Analyses of the Redistribution of Work following Cardiac Resynchronisation Therapy in a Patient Specific Model

Regulation of regional work is essential for efficient cardiac function. In patients with heart failure and electrical dysfunction such as left branch bundle block regional work is often depressed in the septum. Following cardiac resynchronisation therapy (CRT) this heterogeneous distribution of work can be rebalanced by altering the pattern of electrical activation. To investigate the changes in regional work in these patients and the mechanisms underpinning the improved function following CRT we have developed a personalised computational model. Simulations of electromechanical cardiac function in the model estimate the regional stress, strain and work pre- and post-CRT. These simulations predict that the increase in observed work performed by the septum following CRT is not due to an increase in the volume of myocardial tissue recruited during contraction but rather that the volume of recruited myocardium remains the same and the average peak work rate per unit volume increases. These increases in the peak average rate of work is is attributed to slower and more effective contraction in the septum, as opposed to a change in active tension. Model results predict that this improved septal work rate following CRT is a result of resistance to septal contraction provided by the LV free wall. This resistance results in septal shortening over a longer period which, in turn, allows the septum to contract while generating higher levels of active tension to produce a higher work rate.     

Return to work and quality of life after surgery for coronary artery disease.

Changes in work capability and quality of life were assessed retrospectively in 130 patients with ischaemic heart disease who had undergone aortocoronary bypass operations during 1976-7 because of medically uncontrollable angina. A total of 85 patients (65.4%) reported complete relief from angina six months after operation, though 12 later suffered a recurrence. Substantially fewer patients needed drugs after the operation. Before operation 9 out of 117 men fully employed at the onset of angina were working without restriction or doing lighter, fulltime work, 38 were at work but seriously incapacitated by angina, and 70 were forced to stop work. After operation 70 were working without restriction or engaged in lighter work, 15 were at work but still restricted by angina, and only 32 were forced to stop work. This result was highly significant (P less than 0.001). These differences were even more pronounced in heavy manual workers, of whom none cobld work normally before operation, whereas 16 were working without restriction afterwards. Of patients wishing to engage in hobbies or sports, social activity, and sexual intercourse but were restricted before operation, about two-thirds could resume these activities afterwards. Coronary artery surgery provided dramatic symptomatic relief in up to 90% of patients and permitted rehabilitation and return to gainful employment irrespective of type of labour. The degree of symptomatic improvement and increase in exercise tolerance after successful surgery is usually far greater than occurs with any other form of treatment and directly improves quality of life and work capability.     

Who undertakes the consultations in the outpatient department?

In a study of all 4275 outpatient consultations over one month in a district general hospital it was found that the clinics in surgical specialties had the largest numbers of patients. In general surgery less than half of new patients and only one third of all patients attending the clinic were seen by a consultant. (Nine months later about a third of all new patients had still not seen a consultant in the clinic.) In the medical clinics just over a quarter of patients were seen by doctors who had less than six months'' experience in their present specialty after registration. Overall, doctors had been on continuous duty for at least 24 hours before a third of consultations. Doctors in training had actually worked during the previous night before attending a quarter of the clinics.Much of the large volume of work is performed by tired, incompletely trained doctors. It is suggested that a greater proportion of the work should be performed by fully trained staff. The workload might be reduced by modifying the pattern of the consultation.     

Team Work Load in an English General Practice—I

A survey of the total care provided by a general practitioner and his paramedical team for 3,137 patients in Teesside in 1972 showed that even in this area of high morbidity and mortality the work load was very small. The doctor held an average of 2·3 consultations per patient per year, and the overall average for the team of doctor, nurse, and health visitor was only 3·1. By delegating work to a team of trained paramedical workers, by increasing the proportion of personal medicine, and by engaging the co-operation of his patients, the general practitioner reduced his work load considerably, without any apparent reduction in standard of care.     

Methodical aspects of perceived exertion rating and its relation to pedalling rate and rotating mass.

