Enhancing Nurses' Pain Assessment to Improve Patient Satisfaction.

Patient satisfaction with pain management has increasing importance with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores tied to reimbursement. Previous studies indicate patient satisfaction is influenced by staff interactions. This single-group pre/post design study aimed to improve satisfaction with pain management in older adults undergoing total joint replacement. This was a single-group pre-/posttest design. Nurse (knowledge assessment) and patient (American Pain Society Patient Outcomes Questionnaire Revised [APS-POQ-R], HCAHPS) responses evaluated pre- and postimplementation of the online educational program. Nurse focus group followed intervention. Nurses' knowledge improved significantly (p < .006) postintervention. HCAHPS scores (3-month average) for items reflecting patient satisfaction improved from 70.2 ± 9.5 to 73.9 ± 6.0. APS-POQ-R scores did not change. Focus group comments indicated need for education regarding linkages between pain management and patient satisfaction. Education on linkages between patient satisfaction and pain management can improve outcomes; education on strategies to further improve practice may enhance ability to achieve benchmarks.

Postthoracotomy Pain Syndrome Following Surgery for Lung Cancer: Symptoms and Impact on Quality of Life.

Postthoracotomy pain syndrome (PTPS) is a common complication following thoracic surgery. Most studies examining the influence of PTPS on patient-reported symptoms include few patients managed using a minimally invasive approach. Associated sensory changes, potentially neuropathic in origin, are not well described. We therefore examined the symptoms and quality of life (QOL) of patients with and without PTPS who underwent a standard thoracotomy (n = 43) or minimally invasive surgery (n = 54). Patients in this prospective, cross-sectional study completed questionnaires to assess pain (McGill Pain Questionnaire), neuropathic symptoms (Neuropathic Symptom Questionnaire), symptom distress (Symptom Distress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and QOL (Functional Assessment Cancer Therapy-Lung). Excepting younger age (p = .009), no demographic or surgical characteristic differentiated patients with and without PTPS. Patients with PTPS described discomfort as pain only (15.1%), neuropathic symptoms only (30.2%) or pain and neuropathic symptoms (54.7%). Scores differed between patients with and without PTPS for symptom distress (p < .001), anxiety and depression (p < .001), and QOL (p = .009), with higher distress associated with PTPS. Despite new surgical techniques, PTPS remains common and results in considerable distress. A focused assessment is needed to identify all experiencing this condition, with referral to pain management specialists if symptoms persist.

Perception of facial attractiveness following modification of the nose and teeth.

OBJECTIVE: We investigated how laypeople perceive persons with straight teeth and nose, mild to moderate modification of the nose, and mild to moderate modification of the teeth. The objectives were to determine: (1) how modification of the nose or teeth affects others' perceptions of target persons' facial attractiveness, (2) whether these evaluations are affected by the target persons' or raters' gender, (3) whether the frontal view or three-quarter view has any effect on the ratings. MATERIALS AND METHODS: Survey data were collected from 226 college students at Seton Hill University (49% male, 51% female; age range, 18-25 years) who rated, on a 100mm VAS, photos of subjects with straight teeth and nose (control), mild to moderate modification of the nose, and mild to moderate modification of the teeth from the frontal and three-quarter views. RESULTS: Male and female target photos with teeth modification were considered the least attractive. Both male and female target photos showed that female raters evaluated both control and nose modification conditions more positively than did male raters. For male and female target photos, the frontal view was less esthetically pleasing under teeth modification. CONCLUSIONS: Both male and female evaluators judged teeth modification as the least attractive compared to nose modification. It is recommended for rhinoplasty patients with malaligned teeth that it may be beneficial for cosmetic surgeons to establish an interdisciplinary approach working with orthodontists.

Effects of a video guided T'ai Chi group intervention on center of balance and falls efficacy: a pilot study.

