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PubMed1999

Patient recall and appropriate timing for obtaining informed consent for endoscopic procedures.

OBJECTIVES: Although informed consent is an issue in many medical malpractice claims, there is no standardized time or method to obtain informed consent for endoscopic procedures. The objectives of this study were to determine whether sedation for endoscopic procedures interfered with pre-endoscopic informed consent and to determine the appropriate time to obtain informed consent. METHODS: Patients undergoing a sedated esophagogastroduodenoscopy had informed consent obtained either 48-72 h before the procedure (group 1A, n = 50) or 10-60 min before the procedure (group 1B, n = 50). Patients undergoing an unsedated flexible sigmoidoscopy had informed consent obtained either 48-72 h before (group 2A, n = 47) or 10-60 min before the procedure (group 2B, n = 49). Methods of informed consent consisted of an oral and a written explanation about the procedure. Patients were sedated with midazolam and meperidine. A Trieger test evaluated recovery from sedation. Recall was assessed by asking six questions about the procedure before discharge and again 2-3 days later. RESULTS: Standard t tests and Mann-Whitney U nonparametric rank tests were used to compare the 1) 1-h recall scores, 2) 2-3-day recall scores, and 3) recall difference scores for groups 1A and 1B, 1A and 2A, 2A and 2B, and 1B and 2B. There were no differences in recall for the different groups. CONCLUSIONS: This study shows that sedation for endoscopic procedures does not interfere with pre-endoscopic informed consent. Informed consent for endoscopic procedures can be obtained at any time before sedation with similar recall.

Adult↗

PubMed1994

Further studies of a maximum-likelihood yes-no procedure.

Absolute thresholds were estimated for pure tones of 500, 1000, and 2000 Hz using both a maximum-likelihood yes-no procedure and a traditional three-down one-up forced-choice adaptive procedure. Threshold estimates obtained with the two procedures were highly correlated. In the maximum-likelihood yes-no procedure, the false-alarm probability was poorly estimated. A simple change in that procedure produced less-biased estimates of the false-alarm rate. In a second experiment, the influence of the false-alarm rate on the threshold estimates was investigated. The listeners' absolute thresholds were estimated when they adopted either a liberal or conservative criterion for detecting the signals. Data were collected using both a constant-stimulus yes-no procedure and a maximum-likelihood yes-no procedure. Threshold estimates are 5 to 6 dB higher for the low than for the high false-alarm rates. Psychometric functions based on a stimulus-power model provided the best fit to the data obtained with the constant-stimulus method. This stimulus-power model was used to produce the assumed psychometric function in the maximum-likelihood yes-no procedure. Computer simulations were conducted to determine how threshold estimates were affected by the listener's inattention or by mismatches between the slope parameter of the listener's psychometric function and that assumed in the maximum-likelihood procedure.

Attention↗

PubMed2002

Interventional musculoskeletal procedures performed by using MR imaging guidance with a vertically open MR unit: assessment of techniques and applicability.

PURPOSE: To evaluate the safety of and time required for a broad range of musculoskeletal interventional procedures performed by using magnetic resonance (MR) imaging guidance with a vertically open 0.5-T unit. MATERIALS AND METHODS: Sixty-three MR imaging-guided procedures were performed. A vertically open MR unit equipped with in-room display monitors allowed interactive freehand MR guidance predominantly with fast spin-echo and gradient-echo sequences. Each procedure was classified in terms of the anatomic location, procedure type, and tissue type involved. The procedures were evaluated for success of needle placement, adequacy of tissue sampling, total procedural time, needle time, number of needle passes, and complications. RESULTS: Procedures consisted of tissue sampling with core-needle (n = 6) or fine-needle aspiration (n = 20) biopsy, corticosteroid or contrast agent injection (n = 19), joint cyst aspiration (n = 7), and drainage (n = 11). Successful needle placement was achieved in all 63 cases. Cytologic and histologic tissue samples were sufficient for pathologic diagnosis in 24 of 26 cases. In two cases, complications occurred: transient local bleeding and a brief vasovagal episode. The mean total procedural time was 64.8 minutes; the mean needle time, 26.2 minutes; and the mean number of needle passes per patient, 1.6. CONCLUSION: With use of a vertically open MR unit, MR-guided interventional procedures involving bone, soft tissue, intervertebral disks, and joints are safe and sufficiently rapid for use in clinical practice.