Methodical aspects of the relationship between pedalling rate and rotating mass and perceived exertion rating (PER; Borg, 1962) were studied in trained, untrained, and ill subjects in bicycle ergometry. Pedalling rate varied between 40 and 100 rpm, work load steps were 5, 10, 15 and 20 mkp/sec in the healthy subjects, and 2.5, 5, 7.5 and 10 mkp/sec in the patients. PER decreased with increasing pedalling rate in all healthy subjects. In the patients, PER increased moderately at work load of 2.5 mkp/sec, but decreased at higher work loads up to 80 rpm, followed by a slight increase at 100 rpm. Higher mass of the flywheel, studied in 6 trained subjects, lowered the PER insignificantly. In the healthy subjects, test criteria, such as reproducibility, reliability, sensitivity, and linearity remained almost unaffected by pedalling rate. In patients, increasing pedalling speed diminished reproducibility and sensitivity. The strictness of the PER work load relationship is lowered at higher pedalling rate, especially at 100 rpm. When using the PER scale, pedalling rate has to be considered as an factor of main influence.     

Follow-up of Hydatidiform Mole by Radioimmunoassay of Human Chorionic Gonadotrophin

An improved method for the follow-up of patients delivered of a hydatidiform mole using radioimmunoassay of human chorionic gonadotrophin is employed to ensure adequate sensitivity. Four illustrative case histories are described. Their HCG findings are presented to show that this is the principal basis on which decisions should be made.There are three aspects to the work of the laboratory. The technical work of the assay, the clerical effort of patient follow-up, and the clinical interpretation of results. The laboratory keeps a close check on follow-up (one of its most important functions) and receives specimens direct from patients. Overall control of all three aspects is by a clinician. It has been found useful to organize a special clinic for these patients to be seen. In this region it has been possible for this to be run by the same clinician.     

An aggressive return-to-work program in surgical treatment of carpal tunnel syndrome: a comparison of costs.

Carpal tunnel syndrome is a common malady associated with modern manufacturing. An aggressive return-to-work program was begun in 1980. A prospective study was begun in 1982, and data matured through 1988 comparing the costs of a control group of patients treated by the more traditional method (in the author's geographic area) and the author's aggressive return-to-work policy. Sixty-seven patients with 94 carpal tunnel surgeries were studied. The results reveal that the aggressively treated group had 1 of 44 patients fail to return to work following surgery, and 3 of 23 failed to return to work from the control group. One patient of each group developed a recurrence. The tangible costs that could be computed were found to be 58 percent less in the aggressively treated group than in the control group. At the same time, the patients can maintain their standard of living.     

临床护理工作中的人际关系论析

护理工作是整个医疗工作中的重要组成部分,做好护理工作,需要多方面的配合,而工作中的人际关系融洽与否,直接关系到护士的工作情绪和工作的积极性,进而影响护理质量和患者的康复。护士在整个医疗工作中处于人际交往的中心地位,扮演着举足轻重的特殊角色。人际交往能力是一个护士的道德修养,文化教育,社会经历,行为举止,言谈仪表,人格特征的综合体现,是护士职业成功的最主要因素。因此,处理好这些人际关系对我们护理工作者显得尤为重要.     

Neurological complications of coronary artery bypass graft surgery: six month follow-up study.

As part of a major prospective study of the neurological complications of coronary artery bypass graft surgery patients were reviewed over six months to determine the clinical course and functional impact of early postoperative complications. One hundred and ninety one out of 312 (61%) patients had developed early postoperative disorders. At six months 165 of the 191 patients with early neurological complications were reviewed. Of the 165, 85 still had detectable neurological signs, but these were often minor and of little functional importance. Only 10 patients had neurological disability at six months, and this was major in only four patients, all of whom had suffered major perioperative stroke. No patient with non-disabling neurological complications in hospital became functionally impaired on returning home. Neurological disorders are not a major cause of failure to return to work by six months after coronary artery bypass surgery. Of 139 patients who were of working age and had not returned to work by six months, only four were prevented by neurological injury related to surgery. The long term prognosis for early neurological disorders after coronary artery bypass surgery is usually favourable, except in those patients who have sustained major perioperative stroke.     

Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice.

