Anesthesiologist board certification and patient outcomes

BACKGROUND: Board certification is often used as a surrogate indicator of provider competence, although few outcome studies have demonstrated its validity. The aim of this study was to compare the outcomes of patients who underwent surgical procedures under the care of an anesthesiologist with or without board certification. METHODS: Medicare claims records for 144,883 patients in Pennsylvania who underwent general surgical or orthopedic procedures between 1991 and 1994 were used to determine provider-specific outcome rates adjusted to account for patient severity and case mix, and hospital characteristics. Outcomes of 8,894 cases involving midcareer anesthesiologists, 11-25 yr from medical school graduation, who lacked board certification were compared with all other cases. Midcareer anesthesiologist cases were studied because this group had sufficient time to become certified during an era when obtaining certification was already considered important, and consequently had the highest rate of board certification. Mortality within 30 days of admission and the failure-to-rescue rate (defined as the rate of death after an in-hospital complication) were the two primary outcome measures. RESULTS: Adjusted odds ratios for death and failure to rescue were greater when care was delivered by noncertified midcareer anesthesiologists (death = 1.13 [95% confidence interval, 1.00, 1.26], P < 0.04; failure to rescue = 1.13 [95% confidence interval, 1.01, 1.27], P < 0.04). Adjusting for international medical school graduates did not change these results. CONCLUSIONS: When anesthesiology board certification is very common, as in midcareer practitioners, the lack of board certification is associated with worse outcomes. However, the poor outcomes associated with noncertified providers may be a result of the hospitals at which they practice and not necessarily their manner of practice.     

Carbon Dioxide and Gadopentetate Dimeglumine Venography to Guide Percutaneous Vertebroplasty

Percutaneous vertebroplasty with polymethylmethacrylate (PMMA) is an effective procedure for relieving pain due to vertebral body compression fractures. The technique employs iodinated contrast venography to exclude needle placement directly within the basivertebral complex. We present two cases in which carbon dioxide (CO₂) and gadopentetate dimeglumine venography was used to guide percutaneous vertebroplasty in patients with a contraindication to iodinated contrast.     

Psychosocial aspects of chronic illness in adolescence

Success in the survival of children with significant medical conditions has resulted in a dramatic increase in the prevalence of adolescents with chronic illness. Unfortunatelly, the traditional biomedical approach does not prepare practitioners for the complexities of managing chronic illness, because numerous psychosocial factors are involved. This article will address the need for integrating psychosocial issues into the assessment and treatment of the chronically ill adolescent. Assessment of the teen should incorporate an understanding of the developmental stages of adolescence, a review of how these developmental tasks are being accomplished, a discernment of individual characteristics, and knowledge of the family and community to which they belong. Management should take into account the phases of illness (acute, chronic or terminal) and encourage empowerment of the adolescent and family in decision making. A team approach that is community—based, comprehensive, and culturally appropriate is ideal.     

Phänomenologie zykloider Achsensyndrome und ihre Abgrenzung gegen eine schizophrene Kerngruppe

Zusammenfassung Der Begriff „zykloide Psychosen” bezeichnet eine zun?chst nach dem Erscheinungsbild abzugrenzende Art innerhalb der Gattung „schizophrener Formenkreis”. Ausgehend von der klinischen Beobachtung wird in der vorliegenden ph?nomenologisch-konzeptuellen Arbeit die Auffassung vertreten, da? die Leonhardschen Subtypen bzw. deren jeweilige Pole als Achsensyndrome zu begreifen sind, die w?hrend ein und derselben Episode gemeinsam auftreten und ineinander übergehen k?nnen. Die „inneren” Zusammenh?nge dieser Achsensyndrome werden herausgearbeitet. Neben dem kongruenten Verweisungscharakter ihrer Aufbauelemente erweist sich dabei das Fehlen struktureller Verformungen 1. von Affektausdruck und Affekt, 2. des Denkens und 3. der Bewegungsimpulse und -abl?ufe als entscheidende Differentia specifica gegenüber einer schizophrenen Kerngruppe. Unseren pr?zisierten Ph?nomenbegriff machen wir zur Grundlage einer Kritik bisheriger Operationalisierungsvorschl?ge, für die wir eine Alternative anbieten.