[The results of an expert evaluation of continuity in the rehabilitation of the patients from hospitals and outpatient institutions].
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Adult↗
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The cost of osteoporosis in men: the French situation.
The objective of this study was to estimate the annual direct medical costs of osteoporosis and osteoporotic fractures incurred by French men > or =50 years of age. Costs were assessed from a societal perspective for 1999 and expressed in Euros. An expert panel was consulted to identify fractures attributable to osteoporosis according to International Classification of Diseases (ICD)-10 codes. Available age- and gender-specific osteoporosis attribution probabilities (OAP) were used to derive the proportion of health-care utilization for fractures resulting from osteoporosis. Hospital and ambulatory care costs due to fractures were obtained from French databases. A total of 23,260 acute hospitalizations were found to be caused by osteoporosis, 52% of which are for hip fractures. Mean cost per stay varied widely according to the site of fracture, from 1300 (wrist fracture) to 5900 (hip fracture). Consequently, the total cost of acute hospitalization amounts to 97.6 million, with hip fractures accounting for 73.2% of the expenditures. Rehabilitation and convalescence costs were estimated to be 90.8 million, generating a total hospital cost of 188.4 million. The total outpatient costs were estimated to be 9.1 million. Thus, the total medical costs of male osteoporosis amount to 197.5 million. A sensitivity analysis was performed to test the robustness of this figure. We estimate the number of fractures by applying international incidence rates from the literature to the French male population aged > or =50 years, whereas the OAP and unit costs were kept constant. This approach yielded an estimate of 21,857 fractures, which is only 6% below the base case. When compared with values from other countries, our study results appear very conservative.
Aged↗
Clinical pathway management of total knee arthroplasty: a retrospective comparative study.
BACKGROUND: Clinical pathways facilitate the management of defined patient groups using interdisciplinary plans of care. The aim of the present study was to evaluate the effectiveness of a clinical pathway in improving a range of selected outcome measures in patients who have undergone total knee arthroplasty (TKA). METHODS: The present study was conducted at Queen Elizabeth Hospital, Adelaide. Using a retrospective comparative study design, 119 TKA patients who were managed on a clinical pathway from July 1997 to January 1998 (group 2) were compared with a retrospective group of 58 patients who underwent the same procedure from July 1996 to January 1997 (group 1) prior to the pathway's implementation. The following outcomes were measured: length of hospital stay; postoperative complications; readmissions and emergency service visits within 6 months of discharge; day of transfer to the convalescent unit; convalescent unit utilization and admission and discharge times. RESULTS: There was a significant reduction in the median length of stay in group 2 patients (9 vs 7 days; P < 0.0001). In addition there was a 66% increase in the proportion of patients in group 2 who were admitted on the day of surgery (P < 0.0001) and a 19.6% increase in the number of patients discharged within 8 postoperative days (P < 0.01). There were no significant differences between the groups with respect to the occurrence of postoperative complications. Although there was a trend toward a reduction in emergency service utilization and readmissions within 6 months of discharge for patients managed on the pathway, this was not significant. CONCLUSIONS: The development and implementation of a TKA clinical pathway resulted in a significant reduction in length of stay and improved streamlining of admission, discharge and transfer processes without adversely affecting patient outcomes.
Aged↗
Needlescopic adrenalectomy--the initial series: comparison with conventional laparoscopic adrenalectomy.
