SRTR Center-Specific Reporting Tools: Posttransplant Outcomes

Measuring and monitoring performance—be it waiting list and posttransplant outcomes by a transplant center, or organ donation success by an organ procurement organization and its partnering hospitals—is an important component of ensuring good care for people with end-stage organ failure. Many parties have an interest in examining these outcomes, from patients and their families to payers such as insurance companies or the Centers for Medicare and Medicaid Services; from primary caregivers providing patient counseling to government agencies charged with protecting patients.
The Scientific Registry of Transplant Recipients produces regular, public reports on the performance of transplant centers and organ procurement organizations. This article explains the statistical tools used to prepare these reports, with a focus on graft survival and patient survival rates of transplant centers—especially the methods used to fairly and usefully compare outcomes of centers that serve different populations. The article concludes with a practical application of these statistics—their use in screening transplant center performance to identify centers that may need remedial action by the OPTN/UNOS Membership and Professional Standards Committee.     

167例老年人心力衰竭的循证治疗实践

目的:探讨老年人充血性心力衰竭(CHF)的循证医学(EBM)标准化治疗。方法:167例确诊为CHF的住院患者,年龄60￣90岁,平均(74.38±6.84)岁,按照循证医学的基本原理,在病因、诱因和改善心衰症状的基础上,强调能改善预后的神经内分泌拮抗剂的应用。结果:本组167例CHF患者,显效96例(57.5%),有效62例(37.1%),总有效率94.6%,死亡9例(5.4%)。神经内分泌拮抗剂践行率分别为:ACEI类119例(71.3%),β受体阻滞剂69例(41.32%),醛固酮拮抗剂88例(52.7%);随访6￣36个月,平均(16.25±9.30)个月;107例(67.7%)再入院1￣5次,院外死亡6例。结论:按照EBM原理对老年CHF患者制定的个体化治疗方案,效果理想。在老年CHF患者中,神经内分泌拮抗剂践行率较低,可能是再住院次数多的原因之一。     

Challenging the world: patient safety and health care-associated infection.

Improving the safety of patient care is an issue which affects health systems in both developed and developing countries. To co-ordinate and accelerate improvements in patient safety, the World Health Organization (WHO) has supported the creation of the World Alliance for Patient Safety which was launched in October 2004. The six action areas of the Alliance are Patients for Patient Safety, Taxonomy, Research, Solutions for Patient Safety, Reporting and Learning, and a biennial Global Patient Safety Challenge. The first Challenge covering 2005-2006 was launched in October 2005 under the banner 'Clean Care is Safer Care'. The Challenge addresses health care-associated infection, a major, patient safety problem affecting hundreds of millions of people worldwide.     

Diabetic and nondiabetic hyperglycemia in the ICU

Hyperglycemia is a common feature in critically ill patients, whether they are diabetic or not, and it is associated with unfavorable outcome. The more severe the underlying disease, the more important the hyperglycemia appears to be although, we still cannot define whether hyperglycemia is just a marker of the severity of the acute illness or rather an active contributor to poor outcome. The review of the literature on this subject published from 2001 up today conveys a massive amount of information the interpretation of which is equivocal, due to the heterogeneity of patients (nondiabetic vs. diabetic, medical intensive care unit (ICU) pts vs. surgical ICU pts) and of interventions (dose and modality of insulin infusion).The association between high glucose level and mortality is strong in critically ill patients without a previous history of diabetes. Admission hyperglycemia seems to be an independent risk factor of in-hospital mortality in patients both with and without diabetes in cardiac, cardiothoracic and neurosurgical ICUs. No data are still available on general surgical ICU patients.Tight control of blood glucose levels has been demonstrated to improve outcome in both diabetic and nondiabetic critically ill patients. In surgical ICUs, tight glucose control improves mortality and reduces morbidity only among patients admitted in ICU for more than 5 days, while outcome is not improved in patients who stay in ICU for less than 3 days.However, it is not yet understood if such favorable effect is secondary to glucose control itself or if insulin plays a part, by means of its nonglucose, anabolic effects. More randomized controlled trials are needed, addressing specific issues—such as the optimal target glucose concentration and the most effective insulin regimen—especially in the general surgical patient.     

老年牙周组织疾病216例证候分析

目的 探讨老年牙周组织疾病的证候特点。方法 对 1998 年 1 月-2003 年 12 月门诊接诊的 216 例老年牙周组织疾病进行回顾性分析。结果 阴虚火旺型 124 例(57.4%),气血不足型 51 例(23.6%),胃火炽盛型 16 例(7.5%),气滞血瘀型 14 例(6.4%),痰湿阻络型 11 例(5.1%)。结论 老年牙周组织疾病证候表现以虚为主、虚中夹实,阴虚火旺型和气血不足型是其主要证候类型。     

瑞波西汀与多虑平治疗老年抑郁症对照研究

目的观察瑞波西汀治疗老年抑郁症的疗效和安全性。方法随机将60例年龄≥60岁的老年抑郁症患者分为多虑平组（30例）和瑞波西汀组（30例），疗程6周，采用汉密尔顿抑郁量表（HAMD）和副反应量表（TESS）在治疗前和治疗后1、2、4、6周末评定药物疗效和副反应。结果两组疗效无显著差异，HAMD总分反各因子分从疗后2周至6周均较治疗前显著降低，两组间比较无显著性差异；治疗结束时TESS评分瑞波西汀组显著低于多虑平组。结论瑞波西汀适合于老年抑郁症患者的治疗，服用方便、安全，可首选使用。     