OBJECTIVE--To describe the natural course of recent acute low back pain in terms of both morbidity (pain, disability) and absenteeism from work and to evaluate the prognostic factors for these outcomes. DESIGN--Inception cohort study. SETTING--Primary care. PATIENTS--103 patients with acute localised non-specific back pain lasting less than 72 hours. MAIN OUTCOME MEASURES--Complete recovery (disappearance of both pain and disability) and return to work. RESULTS--90% of patients recovered within two weeks and only two developed chronic low back pain. Only 49 of 100 patients for whom data were available had bed rest and 40% of 75 employed patients lost no time from work. Proportional hazards regression analysis showed that previous chronic episodes of low back pain, initial disability level, initial pain worse when standing, initial pain worse when lying, and compensation status were significantly associated with delayed episode recovery. These factors were also related to absenteeism from work. Absenteeism from work was also influenced by job satisfaction and gender. CONCLUSIONS--The recovery rate from acute low back pain was much higher than reported in other studies. Those studies, however, did not investigate groups of patients enrolled shortly after the onset of symptoms and often mixed acute low back pain patients with patients with exacerbations of chronic pain or sciatica. Several sociodemographic and clinical factors were of prognostic value in acute low back pain. Factors which influenced the outcome in terms of episode recovery (mainly physical severity factors) were only partly predictive of absenteeism from work. Time off work and return to work depended more on sociodemographic and job related influences.     

Perceived discrimination against cured cancer patients in the work force.

To evaluate perceived discrimination against cured cancer patients in the work force in Montreal, in 1982-83 we surveyed 101 cured cancer patients and 101 control subjects who had never had cancer and who were matched for age, sex and neighbourhood of residence. In addition, 24 of the cured patients were randomly selected and paired with cancer patients with a poor prognosis who were matched for age and sex. Discrimination was slightly more common among cured patients (18%) than among control subjects (15%), and 21% of the cancer patients with a poor prognosis reported discrimination. Analysis of the comparisons between the cured and control groups indicated no statistically significant differences. The cured cancer patients reported the following problems faced by cancer patients returning to work: fatigue (30%), absenteeism (14%), psychologic problems (12%), social stigma (12%) and discrimination by an employer (10%).     

Plastic surgery-important advances in clinical medicine: collagen

Workers'' compensation laws influence recovery from injury. They affect the “cause” of disease, access to care, diagnostic evaluation, treatment, response to treatment and residual disability. Paradoxically, financial compensation may discourage return to work, the appeal process may increase disability, an open claim may inhibit return to work and recovering patients may be unable to return to work.Physicians may help improve the prospects of returning patients to work by providing care that is medical, caring and independent. It is essential that the treatment of back pain be based on the known natural history and on the understanding that the management of acute pain differs from that of chronic pain.Increased awareness of the factors controlling return to work should motivate legislative bodies, labor and industry to alter those features of the compensation system that interfere with the return to work of injured workers.     

New roles for general practitioners.

General practice is likely to change greatly over the next few years. Increases in care in the community and day surgery will lead to more work, and the demand for better data on practice activity will mean the development of audit and epidemiological work. To make time general practitioners will have to learn to delegate work that does not require a doctor. Fundholding has already stimulated some practices to bring services to patients rather than send patients to hospital, and this trend seems set to continue. It is important to pool resources, not only within practices but among other practices in the area--joint action will increase the ability to improve the services for patients. If general practitioners take the opportunity to gain control of the changes the morale of the profession should improve.     

Delayed-Type Hypersensitivity to Metals of Environmental Burden in Patients with Takotsubo Syndrome – Is There a Clinical Relevance?

ObjectiveTakotsubo syndrome (TS) is a heart condition characterised by a sudden transient left ventricular dysfunction; its pathophysiology is probably associated with elevated levels of catecholamines but the exact mechanism is not known as yet. Literature and clinical experience suggest that TS affects persons with various comorbidities. This pilot work aims to evaluate the frequency of comorbidities with potential pathological immune reactivity, and to evaluate the potential association between TS and hypersensitivity to metals assessed by LTT-MELISA®.ConclusionOur work shows that conditions with pathological immune reactivity occur frequently in TS patients, and our data suggest a possible association between TS and hypersensitivity to metals (mercury in particular) evaluated by LTT-MELISA®. We also suggest that apart from the triggering stress factor, potential existence of other serious conditions should be considered when taking medical history of TS patients.     

Prevention and conservative treatment of backache related to intervertebral disc disease]

Despite epidemic character of backache in the developed countries, proper treatment is still facing a lot of difficulties and disbelief. Backache are considered incurable disease disabling normal life and work by both numerous patients and physicians. Proper information on causes and sequelae of backache, prophylaxis, ergonomics of work and ways of decreasing complaints should be valuable. Conservative treatment, based on the Backache Exercise School doctrine, is very effective, saving unnecessary suffering and tragedies, and saving costs of disability.     

Coenzyme Q10 treatment in serious heart failure.

