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At least 487 records · Page 27Linked to original sources
PubMed1998

Ten-year survival of Finnish lower limb amputees.

Data on mortality for the ten years following lower limb amputation were obtained from all the 16 surgical units in Southern Finland and the National Social Insurance Institution. In Southern Finland during the period 1984-1985, amputations of the lower limb were performed on 705 patients, of whom 382 (54%) were women and 323 (46%) men. The majority of the amputations, 47% were performed for vascular diseases and 41% were performed for diabetes mellitus. The overall survival was 62% at one year after amputation, 49% at two years, 27% at five years and 15% at ten years. The median survival after amputation was 1 yr 5 mth for the women and 2 yr 8 mth for the men. Of the arteriosclerotics, 43% died within one postoperative year while 43% lived longer than two years and 23% longer than five years. The median survival of arteriosclerotics was 1 yr 6 mth. The corresponding figure for patients with diabetes was 1 yr 11 mth. Of the diabetics, 38% died within one postoperative year while 47% lived longer than two years and 20% longer than five years. Of the trauma patients, 86% lived longer than five years and 71% longer than ten years. Of the trans-femoral amputees, 54% lived longer than one year, 36% over two years, 18% over five years and 8% over ten years. The corresponding figures for trans-tibial amputees were 70%, 53%, 21% and 4%. Many elderly vascular and diabetic patients undergoing amputation have a reduced physiological reserve and high mortality. The more proximal the amputation, the greater the risk that the patient will never be able to walk or that the duration of use of the prosthesis will be short. If a prosthesis seems to be a reasonable option for the elderly amputee, any delays in prosthetic fitting should be avoided in older age groups.

Adolescent↗
PubMed2000

Infrainguinal reconstruction in octogenarians: should age be a contraindication?

With the graying of America comes an increasing demand for medical care of the elderly. Unfortunately, due to a combination of rising costs of health care and driving force from the public to lower spending, health maintenance organizations and insurance companies are less willing to pay for expensive surgical procedures. Recently, infrainguinal arterial reconstructions have been denied at our institution solely on the basis of patient's age, without adequate assessment of data. We evaluated the results of patients aged over 80 years who underwent infrainguinal reconstruction and compared them to results of younger cohorts during the same time period. From 1989 to 1998, 629 octogenarians had infrainguinal reconstructions performed at our institution. In the same time period, 3257 procedures were performed on patients <80 years old. Demographics, indications for operations, and outcomes were compared. Statistical analysis was performed with Fisher's exact test and log rank analysis, assuming significance for p < 0.05. Indications for operation were significantly more often limb salvage and less often claudication in the older group. Nonfatal complication rates were similar. Primary and secondary patency rates as well as limb salvage rates were comparable in both groups. Patients who are >80 years of age should expect comparable outcomes to those of their younger cohorts when undergoing infrainguinal reconstructions. Health care dollars can be well spent on octogenarians and age should not be a contraindication for infrainguinal reconstruction.

Age Factors↗
PubMed2001

Overview: procedure versus protection: an impossible separation.

This overview focuses upon the fundamental cohesion between myocardial protection and mechanical repair for surgical success. Currently, our attention is directed toward the natural evolution of more complex surgical methods, while there is slower rise in interest in advanced methods of protection. The absence of manuscripts on myocardial protection in major meetings suggests that the concept of protection has been solved, even though there remain reports of use of intraaortic balloon and mechanical devices that appear when protection is inadequate. This Seminar volume will introduce a series of articles about risk patients for whom evolving methods of protection are used. We will point out frontiers of protection that should develop together with advances in technical surgical approaches so that these two essential components that insure the safe conduct of cardiac operations can grow together.

Heart Arrest, Induced↗
PubMed1998

Auto theft-related trauma.

