Inova Fairfax Hospital Research Articles

The distance-saturation product predicts mortality in idiopathic pulmonary fibrosis

The 6-min walk test (6MWT) has prognostic value in various pulmonary disorders including idiopathic pulmonary fibrosis (IPF). We determined the individual prognostic accuracy of distance walked and oxygen saturation during the 6MWT in patients with IPF. We defined a new composite index, the distance-saturation product (DSP), which is the product of distance walked and lowest oxygen saturation during the 6-min walk test. We compared the performance of the DSP to the individual 6MWT parameters in predicting mortality. We evaluated pulmonary function tests, 6-min walk parameters and the DSP between survivors and non-survivors. The ability of each measure to discriminate outcomes was determined by receiver operator curves. 81 patients (48 survivors, 33 non-survivors) were included. Pulmonary function tests were similar and did not correlate with survival. Desaturation was greater (89.4% versus 83.7%, P<0.001) and distance walked was lower (406.9 versus 181.3m, P = 0.005) in non-survivors. The DSP was significantly lower among non-survivors (364.8 versus 153.5m%, P < 0.001) and predicted mortality more accurately than either individual 6MWT component (P = 0.035 versus desaturation, P=0.040 versus distance). A DSP <200 m% was associated with a seven-fold greater risk of 12-month mortality and an 18.0% shorter median survival compared with a DSP > 200 m% (P < 0.001). Each component of the 6-min walk independently predicted mortality in IPF with greater accuracy than spirometry. However, a composite of both parameters, the DSP, provides slightly greater accuracy and represents a novel measure for assessing survival in patients with IPF.

Thoracic esophageal perforation: one surgeon’s experience

Recognition of the importance of early diagnosis and aggressive, definitive surgical intervention has brought about a dramatic decline in mortality related to distal esophageal perforation. In the following retrospective analysis, we have examined all cases of thoracic esophageal perforations diagnosed, consulted, and/or treated by one author (PDK) at the Inova Fairfax Hospital from June 1, 1988 through March 17, 2005. These cases consisted of 48 patients (34 male) with a mean age of 59.4 years (range, 20-92). Among 25 patients with early diagnosis (< or = 24 h), hospital survival was 92%, increasing to 96% when early diagnosis was combined with surgical treatment. Among the 23 patients with late diagnosis (> 24 h), hospital survival was 82.6%, increasing to 92.3% when treated with surgery. We recommend aggressive, definitive surgery for thoracic esophageal perforations, regardless of time of diagnosis. In the absence of phlegmon or implacable obstruction, primary repair offers excellent results with the shortest length of stay. Resection and reconstruction are the best choices in circumstances where significant phlegmon or distal obstruction render primary repair hazardous or inapplicable. Diversion, preferably with proximal and distal esophageal exclusion, may be necessary for patients too ill to undergo more formidable surgery. Conservative, medical therapy may be appropriate in patients with 'microperforations' with no continuing leak. Finally, comfort measures alone may be appropriate where circumstances merit no effort at resuscitation.

Late Stage (III and IV) Non-small Cell Cancer of the Lung: Results of Surgical Resection at Inova Fairfax Hospital

One hundred forty-two patients underwent surgery and related treatment for advanced stage (III, IV) non-small cell cancer of the lung. One hundred seventeen patients underwent up-front surgery, with a hospital mortality rate of 1.7% (2/117). Kaplan-Meier 5-year survival in this group was 31% (+/- 5). Twenty-five patients underwent neoadjuvant therapy followed by surgical resection, with respective rates of hospital mortality, complete pathologic response, and major pathologic response of 0%, 16%, and 64%. Kaplan-Meier 5-year survival in this latter group was 34% (+/- 11). Of the 16 patients undergoing neoadjuvant therapy who had complete pathologic response or significant downstaging from stage III disease, Kaplan-Meier 5-year survival was 61% (+/- 15). Three clinical observations of interest emerged regarding survival. First, in those patients with postresection FEV1 < 1.0 L, hospital mortality rate was 20%, and there were no 5-year survivors (P < 0.0001). Second, where neoadjuvant therapy was associated with complete pathologic response or significant downstaging of disease, there was a trend for improved survival in the downstaged group, but it did not reach statistical significance (P = 0.14). Third, adjuvant therapy was associated with improved 5-year survival (P = 0.03), particularly for combination chemotherapy and radiotherapy (P = 0.02).

