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Biomedical subjects

J Daley

Publications and source records attributed to J Daley.

At least 37 records · Page 2Linked to original sources
PubMed2000

Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program.

OBJECTIVE: To develop and validate a preoperative risk index for predicting postoperative respiratory failure (PRF). SUMMARY BACKGROUND DATA: Respiratory failure is an important postoperative complication. METHOD: Based on a prospective cohort study, cases from 44 Veterans Affairs Medical Centers (n = 81,719) were used to develop the models. Cases from 132 Veterans Affairs Medical Centers (n = 99,390) were used as a validation sample. PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation. Ventilator-dependent, comatose, do not resuscitate, and female patients were excluded. RESULTS: PRF developed in 2,746 patients (3.4%). The respiratory failure risk index was developed from a simplified logistic regression model and included abdominal aortic aneurysm repair, thoracic surgery, neurosurgery, upper abdominal surgery, peripheral vascular surgery, neck surgery, emergency surgery, albumin level less than 30 g/L, blood urea nitrogen level more than 30 mg/dL, dependent functional status, chronic obstructive pulmonary disease, and age. CONCLUSIONS: The respiratory failure risk index is a validated model for identifying patients at risk for developing PRF and may be useful for guiding perioperative respiratory care.

Aged↗
PubMed2000

Changing demographic characteristics of women veterans: results from a national sample.

Women veterans are a small but growing percentage of the U.S. veteran population. There are some indications that, along with this increase, the characteristics and military experiences of younger women veterans differ considerably from those of older colleagues. Many of these characteristics are not well defined, but they could have implications for women's health care needs and health policy initiatives. Using the first sample drawn from the Department of Veterans Affairs' new National Registry of Women Veterans, we designed and administered a telephone survey to a representative sample of women veterans across several major age groups. Groups approximated primary eras of military and wartime service based on the assumption that different eras might be associated with differing military experiences. We found a number of age-related similarities and differences in women veterans' demographic characteristics, military experiences, physical health symptoms, and functional outcomes. Women veterans in general also differed from female civilian counterparts on exposure to sexual trauma. Trends in the population of women veterans are likely to have implications for the variety of health care systems that treat women veterans.

Adult↗
PubMed1999

Inactivation of misselected CD8 T cells by CD8 gene methylation and cell death.

Misselected CD8 cells that express T cell receptors (TCRs) that do not recognize class I major histocompatibility complex (MHC) protein can emerge from thymic selection. A postthymic quality control mechanism that purges these cells from the repertoire is defined here. The failure of mature CD8 cells to simultaneously engage their TCR and CD8 coreceptor triggers an activation process that begins with inhibition of CD8 gene expression through remethylation and concludes with up-regulation of surface Fas and Fas ligand and cellular apoptosis. Thus, inhibition of a death signal through continued TCR-CD8 coengagement of MHC molecules is a key checkpoint for the continued survival of correctly selected T cells. Molecular defects that prevent delivery of the death signal to mistakenly selected T cells underlie the expansion of double-negative T cells, which is the cellular signature of a subset of systemic autoimmune diseases.

Adoptive Transfer↗
PubMed1999

Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study.

OBJECTIVE: To improve the precision and reliability of estimates of the association between preoperative serum albumin concentration and surgical outcomes. DESIGN: Prospective observational study. Patients were followed up for 30 days postoperatively. Multiple logistic regression models were developed to evaluate serum albumin level as a predictor of operative mortality and morbidity in relation to 61 other preoperative patient risk variables. SETTING: Forty-four tertiary care Veterans Affairs (VA) medical centers. PATIENTS: A total of 54215 major noncardiac surgery cases from the National VA Surgical Risk Study. MAIN OUTCOME MEASURES: Thirty-day operative mortality and morbidity. RESULTS: A decrease in serum albumin from concentrations greater than 46 g/L to less than 21 g/L was associated with an exponential increase in mortality rates from less than 1% to 29% and in morbidity rates from 10% to 65%. In the regression models, albumin level was the strongest predictor of mortality and morbidity for surgery as a whole and within several subspecialties selected for further analysis. Albumin level was a better predictor of some types of morbidity, particularly sepsis and major infections, than other types. CONCLUSIONS: Serum albumin concentration is a better predictor of surgical outcomes than many other preoperative patient characteristics. It is a relatively low-cost test that should be used more frequently as a prognostic tool to detect malnutrition and risk of adverse surgical outcomes, particularly in populations in whom comorbid conditions are relatively frequent.

