Technical factors of CT angiography studied with a carotid artery phantom.

PURPOSETo evaluate scanning parameters (conventional versus spiral CT, section thickness, and pitch) and vessel orientation in the performance of CT angiography.METHODSConventional CT and 1.0-, 1.5-, and 2.0-pitch spiral CT acquisitions of a carotid phantom designed with vessels oriented parallel to the z-axis, 45 degrees oblique, and perpendicular to the z-axis were obtained with section thicknesses of 2, 4, and 8 mm. The phantom contained 32 vessels with 0% to 100% stenoses. Normal and stenotic luminal diameters were measured and the number of artifacts was assessed.RESULTSNo overall difference was observed among conventional and spiral CT acquisitions obtained with pitches of 1.0, 1.5, and 2.0. With thicker sections, CT angiographic accuracy decreased and artifacts increased. The three-vessel orientations were relatively comparable in accuracy in terms of the percentage of stenosis measured. Vessels parallel to the z-axis suffered less artifactual degradation. Unique artifacts, such as luminal distortion and beam hardening, were observed in vessels oriented at 45 degrees and perpendicular to the z-axis.CONCLUSIONUse of thinner sections with vessels oriented parallel to the z-axis optimizes CT angiographic quality. There is no apparent degradation with the use of spiral CT, and a pitch of 1.5 or 2.0 provides results equivalent to 1.0-pitch spiral studies.     

Eliminating Intensive Postoperative Care in Same-day Surgery Patients Using Short-acting Anesthetics

Background: A multidisciplinary effort was undertaken to determine whether patients could safely bypass the postanesthesia care unit (PACU) after same-day surgery by moving to an earlier time point evaluation of recovery criteria.

Methods: A prospective, outcomes research study with a baseline month, an intervention month, and a follow-up month was designed. Five surgical centers (three community-based hospitals and two freestanding ambulatory surgical centers) were utilized. Two thousand five hundred eight patients were involved in the baseline period, and 2,354 were involved in the follow-up period. Outcome measures included PACU bypass rates and adverse events. Intervention consisted of a multidisciplinary educational program and routine feedback reports.

Results: The overall PACU bypass rate (58%) was significantly different from baseline (15.9%, P < 0.001), for patients to whom a general anesthetic was administered (0.4-31.8%, P < 0.001), and for those given other anesthetic techniques (monitored anesthesia care, regional or local anesthetics; 29.1-84.2%, P < 0.001). During the follow-up period, the average (SD) recovery duration for patients who bypassed the PACU was significantly shorter compared to that for patients who did not bypass, 84.6 (61.5) versus 175.1 (98.8) min, P < 0.001, with no change in patient outcome. Patients receiving only short-acting anesthetics were 78% more likely (P < 0.002) to bypass the PACU after adjusting for various surgical procedures.     

Delusions of disfigurement in a woman with acne rosacea.

A 36-year-old woman with newly diagnosed acne rosacea is presented. Her skin changes were noticeable only under closest scrutiny, but she quit her job, became despondent about her acne, and developed suicidal ideation. The diagnosis and treatment of this patient allow a broader discussion of the somatically focused patient whose ideation reaches delusional intensity.     

A group intervention to reduce smoking in individuals with psychiatric disorder: brief report of a pilot study

Objectives: To evaluate a group intervention to help individuals with psychiatric disorder stop smoking.
Method: A waitlist-treatment crossover design. Outcome measures included smoking cessation, motivation to stop, the Fagerstrom Test for Nicotine Dependence (FTND), urinary cotinine and psychiatric symptoms on the General Health Questionnaire.
Results: 38 subjects participated, of whom 19 completed the waitlist and intervention phases. There were no significant differences between subjects and dropouts. During the waitlist period there were no significant changes in tobacco use. At the end of the intervention, almost a quarter had stopped smoking, ( z = -2.24, p =0.02). Subjects also showed significant improvements on state of change, FTND score and urinary cotinine levels. These improvements were maintained at three-month follow-up (n=10). Psychiatric morbidity showed no change.
Conclusions: It is possible to reduce smoking in individuals with psychiatric disorder.
Implications: Larger randomised controlled trials are indicated to determine the relative contributions of nicotine replacement, bupropion and group interventions to smoking cessation in this population.     

Pericardium as a thoracic aortic patch: glutaraldehyde-fixed and fresh autologous pericardium

The repair of complex coarctation of the aorta often requires an aortic patch. Prosthetic patches lack growth potential and are associated with an increased incidence of aneurysm formation opposite the patch. We compared buffered glutaraldehyde-fixed patches, used in six animals (group 1), and untreated autologous pericardial aortic patches, used in five animals (group 2). Weanling pigs underwent pericardial patch replacement of a 1 X 2-cm diamond-shaped segment of the lateral wall of the descending thoracic aorta at the level of the aortic isthmus. Six months following patch aortoplasty, the animals were killed and the in situ patch dimensions were measured and compared to the measurements obtained at implantation. The increases in length, recorded as mean percentage change +/- SEM, were 34.7 +/- 3.7% for group 1 and 102.8 +/- 20.3% for group 2 animals; the increases in width were 91.4 +/- 31.7% for group 1 and 192.4 +/- 31.4% for group 2. The percentage changes for both length and width were significantly different between groups (P less than 0.05). Pull strength testing of standard-size patch samples demonstrated no significant difference in tensile breaking load between groups: group 1 = 959 +/- 277 g, group 2 = 795 +/- 86 g. Thoracic aortography revealed no evidence of stenosis or aneurysmal dilation in either group. Autologous pericardium is resilient, strong, and readily available and has expansile potential that makes it an ideal aortic patch material. We conclude that glutaraldehyde fixation does not provide additional strength and limits graft expansile potential when compared to untreated pericardium.     

Financial risk, hospital cost, complications and comorbidities (CCc) in non-CC stratified urology diagnostic related groups

The federal Medicare Diagnosis Related Group payment mechanism is undergoing constant change. Significant interest has been generated at the health policy level regarding reimbursement for patients with complications and comorbidities. The purpose of this study was to analyze hospital resource consumption for patients in the seventeen urology non-complicating condition (CC) stratified Diagnostic Related Groups (DRGs), currently 45 percent of urology DRGs. We analyzed 185 Medicare patients in these non-CC stratified urology DRGs and found that patients with more CCs per patient had higher total hospital costs per patient, financial risk under DRGs, a greater percentage of outliers, and a higher mortality, than patients in these same DRGs with fewer CCs per patient. These findings suggest that the current DRG system is inequitable to some patients and certain hospitals vis-a-vis non-CC stratified urology DRGs. The Health Care Financing Administration has not significantly changed the complicating condition urology DRG classification, as of its recent May, 1988 legislation. Financial disincentives to treat these patients may affect both their access and quality of care in the future.     

Regional differences in oesophageal motor function

Abstract  We tested the hypotheses that oesophageal bolus transit and motor function vary regionally, with bolus viscosity and with body position. In healthy volunteers, we measured the bolus head advance time, bolus presence time and bolus transit time in the proximal and distal oesophagus using water and viscous materials. We compared concurrent manometric responses. Bolus head advance time, bolus presence time and bolus transit time were longer in the distal oesophagus during water and viscous swallows in the upright and supine positions. The total bolus head advance time and transit time, measured across the entire oesophageal body, were shorter for water than viscous swallows. The amplitudes of peristaltic pressure waves were lower for viscous swallows, and varied as a function of region. These studies demonstrated true functional differences between the proximal and distal oesophagus using multichannel intraluminal impedance and that the viscosity of the bolus is a determinant of oesophageal function.