The purpose of this study is to examine the overall impact of IMGs on Kentucky’s physician workforce and determine whether they overcome the shortage of USMGs. Information from the Kentucky Board of Medical Licensure (KBML) was used to examine the distribution and practice patterns of IMGs and USMGs. IMGs are similar to USMGs in terms of gender, age, and average hours worked. IMGs were not any more likely than USMGs to practice in a primary care specialty. They were more likely to practice in a rural county and a county with a critical access hospital.
A 17-month-old infant diagnosed with Short Gut Syndrome developed severe cholestasis and hepatopathy due to chronic parenteral nutrition (PN). In an effort to prevent multivisceral organ transplantation, he was started on Omegaven, an experimental alternative form of parenteral lipid. Within six months, his cholestasis had resolved and his hepatopathy had significantly improved. Omegaven uses Omega-3 rather than Omega-6 triglycerides as its primary fat source, improving fat absorption and modulating the systemic inflammatory response. It has also shown promise as a means of alleviating PN-induced cholestasis in several small trials. Omegaven is only available in the United States on compassionate use basis.
PURPOSE:The American College of Cardiology, the American Heart Association, and the Society for Cardiovascular Angiography and Interventions strongly recommend that primary Percutaneous Coronary Intervention (PCI) should be performed in facilities that have an experienced cardiovascular surgical team available as emergency backup for all procedures. The current study investigates the medical soundness of allowing select facilities in Kentucky to perform primary PCI despite being devoid of onsite emergency backup capabilities.METHODS:Two hospitals in the state of Kentucky, currently without emergency backup capabilities, have been allowed to perform primary PCIs for more than three years (beginning in April 2005) by the Kentucky Cabinet for Health and Family Services. The two hospitals selected were of similar size (approximately 200 beds) and similar distances from hospitals with onsite emergency backup capabilities (approximately one hour). We performed an analysis evaluating if hospitals without backup surgical capability have similar outcomes when compared to hospitals with backup surgical capabilities. Outcome variables included: (1) mortality, (2) cardiac arrest as result of PCI, (3) emergency surgery performed as a result of PCI, and (4) door-to-balloon time.RESULTS:Our results suggest that there is no significant difference in any of the outcome variables studied between facilities with and without onsite emergency backup capabilities.CONCLUSIONS:Recommendations concerning primary PCI may need to be revisited. The principal outcomes associated with primary PCI were not significantly affected by whether a facility has onsite emergency backup capabilities. Therefore, we recommend that hospitals without backup surgical capabilities be allowed to perform primary PCI (with restrictions based on surgeon experience and the facilities' volume).
Type B aortic dissections have remained a difficult management problem. Open surgical techniques have had a very high perioperative mortality, and medical management has not produced satisfactory long-term results. Endovascular grafting techniques may provide a favorable alternative therapy. However, there are currently no endovascular stents approved by the United States Food and Drug Administration for treating Type B aortic dissections. Also, there is very little data from United States centers on the long-term efficacy of endovascular stents used "off-label" to treat aortic dissections. This report discusses the care of a patient with a Type B aortic dissection successfully treated by an endograft in a community hospital. In addition, serial follow-up computerized tomography demonstrates the durability of this repair at three years.
BACKGROUND:An increasing number of parents are questioning the safety and necessity of routine childhood immunizations. Locally produced vaccine risk communication materials may be effective in reassuring these parents. However, little is known about specific vaccine safety concerns in the state of Kentucky.METHODS:An Internet-based survey focusing on parental vaccine safety concerns and potential vaccine risk communication strategies was sent to all members of the Kentucky Chapter of the Amerian Academy of Pediatrics.RESULTS:There were 121 respondents who routinely administered childhood vaccines. Of these, 85% reported parental concern about the combined measles-mumps-rubella (MMR) vaccine. Concerns about the influenza and human papillomavirus (HPV) vaccines were also frequent. Of the respondents, 46% noted parental skepticism about all vaccines in general. However, refusal of all vaccines was uncommon in most practices (median 1%, interquartile range 1%-3%). The belief that vaccines cause autism was the most prevalent parental concern, reported by 70% of pediatricians. Physicians also reported that a list of reliable vaccine information Websites and pamphlets addressing common vaccine safety concerns would be the most helpful materials to use during their discussions with concerned parents.CONCLUSION:These findings suggest that specific information about the MMR, influenza, and HPV vaccines, as well as data refuting the putative link between vaccines and autism would be useful to physicians who administer vaccinations. Respondents were especially interested in reliable vaccine information on the Internet. The Websites listed below offer accurate scientific information about vaccines and the diseases they prevent.