Several noninvasive studies have shown the effect on heart failure of treatment with coenzyme Q10. In order to confirm this by invasive methods we studied 22 patients with mean left ventricular (LV) ejection fraction 26%, mean LV internal diameter 71 mm and in NYHA class 2-3. The patients received coenzyme Q10 100 mg twice daily or placebo for 12 weeks in a randomized double-blinded placebo controlled investigation. Before and after the treatment period, a right heart catheterisation was done including a 3 minute exercise test. The stroke index at rest and work improved significantly, the pulmonary artery pressure at rest and work decreased (significantly at rest), and the pulmonary capillary wedge pressure at rest and work decreased (significantly at 1 min work). These results suggest improvement in LV performance. Patients with congestive heart failure may thus benefit from adjunctive treatment with coenzyme Q10.     

Artificial mountain climate in therapy and rehabilitation of patients with chronic nonspecific pulmonary diseases]

Therapeutic efficiency of artificial Alpine climate was studied in a group of 318 patients with chronic nonspecific pulmonary diseases (CNDP). The Alpine climate was modelled on device "Orotron". The base, progradient and prolonged regimes of therapy by artificial Alpine climate (orhotherapy) were used in work. It is shown that application of optimal conditions of orhotherapy promotes normalization of the external respiration function in patients with CNPD due to a decrease in expression of broncho-obstructive and bronchitic syndromes and in nonuniformity of regional ventilation of lungs. Therapy by artificial Alpine climate is recommended to be used in wide clinical practice for treatment and rehabilitation of patients with CNDP.     

Comparative Study of District and Community Hospitals

Opinions conflict on whether there is a place in the Health Service for general practitioner (community) hospitals in which the patients'' treatment is mainly the responsibility of their family doctors. The authors therefore analysed a sample of the patients admitted in the course of a year to a group of two general district hospitals with a comparable sample of the patients admitted to a general practitioner hospital. The aim was to analyse the type of care provided in the general practitioner hospital, to assess whether it was appropriate for the type of cases treated, and to decide whether the patients would have been better off in the district general hospital (and vice versa). The main conclusions are that a district hospital is best for serious illnesses needing skilled decisions and assessments but that most of the work of these hospitals is not of this kind and a community hospital staffed by general practitioners offers many advantages to patients—provided the work being done is constantly under critical assessment. The authors plead for special refresher courses under the N.H.S. for general practitioners working in community hospitals.     

Outcome following implantation of a peripheral nerve stimulator in patients with chronic nerve pain

This study evaluated the usefulness of the implanted peripheral nerve stimulator in patients with pain following injury to a peripheral nerve. The patient sample (n = 17) consisted of 7 men and 10 women with a mean age of 48 years (SD = 18 years). The mean follow-up time since implantation of the stimulator was 21 months (SD = 15 months). Workers' compensation and/or litigation were involved in 11 cases. Peripheral nerve stimulators were placed in the upper extremity in 12 patients and in the lower extremity in 5 patients. Pain relief following implantation was rated as excellent by five patients, good by six patients, fair by four patients, and poor by two patients. A statistically significant decrease in reported pain level was found postoperatively (p < 0.0003). There was no statistically significant difference in postoperative pain level between men and women (p = 0.30), between cases involving workers' compensation or litigation and those not involving these issues (p = 1.0), or between patients who received an upper-extremity implant and those who received a lower-extremity implant (p = 0.56). Of the 12 patients who were unable to work before the operation, 6 returned to work after the operation. In conclusion, peripheral nerve stimulators can be useful in decreasing pain in carefully selected patients with severe neurogenic pain.     

Long-term Prognosis following Ventricular Fibrillation in Acute Ischaemic Heart Disease

Of 160 patients who survived ventricular fibrillation complicating acute ischaemic heart disease, 80 had had a clinically mild coronary attack. Most of the long-term survivors had ventricular fibrillation within 24 hours of the onset of symptoms. The longterm prognosis of the survivors was similar to that of patients whose myocardial infarction was not complicated by ventricular fibrillation. Those patients who survived ventricular fibrillation which occurred within four hours of the onset of symptoms were younger, usually had had a mild coronary attack, and had the most favourable longterm prognosis. The number of episodes of ventricular fibrillation did not affect adversely the long-term prognosis. Of those who at the time of review were eligible to work, 86% were fit to work and 68% were actually at work.