Audibility of the fourth heart sound. Relationship to presence of disease and examiner experience.

To determine the meaning of an audible fourth heart sound (S4), 51 subjects (21 normal and 30 abnormal persons), aged between 38 and 74 years (mean, 55.4 years), were examined by nine "blinded" physicians (four cardiologists, five house staff officers). Audibility scores were compared with phonocardiographic, echocardiographic, and hemodynamic measurements. An S4 was recorded graphically in 35 (68.6%) of all 51 subjects and splitting of the first sound (S1), in 37 subjects (72.5%). The abnormal group did not differ significantly from the normal subjects in incidence of recordable S4 or splitting of S1. Audibility of S4, however, correlated with its recorded amplitude, size, and palpability of the presystolic apical impulse, left ventricular systolic and diastolic diameters, and history of myocardial infarction. Despite variation among examiners, house staff officers were likelier than cardiologists to believe an S4 present even in cases lacking a recordable S4 and in normal subjects and were more apt to believe an S4 present when splitting of S1 was identified graphically. We conclude that an audible S4 continues to provide evidence for cardiac disease, and that increasing examiner experience renders this finding fairly specific. Less experienced examiners are likelier to confuse splitting of S1 with the S4, suggesting that training should be focused on means to improve this differentiation.

Comparison of the effects of pindolol and atenolol on hemodynamic function in systemic hypertension.

A randomized double-blind study was performed on a group of mild hypertensive patients (WHO class I) to compare the hemodynamic effects of pindolol and atenolol. Blood pressure (BP) was monitored with a mercury gauge sphygmomanometer, while cardiac function and peripheral arterial flows were measured by the noninvasive technique of bioelectric impedance. After a 2-week washout period, patients with a diastolic BP greater than 95 mm Hg but less than 114 mm Hg were randomized into the pindolol (29 patients) or atenolol (28) treatment groups. Patients were treated with 1 of the 2 drugs in an incremental fashion for 12 weeks. Cardiovascular function was measured after the washout period and at the end of the 12-week treatment period. Baseline hemodynamics were similar in both groups. The 2 drugs were equally effective in lowering both systolic and diastolic BP. Hemodynamically, pindolol lowered BP by decreasing total peripheral resistance (-406 +/- 145 dynes.s.cm-5) while atenolol decreased cardiac index (-0.2 +/- 0.1 liters/min/m2) associated with a decrease in heart rate (-12 +/- 2 beats/min). Regarding peripheral vascular beds, pindolol lowered arm vascular resistance (-198 +/- 72 mm Hg/liter/min) and leg vascular resistance (-73 +/- 25 mm Hg/liter/min), especially when subjects who did not respond to pindolol were excluded from the analysis. Both arm (5.5 +/- 5.4% increase above baseline) and leg (1.2 +/- 4.4% increase above baseline) arterial flow indexes were maintained with pindolol. Conversely, atenolol decreased the arm arterial flow index (-9,8 +/- 5.6% decrease below baseline), but not significantly and with no change in resistance (+54 +/- 62 mm Hg/liter/min).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of thrombolysis (streptokinase) on left ventricular function during acute myocardial infarction.

One hundred ninety-two consecutive patients with acute myocardial infarction were enrolled in a prospective trial of coronary thrombolysis in which either intracoronary or intravenous streptokinase was administered. First-pass radionuclide ejection fraction (EF) was measured early (within 24 hours of admission) and late (10 to 14 days after admission) to assess changes in left ventricular (LV) function. In 68 patients in whom reperfusion was successful, mean EF increased from 39 +/- 11% early to 47 +/- 13% late. In 36 patients in whom reperfusion was not successful, the mean EF increase was significantly smaller (from 38 +/- 10% to 42 +/- 11%, p less than 0.025). Patients in whom reperfusion was successful were then grouped according to extent of LV functional change. The extent of EF change (delta EF) was not significantly influenced by time to lysis at intervals up to 7 hours (delta EF = 9.1 +/- 10% at 2 to 3 hours, 8.7 +/- 12% at 3 to 4 hours, 10 +/- 10% at 4 to 5 hours, and 7.0 +/- 10% at 5 to 7 hours; difference not significant [NS]), location of the infarct (delta EF = 8.9 +/- 11% for inferior and 5.7 +/- 8.0% for anterior, NS), or presence of Q waves on the initial electrocardiogram (delta EF = 8.8 +/- 11% in patients with and 7.8 +/- 9.9% in patients without Q waves). Only the initial EF was predictive of subsequent EF change.(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in serum catecholamine levels in patients who are brain dead.

