Improving the quality of coronary bypass surgery with intraoperative angiography: validation of a new technique.

OBJECTIVES: We report a comprehensive assessment and validation of a new intraoperative angiography technique. BACKGROUND: Technical problems at the site of the distal anastomosis compromise an underappreciated proportion of coronary bypass grafts. The absence of a systematic, validated technique to verify graft patency in the operating room represents a significant breach in quality assurance. METHODS: Fluorescent indocyanine green (ICG) dye is excited with dispersed laser light to create an angiographic depiction of the graft, native vessel, and anastomosis. One-hundred twenty patients underwent ICG angiography. Angiograms were reviewed for reliability and validity studies. RESULTS: A total of 348 coronary bypass grafts were studied. Each ICG angiogram took 2.2 +/- 1.1 min to perform. The ICG angiography found 4.2% of patients had significant graft problems requiring major revision. Quality of visualization was rated according to a seven-point Likert scale (1 = worst, 7 = best). Among conduits, saphenous veins were best visualized (mean score +/- standard deviation), 6.4 +/- 1.5 versus 5.5 +/- 1.9 for internal mammary arteries and 4.4 +/- 2.3 for radial arteries (p = 0.02). Location of distal anastomosis did not influence quality of visualization. There was high inter-rater reliability for graft revision (kappa = 1.0) and graft patency (kappa = 0.97) between surgeons. Sensitivity and specificity of the ICG angiograms for graft stenosis >50% was 100% among 22 grafts also studied with X-ray angiography. CONCLUSIONS: Information from ICG angiograms led to graft revisions for technical problems in 4.2% of patients that would have otherwise gone unrecognized. Intraoperative angiography is an emerging tool for improving the quality of coronary bypass surgery.     

The risk of seizures after receipt of whole-cell pertussis or measles, mumps, and rubella vaccine

BACKGROUND: The administration of the diphtheria and tetanus toxoids and whole-cell pertussis (DTP) vaccine and measles, mumps, and rubella (MMR) vaccine has been associated with adverse neurologic events, including seizures. We studied the relation between these vaccinations and the risk of a first seizure, subsequent seizures, and neurodevelopmental disability in children. METHODS: This cohort study was conducted at four large health maintenance organizations and included reviews of the medical records of children with seizures. We calculated the relative risks of febrile and nonfebrile seizures among 679,942 children after 340,386 vaccinations with DTP vaccine, 137,457 vaccinations with MMR vaccine, or no recent vaccination. Children who had febrile seizures after vaccination were followed to identify the risk of subsequent seizures and other neurologic disabilities. RESULTS: Receipt of DTP vaccine was associated with an increased risk of febrile seizures only on the day of vaccination (adjusted relative risk, 5.70; 95 percent confidence interval, 1.98 to 16.42). Receipt of MMR vaccine was associated with an increased risk of febrile seizures 8 to 14 days after vaccination (relative risk, 2.83; 95 percent confidence interval, 1.44 to 5.55). Neither vaccination was associated with an increased risk of nonfebrile seizures. Analyses of automated data alone gave results similar to the analyses of the data from medical-record reviews. The number of febrile seizures attributable to the administration of DTP and MMR vaccines was estimated to be 6 to 9 and 25 to 34 per 100,000 children, respectively. As compared with other children with febrile seizures that were not associated with vaccination, the children who had febrile seizures after vaccination were not found to be at higher risk for subsequent seizures or neurodevelopmental disabilities. CONCLUSIONS: There are significantly elevated risks of febrile seizures on the day of receipt of DTP vaccine and 8 to 14 days after the receipt of MMR vaccine, but these risks do not appear to be associated with any long-term, adverse consequences.     

Pathological findings in 377 patients with differentiated thyroid cancer in a single centre

Aim-Background

The purpose of this study is to review the pathology findings of 377 patients diagnosed with differentiated thyroid cancer (DTC) in a single centre over a period of six years.

Methods

Retrospective review of all total and near-total thyroidectomies (TT and NTT) performed in a single institution. Clinical records were accessed for patient demographic data and clinical characteristics. Patients with a histopathologic diagnosis of DTC were grouped in incidental DTC and non-incidental DTC groups and TNM staging was used.

Results

1465 thyroidectomies were included. The M:F ratio was 1:2.9. 377/1465 patients had a histologic diagnosis of DTC (26%). T1b group (n=227) had a statistically significant higher number of cases, where tumor invaded the capsule, tumor extending extrathyroidally, tumor invading the blood vessels compared to T1a group (n=64) (p=0.001 for all three variables). T1a group had a statistically significant higher number of papillary conventional variant of DTC and more unifocal tumors (p=0.045 and p=0.004 respectively). In the non-incidental DTC group (n=79), there were 29 patients (37%) in T1a category and 16 of them had a unifocal papillary DTC.

Conclusions

16/79 of patients (20%) operated for DTC had a subcetrimetric, unifocal papillary DTC. According to the 2106 American Thyroid Association (ATA) Management Guidelines, these patients could potentially have been treated with a lobectomy alone. Patients in T1b category present more aggressive histologic features and should undergo multi-disciplinary team discussion to decide optimal surgical treatment.

     

Relation of Stride Activity and Participation in Mobility-Based Life Habits Among Children With Cerebral Palsy

Objective

To examine the relation between walking performance and participation in mobility-related habits of daily life in children with cerebral palsy (CP). To date, walking outcomes in CP have been capacity-based (what a child does in structured setting). Physical activity performance (what a child really does in daily life) has been documented to affect the relation of capacity-based gross motor measures and participation.

Design

Cross-sectional prospective cohort study.

Setting

Regional pediatric specialty care centers.

Participants

A cohort of ambulatory children with CP (N=128; age, 2 to 9y; 41% girls; 49% having hemiplegia) participated.

Interventions

Not applicable.

Main Outcome Measures

Walking performance was quantified from a 5-day sample of accelerometry data. Stride activity was summarized through the outcomes of the average number of total strides per day (independent of intensity) and the average number of total strides per day at >30 strides/min (marker of intensity). Mobility-based participation was assessed by using the Assessment of Life Habits for Children questionnaire categories of personal care, housing, mobility, and recreation. Regression models were developed controlling for sex, age, cognition, communication, pain, and body composition.

Results

The average number of total strides per day was positively associated with the personal care, housing, mobility, and recreation Assessment of Life Habits for Children questionnaire categories (β=.34–.41, P<.001). The average number of total strides per day at >30 strides/min was associated with all categories (β=.54–.60, P<.001).

Conclusions

Accelerometry-based walking activity performance is significantly associated with levels of participation in mobility-based life habits for ambulatory children with CP. Evaluation of other factors and the direction of the relation within the International Classification of Functioning, Disability and Health is warranted to inform rehabilitation strategies.     

Racial disparity in hospice use in the United States in 2002

We used complete Centers for Disease Control death certificate records and the Centers for Medicare and Medicaid Services 100% Standard Analytic File for hospice claims for 2002 to examine differences in hospice utilization between African-American and white decedents living in the United States. White decedents were more likely to use hospice in the year before their death than African-American decedents (29% vs 22%). Cause-specific hospice utilization rates among women were consistently higher than among men within a given race. African-American decedents were consistently less likely to use hospice than white decedents for almost all conditions. Hospice utilization was lower among African-American than among white decedents in 31 of 40 states. The higher the overall hospice utilization in a state, the less the positive difference between white and African-American usage rates; that is, the more accepted hospice is, as measured by 'market share', the lower the racial disparity in its use.