OBJECTIVES: To report the initial series of needlescopic transperitoneal adrenalectomy and to compare the results with a contemporary series of conventional transperitoneal laparoscopic adrenalectomy performed at the same institution. METHODS: Fifteen patients underwent needlescopic adrenalectomy over a 4-month period. Outcome data were retrospectively compared with 21 conventional laparoscopic adrenalectomies performed over the preceding 12-month period at the same institution. The needlescopic technique included three subcostal ports (two, 2 mm; one, 5 mm) and one umbilical port for ultimate specimen extraction (10/12 mm). The laparoscopic technique included four subcostal ports (all 10/12 mm). Endoscopic transperitoneal adrenalectomy was completed by the standard technique in both groups. RESULTS: Baseline demographics were comparable between the needlescopic (n = 15) and laparoscopic (n = 21) groups. The needlescopic group had a shorter surgical time (169 versus 220 minutes, P = 0.05), less blood loss (61 versus 183 mL, P = 0.002), and shorter hospital stay (1.1 versus 2.7 days, P < 0.001). Convalescence averaged 2.1 weeks in the needlescopic group and 3.1 weeks in the laparoscopic group (P < 0.001). No significant complications occurred in either group. One patient in the needlescopic group was converted to conventional laparoscopy because of marked obesity; hospital stay in this patient was 2 days. CONCLUSIONS: Reported herein is the initial series of needlescopic adrenalectomy. Compared with conventional laparoscopy, needlescopic adrenalectomy results in an overnight hospital stay, rapid recovery, and excellent cosmesis. However, prior experience with conventional laparoscopy is essential before embarking on needlescopic surgery.
Adrenalectomy↗
[Study on direct economic-burden and its risk factors of osteoporotic hip fracture].
OBJECTIVE: To investigate the net "per case" direct economic burden of osteoporotic hip fracture of in-patients at Peking Union Medical College Hospital (PUMCH), and to explore the related factors which will influence the burden of the disease. METHODS: Data was from a retrospective questionnaire on 90 osteoporotic hip fracture in-patients of PUMCH above 50 years old from 1998 to 2002. The direct cost of fracture consisted of inpatient care, outpatient care, home care, appliance, and nutrition etc. Multiple statistics method was used to analyze the factors affecting the direct costs of disease. RESULTS: The average age of the studied population was 71.78 +/- 9.7 years, including 29 males and 61 females. Yearly direct economic burden for one patient of osteoporotic hip fracture was 32 776 RMB, in which hospitalization expense was 23 107 RMB, accounting for 70.5%. Factors which influencing total direct costs would include: length of hospitalization, occupation and the outcome of disease, while types of hip fracture,occupation and the length of hospitalization affecting the cost during hospitalization. The outcome of disease, length of hospitalization and rehabilitation influenced the cost during convalescence while age, type of payment and treatment, did not show significant influence on the cost of hip fracture. CONCLUSION: Osteoporosis had become a serious public health problem among the elderly, bringing about the increase of economic burden all over the world both on social healthcare and families of the patients. Our data provided base for preventive health care or health insurance on osteoporosis.
Adult↗
Pathways to long-term geriatric hospital care.
This paper describes the pathways that are taken to long-term geriatric hospital care. Information was collected for 160 people currently receiving such care, and it was found that 110 different pathways were taken to a long-term geriatric bed. The most commonly experienced accommodation settings were acute hospital care, and living in the community with some form of disability but no domiciliary services, which were also the most frequent ways of beginning the pathways. The ends of the pathways were characterized by acute hospital care, short-term geriatric or convalescent care and rest or residential care. Domiciliary services had been used by less than half of the sample, and many of these appeared to have been receiving only a minimal level of support. This paper also examines the role of the assessment and rehabilitation unit, and seeks to comment on how services designed to reduce the demand for long-term geriatric care have been used.
Aged↗
Randomized clinical trial of laparoscopic versus open appendicectomy.
BACKGROUND: Laparoscopy in patients with a clinical suspicion of acute appendicitis has not gained wide acceptance, and its use remains controversial. METHODS: In a randomized controlled trial of laparoscopic versus open appendicectomy, 583 of 828 consecutive patients consented to participate. Three hundred and one patients were allocated to open appendicectomy and 282 patients to laparoscopy, 65 of whom required conversion to open appendicectomy. Length of stay in hospital was the primary endpoint, while operating time, postoperative morbidity, duration of convalescence and cosmesis were secondary endpoints. RESULTS: Intention-to-treat analysis revealed an equally short hospital stay in the two groups (median 2 days). The median time to return to normal activity (7 versus 10 days) and work (10 versus 16 days) was significantly shorter following laparoscopy. Laparoscopy was associated with fewer wound infections (P < 0.03) and improved cosmesis (P < 0.001), but the operating time was longer (60 versus 40 min). Laparoscopy was associated with more intraperitoneal abscesses (5 versus 1 per cent) but, adjusted for a greater number of gangrenous or perforated appendices in this group, the difference failed to reach statistical significance. CONCLUSION: Hospital stay was equally short, whereas laparoscopic appendicectomy was associated with fewer wound infections, faster recovery, earlier return to work and improved cosmesis.
