Sunni A. Barnes

The burden of fatigue and quality of life in myeloproliferative disorders (MPDs): An international internet-based survey of 1179 MPD patients

Few objective data exist on the burden of fatigue and other constitutional symptoms in patients with myeloproliferative disorders (MPD).

Safety, Feasibility, and Short-term Outcomes of Laparoscopic Ileal-Pouch-Anal Anastomosis: A Single Institutional Case-Matched Experience

Objective:To compare safety and short-term outcomes of 100 laparoscopic ileal pouch-anal anastomosis (IPAA) versus 200 conventional open IPAA patients. Summary Background Data:Outcomes of laparoscopic IPAA (LAP-IPAA) have been incompletely characterized. Previous reports are characterized by small numbers of patients and rarely include case-matched or randomized trial methodology. This report describes 100 LAP-IPAA patients case matched to 200 open IPAA patients. Methods:Between 1998 and 2004, 100 consecutive LAP-IPAA patients (75 laparoscopic assisted, 25 hand assisted) were identified and case matched to 200 open IPAA control patients by age, operation, gender, date of operation, and body mass index. Operative and postoperative outcomes at 90 days were compared. Results:A total of 300 patients (180 female) with a median age of 32 years (range, 17–66 years), and a median body mass index of 23 kg/m2 (range, 16–34 kg/m2) underwent IPAA (100 LAP-IPAA, 200 open IPAA). Diagnosis (chronic ulcerative colitis 97%, familial adenomatous polyposis 3%) and previous operative history were equivalent between groups. One intraoperative complication occurred in each group. Overall, the laparoscopic conversion rate was 6%. Median operative time was longer for the LAP-IPAA group (333 minutes versus 230 minutes, P < 0.0001). LAP-IPAA patients had shorter median time to regular diet (3 versus 5 days), time to ileostomy output (2 versus 3 days), length of stay (4 versus 7 days), and decreased IV narcotic use (all P < 0.05.Postoperative morbidity was equivalent (LAP-IPAA = 33%, open IPAA = 37%), mortality was nil, and readmission rates were equal (LAP-IPAA = 21%, open IPAA = 22%). Reoperation was required in 3% of LAP-IPAA and 6.5% of open IPAA patients (P < 0.2) during the first 3 months. Conclusion:LAP-IPAA is equivalent to open IPAA in terms of safety and feasibility. In addition, LAP-IPAA provides significant improvements in short-term recovery outcomes.

Patient and physician-assessed shoulder function after arthroplasty.

BACKGROUND We found no information in the literature regarding the relationship between patient and physician-derived outcome assessments with a shoulder questionnaire. In this study, we examined a group of patients who were assessed with patient and physician-administered questionnaires following shoulder arthroplasty. METHODS From August 2003 to February 2004, sixty-seven consecutive patients who had been followed for a minimum of six months after shoulder arthroplasty were evaluated with a self-administered and an identical physician-directed shoulder questionnaire that assessed clinical and functional outcomes at the time of routine follow-up. An assessment of the agreement between physicians and patients as well as the factors that affected agreement was performed. RESULTS The intraclass correlation indicated almost perfect physician-patient agreement (>0.80) on items related to overall pain, pain at night, pain with activity, stability, and active elevation and substantial agreement (intraclass correlation, 0.66 and 0.69) between the physician and patient assessments of pain without activity and strength. While the differences were small, on the average physician ratings for pain were lower (indicating less pain) than patient ratings for pain, physicians rated stability and strength as being closer to normal, and they reported less active elevation. There was substantial agreement between the physician and patient assessments of outcome with the modified Neer system (intraclass correlation = 0.75), with 87% agreement if excellent and satisfactory outcomes were combined. CONCLUSIONS A patient-derived questionnaire can provide a high level of agreement with surgeon assessments of outcome following shoulder surgery. Patient-administered methods should continue to be evaluated as a means of assessment of these patients.

Sexual Function, Body Image, and Quality of Life after Laparoscopic and Open Ileal Pouch-Anal Anastomosis

PurposeThis study was designed to compare self-reported sexual function, body image, and quality of life outcomes among ulcerative colitis patients undergoing laparoscopic or open ileal pouch-anal anastomosis.MethodsBetween 1978 and 2004, 100 laparoscopic and 189 open operations were performed in patients who were identified from a previously published cohort. Patients were surveyed one year after operation to evaluate sexual function, body image, and quality of life.ResultsA total of 125 of 289 patients (43 percent) returned completed surveys. There were no significant differences in terms of demographics, complications, or long-term functional outcomes between those who completed the surveys and those who did not. There were no clinical differences in results between laparoscopic and open patients using the three survey instruments. Orgasmic function scores were lower in men who underwent laparoscopic ileal pouch-anal anastomosis (P < 0.05) compared with open ileal pouch-anal anastomosis. Overall, sexual function scores were equal to or better than normal values for men but were lower in women. Finally, overall body image and quality of life scores were above the means published for the United States.ConclusionsAfter ileal pouch-anal anastomosis, men and women reported excellent body image and high cosmetic and quality of life scores regardless of operative approach. Female sexual function was more adversely affected after ileal pouch-anal anastomosis than was male sexual function.

