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PubMed2001

Benign paroxysmal positional vertigo after stapedectomy.

OBJECTIVE: To determine the incidence of benign paroxysmal positional vertigo (BPPV) following stapedectomy in a patient group and the efficacy of the Epley maneuver in this group. STUDY DESIGN: Prospective study in a university-based tertiary referral system. METHODS: The patient group comprised 63 patients who had undergone stapedectomy; a control group consisted of normal healthy individuals with no otolaryngological complaints. All individuals underwent the Dix-Hallpike maneuver for the diagnosis of BPPV. Patients who exhibited vertigo, torsional nystagmus (which reverses its direction on return to sitting position) preceded by a latent period, and the fatigability of these findings were considered to have BPPV. If the test result was positive, they underwent the Epley therapeutic maneuver. RESULTS: Four of the patients who had undergone a stapedectomy showed characteristic findings of BPPV. No individual in the control group had BPPV. All patients responded well to the Epley maneuver. CONCLUSIONS: Stapedectomy may be regarded as an etiological factor in BPPV. Because the fenestra is located in the posterior part of the stapes footplate, the pathophysiology appears to be related to utricular rather than saccular trauma. Correct measurement of the distance between the incus and stapes footplate is essential in stapedectomy. An Internet survey of the relevant literature in English shows a scarcity of publications on the incidence of BPPV following stapedectomy. In the present study, 63 patients who had undergone a stapedectomy were investigated for the presence of BPPV; all had Dix-Hallpike maneuvers performed for the diagnosis. Sixty-three individuals with no otolaryngological complaints made up the control group. Four of the patients who had undergone stapedectomy showed characteristic findings of BPPV, and no individual in the control group had BPPV; the difference between the two groups was statistically significant. All four of the patients diagnosed with BPPV responded well to the Epley maneuver. The pathophysiology appears to be related to utricular trauma. Correct measurement of the distance between the incus and stapes footplate is essential in stapedectomy.

Adult↗
PubMed2000

Quality assurance in hip arthroplasty.

Documentation is key to quality assurance (QA): Data must be complete, plausible, and comparable, and then analyzed to implement corrective measures. Important factors are: qualification of care-providing staff, equipment and implants available (structural quality), effective scheduling of operations and therapy management (process quality), and patient status monitoring (outcome quality). The primary aim is to reveal deficits in process quality and develop and implement improvements in care. QA does not aim at exposing individual mistakes or flawed techniques; rather it is designed to analyze processes and treatments and implement specific solutions. An evaluation profile with the key quality indicators and a QA guideline is presented. A survey conducted in Germany, Austria, and Switzerland revealed: (1) up to 12-month waiting period for surgery in 6%, (2) only 40% written instructions, (3) data mostly written by hand, (4) differences in surgery planning and use of prosthesis passport, (6) inconsistent data analysis, (7) corrective measures rarely implemented.

Arthroplasty, Replacement, Hip↗
PubMed2001

[Evaluation of the organisation of care for patients without appointment].

OBJECTIVES: To calculate the improvement achieved in organising care for patients without appointments after introducing corrective measures. Second, to study the reasons for consultation, the duration of the symptoms because of which consultations without appointment take place, and the assessment by health personnel of the relevance of the emergency. DESIGN: Before-and-after study.Setting. Health Area 9, urban health centre, Leganés, Madrid. PATIENTS: All the patients attending consecutively without appointment in the study periods (assessment: November 1998; reassessment: November-December 1999). MAIN RESULTS: 588 patients were included in the assessment and 562 in the reassessment. They belonged to general practice and paediatrics. 5 quality criteria were set: recording of basic details; recording of reason for consultation; assessment in under ten minutes; attempt at prior appointment; and record in the clinical notes. As there were no references in the bibliography, they were agreed by the team. After corrective measures were taken, all criteria except the fourth improved significantly. Nonetheless, the previously set norm was only achieved in the second. The professionals thought 27% of the consultations without appointment in paediatrics were urgent, and 30% in general medicine. Mean duration of symptoms in non-urgent pathologies was 1.5 days in paediatrics and 13.4 in general medicine. The most common reasons for consultation were prescriptions (20%) in general medicine and digestive pathology (20.4%) in paediatrics. CONCLUSIONS: Setting up an improvement cycle at our health centre managed to raise the quality of care given to patients without appointment, although there are still some facets that could be improved so as to reach, at least, the standards set.

