Occult aortic stenosis as cause of intractable heart failure

During a three-year period 10 patients with critical aortic stenosis were referred to a cardiac referral centre with symptoms and signs of intractable cardiac failure and low cardiac output. In nine patients the correct diagnosis was not suspected at the referring hospital, and in the remaining patient the true severity of the aortic stenosis was not appreciated and cardiomyopathy was suggested as an additional diagnosis. The most common referral diagnoses were severe mitral regurgitation (four patients), congestive cardiomyopathy (two patients), or both (three patients). Only two patients had soft ejection systolic murmurs at the base of the heart radiating into the neck, and such a murmur appeared in a third patient during medical treatment. The carotid pulses were of small volume but the characteristic slow-rising, anacrotic nature of the pulse could not be appreciated clinically. The diagnosis was suspected in nine patients because of aortic valve calcification detected by lateral chest x-ray examination in seven patients and by x-ray screening of the heart in two, and because of abnormal aortic valve echoes in the echocardiogram of all five patients in whom the aortic valve could be seen. Eight patients underwent aortic valve replacement despite seemingly poor preoperative left ventricular function. Three patients died, of whom two had severe coexistent coronary artery disease. The five survivors all returned to normal lives and needed little or no medication.Critical aortic stenosis should be actively sought in patients with severe heart failure of unknown cause since surgery may enable them to resume their normal lives.     

Port Health Control

Almost 950,000 of the 21 million passengers passing through London (Heathrow) Airport in 1973 were seen by the health control unit, which is run by the London Borough of Hillingdon. The unit provides 24-hour medical cover and its responsibilities include x-ray examination for tuberculosis and screening passengers from smallpox-infected areas. It is suggested that, in view of changing epidemiological patterns throughout the world, there is a need to modify existing procedures rather than to abandon them. The development of a follow-up system for tracing passengers at risk and improvements in presenting information about health risks to intending travellers are advocated. While such proposals might be opposed, they could be practicable.     

Effect of clinician information sessions on diagnostic testing for Chagas disease

BackgroundChagas disease is a potentially life-threatening neglected disease of poverty that is endemic in continental Latin America. Caused by Trypanosoma cruzi (T. cruzi), it is one of six parasitic diseases in the United States targeted by the Centers for Disease Control as a public health problem in need of action. An estimated 300,000 people are infected with T. cruzi in the United States (US). Although its morbidity, mortality and economic burden are high, awareness of Chagas disease is lacking among many healthcare providers in the US. The purpose of this analysis is to determine if the number of diagnostic tests performed at a community health center serving an at-risk population for Chagas disease increased after information sessions. A secondary aim was to determine if there was a difference by provider type, i.e., nurse practitioner vs. physician, or by specialty in the number of patients screened.Methodology/Principal findingsWe conducted a retrospective data analysis of the number of Chagas serology tests performed at a community health center before and after information sessions for clinicians. A time series analysis was conducted focusing on the Adult and Family Medicine Departments at East Boston Neighborhood Health Center (EBNHC). Across all departments there were 1,957 T. cruzi tests performed before the sessions vs. 2,623 after the sessions. Interrupted time series analysis across departments indicated that testing volume was stable over time prior to the sessions (pre-period slope = +4.1 per month; p = 0.12), followed by an immediate shift after the session (+51.6; p = 0.03), while testing volume remained stable over time after the session (post-period slope = -6.0 per month; p = 0.11).Conclusion/SignificanceIn this study, Chagas testing increased after information sessions. Clinicians who began testing their patients for Chagas disease after learning of the importance of this intervention added an extra, potentially time-consuming task to their already busy workdays without external incentives or recognition.     

