Anesthesia and Poliomyelitis: A Matched Cohort Study.

BACKGROUND: Poliomyelitis is a viral infectious disease caused by 1 of the 3 strains of poliovirus. The World Health Organization launched an eradication campaign in 1988. Although the number of cases of poliomyelitis has drastically declined, eradication has not yet been achieved, and there are a substantial number of survivors of the disease. Survivors of poliomyelitis present a unique set of challenges to the anesthesiologist. The scientific literature regarding the anesthetic management of survivors of poliomyelitis, however, is limited and primarily experiential in nature. Using a retrospective, matched cohort study, we sought to more precisely characterize the anesthetic implications of poliomyelitis and to determine what risks, if any, may be present for patients with a history of the disease. METHODS: Using the Mayo Clinic Life Sciences System Data Discovery and Query Builder, study subjects were identified as those with a history of paralytic poliomyelitis who had undergone major surgery at Mayo Clinic Rochester between 2005 and 2009. For each case, 2 sex- and age-matched controls that underwent the same surgical procedure during the study period were randomly selected from a pool of possible controls. Medical records were manually interrogated with respect to demographic variables, comorbid conditions, operative and anesthetic course, and postoperative course. RESULTS: We analyzed 100 cases with 2:1 matched controls and found that the peri- and postoperative courses were very similar for both groups of patients. Pain scores, postanesthesia care unit admission, length of postanesthesia care unit stay, intensive care unit admission, length of intensive care unit stay, and initial extubation location were not significantly different between the 2 groups. Looking at pulmonary complications in our primary outcome, there was no significant difference between the 2 groups (17% vs 14% for polio versus control, respectively; conditional logistic regression odds ratio = 1.5; 95% confidence interval, 0.7-3.3; P = 0.33). In addition, no difference was noted in those requiring a code or rapid response team intervention (4% vs 3% for polio versus control; P = 0.46) and the 30-day mortality rate was also not significantly different, with 2% of polio patients dying compared with 3% of controls (P = 0.79). The analysis of the primary outcome was repeated for the subset of patients with a history of poliomyelitis who had persistent neurologic deficits preoperatively (n = 36) and their matched controls (n = 72). In this subset analysis, there were 4 (11%) polio patients and 8 (11%) control patients who experienced pulmonary complications (conditional logistic regression odds ratio = 1.00; 95% confidence interval, 0.27-3.72; P = 1.00). The percentage of patients experiencing specific pulmonary complications of interest was similar between groups (postoperative mechanical ventilation: 6% vs 8% for polio and control patients, respectively; prolonged mechanical ventilation: 0% vs 1%; reintubation: 8% vs 4%; pulmonary infection: 6% vs 6%; and aspiration: 0% vs 1%). CONCLUSIONS: This study suggests that patients with a history of poliomyelitis do not seem to have an increased risk of pulmonary complications in the perioperative period. However, an odds ratio as great as 3.3-fold may be present.

Neuraxial labor analgesia for vaginal delivery and its effects on childhood learning disabilities.

BACKGROUND: In prior work, children born to mothers who received neuraxial anesthesia for cesarean delivery had a lower incidence of subsequent learning disabilities compared with vaginal delivery. The authors speculated that neuraxial anesthesia may reduce stress responses to delivery, which could affect subsequent neurodevelopmental outcomes. To further explore this possibility, we examined the association between the use of neuraxial labor analgesia and development of childhood learning disabilities in a population-based birth cohort of children delivered vaginally. METHODS: The educational and medical records of all children born to mothers residing in the area of 5 townships of Olmsted County, Minnesota from 1976 to 1982 and remaining in the community at age 5 years were reviewed to identify those with learning disabilities. Cox proportional hazards regression was used to compare the incidence of learning disabilities between children delivered vaginally with and without neuraxial labor analgesia, including analyses adjusted for factors of either potential clinical relevance or that differed between the 2 groups in univariate analysis. RESULTS: Of the study cohort, 4684 mothers delivered children vaginally, with 1495 receiving neuraxial labor analgesia. The presence of childhood learning disabilities in the cohort was not associated with use of labor neuraxial analgesia (adjusted hazard ratio, 1.05; 95%confidence interval, 0.85-1.31; P = 0.63). CONCLUSION: The use of neuraxial analgesia during labor and vaginal delivery was not independently associated with learning disabilities diagnosed before age 19 years. Future studies are needed to evaluate potential mechanisms of the previous finding indicating that the incidence of learning disabilities is lower in children born to mothers via cesarean delivery under neuraxial anesthesia compared with vaginal delivery.

