What is the paradigm: hospital or home health care for pressure ulcers?

A home health care (HHC) referral should link the patient in a cost-effective fashion to the physician, home care, and instructions regarding ulcer management. Twenty-one patients (mean age, 74.6 years) had stage III pressure ulcers (<100 cm2) and an involved family member at home. Risk and contributing factors included cardiac disease (n = 9), hypertension (n = 14), end-stage renal disease (n = 7), smoking (n = 11), diabetes (n = 8), chronic brain syndrome (n = 14), cerebrovascular accident (n = 5), and above-the-knee amputation (n = 2). Treatment regimens included standard wound care, pressure relief and, where appropriate, culture-specific antibiotics, as well as a rehabilitation program. Home care progressively decreased the frequency of the nurse HHC and physician office visits. Resolution of the pressure ulcer varied from 6 to 32 weeks. Only two patients had progression of their wound and required hospital readmission. The billable fees included: 1) an office visit, $30.00 (medicare reimbursement, $14.00); 2) the HHC nurse visit, $159.00 (medicare reimbursement, $105.00); 3) supplies, $75.00 to $150.00/week (variable reimbursement); 4) hospitalization, $400.00 to $900.00/day; and 5) a chronic-care bed, $400.00 to $750.00/day. HHC, given a responsible support team and an involved family member, was more socially and financially acceptable than an inpatient facility. Intermittent physician visits with HHC proved safe and reliable, with 90 per cent successfully healing their wounds.

Sequential biannual prevalence studies of pressure ulcers at Allegheny-Hahnemann University Hospital.

To assess the prevalence, documentation and care of pressure ulcers, and the effect of teaching and prevention strategies in a 750-bed university hospital, one-day studies were conducted in 1993, 1995, and 1997. Data gathered was used to evaluate areas in need of improvement and find cost-effective ways to reduce the prevalence of pressure ulcers. The overall prevalence of ulcers decreased from 18 percent in 1993 to 10 percent in 1995 and 1997. The prevalence of nosocomial ulcers decreased from 14 percent in 1993 to 8 percent in 1995 and 6 percent in 1997. The number of nutritional consults increased from 54 percent in 1993 to 67 percent in 1997, and more than half of all patients tested had serum albumin levels < 3.5 mg/dL. Skin assessments upon admission were completed in the majority of patients. While ulcer documentation was less than adequate for the majority of patients in 1993 and 1997, care measures, e.g., placement of patients on specialty beds or mattresses and use of dressings that provide a moist environment, improved considerably. The results of this study indicate that system-wide educational efforts aimed at all levels of patient care providers, and multi-specialty prevention and care efforts can reduce the prevalence of pressure ulcers.

Treating wounds associated with decreased sensibility.

Neuropathic wounds are a problem most often associated with diabetes, particularly in those patients with decreased sensibility. More often than not, the patient is unaware of the insidious progression of dysfunction and its direct impact on tissue necrosis. Even when the underlying cause is discovered, often no mechanism is present to compensate for the loss of sensory protection. Current pharmacologic treatment for peripheral neuropathy is palliative with capsaicin and amitriptyline, used most frequently to treat symptoms of painful peripheral neuropathy. Orthotists and prosthetists are helpful in developing shoes or support devices to provide relief or lifts from weight-bearing areas in the insensate patient. Proper patient education and primary-care monitoring can greatly decrease the number of non-heating foot lesions and amputations.

Prediction of outcome in "resectable" esophageal carcinoma.

A retrospective review was performed of 51 patients with esophageal carcinoma, deemed "resectable" by preoperative workup (e.g., CT scan, barium swallow), who presented to Hahnemann University Hospital between 1980 and 1991. This represented 21.8% of the total number of patients (234) with esophageal cancer who presented during that time period. At exploration, only 21 of the 51 patients (41%, or 9% overall) were truly resectable; 59% had more extensive disease than was appreciated preoperatively and that precluded resection for cure. Of the 21 patients resected for cure, 24% were alive at two years and only 5% were alive at 3 years. Neither age, gender, tumor type nor location in the esophagus significantly affected overall survival. Furthermore, none of these parameters, taken as independent variables, were able to predict true resectability at the time of operation. We conclude that preoperative assessment of resectability, even in those patients who appear to be good candidates for cure, remains imprecise at best. Given an operative mortality rate of 6-8% (in most series) and an overall 3- to 5-year survival rate of less than 10% (even in patients thought to have had curative resections), we reinforce the fact that meticulous patient selection and multimodality management strategies remain the keys to making any impact on this disease.