Adult↗

PubMedDate not supplied

Influence of different screening procedures on the stroke prevalence estimates: the Italian Longitudinal Study on Aging.

Stroke prevalence surveys are more and more needed for health care and facility planning. Prevalence estimates and costs of the definition procedure may vary depending on different screening strategies. We evaluated the impact of these different strategies on the overall diagnostic procedure and on stroke prevalence estimates in the Italian Longitudinal Study on Aging. A population sample of 5, 632 individuals aged 65-84 years was screened for stroke by a simple question on previous stroke diagnosis, questions on possible stroke symptoms and a simple neurological examination. Those screened positive by any of these procedures were fully examined by a neurologist for conclusive diagnosis. We determined the positive predictive value of each procedure on the final stroke diagnosis and calculated prevalence as if each procedure had been used separately. Using the three procedures combined, the prevalence rate was 6.0% (95% confidence interval, 5.4-6.7%). If each procedure had been used as the unique screening tool, the rates would have been 5.1% (4.5-5. 7%), 4.1% (3.6-4.7%) and 2.3% (1.9-2.7%), and positive predictive values 66.4, 55.2 and 45.1%, respectively. Different screening procedures can affect stroke prevalence estimates. Compared to more complex screening strategies, the use of a simple question about previous diagnosis as the unique screening tool leads to only a slight underestimation of stroke prevalence and avoids a 66% increase in the number of subjects to be examined in a second-level specialist evaluation, potentially reducing the costs of the overall diagnostic procedure.

Age Factors↗

PubMed2004

Preference assessment procedures for individuals with developmental disabilities.

Significant advancements have been made in the development of procedures to systematically identify preferred stimuli that may function as reinforcers for persons with developmental disabilities. Indirect assessment procedures include care provider and client interviews, whereas direct assessment procedures involve systematically exposing participants to stimuli while recording their responses. These types of direct assessment procedures can be categorized as either approach-based or engagement-based. Approach-based procedures involve recording the individuals' approach responses to stimuli presented singly or concurrently with other stimuli, whereas engagement-based procedures involve recording duration of engagement with stimuli. Although the predictive validity of indirect preference assessment procedures has yet to be established, using them in combination with direct measures of preference may be most efficacious for identifying potential reinforcers. Recent research on preference assessment procedures used with persons with developmental disabilities is reviewed and the variables that one might consider prior to selecting which procedure to use in a given situation are discussed.

Attention↗

PubMed2004

Reconstruction of the lateral ligaments: do the anatomical procedures restore physiologic ankle kinematics?

BACKGROUND: If conservative therapy fails, the standard treatment for chronic ankle instability is surgical reconstruction of the lateral ligaments. For the last seventy years, the tenodesis principles have been used for reconstruction. Recently however, surgical reconstructions--respecting the intact joint anatomy--have been developed, thus called "anatomical reconstruction principles". METHODS: This study focused on the investigation of the range of motion of the ankle and the subtalar joint following anatomical reconstruction surgery. Three different types of anatomical reconstruction procedures were compared: Direct ligament repair, tendon graft and carbon-fiber implant. RESULTS: All procedures restored the original range of motion of the subtalar joint, except for the plantarflexed/dorsiflexed positions. As for the talocrural joint, the tendon graft and the carbon fiber implant left a small laxity for movements of inversion/eversion and internal/external rotation. The direct repair procedure achieved a more accurate result and restored the physiologic kinematics almost completely. During each procedure the insertion points and the direction of the original ligaments were maintained. However, the different results for the procedure of direct ligament repair compared to the other two anatomical reconstruction procedures showed that this condition alone is not sufficient to perfectly restore the kinematics of the talocrural and subtalar joints. It is important to note that none of the procedures caused a restriction of the range of motion. CONCLUSIONS: The maintenance of the range of hindfoot motion decreases the risk of osteoarthritis as well as chronic pain or problems for the patient to walk on uneven surface. Therefore, we believe that standard therapy for chronic instability of the ankle should include direct surgical reconstruction of the ligaments. If this direct procedure cannot be performed because of poor quality of the ligaments an alternative anatomical reconstruction procedure should be considered.