Prospective blood samplings from 15 patients admitted with a Glasgow Coma Score of less than 7 were obtained to observe and compare epinephrine, norepinephrine, and dopamine serum levels in patients with brain injury before, after, and in the absence of brain death. Nine of the patients developed or were admitted after brain death. Wide variations in catecholamine blood levels over time were documented, and subgroup analysis precluded useful statistical comparison or inference of the data. The data are presented therefore as descriptive observations only. No apparent differences were noted between similarly injured patients in whom brain death did not develop and patients before brain death or between patients with penetrating versus nonpenetrating brain injury. Brain death was preceded by hypertension and corresponding elevations in serum catecholamine levels in one patient with complete data. Catecholamine levels appeared to fall after brain death in most patients. Only minimal changes in myocardial histology were present in three donor hearts, and the two transplanted hearts functioned satisfactorily. Serum catecholamine measurement or monitoring does not provide a precise method of determining potential injury to the donor heart before or after brain death. Other experimental data and clinical observation indicate that some hearts may be injured in the donor during the evolution of brain death. Pharmacologic intervention may prevent such injury in experimental animals but must be used before brain death is induced. Such interventions should be studied in selected human donors before brain death to determine whether cardiac function is improved in the donor or recipient.

The learning curve and the cost of heart transplantation.

The effect of learning on hospital outcomes such as mortality or adverse events (the so-called "practice makes perfect" hypothesis) has been studied by numerous investigators. The effect of learning on hospital cost, however, has received much less attention. This article reports the results of a multiple regression model demonstrating a nonlinear, decreasing trend in operative and postoperative hospital costs over time in a consecutive series of 71 heart transplant patients, all treated in the same institution. The cost trend is shown to persist even after controlling for various preoperative demographic and clinical risk factors and the specific experience of individual surgeons. Using a reference case, the model predicts a cost of $81,297 for the first heart transplant procedure performed at the hospital. If this same patient had been the tenth case rather than the first, with the hospital having benefited from the experience gained in nine previous cases, the model predicts the cost would now be only $48,431, or approximately 60 percent of the cost of the first case. Had this patient been the twenty-fifth case, the predicted cost would be $35,352 (43 percent of the original cost), and had this been the fiftieth case, the cost would be $25,458 (31 percent of the original cost). The longitudinal study design used in this analysis greatly reduces the likelihood that the observed cost reduction is due to economies of scale rather than learning. The results have implications for a policy of regionalization as a tactic for containing hospital cost. Whereas others have pointed to a volume-cost relationship as an argument for the regionalization of expensive and complex hospital procedures, the present data isolate a learning-cost relationship as a separate argument for regionalization.

Community hospital and medical school cooperation in continuing medical education.

