One-stage coronary angiography and angioplasty.

The combination of diagnostic angiography and angioplasty as a single procedure is becoming common practice in many institutions, but the feasibility and safety of this strategy have not been reported. This report describes 2,069 patients who underwent coronary angioplasty over a 3-year period at an institution where combined angiography and angioplasty is the norm. All patients were prepared before angiography for potential immediate angioplasty. In 1,719 patients, angioplasty was performed immediately after the diagnostic angiogram, while separate procedures were performed in 350 patients. Of those 350 patients, 254 were referred for angioplasty after diagnostic angiography at other hospitals. One thousand one hundred ninety-seven patients were admitted electively for treatment of stable angina pectoris, and 872 underwent procedures during hospitalization for unstable angina or acute myocardial infarction. One thousand nine hundred seven patients (92.2%) had successful angioplasties; in 130 patients (6.3%) the lesion could not be dilated, but no complication occurred, and in 32 patients (1.5%) angioplasty ended with a major complication (0.8% death, 1.0% Q-wave myocardial infarction, 0.5% emergency coronary artery bypass surgery). There was no difference between the combined and staged groups with regard to success, major and minor complication rates or in length of hospitalization after angioplasty. We conclude that routine combined strategy for angiography and angioplasty is feasible, safe, easier for the patient, and more cost-effective than 2 separate procedures.

Prognosis and quality of life after valve surgery in patients older than 75 years.

BACKGROUND: Assessment of quality of life has become an increasingly important aspect of the risk-benefit analysis of any therapeutic intervention, particularly in high-risk populations, such as the elderly. METHODS: Clinical outcomes of 147 consecutive patients older than 75 years undergoing valve surgery between 1992 and 1995 were reviewed. Long-term quality of life was assessed using a modified version of the Duke University Medical Outcomes Study system. RESULTS: Mean age was 79.3+/-4 years, range was 75 to 89 years, and 67% (99/147) were male. Preoperatively, 128 patients (87%) were in New York Heart Association (NYHA) functional class III/IV. Fifty-two percent (77/147) of the operations were nonelective. Concomitant coronary artery bypass grafting was performed in 69 patients (47%). Thirty-day hospital mortality was 7.5% (11/147). Mean follow-up for 98% (133/136) of hospital survivors was 30+/-13 months (range, 2 to 55 months). Actuarial survival at 55 months was 71+/-6%-equivalent to a general age-, race-, and gender-matched population reported in the Life Tables of the US National Center for Health Statistics. At the time of follow-up, 112 patients (96%) lived at home, 78% (91/116) defined their health between good to excellent, and 81% (93/114) stated that the operation improved their health status. Ninety-seven percent (112/116) were able to bathe and dress independently, 92% (104/113) could walk at least one block, and 88.5% (100/113) could climb at least one flight of stairs. Moderate to vigorous activities could be performed by 59.2% (67/113). Overall, at the time of follow-up, 81% (95/117) were in NYHA class I/II. CONCLUSION: In a selected patient population, valve surgery in the elderly is associated with acceptable early morbidity and mortality. Long-term survival and quality of life are excellent. These facts strongly support the performance of these procedures in patients older than 75 years.

Case series: hyponatremia associated with moderate exercise.

Exercise-induced hyponatremia is commonly believed to be associated only with extraordinary physical efforts, or particularly strenuous exercise. Hyponatremia complicating moderate exercise has not been described previously. The authors describe the characteristics of seven patients with life-threatening hyponatremia associated with mild to moderate exercise. All patients suffered from nausea, vomiting, agitation, and confusion, appearing during or after moderate physical activity. Grand mal convulsions occurred in five of the patients. In laboratory results, hyponatremia was as low as 115 mEq/L, with a relatively high sodium concentration in the urine. High serum creatine kinase activity levels were found in most of the patients. All patients were discharged in good condition, without neurologic sequela. The authors conclude that hyponatremia is a possible complication of moderate exercise, and not only of endurance sports, and that exercise-induced hyponatremia can produce severe neurologic manifestations. The mechanism of the hyponatremia is unclear, but may be due to a hemodynamically inappropriate stimulus for antidiuretic hormone secretion.