Female↗
PubMed1999

Prognostic models of thirty-day mortality and morbidity after major pulmonary resection.

BACKGROUND: A part of the prospective, multi-institutional National Veterans Affairs Surgical Quality Improvement Program was developed to predict 30-day mortality and morbidity for patients undergoing a major pulmonary resection. METHODS: Perioperative data were acquired from 194,319 noncardiac surgical operations at 123 Veterans Affairs Medical Centers between October 1, 1991, and August 31, 1995. Current Procedural Terminology code-based analysis was undertaken for major pulmonary resections (lobectomy and pneumonectomy). Preoperative, intraoperative, and outcome variables were collected. The 30-day mortality and morbidity models were developed by means of multivariable stepwise logistic regression with the preoperative and intraoperative variables used as independent predictors of outcome. RESULTS: A total of 3516 patients (mean age 64 9 years) underwent either lobectomy (n = 2949) or pneumonectomy (n = 567). Thirty-day mortality was 4.0% for lobectomy (119/2949) and 11.5% for pneumonectomy (65/567). The preoperative predictors of 30-day mortality were albumin, do not resuscitate status, transfusion of more than 4 units, age, disseminated cancer, impaired sensorium, prothrombin time more than 12 seconds, type of operation, and dyspnea. When the intraoperative variables were considered, intraoperative blood loss was added to the preoperative model. In the presence of these intraoperative variables in the model, do not resuscitate status and prothrombin time more than 12 seconds were only marginally significant. Thirty-day morbidity, defined as the presence of 1 or more of the 21 predefined complications, was 23.8% for lobectomy (703/2949) and 25.7% for pneumonectomy (146/567). In multivariable models, independent preoperative predictors (P <.05) of 30-day morbidity were age, weight loss greater than 10% in the 6 months before surgery, history of chronic obstructive pulmonary disease, transfusion of more than 4 units, albumin, hemiplegia, smoking, and dyspnea. When intraoperative variables were added to the preoperative model, the duration of operation time and intraoperative transfusions were included in the model and albumin became marginally significant. CONCLUSIONS: This analysis identifies independent patient risk factors that are associated with 30-day mortality and morbidity for patients undergoing a major pulmonary resection. This series provides an initial risk-adjustment model for major pulmonary resections. Future refinements will allow comparative assessment of surgical outcomes and quality of care at many institutions.

Adult↗
PubMed1999

Racial variation in the use of laparoscopic cholecystectomy in the Department of Veterans Affairs medical system.

BACKGROUND: While studies have found racial differences in the rates of use of established invasive cardiac and cerebrovascular procedures, no study has evaluated racial variation in the rates of adoption of new surgical procedures. For patients undergoing laparoscopic cholecystectomy, the procedure represents a new and safe option that shortens the duration of postoperative hospitalization by almost one week. In this study, we evaluated whether, in the equal access Veterans Affairs (VA) medical system, the rate of adoption of this procedure and improvements in the duration of postoperative hospitalization differed between African-American and Caucasian patients. STUDY DESIGN: Data were obtained from two sources-administrative claims files and prospectively compiled dinical data from medical records and patient interviews. In both data sets, frequency of use, length of stay, and outcomes for African-American and Caucasian patients undergoing minimally invasive and open gallbladder surgery were analyzed for the first four years of use of the procedure in the VA system (1992 to 1995). RESULTS: Analyses based on claims files indicated that, after adjustment for potentially confounding variables, African-American patients who underwent cholecystectomy in VA medical centers were 25% less likely to undergo a minimally invasive cholecystectomy during the first 4 years of use of the new procedure (adjusted odds ratio, 0.74; 95% confidence interval, 0.66-0.83). Shortening of the average postoperative length of stay from 9 days or more in the prelaparoscopic era to less than 4.5 days for patients undergoing the laparoscopic procedure occurred in the first year for Caucasian patients, but did not occur until the fourth year for African-American patients (p<0.001). The overall difference in postoperative length of stay between African-American and Caucasian patients more than doubled from 1.7 days before introduction of laparoscopic cholecystectomy to 3.8 days in the fourth year. In comparison, analyses based on nurse-compiled clinical data indicated that, after adjustment for relevant clinical factors, racial variations in the rate of laparoscopic surgery were even larger (adjusted odds ratio for laparoscopic versus open cholecystectomy for African-American versus Caucasian veterans, 0.68; 95% confidence interval, 0.55-0.84). CONCLUSIONS: Compared to Caucasian patients, African-American patients who underwent cholecystectomy in VA medical centers had an approximately 25% to 32% lower likelihood of undergoing minimally invasive cholecystectomy procedures. The differences in rates of adoption of laparoscopic surgery did not appear to be from more comorbid illnesses among African-American patients. African-American and Caucasian veterans may differ in their preference for new surgical procedures like laparoscopic cholecystectomy. Conversely, VA physicians may have been less likely to recommend laparoscopic cholecystectomies to African-American patients.