This pilot study evaluated effects of a video-guided T'ai Chi group intervention on center of balance (COB) and falls efficacy, using a one arm, pre/post design. Thirty-two participants began the study, 17 completed pre- and post-testing and 15 were lost to follow-up. Outcomes were compared for the 17 participants who completed pre- and post-testing and subgroups based on session attendance. Irrespective of session attendance, participant COB scores improved. There was a significant negative correlation between number of sessions attended and pre and post scores on the fall efficacy (fear of falling) measure, indicating those with higher fear of falling were less likely to complete the study. Older participants were also less likely to continue participation. Findings indicate potential benefits of T'ai Chi in improving COB (a fall risk factor) among community-dwelling older adults. However, those with greater potential benefit (higher fear scores, older participants) were less likely to continue participation.

Development and validation of the Dyspnea Index (DI): a severity index for upper airway-related dyspnea.

OBJECTIVES: To (1) develop and validate the Dyspnea Index (DI); (2) quantify severity of symptoms in upper airway dyspnea; and (3) validate the DI as an outcome measure. STUDY DESIGN: Survey development and validation. METHODS: Three hundred sixty-nine participants were recruited for different phases of the study. Two hundred participants with chief complaints of dyspnea were given a 41-item questionnaire addressing common symptoms of dyspnea related to the upper airway. The questions were then reduced based on principal component analysis (PCA) and internal consistency resulting in a 10-item questionnaire. Cognitive interviews were conducted with 15 participants. Test-retest reliability and discriminant validity were measured from 51 participants. The DI was further validated by administering the index to 57 healthy controls (HC). Validation of the DI as a treatment outcome tool occurred with 46 participants' pre- and post-treatment scores. RESULTS: PCA revealed that only a single factor was being measured in both the original 41- and 10-item questionnaires. Additional cognitive interviewing suggested that no modification was needed to the DI. Test-retest reliability was r = 0.83. Discriminant validity was r = 0.62. The Mann-Whitney test demonstrated significant differences between healthy/symptomatic participants. Scores from the HC cohort resulted in a mean of 3.12 (SEM = 0.484; SD = 3.65) for the normative values. CONCLUSIONS: The DI is an effective and efficient instrument to quantify patients' symptoms of upper airway dyspnea. It is a statistically robust index, with significant reliability and validity, and can be dependably used as a treatment outcome measure.

Perceptions of midline deviations among different facial types.

INTRODUCTION: The correction of a deviated midline can involve complicated mechanics and a protracted treatment. The threshold below which midline deviations are considered acceptable might depend on multiple factors. The objective of this study was to evaluate the effect of facial type on laypersons' perceptions of various degrees of midline deviation. METHODS: Smiling photographs of male and female subjects were altered to create 3 facial type variations (euryprosopic, mesoprosopic, and leptoprosopic) and deviations in the midline ranging from 0.0 to 4.0 mm. Evaluators rated the overall attractiveness and acceptability of each photograph. RESULTS: Data were collected from 160 raters. The overall threshold for the acceptability of a midline deviation was 2.92 ± 1.10 mm, with the threshold for the male subject significantly lower than that for the female subject. The euryprosopic facial type showed no decrease in mean attractiveness until the deviations were 2 mm or more. All other facial types were rated as decreasingly attractive from 1 mm onward. Among all facial types, the attractiveness of the male subject was only affected at deviations of 2 mm or greater; for the female subject, the attractiveness scores were significantly decreased at 1 mm. The mesoprosopic facial type was most attractive for the male subject but was the least attractive for the female subject. CONCLUSIONS: Facial type and sex may affect the thresholds at which a midline deviation is detected and above which a midline deviation is considered unacceptable. Both the euryprosopic facial type and male sex were associated with higher levels of attractiveness at relatively small levels of deviations.

Development and validation of the cough severity index: a severity index for chronic cough related to the upper airway.

