Use and outcomes of venous thromboembolism prophylaxis after spinal fusion surgery.

BACKGROUND: The number of spinal fusion operations in the USA is rapidly rising, but little is known about optimal venous thromboembolism prophylaxis after spinal surgery. OBJECTIVES: To examine the use of and outcomes associated with venous thromboembolism prophylaxis after spinal fusion surgery in a cohort of 244 US hospitals. PATIENTS/METHODS: We identified all patients with a principal procedure code for spinal fusion surgery in hospitals participating in the Premier Perspective database from 2003 to 2005, and searched for receipt of pharmacologic prophylaxis (subcutaneous unfractionated heparin, low molecular weight heparin, or fondaparinux) and/or mechanical prophylaxis (compression devices and elastic stockings) within the first 7 days after surgery. We also searched for discharge diagnosis codes for venous thromboembolism and postoperative hemorrhage during the index hospitalization and within 30 days after surgery. RESULTS: Among 80,183 spinal fusions performed during the time period, cervical fusions were the most common (49.0%), followed by lumbar fusions (47.8%). Thromboembolism prophylaxis was administered to 60.6% of patients within the first week postoperatively, with the most frequent form being mechanical prophylaxis alone (47.6%). Of the 244 hospitals, 26.2% provided prophylaxis to ≥ 90% of their patients undergoing spinal fusion; however, 33.2% provided prophylaxis to fewer than 50% of their patients. The rate of diagnosed venous thromboembolism within 30 days after surgery was 0.45%, and the rate of postoperative hemorrhage was 1.1%. CONCLUSIONS: Substantial variation exists in the use of thromboembolism prophylaxis after spinal fusion surgery in the USA. Nevertheless, overall rates of diagnosed thromboembolism after spinal fusion appear to be low.

Use of antihypertensive agents in the management of patients with acute ischemic stroke.

BACKGROUND: To protect the ischemic penumbra, guidelines have recommended against treating all but the severest elevations in blood pressure during acute ischemic stroke. OBJECTIVE: To determine how often antihypertensive agents were used in routine clinical practice and whether this use was consistent with guideline recommendations. METHODS: The records of patients discharged with ischemic stroke in 2000 at Baystate Medical Center in Springfield, MA, were reviewed. Adherence was evaluated by examining the use of antihypertensive agents in the context of daily blood pressure recordings during the first 4 days of hospitalization. Therapy was considered appropriate in the setting of severe hypertension (systolic blood pressure of >220 mm Hg or mean arterial blood pressure of >130 mm Hg) and potentially harmful in the setting of relative (systolic blood pressure of <120 mm Hg or mean arterial blood pressure of <85 mm Hg) or absolute (systolic blood pressure of <90 mm Hg or mean arterial blood pressure of <60 mm Hg) hypotension. RESULTS: One hundred (65%) of the 154 ischemic stroke patients were treated with antihypertensive agents. Forty-two percent of those who had received therapy prior to admission had their regimen intensified, and 36% of previously untreated patients had therapy initiated. Sixteen (11%) patients had hypertension severe enough to warrant treatment upon arrival, and 34 (22%) had at least one episode of severe hypertension during the first 4 hospital days. Sixty-five (65%) patients developed relative hypotension on a day when antihypertensive agents were administered, and five (5%) developed absolute hypotension. CONCLUSIONS: Most patients with acute ischemic stroke are treated with antihypertensive agents despite the absence of severe hypertension. Although low blood pressure is common among treated patients, frank hypotension is unusual.

Dying well after discontinuing the life-support treatment of dialysis.