Sustaining Magnet

This article describes one health system's journey toward sustained redesignation of Magnet status for its flagship hospital, Inova Fairfax Hospital. The 14 forces of magnetism are described, with examples of how those forces are being met in a culture of shared governance and participation in decision making about clinical practice. The fundamental shift in thinking from Magnet designation as a project to Magnet as a way of organizing nursing services is underscored.

A New Model for Physician Group Structure

A New Model for Physician Group Structure

Screening for Inhalational Anthrax Due to Bioterrorism: Evaluating Proposed Screening Protocols

Eleven known cases of bioterrorism-related inhalational anthrax (IA) were treated in the United States during 2001. We retrospectively compared 2 methods that have been proposed to screen for IA. The 2 screening protocols for IA were applied to the emergency department charts of patients who presented with possible signs or symptoms of IA at Inova Fairfax Hospital (Falls Church, Virginia) from 20 October 2001 through 3 November 2001. The Mayer criteria would have screened 4 patients (0.4%; 95% CI, 0.1%-0.9%) and generated charges of 1900 dollars. If 29 patients (2.6%; 95% CI, 1.7%-3.7%) with >or=5 symptoms (but without fever and tachycardia) were screened, charges were 13,325 dollars. The Hupert criteria would have screened 273 patients (24%; 95% CI, 22%-27%) and generated charges of 126,025 dollars. In this outbreak of bioterrorism-related IA, applying the Mayer criteria would have identified both patients with IA and would have generated fewer charges than applying the Hupert criteria.

A pragmatic and successful approach to treating nonsmall-cell lung carcinoma

Lung cancer is the single leading cause of cancer deaths for men and women combined. Nonsmall-cell lung carcinoma (NSCLC), which results largely from smoking tobacco, accounts for 87% of all lung cancer cases. Methods of patient selection, preoperative and intraoperative care, and postoperative outcomes for patients with NSCLC who were treated from 1991 through 2003 at Inova Fairfax Hospital are discussed. All patients were treated with surgery, some selectively and progressively with a combination of preoperative neoadjuvant therapy, to try to downstage the disease to make complete resection feasible. Outcomes from this data collection period match or exceed the best results for treatment of late-stage (ie, III and IV) disease reported anywhere to date.

A comparison of fever management by pediatric-trained and non–subspecialty-trained emergency physicians

Study objectives: In 1993, the American Academy of Pediatrics and the American College of Emergency Medicine jointly published guidelines for the management of fever without a source in infants and young children. Despite widespread recognition in the literature, actual compliance with these guidelines has produced a far different picture and demonstrates that acceptance has been less than robust. Our null hypothesis is that no differences exist between general emergency physicians and pediatric emergency physicians in evaluating infants and young children with fever. Methods: The research protocol was approved by the Inova Fairfax institutional review board. The Inova Fairfax Hospital emergency department (ED) is a general ED with an annual pediatric census of 21,000. The emergency pediatric section consists of 10 subspecialty-trained emergency physicians. Consecutive medical records of febrile children younger than 36 months were retrospectively examined between December 1, 2003, and March 31, 2004. Evaluation and management of fever in the well-appearing child by physicians with advanced pediatric training and general emergency medicine training were compared with accepted published guidelines. Fever thresholds used were 38.0°C for children younger than 1 month, 38.2°C for children aged 31 to 90 days, and 38.5°C for children older than 3 months of age. General emergency physician and pediatric emergency physician practices were compared for diagnostic studiesials. Nominal data were analyzed using either χ² or Fisher's exact tests. Parametric continuous data were analyzed using a <i>t</i> test. Means and confidence intervals (CIs) were calculated. α Was set at 0.05 for all comparisons. Results: Of 184 records examined, 101 (55%) were seen by pediatric specialists and 83 (45%) by general emergency physicians. No significant differences in adherence to generally accepted fever guidelines were detected between general emergency physicians and pediatric emergency physicians. The violation rates were 38 of 101 (38%, 95% CI 28% to 48%) for pediatric specialists and 31 of 83 (37%; 95% CI 27% to 49%) for general emergency physicians; the 2 groups were not significantly different. Five of 38 (13%; 95% CI 4% to 28%) violations were related to inappropriate treatment. The other 33 of 38 (87%; 95% CI 72% to 96%) were omissions of indicated laboratory studies. Although there was a trend toward increased use of diagnostic studies by general emergency physicians, nothing approached statistical significance; however, the number of viral antigen studies ordered by general emergency physicians was of interest: pediatric emergency physicians 38% (95% CI 28% to 48%) versus general emergency medicine 52% (95% CI 41% to 63%). Disposition and management between general emergency physicians and pediatric emergency physicians also were similar: antibiotic administration rates for pediatric emergency physicians were 52% (95% CI 42% to 62%) versus general emergency physicians 48% (95% CI 37% to 59%), and hospital admission rates for pediatric emergency physicians were 19% (95% CI 12% to 28%) versus general emergency physicians 18% (95% CI 11% to 28%). Conclusion: In a busy practice where general emergency physicians are treating children alongside specialty-trained pediatric emergency physicians, the management of pediatric fever is equivalent. General emergency physicians do not differ from their pediatric emergency physicians colleagues in terms of deviation from published guidelines, disposition, or management of febrile children 0 to 36 months of age.