Segmental vs. Extended Colectomy : Measurable Differences in Morbidity, Function, and Quality of Life

PurposeThe colon coordinates fecal elimination while reabsorbing excess fluid. Extended colonic resection removes synchronous and prevents metachronous disease but may adversely alter bowel function and health-related quality of life to a greater degree than segmental resection. This study examined the short-term morbidity and long-term function and quality of life after colon resections of different extents.MethodsPatients undergoing extended resections (n = 201, subtotal colectomy with ileosigmoid or total abdominal colectomy with ileorectal anastomosis) and segmental colonic resections (n = 321) during 1991 to 2003 were reviewed for perioperative outcomes and surveyed for bowel function and quality of life using an institutional questionnaire and a validated quality of life instrument (response rate: 70 percent).ResultsThe most common indication for extended resections was multiple polyps, and for segmental resections, single malignancy. The complication-free rate was 75.4 percent after segmental resections, 42.8 percent after ileosigmoid anastomosis, and 60 percent after ileorectal anastomosis. Median daily stool frequency was two after segmental resections, four after ileosigmoid anastomosis, and five after ileorectal anastomosis, despite considerable dietary restrictions (55.6 percent) and medication use (19.6 percent daily) after ileorectal anastomosis. Significant proportions of patients felt restricted from preoperative social activity (31.5 percent), housework (20.4 percent), recreation (31.5 percent), and travel (42.6 percent) after ileorectal anastomosis. The overall quality of life after segmental resection, ileosigmoid anastomosis, and ileorectal anastomosis was 98.5, 94.9, and 91.2, respectively.ConclusionsMeasurable compromises in long-term bowel function and quality of life were observed after extended vs. segmental resections. The relative differences in patient-related outcomes should be deliberated against the clinical benefits of extended resection for the individual patient.

Global endometrial ablation for menorrhagia in women with bleeding disorders

OBJECTIVE: To evaluate the efficacy of global endometrial ablation in women with bleeding disorders who presented with menorrhagia. METHODS: A records-linkage system was used to construct a retrospective cohort of 41 women with bleeding disorders (coagulopathy) and a reference group of 111 randomly selected women without bleeding disorders from a pool of 943 women who underwent global endometrial ablation (with thermal balloon ablation technology or bipolar radiofrequency ablation technology) for menorrhagia at Mayo Clinic (Rochester, Minnesota) from January 1995 through December 2005. Demographic data, type of global endometrial ablation therapy and reablation, and hysterectomy data were extracted from the database. RESULTS: There was no significant difference in baseline age, parity, body mass index, uterine size, type of global endometrial ablation therapy, or duration of follow-up between the groups. Two women (5%) in the coagulopathy group had hysterectomy or reablation, compared with 8 (7%) in the reference group (Fisher exact test, P=.728). A Kaplan-Meier plot showed no difference in the time to treatment failure between the groups (log-rank test, P=.534). Procedural-related complications were generally minor and infrequent (9 of 152 [6%]). Complications were equally distributed in the coagulopathy (4 of 41) and reference groups (6 of 111) (Fisher exact test, P=.267). CONCLUSION: Global endometrial ablation is an effective treatment choice for women with coagulopathy presenting with menorrhagia. LEVEL OF EVIDENCE: II

Suboptimal compliance with evidence-based guidelines in patients with traumatic brain injuries: Clinical article

OBJECT Evidence-based management (EBM) guidelines for severe traumatic brain injuries (TBIs) were promulgated decades ago. However, the extent of their adoption into bedside clinical practices is not known. The purpose of this study was to measure compliance with EBM guidelines for management of severe TBI and its impact on patient outcome. METHODS This was a retrospective study of blunt TBI (11 Level I trauma centers, study period 2008-2009, n = 2056 patients). Inclusion criteria were an admission Glasgow Coma Scale score ≤ 8 and a CT scan showing TBI, excluding patients with nonsurvivable injuries-that is, head Abbreviated Injury Scale score of 6. The authors measured compliance with 6 nonoperative EBM processes (endotracheal intubation, resuscitation, correction of coagulopathy, intracranial pressure monitoring, maintaining cerebral perfusion pressure ≥ 50 cm H2O, and discharge to rehabilitation). Compliance rates were calculated for each center using multivariate regression to adjust for patient demographics, physiology, injury severity, and TBI severity. RESULTS The overall compliance rate was 73%, and there was wide variation among centers. Only 3 centers achieved a compliance rate exceeding 80%. Risk-adjusted compliance was worse than average at 2 centers, better than average at 1, and the remainder were average. Multivariate analysis showed that increased adoption of EBM was associated with a reduced mortality rate (OR 0.88; 95% CI 0.81-0.96, p < 0.005). CONCLUSIONS Despite widespread dissemination of EBM guidelines, patients with severe TBI continue to receive inconsistent care. Barriers to adoption of EBM need to be identified and mitigated to improve patient outcomes.