BACKGROUND: Cessation of life-prolonging treatments precedes death in an increasing number of cases, but little attention has been accorded to the quality of dying. OBJECTIVE: To examine the quality of dying following dialysis termination. PATIENTS AND METHODS: A prospective cohort, observational study involved 6 dialysis clinics in the United States and 2 clinics in Canada, and 131 adult patients receiving maintenance dialysis who died after treatment cessation. Sixty percent (n = 79) underwent patient (n = 23) and/or family (n = 76) interviews and follow-up with caretakers. A quality of dying tool quantified duration, pain and suffering, and psychosocial factors. RESULTS: The sample was 59% female, the age was 70.0+/-1.2 years old, the duration of dialysis was 34.0+/-2.8 months, and death occurred 8.2+/-0.7 days after the last dialysis treatment. (Data are given as mean +/- SE.) Thirty-eight percent of the subjects who completed the protocol were judged to have had very good deaths, 47% had good deaths, and 15% had bad deaths. During the last day of life, 81% of the sample did not suffer, although 42% had some pain and an additional 5% had severe pain. According to the psychosocial domain of the quality of dying measure, patients who died at home or with hospice care had better deaths than those who died in a hospital or nursing home. CONCLUSIONS: Most deaths following withdrawal of dialysis were good or very good. The influence of site of death and physician attitudes about decisions to stop life support deserves more research attention. Quality of dying tools can be used to establish benchmarks for the provision of terminal care.

Is there a relationship between systemic perfusion temperature during coronary artery bypass grafting and extent of intraoperative ischemic central nervous system injury?

OBJECTIVE: This study was designed to compare the volume of cerebral infarction in patients operated on under either hypothermic or tepid/normothermic perfusion for coronary revascularization. METHODS: A randomized trial with preoperative, postoperative, and late neurologic evaluation was conducted in patients undergoing coronary revascularization having either hypothermic or tepid/normothermic perfusion for coronary revascularization. The goal was to determine whether perfusion temperature correlated with neurologic dysfunction associated with coronary artery bypass. RESULTS: Twelve intraoperative ischemic strokes occurred during coronary revascularization in a series of 291 patients. Six of these were in the group receiving hypothermic perfusion and 6 in groups receiving the tepid/normothermic perfusion. Measuring the infarct volume documented that 3 of the strokes in each group resulted in minor or small infarcts and 3 in each group were significant, major strokes. The volume of infarction, whether including all 6 patients in each group or only those with major strokes, was no different between the hypothermic and the tepid/normothermic groups. CONCLUSIONS: In this series of 291 patients randomized to perfusion temperature, we observed no relationship between the size of a cerebral ischemic infarct and the perfusate temperature during coronary revascularization.

Influence of cardiopulmonary bypass perfusion temperature on neurologic and hematologic function after coronary artery bypass grafting.

BACKGROUND AND METHODS: A National Institutes of Health-sponsored trial (1994 to 1998) randomized patients undergoing coronary artery bypass grafting that required three or more grafts to receive perfusion at either cold (20 degrees C), tepid (32 degrees C), or warm (37 degrees C) temperature. The goal of the study was to evaluate morbidity, primarily neurologic dysfunction and secondarily hematologic factors. One thousand seven hundred seventy-seven patients were screened and 291 enrolled. Neurologic function was studied by a dedicated pool of blinded neurologists. A standard test battery termed the Mathew Scale using three subscales--cognitive function, elemental skills, and disability--was used to study central nervous system function. Hematologic function was assessed in 53 of the 291 patients with measurements of postoperative fibrinolytic potential. RESULTS: All preoperative and operative data were comparable between groups. A decrease in Mathew Scale was seen in 69% of patient from before operation to immediately after operation. However, between the early postoperative study and the 1-month follow-up, 48% of patients had returned to baseline. There was no difference noted across temperature groups in any neurologic parameter of function. In all, 55% of the group were at or above their preoperative level at 1 month. Forty-nine patients suspect for cerebrovascular accident had a computed tomographic scan, but only 13 (4.5%) had a documented cerebrovascular accident (4 patients in the warm, 3 in the tepid, and 6 patients in the cold group). Fibrinolytic changes correlated with perfusion temperature documented that fibrinolysis was most active at 37 degrees C. Thus, increasing perfusate temperature increases fibrinolysis, which was associated with reoperation for bleeding in 4% warm group patients, 1% tepid, and 0% cold group patients (0.1 > p > 0.05). No other perioperative complications were temperature related. There were 4 deaths (1.4%) (1 in the warm group, 2 in the tepid group, and 1 in the cold group). CONCLUSIONS: (1) Persistent postoperative neurologic dysfunction at 1 month occurs in 36% of patients undergoing coronary artery bypass grafting and is not related to a cerebrovascular accident; 2) perfusion temperature has no relationship to neurologic function after bypass; and 3) fibrinolytic activity is greatest at warm temperatures.

