Inappropriate Cases Research Articles

The Red Blood Cell Utilization Review Experience

The Joint Commission on Accreditation of Healthcare Organizations catalyzed peer-review of blood transfusion and gave it new form in 1984. This process became mostly comprehensive, retrospective, bi-level, and chart-based with an initial screening phase followed by physician- review. Studies were identified and evaluated to test the efficacy of this process, which has recently come under question. In two-thirds of the studies, transfusions were judged appropriate in over 90% of cases. In most hospitals reporting, there were no inappropriate transfusions. It is concluded that the process often results in too few inappropriate cases to readily identify opportunities for improvement.

Feline Inappropriate Elimination

Cases involving inappropriate elimination can be treated successfully through careful diagnosis, identification of causative factors, and development of an appropriate treatment plan. Veterinarians can provide a valuable service to their clients through case workups, educational information, and timely referrals. Normal elimination and marking behavior and causative factors involved in inappropriate elimination cases are reviewed. Treatments, including behavior modification techniques and drug therapy suggestions, also are included in this article.

A case-based approach to planar linkage design

We describe a method to store and retrieve design cases of four-bar linkages. The method abstracts relevant features from the planar curve that characterizes each linkage design, and records these features at several levels of abstraction. This allows use of a fast multi-level retrieval procedure, that successively eliminates inappropriate cases at each level. The retrieval incorporates tolerance measures and allows for incomplete problem specifications. Adaptation methods are then used to transform the cases retrieved to match the new design problem. Results of experimental studies to evaluate the efficacy of our method are presented.

A survey of foal rejecting mares

History forms were obtained from the owners of 135 foal rejecting mares. The owners had either contacted the Cornell University's Animal Behavior Clinic directly or had mailed-in a form published in Equine Practice, Compendium of Continuing Education, Horse and Rider, and other equine publications for veterinarians or laypersons. Of the 135 horses, 70 were Arabian, 24 were Quarter horses, 14 were Thoroughbreds and 4 were Morgans. Most ( 101 ) of the mares were primiparous, but 20 mares had rejected at least one other foal. Most (115) mares were between 4 and 10 years old. Rejection occurred immediately after birth by 95 of the mares, after 12 h by 11 and after 24 h by 14. Of the cases in which the outcome was known, 36 accepted their foals, 49 were separated from the foals who were either fostered onto another mare or hand raised. Ten foals were killed or died as a result of rejection.The common factor in eventual acceptance was very frequent opportunities for the foal to suckle provided by restraint of the mare. Detecting and neutralizing odor sources in dog and cat elimination problems Patrick Melese Veterinary Behavior Consultants, P.O. Box 99098, San Diego, CA 92169, USA Abstract Detection and effective treatment of soiled areas in a home is vital to the successful outcome of a behavioral consultation in inappropriate elimination cases. To detect urine odor sources, four methods were discussed including one's nose and eyes, as well as ultra-Detection and effective treatment of soiled areas in a home is vital to the successful outcome of a behavioral consultation in inappropriate elimination cases. To detect urine odor sources, four methods were discussed including one's nose and eyes, as well as ultra-

Placing patients in the queue for coronary revascularization: evidence for practice variations from an expert panel process.

A panel of 16 cardiologists and cardiac surgeons rated 438 case scenarios for the maximum acceptable delay prior to revascularization, using a scale with seven interventional time frames and two nodes for designating dubious or inappropriate cases. If consensus was defined as agreement by 12 or more panelists, only 1.4 percent of the case scenarios showed consensus on a single rating. Dividing the scale into three broad clinical categories (revascularize promptly, place on a waiting list, or no intervention), 11.4 percent of scenarios showed all 16 panelists agreeing on a single category, rising to 59.4 percent of scenarios if agreement by 12 panelists was accepted as a consensus. The mean difference between the panelists' highest and lowest urgency ratings yielded waiting time differences of two weeks for scenarios of very unstable angina, and more than three months for those with stable angina. However, in a regression model, individual panelist factors on average had less effect than clinical features such as severity and stability of angina, or stenosis of major coronary arteries. These findings strongly support the need for consensus criteria to ensure that triage practices are consistent and fair, and also suggest that widespread adoption of a standardized approach to revascularization priorities may be feasible.

Surgical standby for percutaneous transluminal coronary angioplasty: A survey of patterns of practice

