Biomedical subjects

P Williams-Russo

Publications and source records attributed to P Williams-Russo.

8 recordsLinked to original sources

PubMed1995

Cognitive effects after epidural vs general anesthesia in older adults. A randomized trial.

OBJECTIVE: To compare the effect of epidural vs general anesthesia on the incidence of long-term cognitive dysfunction after total knee replacement surgery in older adults. DESIGN: Randomized controlled clinical trial. SETTING: Orthopedic specialty academic hospital. PATIENTS: A total of 262 patients undergoing elective primary total knee replacement with a median age of 69 years; 70% women. INTERVENTION: Random assignment to either epidural or general anesthesia. MAIN OUTCOME MEASURES: A thorough neuropsychological assessment was performed preoperatively and repeated at 1 week and 6 months postoperatively. Cognitive outcome was assessed by within-patient change on 10 tests of memory, psychomotor, and language skills. Prospective standardized surveillance for cardiovascular complications was performed to allow simultaneous assessment of anesthetic effects on cognitive and cardiovascular outcomes. RESULTS: The two groups were similar at baseline in terms of age, sex, comorbidity, and cognitive function. There were no significant differences between the epidural and general anesthesia groups in within-subject change from baseline on any of the 10 cognitive test results at either 1 week or 6 months. Overall, 5% of patients showed a long-term clinically significant deterioration in cognitive function. There was no difference between the anesthesia groups in the incidence of major cardiovascular complications (3% overall). CONCLUSIONS: The type of anesthesia, general or epidural, does not affect the magnitude or pattern of postoperative cognitive dysfunction or the incidence of major cardiovascular complications in older adults undergoing elective total knee replacement. This is the largest trial of the effects of general vs regional anesthesia on cerebral function reported to date, with more than 99% power to detect a clinically significant difference on any of the neuropsychological tests.

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PubMed1995

Clinical reproducibility of dual energy x-ray absorptiometry.

Dual energy x-ray absorptiometry is a technique advocated for the measurement of bone mass throughout the skeleton, and recently it has been used to measure changes in periprosthetic bone mass after joint replacement. The accuracy and precision of the method in clinical patient populations have not been firmly established. This study sought to establish the short-term reproducibility of measurements made with dual energy x-ray absorptiometry of multiple sites in a large sample of elderly patients with rheumatic disease. Reproducibility was assessed in the lumbar spine and in three femoral sites in 69 patients participating in a longitudinal clinical trial. In each patient, absorptiometry was performed twice in the same day at as many as five time points over a 2-year period. The mean (+/- SD) baseline bone density was 0.783 +/- 0.128 g/cm2 for the femoral neck and 1.015 +/- 0.218 g/cm2 for the lumbar spine. The correlations between the duplicate baseline measurements of the spine were excellent (r = 0.9936, p < 0.001) and were stable over the 2-year period; the mean difference between the duplicate baseline measurements was 1.82 +/- 1.54% and the mean coefficient of variation was 1.29%. Measurements in the femur were much less precise; these values were 3.61 +/- 3.14% and 2.55% in the femoral neck, 3.66 +/- 4.35% and 2.59% in the greater trochanter, and 5.28 +/- 5.61% and 3.73% in Ward's triangle. This study evaluated the short-term reproducibility of dual energy x-ray absorptiometry in a clinical population.(ABSTRACT TRUNCATED AT 250 WORDS)

Absorptiometry, Photon↗

PubMed1995

Improvement of outcomes after coronary artery bypass. A randomized trial comparing intraoperative high versus low mean arterial pressure.

BACKGROUND: The objective of this randomized clinical trial of elective coronary artery bypass grafting was to investigate whether intraoperative mean arterial pressure below autoregulatory limits of the coronary and cerebral circulations was a principal determinant of postoperative complications. The trial compared the impact of two strategies of hemodynamic management during cardiopulmonary bypass on outcome. Patients were randomized to a low mean arterial pressure of 50 to 60 mm Hg or a high mean arterial pressure of 80 to 100 mm Hg during cardiopulmonary bypass. METHODS: A total of 248 patients undergoing primary, nonemergency coronary bypass were randomized to either low (n = 124) or high (n = 124) mean arterial pressure during cardiopulmonary bypass. The impact of the mean arterial pressure strategies on the following outcomes was assessed: mortality, cardiac morbidity, neurologic morbidity, cognitive deterioration, and changes in quality of life. All patients were observed prospectively to 6 months after the operation. RESULTS: The overall incidence of combined cardiac and neurologic complications was significantly lower in the high pressure group at 4.8% than in the low pressure group at 12.9% (p = 0.026). For each of the individual outcomes, the trend favored the high pressure group. At 6 months after coronary bypass for the high and low pressure groups, respectively, total mortality rate was 1.6% versus 4.0%, stroke rate 2.4% versus 7.2%, and cardiac complication rate 2.4% versus 4.8%. Cognitive and functional status outcomes did not differ between the groups. CONCLUSION: Higher mean arterial pressures during cardiopulmonary bypass can be achieved in a technically safe manner and effectively improve outcomes after coronary bypass.