Performance improvement system and postoperative corneal injuries: incidence and risk factors.

BACKGROUND: The authors' department conducted a performance improvement initiative aimed to reduce the rate of perioperative corneal injuries. This study reports the effects of the initiative and examines the risk factors for corneal injury. METHOD: The rate of corneal injuries during nonophthalmologic procedures under anesthesia was compared between the two time periods: preinitiative baseline (August 1, 2005-December 31, 2005) and initiative period (January 1, 2006-April 30, 2007). To examine the risk factors for corneal injury, a nested case-control study with a 2:1 matched-set design was separately performed and included cases between January 1, 2006 and July 31, 2008. RESULTS: During the baseline period, the corneal injury rate was 1.51 per 1,000, and it decreased to 0.79 per 1,000 during the performance initiative (P = 0.008). Independent risk factors were longer anesthetics (odds ratio = 1.2, 95% confidence interval (CI) 1.1-1.3 per 30 min), lower American Society of Anesthesiologists physical status (odds ratio 0.5, 95% CI 0.3-0.8 for American Society of Anesthesiologists physical status 3-4 vs. 1-2), and student nurse anesthetist as a primary anesthesia provider (odds ratio 2.6, 95% CI 1.3-5.0). CONCLUSION: Corneal injury rate in our institution was significantly reduced and remains at low levels long after initiation of perioperative eye care improvement initiative. The higher rate of corneal injuries among student nurse anesthetists highlights the importance of standardizing education and supervision among all anesthesia providers. We believe that our model of performance improvement initiative can be used to improve other perioperative outcomes.

An emerging model of primary care for older adults: the house call-home care practice.

House calls to older adults have become more common, in part related to the emergence of medical practices that either emphasize or exclusively provide house calls. In this article we seek to describe organizational, clinician, and patient characteristics of house call-home medical care practices in the United States. We conducted telephone interviews with clinicians representing 36 randomly selected practices from across the United States. This study found that house call-home care practices typically are recently formed small groups of physicians and nurse practitioners that provide in-home primary care, especially chronic disease care, to Medicare beneficiaries. Clinicians are motivated by the opportunity to improve care and to maintain autonomy. This emerging model may represent a mutually beneficial trend for older adults and physicians.

The impact of minimally invasive techniques on open partial nephrectomy: a 10-year single institutional experience.

PURPOSE: With the advent of minimally invasive, nephron sparing surgical options we hypothesized that the indications, perioperative parameters and complication rates of open partial nephrectomy may have changed significantly during a 10-year period. MATERIALS AND METHODS: Open partial nephrectomy was compared during 2, 3-year periods. From 1994 to 1996 (before laparoscopic partial nephrectomy, cryoablation and radio frequency ablation) 208 cases were compared vs 347 open partial nephrectomies performed from 2004 to 2006 with regard to indications, perioperative parameters and complication rates. RESULTS: There were no significant differences between the groups with regard to age (59 vs 58 years), gender (65.5% vs 65.0% male) and tumor size (3.9 vs 3.6 cm). Tumors removed in the recent era were more often in a solitary kidney (40.0% vs 15.6%) and centrally located (55.6% vs 37.3%), and pathological evaluation more often revealed higher grade (Fuhrman 3 or 4) (43.1% vs 27.8%, each p <0.0001). Despite increased technical difficulty ischemia time in the more recent era was shorter (19.1 vs 40.6 minutes, p = 0.0000), and the urological and overall complication rates were statistically similar (7.5% vs 8.9%, p = 0.6071 and 19.1% vs 14.4%, p = 0.1723, respectively). CONCLUSIONS: At a tertiary referral center the introduction of minimally invasive, nephron sparing surgical techniques has drawn away less complicated, less aggressive tumors, reserving the bulk of more complicated central tumors for open partial nephrectomy without decreasing the total number of open cases. With experience these more difficult central tumors are being successfully treated with decreased warm ischemia time and complication rates that are comparable to those in historical series.

Underdiagnosis of hypertension in children and adolescents.