Aged↗

PubMed2006

House officer procedure documentation using a Personal Digital Assistant: a longitudinal study.

BACKGROUND: Personal Digital Assistants (PDAs) have been integrated into daily practice for many emergency physicians and house officers. Few objective data exist that quantify the effect of PDAs on documentation. The objective of this study was to determine whether use of a PDA would improve emergency medicine house officer documentation of procedures and patient resuscitations. METHODS: Twelve first-year Emergency Medicine (EM) residents were provided a Palm V (Palm, Inc., Santa Clara, California, USA) PDA. A customizable patient procedure and encounter program was constructed and loaded into each PDA. Residents were instructed to enter information on patients who had any of 20 procedures performed, were deemed clinically unstable, or on whom follow-up was obtained. These data were downloaded to the residency coordinator's desktop computer on a weekly basis for 36 months. The mean number of procedures and encounters performed per resident over a three year period were then compared with those of 12 historical controls from a previous residency class that had recorded the same information using a handwritten card system for 36 months. Means of both groups were compared a two-tailed Student's t test with a Bonferroni correction for multiple comparisons. One hundred randomly selected entries from both the PDA and handwritten groups were reviewed for completeness. Another group of 11 residents who had used both handwritten and PDA procedure logs for one year each were asked to complete a questionnaire regarding their satisfaction with the PDA system. RESULTS: Mean documentation of three procedures significantly increased in the PDA vs handwritten groups: conscious sedation 24.0 vs 0.03 (p = 0.001); thoracentesis 3.0 vs 0.0 (p = 0.001); and ED ultrasound 24.5 vs. 0.0 (p = 0.001). In the handwritten cohort, only the number of cardioversions/defibrillations (26.5 vs 11.5) was statistically increased (p = 0.001). Of the PDA entries, 100% were entered completely, compared to only 91% of the handwritten group, including 4% that were illegible. 10 of 11 questioned residents preferred the PDA procedure log to a handwritten log (mean +/- SD Likert-scale score of 1.6 +/- 0.9). CONCLUSION: Overall use of a PDA did not significantly change EM resident procedure or patient resuscitation documentation when used over a three-year period. Statistically significant differences between the handwritten and PDA groups likely represent alterations in the standard of ED care over time. Residents overwhelmingly preferred the PDA procedure log to a handwritten log and more entries are complete using the PDA. These favorable comparisons and the numerous other uses of PDAs may make them an attractive alternative for resident documentation.

Computers, Handheld↗

PubMedDate not supplied

Music versus distraction for procedural pain and anxiety in patients with cancer.

PURPOSE/OBJECTIVES: To test the hypotheses that the effects of a music intervention are greater than those of simple distraction and that either intervention is better at controlling procedural pain and anxiety than treatment as usual. DESIGN: Randomized, controlled experiment. SETTING: A midwestern comprehensive cancer center. SAMPLE: 60 people with cancer having noxious medical procedures such as tissue biopsy or port placement or removal; 58 provided usable data. METHODS: Participants completed measures of pain and anxiety before and after their medical procedures and provided a rating of perceived control over pain and anxiety after the procedure. MAIN RESEARCH VARIABLES: Procedural pain, state anxiety, and perceived control over pain and anxiety. FINDINGS: Contrary to hypotheses, outcomes achieved with music did not differ from those achieved with simple distraction. Moreover, outcomes achieved under treatment as usual were not significantly different from those obtained with music or distraction interventions. Some patients found that the interventions were bothersome and reported that they wanted to attend to the activities of the surgeon and the medical procedure itself. CONCLUSIONS: The effects of music, distraction, and treatment as usual are equivocal. In addition, patients have individual preferences for use of distraction during painful or anxiety-provoking procedures. IMPLICATIONS FOR NURSING: Patients having noxious medical procedures should be asked about their desire to be distracted before and during the procedure and offered a strategy that is consistent with their preferences.