PURPOSE: To determine the extent and trends of cooperation in continuing medical education (CME) between community teaching hospitals and medical schools in the United States. METHOD: A questionnaire was sent in September 1992 to the directors of CME at 276 teaching hospital members of the Association for Hospital Medical Education (AHME). The survey was designed to answer two questions: (1) What is the extent of cooperation between hospital CME providers and medical schools? (2) In the next three years will community hospitals seek competitive or collaborative relationships in CME with medical schools? RESULTS: By late April 1993, 216 (78%) of the questionnaires had been returned. Of these, 177 (64% of the sample) were analyzed. Of the responding hospitals, 91 (52%) cooperated with 92 medical schools in CME; 75 (45%) of the hospitals planned to increase cooperation. Only ten (11%) of the hospitals described their current CME relationship with a medical school as "competitive in most areas"; 23 (14%) expected to increase competition in the next three years. Forty-one (24%) of the respondents were part of a community hospital CME consortium; only 20 (16%) of the other institutions expected to participate in a consortium in the next three years. Hospital size and membership in the Association of American Medical Colleges' Council of Teaching Hospitals were generally correlated with current and future competition in CME with a medical school and likely participation in a community CME consortium. CONCLUSION: The majority of teaching hospital members of the AHME perceived that they would have cooperative relationships in CME with affiliated medical schools in the three years following the survey. These collaborative relationships should provide an important basis for the further planning and development of medical education consortia.

The use of a break-even analysis: financial analysis of a fast-track program.

OBJECTIVE: To calculate the financial break-even point and illustrate how changes in third-party reimbursement and eligibility could affect a program's fiscal standing. METHODS: Demographic, clinical, and financial data were collected retrospectively for 446 patients treated in a fast-track program during June 1993. The fast-track program is located within the confines of the emergency medicine and trauma center at a 1,050-bed tertiary care Midwestern teaching hospital and provides urgent treatment to minimally ill patients. A financial break-even analysis was performed to determine the point where the program generated enough revenue to cover its total variable and fixed costs, both direct and indirect. RESULTS: Given the relatively low average collection rate (62%) and high percentage of uninsured patients (31%), the analysis showed that the program's revenues covered its direct costs but not all of the indirect costs. CONCLUSIONS: Examining collection rates or payer class mix without examining both costs and revenues may lead to an erroneous conclusion about a program's fiscal viability. Sensitivity analysis also shows that relatively small changes in third-party coverage or eligibility (income) requirements can have a large impact on the program's financial solvency and break-even volumes.

Alterations in predicted growth rates of pediatric kidneys treated with extracorporeal shockwave lithotripsy.

The long-term effects of extracorporeal shockwave lithotripsy (SWL) on the kidneys of children treated for renal calculi are unclear. In order to determine if SWL has any negative effects on renal growth rates, we reviewed long-term (mean 9-year) follow-up data on 29 pediatric patients treated between 1984 and 1988 with an unmodified Dornier HM3 lithotripter. Changes in renal length, serum creatinine, and blood pressure were analyzed. Predicted renal growth was calculated using a formula for age-adjusted renal length. Treated kidneys were stratified into normal and abnormal groups based on a history of renal surgery, evidence of recurrent infection, and obvious anatomic abnormalities. Fifty-six upper urinary tract calculi were treated in 34 renal units. Twenty-two renal units (68%) were rendered stone free, and 65% of the patients continue to be stone free. At follow-up, one patient was classified as having new-onset hypertension, and the mean serum creatinine was 0.93 +/- 0.08 mg/dL. Both at treatment and at follow-up, no significant differences were found in the sizes of the treated and untreated kidneys. However, at treatment, the abnormal group of kidneys seemed to be smaller than expected (mean Z -1.30 +/- 1.10), whereas the group of normal kidneys was very close (mean Z 0.18 +/- 0.54) to the predicted length. At follow-up, the deviations between actual and predicted renal length were significantly more negative. Treated kidneys were an additional 1.26 +/- 0.49 SD units below their expected length (p = 0.02). Untreated kidneys were further below normal as well but possibly to a lesser degree (-0.82 +/- 0.36; p <0.04). Although there was a trend for the abnormal group to have smaller kidneys than the normal group, both groups showed the same trend toward an age-adjusted reduction in renal growth at follow-up. The alterations in renal growth patterns observed in this population are unsettling and could be secondary to either treatment effect (SWL) or, more likely, to some underlying pathology intrinsic to pediatric kidneys with urolithiasis. Until further data are available, SWL in the pediatric population should be applied with caution and at the lowest dosage sufficient to achieve stone comminution.