Blastomycosis is a well known infection caused by Blastomyces dermatitidis. It appears usually as a mild and self-limited disease, but disseminated cases are seen, especially in immunocompromised patients. In organ transplant recipients, fungal infections play an important role and in some cases can be fatal, but blastomycosis is a rare and uncommon condition in this setting and specifically in renal transplant patients. Its occurrence is probably due to previous exposure, but sometimes there is no clear history that indicates such exposure. We describe a patient who underwent a renal transplant and developed pulmonary blastomycosis.
BACKGROUND The number of procedures available to pediatric residency trainees is few in number and patient size leaves little margin for error. Artificial simulation labs have not been developed for neonatal chest tubes. Use of live animal models is coming under increased scrutiny and is expensive. METHODS We conducted a simulation skills lab for neonatal chest tube placement using a fryer chicken model. Thirty incoming pediatric interns were prospectively queried on comfort levels of inserting chest tubes prior to and following the simulation lab. RESULTS On a 5-point Likert scale, comfort levels increased from a median of 1 to 3. All interns reported feeling more comfortable with chest tube placement and all reported having better understanding of the process of chest tube placement following the procedure lab. CONCLUSION The fryer chicken model is an advantageous, effective model of teaching chest tube placement.
Thoracic aortic aneurysms (TAA) have remained a formidable operative challenge. Open surgical techniques have been associated with high rates of morbidity and mortality. Thoracic endovascular aneurysm repair (TEVAR) has produced results equal to or better than the traditional open surgical approach. This report presents a patient with a complex thoracic aortic aneurysm involving the ascending, transverse, and proximal descending thoracic aorta. This patient was successfully managed by the creation of Landing Zone-Zero, arch vessel debranching, and endografting the entire aortic arch without the need for hypothermic circulatory arrest or cerebral perfusion strategies. Computer tomographic images demonstrate the repair to be durable at 18 months.
OBJECTIVE:To measure the relationship between procedural volume and quality by examining the association between hospital procedural volume and mortality in coronary artery bypass graft (CABG) and percutaneous transluminal coronary angioplasty (PTCA).METHODS:A retrospective quantitative analysis was conducted of Kentucky hospital discharge database for patients who underwent CABG and PTCA from 2000 through 2005. Hospitals were classified into three categories based on annual number of procedures--low (12-249), medium (250-499), and high-volume (> or = 500) CABG and PTCA facilities. This study employed a multiple logistic regression model to compare the odds for fatal outcome for patients treated in high, medium, and low-volume facilities, while controlling for patient age, gender, admission urgency, hospital length-of-stay, case severity, and pre-existing clinical conditions.RESULTS:From 2000 through 2005, 24 facilities performed 47,972 CABGs, while 30 facilities performed 75,869 PTCAs across the state of Kentucky. In non-emergent CABG and PTCA patients between the ages of 18 to 65 years, there was no statistically significant difference in the odds for fatal outcomes between low-, medium-, and high-volume hospitals. However, older (> or = 65 years old) emergent CABG and PTCA patients were more likely to die at high-volume and low-volume hospitals than medium-volume hospitals (odds ratio for CABG surgery--1.260 [1.004-1.580], 1.753 [1.266-2.4261, and odds ratio for PTCA--1.106 [1.207-2.163], 1.616 [1.207-2.163]).CONCLUSIONS:This study indicates that in hospital procedural volume Kentucky, is an imprecise predictor of quality as measured by CABG and PTCA outcomes, and should not be used by purchasers and policy makers as the only index of hospital quality.
BACKGROUND:Kentucky is one of only six states with laws mandating that intimate partner violence be reported to authorities. The purpose of this project was to understand the attitudes of women clinic patients in Kentucky regarding mandatory reporting of intimate partner violence and how these attitudes may differ by abuse status.METHODS:Women presenting to an internal medicine clinic in the summer of 2003 were asked to complete an anonymous 30-item questionnaire, including personal history of abuse and their opinions about mandatory reporting of intimate partner violence to the police.RESULTS:Surveys were completed by 238 women, of which 29% reported a history of intimate partner violence. Of abused women, 49% supported mandatory reporting of intimate partner violence to the police, compared to 61% of women without an abuse history (p = 0.05)CONCLUSION:Women with a history of abuse are more ambivalent about mandatory reporting of intimate partner violence to the police than women without a history of abuse.
