Systematic review of the incidence, presentation and management of gastroduodenal artery pseudoaneurysm after pancreatic resection.

Background: Gastroduodenal artery (GDA) pseudoaneurysm is a serious complication following pancreatic resection, associated with high morbidity and mortality rates. This review aimed to report the incidence of GDA pseudoaneurysm after pancreatic surgery, and describe clinical presentation and management. Methods: MEDLINE and Embase were searched systematically for clinical studies evaluating postoperative GDA pseudoaneurysm. Incidence was calculated by dividing total number of GDA pseudoaneurysms by the total number of pancreatic operations. Additional qualitative data related to GDA pseudoaneurysm presentation and management following pancreatic resection were extracted and reviewed from individual reports. Results: Nine studies were selected for systematic review involving 4227 pancreatic operations with 55 GDA pseudoaneurysms, with a reported incidence of 1·3 (range 0·2-8·3) per cent. Additional data were extracted from 39 individual examples of GDA pseudoaneurysm from 14 studies. The median time for haemorrhage after surgery was at 15 (range 4-210) days. A preceding complication in the postoperative period was documented in four of 21 patients (67 per cent), and sentinel bleeding was observed in 14 of 20 patients (70 per cent). Postoperative complications after pseudoaneurysm management occurred in two-thirds of the patients (14 of 21). The overall survival rate was 85 per cent (33 of 39). Conclusion: GDA pseudoaneurysm is a rare yet serious cause of haemorrhage after pancreatic surgery, with high mortality. The majority of the patients had a preceding complication. Sentinel bleeding was an important clinical indicator.

Antecedentes: El pseudoaneurisma (PA) de la arteria gastroduodenal (gastroduodenal artery, GDA) es una complicación grave después de la resección pancreática que conlleva elevadas tasas altas de morbilidad y mortalidad. Esta revisión tiene como objetivo estudiar la incidencia de PA de la GDA tras cirugía pancreática y describir la forma de presentación clínica y el tratamiento. Métodos: Se realizó una búsqueda sistemática en MEDLINE y EMBASE de los estudios clínicos que analizasen el PA postoperatorio de la GDA. Se calculó la incidencia dividiendo el número total de PA de GDA por el número total de intervenciones pancreáticas. De los informes de cada caso, se extrajeron los datos cualitativos relacionados con la forma de presentación y el tratamiento del PA de la GDA tras la resección pancreática. Resultados: Para la revisión sistemática se seleccionaron nueve estudios con 4.227 intervenciones sobre el páncreas y 55 PA de la GDA (incidencia 1,30% (rango 0,22­8,33%). Se obtuvieron, además, datos individuales de 39 casos de PA de la GDA en 14 estudios. La hemorragia se presentó, como mediana, el día 15 (rango: 4­210) del postoperatorio. Fue precedida de una complicación postoperatoria en el 66,7% de los casos y se observó una hemorragia centinela en el 70,0% de los pacientes. En dos tercios de los pacientes hubo complicaciones postoperatorias después del tratamiento del PA y la supervivencia global fue del 84,6%. Conclusión: Los PA de la GDA son una causa poco frecuente, pero grave, de hemorragia después de la cirugía pancreática, con una elevada mortalidad. La mayoría de los pacientes presentaron alguna complicación previa. La hemorragia centinela fue un indicador clínico de importancia.

Safety and cost-effectiveness of early discharge after primary angioplasty in low risk patients with acute myocardial infarction. PAMI-II Investigators. Primary Angioplasty in Myocardial Infarction.

OBJECTIVES: The second Primary Angioplasty in Myocardial Infarction (PAMI-II) study evaluated the hypothesis that primary percutaneous transluminal coronary angioplasty (PTCA), with subsequent discharge from the hospital 3 days later, is safe and cost-effective in low risk patients. BACKGROUND: In low risk patients with myocardial infarction (MI), few data exist regarding the need for intensive care and noninvasive testing or the appropriate length of hospital stay. METHODS: Patients with acute MI underwent emergency catheterization with primary PTCA when appropriate. Low risk patients (age <70 years, left ventricular ejection fraction >45%, one- or two-vessel disease, successful PTCA, no persistent arrhythmias) were randomized to receive accelerated care (admission to a nonintensive care unit and day 3 hospital discharge without noninvasive testing [n = 237] or traditional care [n = 234]). RESULTS: Patients who received accelerated care had similar in-hospital outcomes but were discharged 3 days earlier (4.2+/-2.3 vs. 7.1+/-4.7 days, p = 0.0001) and had lower hospital costs ($9,658+/-5,287 vs. $11,604+/-6,125 p = 0.002) than the patients who received traditional care. At 6 months, accelerated and traditional care groups had a similar rate of mortality (0.8% vs. 0.4%, p = 1.00), unstable ischemia (10.1% vs. 12.0%, p = 0.52), reinfarction (0.8% vs. 0.4%, p = 1.00), stroke (0.4% vs. 2.6%, p = 0.07), congestive heart failure (4.6% vs. 4.3%, p = 0.85) or their combined occurrence (15.2% vs. 17.5%, p = 0.49). The study was designed to detect a 10% difference in event rates; at 6 months, only a 2.3% difference was measured between groups, indicating an actual power of 0.19. CONCLUSIONS: Early identification of low risk patients with MI allowed safe omission of the intensive care phase and noninvasive testing, and a day 3 hospital discharge strategy, resulting in substantial cost savings.

Baseline and 6-month costs of primary angioplasty therapy for acute myocardial infarction: results from the primary angioplasty registry.

OBJECTIVES: This study sought to describe the economic outcomes from a prospective multicenter registry of primary coronary angioplasty. BACKGROUND: Interest in coronary angioplasty without preceding thrombolytic therapy as a primary reperfusion strategy has increased as a result of three recent randomized trials showing outcomes equivalent to or better than standard thrombolytic therapy. METHODS: The Primary Angioplasty Registry enrolled 270 patients with acute myocardial infarction at six private tertiary care medical centers. Baseline and follow-up medical costs and counts of resources consumed were collected from enrollment to the 6-month follow-up visit. Correlates and predictors of cost were identified with multivariable linear regression modeling. RESULTS: Ninety-five percent of patients had a revascularization procedure during the baseline hospital period: 85% had coronary angioplasty only; 4% had coronary bypass surgery only; 6% had both procedures. The total mean baseline hospital cost (not charge) was $13,113, with mean physician fees of $5,694. During the follow-up period, repeat coronary angiography was performed in 21% of patients, whereas 13% had repeat angioplasty and 3% bypass surgery. Mean hospital follow-up costs were $3,174, with mean physician fees of $1,443. Independent correlates of higher baseline hospital costs included older age (p = 0.049), anterior infarction (p = 0.03), initial Killip class (p < 0.0001), more severe coronary disease (p = 0.0015), need for bypass surgery alone or in addition to angioplasty (p < 0.0001) and recurrent ischemia (p < 0.0001). CONCLUSIONS: Costs of primary angioplasty for patients with acute myocardial infarction eligible for thrombolysis were strongly influenced by infarction- and procedure-related complications but only modestly influenced by patient selection factors.

Home health care agencies: what constitutes success?

Dramatic changes in the health care delivery system have produced a highly competitive environment for home health agencies. This study examined the characteristics perceived to be present in successful home health agencies. The results reflect both similarities and differences from studies of successful hospitals and businesses.