OBJECTIVES/HYPOTHESIS: To develop and validate a cough severity index (CSI) which quantifies patients' symptoms associated with upper airway chronic cough and to provide a tool for treatment outcome measures. METHODS: Two hundred patients who had a complaint of chronic cough and/or dyspnea were given a 49- item questionnaire developed through a clinical consensus of the most common symptoms of chronic cough of upper airway origin. The instrument was reduced to 10 questions using statistical methodology. Fifty subsequent patients were given the CSI to measure test-retest reliability at two different moments in time. Twenty healthy controls (HC) were given the instrument to obtain validity. An additional 95 participants provided pre- and posttreatment outcomes using the CSI. RESULTS: Principle Component Analysis (PCA) revealed a single factor with the original 49 questions. A combination of PCA, rank-ordering item-total correlation and communality, as well as clinical consensus further reduced the questionnaire to 10 items. Internal consistency of the CSI was 0.97. Test-retest reliability was r = 0.83. An r = 0.60 for divergent validity between the CSI and the Cough-Specific Quality-of-Life Questionnaire (CQLQ) demonstrated two fairly separate instruments, although both measured cough. Mann-Whitney test was significant between symptomatic patients and healthy controls (P < 0.0004). The results of 20 HC showed a mean of 0.45 (standard deviation = 1.39). Results for treatment outcomes revealed significance with the Wilcoxon test (P < 0.0001) and paired samples t test showed significantly different correlations between pre- and postmeasures. CONCLUSION: The CSI is a short, simple instrument that can be used in the clinical setting to quantify a patient's symptoms of chronic cough of upper airway origin. It represents a statistically reliable, valid, and clinically relevant instrument that can be used to measure treatment outcomes for chronic cough.

Quantifying component parts of indirect and direct voice therapy related to different voice disorders.

Voice therapy changes how people use and care for their voices. Speech-language pathologists (SLPs) have a multitude of choices from which to modify patient's vocal behaviors. Six SLPs performed 1461 voice therapy sessions and quantified the percentage of time spent in eight component parts of indirect and four component parts of direct voice therapy across five common voice disorders. Voice therapy data collection forms were prospectively completed immediately following each therapy visit. The SLPs were free to choose the component parts of voice therapy best suited for their respective patients. Results showed that direct voice therapy represented more than 75% of the treatment time across all voice therapy sessions. In the components of direct voice therapy, there was no statistical difference between percentages of time spent in resonant voice and flow phonation across all voice disorders. However, a significant difference was found for the time spent addressing transfer to conversational speech for muscle tension dysphonia, lesions, and scar than for vocal immobility and atrophy. Interestingly, while SLPs used a more common approach to direct voice therapy across voice disorders, they tended to vary the use of indirect components of therapy across voice disorders with certain components being addressed in greater length for specific voice disorders. Collectively, these results indicate that although SLPs may individualize their approach to indirect voice therapy, when it comes to direct voice therapy, SLPs have a common approach to voice therapy regardless of voice disorder.

Caregivers of the chronically critically ill after discharge from the intensive care unit: six months' experience.

BACKGROUND: Chronically critically ill patients typically undergo an extended recovery after discharge from the intensive care unit, making involvement of family caregivers essential. Prior studies provide limited detail about specific ways this experience affects caregivers. OBJECTIVES: To (1) describe lifestyle restrictions and distress among caregivers of chronically critically ill patients 1 and 6 months after discharge and (2) explore how caregivers' lifestyle restrictions and distress differ according to patients' and caregivers' characteristics. METHODS: Sixty-nine chronically critically ill patients and their family caregivers completed follow-up at 1 and 6 months after discharge from the intensive care unit. Data were collected from medical records and survey via telephone or mail. RESULTS: Caregivers' perceived lifestyle restrictions (Changes in Role Function) decreased from 1 month (mean [SD], 23.0 [8.3]) to 6 months (19.4 [8.6]) after discharge (P = .003), although patients' problem behaviors and caregivers' distress (8.9 [9.3] vs 7.9 [9.6], respectively; P = .32) did not change. Change in caregivers' lifestyle restrictions differed by patients' disposition (P = .02) and functional status (Health Assessment Questionnaire; P = .007). Caregiver's lifestyle restrictions remained high when patients never returned home or never recovered their preadmission functional status. Caregivers reported the most restrictions in social life and personal recreation. Patients' negative emotions and pain caused the most caregiver distress. CONCLUSIONS: Caregivers of chronically critically ill patients perceived fewer lifestyle restrictions over time but reported no change in patients' problem behaviors or distress. Lifestyle restrictions and distress remained high when patients never returned home or regained their preadmission functional status.

