that are transfused in this country (4,5). Many methods of blood conservation have been described (Table 1), but there still exists a wide variance in blood product utilization for adult patients undergoing cardiopulmonary bypass procedures. A review of the literature reveals average packed red blood cell transfusion rates from 0.3 up to 8 units per patient (4,6-8). If we further add the transfusion of platelets, fresh frozen plasma, and cryoprecipitate, the total donor exposure to the patient goes up substantially more. A varied patient population has been cited as the reason for these discrepancies but it has been demonstrated in similarly matched groups of patients receiving transfusions, that the patterns were based to some extent upon "prevailing practice" rather than on need (9,10).

Due to a low estimated blood volume, small adults (weight less than 70 kg) undergoing cardiopulmonary bypass (CPB) are at highest risk for low hematocrit and homologous blood transfusion (HBT). To determine whether reductions in HBT could be achieved we compared the use of a low prime circuit (1400 ml) with our standard (2200 ml) cardiopulmonary bypass (CPB) circuit.

The increased use of the centrifugal pump during coronary artery bypass surgery has been based primarily on theoretical data related to patient safety. There is minimal evidence suggesting improved outcome when compared to the traditional roller pump technology. We prospectively randomized 200 patients undergoing elective coronary artery bypass grafting into centrifugal pump (100 patients) and roller pump (100 patients) groups to compare differences in blood product usage, complication rate, length of stay and net hospital financial balance.

This study was conducted to determine the relationship of frontal lobe cortical thickness and basal ganglia volumes to measures of cognition in adults with sickle cell anemia (SCA).

AbstractBackground:Pediatric chronic pain not only affects the child but also has a ripple effect on the entire family. While several studies have shown that acupuncture is beneficial for decreasing pain intensity in adults, few studies have examined the effectiveness of acupuncture in children and adolescence as well as the impact of acupuncture on the association between parent stress and child pain.Objective:This study examined whether two acupuncture treatments may help reduce child pain and parent stress as well as examining the bidirectional relationship between parent stress and child pain across the two treatments.Design:The study was a pre/post test design. Participants completed the Pediatric Inventory for Parents and Faces Pain Scale-Revised at baseline and at the conclusion of the second acupuncture treatment (at Time 2).Setting:Participants were recruited from a pain clinic at an academic pediatric hospital.Patients:Parent–child dyads (N=29; Mage=14.13; standard deviation=2.43) participated in the study.Results:Child pain and parent stress significantly decreased after two acupuncture treatments. Child pain significantly predicted parent stress frequency, difficulty, and stress frequency, while parent stress difficulty significantly predicted child pain at baseline. At T2, there was a bidirectional relationship between parent stress frequency, difficulty and child pain.Conclusions:These findings suggest that acupuncture is beneficial for reducing child pain and parent stress. The results also emphasize the bidirectional relationship between parent stress frequency and the child's perception of pain.

The Family Satisfaction in the Intensive Care Unit 24 (FS-ICU 24) survey consists of two domains (overall care and medical decision-making) and was validated only for family members of adult patients in the ICU. The purpose of this study was to evaluate the internal consistency and construct validity of the FS-ICU 24 survey modified for parentscaregivers of pediatric patients (Pediatric Family Satisfaction in the Intensive Care Unit 24 pFS-ICU 24) by comparing it to McPherson’s PICU satisfaction survey, in a similar racialethnic population as the original Family Satisfaction in the Intensive Care Unit validation studies (English-speaking Caucasian adults). We hypothesized that the pFS-ICU 24 would be psychometrically sound to assess satisfaction of parentscaregivers with critically ill children.

We compared the degree of psychosocial impairment in patients seen in the emergency department (ED) for acute complaints with that of patients presenting with chronic complaints using the Youth Pediatric Symptom Checklist (PSC-Y). Our hypothesis was that patients with multiple visits for chronic complaints (>3 health care visits for the chief complaint during the previous 12 months) would be more likely than patients with acute complaints to test positive for psychosocial issues.

To evaluate posttraumatic stress disorder in children who have been admitted to the pediatric intensive care unit and their families.