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PubMed1995

Changes in mortality after total hip and knee arthroplasty over a ten-year period.

A retrospective review of in-hospital mortality after total hip and total knee arthroplasty was performed to determine whether extensive changes in anesthesia care, introduced in this institution in July 1986, were associated with changes in mortality rates. From 1981 to 1985, the mortality rate was 0.39% (23 of 5874 patients) and from 1987 to 1991, the mortality rate was 0.10% (10 of 9685 patients) (P = 0.0003). Significant reductions in mortality rate were observed for both total hip arthroplasty (from 0.36% to 0.10%) (P = 0.0277) and total knee arthroplasty (from 0.44% to 0.10%) (P = 0.0131). The mortality rate of 0.10% is significantly less than previously published rates. Marked changes in anesthesia management were associated with a significant reduction in mortality after total hip and knee arthroplasty.

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PubMed1992

Using faculty consensus to develop and implement a medical ethics course.

This report describes the development and implementation of a new required course in medical ethics for second-year medical students at the Cornell University Medical College, 1988-89 and 1989-90. The course was specifically designed to teach students who had not yet started their clinical clerkships to think critically and systematically about ethical issues faced by practicing physicians. The goals, structure, and content of the course were developed using an innovative technique, a planning model involving faculty consensus. The faculty members found the planning sessions intellectually challenging and enjoyable, and reported that the sessions added greatly to their teaching of the course. The students' evaluations over the first two years of the course (with 188 of the 201 students--94%--responding) documented the students' satisfaction with the content and the structure of the course, and their belief that the course had achieved its goals. The authors conclude that the faculty's participation in the planning process was crucial to the success of the course.

Consensus↗

PubMed1992

Health services research in arthritis musculoskeletal disease.

This paper reviews recent studies in national patterns of disability related to arthritis, longitudinal studies of outcome in arthritis, the effects of the prospective payment system on outcomes of hip fracture patients, and recent studies of geographic variation in treatment of arthritis and musculoskeletal disease. It also reviews recent papers on clinimetric issues and advances in measuring disease activity.

Arthritis↗

PubMed1992

Post-operative delirium: predictors and prognosis in elderly orthopedic patients.

OBJECTIVE: To compare the effect of post-operative analgesia using epidural versus intravenous infusions on the incidence of delirium after bilateral knee replacement surgery in elderly patients. Additional risk factors and impact on post-operative recovery were also assessed. DESIGN: Prospective randomized controlled trial. SETTING: Urban referral hospital specializing in elective orthopedic surgery. PATIENTS: 60 consecutive patients undergoing bilateral knee replacement surgery with epidural anesthesia were approached; 51 patients were eligible and consented. The mean age was 68, 55% were women, and there was a high prevalence of comorbid medical disease. No patient was demented pre-operatively. INTERVENTION: Random allocation to either continuous epidural infusion of bupivacaine and fentanyl or continuous intravenous infusion of fentanyl. Infusions were initiated at the first complaint of pain and continued through the 36- to 48-hour stay in the recovery room. MAIN OUTCOME MEASURE: Acute post-operative delirium defined using an algorithm based on DSM III criteria. RESULTS: The overall incidence of acute delirium was 41%, with no difference between types of post-operative analgesia. Predictors of delirium were age, gender, and pre-operative alcohol use. All cases resolved within 1 week, and length of stay and achievement of physical therapy goals were the same for delirious and non-delirious patients. CONCLUSIONS: There is a high incidence of post-operative delirium in elderly non-demented patients following bilateral knee replacement, regardless of whether post-operative analgesia is administered by the epidural or intravenous route.

Age Factors↗

PubMed1992

Predicting postoperative pulmonary complications. Is it a real problem?

To identify predictors of postoperative pulmonary complications, a population of 278 patients, mainly hypertensive and diabetic patients undergoing elective general surgery was studied; 60% of the patients underwent abdominal surgery. Of the 278 patients, 6% had postoperative pulmonary complications: 3% had radiographic evidence of infiltrates or segmental atelectasis and 3% had clinical evidence of atelectasis. Among the two thirds of patients undergoing abdominal surgery, only patients with underlying asthma or chronic bronchitis were at increased risk. Generally, patients with better exercise tolerance by self-report, walking distance, or cardiovascular classification had lower rates. Pulmonary function tests did not help to delineate patients at higher risk of postoperative pulmonary complications. Simple clinical information provided as much data about the patients' risk as pulmonary function tests. Many of these complications occurred in patients who sustained other types of postoperative morbidity, suggesting that predicting and preventing postoperative cardiac morbidity may be the best approach to reducing postoperative pulmonary morbidity.

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