Anxiety↗

PubMed1994

Redo Gastric Restriction: A Higher Risk Procedure.

Twenty-one patients have undergone redo gastric restrictive procedures, three after gastric bypass, 18 after gastroplasty. Weight at the time of the redo procedure was 101 kg +/- 32.4 SD (222 lb +/- 71.2) (178% IBW +/- 33.8), down from 137 kg +/- 65.5) (217% ISW +/- 33.9) at the time of initial procedure. Sixteen of 21 (76%) initial procedures failed because of staple-line dehiscence, at least in part. Redo procedures were vertical banded gastroplasty (VBG) in ten, gastric bypass (GB) in ten, and silico ring banded gastroplasty in one. Early complications were three gastric leaks, one enterocutaneous fistula, one gastroplasty outlet obstruction, and one wound infection occurring in three of ten VBG and three of ten GB. All three leaks and one fistula were not seen on gastrograffin/barium swallow done 2-4 days after the redo procedure. Late complications were failure of seven redo procedures, one small bowel obstruction, and one recurrent enterocutaneous fistula, with two lost to follow-up. We conclude that redo gastric restriction procedures carry relatively high perioperative risks. Radiologic contrast studies done in the early postoperative period do not necessarily detect leaks, which are presumably due to gastric ischemia and subsequent infarction. Ischemia is thought to be due to devascularization from the initial procedure. Late failure is unfortunately common, possibly reflecting behaviors which lead to the initial staple line dehiscence and failure. Higher risk of perioperative complications and late failure must be considered prior to revisional surgery.

Journal Article↗

PubMed1999

Gastric restrictive procedures through a mini-incision: a cost-effective alternative to laparoscopic bariatric surgery in Egypt.

BACKGROUND: Gastric restrictive procedures such as vertical banded gastroplasty (VBG), Roux-en-Y gastric bypass (RYGB) and gastric banding have become the standard in morbid obesity surgery. Surgeons have started to perform these procedures through the laparoscope to give the patient the advantages of smaller incisions, less postoperative pain, shorter hospital stay, and earlier return to work. These laparoscopic procedures have not gained popularity in Egypt because they are more expensive and require longer operating times than open surgery. Instead, we have refined our open surgery technique into a method that gives most of the laparoscopic advantages and yet retains all of the open surgery advantages, i.e., performance of the open procedure through a 7- to 8-cm incision. METHODS: From September 1997 to July 1999, 25 morbidly obese patients underwent gastric restrictive procedures through mini-incisions with a follow-up period of < or =22 months. Twenty-one patients underwent VBG, and 4 patients underwent RYGB. Ninety-two percent of these patients were female, with a mean age of 28.8 years, a mean weight of 117 kg, and a mean body mass index of 45.7 kg/m2. RESULTS: The operative time was a mean of 56 minutes for the gastroplasty group and a mean of 116 minutes for the bypass group. The mean hospital stay was 3.3 days. Patients returned to normal activity within 15.6 days. Wound infections developed in 3 patients (12%) and incisional hernias in 2 (8%). The total expense of the procedure was one-third to one-half that of the laparoscopic procedure. CONCLUSION: If cost prevents the wide use of laparoscopic procedures for morbid obesity, performing open procedures through a miniincision is an alternative approach.

