Nurse practitioners and physicians: patients' perceived health and satisfaction with care.

The advent of managed care has created changes in the health care environment and nurse practitioners have found a need to evaluate their care. Perceived health and patient satisfaction were measured in a multiethnic sample of 160 clinic patients, ages 18 to 89, in a managed care setting. Results of the Medical Outcomes Study SF-20 and the Nurse Practitioner Satisfaction Instrument indicated no statistically significant difference in perceived health and satisfaction with care, whether the care was given by a nurse practitioner or a primary care physician. The findings warrant further study and may mean that nurse practitioners placed in managed care environments can be expected to perform as effectively as they have in non-managed care environments.

Ethical issues in managed care for the obstetrician and gynecologist.

The practice of medicine is now managed. Of this there is no doubt. The individual physician is placed in an ever-increasingly vulnerable position. He or she must cope with a myriad of contractual arrangements with strange concepts such as "withholds," "capitation," "covered lives," "limited liability on the part of the managed care organization;" "outcomes analysis," "practice guidelines," and, last but not least, "gag rules." Patients are being denied care that the physician may consider, if not essential, at least most desirable. On the one hand, the physician must serve a fiduciary obligation to the patient and act as the patient's advocate; on the other hand, the physician's income may be proportionally dependent on limiting the extent of the patient's access to unlimited care. The physician may be limited by restrictions imposed by the managed care organization as to what disclosures he or she may make to the patient regarding limitations of care. We will explore these issues from an ethical perspective and attempt to offer some insights on the basis of a review of the comments of many knowledgeable commentators on this topic, and we will explore the virtues that physicians will need to rely on to come to grips with the dilemmas they will face in the future with managed care.

Should patient age be a consideration in carotid endarterectomy?

Age as a factor in the selection of patients for carotid endarterectomy was studied with a retrospective evaluation of the perioperative and late results of procedures performed on 115 elderly patients. The results were taken from an experience of 685 operations performed on 607 patients. Perioperative results in 420 patients under 75 years of age (560 operations) were compared with results in 115 patients over 75 years of age (125 operations). Statistical comparison revealed a greater proportion of men in group I (66%, 55%, p = 0.0186) and a greater proportion of patients in group II with contralateral carotid stenosis (24%, 33%, p = 0.0382) and stroke as a preoperative indication for operation (14%, 22%, p = 0.0393). No statistical difference was found between group I and group II as regards other operative indications, contralateral carotid occlusion, bilaterality of operation, emergency operation, operation for recurrent carotid disease, frequency of shunt use, perioperative wound bleeding, and perioperative transient ischemic attack. Ipsilateral perioperative stroke occurred in 12 patients (2%), with all strokes occurring in the younger group of patients (2.4%) (NS). Perioperative death occurred in six (1%) patients, with five deaths (1%) occurring in the younger group (cardiac, 2; stroke, 2; protamine reaction, 1) and one (0.9%) death occurring in the elderly group of patients (ruptured abdominal aortic aneurysm) (NS). Life-table analysis of the late results of the 115 elderly patients revealed cumulative survival rates of 85.4% and 63.8% at 2 and 5 years, respectively. The principal causes of late death were cardiac (48%), cancer (15%), and stroke (9%).(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous electroencephalographic monitoring during carotid endarterectomy.

Four hundred and twenty-seven carotid endarteriectomies were performed on 377 patients. The electroencephalogram was used as the sole determinant for the use of a carotid shunt in 386 carotid endarterectomies. With clamping of the internal carotid artery, 51 (13%) had electroencephalographic changes. The most common electroencephalographic change (60%) was rapid, ipsilateral attenuation of background activity. In the 30 day follow up period there were 3 deaths (0.7%) and 11 strokes (2.5%). Two patients (0.5%) had intraoperative strokes. The combined morbidity and mortality was 2.8% (12 of 427). Neurologic complications increased significantly with contralateral carotid occlusion. The electroencephalogram correlated well with neurological deficits occurring in surgery, but stump pressures neither correlated with neurological deficits nor electroencephalographic changes. Continuous electroencephalographic monitoring during carotid endarterectomy is an effective method of determining significant cerebral ischemia and the need for a carotid shunt.

Endometrial metaplasia associated with endometrial adenocarcinoma.

Endometrial metaplasia is a complex group of epithelial proliferations. The relationship of metaplasia, other than squamous metaplasia, to endometrial adenocarcinoma has not been clearly established. Between 1969 and 1979, 183 patients diagnosed as having Stage I endometrial adenocarcinoma (according to International Federation of Gynecology and Obstetrics) were treated at the University of Virginia Medical Center. Sixty of the patients were treated with hysterectomy without preoperative irradiation. A histopathologic review was performed without knowledge of the clinical outcome and subsequent clinicopathologic correlations were analyzed. On review, 32/60 had carcinoma without metaplasia and 15/60 had both carcinoma and metaplasia. Thirteen of the 60 patients were judged not to have cancer: 12 had both hyperplasia and metaplasia and one had hyperplasia without metaplasia. None of the 12 patients reclassified as having metaplasia had a recurrence or died of endometrial carcinoma. Patients with both metaplasia and carcinoma were significantly younger than patients with only carcinoma and the associated carcinomas were more frequently well differentiated.