To determine patterns of surgical standby for percutaneous transluminal coronary angioplasty (PTCA), a questionnaire was mailed to 196 US institutions in which PTCA and coronary artery bypass grafting (CABG) are performed regularly. Eighty-nine responses (46%) were received and comprise this report. Of responding institutions, the mean number of hospital beds was 615. In 1987, these institutions performed a mean of 337 PTCAs and 558 open-heart surgical procedures. The rate of emergency CABG for PTCA complications (occlusion, dissection, or coronary perforation) was 4.4% ± 0.3%, whereas the rate of urgent CABG (within 24 hours) for PTCA failure was 3.7% ± 0.6%. The incidence of emergency CABG for PTCA complications was higher (5.1% ± 0.6%) among low-volume PTCA centers (less than 250 cases per year) than at high-volume centers (more than 250 cases per year) (3.7% ± 0.3%; p < 0.05). The most common pattern of surgical backup was to maintain an open operating room on standby (57/89, 64%), and the second most common pattern was to make the next open operating room available, allowing operating room access within 1 to 3 hours (21/89, 24%). Nearly a third of institutions (26/89, 29%) maintained a flexible backup arrangement according to PTCA risk. Routine pre-PTCA patient evaluation by surgeon and/or anesthesiologist occurred in 38% (34/89). Fees for standby services were charged by 51% of surgical teams (45/89), 39% of anesthesia teams (35/89), and 38% of operating room facilities (34/89). Thirty-seven percent of surgeons (33/89) were dissatisfied with their present standby arrangements; sources of dissatisfaction included poor communication with cardiologists about high risk or possibly inappropriate PTCA cases, waste of operating room resources, and inadequate compensation. In summary, although PTCA infrequently requires emergent surgical revascularization, many institutions still maintain an open operating room on standby. The economic burden of this support frequently is not compensated. This survey describes current practices of surgical standby for PTCA and encourages closer examination of the total cost of PTCA.

How Coronary Angiography Is Used

Using ratings of appropriateness derived from an expert physician panel, we measured how appropriately physicians in 1981 performed coronary angiography in a randomly selected, community-based sample of cases in the Medicare population. We studied large geographic areas (three sites) in three states, representing regions of high and low use. The high-use site had fewer procedures classified as appropriate (72%) than either low-use site (77% and 81%, respectively). Over all sites, 17% of procedures were classified as inappropriate. Patients in the high-use site were older, had less severe angina, and were less intensively medically treated than patients in either of the low-use sites. Patients without angina who had not undergone exercise testing constituted the most common subgroup of inappropriate cases. Although overall differences in appropriateness were not large, practice differences do exist. This analysis of practice differences among study sites provides the clinical basis for understanding the small, but significant, differences in the appropriateness of use of coronary angiography. The finding of 17% inappropriate use may be cause for concern.

The continent ileostomy (Kock's pouch) versus the restorative proctocolectomy (pelvic pouch).

AbstractThe Kock continent ileostomy and the ileoanal anastomosis with a pelvic ileal reservoir are each alternatives to conventional ileostomy in patients undergoing proctocolectomy for ulcerative colitis and polyposis coli. Problems associated with construction of the nipple valve have been the chief factor limiting the popularity of continent ileostomy, but these can be minimized by strict attention to technique. The cumulative revision rate for nipple valve dysfunction over a 7‐year period has been below 30%, and continence can usually be restored by reoperation. A successful pelvic reservoir procedure maintains both the normal defecation pathway and satisfactory continence, although rectal sensation is impaired; pelvic sepsis is the major postoperative risk (15–20%). Both types of operation are associated with nonspecific inflammation of the reservoir (“pouchitis”) in some 20% of patients. The pelvic pouch procedure is likely to become the chief method for preserving fecal continence after proctocolectomy, but the Kock pouch should be considered for inappropriate or unsuccessful cases.

Medical decisions concerning noncompetent patients.

Medical decisions concerning noncompetent patients that are most morally problematical are those that involve life and death choices. In making these choices for others, I urge that decision-makers carefully attend to the degree and history of a person's noncompetence, and distinguish four relevant categories of competence: partial, potential, lost and never possessed. Attending to these will help enable us to sort out when and how autonomous choice is possible and desirable and when and how to rely upon a judgment of a patient's best interests instead. This conflict is explored with particular reference to the Quinlan, Fox and Saikewicz cases. I argue that respect for autonomy, wherever possible, has presumptive priority, and that it is more often possible than frequently supposed. On the other hand, the notion of autonomous choice itself is perverted when forced upon inappropriate cases, such as those presented by the never competent. Here it is not merely legitimate, but inescapable to use a best interest criterion that ignores autonomy in making treatment decisions. Specific cases in which these normally distinct guidelines for decision-making concur, conflict and need resolution are discussed. In the end it is often more important to determine who will choose than by what substantive criteria he or she will be guided. In considering this issue, I try to show that the substantive criteria have implications for who the proper decision-makers are in many problematical cases.

Letter: Distribution and supervision of oral contraceptives.

This letter comments on a previous letter (October 19) from Dr. M.V. Smith which advocated widening the range of those empowered to dispense oral contraceptives. Registered nurses, midwives, and health visitors with some training were to be included. The previous letter also recommended that any woman who wished to see a doctor when starting this therapy or during its use should have an opportuntiy to do so. Also, doctors were to continue to supervise the service. The present writer warns that the experise should not be too diluted and that the standard of care should not be allowed to fall. Nurses might require only small additional training. For other health personnel an adequate theroretical and practical training is essential. Weekly sessions for 3 months are suggested. The pill is considered potentially dangerous if used wrongly or for inappropriate cases.