Adult↗

PubMed2002

IFCC primary reference procedures for the measurement of catalytic activity concentrations of enzymes at 37 degrees C. International Federation of Clinical Chemistry and Laboratory Medicine. Part 7. Certification of four reference materials for the determination of enzymatic activity of gamma-glutamyltransferase, lactate dehydrogenase, alanine aminotransferase and creatine kinase accord.

This paper is the seventh in a series dealing with reference procedures for the measurement of catalytic activity concentrations of enzymes at 37 degrees C and the certification of reference preparations. Other parts deal with: Part 1. The Concept of Reference Procedures for the Measurement of Catalytic Activity Concentrations of Enzymes; Part 2. Reference Procedure for the Measurement of Catalytic Concentration of Creatine Kinase; Part 3. Reference Procedure for the Measurement of Catalytic Concentration of Lactate Dehydrogenase; Part 4. Reference Procedure for the Measurement of Catalytic Concentration of Alanine Aminotransferase; Part 5. Reference Procedure for the Measurement of Catalytic Concentration of Aspartate Aminotransferase; Part 6. Reference Procedure for the Measurement of Catalytic Concentration of Gamma-Glutamyltransferase. A document describing the determination of preliminary reference values is also in preparation. The certification of the catalytic activity concentrations as determined by the recently elaborated IFCC primary reference methods at 37 degrees C of four enzyme preparations, namely IRMM/IFCC 452 (gamma-glutamyltransferase), IRMM/IFCC 453 (lactate dehydrogenase 1), IRMM/IFCC 454 (alanine aminotransferase) and IRMM/IFCC 455 (creatine kinase) is described. Homogeneity data were derived from previous results. Stability was assessed using recently obtained data as well as data from previous stability studies. The collaborative study for value assignment was performed under a strict quality control scheme to ensure traceability to the primary reference method. Uncertainty of the materials was assessed in compliance with the Guide to the Expression of Uncertainty in Measurement. The certified values obtained at 37 degrees C are 1.90 microkat/l +/- 0.04 microkat/l (114.1 U/l +/- 2.4 U/l), for gamma-glutamyltransferase, 8.37 microkat/l +/- 0.12 microkat/l (502 U/l +/- 7 U/l), for lactate dehydrogenase 1, 3.09 microkat/l +/- 0.07 microkat/l (186 U/l +/- 4 U/l), for alanine aminotransferase and 1.68 microkat/l +/- 0.07 microkat/l (101 U/l +/- 4 U/l), for creatine kinase. The materials are intended for internal quality control as well as for the evaluation of test systems as required by recent European Union legislation. Furthermore, the materials can be used to transfer accuracy from a reference method to a routine procedure provided the procedures exhibit the same analytical specificity and the certified materials are commutable.

Alanine Transaminase↗

PubMed2003

Comparison of several point-of-care testing (POCT) glucometers with an established laboratory procedure for the diagnosis of type 2 diabetes using the discordance rate. A new statistical approach.

The applicability of point-of-care testing (POCT) glucometers for monitoring blood glucose concentrations has been demonstrated. However, their use in diagnosing type 2 diabetes is still debated. Therefore, a new statistical procedure for estimating discordance rates (DRs) was applied in comparing a well-established laboratory method (Ebio) with another laboratory method (Cobas Integra 700) and with several POCT glucometers (Accu-Chek, Accutrend, Elite, HemoCue, Omni) in detecting glucose intolerance states. All procedures led to parallel glucose concentration patterns in capillary blood, venous plasma, and venous blood during oral glucose tolerance tests. However, the mean concentrations differed more or less. The Ebio and Integra results agreed within a maximal deviation of 3%. In blood samples, the HemoCue and Accutrend results were closest to the laboratory procedures (Ebio and Integra) and the highest differences were obtained with the Elite. Comparing whole blood values with those obtained in the aqueous blood compartment (Omni), even greater differences were observed. When all procedures were referred to the same glucose standard, the Ebio, Integra, Accutrend, and Omni results remained almost unchanged, whereas the Elite "moved" toward the Ebio results, and the Accu-Chek results toward the Omni results. Thus, traceability to an aqueous standard was observed with the Ebio, Integra, Accutrend, and Elite in all three sample systems. The Accu-Chek was only traceable in the presence of albumin, and HemoCue was not traceable at all. The clinical relevance of the differences observed between Ebio and POCT glucometers was tested by comparing the relative number of discordant classifications. The highest DRs were observed in the fasting state. They were higher in capillary blood than in the other sample systems. The DRs were found higher with POCT glucometers than with the other established laboratory procedure (Integra). Thus, at least in the fasting state, all POCT glucometers were less reliable than the established laboratory procedures and above the chosen criteria of clinical acceptability (DR < or = 5%). After transforming all glucometer results with a regression function (bias correction), the DRs were less than 5% if compared with the Ebio procedure in all sample systems. In conclusion, the WHO recommendation not to use POCT glucometers for diagnosing type 2 diabetes must be supported. However, after proper recalibration, the tested systems were acceptable. Therefore, manufacturers should reconsider their calibration procedure. Those POCT procedures should be preferred that can be referred to aqueous glucose solutions.