Hospital Topics: Examination of the Whole Colon with the Fibreoptic Colonoscope

During examination of the intact colon with the Olympus CF LB 185-cm colonoscope it has proved possible to reach the caecum or terminal ileum in 47 out of 50 cases (94%). Careful bowel preparation, moderately heavy sedation, and some x-ray screening are necessary for the procedure, but it was well tolerated by all patients and there was no morbidity. The average time taken to the caecum was 40 minutes and the average time to completion of examination 90 minutes. The long colonoscope was as convenient to use as the fibresigmoidoscope in examinations confined to the sigmoid colon or in patients with a colostomy, ileostomy, or ileorectal anastomosis. Of the two, the long colonoscope is the instrument of choice for clinical use.Because of the expense, time, and equipment involved colonoscopy appears to be best offered as a specialist service after x-ray studies. There is alo a limited place for colonoscopy during abdominal surgery, when it is technically an easier procedure. In this series 10 patients were saved exploratory laparotomy by examination with the colonocope, and we also diagnosed four resectable carcinomas not seen on double-contrast barium-enema studies. The colonoscope provides an effective new means of diagnosis of lesions throughout the colon.     

Deceleration Trauma to the Heart and Great Vessels after Road-traffic Accidents

Four young men involved in high-speed car crashes developed cardiovascular trauma. Two patients had aortic aneurysms, one rupture of the mitral valve, and one ventricular septal defect; successful surgical correction was undertaken in all. The importance of considering the possibility of cardiovascular trauma in these circumstances is emphasized, and x-ray films (repeated if necessary) should be taken even when there are no external signs of trauma.     

Mobile Unit for Screening for Cervical and Breast Cancer

In 12 months'' use of a mobile unit for cervical and breast cancer screening in Gloucestershire 3,211 women attended at an average of five sessions a week. Clinic sessions were organized and the running costs of the service met by a voluntary organization. The keeping of records, provision of laboratory facilities, and the follow-up of patients were carried out in close cooperation with the county health department.     

Work of a nurse in a health centre treatment room

In six months there were 1,704 attendances at the treatment room of a small health centre. The attendance rate for the population registered with the health centre doctors was 448 per 1,000 patients per year. Females between 15 and 44 years and males under 15 had the highest attendance rates. There were 256 casual attenders, 58 (23%) of whom were referred to a doctor or hospital for further advice or treatment.It is suggested that in a health centre treatment room about six hours of nursing time a week for every 1,000 patients is required, and that a case can be made out for some of the routine work of casualty departments being done in health centres.     

Kinetic analysis of the growth of Spirulina sp. in batch culture

Batch cultivation of Spirulina sp. was carried out under limited light at 30°C in the pH range of 9.2 to 9.7. The specific growth rate D was calculated from the tangent of the growth curve and the cell concentration at that time, and the amount of light energy absorbed per unit time per unit cell weight (E_x), namely, the specific absorption rate of light energy, was also calculated from the total amount of radiant flux of transmitted light at the surface of the culture vessel and cell concentration of the culture solution. A plot against E_x of D in the linear growth phase in batch culture and at various phases in continuous culture gave, for E_x of less than 1.0 kcal/g·h, points scattered near a straight line with slope m 0.037 g/kcal and an intercept on the ordinate, −b, of −0.0046 h⁻¹, and, for higher E_x values, points scattered near a curve of gradually decreasing slope which tended to approach a constant value.A Lineweaver-Burk plot of the reciprocal of D plus b against that of E_x yielded an equation for the growth rate which represented well the growth curve in batch culture. This equation also expressed the linear increase of D with increase of E_x at high cell concentration in the culture solution. The relation between cell growth rate and cell fluidity is discussed by use of a vector equation obtained by applying this relation to a culture solution contained in a given closed surface.     

Protein-Bound Uremic Toxin Profiling as a Tool to Optimize Hemodialysis

Aim

We studied various hemodialysis strategies for the removal of protein-bound solutes, which are associated with cardiovascular damage.