Antibiotic irrigation prophylaxis in the high-risk cesarean section patient.

Two hundred twenty-three women who underwent cesarean section delivery were studied to assess the effectiveness of operative antibiotic irrigation in preventing postoperative uterine infection. Patients were prospectively randomized into high-risk and low-risk groups according to length of labor, and received irrigation with either a 2 gm solution of cefamandole or normal saline solution, or no irrigation. Infection rates of 48.6% and 54.8% were observed in high-risk patients given either saline solution or no irrigation, respectively. Three of 27 high-risk patients (11.1%) given antibiotic irrigation developed metritis. The authors find this method of preventing infection to be advantageous in terms of both efficacy and minimization of antibiotic exposure.

Femorotibial vein bypass in a child.

This report details the course and management of a 5-year-old girl with intermittent claudication, a chronic leg ulcer, and discrepancy in leg growth caused by unilateral femoropopliteal arterial occlusive lesions of obscure etiology. Angiographic evaluation, pathologic observations, and surgical management of this child are detailed. A 4-year follow-up has provided gratifying results that justify the surgical approach to this unique patient.

Cystic adventitial disease of the popliteal artery.

Cystic adventitial disease of the popliteal artery is a rare but well recognized cause of arterial occlusive changes producing disabling symptoms in young patients. We have described a 37-year-old long-distance runner who noticed progressive decrease in the function of his right leg over a period of several months. The presence of an arterial occlusive lesion was difficult to define on clinical grounds, but was confirmed with noninvasive vascular studies and angiography. Surgical treatment by resection of the diseased segment and end-to-end saphenous vein interposition graft yielded excellent results.

Primitive hypoglossal artery and carotid endarterectomy.

A patient with transient ischemic symptoms in the carotid and vertebrobasilar distribution is reported. His arteriogram demonstrated a persistent primitive hypoglossal artery which in part may explain the clinical picture. The embryology, radiology, clinical manifestations, and surgical considerations of this rare anomaly are discussed.

Surgical treatment of renovascular hypertension.

The evaluation of patients with inadequate control of diastolic blood pressure for surgically correctable forms of hypertension led to the detection and surgical treatment of 56 patients. Detection was facilitated by the use of hypertensive intravenous pyelography and Hippuran renal Scanning. Aortography proved the presence of renal artery disease and renal vein renin assay established its significance in the etiology of the patients' hypertension. Renal artery reconstruction was performed in 50 patients, including 5 who also had reconstruction of major aortoiliac lesions. The extent of renal artery disease precluded arterial reconstruction in six patients, who required nephrectomy. Two postoperative deaths occurred, for a mortality rate of 3.6 per cent. Improvement in mean diastolic blood pressure for the total group of patients from 118 mm Hg preoperatively to 86 mm Hg postoperatively was achieved. Forty-six patients (85 per cent) have a diastolic blood pressure of 90 mm Hg or less; in 5 patients the diastolic blood pressure is 91 to 100 mm Hg but is at least 20 mm Hg lower than the preorative level.

Intestinal vascular malformations.

Eleven patients with intestinal vascular malformations (VMs), all diagnosed by angiography, are presented. Two of the VMs were incidental findings in patients treated for other problems; the other nine patients all presented with gastrointestinal hemorrhage, and all had resection of the portion of intestine containing the VM. None has rebled. The specimens from these nine patients revealed a variety of histological findings. One VM was the vasculature of small bowel leiomyoma. Three other specimens contained obvious VMs without associated findings, and one specimen contained no identifiable pathology. In the remaining four specimens, a variety of inflammatory conditions were found on histological study, including one case of Crohn's disease and another of ischemic colitis. In only one of these specimens did we identify the VM. None of these last four cases conforms to the degenerative lesions described by Boley and his colleagues. Therefore, we propose a fourth type of VM that is associated with or perhaps secondary to another disease of the intestine. We precisely localized one VM in the duodenum during operation with the Doppler ultrasonic flow detector, thus enabling us to limit the extent of the resection. We also propose the use of this technique for pinpointing the area where sections should be made for histological study.

Erosion of Dacron graft by atherosclerotic plaque.

Erosion of a Dacron prosthetic graft used in aortic reconstruction following the intrasaccular resection of an infrarenal abdominal aneurysm resulted in perforation of the graft and the formation of a false aneurysm which ruptured. The pathogenesis and prevention of this problem are discussed.