Blood Glucose↗

PubMed2004

Validation of a multistage asthma case-detection procedure for elementary school children.

OBJECTIVE: The purpose of this study was to validate a 3-stage asthma case-detection procedure for elementary school-aged children. METHODS: The study was performed in 10 elementary schools in 4 inner-city school systems, with a total enrollment of 3539 children. Results of the case-detection procedure were compared with the diagnosis of an asthma specialist study physician, to determine the sensitivity and specificity of the case-detection procedure. RESULTS: Ninety-eight percent of children returned the asthma symptoms questionnaires, and 79% of those children consented to additional testing. Results indicated that the 3-stage procedure had good validity, with sensitivity, specificity, and predictive value of 82%, 93%, and 93%, respectively. A 2-stage procedure using questionnaires and spirometry had similar validity, with sensitivity, specificity, and predictive value of 78%, 93%, and 93%, respectively. However, given the time and expense associated with the 2- or 3-stage procedure and the difficulty of obtaining physician follow-up evaluation of the case-detection diagnosis, schools may prefer to use a 2-item questionnaire that has a lower sensitivity (66%) but higher specificity (96%) and predictive value (95%). CONCLUSIONS: Case-detection programs are generally well received by school personnel and can identify children with unrecognized or undiagnosed disease, as well as those with a current diagnosis but poorly controlled disease. This study yields substantial information regarding the validity, yield, and specific types of children who might be identified with the use of such procedures. For the choice of the method of case detection used in a school, the strengths and weaknesses of each procedure, as well as the resources available for case detection, physician referral, and follow-up procedures, must be considered.

Asthma↗

PubMed2005

Ethnic differences in parent preference to be present for painful medical procedures.

OBJECTIVE: To examine ethnic differences between white, black, and Hispanic (English-speaking and Spanish-speaking) parents in their desire to remain present during their children's painful medical procedures. METHODS: A convenience sample of parents from each of 4 ethnic groups (black, white, and Hispanic [divided into English-speaking Hispanic and Spanish-speaking Hispanic]) was surveyed regarding their preferences for remaining present for 5 hypothetical painful procedures: venipuncture, laceration repair, lumbar puncture, fracture reduction, and critical resuscitation. For each procedure, a short description of the procedure was read to the parent, and a picture of the procedure was shown. The effect of ethnicity on parental desire to stay was examined by using the chi2 test and multivariate logistic regression. RESULTS: Complete data on 300 parents, 72 to 79 from each ethnic group, were obtained. There were no significant demographic differences between groups except that English-speaking Hispanic parents were younger, and black parents were relatively well educated, whereas Spanish-speaking Hispanic parents were relatively less well educated. Overall, the percentages of those who would wish to remain with their child during the procedures were 94% (venipuncture), 88% (laceration repair), 81% (lumbar puncture), 81% (fracture reduction), and 81% (critical resuscitation). The only significant ethnic difference was that English-speaking Hispanic parents were less likely to want to remain present during a critical resuscitation (P = .01). Black parents were less likely, and English-speaking Hispanic parents were more likely, to want physicians to decide for them whether they should remain present. Parents generally preferred to actively participate during the procedure by coaching and soothing their child rather than to just observe. CONCLUSIONS: We found few ethnic differences in parents' desire to be present during their child's painful medical procedures. Overall, the vast majority of parents would prefer to remain present even for highly invasive procedures.