Analysis of laryngeal framework surgery: 10-year follow-up to a national survey.

OBJECTIVES: Laryngeal framework surgery, including medialization laryngoplasty (ML) and arytenoid adduction (AA), are common treatments for vocal fold paralysis and glottal incompetence. Little information is known about the incidence of ML/AA surgery nationwide, in particular the success and complication rates. METHODS: A 25-item questionnaire was mailed to 6,644 Board-certified otolaryngologists. RESULTS: The response rate was 25.7% (n = 1,707). Sixty-three percent perform ML and/or AA, representing 29,748 procedures. Experience with Silastic medialization implants has decreased over time, while utilization of other materials has increased. The overall complication rate was 15%, including 0.8% implant extrusion and 6% revision rates. The most common revision was placement of a larger implant (37% of all revisions). Airway compromise requiring intervention was observed in 2.2%, and suboptimal voice outcome in 4%. Although not statistically significant, a trend was observed of decreasing complication rate with increasing experience. CONCLUSIONS: Laryngeal framework surgeries are being performed with increasing frequency in the United States. The overall complication rate is slightly increased in the present study, but airway compromise and poor vocal outcome are decreased, and the need for revision surgery is unchanged. These findings suggest a continued high level of efficacy of these procedures.

Critical thinking skills in nursing students: comparison of simulation-based performance with metrics.

AIM: This paper is a report of an examination of the relationship between metrics of critical thinking skills and performance in simulated clinical scenarios. BACKGROUND: Paper and pencil assessments are commonly used to assess critical thinking but may not reflect simulated performance. METHODS: In 2007, a convenience sample of 36 nursing students participated in measurement of critical thinking skills and simulation-based performance using videotaped vignettes, high-fidelity human simulation, the California Critical Thinking Disposition Inventory and California Critical Thinking Skills Test. Simulation-based performance was rated as 'meeting' or 'not meeting' overall expectations. Test scores were categorized as strong, average, or weak. RESULTS: Most (75.0%) students did not meet overall performance expectations using videotaped vignettes or high-fidelity human simulation; most difficulty related to problem recognition and reporting findings to the physician. There was no difference between overall performance based on method of assessment (P = 0.277). More students met subcategory expectations for initiating nursing interventions (P ≤ 0.001) using high-fidelity human simulation. The relationship between videotaped vignette performance and critical thinking disposition or skills scores was not statistically significant, except for problem recognition and overall critical thinking skills scores (Cramer's V = 0.444, P = 0.029). There was a statistically significant relationship between overall high-fidelity human simulation performance and overall critical thinking disposition scores (Cramer's V = 0.413, P = 0.047). CONCLUSION: Students' performance reflected difficulty meeting expectations in simulated clinical scenarios. High-fidelity human simulation performance appeared to approximate scores on metrics of critical thinking best. Further research is needed to determine if simulation-based performance correlates with critical thinking skills in the clinical setting.

Impact of a disease-management program on symptom burden and health-related quality of life in patients with idiopathic pulmonary fibrosis and their care partners.

BACKGROUND: Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled "Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management," which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden. METHODS: Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management. RESULTS: After the intervention, experimental group patients rated their HRQoL less positively (P = .038) and tended to report more anxiety (P = .077) compared with controls. Care partners rated their stress at a lower level (P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others. CONCLUSION: Further exploration of the impact of disease-management interventions in patients with advanced lung disease and their care partners is needed using both qualitative and quantitative methodology. Disease-management interventions have the potential to positively affect patients with advanced lung disease and their care partners.

Effect of short periods of normobaric hyperoxia on local brain tissue oxygenation and cerebrospinal fluid oxidative stress markers in severe traumatic brain injury.

