Implementation Evaluation of a Complex Intervention to Improve Timeliness of Care for Veterans with Transient Ischemic Attack.

BACKGROUND: The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurologic Symptoms (PREVENT) program was designed to address systemic barriers to providing timely guideline-concordant care for patients with transient ischemic attack (TIA). OBJECTIVE: We evaluated an implementation bundle used to promote local adaptation and adoption of a multi-component, complex quality improvement (QI) intervention to improve the quality of TIA care Bravata et al. (BMC Neurology 19:294, 2019). DESIGN: A stepped-wedge implementation trial with six geographically diverse sites. PARTICIPANTS: The six facility QI teams were multi-disciplinary, clinical staff. INTERVENTIONS: PREVENT employed a bundle of key implementation strategies: team activation; external facilitation; and a community of practice. This strategy bundle had direct ties to four constructs from the Consolidated Framework for Implementation Research (CFIR): Champions, Reflecting & Evaluating, Planning, and Goals & Feedback. MAIN MEASURES: Using a mixed-methods approach guided by the CFIR and data matrix analyses, we evaluated the degree to which implementation success and clinical improvement were associated with implementation strategies. The primary outcomes were the number of completed implementation activities, the level of team organization and > 15 points improvement in the Without Fail Rate (WFR) over 1 year. KEY RESULTS: Facility QI teams actively engaged in the implementation strategies with high utilization. Facilities with the greatest implementation success were those with central champions whose teams engaged in planning and goal setting, and regularly reflected upon their quality data and evaluated their progress against their QI plan. The strong presence of effective champions acted as a pre-condition for the strong presence of Reflecting & Evaluating, Goals & Feedback, and Planning (rather than the other way around), helping to explain how champions at the +2 level influenced ongoing implementation. CONCLUSIONS: The CFIR-guided bundle of implementation strategies facilitated the local implementation of the PREVENT QI program and was associated with clinical improvement in the national VA healthcare system. TRIAL REGISTRATION: clinicaltrials.gov: NCT02769338.

The protocol-guided rapid evaluation of veterans experiencing new transient neurological symptoms (PREVENT) quality improvement program: rationale and methods.

BACKGROUND: Transient ischemic attack (TIA) patients are at high risk of recurrent vascular events; timely management can reduce that risk by 70%. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) developed, implemented, and evaluated a TIA quality improvement (QI) intervention aligned with Learning Healthcare System principles. METHODS: This stepped-wedge trial developed, implemented and evaluated a provider-facing, multi-component intervention to improve TIA care at six facilities. The unit of analysis was the medical center. The intervention was developed based on benchmarking data, staff interviews, literature, and electronic quality measures and included: performance data, clinical protocols, professional education, electronic health record tools, and QI support. The effectiveness outcome was the without-fail rate: the proportion of patients who receive all processes of care for which they are eligible among seven processes. The implementation outcomes were the number of implementation activities completed and final team organization level. The intervention effects on the without-fail rate were analyzed using generalized mixed-effects models with multilevel hierarchical random effects. Mixed methods were used to assess implementation, user satisfaction, and sustainability. DISCUSSION: PREVENT advanced three aspects of a Learning Healthcare System. Learning from Data: teams examined and interacted with their performance data to explore hypotheses, plan QI activities, and evaluate change over time. Learning from Each Other: Teams participated in monthly virtual collaborative calls. Sharing Best Practices: Teams shared tools and best practices. The approach used to design and implement PREVENT may be generalizable to other clinical conditions where time-sensitive care spans clinical settings and medical disciplines. TRIAL REGISTRATION: clinicaltrials.gov: NCT02769338 [May 11, 2016].

Mild to moderate increase of serum calcitonin levels only in presence of large medullary thyroid cancer deposits.

Many open questions remain to be elucidated about the diagnosis, treatment and prognosis of medullary thyroid cancer (MTC). The most intriguing concerns the outcome of MTC patients after surgery. Great importance is usually given to serum calcitonin (Ct) and carcinoembryonic (CEA) levels. It is commonly believed that the higher are the levels of these tumor markers and their kinetics (double time and velocity of markers levels) the worst is the prognosis. However, this is not the rule, as there are huge MTC metastatic deposits characterized by low serum Ct and CEA levels, and this condition is not closely related to the outcome of the disease during post-surgical follow-up. A series is reported here of patients who have these characteristics, as well as a description of their prognosis and clinical outcome.

