Discharge against Medical Advice in Surgical Patients with Posttraumatic Stress Disorder: A Case Report Series Illustrating Unique Challenges.

Discharge against medical advice (DAMA) can have detrimental effects on patient outcomes. Recently, the diagnosis of posttraumatic stress disorder (PTSD) has been linked with DAMA in the setting. However, PTSD as a risk factor for DAMA in patients has not received much consideration, although such patients may be at risk for triggering or amplification of PTSD symptoms perioperatively.

Serotonin Syndrome Following an Uncomplicated Orthopedic Surgery in a Patient With Post-Traumatic Stress Disorder.

Serotonin syndrome (SS) is a potentially life-threatening adverse drug reaction that may occur in patients treated with serotonin agonist medications. Medications responsible for serotonin syndrome include commonly prescribed antidepressants, anxiolytics, analgesics, and antiemetics. Veterans with post-traumatic stress disorder (PTSD) are at risk for polypharmacy with serotoninergic medications, given their psychological comorbidities and service-related musculoskeletal injuries.

Invasive Mechanical Ventilation in California Over 2000-2009: Implications for Emergency Medicine.

Introduction: Patients who require invasive mechanical ventilation (IMV) often represent a sequence of care between the emergency department (ED) and intensive care unit (ICU). Despite being the most populous state, little information exists to define patterns of IMV use within the state of California.

Methods: We examined data from the masked Patient Discharge Database of California's Office of Statewide Health Planning and Development from 2000-2009.

Development of a Veterans Affairs hybrid operating room for transcatheter aortic valve replacement in the cardiac catheterization laboratory.

Importance: Transcatheter aortic valve replacement (TAVR) revolutionized the treatment of aortic stenosis. Developing a TAVR program with a custom-built hybrid operating room (HOR) outside the surgical operating room area poses unique challenges in Veterans Affairs (VA) institutions.

Objective: To present the process by which the San Francisco VA Medical Center developed a VA-approved TAVR program, in which an HOR exists in a cardiac catheterization laboratory, as a guideline for future programs.

Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System.

Background: Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I.

Objective: To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I.

Perioperative β-blockade: atenolol is associated with reduced mortality when compared to metoprolol.

Background: The Atenolol study of 1996 provided evidence that perioperative β-blockade reduced postsurgical mortality. In 1998, the indications for perioperative β-blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Affairs Medical Center. The current study tested the following hypothesis: Is there a difference in mortality rates between patients receiving perioperative atenolol and metoprolol?

Methods: Epidemiologic analysis of the operations performed at the San Francisco Veterans Affairs Medical Center since 1996 was performed.

The effect of race and ethnicity on outcomes among patients in the intensive care unit: a comprehensive study involving socioeconomic status and resuscitation preferences.

Objective: We sought to determine whether race or ethnicity is independently associated with mortality or intensive care unit length of stay among critically ill patients after accounting for patients' clinical and demographic characteristics including socioeconomic status and resuscitation preferences.

Design: Historical cohort study of patients hospitalized in intensive care units.

Setting: Adult intensive care units in 35 California hospitals during the years 2001-2004.

Association of the pattern of use of perioperative β-blockade and postoperative mortality.

Background: The 1996 atenolol study provided evidence that perioperative β-adrenergic receptor blockade (β-blockade) reduced postsurgical mortality. In 1998, the indications for perioperative β-blockade were codified as the Perioperative Cardiac Risk Reduction protocol and implemented at the San Francisco Veterans Administration Medical Center, San Francisco, California. The present study analyzed the association of the pattern of use of perioperative β-blockade with perioperative mortality since introduction of the Perioperative Cardiac Risk Reduction protocol.

Predictors of early postdischarge mortality in critically ill patients: a retrospective cohort study from the California Intensive Care Outcomes project.

Purpose: Existing intensive care unit (ICU) mortality measurement systems address in-hospital mortality only. However, early postdischarge mortality contributes significantly to overall 30-day mortality. Factors associated with early postdischarge mortality are unknown.

Mortality probability model III and simplified acute physiology score II: assessing their value in predicting length of stay and comparison to APACHE IV.

Background: To develop and compare ICU length-of-stay (LOS) risk-adjustment models using three commonly used mortality or LOS prediction models.

Methods: Between 2001 and 2004, we performed a retrospective, observational study of 11,295 ICU patients from 35 hospitals in the California Intensive Care Outcomes Project. We compared the accuracy of the following three LOS models: a recalibrated acute physiology and chronic health evaluation (APACHE) IV-LOS model; and models developed using risk factors in the mortality probability model III at zero hours (MPM(0)) and the simplified acute physiology score (SAPS) II mortality prediction model.

Retrograde cerebral perfusion and delayed hyperbaric oxygen for massive air embolism during cardiac surgery.

We report a case of massive air embolism from a ventricular vent line during cardiac surgery successfully treated with emergent retrograde cerebral perfusion and delayed hyperbaric oxygen therapy. The etiologies of this rare but potentially devastating complication are discussed along with prevention and treatment options.

Effects of hospital procedure volume and resident training on clinical outcomes and resource use in radical retropubic prostatectomy surgery in the Department of Veterans Affairs.

Purpose: In this retrospective cohort study we used data from the National Surgical Quality Improvement Program of the Veterans Health Administration to examine the effect of case volume and resident participation on radical retropubic prostatectomy outcomes.

Materials And Methods: The study population included 5,736 patients who underwent radical retropubic prostatectomy in Veterans Administration hospitals between October 1, 2001 and September 30, 2004. Resource related outcomes included operative times and length of stay.

Isoflurane-induced dilation of porcine coronary microvessels is endothelium dependent and inhibited by glibenclamide.

Background: Isoflurane has been reported to cause dose-dependent constriction in isolated coronary microvessels. However, these results are inconsistent with data from in situ and in vivo heart preparations which show that isoflurane dilates the coronary vasculature. To clarify the direct effects of isoflurane on coronary tone, we measured the response of isolated porcine resistance arterioles (ID, 75 +/- 4.