Preliminary evidence suggests local brain tissue oxygenation (PbtO(2)) values of or=20 mm Hg to avoid hypoxia. This study tested the impact of a short (2 h) trial of normobaric hyperoxia on measures of oxidative stress. We hypothesized this treatment would positively affect cerebral oxygenation but negatively affect the cellular environment via oxidative stress mechanisms. Cerebrospinal fluid (CSF) was serially assessed in 11 adults (9 male, 2 female), aged 26 +/- 1.8 years with severe TBI (Glasgow Coma Scale score, 6 +/- 1.4) before, during, and after a FiO(2) = 1.0 challenge for markers of oxidative stress, including lipid peroxidation (F(2)-isoprostane [ELISA]), protein oxidation (protein sulfhydryl [fluorescence]), and antioxidant defenses (total antioxidant reserve (AOR) [chemiluminescence] and glutathione [fluorescence]). Physiological parameters [PbtO(2), arterial oxygen content (PaO(2)), intracranial pressure (ICP), mean arterial pressure (MAP), and cerebral perfusion pressure (CPP)] were assessed at the same time points. Mean (+/-SD) PbtO(2) and PaO(2) levels significantly changed for each time point. Oxidative stress markers, antioxidant reserve defenses, and ICP, MAP, and CPP did not significantly change for any time period. These preliminary findings suggest that brief periods of normobaric hyperoxia do not produce oxidative stress and/or change antioxidant reserves in CSF. Additional studies are required to examine extended periods of normobaric hyperoxia in a larger sample.

Critical thinking ability of new graduate and experienced nurses.

AIM: This paper is a report of a study to identify critical thinking learning needs of new and experienced nurses. BACKGROUND: Concern for patient safety has grown worldwide as high rates of error and injury continue to be reported. In order to improve patient safety, nurses must be able to recognize changes in patient condition, perform independent nursing interventions, anticipate orders and prioritize. METHODS: In 2004-2006, a consecutive sample of 2144 newly hired nurses in a university-affiliated healthcare system completed the Performance Based Development System Assessment consisting of 10 videotaped vignettes depicting change in patient status. Results were reported as meeting or not meeting expectations. For nurses not meeting expectations, learning needs were identified in one of six subcategories. RESULTS: Overall, 74.9% met assessment expectations. Learning needs identified for nurses not meeting expectations included initiating independent nursing interventions (97.2%), differentiation of urgency (67%), reporting essential clinical data (65.4%), anticipating relevant medical orders (62.8%), providing relevant rationale to support decisions (62.6%) and problem recognition (57.1%). Controlling for level of preparation, associate (P=0.007) and baccalaureate (P<0.0001) nurses were more likely to meet expectations as years of experience increased; a similar trend was not seen for diploma nurses (P=0.10). Controlling for years of experience, new graduates were less likely to meet expectations compared with nurses with >or=10 years experience (P=0.046). CONCLUSION: Patient safety may be compromised if a nurse cannot provide clinically competent care. Assessments such as the Performance Based Development System can provide information about learning needs and facilitate individualized orientation targeted to increase performance level.

Hemodynamic and molecular response to intermittent hypoxia (IH) versus continuous hypoxia (CH) in normal humans.

