Allen W. Nyhuis

Management of Lower Pole Nephrolithiasis: A Critical Analysis

The results of extracorporeal shock wave lithotripsy (ESWL*) and percutaneous nephrostolithotomy for the treatment of lower pole nephrolithiasis were examined in 32 consecutive patients undergoing percutaneous nephrostolithotomy at the Methodist Hospital of Indiana and through meta-analysis of publications providing adequate stratification of treatment results. Of 101 cases managed with percutaneous nephrostolithotomy 91 (90%) were stone-free, a result significantly better than that achieved with ESWL (1,733 of 2,927 stone-free, 59%). Stone-free rates with percutaneous nephrostolithotomy were independent of stone burden, whereas stone-free rates with ESWL were inversely correlated to the stone burden treated. The morbidity of patients undergoing percutaneous nephrostolithotomy at our hospital was minimal, with a mean hospital stay of 4.7 +/- 2.8 days. No blood transfusions were required. All patients became stone-free. The percentage of urolithiasis patients with lower pole calculi is increasing. Because of the significantly greater efficacy of percutaneous nephrostolithotomy for lower pole calculi, particularly stones larger than 10 mm. in diameter, further consideration should be given to an initial approach with percutaneous nephrostolithotomy.

Validation of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients

This large case/control study of fall and non-fall patients, in an acute care tertiary facility, was designed to concurrently test the Hendrich Fall Risk Model. Cases and controls (355/780) were randomly enrolled and assessed for more than 600 risk factors (intrinsic/extrinsic). Standardized instruments were used for key physical attributes as well as clinician assessments. A risk factor model was developed through stepwise logistic regression. Two-way interactions among the risk factors were tested for significance. The best fitting model included 2 Log L chi square statistic as well as sensitivity and specificity values retrospectively. The result of the study is an easy to use validated Hendrich Fall Risk Model with eight assessment parameters for high-risk fall identification tested in acute care environments.

Hospital falls: development of a predictive model for clinical practice

A retrospective case-control study related to falls was conducted at an 1,120-bed acute care tertiary hospital. The case (fall) sample consisted of 102 falls and 236 control (nonfall) charts during a 1-month period. An instrument developed by Hendrich (1988) was modified for use in the study. Demographic data and risk factors were recorded. Descriptive statistics included risk factor percentages for each sample and the corresponding univariate relative risks. Logistic regression was used to develop a multivariate risk factor model with seven risk factors. The significant risk factors were recent history of falls, depression, altered elimination patterns, dizziness or vertigo, primary cancer diagnosis, confusion, and altered mobility. The adjusted relative risks were converted to risk points to be used to assess a patients level of fall risk. Within the data set, a sensitivity of 77% (79 of 102) and specificity of 72% (169 of 236) were calculated. The model was cross-validated in a 1987 data set with a sensitivity of 83% (59 of 71) and specificity of 66% (106 of 161).

Financial analysis of an inner-city helicopter service: Charges versus collections

Trauma centers are now being perceived as financial burdens because of recent changes in trauma reimbursement for the Medicare Prospective Payment System population and the perception that collection rates are lower among trauma patients. We examined the demographic and clinical factors associated with the collection experience in a series of 114 trauma patients transferred by helicopter from the accident site to an inner-city trauma center. Factors affecting payment at 30, 60, 90, and 180 days included patient age, insurance class, and discharge status. While not as high as the collection rate for the facility as a whole, we found an average 71.2% collection rate for trauma patients at 180 days. As long as trauma reimbursement continues to be cost based for nonMedicare patients, collection rates remain an important consideration in determining the financial viability of trauma centers.

An analysis of reimbursement for outpatient medical care in an urban hospital emergency department

The investigators examined the demographic and clinical factors associated with the collection experience in a series of 786 patients who were treated in an urban hospital emergency department (ED) but not admitted to the hospital. They found that 57% of the total net charge of

Residents' perception of their skill levels in the clinical management of adolescent health problems

150,489 had been paid within 180 days. This rate can be compared with an average inpatient collection rate of 85% at 180 days. Seven factors were found to account for the collection rate variation, making up 38.4% of the total variation. Age, gender, primary diagnosis, season of visit, time of arrival, and residence were not found to be main contributors. Insufficient collection rates may be an indication that EDs increasingly are becoming a financial risk to hospitals. The hospitals collection experience will become more important as an indicator of financial risk if the costs of operating EDs continue to escalate and collection rates do not improve. Both the costs of providing a service and the amount of the charge actually collected are valid concerns to those operating EDs.

