A yearly summary of quality assessment and improvement in the optometric pediatric clinics of the SUNY College of Optometry.

BACKGROUND: Each clinic within the University Optometric Center (UOC) of the State University of New York (SUNY) College of Optometry develops a Quality Management (QM) Plan for each calendar year. The vehicle for implementation is a Quality Assessment and Improvement (QA&I) committee. The clinical adherence to the objectives are reviewed each year. The following article is a review of the QA&I reports of the Pediatric Vision Clinics within the College for the year 1996. METHODS: Clinical records were concurrently and retrospectively reviewed for completeness and appropriateness of care. One hundred percent of the records were concurrently reviewed, and 10% of each doctors' total records were retrospectively reviewed. In addition, records with specific diagnoses--chosen as clinical indicators--were reviewed for a specified period of time. RESULTS: Patient satisfaction exceeded predetermined threshold values. On general review, the clinical faculty performed at a 95% efficiency level. The pediatric population yielded only minimal major pathologies. In our strabismic sample, patients with esotropia exceeded those with exotropia (61% vs. 39%). Strabismic amblyopes were more prevalent than refractive amblyopes (80% vs. 20%). Preschool vision therapy appeared to be successful in most cases. CONCLUSION: Quality assessment and improvement is an ongoing process that can provide an overview of case management and type. The process serves to monitor quality of care, provide a modality for improvement, enhance outcomes, and guide future QM plans.

Dipyridamole echocardiography and 99mTc-MIBI spect dipyridamole scintigraphy for cardiac evaluation prior to peripheral vascular surgery.

Coronary artery disease accounts for most of the early and late mortality and morbidity associated with vascular surgery. Cardiac pre-operative evaluation is mandatory for the assessment of cardiac risk. The aim of this study is to compare dipyridamole scintigraphy with 99mTc-MIBI (MIBI-dipy) and dipyridamole echocardiography (ECHO-dipy) and to evaluate their capability in identifying cardiac risk for strong events such as death, unstable angina or myocardial infarction. METHODS. Sixty consecutive patients (mean age 67 +/- 7) were enrolled. 52 performed ECHO-dipy, 51 MIBI-dipy. 40 patients went to aorto-femoral or aorto-iliac graft replacement and 15 to vascular angioplasty. Five patients did not undergo surgery. RESULTS. Eighteen patients (30%) had stress defects and 9 patients also rest defects with MIBI-dipy. Six patients new asinergic areas at ECHO-dipy. Three pts died in the first year follow-up for a cerebrovascular event, a myocardial infarction and a sudden death respectively. Sensitivity and specificity, positive and negative predictive value were 100%, 69%, 16%, 100% for MIBI-dipy and 66%, 94%, 40%, 98% for ECHO-dipy. CONCLUSIONS. As other authors reported, stress scintigraphy is a pre-operative test showing high sensitivity but with no satisfying specificity. Stress echocardiography, in our population, can produce a good negative predictive value. It is a less expensive and widespread clinical tool useful in the evaluation of preoperative patients. Its positive predictive power is not satisfying but it is shared with all non-invasive pre-operative tests available now.

[Primary hepatic leiomyoma]. / Leiomioma epatico primitivo.

A young woman of 34 years old had an asymptomatic intrahepatic mass. The histological diagnosis, performed after a right lobe hepatectomy, was of leiomyoma of the liver.

Control of gastroesophageal bleeding varices by percutaneous transhepatic portography.

We used the transhepatic approach to the portal system to obliterate bleeding gastroesophageal varices as an alternative to portosystemic shunt performed as an emergency. In eight of 13 patients, we obtained complete arrest of bleeding, while rebleeding was observed in five patients. The shunt was performed upon six patients, and only one patient died. Transhepatic obliteration of varices seems to be the more useful method for the control of untractable hemorrhage and to prepare the patient for an elective operation.

Differences in serum bile acid composition between unoperated cirrhotic patients and patients with portacaval or mesocaval shunt.

Serum bile acids were determined in 13 cirrhotic patients with portacaval shunt and in 15 with mesocaval shunt. 20 nonshunted cirrhotics were used as controls. Serum bile acid levels were higher in portacaval (26.7 +/- 14.3 micrograms/ml) than in mesocaval shunt patients (16.9 +/- 8.1 micrograms/ml) and controls (14.1 +/- 11.5 micrograms/ml). The cholic/chenodeoxycholic ratio was lower after portacaval shunt than after mesocaval shunt (0.36 +/- 0.15 and 0.63 +/- 0.26, respectively). It is hypothesized that these findings may be consistent with a larger hepatic blood flow present in mesocaval shunted patients and with chenodeoxycholic absorption in the upper small intestine.

Mesentericocaval shunt with the internal jugular vein.

Seventy-nine mesocaval shunts using the internal jugular vein and 54 side-to-side portocaval shunts have been performed during the past six years. Patients were evaluated from the stand-point of protection from recurrent bleeding, patency of the shunt, encephalopathy, rehabilitation and long term survival. All of the patients underwent follow-up observation. In a selected group of patients, postoperative angiographic control was performed, and serum levels of octopamine were examined. In the mesentericocaval group, patency of the shunt was demonstrated in 82 per cent, the incidence of encephalopathy was 35 per cent and the long term survival rate, as computed by the actuarial method, was 65 per cent. In the portocaval group, the incidence of encephalopathy was 54 per cent and the survival rate, 38 per cent. There was no correlation between octopamine serum levels and encephalopathy. Persistent perfusion of the liver was documented in 95 per cent of the patents controlled by arteriography in the mesentericocaval group with patent shunts. The mesentericocaval shunt seems to be an effective technique in terms of incidence of encephalopathy and survival rate, but a randomized study will be necessary to prove that this technique is more effective than the standard portocaval shunt.

[Evaluation of hepatic encephalopathy in portacaval shunts and mesenterico-caval bypass with the jugular vein]. / Valutazione dell'encefalopatia epatica nello shunt porta-cava e nel by-pass mesenterico-cava con vena giugulare

Data relating to 30 patients subjected to side-to-side porta-cava anastomosis and 30 to mesenterico-cava by-pass with the internal jugular vein are presented. At follow-up after a period of over 1 yr, encephalopathy was observed in 40% and 21% of the two groups respectively. Angiography of the coeliac tripod and superior mesenteric showed the existence of a post-operative hepatopetal flow in 80% of porta-cava cases. This incidence was only 30% in the mesenterico-cava group. The relation between the clinical and angiographic data is briefly discussed and neuropsychiatric findings in patients with a picture of hepatic encephalopathy are also presented.