Impact of continued hospitalization in patients pre-treated with clopidogrel prior to coronary angiography and undergoing coronary artery bypass grafting

Pre-treatment of patients with clopidogrel prior to coronary angiography (CAG) and possible percutaneous coronary intervention (PCI) is a standard practice. Candidates for coronary artery bypass surgery (CABG) are discharged or remain in the hospital until CABG after clopidogrel is discontinued. We investigated whether any differences exist in the rates of surgical complications and outcomes between these two groups of patients. We conclude that continued hospitalization of clopidogrel pre-treated patients does not confer any safety benefit with regard to post-operative complications and 30-day mortality. Discharging these patients after CAG may reduce hospitalization costs.     

A comparison of the case-control and case-crossover designs for estimating medical costs of nonfatal fall-related injuries among older Americans

OBJECTIVES: Although the case-crossover design has been used widely in epidemiological and cost-offset studies as an alternative to the case-control design, it is rarely applied to cost-of-illness studies. In this study, costs for a series of hospitalized and nonhospitalized fall-related injuries were computed using the 2 approaches to allow for a direct comparison of the results. RESEARCH DESIGN: We used claims data from the Medicare fee-for-service 5% Standard Analytical Files. For the case-control design, those who sustained nonfatal fall-related injuries were tracked for 1 year after their first fall, and costs were compared, using regression analysis, to annual costs for a comparison sample of nonfallers. The case-crossover design used a modified regression approach that compared monthly costs of fallers before and after fall. RESULTS: We present unit costs for falls requiring (1) a hospitalization resulting in a live discharge, (2) an emergency department visit not resulting in an admission, and (3) falls requiring office-based or hospital outpatient visits only. Using the case-control design, these costs were $22,260, $3890, and $5040 respectively. Using the case-crossover design, these estimates were reduced to $20,920, $3230, and $4200. CONCLUSIONS: On average, estimates of the costs of fall injuries from the case-control design were between 6% and 17% greater than those from the case-crossover approach. These differences likely result from our inability to control for comorbidity differences between fallers and nonfallers in the case-control design. Under several scenarios, including unobserved heterogeneity between cases and controls, the case-crossover design, although computationally more intensive, produces more accurate results.     

Can intestinal innervation be preserved in pancreatoduodenectomy for cancer? Results of an anatomical study

Twenty dissections were carried out, in all of which the splanchnic nerves, celiac plexuses, capital pancreatic plexus and superior mesenteric plexus were identified and traced. The capital pancreatic plexus was formed from two bundles, the first taking its origin from the right celiac plexus, the second from the superior mesenteric plexus. These two bundles joined together just behind the head of the pancreas. Two preganglionic bundles, a ganglion and two postganglionic bundles composed the superior mesenteric plexus. Postganglionic bundles received fibers from both right and left celiac plexuses. In small cancers a thin layer of nervous tissue around the superior mesenteric artery might be spared in order to avoid diarrhea from intestinal denervation. This study has provided anatomical evidence that a part of the mesenteric plexus, which receives fibers from both left and right celiac plexuses, maintains a sufficient intestinal innervation.     

Rethinking the teaching major in nursing under current curricular guidelines

This is a report about the design of a curricular proposal for the Teaching Major in Nursing from Federal University of Rio Grande do Sul (UFRGS). In this article, we present a brief history line of this undergraduate program, its current curricular structure at UFRGS, as well as existing legislation both at its educational and nursing levels. Finally, the results of studies carried out by the Teaching Majors Coordination (COORLICEN) at UFRGS are reported, besides a proposal for curricular changes to the nursing major, according to the National Curricular Guidelines for Teacher Education and legislation pertaining to this profession.     

Allogeneic blood transfusion requirements after minimally invasive versus conventional aortic valve replacement: a risk-adjusted analysis

BACKGROUND: Aortic valve replacement (AVR) through a partial sternotomy (mini-AVR) has been suggested to significantly reduce postoperative morbidity compared with conventional AVR. This study sought to investigate whether mini-AVR patients require fewer transfusions than patients who had conventional AVR. METHODS: Of 511 patients who had AVR, 56 had mini-AVR and 455 had conventional AVR. A matched-case logistic regression analysis was used to adjust for these imbalances between groups. RESULTS: No patient in the mini-AVR cohort required conversion to a conventional AVR. Cardiopulmonary bypass time was longer in the mini-AVR group compared with the conventional AVR group, with a median of 102 minutes (range, 78 to 119 minutes) versus 75 minutes (range, 61 to 96 minutes; p < 0.01) in the conventional AVR group. A total of 31 patients (55%) in the mini-AVR group and 336 patients (74%) in the conventional sternotomy group required transfusions during their hospital stay (p < 0.01). After adjusting for differences in preoperative risk factors, year of operation, and surgeon, by matching on propensity score, the differences were not statistically significant (odds ratio = 0.84, 95% confidence interval = 0.40 to 1.75, p = 0.63). CONCLUSIONS: Mini-AVR produces better wound cosmesis and less surgical trauma but requires more time to perform. Matched-case analysis failed to show a significant difference in blood transfusion requirements after mini-AVR compared with the conventional AVR approach.     