Adolescent↗
Changing illness perceptions after myocardial infarction: an early intervention randomized controlled trial.
OBJECTIVE: This study was designed to examine whether a brief hospital intervention designed to alter patients' perceptions about their myocardial infarction (MI) would result in a better recovery and reduced disability. DESIGN: In a prospective randomized study, 65 consecutive patients with their first MI aged were assigned to receive an intervention designed to alter their perceptions about their MI or usual care from rehabilitation nurses. Patients were assessed in hospital before and after the intervention and at 3 months after discharge from hospital. RESULTS: The intervention caused significant positive changes in patients' views of their MI. Patients in the intervention group also reported they were better prepared for leaving hospital (p<.05) and subsequently returned to work at a significantly faster rate than the control group (p<.05). At the 3-month follow-up, patients in the intervention group reported a significantly lower rate of angina symptoms than control subjects (14.3 vs. 39.3, p<.03). There was no significant differences in rehabilitation attendance between the two groups. CONCLUSIONS: An in-hospital intervention designed to change patients' illness perceptions can result in improved functional outcome after MI.
Attitude to Health↗
Pre-discharge immunization among hospitalized Filipino children.
Identifying opportunities to vaccinate eligible children is one way to boost rates of immunization especially in countries with low immunization coverage and where convalescence from infectious illness is a contraindication to vaccination. To determine the safety and immunogenicity of diphtheria-tetanus toxoid-pertussis and oral polio immunization, 210 convalescing infants and children and community controls, comparable image and nutritional status, were studied. Using the pertussis agglutination and poliovirus neutralization tests, quantitative serologic responses were compared in the two study groups. No significant differences in the incidence rates of febrile reactions (23% in controls; 28% in convalescents) of local reactions (92% in controls; 87% in convalescents) and of seroconversion (P greater than 0.05) were noted between the two groups. Our investigation suggests that infants and children convalescing from infectious illnesses can be safely and effectively vaccinated. This study further suggests that hospitalization provides an opportunity to vaccinate such children.
Child, Preschool↗
Management of adult patients with a left ventricular assist device.
The number of left ventricular assist device (LVAD) implantations is growing as a result of increased waiting periods for cardiac transplantation and the decreased availability of organ donors. Furthermore, the Food and Drug Administration (FDA) has approved permanent LVAD support. After an acute hospitalization, patients with LVADs may need prolonged convalescence in a healthcare facility because they have complex medical needs and are physically disabled. Admission criteria need to be developed as essential patient and nursing competencies need to be defined as a part of a successful LVAD program in an acute rehabilitation center. Acute rehabilitation centers can help patients with LVADs transition to a home setting.
Adult↗
Should laparoscopy be the standard approach used for radical nephrectomy?
Since its inception in June 1990, laparoscopic radical/total nephrectomy for renal tumor has been successfully applied worldwide to hundreds of patients. Recent 5-year follow-up data have shown this procedure to produce cancer control identical to that of open radical/total nephrectomy. Although in most centers the cost of the procedure remains higher than open surgery, the patient benefits of decreased pain, reduced hospitalization, less blood loss, and more rapid convalescence appear to be universal. At this time, we believe that laparoscopic radical/total nephrectomy for the treatment of renal tumors should become the new standard of care.
Humans↗
Pituitary and adrenal hormones in patients after myocardial infarction under ergometer load.
