Academic models of clinical care for women: the National Centers of Excellence in Women's Health.

Between 1996 and 1999, 18 academic health centers were awarded the designation of National Center of Excellence (CoE) in Women's Health by the Office on Women's Health within the Department of Health and Human Services and were provided with seed monies to develop model clinical services for women. Although the model has evolved in various forms, core characteristics that each nationally designated CoE has adopted include comprehensive, women-friendly, women-focused, women-relevant, integrated, multidisciplinary care. The permanent success of these comprehensive clinical programs resides in the ability to garner support of leaders of the academic health centers who understand both the importance of multidisciplinary programs to the clinical care they provide women and the education they offer to the future providers of women's healthcare.

Early tracheal extubation after liver transplantation.

OBJECTIVE: To assess the value and safety of tracheal extubation in the operating room at the end of liver transplantation. DESIGN: Retrospective chart review. SETTING: University Medical Center. PARTICIPANTS: Eighteen adult patients extubated in the operating room at the end of liver transplantation (study patients) compared with 17 patients who were not extubated and had < or = 3 U of blood transfused during liver transplantation (control patients). INTERVENTIONS: Data collected include severity of preoperative liver disease, anesthetic technique, use of venovenous bypass, surgical time, intraoperative blood replacement, core temperature and arterial blood gases on admission to the intensive care unit (ICU), times to discharge from ICU and the hospital. MEASUREMENTS AND MAIN RESULTS: Except for age (43.9 +/- 2.7 in study patients v 52.4 +/- 2.5 years; p = 0.03), patients were similar with regard to preoperative Child's-Pugh class and liver function tests. Study patients received more crystalloid in the OR (5,306 +/- 561 v 3,771 +/- 454 mL; p = 0.04), were warmer (36.6 degrees C +/- 0.2 degree C v 35.6 degrees C +/- 0.3 degree C; p = 0.01), had a lower arterial pH (7.29 +/- 0.01 v 7.36 +/- 0.02; p = 0.003) and higher arterial carbon dioxide tension (45 +/- 1 v 35 +/- 2 mmHg; p < 0.001) on admission to ICU than controls. There were no significant differences between groups with regard to discharge times from the ICU (50.6 +/- 2.7 hours in the study group v 61.2 +/- 4.7 in control group; p = 0.06), or discharge from the hospital (14.8 +/- 1.6 in the study group v 21.3 +/- 3 days in control group; p = 0.06). CONCLUSIONS: Tracheal extubation of selected patients at the end of liver transplant surgery in the operating room is safe but did not result in decreased ICU or hospital stay.

Randomized controlled trial to evaluate flush and reperfusion techniques in liver transplantation.

To determine the impact of different flush and reperfusion techniques on postreperfusion syndrome (PRS) and postoperative graft function, 100 transplants were randomly assigned into four groups as follows: group 1 (n=31), portal vein flush, no vena caval venting; group 2 (n=21), hepatic arterial flush, no vena caval venting; group 3 (n=29), portal vein flush with vena caval venting; and group 4 (n=19), hepatic artery flush with vena caval venting. Donor and recipient characteristics were similar. Extensive intraoperative and postoperative monitoring was performed and measurements were documented immediately before reperfusion and at 1, 5, 15, and 30 min after reperfusion. PRS was defined by three criteria: mean arterial pressure (MAP) <60 mmHg at 1 min after reperfusion, MAP <60 mmHg at 5 min after reperfusion, and a decrease of 30% or more for the MAP percent area under the curve during the initial 5 min after reperfusion (%AUC). Using these definitions, the overall incidence of PRS was 21%, 8%, and 43%, respectively. Group 1 was the most hemodynamically stable; the incidence of PRS in group 1 was 2/31 (7%) at 1 min and 8/31 (25%) using %AUC criteria compared with 7/21 (33%) at 1 min and 12/21 (57%) using %AUC criteria for group 2 (P<0.05). The patients in groups 3 and 4 (vena caval venting) demonstrated smaller percentage increases in serum potassium levels (as determined by %AUC; 4.3+/-6.8 and 0.3+/-5.4, vs. 15.1+/-8.1 for group 1 and 22.9+/-8.2 for group 2). The difference between group 4 and group 2 was statistically significant (P<0.05). The increases in serum potassium did not translate into increased cardiac or hemodynamic instability. Combining all data obtained over the first 30 min after reperfusion, there was no statistically significant difference in hemodynamic or biochemical changes noted among the four groups. Postoperative liver function was similar among the four groups. We conclude that portal vein flush without vena caval venting provided a lower incidence of PRS than any other technique. Vena caval venting decreased the release of potassium into the circulation. Postoperative graft function was not significantly affected by flush and reperfusion techniques.

Liver transplantation in the morbidly obese.