Paediatric trainees and the transportation of critically ill neonates: experience, training and confidence

AIM: To study the experience of, training in, and confidence in the transportation of critically ill neonates amongst paediatric trainees in one UK region. DESIGN: An anonymized questionnaire was sent to all middle grades with paediatrics National Training Numbers from the Trent region. RESULTS: The response rate was 78%. Less than half (45%) of the respondents reported receiving any training in the transportation of neonates, either in the UK or abroad; 45% (30/66) of the trainees reported having performed 10 or fewer neonatal transfers. The self-perceived confidence for transporting neonates was scored on a 10-point scale, to produce a "confidence score", the median score being 7 (IQ range 5, 8). Both as a group and individually, the trainee paediatricians were more confident in transporting neonates than older infants or children (p < 0.0001). Using multiple analysis of covariance, it was found that the most important and significant variables affecting the "confidence scores" for the inter-hospital transportation of critically ill neonates were receipt of any relevant transport training, and the current frequency of transports performed. CONCLUSIONS: Many training-grade paediatricians lack both the experience and training in transporting critically ill neonates, factors that were found to affect their confidence in transferring sick neonates. As the overwhelming majority of neonatal transports in the UK are still arranged by individual units and performed by training-grade paediatricians, concerns regarding both the safety and effectiveness of the current service provision for the inter-hospital transfer of critically ill neonates remain valid.     

Silastic drains vs conventional chest tubes after coronary artery bypass

STUDY OBJECTIVES: To investigate differences in drainage amounts and early clinical outcomes associated with the use of Silastic drains, as compared with the conventional chest tube after coronary artery bypass grafting (CABG). DESIGN: Retrospective nonrandomized case control study. SETTING: A tertiary teaching hospital. Patients and participants: Outcome data from 554 patients who underwent postoperative pericardial decompression using small Silastic drains were compared with those from 556 patients who had conventional chest tubes after first-time CABG at our institution between January 1 and August 1, 2000. Measurement and results: Univariate analysis of preoperative characteristics was used to ensure similarity between the two patient groups. Operative mortality, mediastinitis, reoperation for bleeding, and early and late cardiac tamponade occurred in 9 patients (1.6%), 6 patients (1.1%), 6 patients (1.1%), 6 patients (1.1%), and 1 patient (0.2%), respectively, in the Silastic drain group, compared with 11 patients (2.0%), 9 patients (1.6%), 4 patients (0.7%), 2 patients (0.4%), and 6 patients (1.1%) in the conventional group. No statistically significant differences between the two drains were identified. Drainage amounts (mean +/- SD) were 552.2 +/- 281.8 mL and 548.8 mL +/- 328.7 mL for the Silastic and conventional groups, respectively (p = 0.51). Postoperative length of stay was longer for the conventional chest tube group (median, 5 d; range, 1 to 119 d) when compared to the Silastic drain group (median, 4 d; range, 1 to 66 d; p = 0.01). CONCLUSIONS: We demonstrated that small Silastic drains are equally as effective as the conventional, large-bore chest tubes after CABG with no significant risk of bleeding or pericardial tamponade. Additionally, use of Silastic drains allows more mobility than the conventional chest tubes. As a result of this study, there was a change in our clinical practice toward the exclusive use of Silastic drains after all cardiac surgical procedures.     

Ventral hernia repair: a study of current practice

Ventral wall hernias are common; despite this, there are no guidelines on the best surgical management. The aim of this study was to examine the types of repair in use for abdominal wall hernias in the West of Scotland over a 3-month period. Data were gathered on 120 patients. There were 60 incisional, 32 umbilical, and 28 epigastric hernias. The main indication for repair was pain (78%), while 12 patients (10%), presented acutely with incarceration or strangulation. The most common method of repair was sutured (55%), followed by mesh (29%) and Mayo repair (16%). There was no correlation between use of mesh and hernia size or whether repair was for a recurrent hernia. Surgical practice varies widely in the repair of ventral wall hernias. Clinical trials are required to establish the best method of repair for this common condition. Electronic Publication