The levels of human growth hormone (HGH), ACTH and cortisol in the plasma of 100 middle-aged men were measured by means of radioimmunoassay (12 patients in the phase of hospitalization after myocardial infarction, 47 patients in convalescence, 31 patients in post-convalescence, 10 healthy men). Twenty patients in the phase of convalescence and all patients in post-convalescence did exercises on bicycle ergometer with submaximal loading. Patients after myocardial infarction showed significantly lower basic levels of HGH than healthy persons, and the increase in the HGH level induced by exercise was significantly lower. The hormones ACTH and cortisol showed only slight differences. The secretion of the pituitary hormones, mainly HGH, seems to be altered in patients after myocardial infarction.
Adrenocorticotropic Hormone↗
Effects of droperidol dosage on postoperative emetic symptoms following pediatric strabismus surgery.
STUDY OBJECTIVE: To compare the frequency of postoperative emetic symptoms and side effects in pediatric strabismus surgery using four doses of droperidol. DESIGN: Randomized, blinded study. SETTING: University eye institute. PATIENTS: 82 ASA physical status I and II pediatric patients, aged 1 to 16 years, undergoing outpatient strabismus surgery. INTERVENTIONS: Patients were assigned to one of four doses of droperidol (10, 20, 40, or 80 microg.kg(-1)) (Groups 1, 2, 3, and 4, respectively). All patients received the same anesthetic management, with droperidol administered intravenously immediately after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Postoperatively, patients were evaluated for emetic symptoms (nausea, retching, and/or vomiting) and side effects (postoperative sedation or extrapyramidal symptoms). There was a dose-dependent reduction of emetic symptoms seen with increasing droperidol dose. Predischarge emetic symptoms were 50%, 15%, 15%, and 5% in Groups 1, 2, 3, and 4, respectively (p < 0.009). Peak emetic symptoms were observed after discharge: 75%, 40%, 35%, and 15% in Groups 1, 2, 3, and 4, respectively (p < 0.003). Convalescence times, including awakening, extubation, recovery, and hospitalization, were unaffected by increasing droperidol dose. Sedation was similar in all groups and no patient exhibited any side effects. However, when patients exhibited emetic symptoms, discharge time increased from 207 +/- 57 minutes to 283 +/- 128 minutes (p < 0.001). CONCLUSIONS: Prophylactic administration of droperidol 80 microg.kg(-1) is most effective in reducing postoperative emetic symptoms without increasing time to discharge. In those patients with emetic symptoms who also received prophylactic droperidol, time to discharge was significantly delayed.
Adolescent↗
[Coronary surgery with minimum access and cardiopulmonary bypass].
From October 1997 to March 1998 we operated on seven patients with minimal incision, cardiopulmonary by-pass with femoral cannulation and antegrade blood cardioplegic arrest using the "endoclamp" (Heartport Inc.). The seven patients with isolated severe lesions of the left anterior descending underwent a left internal thoracic artery graft under direct vision. Three had saphenous vein coronary bypass grafts performed to the diagonal (2) and obtuse marginal branches of the left coronary artery. The median cardiopulmonary bypass duration was 75 minutes (30-230) and the aortic occlusion time was 33 minutes (10-117). No major complications occurred and only two minor ones were noted. The median intensive care unit stay was 2 days (1 to 4) and the total hospital stay was 6.5 days (3 to 13). All the patients are in NYHA FC I, without treatment and a follow up of 3 to 6 months after the surgery. With this method of myocardial revascularization with minimal incision and cardiopulmonary bypass the sternotomy-related complications can be avoided, the intensive care unit and hospital stay can be reduced with better convalescence for the selected patients. We believe that this technique is a valid option for an increasing number of patients.
Adult↗
Subclinical brain swelling in children during treatment of diabetic ketoacidosis.
Clinically apparent cerebral edema is a rare and often fatal complication of diabetic ketoacidosis. To determine whether subclinical brain swelling occurs more commonly, we obtained cranial CT scans in six children with diabetic ketoacidosis treated with fluid resuscitation and continuous low-dose insulin therapy. Control scans were obtained before hospital discharge. Compared with the scans during convalescence, the early scans of all six children showed a narrowing of the brain's ventricular system, compatible with brain swelling. Average changes in diameter were 1.3 +/- 0.1 mm for the third ventricle and 3.7 +/- 0.8 mm for the lateral ventricles (P less than 0.01). In addition, a narrowing of the subarachnoid spaces was subjectively noted during a blind reading of the early scans. Although no single scan was overtly indicative of cerebral edema, the data suggest that subclinical brain swelling may be a common occurrence during treatment of diabetic ketoacidosis in children. Sequential CT scans of the brain may provide a means of evaluating modifications of standard therapy aimed at preventing cerebral edema.