Octamerization of lambda CI repressor is needed for effective repression of P(RM) and efficient switching from lysogeny.

The CI repressor of bacteriophage lambda is a model for the role of cooperativity in the efficient functioning of genetic switches. Pairs of CI dimers interact to cooperatively occupy adjacent operator sites at O(R) and at O(L). These CI tetramers repress the lytic promoters and activate transcription of the cI gene from P(RM). CI is also able to octamerize, forming a large DNA loop between O(R) and O(L), but the physiological role of this is unclear. Another puzzle is that, although a dimer of CI is able to repress P(RM) by binding to the third operator at O(R), O(R)3, this binding seems too weak to affect CI production in the lysogenic state. Here we show that repression of P(RM) at lysogenic CI concentrations is absolutely dependent on O(L), in this case 3.8 kb away. A mutant defective in this CI negative autoregulation forms a lysogen with elevated CI levels that cannot efficiently switch from lysogeny to lytic development. Our results invalidate previous evidence that Cro binding to O(R)3 is important in prophage induction. We propose the octameric CI:O(R)-O(L) complex increases the affinity of CI for O(R)3 by allowing a CI tetramer to link O(R)3 and the third operator at O(L), O(L)3.

Microsatellite variation in the yellowhammer Emberiza citrinella: population structure of a declining farmland bird.

In recent years, there has been much concern in the UK about population declines of widespread species in agricultural habitats. Conservation-orientated research on declining birds has focused on vital rates of survival and productivity. However, the environmental factors which may influence movements between populations of widespread species is poorly understood. Population genetic structure is an indirect description of dispersal between groups of individuals. To attempt to develop an understanding of genetic structuring in a widespread, but declining, farmland bird, we therefore investigated the yellowhammer, Emberiza citrinella, population in England and Wales using microsatellite data. Our first aim was to investigate whether there was genetic substructuring in the population. A second aim was to investigate if there was a relationship between genetic distances and various environmental variables. Finally, we analysed the microsatellite data for evidence of loss of genetic variation due to population decline. Our data showed a slight but significant structure within the yellowhammer population. This therefore cannot be considered a panmictic population. Our example from South Cumbria implies that high-altitude barriers may have a slight influence on population structure. However, on the whole, genetic distances between sample sites were not significantly correlated with geographical distances, degrees of population connectivity, high altitudes, or differences in precipitation between sites. Finally, we detected departures from mutation-drift equilibrium (excess heterozygosity), which is indicative of a loss of genetic variation through recent decline.

Assessing the association of walking with health services use and costs among socioeconomically disadvantaged older adults.

BACKGROUND: The costs of physical inactivity are beginning to be recognized. Research to pinpoint these costs will provide needed information for researchers and policy-makers to develop cost-effective physical activity promotion programs. We present the association of walking with health services use and costs within a sample of 695 older, urban primary care patients. METHODS: A survey provided most data, but utilization and cost data were obtained from a medical records system. Multivariate models were developed to assess the association of walking with health services use and costs, adjusting for sociodemographic characteristics, chronic disease, health status, and previous utilization. RESULTS: Thirty-eight percent of respondents reported walking 0 minutes per week, 49% walked 1 to 119 minutes, and 13% walked 120 minutes or more. In the multivariate analyses, a report of walking 120 or more minutes was associated with a lower risk of emergency room visit and hospital stay in the subsequent year. No association was found between walking and primary care visits and total cost. CONCLUSION: These analyses suggest an association of walking 120 minutes or more with decreased emergency room visits (OR = 0.5, P = 0.046) and hospital stays (OR = 0.6, P = 0.034). This suggests that physical activity promotion among socioeconomically disadvantaged older adults has the potential to provide cost savings. This will not be known, however, until physical activity can be promoted and maintained among these adults.