The hemodynamic response to hypoxia may be influenced by exposure pattern and inducible biological signals, such as nitric oxide synthase (iNOS) expression. The systemic blood pressure (BP) and heart rate (HR) response to intermittent and continuous hypoxia (IH and CH) were examined as was the relationship between these responses and iNOS expression in 10 normal subjects. BP and HR were recorded during exposure to IH or CH (total hypoxic time=60 min/dayx3 days for each exposure profile), whereas arterial oxygen saturation (SpO2) was maintained at 80-90%. Total RNA was isolated from peripheral blood lymphocytes before exposure on Day 1 and 2 hours after the last exposure on Day 3, and it was assayed for iNOS messenger RNA (mRNA) expression using quantitative polymerase chain reaction (PCR). HR, systolic BP (SBP), and diastolic BP (DBP) increased during both experimental conditions (P<0.05), with no difference by exposure pattern or evidence of facilitation over 3 days. No significant change occurred in iNOS mRNA during IH or CH when pre- and post-exposure values were compared. However, iNOS expression at the end of Day 3 was negatively correlated with the average end-exposure DBP (r=-0.79) and mean BP (MBP; r=-0.76) on Days 1-3 of the IH (P<0.05), but not CH exposure. It is concluded that both IH and CH are associated with significant but comparable hemodynamic changes. The negative correlation between BP and iNOS mRNA with IH, but not CH, may suggest differential modulation of the hemodynamic response to the 2 exposure patterns.

Comparison of 2 models for managing tracheotomized patients in a subacute medical intensive care unit.

OBJECTIVE: To compare 2 models for managing patients admitted to a subacute medical intensive care unit (MICU) who required prolonged mechanical ventilation (> or = 7 d). METHODS: The subjects were 192 consecutive patients (mean +/- SD age 61.5 +/- 16.1 y, 52% male, 86% white) managed during alternating 7-month blocks of time by an attending physician in collaboration with an acute care nurse practitioner (ACNP) (n = 98 patients) or by an attending physician in collaboration with critical care/pulmonary fellows (n = 94 patients). The total observation time was 28 months (14 mo per team). RESULTS: At unit entry, there were no significant differences in age, sex, race, comorbidity, Acute Physiology and Chronic Health Evaluation III score, or time of tracheostomy between the patients managed by the 2 teams. Patients managed by the ACNP team were more likely to have required mechanical ventilation due to an acute pulmonary problem (p = 0.005). At subacute MICU discharge, the groups were not significantly different in regard to subacute MICU length of stay, days on mechanical ventilation, or discharge weaning status (p > 0.05). The number of readmissions to the MICU was similar for the ACNP team (n = 7) and fellows team (n = 8), as were readmissions to the subacute MICU < or = 72 h after discharge (ACNP = 2, fellows = 1). Each team had 2 deaths without treatment limitation. CONCLUSION: As hypothesized, management of patients who required prolonged mechanical ventilation with tracheostomy had equivalent outcomes with the ACNP team or the fellows team.

Outcomes of care managed by an acute care nurse practitioner/attending physician team in a subacute medical intensive care unit.

BACKGROUND: Many academic medical centers employ nurse practitioners as substitutes to provide care normally supplied by house staff. OBJECTIVE: To compare outcomes in a subacute medical intensive care unit of patients managed by a team consisting of either an acute care nurse practitioner and an attending physician or an attending physician and critical care/pulmonary fellows. METHODS: During a 31-month period, in 7-month blocks of time, 526 consecutive patients admitted to the unit for more than 24 hours were managed by one or the other of the teams. Patients managed by the 2 teams were compared for a variety of outcomes. RESULTS: Patients managed by the 2 teams did not differ significantly for any workload, demographic, or medical condition variable. The patients also did not differ in readmission to the high acuity unit (P = .25) or subacute unit (P = .44) within 72 hours of discharge or in mortality with (P = .25) or without (P = .89) treatment limitations. Among patients who had multiple weaning trials, patients managed by the 2 teams did not differ in length of stay in the subacute unit (P = .42), duration of mechanical ventilation (P = .18), weaning status at time of discharge from the unit (P = .80), or disposition (P = .28). Acute Physiology Scores were significantly different over time (P = .046). Patients managed by the fellows had more reintubations (P=.02). CONCLUSIONS: In a subacute intensive care unit, management by the 2 teams produced equivalent outcomes.

Are symptom reports useful for differentiating between acute rejection and pulmonary infection after lung transplantation?