Methods

This study included 10 patients on standard (3x4h/week) high-flux hemodialysis. Blood was collected at the dialyzer inlet and outlet at several time points during a midweek session. Total and free concentration of several protein-bound solutes was determined as well as urea concentration. Per solute, a two-compartment kinetic model was fitted to the measured concentrations, estimating plasmatic volume (V₁), total distribution volume (V_tot) and intercompartment clearance (K₂₁). This calibrated model was then used to calculate which hemodialysis strategy offers optimal removal. Our own in vivo data, with the strategy variables entered into the mathematical simulations, was then validated against independent data from two other clinical studies.

Results

Dialyzer clearance K, V₁ and V_tot correlated inversely with percentage of protein binding. All Ks were different from each other. Of all protein-bound solutes, K₂₁was 2.7–5.3 times lower than that of urea. Longer and/or more frequent dialysis that processed the same amount of blood per week as standard 3x4h dialysis at 300mL/min blood flow showed no difference in removal of strongly bound solutes. However, longer and/or more frequent dialysis strategies that processed more blood per week than standard dialysis were markedly more adequate. These conclusions were successfully validated.

Conclusion

When blood and dialysate flow per unit of time and type of hemodialyzer are kept the same, increasing the amount of processed blood per week by increasing frequency and/or duration of the sessions distinctly increases removal.     

Computer Simulation Model of an X-ray Department

A computer simulation model has been designed to predict the effects of changes in the work load and resources of an x-ray department. The model has been used to produce histograms of patient waiting times and to show the effect on these of introducing changes in the speed of processing films and in the numbers of cubicles and radiographers available. The predicted benefit of using a faster film processor has been confirmed in practice.     

Use of Gastric Function Tests by British Gastroenterologists

A questionnaire was used to study the choice and use of gastric function tests by members of the British Society of Gastroenterology.Pentagastrin has largely replaced older drugs as the stimulant of choice for evoking maximal acid secretion. Insulin tests are being used in situations where they are unlikely to provide useful clinical information. Fewer physicians than surgeons measure gastric secretion, and they use tests less often. The reluctance of physicians to test patients with uninvestigated dyspepsia or gastric ulcer seems justified, but in patients having dyspepsia with negative x-ray films, or after gastrectomy or vagotomy, the greater investigative keenness of surgeons seems commendable. Only half the surgeons ever try to assess the completeness of their vagotomies, and in only one-third of this half is it their usual practice. Criticism is made of the practice of routine measurement of acid in patients with duodenal ulcer, and of the use of acid measurements to decide whether a patient should have surgery or which type of operation should be performed.     

Cost-utility of an 8-month aquatic training for women with fibromyalgia: a randomized controlled trial

Introduction

Physical therapy in warm water has been effective and highly recommended for persons with fibromyalgia, but its efficiency remains largely unknown. Should patients or health care managers invest in this therapy? The aim of the current study was to assess the cost-utility of adding an aquatic exercise programme to the usual care of women with fibromyalgia.

Methods

Costs to the health care system and to society were considered in this study that included 33 participants, randomly assigned to the experimental group (n = 17) or a control group (n = 16). The intervention in the experimental group consisted of a 1-h, supervised, water-based exercise sessions, three times per week for 8 months. The main outcome measures were the health care costs and the number of quality-adjusted life-years (QALYs) using the time trade-off elicitation technique from the EuroQol EQ-5D instrument. Sensitivity analyses were performed for variations in staff salary, number of women attending sessions and time spent going to the pool. The cost effectiveness acceptability curves were created using a non-parametric bootstrap technique.

Results

The mean incremental treatment costs exceeded those for usual care per patient by € 517 for health care costs and € 1,032 for societal costs. The mean incremental QALY associated with the intervention was 0.131 (95% CI: 0.011 to 0.290). Each QALY gained in association with the exercise programme cost an additional € 3,947/QALY (95% CI: 1,782 to 47,000) for a health care perspective and € 7,878/QALY (3,559 to 93,818) from a societal perspective. The curves showed a 95% probability that the addition of the water-based programme is a cost-effective strategy if the ceiling of inversion is € 14,200/QALY from a health care perspective and € 28,300/QALY from a societal perspective.