The effect of discussions about advance directives on patients' satisfaction with primary care.

BACKGROUND: Discussions of end-of-life care should be held prior to acute, disabling events. Many barriers to having such discussions during primary care exist. These barriers include time constraints, communication difficulties, and perhaps physicians' anxiety that patients might react negatively to such discussions. OBJECTIVE: To assess the impact of discussions of advance directives on patients' satisfaction with their primary care physicians and outpatient visits. DESIGN: Prospective cohort study of patients enrolled in a randomized, controlled trial of the use of computers to remind primary care physicians to discuss advance directives with their elderly, chronically ill patients. SETTING: Academic primary care general internal medicine practice affiliated with an urban teaching hospital. PARTICIPANTS: Six hundred eighty-six patients who were at least 75 years old, or at least 50 years old with serious underlying disease, and their 87 primary care physicians (57 residents, 30 faculty general internists) participated in the study. MEASUREMENTS AND MAIN RESULTS: We assessed patients' satisfaction with their primary care physicians and visits via interviews held in the waiting room after completed visits. Controlling for satisfaction at enrollment and physician, patient, and visit factors, discussing advance directives was associated with greater satisfaction with the physician (P =.052). At follow-up, the strongest predictor of satisfaction with the primary care visit was having previously discussed advance directives with that physician (P =.004), with a trend towards greater visit satisfaction when discussions were held during that visit (P =.069). The percentage of patients scoring a visit as "excellent" increased from 34% for visits without prior advance directive discussions to 51% for visits with such discussions (P =.003). CONCLUSIONS: Elderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed. The improvement in visit satisfaction was substantial and persistent. This should encourage physicians to initiate such discussions to overcome communication barriers might result in reduced patient satisfaction levels.

Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair.

PURPOSE: The aim of this study was to define whether veterans who survived repair of ruptured abdominal aortic aneurysms (AAA) experienced late survival rates similar to those surviving repair of intact AAA. METHODS: All veterans undergoing AAA repair in DRGs 110 and 111 during fiscal years 1991-1995 were identified using the Veterans Affairs (VA) Patient Treatment File (PTF). Late mortality was defined using VA administrative databases including the Beneficiary Identification and Record Locator System and PTF. Illness severity and patient complexity were defined using PTF discharge data that were further analyzed by Patient Management Category software. Veterans were followed up to 6 years after AAA repair. RESULTS: During the study, 5833 veterans underwent repair of intact AAA while 427 had repair of ruptured AAA in all VA medical centers. Operative mortality was defined as that which occurred within 30 days of surgery or during the same hospitalization as aneurysm repair. For those undergoing repair of intact AAA, operative mortality thus defined was 4.5% (265/5833). Operative mortality was 46% (195/427) after repair of ruptured AAA. Overall mortality (including operative mortality) during 2.62+/-1.61 years follow-up was 22% (1282/5833) with intact AAA versus 61% (260/427) for those with ruptured AAA (P<0.001). Further analysis of survival outcomes was performed in patients who survived AAA repair (i.e., those who were discharged alive and lived 30 days or more after surgery). Of those who initially survived repair of ruptured AAA, 28% (65/232) died during follow-up versus 18% (1017/5568) who initially survived repair of intact AAA (odds ratio 1.74; 95% confidence limits 1.30-2.34; P<0.001). In those initially surviving AAA repair, stepwise logistic regression analysis revealed that increasing age, illness severity, patient complexity, as well as AAA rupture and aortic graft complications were increasingly and independently associated with late mortality. Mean survival time was 1681 days for those who survived >30 days and who were discharged alive after repair of ruptured AAA versus 1821 days for those who initially survived repair of intact AAA (P< 0.001). CONCLUSIONS: In addition to higher postoperative mortality rates with ruptured AAA, mortality during follow-up for survivors of AAA repair was also greater for those who survived repair of ruptured AAA. The toll taken by ruptured abdominal aortic aneurysms did not end in the immediate postoperative period.

Major lower extremity amputation in Veterans Affairs medical centers.