Cardiac pathology in 470 consecutive forensic autopsies.

Cardiovascular disease continues to be the single most common generic cause of sudden and unexpected deaths. Atherosclerotic coronary heart disease and acute myocardial infarction are the most prevalent forms of fatal cardiac disease observed at autopsy. Other cardiac lesions are frequently listed as causes of death, but the prevalence of such lesions as incidental findings in the general population is unknown. In this study, 470 consecutive forensic autopsies were evaluated for minor and major anomalies. The most frequently observed major congenital finding was floppy mitral valve (5%). Tunneled coronary arteries, considered minor congenital findings, were seen in 29%. Atherosclerotic coronary heart disease was the most common major acquired finding, observed in 16% of cases. Of the 470 hearts, only 8% were considered normal.

Orthopedic research: an overview of data entry, database management, and statistical analysis.

An orthopedic practitioner can facilitate clinical research and analyze quality assurance data with a minor investment in a personal computer, an optical scanner, and two software packages, namely a database manager and a statistics program. One of the most time-consuming stages in the research process includes entering patient chart data, editing and manipulating the data (database management), and analyzing the data (statistical analysis). This can be automated to a large extent with the above mentioned equipment. This article focuses on the steps involved in organizing an orthopedic office for research. The steps include choosing a method of data entry, choosing and implementing a database package, and choosing and implementing a statistics package. This discussion is followed by a practical review of basic statistics applicable to orthopedic research. Several simple and advanced tests are described and examples are given for each.

Factors associated with nursing interventions to reduce incontinence in hospitalized older adults.

INTRODUCTION: The problem of incontinence in hospitalized elderly patients is rarely documented, and there is little research that determines why nurses choose to help or not help with this problem. Are hospital-based acute care nurses' attitudes and beliefs about incontinence associated with the perceived opportunity to assist the patient with the problem? What do hospital nurses know about causes and interventions relative to incontinence? METHODS: Two vignettes, one describing a patient with stress incontinence and one describing a patient with urge incontinence, were created. Questions measuring variables of a help-giving model were developed, and nurses were asked to mark on a Likert-type scale when answering each question. RESULTS: One hundred-fifty respondents returned completed questionnaires along with three nurse experts. Many hospital nurses believed incontinence was temporary and part of being old. As a group they had a more positive attitude toward intervening for urge incontinence and believed the physician and their nurse manager expected them to assist the patient with urge incontinence. Respondents tended to believe the patient was least likely to expect help. Respondents were evenly divided about opportunity to provide assistance for stress or urge incontinence. Less than half of the nurses correctly listed causes and interventions for stress or urge incontinence. CONCLUSIONS: Other clinical problems perceived as more pressing and lack of knowledge concerning appropriate helping measures affect nurses' perceptions of opportunity to intervene when elderly hospital patients are incontinent. Assessment and intervention are essential to quality nursing care. Undergraduate nursing education and ongoing staff education about incontinence are crucial if assessments and interventions are to be correct. Patients, as health care consumers, have to be more educated about incontinence and choose to have the problem addressed during hospitalization. The Agency for Health Care Policy and Research Clinical Practice Guidelines is a major recommended reference.

Residents' perception of their skill levels in the clinical management of adolescent health problems.

Residents in six specialty training programs completed a 126-item questionnaire designed to assess their skill or confidence to manage adolescent health issues. The residency programs studied were family practice, internal medicine, pediatrics, emergency medicine, obstetrics/gynecology, and combined medicine/pediatrics. Although almost three-fourths of the residents were at least moderately interested in adolescent health care and 90% expected to care for adolescents, only 26% believed an adolescent rotation should be required during training. Residents generally considered themselves unskilled to manage adolescents in the areas of sexuality, handicapping conditions, and psychosocial problems. Significant differences in perceived skills were found among the specialty programs on 45% of the items presented. Resident training appears to be needed in the areas of adolescent growth and development, counseling, and sexuality.

