Safety of endovascular treatment of chronic cerebrospinal venous insufficiency: a report of 240 patients with multiple sclerosis.

PURPOSE: To evaluate the safety of outpatient endovascular treatment in patients with multiple sclerosis (MS) and chronic cerebrospinal venous insufficiency (CCSVI). MATERIALS AND METHODS: A retrospective analysis was performed to assess complications occurring within 30 days of endovascular treatment of CCSVI. The study population comprised 240 patients; 257 procedures were performed over 8 months. The indication for treatment in all patients was symptomatic MS. Of the procedures, 49.0% (126 of 257) were performed in a hospital, and 51.0% (131 of 257) were performed in the office. Primary procedures accounted for 93.0% (239 of 257) of procedures, and repeat interventions accounted for 7% (18 of 257). For patients treated primarily, 87% (208 of 239) had angioplasty, and 11% (26 of 239) had stent placement; 5 patients were not treated. Of patients with restenosis, 50% (9 of 18) had angioplasty, and 50% (9 of 18) had stent placement. RESULTS: After the procedure, all but three patients were discharged within 3 hours. Headache after the procedure was reported in 8.2% (21 of 257) of patients; headache persisted > 30 days in 1 patient. Neck pain was reported in 15.6% (40 of 257); 52.5% (21 of 40) of these patients underwent stent placement. Three patients experienced venous thrombosis requiring retreatment within 30 days. Sustained intraprocedural arrhythmias were observed in three patients, and two required hospital admission. One of these patients, who was being retreated for stent thrombosis, was hospitalized because of a stress-induced cardiomyopathy. CONCLUSIONS: Endovascular treatment of CCSVI is a safe procedure; there is a 1.6% risk of major complications. Cardiac monitoring is essential to detect intraprocedural arrhythmias. Ultrasonography after the procedure is recommended to confirm venous patency and to identify patients experiencing acute venous thrombosis.

Perception of secondary conditions in adults with spina bifida and impact on daily life.

BACKGROUND: Spina bifida is a congenital defect of the neural tube resulting in motor and sensory disruption. Persons with spina bifida can also experience executive function impairments. Secondary conditions are physical, medical, cognitive, emotional, or psychosocial consequences to which persons with disabilities are more susceptible. Our experience suggested clinicians underappreciate the presence and impact of secondary conditions in adults with spina bifida because they do not specifically ask for this information. OBJECTIVE: Describe the presence and impact of secondary conditions on daily life, as perceived by adults with spina bifida. METHODS: A clinic-based sample was recruited from the active patient population of an adult specialty center for spina bifida-related care. All subjects were verbally administered a survey developed through literature review and clinical experience of the researchers. The survey measured the presence and perceived impact of secondary conditions. Recruitment and survey data collection occurred over a 6-month period to maximize age representation. Survey data were stratified by age, gender and lesion level for analysis. RESULTS: Seventy-two respondents completed the survey. Pain was commonly reported, along with pressure ulcers, bowel & bladder concerns, depression, sleep disturbance, and limited social and community participation. No significant relationships were found between the presence or perceived impact of secondary conditions and age, gender or level of lesion. CONCLUSIONS: Secondary conditions in spina bifida are present by early adulthood. Identifying these conditions during clinical encounters requires specific rather than general questions. Future study should evaluate earlier initiation of preventative measures by pediatric providers.

Collaborative testing: an innovative approach to test taking.

Collaborative testing was used with second semester associate degree nursing students during their fluid and electrolyte content to enhance collaboration and joint problem solving. Student nurses were randomly assigned a partner and allowed to change answers to test questions for 10 minutes at the end of the exam. Outcomes included an increase in student comprehension and test scores with decreased test anxiety.

The use of tissue plasminogen activator infusion to re-establish function of tunneled hemodialysis catheters.