Our objective was to assess outcomes for 8696 patients who underwent 9236 above- (AKA) and/or below-knee (BKA) amputations during a 4-year period for disorders of the circulatory system. Veterans Affairs (VA) Patient Treatment File (PTF) data were acquired for all patients in Diagnosis Related Groups (DRGs) 113 and 114 hospitalized in VA medical centers (VAMCs) during fiscal years 1991-1994. Data were further analyzed by Patient Management Category (PMC) software, which measured illness severity, patient complexity, and relative intensity score (RIS), a measure of resource utilization. The results of this analysis showed that mortality and morbidity rates remain high after AKA and BKA. Differing amputation practice patterns found in this study warrant further investigation.

Outcomes after lower-extremity reconstruction in DRGs 478 and 479.

PURPOSE: To assess outcomes for 21,261 patients in DRGs 478 and 479 hospitalized in Veterans Affairs Medical Centers (VAMCs) during fiscal years 1991-1994. DRGs 478 and 479 contain patients undergoing a variety of vascular procedures including lower-extremity arterial reconstruction. METHODS: VA Patient Treatment File (PTF) data were analyzed using Patient Management Category (PMC) software which defined illness severity, patient complexity as defined by PMC count, and calculated resource intensity scale (RIS), a measure of resource utilization, for each admission. RESULTS: In-hospital mortality rate was 3.16% (671/21,261) for all patients. Mortality did not differ between the 14,155 patients who underwent extremity arterial reconstruction (3.22%) and the remaining patients (3.03%). The incidence of ICD-9-CM-coded complications was 20.4% after limb revascularization versus 12.8% for remaining patients (P < 0.001). Length of stay (LOS) was 18.6 +/- 17.6 days with versus 10.3 +/- 14. 5 days without limb revascularization (P < 0.001). As defined in this study, patients who underwent limb revascularization were older (64.1 +/- 9.6 vs 62.2 +/- 11.0, P < 0.001); had higher illness severity scores (3.63 +/- 1.60 vs 2.72 +/- 1.72, P < 0.001); were more complex (had higher PMC count: 2.59 +/- 1.35 vs 2.54 +/- 1.34, P = 0.016); and required utilization of more resources (had higher RIS: 2.16 +/- 0.81 vs 1.68 +/- 0.76, P < 0.001) than remaining patients. Logistic regression analysis limited to those undergoing extremity revascularization revealed that age, presence of complications, patient complexity, illness severity, and acute arterial thromboembolism were increasingly and independently associated with greater in-hospital mortality. The logistic regression model also showed that the type of arterial reconstruction was related to in-hospital mortality: arterial bypass (ICD-9-CM 39.29) was associated with lower mortality. Outcomes were defined for the subgroup (n = 7,728) undergoing arterial bypass (ICD-9-CM 39.29) who were assigned to Patient Management Category 4101, 4113, or 4141: Mortality rates were 2.26, 2.19, and 5.03% for those undergoing elective bypass (n = 3003), urgent bypass (n = 3,513), and bypass for gangrene (n = 1212), respectively. Octogenarians did not experience higher mortality rates after elective bypass ¿1.4% (1/73) vs 2.3% (67/2,930), n.s., but experienced higher mortality rates after urgent bypass ¿8.6% (8/93) vs 2.0% (69/3,420), P < 0.001 and after bypass for gangrene ¿11.6% (5/43) vs 4.8% (56/1,169), P < 0.045. CONCLUSIONS: Outcomes for patients in DRGs 478 and 479 who underwent extremity revascularization differed from those who did not. Outcomes varied by the type of arterial reconstruction and its urgency and indication and within selected subpopulations (i.e., octogenarians). DRG-based reimbursement would not be sensitive to these clinically important factors which have a major impact on outcomes and resource utilization.

Outcomes after abdominal aortic aneurysm repair: comparison of mortality defined by centralized VA Patient Treatment File data versus hospital-based chart review.