Adult↗
PubMed1998

[Cancellations in pediatric surgery].

UNLABELLED: Cancellations have an important role in the effectiveness of the surgical schedule. OBJECTIVE: Analyze the evolution of the cancellations during the years 1994-1997, after institution of several corrective measures. MATERIAL AND METHOD: We started in 1994 together with the Quality Unit of the Hospital, a program to reduce surgical cancellations. It consisted in improvement of parents information, surgical schedule centralization, and increasing the awareness of the importance of constant improvement. Cancellations have been divided in: inevitables and inevitables, and analyzed for the entire Service and for each speciality. RESULTS: A significant reduction of cancellations have been obtain (from 12.38% in 1992 to 3.35% in 1997). The inevitable causes (no presentation, inadequate preparation and lack of time in the surgical room) have shown the most improvement. Although the inevitable causes (intercurrent disease) were also significantly improved, after obtaining prior information of the health of the child, by telephone call or parents advise. ENT is the speciality with greatest improvement by significant reduction of the non presentation and intercurrent disease. CONCLUSION: After corrective measures conjointly with a realistic surgical schedule, prior telephone call and improvement quality concept, have permitted a significant reduction of cancellations.

Ambulatory Surgical Procedures↗
PubMed2003

[Two years of mortality and morbidity conferences in a hospital gastrointestinal endoscopy unit].

UNLABELLED: Mortality and morbidity conferences (M & MC) are designed to establish a collegial analysis of all complications in order to define their cause, assess avoidability and propose corrective measures aimed at preventing recurrence of the same kind of complications. AIM: The aim of this study was to report the results of a quality improvement program focused on the complications of gastrointestinal endoscopy in a hospital endoscopy unit. METHODS: From 1/7/1999 to 30/6/2001, the complications of gastrointestinal endoscopic procedures were systematically and prospectively recorded and then retrospectively analysed during monthly M & MC. RESULTS: Eleven thousand seven hundred forty-four procedures were performed and 79 complications (0.7%) were recorded and analyzed. Seventy percent of the complications occurred during therapeutic procedures. Thirty-four percent of complications were due to an error: 22 attributed to the endoscopists, 4 to the nurses and 1 to the material. Thirteen percent of the complications were considered avoidable and 24% probably avoidable. The rate of avoidable complications was 0.07% for diagnostic procedures and 1.4% for therapeutic procedures (P<0.001). Avoidable complications affected mainly endoscopic gastrostomy procedures (48%) and ERCP (24%). The analysis of 15 complications enabled seven corrective measures which concerned 52% of avoidable complications. CONCLUSION: Systematic prospective recording of complications and careful exhaustive retrospective analysis during M & MC are efficient and complementary tools for continuous quality improvement programs in gastrointestinal endoscopy.

Endoscopy, Gastrointestinal↗
PubMed2004

Structural failures in abdominal aortic aneurysm stentgrafts: Threat to durability and challenge to technology.

A variety of structural defects or failures have appeared in the majority of commercially developed stentgrafts for endoluminal abdominal aortic aneurysm (AAA) repair. Some have resulted in device withdrawal; others have been dealt with by device modification. Newer devices have been designed to avoid some of these failure modes but, because many have not become apparent until as late as 2 years, these corrective measures will require long-term follow-up to establish device durability. Typically, routine surveillance has missed these problems or discovered them late and, when fully investigated, most structural problems have been more prevalent than initially suspected and/or increased with time. However, analyses documenting the full extent and clinical consequences of these structural failures have not been openly reported. This lack of information, and the nature of the structural failures themselves, have undermined confidence in the durability of endovascular aneurysm repair (EVAR), mandated indefinite periodic surveillance, and further increased its costs. Prospects for controlling the described failure modes in the future are good in terms of most device- and operator-specific causes, but aneurysm-specific causes may be more difficult to overcome. Until durability is established by improved technology and long-term follow-up, a more conservative application of EVAR has been suggested, with its use limited primarily to patients with large AAAs (>5.5 cm diameter), favorable anatomy for EVAR, and associated comorbidities that significantly increase the patient's risk for open repair as well as decrease their longevity outlook. The history of these structural failures and the corrective measures taken, as well as their current impact on EVAR are presented in this article.

