Race, ethnicity, and gender representation in clinical case vignettes: a 20-year comparison between two institutions.

BACKGROUND: The medical case vignette has long been used in medical student education and frequently includes demographic variables such as race, ethnicity and gender. However, inclusion of demographic variables without context may reinforce assumptions and biases. Yet, the absence of race, sexual orientation, and social determinants of health may reinforce a hidden curriculum that reflects cultural blindness. This replication study compared proportions of race, ethnicity, and gender with University of Minnesota (UMN) findings. This study sought to determine if there has been progress in the representation of demographic characteristics in case vignettes. METHODS: University of North Carolina (UNC) case vignettes from 2015-2016 were analyzed and compared to UMN case vignettes from 1996-1998. Data included mentions of race, ethnicity, gender and social determinants of health. RESULTS: In the 278 UNC vignettes, white race was noted in 19.7% of cases, black race was in 7.9% cases, and 76.6% of cases were unspecified. In the 983 UMN vignettes, white race was recorded in 2.85% cases, and black race in 0.41% cases. The institutions were significantly different in the proportion of their cases depicting race (0.20; 95% CI (0.15, 0.25)). Males were represented in the majority of vignettes. DISCUSSION: Comparing case vignettes results from two medical schools suggests that reporting explicit demographic diversity was not significantly different. The findings illustrate that sex was the demographic characteristic consistently described, where males were over-represented. Based on these findings, greater cultural diversity as it intersects with social determinants of health is needed in medical student education.

Emergency medicine evaluation and management of the end stage renal disease patient.

BACKGROUND: End stage renal disease (ESRD) is increasing in the U.S., and these patients demonstrate greater all-cause mortality, cardiovascular events, and hospitalization rates when compared to those with normal renal function. These patients may experience significant complications associated with loss of renal function and dialysis. OBJECTIVE: This review evaluates complications of ESRD including cardiopulmonary, neurologic, infectious disease, vascular, and access site complications, as well as medication use in this population. DISCUSSION: ESRD incidence is rapidly increasing, and patients commonly require renal replacement therapy including hemodialysis (HDS) or peritoneal dialysis (PD), each type with specific features. These patients possess greater risk of neurologic complications, cardiopulmonary pathology, infection, and access site complications. Focused history and physical examination are essential. Neurologic issues include uremic encephalopathy, cerebrovascular pathology, and several others. Cardiopulmonary complications include pericarditis, pericardial effusion/tamponade, acute coronary syndrome, sudden cardiac death, electrolyte abnormalities, pulmonary edema, and air embolism. Infections are common, with patients more commonly presenting in atypical fashion. Access site infections and metastatic infections must be treated aggressively. Access site complications include bleeding, aneurysm/pseudoaneurysm, thrombosis/stenosis, and arterial steal syndrome. Specific medication considerations are required for analgesics, sedatives, neuromuscular blocking agents, antimicrobials, and anticoagulants. CONCLUSIONS: Consideration of renal physiology with complications in ESRD can assist emergency providers in the evaluation and management of these patients. ESRD affects many organ systems, and specific pharmacologic considerations are required.

Mind-body therapies for the self-management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures which are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care complementary and integrative medicine (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature (REAL©) methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A panel of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review, 54 of which investigated mind-body therapies, as defined by the authors. CONCLUSIONS: This article summarizes the current evidence, quality, efficacy, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement.

Movement therapies for the self-management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures which are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review, 30 of which investigated movement therapies, as defined by the authors. CONCLUSIONS: This article summarizes the current evidence, quality, efficacy, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement.

Sensory art therapies for the self-management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures which are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review, eight of which investigated sensory art therapies, as defined by the authors. CONCLUSIONS: This article summarizes the current evidence, quality, efficacy, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement.

Physically oriented therapies for the self-management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures that are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's Rapid Evidence Assessment of the Literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review, 10 of which investigated physically oriented therapies, as defined by the authors. CONCLUSION: This article summarizes the current evidence, quality, efficacy, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement.

