Risk-assessment scores, prevention strategies, and the incidence of pressure ulcers among the elderly in four Canadian health-care facilities.

The accurate prediction of pressure ulcer (PU) development among hospitalized elderly patients is a complex endeavour. A prospective, longitudinal, cohort study of 330 patients over age 65 in 2 Canadian tertiary-care teaching hospitals and 2 long-term-care facilities examined the association between risk-assessment scores, prevention strategies, and PU incidence. The overall PU incidence rate was 9.7%, with half of the subjects who developed a PU doing so in the first week of hospitalization. The incidence rate for "at risk" patients (10.1%) was similar to the rate for "not at risk" patients (9.3%). The number of prevention strategies used was related to risk-assessment scores and to PU development. Paradoxically, the incidence rate increased with the number of prevention strategies employed. The total risk-assessment score that appeared to have the best balance of sensitivity (69%) and specificity (55%) was 19. Four of the 6 risk-assessment subscales were associated with PU development. Logistic regression modelling confirmed the univariate results that the number of prevention strategies used was the best single predictor of PU development. The data confirm that predicting PU development for individual patients is difficult at best. Results suggest that use of a risk-assessment scale alone is not sufficient to accurately predict PU development. The clinical judgement and experience of nurses are required in providing supplementary information to standard measurement instruments.

Arthroscopic transglenoid multiple suture repair: 2 to 8 year results in 150 shoulders.

One hundred fifty-six arthroscopic transglenoid multiple suture repairs were performed for chronic anterior shoulder instability. In 150 shoulders (96% follow-up), the outcome with respect to recurrence of instability and the Bankart Score was determined a minimum of 2 years and a mean of 4.1 years after surgery (range, 2 to 8.2 years). During the follow-up interval, 11 shoulders (7.3%) redislocated. Fourteen other shoulders (9.3%) had at least one episode that we interpreted as recurrent subluxation. Shoulders with a Bankart lesion and younger patients had a higher probability of recurrent instability (P < .05). We concluded that this method is most effective in shoulders without a Bankart lesion and in patients older than 25 years of age (regardless of pathology).

Totally laparoscopic aortobifemoral bypass grafting in an experimental model: description of technique with initial surgical results.

Our aim was to examine the feasibility of a totally laparoscopic insertion of a bifurcated aortofemoral bypass graft in a canine model and to compare the surgical results with those in control animals undergoing standard grafting and laparoscopic-assisted bypass procedures. Using a six-port approach, we exposed and cross clamped the aorta, tunneled a bifurcated Dacron graft, and performed an end-to-end aortic anastomosis while maintaining pneumoperitoneum by means of CO2. Proximal anastomoses were performed with 4/0 double-ended continuous Prolene sutures and distal anastomoses were performed through standard groin incisions. Total operating and aortic cross-clamp times were measured as was the total blood loss for each procedure. Clinical outcome was also documented. Eight female laboratory-bred hounds underwent successful totally laparoscopic aortobifemoral bypass grafting, eight underwent "open" grafting, and eight underwent laparoscopic-assisted bypass. Mean operating time was 193 minutes in the animals undergoing totally laparoscopic insertion vs. 156 minutes in the open group and 180 minutes in the laparoscopic-assisted group. Aortic cross-clamping time was also significantly longer at 87 minutes vs. 43 minutes (p < 0.001) in the totally laparoscopic group, but blood loss was less. All eight laparotomy and laparoscopic-assisted dogs were still alive with no complications at 28 days, whereas three of the eight in the totally laparoscopic group showed evidence of temporary paraplegia. This experimental study demonstrates that a totally laparoscopic approach can be used to insert a bifurcated aortofemoral bypass with a proximal end-to-end anastomosis but currently does not save time and may increase the risk of neurologic complications.

Impact of arterial surgery and balloon angioplasty on amputation: a population-based study of 1155 procedures between 1973 and 1992.