Adolescent↗
Laparoscopic hysterectomy.
PURPOSE OF REVIEW: In this review we intend to describe the recent developments and experience gained in recent years with the different types of laparoscopic hysterectomies, and to compare results with those of abdominal hysterectomy. RECENT FINDINGS: In the United States, in the last decade, there has been clear trend towards laparoscopic hysterectomy. An increase from 0.3% to 9.9% was observed within a 7-year period from 1990 to 1997. High costs and lack of appropriate educational systems for residents and fellows slows the anticipated spread of this relatively new modality. From some retrospective publications it seems that complication rates have increased in laparoscopic hysterectomies, especially those involving the urinary system. However, a recent analysis revealed a reasonable complication rate for the procedure, compared with abdominal hysterectomy, if the surgeon passes a learning curve of the first 30 procedures. A conflict arises in regard to preservation of the uterine cervix during laparoscopic hysterectomy. Alternative procedures, such as supracervical laparoscopic hysterectomy or classic intrafascial supra-cervical hysterectomy, have been proposed. However, careful long-term analysis of results demonstrates a high complication rate requiring further operations in 24% of patients. SUMMARY: Less intraoperative bleeding, shorter hospital stay with less morbidity and shorter convalescence period remains the obvious advantages of laparoscopic in comparison with abdominal hysterectomy.
Contraindications↗
Development of a postoperative self-assessment form.
This paper describes a patient self-assessment form developed for use in a research study examining early discharge and transitional nursing follow-up care for women with abdominal hysterectomy. Transitional care nursing involves preparation for an early discharge from the hospital and nursing follow-up for convalescence at home through an 8-week recovery period. The goal of transitional care is to assist the client in regaining her preoperative level of self-care. This article will include a brief overview of the ongoing research study, a description of the role of the clinical nurse specialist (CNS) in transitional care, and the use of the self-assessment form. The form is applicable to numerous clinical settings.
Clinical Nursing Research↗
Coping and psychosocial adaptation: longitudinal effects over time and stages in breast cancer.
OBJECTIVES: This study examined the relationship between coping and psychosocial adaptation in cancer patients over time and across distinct clinical events. METHODS: In a prospective longitudinal study 74 patients with breast cancer were observed for 3 to 5 years at 3- to 6-month intervals. A total of 684 interviews were conducted at different observation points. Three rating scales were used to assess coping and adjustment: first, the Bernese Coping Modes, an observer rating scale devised to elicit 26 coping modes aggregated in this paper as the five Basic Coping Strategies of support, self-control, denial, diverting, and negative-emotional; second, an observer rating scale to ascertain psychosocial adaptation; and third, a self-rating scale as a measure of either emotional distress or well-being. RESULTS: a) When aggregated in illness stages, coping and distress data on the observed clinical time points showed greater variability than time measures alone (analysis of variance (ANOVA) for repeated measures p < .001). b) A significant relationship between the Basic Coping Strategies and psychosocial adaptation was demonstrated using discriminant and correlational analysis. Furthermore, in stage-dependent Pearson r correlations (p < .05 to .001), a clear-cut relationship was found for hospitalization, chemotherapy, and rehabilitation, but not for convalescence and metastasis. c) A positive relationship was demonstrated between psychosocial adaptation and strategies that can be generally categorized as good forms of coping such as support and self-control, and, to a lesser degree, diverting and denial. Conversely, poor coping exerted a negative effect on almost all illness stages and on most criteria of adjustment. CONCLUSIONS: In long-term studies on psychosocial adaptation and coping, stage-related measures should be preferred to time measures alone. The implications of different strategies for the psychological treatment of cancer patients are discussed.
Adaptation, Psychological↗