Conclusion

The addition of an aquatic exercise programme to the usual care regime for fibromyalgia in women is cost effective in terms of both health care costs and societal costs. However, the characteristics of facilities (distance from the patients' homes and number of patients that can be accommodated per session) are major determinants to consider before investing in such a programme.

Trial registration

Current controlled trials ISRCTN53367487.

     

Randomised trial of personalised computer based information for patients with schizophrenia

ObjectivesTo compare use, effect, and cost of personalised computer education with community psychiatric nurse education for patients with schizophrenia.DesignRandomised trial of three interventions. Modelling of costs of alternatives.Participants112 patients with schizophrenia in contact with community services; 67 completed the intervention.InterventionsThree interventions of five educational sessions: (a) computer intervention combining information from patient''s medical record with general information about schizophrenia; (b) sessions with a community psychiatric nurse; (c) “combination” (first and last sessions with nurse and remainder with computer).ResultsRates of completion of intervention did not differ significantly (71% for combination intervention, 61% for computer only, 46% for nurse only). Computer sessions were shorter than sessions with nurse (14 minutes v 60 minutes). More patients given nurse based education thought the information relevant. Of 20 patients in combination group, 13 preferred the sessions with the nurse and seven preferred the computer. There were no significant differences between groups in psychological outcomes. Because of the need to transport patients to the computer for their sessions, there was no difference between interventions in costs, but computer sessions combined with other patient contacts would be substantially cheaper.ConclusionsThe computer based patient education offered no advantage over sessions with a community psychiatric nurse. Investigation of computer use combined with other health service contacts would be worth while.

What is already known on this topic

Education of patients with schizophrenia has limited but positive outcomesComputer based approaches have not been thoroughly evaluated

What this study adds

A computer based method of education for patients with schizophrenia, which personalised the information with details from each patient''s medical record, was acceptable and as effective as educational sessions given by a community psychiatric nurseHowever, because of the need to provide transport for patients to attend their sessions, the computer based intervention was as costly as the nurse based oneInvestigating the addition of computer based education to other routine patient contacts would be worthwhile     

“As du Coeur” study: a randomized controlled trial on quality of life impact and cost effectiveness of a physical activity program in patients with cardiovascular disease

Background

Physical activity programs (PAP) in patients with cardiovascular disease require evidence of cost-utility. To assess improvement in health-related quality of life (QoL) and reduction of health care consumption of patients following PAP, a randomized trial was used.

Methods

Patients from a health insurance company who had experienced coronary artery disease or moderate heart failure were invited to participate (N?=?1891). Positive responders (N?=?50) were randomly assigned to a progressively autonomous physical activity (PAPA) program or to a standard supervised physical activity (SPA) program. The SPA group had two supervised sessions per week over 5?months. PAPA group had one session per week and support to aid habit formation (written tips, exercise program, phone call). To measure health-related quality of life EQ-5D utility score were used, before intervention, 6?months (T6) and 1 year later. Health care costs were provided from reimbursement databases.

Results

Mobility, usual activities and discomfort improved significantly in both group (T6). One year later, EQ-5D utility score was improved in the PAPA group only. Total health care consumption in the intervention group decreased, from a mean of 4097 euros per year before intervention to 2877 euros per year after (p?=?0.05), compared to a health care consumption of 4087 euros and 4180 euros per year, in the total population of patients (N?=?1891) from the health insurance company. The incremental cost effectiveness ratio was 10,928 euros per QALYs.

Conclusion

A physical activity program is cost-effective in providing a better quality of life and reducing health care consumption in cardiovascular patients.

Trial registration

ISRCTN77313697, retrospectively registered on 20 November 2015.