Multimodal, integrative therapies for the self-management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures which are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review, 26 of which investigated multimodal, integrative therapies, as defined by the authors. CONCLUSION: This article summarizes the current evidence, quality, and effectiveness of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement.

Effectiveness of active self-care complementary and integrative medicine therapies: options for the management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures that are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's Rapid Evidence Assessment of the Literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review, 18 of which directly compared ACT-CIM approaches with one another. CONCLUSIONS: This article summarizes the current evidence, quality, effectiveness, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement.

An analysis of the various chronic pain conditions captured in a systematic review of active self-care complementary and integrative medicine therapies for the management of chronic pain symptoms.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures that are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature (REAL©) methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials, covering 33 different pain conditions, were included in the review. CONCLUSIONS: This article categorized studies by pain condition, describing the diagnostic criteria used and modalities that seem most effective for each condition. Complexities associated with investigating chronic pain populations are also discussed. The entire scope of the review, categorized by modality rather than pain condition, is detailed throughout the current Pain Medicine supplement.

The current state of the science for active self-care complementary and integrative medicine therapies in the management of chronic pain symptoms: lessons learned, directions for the future.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures which are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's rapid evidence assessment of the literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review. CONCLUSION: This article summarizes the current state of the science, lessons learned from the gaps exposed by the review, as well as suggestions for next steps toward translation for the field. Although the review's entire scope is detailed throughout the current Pain Medicine supplement, the authors encourage the use of this report as a guide for future ACT-CIM research.

Assessing the quality, efficacy, and effectiveness of the current evidence base of active self-care complementary and integrative medicine therapies for the management of chronic pain: a rapid evidence assessment of the literature.

OBJECTIVES: Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures that are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients' roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management. METHODS: A systematic review was conducted, using Samueli Institute's Rapid Evidence Assessment of the Literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities. RESULTS: Following key database searches, 146 randomized controlled trials were included in the review. CONCLUSIONS: This article provides an introduction and background to the review, summarizes the methodological processes involved, details the initial results, and identifies strengths and weakness of the review. Specific results of the review as well as overall recommendations for moving this field of research forward are detailed throughout the current Pain Medicine supplement.

Race and Ethnicity and Clinician Linguistic Expressions of Doubt in Hospital Admission Notes.

Importance: Stigmatizing language in electronic health records (EHRs) can generate or reinforce negative stereotypes about patients from minoritized groups and erode their trust and experience. However, less is known about the use of such language to cast doubt on patient clinical history in hospital settings. Objective: To compare the prevalence of language expressing doubt about patient clinical history (eg, experiences and symptoms) in hospital admission notes by patient race and ethnicity. Design, Setting, and Participants: In this cohort study, natural language processing tools were applied to analyze 54 936 admission notes from 1249 clinicians about patients aged 18 years or older at admission and hospitalized at an academic health system in the Northeast US between January 1, 2018, and February 28, 2023. Data were analyzed from September 1, 2022, to July 31, 2023. Exposure: Patient race and ethnicity (non-Hispanic Black, non-Hispanic White, and racial and ethnic minoritized groups excluding non-Hispanic Black [includes multiple racial and ethnic groups, such as Hispanic and Asian]) as recorded in the EHR based on self-report or registrar determination. Main Outcome and Measure: Binary indicator for at least 1 term casting doubt on patient clinical history was defined using epistemic stance, a linguistic construct expressing a writer's degree of certainty in information. Terms were manually validated via iterative review of notes by the study team. Results: Among 56 325 admission notes (mean [SD] age of patients, 55.9 [19.0] years; 30 913 notes among female patients [54.9%]; 25 649 notes among non-Hispanic Black patients [45.5%], 26 442 notes among non-Hispanic White patients [46.9%], and 2985 notes among members of racial and ethnic minoritized groups excluding non-Hispanic Black patients [5.3%]), we analyzed 54 936 admission notes that had no missing data. Among all analyzed admission notes, 39 023 notes (71.0%) contained doubt language. Notes written about non-Hispanic Black patients had increased odds of containing at least 1 word or phrase of doubt (adjusted odds ratio, 1.21; 95% CI, 1.14-1.28; P < .001) compared with notes among non-Hispanic White patients. Compared with notes among non-Hispanic White patients, notes written about members of racial and ethnic minoritized groups excluding non-Hispanic Black patients had similar odds of containing at least 1 term of doubt. Conclusion and Relevance: In this study, language casting doubt on patient clinical history was more likely to be found in notes of non-Hispanic Black patients. These results suggest that with the implementation of policies allowing patients full access to their health records, examining clinical documentation standards may be associated with improved patient experience.