BACKGROUND: Outcomes after abdominal aortic aneurysm (AAA) repair have been reported by individual Veterans Affairs medical centers (VAMCs) and for the entire VA patient population. PURPOSE: This study was done to determine whether outcomes defined using VA Patient Treatment File (PTF) data were comparable to those defined by direct chart review in those undergoing repair of intact AAA. METHODS: Focused chart review was performed in all veterans undergoing such AAA repair in a sample of VAMCs (n = 5) for separate 1-year periods during fiscal years (FY) 1991-1993. A previous report of outcomes after AAA repair for all veterans in DRGs 110 and 111 during FY 1991-1993 was based on PTF data that were further analyzed by Patient Management Category (PMC) software. Outcomes after AAA repair were defined in a similar fashion using PTF data and PMC analysis in the same sample VAMCs for which direct chart review data were available. Outcomes defined by chart review were then compared to those based on PTF data. RESULTS: Three of the 69 patients undergoing repair of intact AAA for which chart review data were available were assigned to DRGs other than 110 and 111 and, by definition, were not included in the PTF-derived database. Nine of 10 additional patients undergoing chart review were not identified as having undergone AAA repair by PMC software: 7 had procedure codes 39.25 instead of more standard AAA repair codes 38.34 or 38.44. Two additional patients with codes 38.64 or 38.66 were not identified as having undergone AAA repair by PMC software. The 10th patient not included in the PTF-derived database underwent additional operative procedures. Of the 13 patients missed by the combined PTF and PMC outcome analyses but identified by chart review, none died or had cardiac complications. One of these 13 patients had pulmonary complications based on chart review and PTF but was excluded by PMC analysis. There remained a total of 56 patients at the five sample VAMCs common to the PTF-derived and chart-derived databases identified as having undergone repair of intact AAA. There were two in-hospital deaths in these patients, and both were identified by each approach to outcome assessment. Four of these 56 patients had postoperative cardiac complications (ICD-9-CM code 997. 10) which were identified by both PTF and chart review. Postoperative pulmonary complications (ICD-9-CM code 997.30) were present in 4 of the 56 cases and were also identified by both PTF-based and chart-based outcome analyses. CONCLUSIONS: All deaths as well as cardiac or respiratory complications identified by chart review at the study hospitals were also affirmed by the PTF. Due to study methodologies (which restricted analysis to those in DRGs 110 and 111 and which included secondary analyses of PTF data by PMC software), 19% of patients who underwent repair of intact AAA identified by hospital-based chart review were excluded from the PTF-based outcome analysis. Outcomes defined using large databases such as the VA PTF may be comparable to those defined by chart review if study methodologies permit. Discrepancies in outcome assessment between direct chart review and large database analysis in the present study were due to methodologies used, not to deficiencies, per se, in PTF data.

Pulmonary embolism in Veterans Affairs Medical Centers: is vena cava interruption underutilized?

Veterans with venous thrombosis or pulmonary embolism (PE) were evaluated using Veterans Affairs patient treatment file (PTF) data from fiscal years 1990-1995, inclusive, to define outcomes for those with PE. The specific aims of the study were to define how often those with PE underwent vena cava interruption (VCI) and whether VCI affected in-hospital mortality rates. Outcomes were defined using PTF data and Patient Management Category (PMC) software for 26,132 veterans discharged from all Veterans Affairs Medical Centers (VAMCs) with venous thromboembolism, which included a subset of 4,882 patients identified by both PTF data and PMC software to have PE. PMC software also generated measures of illness severity, patient complexity (PMC count), and resource utilization (called resource intensity scale) for each hospital admission. The in-hospital mortality rate for those with PE was 15.9 per cent (775 of 4882). Only 157 VCIs were performed in those with PE which constituted 3.2 per cent of the latter group. Those with PE who had VCI experienced a 13.4 per cent unadjusted in-hospital mortality rate (21 of 157) versus a 16 per cent unadjusted mortality rate without VCI (754/4725; not significant). In a logistic regression model of in-hospital mortality in those with PE, increasing age and illness severity were directly related to mortality, whereas VCI was independently associated with reduced mortality. The odds of death were reduced by 0.482 (0.287-0.807, 95% limits) for patients with PE who underwent VCI (P<0.005). Utilization of VCI varied among VAMCs: the hospital rates that VCI were performed in those with PE ranged from 0 to 16.7 per cent. Mortality associated with PE was substantial in VAMCs, and VCI was independently associated with reduced in-hospital mortality. The low percentage of veterans with pulmonary embolism who underwent VCI was surprising. VCI may be underutilized in veterans with PE.