Moving from "optimal resources" to "optimal care" at trauma centers.

BACKGROUND: The Trauma Quality Improvement Program has shown that risk-adjusted mortality rates at some centers are nearly 50% higher than at others. This “quality gap” may be due to different clinical practices or processes of care. We have previously shown that adoption of processes called core measures by the Joint Commission and Centers for Medicare and Medicaid Services does not improve outcomes of trauma patients. We hypothesized that improved compliance with trauma-specific clinical processes of care (POC) is associated with reduced in-hospital mortality. METHODS: Records of a random sample of 1,000 patients admitted to a Level I trauma center who met Trauma Quality Improvement Program criteria (age ≥16 years and Abbreviated Injury Scale score ≥3) were retrospectively reviewed for compliance with 25 trauma-specific POC (T-POC) that were evidence-based or expert consensus panel recommendations. Multivariate regression was used to determine the relationship between T-POC compliance and in-hospital mortality, adjusted for age, gender, injury type, and severity. RESULTS: Median age was 41 years, 65% were men, 88% sustained a blunt injury, and mortality was 12%. Of these, 77% were eligible for at least one T-POC and 58% were eligible for two or more. There was wide variation in T-POC compliance. Every 10% increase in compliance was associated with a 14% reduction in risk-adjusted in-hospital mortality. CONCLUSION: Unlike adoption of core measures, compliance with T-POC is associated with reduced mortality in trauma patients. Trauma centers with excess in-hospital mortality may improve patient outcomes by consistently applying T-POC. These processes should be explored for potential use as Core Trauma Center Performance Measures. LEVEL OF EVIDENCE: II.

Compliance with Recommended Care at Trauma Centers: Association with Patient Outcomes

BACKGROUND State health departments and the American College of Surgeons focus on the availability of optimal resources to designate hospitals as trauma centers, with little emphasis on actual delivery of care. There is no systematic information on clinical practices at designated trauma centers. The objective of this study was to measure compliance with 22 commonly recommended clinical practices at trauma centers and its association with in-hospital mortality. STUDY DESIGN This retrospective observational study was conducted at 5 Level I trauma centers across the country. Participants were adult patients with moderate to severe injuries (n = 3,867). The association between compliance with 22 commonly recommended clinical practices and in-hospital mortality was measured after adjusting for patient demographics and injuries and their severity. RESULTS Compliance with individual clinical practices ranged from as low as 12% to as high as 94%. After adjusting for patient demographics and injury severity, each 10% increase in compliance with recommended care was associated with a 14% reduction in the risk of death. Patients who received all recommended care were 58% less likely to die (odds ratio = 0.42; 95% CI, 0.28-0.62) compared with those who did not. CONCLUSIONS Compliance with commonly recommended clinical practices remains suboptimal at designated trauma centers. Improved adoption of these practices can reduce mortality.

Cost-effectiveness of negative pressure wound therapy for postsurgical patients in long-term acute care.

OBJECTIVES: To evaluate the cost-effectiveness of negative pressure wound therapy (NPWT) using reticulated open-cell foam (NPWT/ROCF) as delivered by a Vacuum-Assisted Closure* (KCI Licensing, Inc, San Antonio, Texas) in patients with complex wounds in a long-term acute care (LTAC) setting. These patients are routinely discharged to LTAC hospitals with the goal of accelerating wound healing and timely transfer to a lower acuity care setting and are usually affected with serious comorbidities and deep, complex wounds with exposed anatomical structures, which require extended care (stay > 25 days). DESIGN: A retrospective chart review was conducted to determine the average daily wound volume reduction, average daily wound area reduction, and average cost per cubic centimeter of wound volume reduction for patients treated with NPWT/ROCF as compared with topical advanced moist healing strategies (non-NPWT). SETTING: All patients received treatment in an LTAC hospital. PARTICIPANTS: Patients admitted from November 2001 to August 2004 were identified using a computerized hospital database. The inclusion criteria were postsurgical patients of at least 18 years of age, with a single acute wound. INTERVENTION: Patients were treated with either NPWT/ROCF or advanced moist wound-healing therapies (non-NPWTs). MEASUREMENTS: Data collected included age, sex, wound measurements, Bates-Jensen Wound Assessment Tool severity score, procedures performed, wound care products and devices used, wound-healing outcomes, and costs associated with treatment. RESULTS: Fifty-one patients met the inclusion criteria: 36 were identified as NPWT/ROCF and 15 as non-NPWT. The NPWT/ROCF patients showed a statistically significantly higher average daily rate of volume reduction as compared with the advanced moist wound-healing group (5.02 ± 13.36 vs 0.40 ± 0.88 cm3/day; P = .046). The cost per cubic centimeter reduction was