Patient Experience at US Hospitals Following the Caregiver Advise, Record, Enable (CARE) Act.

Importance: Communication with caregivers is often not established or standardized during hospitalization. The Caregiver Advise, Record, Enable (CARE) Act is a state-level policy designed to facilitate communication among patients, caregivers, and clinical care teams during hospitalization to improve patient experience; 42 states have passed this policy since 2014, but whether it was associated with achieving these goals remains unknown. Objective: To determine whether passage of the CARE Act was associated with improvements in patient experience. Design, Setting, and Participants: This cohort study used a difference-in-differences analysis of short-term, acute-care US hospitals from 2013 to 2019 to analyze changes in patient experience before vs after CARE Act implementation in hospitals located in states that passed the CARE Act compared with those in states that did not. Analyses were performed between September 1, 2021, and July 31, 2022. Exposure: Time-varying indicators for whether a hospital was in a state that passed the CARE Act. Main Outcomes and Measures: Patient-reported experience via the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Results: A total of 2763 hospitals were included, with 2188 hospitals in CARE Act states and 575 in non-CARE Act states. There were differential improvements in patient experience in the measures of communication with nurses (unadjusted mean [SD] score, 78.40% [0.42%]; difference, 0.18 percentage points; 95% CI, 0.07-0.29 percentage points; P = .002), communication with physicians (mean [SD] score, 80.00% [0.19%]; difference, 0.17 percentage points; 95% CI, 0.06-0.28 percentage points; P = .002), and receipt of discharge information (mean [SD] score, 86.40% [0.22%]; difference, 0.11 percentage points; 95% CI, 0.02-0.21 percentage points; P = .02) among CARE Act states compared with non-CARE Act states after policy passage. In subgroup analyses, improvements were larger among hospitals with lower baseline Hospital Consumer Assessment of Healthcare Providers and Systems performance on measures of communication with nurses, communication with physicians, and overall hospital rating. Conclusions and Relevance: These findings suggest that implementation of the CARE Act was associated with improvements in several measures of patient experience. Policies that formally incorporate caregivers into patient care during hospitalization may improve patient outcomes.

Aerococcus urinae and trimethoprim-sulfamethoxazole.

Aerococcus urinae has been described as resistant to trimethoprim-sulfamethoxazole (SXT), but the test medium may affect this observation. Twenty-seven clinical isolates of A. urinae tested susceptible to SXT in cation-adjusted Mueller-Hinton broth (CAMHB) plus lysed horse blood and resistant in CAMHB plus lysed sheep blood.

Older adults with multi-morbidity: medication management processes and design implications for personal health applications.

BACKGROUND: Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults' needs, preferences, and practices. OBJECTIVE: The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA. METHODS: We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling. RESULTS: We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers. CONCLUSIONS: This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.

Impact of shockwave coupling on efficacy of extracorporeal shockwave lithotripsy.