Association of antioxidants with memory in a multiethnic elderly sample using the Third National Health and Nutrition Examination Survey.

Oxidative stress has been implicated both in the aging process and in the pathological changes associated with Alzheimer's disease. Antioxidants, which have been shown to reduce oxidative stress in vitro, may represent a set of potentially modifiable protective factors for poor memory, which is a major component of the dementing disorders. The authors investigated the association between serum antioxidant (vitamins E, C, A, carotenoids, selenium) levels and poor memory performance in an elderly, multiethnic sample of the United States. The sample consisted of 4,809 non-Hispanic White, non-Hispanic Black, and Mexican-American elderly who visited the Mobile Examination Center during the Third National Health and Nutrition Examination Survey, a national cross-sectional survey conducted from 1988 to 1994. Memory is assessed using delayed recall (six points from a story and three words) with poor memory being defined as a combined score less than 4. Decreasing serum levels of vitamin E per unit of cholesterol were consistently associated with increasing levels of poor memory after adjustment for age, education, income, vascular risk factors, and other trace elements and minerals. Serum levels of vitamins A and C, beta-carotene, and selenium were not associated with poor memory performance in this study.

Health status in veterans undergoing noninvasive lower extremity arterial evaluation.

The health status of outpatients (n = 299) undergoing lower extremity arterial Doppler studies (LES) in a Veterans Affairs Medical Center-based vascular laboratory was assessed from 9/95 through 6/96 using the SF-36 Health Survey. The purpose of this study was to compare health status of these outpatients to national norms and to determine whether Doppler-derived ankle/brachial indices (ABI) correlated with the eight health concepts measured by the SF-36 Health Survey. Physical functioning (PF), role limitations by physical illness (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations by emotional illness (RE), and mental health (MH) were more impaired in study patients (65.9 +/- 9.6 years of age) undergoing LES than national norms for males >/=65 years old (P < 0.0001). In fact, each health concept was below the 25th percentile of the national norms. PF was 33.4 +/- 22.4 for outpatients compared to the national norm of 65.8 +/- 28.3. Physical functioning was the only SF-36 health concept defined above which correlated with lowest ABI (r = 0.15; P = 0.012), adjusting for age but not comorbidities. Veterans undergoing only carotid duplex during the study period (n = 169) were compared to the veterans undergoing only LES (n = 251) during the study. PF, RP, BP, GH, VT, SF, and RE were significantly more impaired in those undergoing only LES compared with carotid duplex (P < 0.05). Veteran outpatients referred to a vascular laboratory have broad-based and profound impairments in health status. In addition, only physical functioning correlated with ABI, a measure of lower extremity arterial disease severity.

Carotid surgery in octogenarians in Veterans Affairs medical centers.

The purpose of this study was to define outcomes after carotid surgery in octogenarians in the Veterans Affairs health care system. During fiscal years 1991-1994, 9152 patients in DRG 5 underwent extracranial vascular surgery procedures in Veterans Affairs medical centers. Those >/=80 years of age constituted 2.1% (n = 195) of such patients. In-hospital mortality rates were 1.03% (92/8957) in those <80 versus 3.08% (6/195) in those >/=80 years old (P = 0.018). Of those >/=80, 11.8% (23/195) had an ICD-9-CM-coded complication during hospitalization versus 11.2% of those <80 (1004/8957, NS). Surgical complications of the central nervous system (CNS) were present in 0.51% of octogenarians (1/195) and in 0.93% of those younger (83/8957, NS). Myocardial infarction (MI) occurred in 1.0% (2/195) of octogenarians and 0.74% (66/8967) of younger patients (NS). Patient Management Category software was used to define illness severity and resource intensity scale (RIS, a measure of resource utilization). Logistic regression analysis showed that age, illness severity, MI, and surgical complications of the CNS were associated with greater likelihood of mortality after extracranial vascular surgery. When the dichotomous variable "octogenarian status" was substituted for the continuous variable "age," in this model, there was no significant association of octogenarian status per se with mortality, though the association of illness severity, MI, and CNS complications with mortality persisted. Illness severity was greater for octogenarians (2.03 +/- 1.36) versus those younger (1.84 +/- 1.13, P < 0.05). RIS was 2.57 +/- 0.57 in octogenarians versus 2.47 +/- 0.48 for younger patients (P < 0.015). Length of stay (LOS) was a mean of 3.2 days longer for octogenarians (P < 0. 001). The risk of postoperative CNS complications was not higher in octogenarians. Mortality, resource utilization, and length of stay were, however, greater for octogenarians, but so was illness severity. Though mortality rates were greater for octogenarians in DRG 5, illness severity, MI, and postoperative CNS complications had greater impact on mortality after extracranial vascular surgery than octogenarian status per se.