Importance of delaying balloon angioplasty in patients with unstable angina pectoris.

Angioplasty in patients with unstable coronary artery disease is associated with higher complication rates compared with patients with stable disease. In this report we describe our results from a group of patients with unstable disease (unstable angina pectoris and postmyocardial infarction) where a strategy of delaying angioplasty for > 5 days after admission was undertaken. Included are 2069 consecutive patients: 1197 treated for stable angina pectoris and 872 treated during admission for unstable angina or myocardial infarction. There was no difference between the two groups in angioplasty success (92.1% stable, 92.3% unstable), failure to dilate without complication (6.4% stable, 6.1% unstable), or in the rate of major complications: death (0.5% stable, 1.1% unstable), Q-wave myocardial infarction (0.9% stable, 1.1% unstable), and emergency coronary artery bypass (0.6% stable, 0.3% unstable). The duration of hospitalization following angioplasty was longer in the unstable group (5.6 +/- 8.1 days vs. 4.2 +/- 4.1 days; p < 0.001) because of longer duration of heparin infusion. There was no difference between groups in minor complications such as groin hematoma and pseudoaneurysm, renal failure, or infections. It was concluded that delaying angioplasty in unstable patients for > 5 days after admission is a safe and effective therapeutic strategy for this group of patients. The need for prolonged heparin infusion after angioplasty is increased in unstable patients and thus the duration of hospitalization after the procedure is longer.

Maternal rehospitalization after singleton term vaginal delivery.

OBJECTIVE: To determine risk factors for maternal rehospitalization after term vaginal delivery. STUDY DESIGN: The study group consisted of all women who were rehospitalized following singleton vaginal deliveries during 1996-1998 (n = 194). The control group consisted of 427 women who were not rehospitalized during the same period. RESULTS: The incidence of rehospitalization was 0.75% (194/25885). Maternal chronic diseases, preterm contractions and pre-eclampsia rates were significantly higher among the study group as compared to the controls (25.3% vs. 8.4%, p < 0.001; 6.7% vs. 2.8%, p = 0.022; 9.3% vs. 4.9%, p = 0.037, respectively). Duration of labor was significantly longer in the study group as opposed to the controls (379 +/- 406 min vs. 259 +/- 276 min, p < 0.001). The rates of postpartum hemorrhage, blood transfusion and antibiotic treatment during delivery hospitalization were significantly higher among the study group (1.5% vs. 0.2%, p = 0.021; 4.6% vs. 0.7%, p < 0.001; 26.8% vs. 14.1%, p < 0.001, respectively). Using a forward logistic regression analysis, prolonged labor and blood transfusion during labor were found as independent risk factors associated with rehospitalization (OR 1.001, 95% CI 1.001-1.002, p = 0.001; OR 4.751, 95% CI 1.698-13.292, p = 0.003). In contrast, vertex presentation had a protective effect against rehospitalization (p = 0.027, OR 0.084, 95% CI 0.009-0.758). CONCLUSIONS: Blood transfusion and prolonged labor are independent risk factors for rehospitalization after term vaginal delivery. Special attention should be given during the early postpartum period to patients receiving blood transfusions and those with prolonged deliveries, in order to reduce rehospitalization rates.

A comprehensive computerized critical laboratory results alerting system for ambulatory and hospitalized patients.