BACKGROUND: Prompt treatment of acute rejection and pulmonary infection reduces morbidity and mortality in lung transplant recipients. Symptoms, spirometry, and bronchoscopy are used to detect these complications. Of these, symptom reporting is the least invasive, yet has received little critical examination. OBJECTIVE: To examine the potential for using reports of symptoms, such as cough and shortness of breath, to recognize clinically significant acute rejection and pulmonary infection after lung transplantation. METHODS: Symptoms reported during routine follow-up visits were compared between lung transplant recipients (LTR) with clinically significant acute rejection (grade >or= A2) and those without (grade A0 or A1) and between LTR with rejection (grade >or= A2) and those with pulmonary infection. RESULTS: LTR with rejection (grade >or= A2) reported more symptoms (P < .01) than did those without (grade A0, A1); however, the magnitude of difference was minimal. LTR with clinically significant acute rejection (grade >or= A2) reported symptoms at a rate comparable with those having pulmonary infection. CONCLUSIONS: Although symptoms may alert LTR to changes in their condition, no symptoms (respiratory, general, or activities of daily living [ADL]) differentiate between grades of rejection or pulmonary infection.

Short-term complications and resource utilization in matched subjects after on-pump or off-pump primary isolated coronary artery bypass.

BACKGROUND: Studies suggest that patients who undergo off-pump coronary artery bypass grafting (OPCABG) have fewer short-term complications and use fewer inpatient resources than do patients who undergo standard coronary artery bypass grafting (CABG) with extracorporeal circulation. However, dissimilarity between groups in risk factors for complications has hindered interpretation of results. OBJECTIVES: To compare the prevalence of selected complications (atrial fibrillation, stroke, reoperation, and bleeding) and inpatient resource utilization (length of stay, discharge disposition, total charges) between subjects undergoing primary isolated CABG or OPCABG who were matched with respect to key risk factors. METHODS: Retrospective, causal-comparative survey conducted in 1 center for 18 months. Patients who underwent primary isolated CABG or OPCABG were matched for sex, age (within 2 years), left ventricular ejection fraction (within 0.05), and graft-patient ratio (exact match) and compared for prevalence of new-onset atrial fibrillation, stroke, reoperation within 24 hours, and bleeding. Statistical analysis included Wilcoxon and t tests for paired comparisons. RESULTS: The sample (107 matched pairs) was 63% male, with a mean age of 66 (SD 9.5) years, a mean left ventricular ejection fraction of 0.51 (SD 0.13), and a mean graft-patient ratio of 3.41 (SD 0.74). The 2 groups did not differ significantly in New York Heart Association class (P = .43), Acute Physiology and Chronic Health Evaluation III score (P = .22), postoperative beta-blocker use (P = .73), or comorbid conditions. None of the complications examined differed significantly between pairs. CONCLUSION: Patients with comparable risk profiles have similar prevalences of selected complications after CABG and OPCABG.

Pattern and predictors of early rejection after lung transplantation.

BACKGROUND: Most lung transplant recipients experience improvement in their underlying pulmonary condition but are faced with the threat of allograft rejection, the primary determinant of long-term survival. Several studies examined predictors of rejection, but few focused on the early period after transplantation. OBJECTIVES: To describe the pattern and predictors of early rejection during the first year after transplantation to guide the development of interventions to facilitate earlier detection and treatment of rejection. METHODS: Data for donor, recipient, and posttransplant variables were retrieved retrospectively for 250 recipients of single or double lung transplants. RESULTS: Most recipients (85%) had at least 1 episode of acute rejection; 33% had a single episode; 23% had recurrent rejection; 3% had persistent rejection; 13% had refractory rejection; and 14% had clinicopathological evidence of chronic rejection. Serious rejection (refractory acute rejection or chronic rejection) developed in 27% of recipients. Compared with other recipients, recipients who had serious rejection had more episodes of acute rejection (P = .004), and the first acute episodes occurred sooner after transplantation (P = .01) and were of a higher grade (P = .002). CONCLUSIONS: Recipients who experienced higher grades for their first episode of acute rejection (P = .03) and higher cumulative rejection scores (P = .004) were significantly more likely than other recipients to have serious rejection during the first year after transplantation.