PURPOSE: To evaluate the impact of a slow gated treatment rate on the efficacy of extracorporeal shockwave lithotripsy (SWL). PATIENTS AND METHODS: From August 1990 to July 2002, 40,462 SWL procedures were performed using the slow frequency electrocardiography (ECG)-gated lithotripter (82.5%) and fast frequency ECG-ungated (17.5%) modes for the Medstone STS lithotripter. Treatment characteristics, including the mode of SWL, location and size of the stone, re-treatment status, auxiliary procedures required, perioperative complications, and treatment outcomes, were recorded. The stone-free rate was reported by the treating physician on the basis of the finding of no residual stone fragments on a plain radiographic image. RESULTS: The treatment rate for the slow mode was a mean of 79.6 shocks/min, while the rate for the fast mode was 120/min. The total procedure time was 47.0 minutes for the slow mode and 40.6 minutes for the fast. The overall stone-free rate was higher for slow (66.9%) than fast (63.6%) procedures (P < 0.001). The stone-free rate for 1- to 10-mm stones was higher for the slow procedures (75.7%) than the fast procedures (70.7%; P < 0.001). Upper-ureteral stones responded better to slow treatment in terms of stone-free rate (79.5% v 72.6%; P < 0.001), re-treatment rate (6.5% v 8.0%, P = 0.05), auxiliary-procedure rate (6.1% v 8.9%; P = 0.01), and efficiency quotient (71 and 62). There was no significant difference in complication rates overall between slow and fast treatment. CONCLUSIONS: With a minimal increase in procedure time, greater efficacy can be obtained for the treatment of radiopaque stones with a slower shock-delivery rate. In particular, upper-ureteral calculi and calculi <10 mm benefit from a slower treatment rate.

Impact of renal function on efficacy of extracorporeal shockwave lithotripsy.

BACKGROUND AND PURPOSE: Adequate urine production and excretion may be important for clearance of stone fragments after extracorporeal shockwave lithotripsy (SWL). This study evaluated the impact of renal function, measured by preoperative serum creatinine concentration, on the efficacy of SWL. PATIENTS AND METHODS: From 1986 to 2001, 27,299 patients with urolithiasis were treated with Medstone STS lithotripters. Seven hundred ninety-eight of these patients (2.92%) had serum creatinine concentrations >or=2.0 mg/dL. Perioperative renal function (serum creatinine), treatment parameters, stone-free success rate (no residual fragments on plain film), and perioperative complications and procedures were recorded. RESULTS: The stone-free rate for patients with serum creatinine values from 2.0 to 2.9 mg/dL (56.69%) was significantly less than that seen in patients with a creatinine concentration <2.0 mg/dL (66.20%). The retreatment rate and secondary-procedure rate were significantly higher in patients with higher serum creatinine values (9.62% and 8.92%, respectively) than in those with serum creatinine within the normal range (6.07% and 4.27%, respectively). There was no significant difference in the stone-free rate, re-treatment rate, and secondary-procedure rate of patients with serum creatinine >or=3.0 mg/dL in comparison with patients with values <2 mg/dL. Complication rates were higher for patients with serum creatinine values >4.0 mg/dL (10.91%) than for patients with creatinine <2.0 mg/dL (2.62%). CONCLUSIONS: The efficacy of SWL is decreased in patients with serum creatinine concentrations of 2.0 to 2.9 mg/dL, and the complication rate is higher in patients with serum creatinine >4.0 mg/dL. Preoperative counseling may include a discussion of the impact of renal insufficiency on success and complication rates associated with SWL.

Impact of type of anesthesia on efficacy of medstone STS lithotripter.

PURPOSE: To evaluate the impact of the type of anesthesia on treatment efficacy, using a comparison of general anesthesia (GEN) and monitored anesthesia care with intravenous sedation (MAC), for patients undergoing extracorporeal shockwave lithotripsy (SWL) on the Medstone STS lithotripter. PATIENTS AND METHODS: A case-control study was conducted of 660 patients treated from 1986 to 2002. General anesthesia and MAC were utilized in 330 procedures each. Case matching was performed for stone size, stone location, and body mass index. All lithotripter units were staffed by a rotating schedule of the same 10 SWL-certified radiologic technicians. Patient characteristics, treatment parameters, complications, repeat procedures, and secondary procedures were recorded. Stone-free success rates (no residual fragments) were reported by the treating physician on the basis of plain radiographs. Chi-square analysis was used to compare patients in the two groups. RESULTS: The overall stone-free rate was better with GEN (67%) than MAC (55%; P = 0.04). Stone-free rates were not affected for stones 10 mm or in an upper calix. General anesthesia may decrease excursion of the calculus out of the focal area secondary to breathing or patient movement.