Adult↗
PubMed1999

Positive predictive value of the diagnosis of acute myocardial infarction in an administrative database.

OBJECTIVE: To determine the positive predictive value of ICD-9-CM coding of acute myocardial infarction and cardiac procedures. METHODS: Using chart-abstracted data as the standard, we examined administrative data from the Veterans Health Administration for a national random sample of 5,151 discharges. MAIN RESULTS: The positive predictive value of acute myocardial infarction coding in the primary position was 96.9%. The sensitivity and specificity of coding were, respectively, 96% and 99% for catheterization, 95.7% and 100% for coronary artery bypass graft surgery, and 90.3% and 99. 7% for percutaneous transluminal coronary angioplasty. CONCLUSIONS: The positive predictive value of acute myocardial infarction and related procedure coding is comparable to or better than previously reported observations of administrative databases.

Aged↗
PubMed1999

A preliminary investigation of alternatives to fumagillin for the treatment of Loma salmonae infection in rainbow trout.

The effects of the following six treatments against Loma salmonae, a microsporidian gill pathogen, were examined in rainbow trout: fumagillin (high dose), pyrimethamine + sulphaquinoxaline, albendazole, amprolium, fumagillin (low dose), and metronidazole. The fish were infected by mouth and the treatments were administered at intervals for a period of several weeks. The results were assessed on the basis of (1) delay in the formation of xenomas, and (2) the number of xenomas per gill arch. The first five treatments, in descending order of efficacy, delayed the formation of xenomas (P<0.01), but metronidazole had no such effect. Fumagillin (high or low dose) and albendazole both reduced the number of xenomas present 10 weeks after infection (P<0.01), but the other three treatments did not do so. From these results, both fumagillin and albendazole appeared to be of potential value in controlling L. salmonae infection in trout.

Albendazole↗
PubMed1999

Risk factors for prolonged length of stay after major elective surgery.

OBJECTIVE: Length of stay (LOS) is an important outcome as a marker of resource consumption. Determining which factors increase LOS may provide information on reducing costs and improving the delivery of care. The purpose of this study was to determine the independent association of intraoperative process of care and postoperative events with prolonged LOS after adjusting for preoperative severity of illness in patients undergoing major elective surgery. METHODS: Cases representing 11 elective operations from the National VA Surgical Quality Improvement Program were analyzed using multivariate logistic regression analysis. The outcome, prolonged LOS, was defined as an LOS greater than or equal to the 75th percentile (in days) for each operation. Hierarchical modeling was used to assess the independent association of groups of variables (preoperative patient characteristics, intraoperative process of care, and postoperative adverse events) with prolonged LOS. RESULTS: For the 11 operations explored, there were 23,919 cases. Common preoperative variables associated with prolonged LOS were functional status, American Society of Anesthesiology class, and age. The most predictive intraoperative and postoperative variables included intraoperative blood transfusion, operative time, return to the operating room, and the number of complications after surgery. CONCLUSIONS: Prolonged LOS is associated with preoperative, intraoperative, and postoperative factors. Although preoperative factors were independently associated with a prolonged LOS, the factors generating the highest risks for a prolonged LOS were the intraoperative process of care and postoperative adverse events. To reduce costs, efforts should be made to improve the intraoperative process of care and to minimize postoperative complications.