Automatic alerting systems for key events in medical practice have been proven effective in improving the clinician's response to the event. Most of the systems described in current literature are hospital based, some in intensive care units. We designed a clinical alerting system that screens laboratory results of both hospitalized patients and most of Israel's Southern region ambulatory patients for critical results, using an integrative CDR and its interfaces to the hospital's laboratory information systems. New alerts can be defined and activated using a rule editor. Alerts are generated by screening all new laboratory results that are entered in to the CDR, by a decision engine. The alerts are dispatched to clinicians through a customizable preferred alerting device that can be either e-mail, fax or cellular phone SMS, and enables additional alerting devices as they become available. Clinicians may customize both the alerting method and the critical levels for alert generation, according to individual specific needs. We hope that this versatile and customizable alerting system will suite the needs of both the hospital and the community clinical staff. The system will be implemented and tested in the near future.

Exploring the Internet.

The Internet is a vast network connecting smaller networks of computers in the United States and overseas. The chief existing structure that will support the proposed information superhighway, the Internet has grown exponentially in recent years. It is now a major tool for sharing computer resources, research issues, and communication with groups or individuals. This review will describe the history of the Internet, the various ways of connecting to it, and some of the tools that are particularly useful for medical researchers and clinicians.

Liver failure and the sea-blue histiocyte/adult Niemann-Pick disease. Case report and review of the literature.

Niemann-Pick disease is a metabolic disorder resulting in accumulation of sphingomyelin in visceral organs. The adult form (type B) is characterized by the sparing of brain involvement, allowing those affected to have a relatively benign course. Although the abnormal lipid accumulation in the liver is commonly recognized, hepatocellular compromise is extremely rare. We describe a patient with adult Niemann-Pick disease who over the course of over 35 years developed hepatic failure and portal hypertension, and we review the literature regarding hepatic involvement in this rare disease.

The effects of continuous operation in a chemical protective ensemble on the performance of medical tasks in trauma management.

Treating casualties in a chemically hazardous environment constitutes a unique problem. Physical protection of the medical personnel may impair their performance and potentially affect patients' prognoses. The present study examined the effect of prolonged physical protection on the accomplishment of medical tasks related to trauma management. Sixty one emergency medical technicians, acclimatized to operating in protective gear, underwent four rounds of testing during eight hours of continuously wearing either a chemical protective suit or regular fatigues. The quality of the designated medical tasks, including sterility, was maintained throughout the study. A significant reduction in speed of performance was noted (approximately 30% slowing, p < 0.0001 in multivariate analysis) because of protective clothing. There was no additional decrement in performance following a prolonged stay in the protective gear. We conclude that in a chemically contaminated area, fully protected medical personnel are capable of treating trauma patients reasonably well, and for a relatively long period of time. The importance of pretraining and proper instruction is emphasized.

An interactive microcomputer program for calculation of combined parenteral and enteral nutrition for neonates.

A responsive, iterating program is described (available on diskette from first author), which enables the physician to formulate a balanced, total parenteral nutrition (TPN) for low-birth-weight and sick newborns. The program allows for the possibility of TPN or simultaneous intravenous, intraarterial, and oral feeding. It calculates the overall balance of fluids, nutrients, calories, electrolytes, minerals, trace elements, and vitamins. It features the integration of algorithms and limit tests of nutritional balance, to produce a feeding program that can be modified by clinical considerations of the physician, specific for each patient. The entire procedure can be accomplished, and a record of the entries and orders to the pharmacy and to the ward staff printed, within about 4-5 min. The program, which is written in BASIC, can be accommodated within and operated with a 16K byte microcomputer, equipped with a monitor, a printer, and a diskette or other program storage device.

Categorization of free-text problem lists: an effective method of capturing clinical data.