Aortic Aneurysm, Abdominal↗
PubMedDate not supplied

[Management and improvement of the process of outpatient treatment of transient ischemic attacks in Neurology departments].

AIMS: To describe our experience in the ambulatory treatment of transient ischemic attacks (TIA) in a second-level hospital with the implementation of an example of process management within the different services involved in attending such conditions. PATIENTS AND METHODS: The following aspects of the process--mission, limits, flowchart, eligibility criteria and performance indicators (process, sentinel and effectiveness)--were defined by multidisciplinary consensus (Emergency, Vascular Surgery, Cardiology, Neurology and Radiology departments). This process was implemented from April 2002 to May 2004, and monthly assessments were carried out to check for problems and to introduce corrective measures. After ending the process, patients with TIA were admitted as inpatients for a hospital study. RESULTS: Definition of the process: medical care (diagnosis and treatment) of TIA patients who are eligible for a complete outpatient study within seven days. Patients evaluated: 254. Indicator 1 (percentage of suitable referrals): 2002: 53%, 2003: 75%, 2004: 73%. Indicator 2 (percentage of complete studies in less than one week): 2002: 35%, 2003: 57%, 2004: 50%; hospitalised: 90%. Indicator 3 (infarcts during the study): 2002: 4.3%, 2003: 0%, 2004: 0%; hospitalised: 0%. Indicator 4 (percentage of adjustments made to treatment): 2002: 39%, 2003: 31%, 2004: 62%; hospitalised: 72%. Mean delay before visit: in February 2002: 90 days, in April 2002: 7.67 days and in April 2003: 5.37. Problems detected: delays in referrals, failure to fit hospitalisation criteria, delays in carrying out examinations not included in the protocol, unsuitable indicator design. Steps taken: redefinition of indicators, modification of the referral system, adjustments made to the circuits involved in carrying out tests, review of hospitalisation criteria. CONCLUSIONS: Process management is an ideal tool for achieving ongoing improvements in clinical praxis. Early monitoring makes it possible to detect problems and to implement corrective measures. In our area, the study of TIA must be performed in a hospital inpatient regimen in order to comply with the guidelines for clinical practice.

Ambulatory Care↗
PubMedDate not supplied

[Quality of care in intensive care units. Retrospective study on long-term patients].

Nursing care must be evaluated in order to determine its effectiveness and identify deficiencies, which makes it possible to introduce corrective measures to optimize quality. The quality of care given to patients in our unit was evaluated with a retrospective analysis of 915 records in the Nursing Care Plan corresponding to 59 patients with a mean ICU stay of 15.5 days. Six areas of care and indicators of deficient practice were identified: orotracheal intubation: accidental disconnection, displacement, obstruction, and pressure sores on lips; arterial catheterization: accidental disconnection and obstruction; central venous catheterization: accidental disconnection and contamination; urinary catheterization: accidental disconnection and urinary bacteriology; nasogastric intubation: accidental disconnection, obstruction, and nasal pressure sores; conservation of skin integrity: presence of pressure sores, and prevention of falls from the bed or chair. The reference standards were taken from the published literature. The results show that airway care was adequate, although the frequency of pressure sores on the lip produced by orotracheal tubes was high. The indicators for following up the care of vascular and urinary catheters showed results similar to established standards. There was a high rate of nasogastric tube obstruction due to the administration of medication. Finally, the frequency of pressure sores was well below established standards and there were no accidental falls. It is concluded that the detection of areas in which care is deficient requires an analysis of relevant nursing activities so that corrective measures can be taken. This study is a useful baseline for future quality control.

Accidental Falls↗
PubMed1993

Unimpaired verbal memory and oculomotor control in asymptomatic adults with the genetic marker for Huntington's disease.