Aged↗
PubMed1999

Relation of surgical volume to outcome in eight common operations: results from the VA National Surgical Quality Improvement Program.

OBJECTIVE: To examine, in the Veterans Health Administration (VHA), the relation between surgical volume and outcome in eight commonly performed operations of intermediate complexity. SUMMARY BACKGROUND DATA: In multihospital health care systems such as VHA, consideration is often given to closing low-volume surgical services, with the assumption that better surgical outcomes are achieved in hospitals with larger surgical volumes. Literature data to support this assumption in intermediate-complexity operations are either limited or controversial. METHODS: The VHA National Surgical Quality Improvement Program data on nonruptured abdominal aortic aneurysmectomy, vascular infrainguinal reconstruction, carotid endarterectomy (CEA), lung lobectomy/pneumonectomy, open and laparoscopic cholecystectomy, partial colectomy, and total hip arthroplasty were used. Pearson correlation, analysis of variance, mixed effects hierarchical logistic regression, and automatic interaction detection analysis were used to assess the association of annual procedure/specialty volume with risk-adjusted 30-day death (and stroke in CEA). RESULTS: Eight major surgical procedures (68,631 operations) were analyzed. No statistically significant associations between procedure or specialty volume and 30-day mortality rate (or 30-day stroke rate in CEA) were found. CONCLUSIONS: In VHA hospitals, the procedure and surgical specialty volume in eight prevalent operations of intermediate complexity are not associated with risk-adjusted 30-day mortality rate from these operations, or with the risk-adjusted 30-day stroke rate from CEA. Volume of surgery in these operations should not be used as a surrogate for quality of surgical care.

Adolescent↗
PubMed1999

Increasing use of Medicare services by veterans with acute myocardial infarction.

OBJECTIVES: Some of the nation's 26 million veterans have two government-financed health care entitlements: Medicare and the Department of Veterans Affairs (VA). The aims of this investigation were to examine trends where Medicare-eligible VA users are initially hospitalized for acute myocardial infarction (AMI) and then to assess rates of cardiac procedure use and mortality for veterans initially admitted to each system of care. METHODS: We used VA and HCFA national databases to identify VA users (age range, > or = 65 years) who were initially admitted to a VAMC or Medicare financed hospital (Medicare hospital) with a primary diagnosis of AMI between January 1, 1992, and December 31, 1995, (n = 47,598). We examined the use of cardiac procedures (cardiac catheterization [CC], coronary artery bypass surgery [CABG], and coronary angioplasty [CA] and mortality (30-day and 1-year) by the type of initial admitting hospital within each system of care. RESULTS: Almost 70% of VA users hospitalized for AMI were initially admitted to Medicare hospitals versus VAMCs between 1992 (64%) and 1995 (72%). After adjusting for patient characteristics in logistic models, VA users initially hospitalized in Medicare hospitals were significantly more likely to undergo cardiac procedures than were VA users hospitalized in VAMCs. Differences in the odds of receiving a procedure were most significant when comparing Medicare hospitals with on-site cardiac technology to VA hospitals without on-site cardiac technology (CC: OR 4.34, 95% CI 3.98-4.73; CABG: OR 2.16, 95% CI 1.92-2.43; CA: OR 4.56, 95% CI 3.98-5.25). We found no significant differences in 30-day and 1-year adjusted mortality rates between VA users initially admitted to VAMCs or Medicare hospitals. CONCLUSIONS: Medicare-eligible VA users are increasingly hospitalized in Medicare hospitals for AMI. VA users cared for in Medicare hospitals receive more cardiac procedures but have the same survival as VA users cared for in VAMCs. These findings have policy implications for access, quality, and costs in both systems of care.

Aged↗