CONTEXT: Pediatric hypertension is increasing in prevalence with the pediatric obesity epidemic. Diagnosis of hypertension in children is complicated because normal and abnormal blood pressure values vary with age, sex, and height and are therefore difficult to remember. OBJECTIVES: To determine the frequency of undiagnosed hypertension and prehypertension and to identify patient factors associated with this underdiagnosis. DESIGN, SETTING, AND PARTICIPANTS: A cohort study of 14,187 children and adolescents aged 3 to 18 years who were observed at least 3 times for well-child care between June 1999 and September 2006 in the outpatient clinics in a large academic urban medical system in northeast Ohio. For children and adolescents who met criteria for hypertension or prehypertension at 3 or more well-child care visits, the proportion with a hypertension-related International Classification of Diseases, Ninth Revision code in the diagnoses list, problem list, or past medical history list of any visit was determined. MAIN OUTCOME MEASURES: Proportion of children and adolescents with 3 or more elevated age-adjusted and height-adjusted blood pressure measurements at well-child care visits and with a diagnosis of hypertension or prehypertension documented in the electronic medical record. Multivariate logistic regression identified patient factors associated with a correct diagnosis. RESULTS: Of 507 children and adolescents (3.6%) who had hypertension, 131 (26%) had a diagnosis of hypertension or elevated blood pressure documented in the electronic medical record. Patient factors that increased the adjusted odds of a correct diagnosis were a 1-year increase in age over age 3 (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.03-1.16), number of elevated blood pressure readings beyond 3 (OR, 1.77; 95% CI, 1.21-2.57), increase of 1% in height-for-age percentile (OR, 1.02; 95% CI, 1.01-1.03), having an obesity-related diagnosis (OR, 2.61; 95% CI, 1.49-4.55), and number of blood pressure readings in the stage 2 hypertension range (OR, 1.68; 95% CI, 1.29-2.19). Of 485 children and adolescents (3.4%) who had prehypertension, 55 (11%) had an appropriate diagnosis documented in the electronic medical record. Patient factors that increased the adjusted odds of being diagnosed with prehypertension included a 1-year increase in age over age 3 (OR, 1.21; 95% CI, 1.09-1.34) and number of elevated blood pressure readings beyond 3 (OR, 3.07; 95% CI, 2.20-4.28). CONCLUSIONS: Hypertension and prehypertension were frequently undiagnosed in this pediatric population. Patient age, height, obesity-related diagnoses, and magnitude and frequency of abnormal blood pressure readings all increased the odds of diagnosis.

Limited pelvic lymph node dissection does not improve biochemical relapse-free survival at 10 years after radical prostatectomy in patients with low-risk prostate cancer.

OBJECTIVES: To compare the long-term differences in actuarial biochemical relapse-free survival rates from a contemporary series of patients who underwent radical prostatectomy with and without pelvic lymph node dissection (PLND). METHODS: The records of 806 consecutive radical prostatectomy cases performed from January 1995 to June 1999 were reviewed. The entire subset of patients (n = 336) with low-risk disease, defined by a prostate-specific antigen level of 10 ng/mL or less, biopsy Gleason score of 6 or less, and clinical Stage T1 or T2a, who had not received adjuvant or neoadjuvant therapy were divided into two groups according to whether PLND was performed (PLND group, n = 140) or omitted (no-PLND group, n = 196). A Cox proportional hazards model was used to analyze the effect of demographic, pretreatment, surgical, and pathologic factors on the likelihood of biochemical failure. Biochemical relapse-free survival for each group was estimated by Kaplan-Meier analysis. The median prostate-specific antigen follow-up time for the entire group was 89.0 months, with a similar follow-up for both cohorts (PLND group 94.5 months and no-PLND group 88.0 months, Mann-Whitney U test, P = 0.14). RESULTS: The long-term biochemical relapse-free survival rate for the entire cohort was 86.1% at 10 years. The 10-year actuarial biochemical relapse-free rate for the PLND and no-PLND groups was 83.8% and 87.9%, respectively (log-rank, P = 0.33). On univariate analysis, PLND was not an independent predictor of outcome (Wald, P = 0.33). CONCLUSIONS: The results of our study have shown that the omission of limited PLND in patients with favorable tumor characteristics does not adversely affect biochemical relapse-free survival at 10 years. Such patients can be spared the morbidity and cost of PLND without affecting their chance for cure.

Underdiagnosis of pediatric hypertension-an example of a new era of clinical research enabled by electronic medical records.

Previously, large scale clinical research required large budgets, significant staff, and long periods of time. Typically most of these resources were spent on data collection to develop electronic research databases. With the proliferation of electronic medical records this clinical research paradigm changes. Here we present a large clinical study of pediatric hypertension (14,187 patients) conducted through an electronic medical record without any budget and within about 70 hours over 6 months.