     

In situ γ-spectrometry several years after deposition of radiocesium

Several years after the deposition of fallout radiocesium, the maximal activity of this radionuclide will not remain at the soil surface but be found rather in deeper layers. In order to estimate the total radiocesium contamination of a large area and the resulting γ-dose rate by in-situ spectrometry, it is necessary to approximate the vertical distribution of this radionuclide by an analytical function. Observations at ten undisturbed grassland soils in Bavaria, Germany, show that the resulting depth distributions can be approximated closely by a three-parameter Lorentz function. This function characterises the observed distributions in all three critical sections, i.e. the surface layer, the distribution around the maximal concentration, and the tail at greater depth. It is also shown that the observed total activity per unit area of the soil due to ¹³⁷Cs agrees very well with the corresponding value obtained from the integrated Lorentz function. The two coefficients of the Lorentz function, which characterise the location (depth) and width of the maximum in the activity distribution, are shown to be correlated. In part II of this study, it will be shown how the parameters of the Lorentz function can also be obtained by in-situ γ-ray spectrometry. As a result, it is possible to use in-situ γ-ray spectrometry to obtain the total ¹³⁷Cs activity per unit area also for sites where the vertical distribution of this radionuclide in the soil is no longer exponential. Received: 7 March 1996 / Accepted in revised form: 20 June 1996     

Susceptibility of N. gonorrhoeae to Antibiotics: A Study of 200 Consecutive Strains Isolated in Winnipeg in 1962

Gonorrhea has increased in incidence over the past five years in Manitoba as elsewhere. Cases which did not respond to routine penicillin treatment were noted to be occuring more often. In 1948, strains of N. gonorrhoeae isolated in Canada were all sensitive to 0.06 unit of penicillin per c.c. in vitro. Commencing in May 1962, strains of N. gonorrhoeae were isolated from 100 patients of each sex attending the clinic at the St. Boniface General Hospital. Eighteen per cent required concentrations of more than 0.05 unit of penicillin per ml. to inhibit growth; 31% were not inhibited by the 2 μg. disc of dihydrostreptomycin; but only one strain was found resistant to sulfisoxazole and none to oxytetracycline. Results of penicillin treatment were markedly less successful in the patients with strains that demonstrated reduced penicillin sensitivity. Use of streptomycin and a sulfonamide proved to be a satisfactory substitute. Intramuscular oxytetracycline was less successful despite the laboratory findings.     

The Hammer and the Eye: Beware

In reporting this small series of foreign-body injuries to the eye it is emphasized how normal an eye may appear and yet have a foreign body lurking in its anterior chamber. The patient''s account of the injury may be very deceptive and an x-ray picture of the eye must be taken if a foreign body is even remotely suspected, particularly if a hammer is mentioned. Prompt diagnosis followed by well executed surgery leads to good results in these cases.     

Improving immunisation: coverage in a province in Papua New Guinea

The effect on immunisation coverage of applying guiding principles to the management of primary health care services in a province in Papua New Guinea is described. These principles were: (a) Each health centre should have a defined geographical area of responsibility. (b) Each health centre should be responsible for a defined population. (c) Each health centre should have defined target groups for immunisation and child health clinic enrolment. (d) An accurate and meaningful reporting system is essential. (e) Each health centre should receive regular feedback on its achievements. Immunisation coverage in the province, as judged by the proportion of children under 1 year of age receiving their second dose of triple antigen, improved from 57-67% in 1980-2 to 89-94% in 1983-4.Immunisation is the most cost effective preventive activity undertaken in child health care. The application of these guiding principles would be relevant in the United Kingdom.     

La unidad de ortogeriatría de agudos. Evaluación de su efecto en el curso clínico de los pacientes con fractura de cadera y estimación de su impacto económico

Objective

To study the effects of the management of hip fracture patients in an acute orthogeriatric unit shared between the departments of Orthopedic Surgery and Geriatrics compared with the usual hospital care, and to analyse financial differences in both systems of care.