Risk groups for clinical complications of norovirus infections: an outbreak investigation

Norovirus infections have been described as self-limiting diseases of short duration. An investigation of a norovirus outbreak in a university hospital provided evidence for severe clinical features in patients with several underlying diseases. Clinical outcomes of norovirus infection were defined. Risk-factor analysis targeting underlying diseases and medication was performed using multivariate analyses. In five outbreak wards, 84 patients and 60 nurses were infected (an overall attack rate of 32% in patients, and 76% in nurses). The causative agent was the new variant Grimsby virus. Severe clinical features, including acute renal failure, arrhythmia and signs of acute graft organ rejection in renal transplant patients, were observed in seven (8.3%) patients. In multivariate analyses, cardiovascular disease (OR 17.1, 95% CI 2.17-403) and renal transplant (OR 13.0, 95% CI 1.63-281) were risk-factors for a potassium decrease of >20%. Age >65 years (OR 11.6, 95% CI 1.89-224) was a risk-factor for diarrhoea lasting >2 days. Immunosuppression (OR 5.7, 95% CI 1.78-20.1) was a risk-factor for a creatinine increase of >10%. Norovirus infections in patients with underlying conditions such as cardiovascular disease, renal transplant and immunosuppressive therapy may lead to severe consequences typified by decreased potassium levels, increased levels of C-reactive protein and creatine phosphokinase. In the elderly, norovirus infection may lead to an increased duration of diarrhoea. Therefore patients at risk should be hospitalised early and monitored frequently. Strict preventional measures should be implemented as early as possible to minimise the risk of nosocomial outbreaks.     

Guardians of health: The dimensions of elder caregiving among women in a Mexico City neighborhood

Little is known about the family care of older adults in Mexico and the role of women in this process. To begin to fill this knowledge gap, this paper describes how a small sample of low-income women in one Mexico City neighborhood conceptualized the caregiver role and identified the forms of assistance they gave to their older relatives on a daily basis. A grounded theory approach was used to collect and analyze the data. Forty-one semi-structured qualitative interviews were conducted with female caregivers. The age of participants was between 19 and 83 years, and care recipients between 56 and 92 years. The relationship of caregiver to care recipient was wife, daughter, daughter-in-law, granddaughter, sibling, and other relative. The mean length of time providing care was 5 years. Most participants were not employed outside the home, and the median monthly household income was 2000 pesos. We found that caregiving was a life-changing event, with 27 of 41 participants viewing themselves as guardians. Caregivers' emphasis was on care recipients' emotional needs in order to provide “the most precious gift” of “time and attention.” Two forms of assistance were ‘keeping company’ and ‘watching out’ as safeguards against poor health or further decline in health. These findings increase the cultural understanding of caregiving in Mexico. Further research is needed to test the caregiving concepts identified in this study.     

Bilateral Mid-Diaphyseal Femoral Stress Fractures in the Elderly

Abstract Background: Osteoporosis is characterized by low bone density and poor bone mineralization. Mid-diaphyseal stress (insufficiency) fractures of the femur caused by osteoporosis are rare. The symptoms of these lesions are vague and confusing. The physician must be alert to the possibility of femoral shaft stress fractures when evaluating an elderly patient complaining of back, hip or leg pain. Case Study: A 72-year-old osteoporotic female patient with bilateral mid-diaphyseal stress fractures of the femur is reported. The diagnosis of femoral shaft stress fracture in the elderly is very difficult when based on physical findings and plain radiography only. A magnetic resonance imaging (MRI) scan or nuclear scintigraphy is necessary for early diagnosis. In the described case, the patient had an excellent result after surgical treatment with intramedullary nails. Conclusion: MRI or nuclear scintigraphy must be obtained to exclude the possibility of femoral shaft stress fractures in the elderly. In the absence of contraindications, surgery is the best solution for this kind of lesion.     

Amputation of a crossover 2nd toe in the presence of hallux valgus

Background: There are many surgical procedures for the correction of hallux valgus and crossover 2nd toe deformity. Amputation of a crossover 2nd toe is often performed as a salvage procedure if the primary 2nd toe corrective procedure fails.Aims: To assess the outcomes of amputating a crossover 2nd toe in the presence of hallux valgus in elderly patients above 70 years old; as a primary procedure.Materials and methods: Seven patients (8 ft) underwent amputation of their crossover 2nd toe. A disease specific questionnaire using a Visual Analogue Scale (VAS) was implemented measuring pain, deformity, discomfort, and walking distance.Results: The mean age of the patients was 82 years old, range 74–89 years old. Amputation of the 2nd toe significantly reduces pain, discomfort and the appearance of deformity, there was no difference in the patient’s walking distance after surgery.Conclusion: We recommend this type of surgery as a primary procedure in elderly patients above 70 years old, if the first ray is not causing symptoms.