Black or African American↗

PubMed1996

Cardiac arrhythmias during central venous catheter procedures in acute renal failure: a prospective study.

To define the frequency and risk factors of cardiac arrhythmias during central venous catheter procedures in acute renal failure, continuous electrocardiographic monitoring with permanent recording was performed before and during 201 guidewire insertions in 171 patients requiring a central venous catheter for parenteral nutrition and/or dialysis access (121 procedures in 107 patients with acute renal failure; 39 procedures in 31 patients with normal renal function; 41 procedures in 33 patients with ESRD on chronic hemodialysis). No differences in cardiac arrhythmia frequencies were found during baseline recording. New arrhythmias were documented in 85 cases (85/201; 42%) during the catheter procedure. Ventricular arrhythmia frequencies increased significantly in all groups, as compared with baseline values (P < 0.05 for the control group, P < 0.01 for the chronic hemodialysis group, P < 0.001 for the acute renal failure group); the most noteworthy increase was observed in the acute renal failure group. Statistically significant differences among frequencies of total ventricular arrhythmias, advanced ventricular arrhythmias, and ventricular tachycardia during central venous catheter procedures were found between the acute renal failure group and both the normal renal function group (P < 0.05 to P < 0.001), and the chronic hemodialysis group (P < 0.05 to P < 0.01). All arrhythmias resolved spontaneously soon after partial guidewire withdrawal; nine episodes were symptomatic (in one case, ventricular tachycardia, followed by 10 s asystolia); no death directly related to the catheter procedure was observed. BUN and serum creatinine levels, as well as guidewire length remaining inside the patient, were significantly higher (P < 0.01) in patients with cardiac arrhythmias during central venous catheter procedures as compared with patients without arrhythmias; differences in other variables known as possible risk factors for arrhythmias (anatomical position, preexistent cardiac disease, utilization of proarrhythmogenic drugs, hypoxemia, acid-base status, and serum electrolytes, etc.) were not significant. Our study suggests that (1) patients with acute renal failure are at increased risk for cardiac arrhythmias during central venous catheter procedures; (2) an important risk factor is also represented by guidewire overinsertion, a technical error that should be avoided.

Acute Kidney Injury↗

PubMed1978

The timeout ribbon: a nonexclusionary timeout procedure.

Recently, the use of timeout rooms has been questioned by various agencies, and some have adopted policies that prohibit or greatly restrict exclusionary timeout. The present study developed a timeout procedure that did not require removal of the misbehaver from the learning environment. The procedure was applied to the disruptive behaviors of five severely retarded children in an institutional special-education classroom. An observer prompted all teacher behaviors related to the procedures to assure their precise implementation. After baseline, a reinforcement-only condition was implemented. Each child was given a different colored ribbon to wear as a tie and received edibles and praise every few minutes for good behavior and for wearing the ribbon. When timeout was added, a child's ribbon was removed for any instance of misbehavior and teacher attention and participation in activities ceased for three minutes or until the misbehavior stopped. Reinforcement continued at other times for appropriate behavior. An ABCBC reversal design was used to demonstrate control of the behavior by the conditions applied. On average, the children misbehaved 42% and 32% of the time during the baseline and reinforcement conditions respectively but only 6% of the time during the timeout conditions. A followup probe during the new school year revealed that the teacher was able to conduct the procedure independently and that the children's disruptive behaviors were maintained at low levels. The practicality and acceptability of the procedure were supported further by the successful implementation of the procedure by a teacher in another state and by responses to a questionnaire given to 40 mental health professionals. The ribbon procedure appears to be a viable form of timeout, provided that disruptive behaviors during timeout can be tolerated within the setting, or a backup procedure such as exclusionary timeout can be tolerated within the setting, or a backup procedure such as exclusionary timeout is available when needed.