Heparin treatment enhances the recovery of neoendothelial acetylcholine-induced vascular relaxation after balloon catheter injury in the rabbit aorta.

BACKGROUND: After catheter injury, the neoendothelium that grows is abnormal in morphology and in acetylcholine-induced generation of endothelium-derived relaxing factor (EDRF). Heparin has been shown to have stimulatory effects on vascular endothelial growth in vitro. Its effect in vivo on neoendothelial cell morphology and metabolism after injury has not been described. We investigated the effect of heparin treatment on the neoendothelium formed after injury. METHODS AND RESULTS: Four groups of New Zealand White rabbits were studied. Group 1 rabbits underwent catheter denudation and were killed 4 weeks after injury without receiving treatment (NO Tx, n = 8). Groups 2 and 3 underwent similar aortic injury, received 2 weeks of treatment with either heparin (n = 7) or low molecular weight heparin (LMWH, n = 5), and were killed at 4 weeks. Group 4 underwent sham operation (SHAM, n = 8). EDRF generation was determined by the relaxation of precontracted aortic rings in an organ bath in response to acetylcholine. The heparin-treated group exhibited a significant improvement in acetylcholine-induced relaxation (27%) versus both LMWH-treated (14%, P = .035) and untreated groups (11%, P = .004), although relaxation was only 50% of that observed in the uninjured control vessels (52%, P = .001). The neoendothelium formed in the heparin-treated group exhibited a more normal histological appearance and was aligned with the direction of blood flow as compared with that observed in the untreated or LMWH-treated groups. CONCLUSIONS: These results demonstrate that in vivo heparin administration enhanced the recovery of EDRF generation and augmented normalization of the morphologic appearance of the neoendothelium.

Factors influencing survival in infiltrating lobular carcinoma of the breast.

Seventy cases of infiltrating lobular (IL) carcinoma of the breast presenting to Hahnemann University Hospital between 1965 and 1990 were reported. This comprised 2.4 per cent of the total number of breast cancer cases during that time period. Fifty-seven of these tumors were pure IL carcinoma, while 13 had both IL and infiltrating ductal characteristics. Two-year, 5-year, and 10-year survival rates were not influenced by stage at the time of presentation, histology, nor operation performed. Though a statistically significant trend toward breast conservation surgery was documented over time, there was no significant relationship between operation performed and survival. This was true for both localized and nodal-metastatic disease. Overall survival was essentially equivalent to that reported for infiltrating ductal carcinoma.

Major long-term complications in 1,422 permanent venous access devices.

A retrospective review was undertaken of 1,422 permanent venous access devices (PVADs) implanted from 1989 to 1991 at Hahnemann University Hospital. This included 730 single-lumen Hickman catheters, 368 double-lumen Hickman catheters, 307 single-lumen Portacath infusion ports, and 17 double-lumen Portacath infusion ports. Indications for placement were as follows: antibiotics in 28%; chemotherapy in 51%; hyperalimentation in 4%; intravenous fluids in 4%; hemodialysis in 3%; and undocumented indications in 10%. There were 60 PVADs removed and/or replaced prior to the completion of intended therapy (4% overall). Indications for removal were catheter infection in 1% of cases and catheter malfunction in 3% of cases. The percentage of Portacath infusion ports removed was significantly greater than the percentage of Hickman catheters that were removed (p < 0.001). However, there was no significant relationship between catheter infection or the malfunction rate, and the number of lumens, initial indication for placement, or number of catheters placed. Life-threatening complications associated with PVAD insertion occurred in fewer than 1% of cases. The insertion of PVADs is a safe and efficient mode of long-term venous access.

Changing patterns in colorectal carcinoma: a 25-year experience.

The pattern of colorectal carcinoma, especially with respect to stage and tumor location, has changed noticeably over the past 25 years. During that time period, 1,959 patients came to Hahnemann University Hospital with colorectal cancer, 1,584 of whom were reviewed in this study. There was a significant relationship between extent of disease and date of diagnosis, with the trend being toward decreasing stage at the time of diagnosis. In addition, there has been a demonstrable "rightward shift" in tumor location, especially over the past 15 years. This has been accompanied by a slight increase in the detection of rectal lesions as well. The trend toward earlier and more proximal lesions is likely due in large part to the increasingly widespread use of surveillance colonoscopy and sigmoidoscopy.