OBJECTIVE: To determine the medical consequences and economic impact of caring for patients injured after motor vehicle crashes (MVC) involving stolen cars. METHODS: Presented is a case series of inpatients injured secondary to a MVC involving a stolen car from January of 1993 to December of 1994 and treated at a university Level I trauma center in Newark, New Jersey. During the time period of the study, 1,232 patients (either as the driver or passenger) were admitted after a MVC, 115 patients (8%) were identified as sustaining injuries secondary to a MVC involving a stolen car. Injuries after car theft represent 8% of all MVC-related admissions. Data collected included demographics, types of injuries, surgical intensive care unit and hospital lengths of stay, insurance status, hospital and physician charges, and ultimate outcome. RESULTS: Of the 84 men and 31 women, 66 were perpetrators, either as the driver (34) or passenger (32) of a stolen vehicle. Perpetrators were significantly younger and more likely to be male than victims. The overall mortality was 11%. An additional nine fatalities occurred at the scene of a MVC linked to a patient in this study. A high rate of speed and the presence of police pursuit seemed to be related to the severity of the crashes. The mean charges (hospital and physician) were over $34,000 per patient, and the aggregate charges for this cohort were greater than $3.6 million. Fifty-four percent of patients were uninsured. CONCLUSION: Injuries involving stolen cars are common in areas in which the activity has a high prevalence and can compose a significant percentage of a trauma center's MVC population. These data run contrary to the popular belief that auto theft is merely a crime against property, because the injuries sustained as a result of this criminal activity tended to be severe and were associated with a high fatality rate. Restricting police pursuit to only those instances in which other felonious activity is suspected may decrease the number of stolen car MVC. Additionally, the total amount of uncompensated care that these patients receive places another financial burden on limited health care and trauma center resources, which ultimately effects all other citizens.

Accidents, Traffic↗
PubMed2003

A review of breast contouring.

This article provides a comprehensive review of breast contouring and recent advances. Most of the material discussed covers both breast reduction and mastopexy, as well as reasons for breast contouring, advances in surgical techniques, results of breast contouring, nursing interventions, and insurance issues.

Body Image↗
PubMed1989

Preoperative cardiac consultations in a teaching hospital.

Perioperative consultations may play a major role in the care of surgical patients in an era of prospective payments. Since insurance reimbursement policy favors limitations in the number of consultants on a case, general medicine ("holistic") consultation services may become preferred perioperative consultants in the future. To focus curriculum planning for perioperative consultants, we reviewed the content of 60 consecutive perioperative consultations by noncardiac surgery services to a university cardiology consultation team. Clinical descriptions of the patients' exercise tolerance showed that 95% of the patients belonged in functional classes I and II. One fourth of the requests were for routine preoperative clearance. The most frequent cardiac conditions for evaluation were congestive heart failure, old myocardial infarctions, murmurs, abnormal electrocardiograms, angina, and previous histories of coronary artery bypass surgery. Few patients needed management of arrhythmias. Physicians involved in perioperative care should assess their abilities in managing these cardiac conditions.

Adult↗
PubMedDate not supplied

Cholesteatoma of the frontal and ethmoid areas.

Cholesteatomas of the frontoethmoid region must always be considered in the differential diagnosis of a mass in the frontoethmoid region. A painless, slow-growing mass, often accompanied by proptosis and diplopia, but without history of trauma or infection, should make one suspect of this pathologic entity. Although histologically a benign lesion, the keratinizing squamous epithelial lining will continue to desquamate and expand, leading to erosion of surrounding structures which could be life-threatening. In order to prevent recurrence, complete removal of the cyst lining is mandatory. Cosmetic reconstruction, often requiring obliteration of the surgical cavity, should be delayed for one year to insure against recurrence of the covering of active squamous tissue adjacent to dura, cribriform plate or ocular structures.

Adult↗
PubMedDate not supplied

Pancreas transplantation: a University of Minnesota perspective.

Because of various difficulties, transplantation is restricted to specific situations. Surgery is considered elective by many insurers, so costs are often borne by the patient. Surgical work-up includes a thorough evaluation of diabetes-related complications, tissue typing, psychological state, and social issues. Options of cadaver versus living related donors are explored. The surgical procedure is lengthy and the hospital stay long and intensive. Once a patient is ambulatory, education is begun to meet the extensive learning needs. After discharge, surgical follow-up focuses primarily on blood chemistries, medication doses, and surgical complications. Medical follow-up includes monitoring for infections and rejection as well as addressing long-term complications of diabetes. Studies of the effects of transplantation on diabetes complications are encouraging which, when coupled with improved surgical outcomes, may increase opportunities for transplant.

Graft Rejection↗
PubMedDate not supplied

The narrow lumbar spinal canal or lumbar spinal stenosis.