What is the best perfusion temperature for coronary revascularization?

BACKGROUND: [corrected] A National Institutes of Health-funded clinical trial of patients undergoing coronary artery bypass randomized perfusate and myocardial preservation to cold, tepid, or warm temperatures. The goal of the trial was to evaluate neurologic function before and after operation (4 days and 1 month after operation) and to measure hematologic data for fibrinolytic potential. METHODS: The three groups comprised 116 patients who completed neurologic evaluation by means of the Mathew scale out of 130 entered into the trial (37 cold group, 50 tepid, and 43 warm). Twenty-five patients had complete hematologic studies done. All three groups were comparable before operation. The myocardial preservation protocol used blood cardioplegic solution at cold (8 degrees to 10 degrees C), tepid (32 degrees C), or warm (37 degrees C) temperature and the systemic perfusate temperature during cardiopulmonary bypass was 20 degrees (cold), 32 degrees C (tepid), or 37 degrees (warm). RESULTS: Patients in the cold group had a longer duration of intubation and postoperative hospitalization and a slightly but significantly higher peak postoperative creatine kinase MB level than patients in the warm group. There were no deaths. There was deterioration in Mathew scale findings in all three groups, and no distinction could be made between groups. However, a significantly higher number in the cold group had an abnormal postoperative neurologic examination result that prompted computed tomographic scanning (18.9% cold, 2% tepid, 9.3% warm). A cerebrovascular accident was documented by computed tomographic scanning in 8.1%, 0%, and 4.7% of patients in the cold, tepid, and warm groups, respectively (not significant). Hematologic data documented significantly increased fibrinolytic potential in the warm group. CONCLUSIONS: Perfusion temperature is a factor in recovery from cardiopulmonary bypass. Cold has more adverse neurologic sequelae that prompt computed tomographic scanning whereas warm has more activation of fibrinolytic potential. Tepid is the best temperature for optimizing recovery from cardiopulmonary bypass.

Does cardiopulmonary bypass temperature correlate with postoperative central nervous system dysfunction?

A National Institutes of Health-funded trial of perfusate temperature and neurological function was begun in the Baystate Medical Center in February 1994. It randomizes patients having coronary revascularization to three temperatures--warm (37 degrees C), tepid (32 degrees C), and cold (20 degrees C)--for systemic perfusate and blood cardioplegia temperature at 37 degrees C warm, 32 degrees C tepid, and 6 degrees C to 10 degrees C cold. The goal is to have a quantitated neurological examination performed prior to operation, prior to discharge at day 3 or 4, and at a 1-month follow-up interval. The initial 51 patients completing a 1-month follow-up broke down to 14 cold, 22 tepid, and 15 warm. The neurological examination quantitated their performance on the Mathew Scale, an ordinal measure from 1 to 100, with 100 being normal. There was a significant (p < 0.05) decrease across the entire study from preoperative to postoperative that was no longer present at late follow-up. Although the lowest mean scores (94.8) occurred in the warm group, they were not statistically different from the other groups', and there was no discernible influence of temperature on neurological function. Additional patients will be entered to validate a difference if such exists.

Fast-track recovery of the coronary bypass patient.

A new approach termed "fast-track recovery" ws undertaken at both the Baystate Medical Center and Hartford Hospital. The fast-track protocol involves the following principles: (1) preoperative education; (2) early extubation; (3) methylprednisolone sodium succinate before bypass followed by dexamethasone for 24 hours postoperatively; (4) prophylactic digitalization, metoclopramide HCl, docusate sodium, and ranitidine HCl; (5) accelerated rehabilitation; (6) early discharge; (7) a dedicated fast-track coordinator to perform both daily telephone contact and a 1-week postoperative examination; and (8) a routine 1-month postoperative visit with a PA or MD. To evaluate the effects of this approach on patient care, a retrospective 1-year analysis was undertaken in both institutions with all coronary artery bypass grafting patients compared in a consecutive manner before the origin of the fast-track protocol and subsequent to its beginning. There were 280 patients in the fast-track and 282 in the non-fast-track group. The two groups were not significantly different except inexplicably there was a lower ejection fraction in the fast-track group and a longer cross-clamp time. Postoperatively, the mean time to extubation decreased from 22.1 to 15.4 hours, and peak weight gain decreased from 2.8 to 1.6 kg from the non-fast-track to the fast-track group (p < 0.01). This was accompanied by significant (p < 0.001) decreases in intensive care unit duration from 2.4 to 1.9 days and in postoperative length of stay from 8.3 to 6.8 days from the non-fast-track to the fast-track group. There was no increase in morbidity or mortality associated with the fast-track protocol either early or late. Thirty-day hospital readmission was not significantly different between the two groups. Fast-track methodology is effective, and we routinely employ this approach for all patients undergoing cardiopulmonary bypass.