PURPOSE: To evaluate the safety and efficacy of the recombinant tissue plasminogen activator alteplase in the clearance of poorly functioning tunneled hemodialysis catheters. METHODS: We retrospectively reviewed the outcomes of 25 patients who presented with poorly functioning hemodialysis catheters and were treated with alteplase. After confirming fluoroscopically the need for thrombolytic therapy, alteplase was administered over 2 hours as a 2.5-mg/hour/catheter lumen infusion (total 10 mg). Treatment was considered a clinical success if a flow rate of 250 mL or more per minute was established. RESULTS: Clinical success was achieved in each of 25 patients (100%). There were no thrombolytic-related complications. Catheter survival was extended 30 days in 54% of patients and 45 days in 33% of patients. CONCLUSION: Alteplase is a safe and effective means of producing clearance of blocked tunneled catheters.

Comparison study of upper arm and forearm non-invasive blood pressures in adult Emergency Department patients.

BACKGROUND: Forearm blood pressures have been suggested as an alternative site to measure blood pressures when the upper arm is unavailable. However there is little evidence utilising clinical populations to support this substitution. OBJECTIVES: To determine agreement between blood pressures measured in the left upper arm and forearm using a singular oscillometric non-invasive device in adult Emergency Department patients. The secondary objective was to explore the relationship of blood pressure differences with age, sex, ethnicity, smoking history and obesity. DESIGN: Single centre comparison study. SETTING: Adult Emergency Department, Tertiary Trauma Centre. PARTICIPANTS: Forty-four participants who met inclusion/exclusion criteria selected sequentially from the Emergency Department arrival board. METHODS: A random assignment of order of measurement for left upper arm and forearm blood pressures was utilised. Participants were eligible if they were aged 18 years or older, had been assigned an Australasian Triage Scale code of 2, 3, 4, or 5, were able to consent, and able to have blood pressures measured on their left arm whilst lying at a 45° angle. The Bland-Altman method of statistical analysis was used, with the level of agreement for clinical acceptability for the systolic, diastolic and mean arterial pressure defined as ±10 mmHg. RESULTS: The forearm measure overestimated systolic (mean difference 2.2 mmHg, 95% limits of agreement ±19 mmHg), diastolic (mean difference 3.4 mmHg, 95% limits of agreement ±14.4 mmHg), and mean arterial pressures (mean difference 4.1 mmHg, 95% limits of agreement ±13.7 mmHg). The systolic measure was not significantly different from zero. Evidence of better agreement was found with upper arm/forearm systolic measures below 140 mmHg compared to systolic measures above 140 mmHg using the Levene's test (p=0.002, F-statistic=11.09). Blood pressure disparity was not associated with participant characteristics. CONCLUSIONS: Forearm measures cannot routinely replace upper arm measures for blood pressure measurement. If the clinical picture requires use of forearm blood pressure, the potential variance from an upper arm measure is ±19 mmHg for systolic pressure, although the variability may be close to ±10 mmHg if the systolic blood pressure is below 140 mmHg.

Survival from in-hospital cardiac arrest in Auckland City Hospital.

OBJECTIVE: To describe in-hospital resuscitation outcomes and factors associated with survival at Auckland City Hospital, New Zealand. METHODS: The Utstein template for in-hospital cardiac arrests was used. A retrospective audit of all cardiac arrests 2004-06 determined patient demographics, resuscitation time intervals, interventions, survival and neurological outcome at 12 months. Factors associated with survival to discharge were explored with logistic regression. RESULTS: There were 3470 in-hospital deaths. Resuscitation was attempted in 415 patients (12%), with survival to discharge 27.2%. Survival was higher in first rhythm VT/VF (52.7% vs 13.1%, χ(2) = 75.3, P < 0.001), when the arrest was 'In-Hours' (41.4% vs 17%, χ(2) = 30.1, P < 0.001) and with younger age (mean [SD] for survivors 59.4 [7.1]vs 69.1 [14] for non-survivors). These associations were independent predictors of survival after multivariate logistic regression, with OR 6.2 (95% CI 3.6-10.5), 3.1 (95% CI 1.8-5.4) and 1.04 (95% CI 1.02-1.06), respectively (all P < 0.001). Other univariate predictors of survival; cardiac arrest team on site, monitored arrest and time to CPR were not significant after multivariate logistic regression. Time intervals to arrest interventions were short. Twelve month neurological outcome was good (CPC1 or 2) in 97.1% (95% CI 91.6-99.4) of survivors. CONCLUSIONS: Survival from cardiac arrest in our hospital compared well to similar centres and good neurological outcome was higher than reported previously. Reduced survival during the 'After-Hours' period is cause for concern, and further research into the factors underlying this is required.