Narrow lumbar spinal canal or lumbar spinal stenosis is a not uncommon problem. Thirty-two patients with this disorder have been treated surgically at the Ochsner Medical Center between 1963 and 1973. The best method of diagnosis is a careful history and second is roentgenographic evidence, particularly the myelogram. The surgical treatment consists of total laminectomy and foraminotomy to insure complete decompression of the nerve roots. Eighteen patients have been followed from 14 to 44 months. Sixteen of the 18 considered their operations a success.

Adult↗
PubMed2000

Patient characteristics and ICU organizational factors that influence frequency of pulmonary artery catheterization.

CONTEXT: Hemodynamic monitoring of patients with a pulmonary artery catheter is controversial because there are few data confirming its effectiveness, and patient and intensive care unit (ICU) organizational factors associated with its use are unknown. OBJECTIVE: To determine pulmonary artery catheter use in relationship to type of ICU organization and staffing, and patient characteristics, including severity of illness and insurance coverage. DESIGN, SETTING, AND PATIENTS: Retrospective database study of 10,217 nonoperative patients who received treatment at 34 medical, mixed medical and surgical, and surgical ICUs at 27 hospitals during 1998 (patients were enrolled in Project IMPACT). MAIN OUTCOME MEASURES: Pulmonary artery catheter use based on severity of illness measured by the Simplified Acute Physiology Score, resuscitation status at ICU admission, and ICU organizational variables, including type, size, and model. RESULTS: A pulmonary artery catheter was used for 831 patients (8.1%) in the ICU. In multivariate analysis adjusted for severity of illness, age, diagnosis, and do-not-resuscitate status, full-time ICU physician staffing was associated with a two-thirds reduction in the probability of catheter use (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.28-0.45). Higher catheter use was associated with white race (OR, 1.38; 95% CI, 1.10-1.72) and private insurance coverage (OR, 1.33; 95% CI, 1.10-1.60). Admission to a surgical ICU was associated with a 2-fold increase in probability of catheter use (OR, 2.17; 95% CI, 1.70-2.76) compared with either medical or mixed medical and surgical ICUs. CONCLUSION: Organizational characteristics of ICUs, insurance reimbursement, and race, as well as clinical variables, are associated with variation in practice patterns regarding pulmonary artery catheter use. Understanding such influences, combined with studies measuring clinical and economic outcomes, can contribute to the development of policies for the rational use of pulmonary artery catheters. JAMA. 2000;283:2559-2567

Adult↗
PubMed1997

Surgery in India.

Surgical practice in India is mostly managed by the central and state governments and is totally government financed, offering free medical aid. However, with the economic growth and affluence of the middle-class population in urban areas, more and more hospitals, nursing homes, and clinics managed by the private sector are arising in cities and towns. Privately owned hospitals are built and managed by large industrial houses and trusts. It is essential, according to government directives, for these hospitals to have certain numbers of general beds that will provide for the economically weaker sections of the population. Medical insurance is popular amongst the urban population; in addition to well-established insurance companies, many new medical service reimbursement organizations are forming. Surgical care standards are uniformly high in the larger teaching institutions and hospitals run by the private sector in major cities in India, in which superspecialty surgical care that meets worldwide standards is available in addition to general surgical care. These hospitals are manned by surgeons holding master's degrees in general surgery, superspecialties, and subspecialties. In the hospitals and dispensaries in rural areas, only basic surgical facilities are available; for major surgical procedures, the patients are referred to the closest urban hospitals. Therefore, the government of India is placing more and more emphasis on building hospitals that offer better surgical facilities away from the cities and towns. A diploma course in surgery is run by the National Board of Surgery, and these diplomates are encouraged to practice more in rural areas and small hospitals. Economic constraints and the population explosion are the biggest hurdles to progress in surgical care, teaching, and research activities. With the advancement in education and growth of the economy, more and more multinationals are walking into the field of medical care, which is proving to be a great boon and providing a rapid increase in the health care expansion in this country. The World Health Organization and the World Bank are providing considerable aid for disease prevention, health care provision, and research activities.

Education, Medical↗
PubMed1999

Management of otitis media among children in a large health insurance plan.