Hospital falls: development of a predictive model for clinical practice.

A retrospective case-control study related to falls was conducted at an 1,120-bed acute care tertiary hospital. The case (fall) sample consisted of 102 falls and 236 control (nonfall) charts during a 1-month period. An instrument developed by Hendrich (1988) was modified for use in the study. Demographic data and risk factors were recorded. Descriptive statistics included risk factor percentages for each sample and the corresponding univariate relative risks. Logistic regression was used to develop a multivariate risk factor model with seven risk factors. The significant risk factors were recent history of falls, depression, altered elimination patterns, dizziness or vertigo, primary cancer diagnosis, confusion, and altered mobility. The adjusted relative risks were converted to risk points to be used to assess a patient's level of fall risk. Within the data set, a sensitivity of 77% (79 of 102) and specificity of 72% (169 of 236) were calculated. The model was cross-validated in a 1987 data set with a sensitivity of 83% (59 of 71) and specificity of 66% (106 of 161).

Does anybody really know what time it is? Does anybody really care?

STUDY OBJECTIVE: To evaluate the difference among time sources in an emergency medical system. DESIGN: Prospective; comparison to a criterion standard. SETTING: Five emergency departments and three emergency medical services systems in Indianapolis, Indiana. INTERVENTIONS: Coordinated Universal Time (UTC), generated by the atomic clock in Boulder, Colorado, and broadcast by the US Commerce Department's National Institute of Standards and Technology, was used as the time standard. The investigators, on a single day, made unannounced visits to the five EDs and the ambulances and fire stations in the three emergency medical services systems. The times displayed on all time sources at each location were recorded. The accuracy to the second of each time source compared to UTC was calculated. RESULTS: Three time sources were excluded (two defibrillator clocks and one ED wall clock that varied more than three hours from UTC). Of the 152 time sources, 72 had analog displays, 74 digital, three both, and three other. The average absolute difference from UTC was 1 minute 45 seconds (SEM, 9 seconds) with a range of 12 minutes 34 seconds slow to 7 minutes 7 seconds fast. Thus, two timepieces could have varied by as much as 19 minutes 41 seconds. Compared to UTC, 47 timepieces (31%) were slow, 100 (66%) were fast, and five (3%) were accurate to the second. Fifty-five percent of the time sources varied one minute or more from UTC. CONCLUSION: Time sources in this health care system varied considerably. Time recording in medicine could be made more precise by synchronizing medical clocks to UTC, using computers to automatically "time stamp" data entries and using only digital time sources with second displays.

Management of lower pole nephrolithiasis: a critical analysis.

The results of extracorporeal shock wave lithotripsy (ESWL*) and percutaneous nephrostolithotomy for the treatment of lower pole nephrolithiasis were examined in 32 consecutive patients undergoing percutaneous nephrostolithotomy at the Methodist Hospital of Indiana and through meta-analysis of publications providing adequate stratification of treatment results. Of 101 cases managed with percutaneous nephrostolithotomy 91 (90%) were stone-free, a result significantly better than that achieved with ESWL (1,733 of 2,927 stone-free, 59%). Stone-free rates with percutaneous nephrostolithotomy were independent of stone burden, whereas stone-free rates with ESWL were inversely correlated to the stone burden treated. The morbidity of patients undergoing percutaneous nephrostolithotomy at our hospital was minimal, with a mean hospital stay of 4.7 +/- 2.8 days. No blood transfusions were required. All patients became stone-free. The percentage of urolithiasis patients with lower pole calculi is increasing. Because of the significantly greater efficacy of percutaneous nephrostolithotomy for lower pole calculi, particularly stones larger than 10 mm. in diameter, further consideration should be given to an initial approach with percutaneous nephrostolithotomy.