Adolescent↗

PubMed1993

Needle-stick injuries and blood contacts during invasive radiologic procedures: frequency and risk factors.

OBJECTIVE: Possible nosocomial transmission of blood-borne pathogens is a serious concern for health care workers and patients alike. Needle-stick injuries and blood contacts pose a risk of pathogen transmission during procedures. We performed a study to determine the frequency of injuries and blood contacts during invasive radiologic procedures and to examine procedure-related factors that may increase risk of injury or exposure. SUBJECTS AND METHODS: A prospective study of needle-stick injuries and blood contacts during invasive radiologic procedures was performed. During a 10-week period, information about procedures was recorded by technologists or physicians, and needle-stick injuries and exposures to patients' blood and body fluids were noted. Data were analyzed with the SAS statistical package. RESULTS: Accidental exposure to patients' blood and body fluids occurred in 15 of 501 cases (3.0%; 95% confidence interval, 1.7-4.9%). Of 729 operators at risk, 15 were exposed (2.0%; 95% confidence interval 1.1-3.3%). Exposure was parenteral in one case and cutaneous in 14. Risk of exposure was correlated with procedure duration (p = .003), but not with emergency vs elective procedure status (p = .796), procedure type (p = .275), or operator experience level (p = .554). Three needle-stick injuries (0.6% of cases) occurred, all with sterile instruments; bleeding occurred in two cases. Risk of injury was correlated only with procedure type (p = .046). In no case was a patient exposed to a physician's blood. CONCLUSION: Whereas cutaneous exposure of physicians to patients' blood was not infrequent, parenteral exposure was rare in this series. Most of the exposures in this study could have been prevented by the use of protective equipment. Patients' contact with physicians' blood did not occur in this study.

Blood↗

PubMed1999

Percutaneous abdominal and pelvic interventional procedures using CT fluoroscopy guidance.

OBJECTIVE: The purpose of our study was to assess the use of low-milliamperage CT fluoroscopy guidance for percutaneous abdominopelvic biopsy and therapeutic procedures. MATERIALS AND METHODS: We reviewed the clinical records and relevant imaging studies of 97 patients who underwent 119 percutaneous CT fluoroscopy-guided abdominal or pelvic procedures: fluid collection aspiration or drainage catheter insertion (n = 59), biopsy (n = 49), hepatocellular carcinoma ethanol ablation (n = 6), chemoneurolysis (n = 4), and brachytherapy catheter insertion (n = 1). These procedures were guided using a helical CT scanner providing real-time fluoroscopy reconstruction at six frames per second. A control panel and video monitor beside the gantry allowed direct operator control during all interventional procedures. RESULTS: One hundred twelve (94.1%) procedures were successfully performed using either a stand-off needle holder and continuous real-time CT fluoroscopy guidance or incremental manual insertion and intermittent CT fluoroscopy to confirm position. Image quality using low milliamperage was adequate for needle or drainage tube placement in all but two low-contrast liver lesions. Two hematomas were accessed but yielded no fluid on aspiration; one drainage procedure was abandoned after the patient developed endotoxic shock. Imaging of ethanol distribution during injection facilitated tumor ablation and neurolytic procedures. CT fluoroscopy allowed rapid assessment of needle, guidewire, dilator, and catheter placement, especially in nonaxial planes. Average CT fluoroscopy time for biopsy and therapeutic procedures was 133 sec (range, 35-336 sec) and 186 sec (range, 20-660 sec), respectively. CONCLUSION: CT fluoroscopy is a practical clinical tool that facilitates effective performance of percutaneous abdominal and pelvic interventional procedures.

Abdomen↗