Endoscopic Cyanoacrylate Injection with Post-injection Audible Doppler Assessment of Gastric Varices: A Single-Institution Experience.

BACKGROUND AND AIMS: Gastric varices (GV) have higher rates of morbidity and mortality from hemorrhage than esophageal varices. Several studies have shown the safety and efficacy of cyanoacrylate (CA) injection for acute gastric variceal hemorrhage. We report data from our experience with CA injection for GV before and after routine use of post-injection audible Doppler assessment (ADA) for GV obturation and describe long-term outcomes after this therapy. METHODS: We retrospectively identified patients who had documented GV, underwent CA injection, and had at least 2 weeks of follow-up. We recorded and analyzed the survival and rebleeding rates with patient demographics, clinical data, and endoscopy findings between two groups of patients who were categorized by CA injection prior to and after inception of the ADA technique. RESULTS: Seventy-one patients were identified with 16 patients analyzed in a group where ADA was not used (Pre-ADA) and 55 analyzed where ADA was used (Post-ADA). No rebleeding events were observed within 1 week of initial CA injection. No embolic events were reported after any initial CA injection within 4 weeks. The rate of bleed-free survival at 1 year was 69.6% in the Pre-ADA group and 85.8% in the Post-ADA without statistical significance. The all-cause 1-year mortality was 13.8% in the Pre-ADA group and 10.7% in the Post-ADA group without statistical significance. CONCLUSIONS: ADA of CA-injected GV does not appear to significantly affect adverse events or clinical outcomes; however, our findings are limited by small sample size and cohort proportions allowing for significant type II statistical error. Further prospective investigation is required to determine the impact of ADA on clinical outcomes after GV obturation.

An analysis of risk factors for patient complaints about ambulatory anesthesiology care.

BACKGROUND: Anesthesiology groups continually seek data sources and evaluation metrics for ongoing professional practice evaluation, credentialing, and other quality initiatives. The analysis of patient complaints associated with physicians has been previously shown to be a marker for patient dissatisfaction and a predictor of malpractice claims. Additionally, previous studies in other specialties have revealed a nonuniform distribution of complaints among professionals. In this study, we describe the distribution of complaints among anesthesia providers and identify factors associated with complaint risk in pediatric and adult populations. METHODS: We performed an analysis of a complaint database for an academic medical center. Complaints were recorded as comments during postoperative telephone calls to ambulatory surgery patients regarding the quality of their anesthesiology care. Calls between July 1, 2006 and June 30, 2010 were included. Risk factors were grouped into 3 categories: patient demographics, procedural, and provider characteristics. RESULTS: A total of 22,871 calls placed on behalf of 120 anesthesiologists were evaluated, of which 307 yielded a complaint. There was no evidence of provider-to-provider heterogeneity in complaint risk in the pediatric population. In the adult population, an unadjusted test for the random intercept variance component in the mixed effects model pointed toward significant heterogeneity (P = 0.01); however, after adjusting for a prespecified set of risk factors, provider-to-provider heterogeneity was no longer observed (P = 0.20). Several risk factors exhibited evidence for complaint risk. In the pediatric patient model, risk factors associated with complaint risk included a 10-year change in age, the use of general anesthesia (versus not), and a 1-hour change in the actual minus scheduled start times. Odds ratios were 1.47 (95% confidence interval (CI), 1.04-2.08), 0.22 (95% CI, 0.07-0.62), and 1.27 (95% CI, 1.10-1.47), respectively. In the adult patient model, risk factors associated with complaint risk included male gender, general anesthesia, a 10-year change in provider experience, and speaking with the patient (rather than a family member). Odd ratios were 0.66 (95% CI, 0.47-0.92), 0.67 (95% CI, 0.47-0.95), 1.18 (95% CI, 1.01-1.38), and 1.96 (95% CI, 1.17-3.29), respectively. CONCLUSIONS: There was apparent evidence in adult patients to suggest heterogeneity in provider risk for a patient complaint. However, once patient, procedural, and provider factors were acknowledged in analyses, such evidence for heterogeneity is diminished substantially. Further study into how and why these factors are associated with greater complaint risk may reveal potential interventions to decrease complaints.

Parenting behavior dimensions and child psychopathology: specificity, task dependency, and interactive relations.

This study examined the specificity of relations between parent or caregiver behaviors and childhood internalizing and externalizing problems in a sample of 70 fourth-grade children (64% boys, M age = 9.7 years). Specificity was assessed via (a) unique effects, (b) differential effects, and (c) interactive effects. When measured as unique and differential effects, specificity was not found for warmth or psychological control but was found for caregiver's use of behavior control. Higher levels of behavior control were uniquely related to lower levels of externalizing problems and higher levels of internalizing problems; differential effects analyses indicated that higher levels of behavior control were related to decreases in the within-child difference in relative levels of level of internalizing versus externalizing problems. Interactive relations among the 3 parenting behavior dimensions also were identified. Although caregivers emphasized different parenting behavior dimensions across 2 separate caregiver-child interaction tasks, relations between parenting behavior dimensions and child psychopathology did not vary as a function of task. These findings indicate the importance of assessing and simultaneously analyzing multiple parenting behavior dimensions and multiple child psychopathology domains.