STUDY OBJECTIVE: To test the hypothesis that morbid obesity implies increased difficulty of liver transplantation and increased risk of adverse outcome. DESIGN: Retrospective review of medical records of 40 morbidly obese patients using a control cohort of patients transplanted just before and after the obese patients. SETTING: University medical center. PATIENTS: All morbidly obese patients who underwent liver transplantation over a 52-month period were included. Forty adult patients met criterion for morbid obesity with body mass index greater than 30 kg/m2. Records for 61 time-matched controls were reviewed. MEASUREMENTS AND MAIN RESULTS: Demographic, intraoperative, and postoperative data were collected including preoperative diagnoses, laboratory and pulmonary function tests, intraoperative transfusion requirements and length of surgery postoperative complications, and survival. Data were analyzed using Student's t-tests, and Chi-square analyses as appropriate, with significance considered a p-value less than 0.05. Obese patients were more hypoxemic than controls prior to surgery (PaO2, 82.9 +/- 3.5 vs. 93.0 +/- 3.0 mmHg), were more likely to be diabetic, and had higher creatinine levels (3.0 +/- 0.6 vs. 1.7 +/- 0.2 mg/dl). Despite this evidence of multi organ dysfunction, intraoperative and postoperative pulmonary and cardiac complications did not differ between groups. Though more obese patients had prior cholecystectomy, length of surgery and intraoperative transfusion requirements were not different between groups. Obese patients did not have an increased incidence of reoperation for wound problems, and lengths of intensive care unit and hospital stays did not differ between groups. Graft and patient survival were similar in obese and nonobese liver transplant recipients. CONCLUSION: Morbid obesity alone does not predispose to increased complications or decreased survival after liver transplantation.

Effectiveness of flumazenil on return of cognitive functions after a general anesthetic.

Benzodiazepines used intra-operatively can occasionally cause prolonged sedation. Flumazenil (Romazicon) is an imidazobenzodiazepine that functions as a benzodiazepine receptor antagonist. This clinical investigation was designed to evaluate the efficacy and of intravenous flumazenil in reversing the central effects of midazolam after a general anesthetic using midazolam for maintenance. 30 ASA I-III inpatients entered and completed this study. All were interviewed preoperatively and baseline performance on a battery of psychomotor tests was obtained. Parameters measured included an assessment of sleep status, vital signs, responsiveness to verbal stimuli, quality of speech, facial expression, eye coordination, recognition of a picture card, finger-finger-to-nose (FFN) coordination and overall discharge readiness. General anesthesia was induced with midazolam. Midazolam and fentanyl were the primary maintenance agents combined with N2O and O2 (70:30) and a limited concentration of isoflurane. In the recovery room the test drug was administered in a double-blinded, randomized manner. 20 patients received flumazenil (F), the rest placebo (P). Testing was done at times 0, 5, 15, 30, 60, 120, and 180 min in the PACU. Memory testing consisted of recall of study pictures at 180 min and recognition on the first postoperative day. Demographic data were similar for both groups with the exception of age. The F group had a higher mean composite score (comprising responsiveness to verbal stimuli, speech, facial expression and eye coordination) and better FFN scores at 5, 15, and 30 min (p < 0.01). There were no significant differences between groups at other times. F patients identified pictures better at 5 and 15 min (p < 0.004 and 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)

Oncologists' reluctance to accrue patients onto clinical trials: an Illinois Cancer Center study.

Clinical trials are recognized as the standard of care for the cancer patient, and the randomized, controlled trial represents the most definitive method to determine the effectiveness or ineffectiveness of a cancer treatment. However, less than 3% of all eligible patients enter a clinical trial. Of the 437 physician members of the Illinois Cancer Center (ICC), 244 responded to a survey designed to determine factors that present a significant barrier to entering patients on clinical trials. Rigid protocol design was the primary deterrent to accrual, especially for medical oncologists. Surgeons, radiation oncologists, and medical oncologists differed with respect to several factors, including willingness to seek a clinical trial, tendency to treat patients off study, quality-of-life issues, and the belief that trials were too excessive in time commitment (P less than .05). Compared with hospital-based physicians, community oncologists had fewer patients on trial, were more likely to enter patients on the basis of age, and were more concerned about aspects of informed consent and the financial burden of a trial (P less than .01). One third of the physicians never pursued a clinical trial because of conflict with the priorities of individual care and excessive follow-up time. Fourteen percent indicated that they discouraged patients from participating in a clinical trial due to the risk of a patient receiving a placebo and patient follow-up requirements (P less than .05). Subgroups of physicians differ in their reluctance to accrue patients, and there are clusters of beliefs expressed by physicians concerning their clinical trial activity. Current conduct of clinical trials needs to be reassessed, and intervention studies are required to determine the best methodology to alter physician reluctance to pursue clinical trials.