Outcomes after abdominal aortic aneurysm repair in those > or =80 years of age: recent Veterans Affairs experience.

During fiscal years 91-95, 6260 patients underwent 6269 abdominal aortic aneurysm (AAA) repairs in Veterans Affairs Medical Centers. Those > or =80 years old comprised 3.7% (n = 231) of the patients. A total of 5833 patients underwent repair of nonruptured AAA: mortality was 4.1% (228/5627) in those <80 and 8.25% (17/206) in those > or =80 years old (p < 0.009). Logistic regression analysis indicated age > or =80 was independently associated with higher mortality (odds ratio 1.834:1, 95% bounds 1.117-3.012). Octogenarian status (defined as > or =80 years of age), however, had a less important association with in-hospital death than did surgical complications of the heart or genitourinary tract, postoperative hemorrhage, septicemia, respiratory insufficiency, myocardial infarction (MI), acute renal failure, surgical complications of the central nervous system (CNS), aneurysm rupture, postoperative shock, or disseminated intravascular coagulation (DIC), in ascending order of importance. Only 5.9% (n = 25) of the 427 patients undergoing repair of ruptured AAA were > or =80 years old. In those > or =80 undergoing repair of ruptured aneurysms, mortality was 48% which did not differ from the 45% mortality in those <80 (NS). The likelihood that one would be operated for rupture was statistically greater (1.66:1) for those > or =80 years (p < 0.025). Length of stay (LOS) for those > or =80 undergoing AAA repair was longer being 22.3 +/- 14.8 days versus 18.3 +/- 13.2 days for younger patients (p < 0.001). Mortality and LOS after AAA repair were statistically greater for those > or =80 years of age. Severity of illness, however, was also greater for octogenarians. Patient Management Category (PMC) software defined illness severity was 4.06 +/- 1.22 in octogenarians versus 3.84 +/- 1.13 for those younger (p < 0.005). Though age > or =80 was independently associated with increased mortality, selected elderly patients could benefit from AAA repair.

Errors of judgement at Greenwich in 1796.

The origins of experimental psychology can be traced back to 1796, when the then Astronomer Royal dismissed his assistant for making some seemingly inaccurate measurements. But there is more to the story than meets the eye.

Percutaneous feeding tube placement in pediatric patients: immediate and 30-day results.

PURPOSE: To evaluate fluoroscopically guided percutaneous feeding tube placement in pediatric patients. MATERIALS AND METHODS: Sixty-one procedures were performed. Periprocedural care protocol was changed after patient nine. Forty-eight-hour and 30-day outcomes were assessed. RESULTS: Almost 97% of procedures were successful. The 48-hour major and minor complication rates were 1.9% and 9.6%, respectively, after the initial nine procedures. Risk factors for early complications were the use of the initial care protocol (P < .01) and patient weight below the 50th percentile (P < .05). Major and minor 30-day complication rates were 8.3% and 12.0%, respectively. Risk factors for delayed complications were placement of a gastrojejunostomy tube rather than a gastrostomy tube (P < .05) and immunosuppression (P < .05). CONCLUSION: Percutaneous feeding tubes can be placed in children with a high rate of technical success. Optimal results require attention to periprocedural care. Morbidity is common during the first month of tube use.