Reliability of quantitating proliferative cell nuclear antigen in epithelial ovarian tumors.

Sources of variability in quantitating proliferative cell nuclear antigen (PCNA) by image analysis were evaluated in paraffin sections of 18 ovarian tumors of low malignant potential (LMP) and grade 1 (G1) carcinomas. The correlation coefficient of reliability (R) was calculated to determine how reliable a single observation was for representing a "true" tumor value. Reliability of 61% was obtained when interobserver and intraobserver variability were assessed. Threshold settings for positive nuclear and antibody signals minimally affected the overall reliability. The reliability of a single block of tumor for representing true tumor value was R = 0.61. These sources of variability render this technique impractical for evaluating proliferative characteristics in LMP and G1 common epithelial ovarian tumors with PCNA staining.

Increasing the efficacy of physician-delivered smoking interventions: a randomized clinical trial.

OBJECTIVE: To assess the relative impacts of three physician-delivered smoking interventions in combination with follow-up contact from behavioral counselors. DESIGN: Randomized controlled trial with pre- post measures of smoking rates. This paper reports six-month outcome data. SETTING: Participants were recruited from among patients seen by 196 medical and family practice residents in five primary care clinics. PARTICIPANTS: Participants were 1,286 patients out of 1,946 eligible smokers approached. The patient group was 57% female and 91% white, had an average age of 35 years, and smoked, on average, slightly over one pack per day. INTERVENTION: Physicians were trained to provide each of three interventions: advice only, brief patient-centered counseling, and counseling plus prescription of nicotine-containing gum (Nicorette). Half the patients received follow-up in the form of telephone counseling at three-monthly intervals from behavioral counselors. MEASUREMENTS AND MAIN RESULTS: Changes in smoking behaviors were assessed by telephone interview six months after physician intervention. The differences in one-week point prevalence cessation rates among the physician interventions were significant (p less than 0.01): advice only, 9.1%; counseling, 11.9%; counseling plus gum, 17.4%; with no effect for telephone counseling. The time elapsed from physician encounter to initial quitting and the length of that period of abstinence also showed significant benefit of the counseling interventions. Patients receiving physician counseling were much more likely than those not receiving counseling to rate their physician as very helpful (p less than 0.001). Multiple regression analyses are also reported. CONCLUSION: Smoking intervention counseling provided by physicians is well received by patients and significantly increases the likelihood of cessation at six months, an effect that is augmented by the prescription of nicotine-containing gum, when compared with physician-delivered advice. Follow-up telephone counseling does not contribute significantly to smoking behavior changes.

An assessment of the incidence of maternal mortality in the United States.

Recent studies in several states have found that the incidence of maternal mortality is higher than traditional vital statistics reports indicate. Since no comprehensive national study has been done to evaluate the completeness of maternal mortality ascertainment through the national vital statistics reporting system, the Centers for Disease Control (CDC) undertook such a study with the assistance of the National Center for Health Statistics and state health departments. The state health departments provided CDC with death certificates for all pregnancy-related deaths occurring during 1974-78. We reviewed and classified these certificates using both International Classification of Diseases, Adapted, Eighth Revision (ICDA-8) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) maternal death codes. We found that the actual incidence of maternal mortality for 1974-78 was approximately 20 per cent and 30 per cent greater than that published in national vital statistics reports using ICDA-8 and ICD-9-CM, respectively.