Inadequacy of bedside clinical indicators in identifying significant intracranial injury in trauma patients.

During 1987 and 1988, the trauma service at Hahnemann University Hospital, a level I trauma center, evaluated 1,875 consecutive patients. Four hundred ninety-seven consecutive computed tomographic (CT) scans were performed to evaluate intracranial trauma in the emergency department. These patients' records were reviewed to determine the adequacy of loss of consciousness, amnesia, Glasgow Coma Scale (GCS) score, and mechanism of injury in predicting intracranial findings. In 302 patients with a GCS score of 13 or greater, 55 (18%) CT scans showed abnormal findings. Eleven (4%) of these patients required neurosurgical intervention. Furthermore, patients with normal CT scans required no interventions for head trauma. Mechanism of injury directly influenced the incidence of neurosurgical intervention. Current bedside methods to evaluate patients for possible intracranial injury in our trauma patient population are inadequate. Emergency department CT scans should be performed on all patients referred to the trauma service with previously classified mild- or low-risk criteria for intracranial trauma, regardless of GCS score.

Noninvasive evaluation of peripheral vasculature following regional hyperthermic chemotherapeutic perfusion (RHCP).

Regional hyperthermic chemotherapeutic perfusion (RHCP) has been used to treat over 1000 patients with advanced melanoma and soft tissue sarcoma. This study analyzes the impact of RHCP on the peripheral vasculature. Forty-one patients (23 women, 18 men) with an average age of 51.3 years were treated by RHCP of an upper or lower extremity using phenyalanine mustard for 60 minutes at a mean extremity temperature of 40 C. Patients were examined preoperatively and postoperatively at 36 hours, 7 days, 1 month, and 6 months by noninvasive arterial (Doppler-resting analog velocity waveform, response to stress) and venous (Doppler, impedance plethysmography [IPG], phleborrheography [PRG]) measurements. Upper-extremity evaluation of 14 patients (9 women, 5 men) indicated no abnormal studies. Response to stress showed an increase of the brachial:distal vessel ratio of 0.1 +/- 0.05; tendency of the analog velocity waveform toward triphasic; and response to stress augmented by 0.18 +/- .03 at 36 hours. Lower-extremity evaluation of 27 patients (15 women, 12 men) indicated two with thrombophlebitis. Response to stress showed an increase of the ankle: brachial ratio of .016 +/- 0.04; change in the analog velocity waveform toward triphasic; and response to stress augmented by 0.08 +/- 0.08 at 36 hours. All measurements returned to preoperative values at 7 days. Results of this study indicate RHCP has no long-term adverse effect on the vasculature of the extremity, as monitored by the noninvasive blood flow studies.

Elemental diet and bile induced pancreatitis.

The effectiveness of an elemental diet was investigated as both a prophylactic and therapeutic agent in experimental canine pancreatitis. Pancreatitis was induced by operative injection of a bile -saline solution mixture under pressure retrograde into the main pancreatic duct. In addition to a preinjection control sample, serial biopsies were obtained at 30 minute intervals for 90 minutes after injection and fixed for light and electron microscopic examinations. In addition, preoperative and postoperative blood samples were drawn and analyzed for amylase. After operation, half of the dogs from each original group were fed Vivonex-100, the other half from each group, regular laboratory chow, yielding four ultimate groups based on preoperative and postoperative diets. Successful induction of pancreatitis was evaluated by the difference between preoperative and postoperative amylase values, all of which were significant by group at the p less than 0.01 level. No ultrastructural evidence was found for the modification of zymogen granules with the pretreatment elemental diet nor were differences evident, histologically or ultrastructurally, in the severity of pancreatitis between the pretreated and nonpretreated groups. Finally, gross mortality figures demonstrated no efficacy of elemental diet for pretreatment prophylaxis of acute pancreatitis.

Barium granuloma of the rectum: an uncommon complication of barium enema.

Barium sulfate granuloma of the rectum may develop when this contrast material is forced through a discontinuity in the rectal mucosa. The ensuing mass may be confused with carcinoma. Preoperative biopsy and attention to plain films will prevent unnecessary inappropriate surgery.