Method

Prospective quasy-experimental randomized intervention study in 506 patients admited to a terciary hospital with an osteoporotic hip fracture. The usual model of care was the admission to the orthopedic ward with a request to Geriatrics (RC) and the study model consisted of the admission to an orthogeriatric unit (OGU) for the shared co-management between orthopaedic surgeons and geriatricians. This model included the appointment of one spokesperson from each department, the specialist geriatric nurse management, early geriatric assessment, shared daily clinical care, weekly joint ward round and coordinated planning of the surgery schedule, the start of the ambulation and the time and setting of patient discharge.

Results

Two hundred fifty five consecutive patients admitted to the OGU and 251 patients managed simultaneusly by the RC model were included. Except for a mean age slightly lower in the OGU group, there were no differences neither in the baseline patients characteristics nor in the surgical rates between the two groups. Among the OGU patients group it was more frequent to receive rehabilitation in the acute setting, to be able to walk at discharge and to be referred to a geriatric rehabilitation unit (all with P<.05). The OGU patients received geriatric assessment and were operated on earlier than the RC patients (P<.001). The length of stay in the acute ward was 34% shorter in the OGU patients (mean 12.48±5 vs 18.9±8.6 days, P<.001) (median 12 [9-14] vs 17 [13-23] days, P<.001). The whole hospital length of stay, including the days spent in the geriatric rehabilitation units, was 11% shorter in the OGU patients (mean 21.16 ±14.7 vs 23.9 ±13.8 days, P<0.05) (median 14 [10-31] vs 20 [14-30] days, P<.001). The OGU saved 1,207 € to 1,633 € per patient when estimated by the costs for process model, and 3,741 € when estimated by the costs for stay model.

Conclusions

The OGU is a hospital setting that provides an improvement in the patients functional outcome and a reduction in the hospital length of stay. Therefore it saves health care resources. These findings show the OGU as an advisable setting for the acute care of hip fracture patients.     

Ca binding to sarcoplasmic reticulum ATPase phosphorylated by Pi reveals four thapsigargin-sensitive Ca sites in the presence of ADP

Sarcoplasmic reticulum (SR) Ca²⁺-ATPase was phosphorylated by P_i at pH 8.0 in the presence of dimethyl sulfoxide (Me₂SO). Under these conditions, it was possible to measure transient ⁴⁵Ca²⁺ binding to the phosphoenzyme. Binding reached 1.2 Ca²⁺ per phosphoenzyme (E-PCa_x) within 10 min in 30% Me₂SO, 20 mM MgCl₂ and 0.1 mM P_i and the phosphoenzyme only decreased by 23% during this period. This Ca²⁺ binding was abolished by thapsigargin, showing that it is associated with functional sites of the Ca²⁺-ATPase. At 40% Me₂SO, simultaneous addition of Ca²⁺ and ADP increased Ca²⁺ binding up to almost four Ca²⁺ per phosphoenzyme (ADPE-PCa_y), revealing a species bearing simultaneously four Ca²⁺ sites. Both E-PCa_x and ADPE-PCa_y were further identified as distinct species by (2′,3′-O-2(2,4,6-trinitrophenyl)adenosine 5′-triphosphate) fluorescence, which revealed long-range modifications in the Ca²⁺-transport sites induced by ADP binding to E-P. In addition, E-PCa_x was shown to be a functional intermediate of the cycle leading to ATP synthesis provided that Me₂SO was diluted. These findings indicate that more than two functional Ca²⁺-sites exist on the functional Ca²⁺-ATPase unit, and that the additional sites become accessible upon ADP addition. This is compatible with a four-site model of the SR Ca²⁺-ATPase allowing simultaneous binding of Ca²⁺ at lumenal and cytosolic sites. The stoichiometries for Ca²⁺ binding found here could either be interpreted as binding of four Ca²⁺ on a Ca²⁺-ATPase monomer considered as the functional unit or as binding of two Ca²⁺ per monomer of a functional dimer.