The development of a CAHPS instrument for Nursing Home Residents (NHCAHPS).

We report on a federal initiative to develop a CAHPS (The Consumer Assessment of Healthcare Providers and Systems) survey to measure residents' experiences with quality-of-care and quality-of-life in nursing homes (known as NHCAHPS). We focus on how we created and tested questions for inclusion in the instrument and tested a possible cognitive screener to determine which residents could participate in a NHCAHPS interview. The major lessons learned were: (1) In contrast to other CAHPS surveys, ratings were more useful than reports because of the difficulty that residents had with summarizing over time and people; (2) consistent with other CAHPS surveys, the 0 to 10 response scale appeared to work well with nursing home residents for many of the quality-of-care questions; however, a different response scale was needed for many of the quality-of-life items; and (3) in contrast with typical survey methodology and other CAHPS surveys where explicit time reference periods are used, a non-specific present reference period in questions seemed to work best.

The "choose with care system" - development of education materials to support informed Medicare health plan choices.

People aging into Medicare need to choose a health plan. Several challenges exist for consumers in choosing a Medicare health plan, including limited knowledge of Medicare, limited experience in using comparative health plan quality information, and limited experience and ability to pull together and use plan information from different sources like employers and the Medicare program. The Choose with Care System was developed to help consumers aging into Medicare make informed Medicare health plan choices. Choose with Care is an innovative decision support tool for employers to use to assist people approaching age 65 to learn about their Medicare health plan options and how to incorporate information on the quality of care and services offered by health plans into their choices. Employers are the targeted channel for distributing the Choose with Care materials because they are one of the most recognized and accessible formal intermediaries for information about health insurance. We used multiple methods to test the Choose with Care products. Product testing showed that the Choose with Care materials increase older consumers' knowledge of Medicare and how it relates to retiree health insurance and improves their comprehension and use of comparative quality information when choosing a health plan.

The interventional radiology clinic: what you need to know.

It is increasingly recognized that clinical management in interventional radiology is necessary. To effectively participate in such management requires patient management infrastructure. The cornerstone of this effort is the clinical office.

The interventional radiology clinic: key ingredients for success.

During the past two decades, the practice of interventional radiology has evolved into one that mandates longitudinal patient care taking place before, during, and after interventional procedures. This requires the establishment of relationships between physicians and patients that often must be fostered in an outpatient clinic setting. Recognition of this practice shift was formally made by the American College of Radiology with the publication of a document concerning the importance of clinical patient management within the practice of interventional radiology. This article will review the clinical patient management as it relates to the practice of interventional radiology, with a focus on the physician-patient relationship and the components of a successful outpatient clinic.

Early ambulation after diagnostic angiography using 4-f catheters and sheaths: a feasibility study.

PURPOSE: To assess the feasibility and safety of early ambulation in patients undergoing transfemoral diagnostic angiography using 4-F catheters or sheaths. METHODS: In this prospective study approved by the institutional review board, patients undergoing diagnostic angiography were randomized to ambulate 3 or 6 hours after catheter or sheath removal. All patients were assessed for hematoma formation, pseudoaneurysm development, and other groin complications during the in-hospital recovery period and after 30 days. Patient satisfaction and comfort level were also assessed by survey. RESULTS: Of 110 patients (66 men; mean age 64.9 +/- 12.8 years) who participated in this study, 47 were randomized to the 6-hour (6-H) group and 63 to the 3-hour (3-H) group. In the 3-H and 6-H groups, respectively, a 4-F catheter was used in 45 (71%) and 35 (74%) patients and a 4-F sheath in 18 (29%) and 12 (26%). No clinically significant groin complications were encountered in either group. Moderate to severe discomfort was reported in 9 (16%) of the 56 patients responding to the discomfort survey in the 3-H group compared to 10 (26%) of the 38 in the 6-H survey respondents. CONCLUSIONS: It is feasible and safe to ambulate patients 3 hours after diagnostic angiography performed with a 4-F catheter with or without a 4-F sheath. Early ambulation of patients after angiography has the additional benefits of increasing patient satisfaction and resource utilization.