Priapism Associated with MethylphenidateSR (Concerta) Withdrawal

A 15-year-old boy with attention deficit hyperactivity disorder, inattention subtype (ADHD), developed stuttering priapism (intermittent, prolonged, painful erections) after withdrawal of OROS methylphenidate (ConcertaR) 36 mg/day, and is reported from Inova Fairfax Hospital for Children, Falls Church, VA, and Children’s National Medical Center, Washington, DC.

Anesthesia Information Management Systems and Operating Room Management: The Inova Fairfax Hospital experience

Anesthesia Information Management Systems and Operating Room Management: The Inova Fairfax Hospital experience

From the Feds

From the Feds

Consultation with the Specialist: Diagnosis and Management of the Newborn and Young Infant Who Have Nasal Obstruction

1. Susannah Q. Olnes, MD* 2. Richard H. Schwartz, MD* 3. Robert S. Bahadori, MD† 1. 2. *Department of Pediatrics. 3. 4. †Section of Otolaryngology, Inova Fairfax Hospital for Children, Falls Church, VA. Because neonates may be obligate nasal breathers until they are at least 2 months old, nasal obstruction, particularly if bilateral and complete, can cause severe respiratory distress quickly. Nasal airway problems far less consequential than total nasal obstruction can be worrisome in the neonate and young infant. Their nasal passages may exhibit as much as 50% of the total airway resistance, and the degree of obstruction often worsens when the infant has an upper respiratory tract infection. Focal obstruction can occur in the nasal vestibule or in any of the three anatomic regions of the nose: nasal piriform aperture, mid-nasal cavity, or the posterior choanae. Most cases of nasal obstruction in the neonate and young infant are due to generalized nasal airway obstruction associated with neonatal rhinitis, viral upper respiratory tract infections, and possibly milk/soy allergies. A relatively unrecognized, but important percentage of neonatal nasal obstruction is due to gastroesophageal reflux disease (GERD), with secondary inflammation of the posterior nasal passages (reflux rhinitis). Less common causes of generalized neonatal/young infant nasal obstruction include rhinitis medicamentosa due to the overuse of topical vasoconstrictor nose drops and maternal ingestion of drugs such as methyldopa, tricyclic antidepressants, or propranalol. Trauma from nasal prongs or nasogastric tubes may produce unilateral or bilateral nasal obstruction. With the exception of posterior choanal atresia, the challenging differential diagnosis and management of the neonate who has nasal obstruction is described in only a few English language pediatric journal articles. There are several reviews of the subject in the subspecialty literature. Syphilitic snuffles, although an infrequent cause of nasal obstruction, merits particular mention because it sometimes is misdiagnosed. The watery nasal secretions associated with snuffles are teeming with spirochetes and highly contagious. Chlamydial rhinitis can produce similar clinical symptoms. Successful management of nasal obstruction in the neonate or young …

REBUILD: an orthopedic trauma support group and community outreach program.