Financial Analysis of an Inner-City Helicopter Service: Charges Versus Collections for Patients Transferred From Another Acute Care Facility

Residents in six specialty training programs completed a 126-item questionnaire designed to assess their skill or confidence to manage adolescent health issues. The residency programs studied were family practice, internal medicine, pediatrics, emergency medicine, obstetrics/gynecology, and combined medicine/pediatrics. Although almost three-fourths of the residents were at least moderately interested in adolescent health care and 90% expected to care for adolescents, only 26% believed an adolescent rotation should be required during training. Residents generally considered themselves unskilled to manage adolescents in the areas of sexuality, handicapping conditions, and psychosocial problems. Significant differences in perceived skills were found among the specialty programs on 45% of the items presented. Resident training appears to be needed in the areas of adolescent growth and development, counseling, and sexuality.

Comparison of the effects of pindolol and atenolol on hemodynamic function in systemic hypertension

Emergency helicopter services provided by trauma centers are now being perceived as contributing to the financial burden of the hospital because of recent changes in trauma reimbursement under the Medicare Prospective Payment System (PPS) and because of the general perception that collection rates are lower among trauma patients. The use of helicopters to transfer patients from one acute care facility to another may also be concentrating the patients with low collection rates at the receiving hospital. We examined retrospectively the demographic and clinical factors associated with the collection experience in a series of 288 trauma patients transferred by helicopter from another acute care facility to an inner-city hospital. Factors affecting payment at 180 and 360 days included patient age, insurance class, discharge status, and size of the hospital charge. As long as reimbursement continues to be cost-based for nonMedicare patients, collection rates remain an important consideration in determining the financial viability of using helicopters to transfer patients.

Effect of thrombolysis (streptokinase) on left ventricular function during acute myocardial infarction

A randomized double-blind study was performed on a group of mild hypertensive patients (WHO class I) to compare the hemodynamic effects of pindolol and atenolol. Blood pressure (BP) was monitored with a mercury gauge sphygmomanometer, while cardiac function and peripheral arterial flows were measured by the noninvasive technique of bioelectric impedance. After a 2-week washout period, patients with a diastolic BP greater than 95 mm Hg but less than 114 mm Hg were randomized into the pindolol (29 patients) or atenolol (28) treatment groups. Patients were treated with 1 of the 2 drugs in an incremental fashion for 12 weeks. Cardiovascular function was measured after the washout period and at the end of the 12-week treatment period. Baseline hemodynamics were similar in both groups. The 2 drugs were equally effective in lowering both systolic and diastolic BP. Hemodynamically, pindolol lowered BP by decreasing total peripheral resistance (-406 +/- 145 dynes.s.cm-5) while atenolol decreased cardiac index (-0.2 +/- 0.1 liters/min/m2) associated with a decrease in heart rate (-12 +/- 2 beats/min). Regarding peripheral vascular beds, pindolol lowered arm vascular resistance (-198 +/- 72 mm Hg/liter/min) and leg vascular resistance (-73 +/- 25 mm Hg/liter/min), especially when subjects who did not respond to pindolol were excluded from the analysis. Both arm (5.5 +/- 5.4% increase above baseline) and leg (1.2 +/- 4.4% increase above baseline) arterial flow indexes were maintained with pindolol. Conversely, atenolol decreased the arm arterial flow index (-9,8 +/- 5.6% decrease below baseline), but not significantly and with no change in resistance (+54 +/- 62 mm Hg/liter/min).(ABSTRACT TRUNCATED AT 250 WORDS)

Does anybody really know what time it is? Does anybody really care?

One hundred ninety-two consecutive patients with acute myocardial infarction were enrolled in a prospective trial of coronary thrombolysis in which either intracoronary or intravenous streptokinase was administered. First-pass radionuclide ejection fraction (EF) was measured early (within 24 hours of admission) and late (10 to 14 days after admission) to assess changes in left ventricular (LV) function. In 68 patients in whom reperfusion was successful, mean EF increased from 39 +/- 11% early to 47 +/- 13% late. In 36 patients in whom reperfusion was not successful, the mean EF increase was significantly smaller (from 38 +/- 10% to 42 +/- 11%, p less than 0.025). Patients in whom reperfusion was successful were then grouped according to extent of LV functional change. The extent of EF change (delta EF) was not significantly influenced by time to lysis at intervals up to 7 hours (delta EF = 9.1 +/- 10% at 2 to 3 hours, 8.7 +/- 12% at 3 to 4 hours, 10 +/- 10% at 4 to 5 hours, and 7.0 +/- 10% at 5 to 7 hours; difference not significant [NS]), location of the infarct (delta EF = 8.9 +/- 11% for inferior and 5.7 +/- 8.0% for anterior, NS), or presence of Q waves on the initial electrocardiogram (delta EF = 8.8 +/- 11% in patients with and 7.8 +/- 9.9% in patients without Q waves). Only the initial EF was predictive of subsequent EF change.(ABSTRACT TRUNCATED AT 250 WORDS)