Citations

Background— Although it is recommended that all patients with heart failure (HF) have advance directives (AD) in place before the end of life is imminent, the use of AD in HF has not been well studied. Methods and Results— We enrolled consecutive Olmsted County residents presenting with HF from October 2007 through October 2011 into a longitudinal study. Information from AD completed before enrollment and hospitalizations in the month before death were abstracted. Among 608 patients (mean age, 74.0 years; 54.9% men; 65.3%; New York Heart Association functional class 3 or 4), 164 (27.0%) patients died after a mean follow-up of 1.8 years. At enrollment, only 249 (41.0%) patients had an AD. Although most AD appointed a proxy decision-maker (90.4%), less than half addressed wishes regarding use of cardiopulmonary resuscitation (41.4%), mechanical ventilation (38.6%), or hemodialysis (10.0%) at the end of life. The independent predictors of AD completion were older age (adjusted odds ratio [OR] per 10-year increase, 1.82; 95% confidence interval [CI], 1.51–2.20), malignancy (OR, 1.58; 95% CI, 1.05–2.37), and renal dysfunction (OR for estimated glomerular filtration rate <60 mL/min 1.55; 95% CI, 1.05–2.29). At the end of life, patients with AD specifying limits in the aggressiveness of care less frequently received mechanical ventilation (OR, 0.26; 95% CI, 0.07–0.88), with a trend toward decreased intensive care unit admission (OR, 0.45; 95% CI, 0.16–1.29). Conclusions— Despite a high mortality rate, over half of patients with HF do not have an AD, and existing AD fail to address important end-of-life medical decisions.

Background: Ulnar collateral ligament (UCL) reconstruction is frequently performed in throwing athletes, but outcomes of UCL reconstruction requiring excision of bone, either within the substance of or replacing the UCL, have not been studied. Hypothesis: Clinical outcome for throwing athletes after UCL reconstruction with gracilis tendon will be less favorable for patients requiring concurrent excision of bone from within the substance of the UCL than for patients with no bone excision within, or replacing, the ligamentous anatomy. Study Design: Cohort Study; Level of evidence, 3. Methods: One hundred twenty pitchers of competitive levels between high school and major league who underwent UCL reconstruction using contralateral gracilis autografts completed a phone survey, and their medical charts were reviewed. Follow-up was a minimum of 2 years. Among the 120 patients, 42 (35%) had bone within, or replacing, the substance of the native UCL (bony group), and 78 (65%) had no bony abnormalities (nonbony group). The latter group of 78 underwent UCL reconstruction using gracilis tendon graft due to the absence of a palmaris longus tendon. Clinical outcomes were compared between the 2 study groups using t tests and χ 2 analyses. Results: There were no statistical differences regarding time to return to throwing, time to return to competition, postoperative complications, or need for additional surgeries. The percentage of patients who returned to the same or higher level was higher in the nonbony group (91%) than in the bony group (81%), but this trend was not statistically significant ( P = .083), likely due to a relatively small sample size. Changes in self-reported pitch control were different ( P = .029) between the 2 groups, with a greater percentage of pitchers experiencing decreased control in the bony group. Conclusion: The presence of bone concomitant with UCL damage can lead to pitch control problems after UCL reconstruction and may also decrease the chance of return to play.

Background— Measurement of hospital quality has traditionally focused on processes of care and postprocedure outcomes. Appropriateness measures for percutaneous coronary intervention (PCI) assess quality as it relates to patient selection and the decision to perform PCI. The association between patient selection for PCI and processes of care and postprocedural outcomes is unknown. Methods and Results— We included 203 531 patients undergoing nonacute (elective) PCI from 779 hospitals participating in the National Cardiovascular Data Registry (NCDR) CathPCI Registry between July 2009 and April 2011. We examined the association between a hospital's proportion of nonacute PCIs categorized as inappropriate by the 2009 Appropriate Use Criteria (AUC) for Coronary Revascularization and in-hospital mortality, bleeding complications, and use of optimal guideline-directed medical therapy at discharge (ie, aspirin, thienopyridines, and statins). When categorized as hospital tertiles, the range of inappropriate PCI was 0.0% to 8.1% in the lowest tertile, 8.1% to 15.2% in the middle tertile, and 15.2% to 58.6% in the highest tertile. Compared with lowest-tertile hospitals, mortality was not significantly different at middle-tertile (adjusted odds ratio [OR], 0.93; 95% confidence interval [CI], 0.73–1.19) or highest-tertile hospitals (OR, 1.12; 95% CI, 0.88–1.43; P =0.35 for differences between tertiles). Similarly, risk-adjusted bleeding did not vary significantly (middle-tertile OR, 1.13; 95% CI, 1.02–1.16; highest-tertile OR, 1.02; 95% CI, 0.91–1.16; P =0.07 for differences between tertiles) nor did use of optimal medical therapy at discharge (85.3% versus 85.7% versus 85.2%; P =0.58). Conclusions— In a national cohort of nonacute PCIs, a hospital's proportion of inappropriate PCIs was not associated with in-hospital mortality, bleeding, or medical therapy at discharge. This suggests PCI appropriateness measures aspects of hospital PCI quality that are independent of how well the procedure is performed. Therefore, PCI appropriateness and postprocedural outcomes are both important metrics to inform PCI quality.

While anal sphincter neurogenic injury documented by needle electromyography (EMG) has been implicated to cause fecal incontinence (FI), most studies have been uncontrolled. Normal values and the effects of age on anal sphincter motor unit potentials (MUP) are ill defined. The functional significance of anal sphincter neurogenic injury in FI is unclear. Anal pressures and EMG were assessed in 20 asymptomatic nulliparous women (age, 38 ± 5 yr; mean ± SE) and 20 women with FI (54 ± 3 yr). A computerized program quantified MUP duration and phases. These parameters and MUP recruitment were also semiquantitatively assessed by experienced electromyographers in real time. Increasing age was associated with longer and more polyphasic MUP in nulliparous women by quantitative analysis. A higher proportion of FI patients had prolonged (1 control, 7 patients, P = 0.04) and polyphasic MUP (2 controls, 9 patients, P = 0.03) at rest but not during squeeze. Semiquantitative analyses identified neurogenic or muscle injury in the anal sphincter (11 patients) and other lumbosacral muscles (4 patients). There was substantial agreement between quantitative and semiquantitative analyses (κ statistic 0.63 ± 95% CI: 0.32–0.96). Anal resting and squeeze pressures were lower ( P ≤ 0.01) in FI than controls. Anal sphincter neurogenic or muscle injury assessed by needle EMG was associated ( P = 0.01) with weaker squeeze pressures (83 ± 10 mmHg vs. 154 ± 30 mmHg) and explained 19% ( P = 0.01) of the variation in squeeze pressure. Anal sphincter MUP are longer and more polyphasic in older than younger nulliparous women. Women with FI have more severe neurogenic or muscle anal sphincter injury, which is associated with lower squeeze pressures.