BACKGROUND: Limited population-based data are available on trends in the incidence of arterial surgery, balloon angioplasty, and amputation for arterial occlusive disease of the legs over the past two decades. METHODS: We identified all elective and emergency arterial operations, balloon angioplasty procedures, and amputations performed for all residents of a defined community, Olmsted County, Minn., between 1973 and 1992. We focused on gender mix, type of procedure, and secular trends in utilization. RESULTS: A total of 1155 procedures were performed, including 733 arterial surgical procedures, 59 balloon angioplasty procedures, and 363 amputations (288 major and 75 minor). Emergency procedures were performed in 12%. Suprainguinal inflow procedures were the most common arterial reconstruction (60%) compared with infrainguinal procedures (40%). The incidence of all revascularization procedures increased in the first decade but reached a plateau after 1985. Utilization rates of revascularization procedures from 1988 to 1992 were higher for men (141.9/100,000 person-years [p-yr]) than women (57.4/100,000 p-yr.). Angioplasty (17.0/100,000 p-yr) rates lagged behind surgery until 1985, but tripled in the past 10 years and have not yet reached a plateau. Although minor amputation rates remain unchanged in 20 years, major amputation rates have been reduced by 50% from 36.7/100,000 p-yr between 1973 and 1977 to 19.0/100,000 p-yr from 1988 to 1992. CONCLUSIONS: From this long-term population-based analysis (1973 to 1992), we conclude that increased vascular surgery and balloon angioplasty rates have coincided with a significant reduction in major amputation rates in the past 10 years.

Improved prognosis of thoracic aortic aneurysms: a population-based study.

CONTEXT: Managing thoracic aortic aneurysms identified incidentally by increased use of computed tomography, echocardiography, and magnetic resonance imaging is problematic, especially in the elderly. OBJECTIVE: To ascertain whether the previously reported poor prognosis for individuals with thoracic aortic aneurysms has changed with better medical therapies and improved surgical techniques that can now be applied to aneurysm management. DESIGN: Population-based cohort study. SETTING AND PATIENTS: All 133 patients with the diagnosis of degenerative thoracic aortic aneurysms among Olmsted County, Minnesota, residents between 1980 and 1994 compared with a previously reported cohort of similar patients between 1951 and 1980. MAIN OUTCOME MEASURES: The primary clinical end points were incidence, cumulative rupture risk, rupture risk as a function of aneurysm size, and survival. RESULTS: In contrast to abdominal aortic aneurysms, for which men are affected predominately, 51% of thoracic aortic aneurysms were identified in women who were considerably older at recognition than men (mean age, 75.9 vs 62.8 years, respectively; P= .01). The overall incidence rate of 10.4 per 100000 person-years (95% confidence interval [CI], 8.6-12.2) between 1980 and 1994 was more than 3-fold higher than the rate from 1951 to 1980. The cumulative risk of rupture was 20% after 5 years. Seventy-nine percent of ruptures occurred in women (P= .01). The 5-year risk of rupture as a function of aneurysm size at recognition was 0% for aneurysms less than 4 cm in diameter, 16% (95% CI, 4%-28%) for those 4 to 5.9 cm, and 31% (95% CI, 5%-56%) for aneurysms 6 cm or more. Overall 5-year survival improved to 56% (95% CI, 48%-66%) between 1980 and 1994 compared with only 19% between 1951 and 1980 (P<.01). CONCLUSIONS: In this population, elderly women represent an increasing portion of all patients with clinically recognized thoracic aortic aneurysms and constitute the majority of patients whose aneurysm eventually ruptures. Overall survival for thoracic aortic aneurysms has improved significantly in the past 15 years.

Comparison of North American Symptomatic Carotid Endarterectomy Trial and population-based outcomes for carotid endarterectomy.

PURPOSE: The North American Symptomatic Carotid Endarterectomy Trial (NASCET) advocated the use of carotid endarterectomy (CEA) for transient ischemic attacks (TIAs), nondisabling strokes, and ipsilateral high-grade stenosis in highly selected patients. Whether similar results are achieved when CEA is applied to an entire geographically defined population is unknown but important if the NASCET recommendations are to be applied broadly to all community patients. METHODS: To determine the survival rate to ipsilateral stroke after CEA for all symptomatic patients in a defined population, we reviewed the medical records of all patients residing in Olmsted County, Minn. (approximately 100,000), who underwent a CEA for TIA or nondisabling stroke between 1970 and 1995. Their outcomes were compared with the NASCET results. RESULTS: In the community of Olmsted County, 297 patients (108 women and 189 men) underwent 322 CEAs during the study period. TIAs or nondisabling stroke was the indication in 254 patients (86%), whereas the remaining 14% had asymptomatic stenosis. After CEA for symptomatic lesions, survival rate free of ipsilateral stroke was 97% at 2 years, 93% at 5 years, and 92% at 10 years. These results are similar to the NASCET survival rates free of ipsilateral stroke at 2 years (91%). However, the 30-day postoperative stroke rate for patients older than 80 years was significantly higher than that for patients younger than 80 years. CONCLUSIONS: When the NASCET results are compared with a population-based experience in which all symptomatic patients undergoing CEA were analyzed, the early outcomes were similar. Our population-based data also document the remarkably durable long-term results of CEA in preventing stroke and present another benchmark for carotid stent angioplasty.