From the earliest days of social work practice, practitioners in both medicine and social work have recognized the value of groups in meeting the needs of patients. Today there is considerable agreement that the therapeutic group mechanism of mutual support is pertinent, especially to the field of health (Spira, 1997). The major purpose for which groups are used in health care settings is to provide peer support in relieving stress felt by patients and families as they face illness and disabilities. REBUILD, an orthopedic trauma support group, offers this healing environment to recovering trauma patients and their families. The group also involves the larger community in its program. Recovering patients provide new-patient support in the hospital, patient-focused training for medical professionals at conferences, and on-going training for recruits and paramedics at the local fire and rescue training academy. Trauma caregivers participating in this training become more sensitive to the emotional needs of their patients and more skilled in facilitating their emotional recovery. The purpose of this article is twofold. It describes the unique development of this hospital-based form of support group and how this development extended the psychoeducational benefits to the larger community. The outreach component of the program expands the social worker's practice to include interventions more commonly used by community workers. BACKGROUND Trauma is the leading cause of death and disability of Americans under age 45 and is the third leading cause of death for people of all ages (National Center for Health Statistics, 1993). The effect of physical trauma can be devastating to victims, with injuries destroying their health, lives, and livelihoods. Patients and families face many psychosocial stressors throughout the recovery process, including social isolation, insurance problems or financial headaches, family stress, chronic or recurring pain, and continuing feelings of anger, depression, or guilt (Scanlon-Schilpp & Levesque, 1981). In times of crisis patients and families need support but may not be able to provide it for each other. The experience of high anxiety and feelings of disorganization affect the patient's and family's ability to cope with the stresses and hinder recovery (Parad & Parad, 1990); if the crisis is prolonged, the family may exhaust its social support system (Harvey, Dixon, & Padberg, 1995). Medical social workers find that the group process is well suited for easing emotional stress felt by patients and their families who have feelings of isolation, loneliness, depression, helplessness, and hopelessness (Spira, 1997). The social work group has the potential to strengthen the recovering person's family connections, reduce isolation and despair (Glassman, 1991), and offer support. The group can enable discussion of taboos central to the concerns of patients and families, such as anger, loss, and mourning (Shulman, 1992). A powerful growth-promoting environment, unique to the group setting, often is created, stimulating group members to work more rapidly toward resolving the crises they face in recovery. A review of the literature reveals a number of support groups for cancer patients, people with HIV/AIDS, recovering alcoholics and substance abusers, and people who have lost loved ones (Burland, 1998; Harvey et al., 1995; Hsu, 1996; Lieberman, 1988; Scanlon-Schilpp & Levesque, 1981). Benefits of these groups reported by families include opportunities to share emotions, ask questions, and improve their coping skills. This same review reveals very few trauma support groups throughout the nation. There is one at the University of California's Irvine Medical Center and another at Connecticut's Hartford Hospital (Harvey et al., 1995; McQuay, 1995). AWARENESS OF AN UNMET NEED At Inova Fairfax Hospital in Falls Church, Virginia, the chief of orthopedic trauma found that many of his trauma patients reported social isolation, depression, family stress, and chronic or recurring pain during their follow-up appointments. …

Managing the Patient with Perforated Intrathoracic Esophagus

The thoracic perioperative specialty team members at Inova Fairfax Hospital, Falls Church, Va, designed guidelines to improve the management of patients with esophageal perforations. They performed a retrospective analysis of 41 patients who were diagnosed with thoracic esophageal perforations from Sept 1, 1979, through Sept 1, 1996. The review affirmed their philosophy of aggressive, surgical intervention for perforations, particularly for patients diagnosed early (i.e., within 24 hours). The process of examining and communicating the results among OR nurses, anesthesia care providers, and surgeons resulted in the increased efficiency and appropriateness with which patients were incorporated into the hospital's surgical and medical treatment groups.