Accuracy of bar codes versus handwriting for recording trauma resuscitation events.

STUDY OBJECTIVES: To compare the accuracy of computerized bar code data entry with conventional handwritten data entry during videotaped trauma resuscitations. SETTING: Laboratory; video simulation. TYPE OF PARTICIPANTS: Twenty-four emergency nurses. DESIGN: The nurses viewed videotapes of four different major trauma resuscitations during a single session. Each nurse recorded resuscitation events by handwritten entry in two cases and by bar code entry in another two. A computerized bar code system was designed specifically for contemporaneous charting of rapidly occurring events during trauma resuscitations. The handwritten and bar-coded records then were compared with a master list of events, and the number of entry errors were counted. Errors were defined as "omissions" (failing to record an event), "commissions" (recording an event that did not occur), or "inaccuracies" (errors in recording details of an event). ANALYSIS: Differences in the number of entry errors between the two recording methods were compared using unpaired t-tests. Differences in the number of errors after adjusting for the different nurses, different case being viewed, and order of viewing were analyzed using balanced analysis of variance techniques. P < .05 was considered significant. MAIN RESULTS: The mean +/- SEM number of total errors per record for bar codes was 2.63 +/- 0.24 compared with 4.48 +/- 0.30 for handwriting (P < .0001). The mean number of omissions per record for bar codes was 2.25 +/- 0.21 compared with 3.65 +/- 0.27 for handwriting (P = .0001). The mean number of inaccuracies per record for bar codes was 0.38 +/- 0.10 compared with 0.83 +/- 0.12 for handwriting (P = .0038). There were no commission-type errors. CONCLUSION: Computerized bar code data entry of trauma resuscitation events had significantly fewer entry errors than handwritten data entry in a laboratory setting. Potential advantages of bar code data entry include keyless data entry, automatic time-stamping, standardization of documentation, legibility of the medical record, and "point-of-care" data capture.

Cost analysis of heart transplantation from the day of operation to the day of discharge.

Hospital costs from the day of transplantation to the day of discharge were examined in a consecutive series of 53 patients who underwent orthotopic heart transplantation between October 1982 and February 1987. An accounting cost methodology was used to convert billable charges, to costs for 29 separate hospital cost centers. Total cost per case has shown a statistically significant decrease of over $30,000 with no indication of a change in patient selection or a decrease in 3-month survival. Most of the cost reductions occurred in five cost centers: operating room, blood and intravenous therapy, medical supplies, heart station, and routine services, as evidenced by decreases in wages and supplies. The results support the premise that new technologies can become more cost-efficient over time and suggest that as the medical team becomes more proficient and experienced, cost reductions can become a reality.

Reducing the costs of patient transfers.

This study examined the potential cost savings of a new patient transfer device that uses air pressure to assist in the movement of patients. The analysis for a single hospital indicates that this new technology is no less expensive than traditional patient transfer methods if only the direct costs of staff utilization are considered. However, reductions are projected for indirect costs associated with work-related back injuries. A methodology is recommended for conducting similar evaluations at other institutions.

An analysis of reimbursement for outpatient medical care in an urban hospital emergency department.

The investigators examined the demographic and clinical factors associated with the collection experience in a series of 786 patients who were treated in an urban hospital emergency department (ED) but not admitted to the hospital. They found that 57% of the total net charge of $150,489 had been paid within 180 days. This rate can be compared with an average inpatient collection rate of 85% at 180 days. Seven factors were found to account for the collection rate variation, making up 38.4% of the total variation. Age, gender, primary diagnosis, season of visit, time of arrival, and residence were not found to be main contributors. Insufficient collection rates may be an indication that EDs increasingly are becoming a financial risk to hospitals. The hospital's collection experience will become more important as an indicator of financial risk if the costs of operating EDs continue to escalate and collection rates do not improve. Both the costs of providing a service and the amount of the charge actually collected are valid concerns to those operating EDs.