BACKGROUND: Otitis media is one of the most common office diagnoses among children in the US and the leading reason for the use of antimicrobials in pediatric practice. We undertook this study to characterize medical and surgical management of otitis media. METHODS: Using claims data from a large New England health insurer, we identified all children <10 years of age who had one or more episodes of acute otitis media between July, 1995, and June, 1996, and examined patterns of treatment for this condition. RESULTS: Study subjects (n = 22,004) averaged 2.9 physician office visits for management of otitis media; among children <2 years of age, one-fourth had 6 or more such visits. Amoxicillin was prescribed as initial therapy in more than one-half (56.6%) of all episodes of acute otitis media, followed by cephalosporins (18.3%), trimethoprim-sulfamethoxazole (12.3%), macrolides (6.4%) and amoxicillin-clavulanate (6.0%). Over multiple episodes, however, use of amoxicillin declined by about 50%. Antimicrobial prophylaxis was received by 7.3% of all study subjects for a mean of 61.3 days; the incidence of breakthrough episodes of acute otitis media during prophylaxis varied according to the antimicrobial used (13.9, 12.3 and 19.5% for amoxicillin, trimethoprim-sulfamethoxazole and sulfisoxazole, respectively). Surgical procedures related to otitis media were performed on 3.8% of all study subjects, including 4.6% of children <2 years of age. CONCLUSIONS: The health care burden of otitis media is large, particularly in the first 2 years of life.

Acute Disease↗
PubMed1991

[The work of the surgical unit nurse in Brazil (the decade of the '80s)].

From the view of the historical and dialectic materialism of the nurse work as a social practice insured in the Brasilian capitalistic mode of production of the eighties, these study, through the decomposition of the surgical room nursing work in his three essential elements, search to point the necessary comprehension not only of these components but, mainly, for the agreement of his superstructural relations through the Brazilian mode of production in sense of, with these reflective praxis, search a synthesis, within what I have (what the operating room nurse work is) and, what I want, synthesis which will allow a new practice.

Brazil↗
PubMed2005

Barriers to health care and protocol-based treatment of ectopic pregnancy.

OBJECTIVE: To evaluate whether treatment provided for ectopic pregnancies was different for patients with identified barriers to health care, including ethnicity, lack of insurance, distance from the treating facility that provides services and undocumented residency, at an institution that utilizes a protocol-based algorithm for treatment of ectopic pregnancies. STUDY DESIGN: Charts of 401 patients who were diagnosed with ectopic pregnancy from January 1, 1993, through December 31, 1998, were reviewed to compare the use of medical treatment using methotrexate versus surgical treatment. Data were analyzed with respect to patient ethnicity, socioeconomic status (including insurance status and possession of a social security card [a proxy for legal residency status]), residence inside or outside the county of the treating facility, patient presentation and treatment outcomes. RESULTS: There was no difference in treatment modality or success of primary treatment for ectopic pregnancies between groups regardless of ethnicity, health care insurance, residence outside the county the treating facility was located in or possession of a social security number. CONCLUSION: The treatment of ectopic pregnancies at the University of New Mexico Health Sciences Center is consistent across ethnic and socioeconomic populations. A well-designed treatment protocol may help provide evidenced-based, consistent treatment for patients requiring care who also have identified barriers to medical and surgical treatment.

Abortifacient Agents, Nonsteroidal↗
PubMed2006

Geographic variation in surgical treatment for work-related carpal tunnel syndrome: does improved return to work matter?

Medical treatment of compensated work-related conditions has two objectives--improve injured workers' health status and allow safe and sustained return to work (RTW). Theoretically, the choice of treatment method should be based primarily on these objectives. Surgical treatment of work-related carpal tunnel syndrome (CTS) provides an opportunity to evaluate whether this occurs. The traditional method of open release has been complemented by an endoscopic procedure, particularly useful in work-related cases due to the anticipated benefit of earlier RTW. The objective of this study was to investigate the differences in surgical treatment for work-related CTS across eight US workers' compensation (WC) jurisdictions, and the factors associated with these differences. From all WC claims reported to a single insurer during the 1995-1999 period, we identified individuals with a one or two surgical procedures for work-related CTS. Among selected individuals (n=4,421), about 20% were treated using the endoscopic procedure; this percentage had a ten-fold variation across the eight jurisdictions. However, utilization of endoscopic release did not increase during the study period, despite reports of better RTW outcomes. The highly jurisdictional nature of the US WC system, with significant differences in reimbursement levels for endoscopic procedures, and geographical differences in medical training were among the potential contributors to the observed variation in utilization.

Carpal Tunnel Syndrome↗