OBJECTIVE: To determine whether asymptomatic individuals at very high genetic risk for Huntington's disease (HD) have demonstrable cognitive or oculomotor abnormalities. DESIGN: A case-control study was employed. Presence of the chromosome-4 DNA marker linked to the HD phenotype was the criterion for HD risk. SETTING: The Baltimore Huntington's Disease Project Presymptomatic Testing Program at The Johns Hopkins University School of Medicine, Baltimore, Md. PARTICIPANTS: Seventy-six asymptomatic adults at risk for HD, voluntarily enrolled for genetic testing, and determined by clinical examination to be free of major psychiatric disorder or evidence of HD. Twenty were determined to be at greater than or equal to 95% risk for HD; 56 were at less than or equal to 5% risk [corrected]. MEASURES: The Hopkins Verbal Learning Test was used to assess verbal learning and memory. Oculomotor functioning was assessed using Novel-Stimulus, Mirror-Stimulus, and Predictive-Saccade paradigms. Outcome measures included number of correctly recalled words, recognition accuracy, and response bias, as well as saccade latency and number of errors on the Mirror-Stimulus Test. RESULTS: With one exception, all participants performed within the normal range on the Hopkins Verbal Learning Test. In a blind follow-up examination of the individual who performed aberrantly on the Hopkins Verbal Learning Test, she exhibited neurologic and psychiatric changes sufficient for a clinical diagnosis of HD. There were no group differences on the tests of oculomotor functioning. CONCLUSIONS: Young, asymptomatic adults at very high genetic risk for HD are unimpaired in tests of verbal learning and memory and oculomotor functioning.

Adult↗
PubMed1976

Incomplete membranous obstruction of the inferior vena cava. Hemodynamic measurements and correction by balloon membranotomy and surgical resection.

This report discusses a patient with chronic liver disease and portal hypertension, initially thought to be caused by chronic bile duct obstruction or chronic hepatitis B. For evaluation of portal hypertension, hepatic vein catheterization was performed, disclosing incomplete membranous obstruction of the inferior vena cava at the level of the diaphragm--the probable cause of the liver disease. The obstruction was corrected by balloon membranotomy and surgical resection of the membrane. Hepatic vein catheterization in patients with chronic liver disease and portal hypertension allows detection of this lesion as well as evaluation of hepatic and portal hemodynamics.

Adult↗
PubMed1995

We may not measure the correct intestinal wall permeability coefficient of drugs: alternative absorptive clearance concept.

It is shown that the conventional method (based on the thin-wall membrane theory) of studying the rate of disappearance or absorption from the lumen alone may not yield the correct intestinal wall (membrane) permeability coefficient of drugs. Potential reasons for causing this problem such as first-pass metabolism and accumulation of drugs in gut wall or tissue as well as back diffusion of drugs from the gut tissue to the lumen (i.e., a part of exsorption phenomenon) and potential major transport barriers across the protoplasm, basal membrane, and basement membrane are discussed. Contrary to the conventional concept, basal and basement membranes should also be considered major barriers for absorption into the blood for compounds with low intestinal permeability, and the protoplasm or cytoplasma should also be considered a major absorption barrier for compounds with high intestinal permeability. Strictly speaking, the conventional experimental method cannot be considered a bona fide method for studying drug permeability that deals with the movement of drug molecules from one side to the other side of a membrane, cell, medium, or device. The wall permeability coefficient thus obtained may therefore not represent the true wall permeability coefficient. "Intestinal absorptive clearance per unit gross surface area" is advocated as the best alternative term because it should more accurately reflect the true meaning of an experimental result for any compounds studied. In contrast to conventional cylindrical, unstirred tube models for the determination of wall permeability coefficients, the absorptive clearance calculation can be made based on a physiologically more realistic model-independent, "flat" or "distended," stirred (not well-stirred) intestinal model. Two model-independent terms, "effective intestinal permeability coefficient" and "effective absorptive permeability coefficient," are recommended as the second alternatives. These terms are theoretically valid for compounds that are not metabolized in the intestinal tissue; they represent the overall permeability across the intestinal tissue (from lumen to blood) under given experimental conditions. Potential shortcomings of using dimensionless wall permeability in the conventional absorption modeling are also discussed.

Animals↗
PubMed1987

Accuracy of temporomandibular joint space measurements using corrected hypocycloidal tomography.

This study underscores the importance of obtaining radiographs in a tomographic plane bisecting the long axis of the condyle. The accuracy of joint relationships and clarity of the images produced using the horizontally and vertically corrected techniques were significantly greater than when both standard or only horizontally corrected techniques were used in the cases examined. Correlative clinical studies are recommended to be studied.

Humans↗