Problem lists assist in organizing patient information in computer based medical records. However, in order to use problem lists for billing, research, decision support and standardization, a categorization of the problems entered is required. We describe the problem list component of our computerized patient record, the On-line Medical Record (OMR), which combines a free-text entry mechanism with a categorization scheme, using a dictionary containing 846 terms. All 118,040 problems entered during the system's six years of use have been analyzed, 477 clinicians have entered a mean +/- S.D. of 238 +/- 604 problems into 22,311 patient records. The average number of problems in each patient's file was 5.1 +/- 3.9. Comments were typed for 80,281 (68%) of the problems, ranging in length from 1 to 2456 characters, with a mean length of 98 +/- 110 characters. Half the problems were entered on the day of the encounter with the patient. Overall, 66% of all problems were categorized in relation to terms from the problem dictionary. Lexical analysis of all problem names showed that 80% could be mapped to Meta 1.4, Snomed 3.0 or a pre-release version of Read 3.0. We conclude that a problem list entry scheme combining free-text entry and optional categorization using a dictionary can result in a high proportion of problems being categorized as desired. Improvement of the system by elimination of unused dictionary terms and addition of 1000 terms identified by the lexical analysis is likely to result in even higher categorization rates.

Enhanced blood conservation and improved clinical outcome after valve surgery using heparin-bonded cardiopulmonary bypass circuits.

BACKGROUND: Recently, heparin-bonded (HBC) cardiopulmonary bypass circuits (CPB) were formed to be associated with improved outcome after coronary artery bypass grafting. There are very few reports on the efficacy and safety of these circuits in valve surgery. METHODS: A retrospective cohort study of all patient populations undergoing first time valve surgery from 1992 to 1995 in a tertiary teaching hospital. Outcomes of 120 patients undergoing valve surgery using HBC and lower anticoagulation HBC were compared to 232 patients treated with conventional circuits and full heparinization (nonheparin-bonded-circuit [NHBC]). RESULTS: Postoperative 24-hour chest tube drainage (558 +/- 466 mL vs 1054 +/- 911 mL, p < 0.00001), and reoperation for bleeding (2.5% vs 8.2%, p = 0.04) were lower in the HBC group. HBC patients required significantly less transfusions (total donor exposure of 6.9 +/- 13.0 units vs 18.6 +/- 26.2 units, p < 0.00001). Multiple linear regression analysis identified CPB time as a predictor of increased homologous blood transfusions, and the use of HBC, a large body surface area, and elective procedure as predictors of decreased transfusions. Perioperative mortality was similar (HBC 2.5%, NHBC 4.7%, p = 0.24). Overall complications were lower in the HBC group (42% vs 56.2%, p = 0.02). Perioperative myocardial infarction (0.8% vs 1.3%, p = 0.58) and cerebrovascular accident (3.3% vs 3.9%, p = 0.53) were similar. Two (1.7%) HBC patients had valve re-replacement compared to none in the NHBC (p = 0.22). Multiple logistic regression model revealed that age and CPB time were associated with increased complications, and the use of HBC with reduced complications. CONCLUSION: Use of HBCs with lower anticoagulation in valve surgery resulted in a significant reduction of transfusion requirements and improved clinical outcome. Because of a potential for early mechanical valve thrombosis, until further data is available, conventional levels of systemic anticoagulation should be achieved when using HBC in valve surgery.

Age- and gender-related differences in success, major and minor complication rates and the duration of hospitalization after percutaneous transluminal coronary angioplasty.

This report describes the effect of age and gender on the results of balloon angioplasty using current technique and indications. A consecutive group of 2,067 patients who underwent angioplasty at a single institution after 1990 is described. Angioplastic success was 92.2% and similar among men and women and the various age groups. Sixteen patients (0.8%) died, and mortality among women was significantly higher (1.4 vs. 0.6%, p < 0.001). There were no age or gender differences in the rate of Q-wave myocardial infarction and the need for coronary artery bypass. Minor complications such as groin complications (10.5% women, 5.0% men; p < 0.001) and infections (6.4% women, 3.7% men; p < 0.05) were more common in women, and as a result the duration of hospitalization after angioplasty was longer. The length of hospitalization after angioplasty was longer with advanced age, mainly as a result of higher groin complications (p < 0.001), infections (p < 0.01) and renal failure (p < 0.05). We conclude that using current indications and technique, angioplasty can be performed safely with a high success rate. Mortality is higher among women. The length of hospitalization after angioplasty is longer in women and, at advanced age, due to higher rate of minor complications.