Factors associated with the frequency of house calls by primary care physicians

Objective:To evaluate factors associated with the frequency of house calls by primary care physicians. Design:A cross-sectional design with a self-administered mailed survey. Setting/participants:751 primary care physicians who care for Medicaid patients in Virginia. Results:Among 389 physician respondents (52%), regular house callers (n=216) were compared with occasional house callers (n=162). Among physician characteristics, specialty and practice duration were associated with house call frequency. Regular house callers also more often cited chronic illness (67% vs. 20%, p<0.01) and terminal illness (67% vs. 40%, p<0.01) as indications for house calls, compared with occasional house callers. Use of visiting nurses to substitute for physician house calls was less often considered appropriate by frequent house callers (7% vs. 24%, p<0.01), and regular house callers were less likely to report being “too busy” to make house calls (71% vs. 29%, p<0.01). Multivariate analysis confirmed the association of these attitudes with house call frequency. Conclusion:These data suggest that specific attitudes among primary care physicians are associated with house call frequency. Presented in part at the annual meeting of the Society of General Internal Medicine, May 2–4, 1990, Arlington, Virginia. Supported in part by a grant from Virgina Commonwealth University.     

Abnormal Q waves on the admission electrocardiogram of patients with first acute myocardial infarction: Prognostic implications

Background: Q waves developed in the subacute and persisting into the chronic phase of myocardial infarction (MI) usually signify myocardial necrosis. However, the mechanism and significance of Q waves that appear very early in the course of acute MI (<6 h from onset of symptoms), especially if accompanied by ST elevation, are probably different. Hypothesis: This study assesses the prognostic implications of abnormal Q waves on admission in 2,370 patients with first acute MI treated with thrombolytic therapy <6 h of onset of symptoms. Results: Patients with abnormal Q waves in ≥2 leads with ST-segment elevation (n = 923) were older than patients without early Q waves (n = 1,447) (60.6 ±11.9 vs. 58.8 ±11.9 years, respectively; p = 0.0003), and had a greater incidence of hypertension (34.3 vs. 30.5% p = 0.05) and anterior MI (60.6 vs. 41.1 % p<0.0001). Time from onset of symptoms to therapy was longer in patients with Q waves upon admission (208 ± 196 vs. 183 ± 230 min; p = 0.01). Peak serum creatine kinase (2235 ± 1544 vs. 1622 ± 1536 IU; p<0.0001), prevalence of heart failure during hospitalization (13.8 vs. 7.0%, p<0.0002), hospital mortality (8.0 vs. 4.6% p = 0.02), and cardiac mortality (6.6 vs. 4.5%, p = 0.11) were higher in patients with anterior MI and with abnormal Q waves than in those without abnormal Q waves upon admission. There was no difference in peak creatine kinase, prevalence of heart failure, in-hospital mortality, and cardiac mortality between patients with and without abnormal Q waves in inferior MI. Multivariate regression analysis confirmed that mortality is independently associated with presence of Q waves on admission (odds ratio 1.61; 95% CI 1.04–2.49; p = 0.04 for all patients; odds ratio 1.65; 95% CI 0.97–2.83; p=0.09 for anterior wall MI. Conclusion: Abnormal Q waves on the admission electrocardiogram (ECG) are associated with higher peak creatine kinase, higher prevalence of heart failure, and increased mortality in patients with anterior MI. Abnormal Q waves on the admission ECG of patients with inferior MI are not associated with adverse prognosis.     

A comparison of the methods and criteria used by traditional and primary care internal medicine programs to select residents

OBJECTIVE: To determine whether there are differences in the methods and criteria used by primary care and traditional internal medicine programs to select first-year residents. DESIGN: A questionnaire was sent to primary care and traditional internal medicine program directors, who were asked to rank in importance ten documents of an applicant’s file and to score the relative importance, on a scale of −5 to +5, of 21 candidate traits of four types: academic, demographic, personal, and career goal. SETTING: Programs at institutions (n=54) that have categorical residency programs in both traditional and primary care internal medicine. PARTICIPANTS: Of 108 questionnaires, the overall response rate was 81%, with 40 pairs (74%) of matched respondents. Seventy-two percent of the responding institutions were university- administered. RESULTS: Primary care and traditional programs use similar methods to process applicants, rank similarly ten documents in an applicant’s file, and value academic success during the clinical years as the most important candidate trait. Compared with traditional tracks, primary care tracks place greater emphasis on a candidate’s career goals and select for candidates planning to pursue primary care careers (3.9±1.4 vs 0.9±1.5, p<0.001), enter practice (1.4±1.5 vs 0.1±1.2, p<0.001), or serve medically indigent populations (2.7±1.5 vs 1.2±1.2, p<0.001). Primary care programs rate negatively candidates who intend to subspecialize, whereas traditional programs view them almost neutrally (−1.8±2.2 vs 0.5±1.5, p<0.001). CONCLUSION: Primary care and traditional track internal medicine programs use similar methods to select residents and both rank academic achievement during the clinical years as a candidate’s most important attribute. However, only primary care programs strongly select for candidates on the basis of their career plans and in particular prefer candidates who are committed to pursuing primary care careers and serving the medically indigent. Received from the Division of General Internal Medicine and Primary Care, Department of Medicine, University of California, Irvine, California. Presented in part at the annual meeting of the Society of General Internal Medicine, Washington, DC, April 29-May 1, 1992. Supported in part by a grant from the U.S. Public Health Service (2 D28 PE19154).     

Effects of depressive symptoms on health-related quality of life in asthma patients

OBJECTIVE: To assess the effects of depressive symptoms on asthma patients’ reports of functional status and health-related quality of life. DESIGN: Cross-sectional study. SETTING: Primary care internal medicine practice at a tertiary care center in New York City. PATIENTS: We studied 230 outpatients between the ages of 18 and 62 years with moderate asthma. MEASUREMENTS AND MAIN RESULTS: Patients were interviewed in person in English or Spanish with two health-related quality-of-life measures, the disease-specific Asthma Quality of Life Questionnaire (AQLQ) (possible score range, 1 to 7; higher scores reflect better function) and the generic Medical Outcomes Study SF-36 (general population mean is 50 for both the Physical Component Summary [PCS] score and Mental Component Summary [MCS] score). Patients also completed a screen for depressive symptoms, the Geriatric Depression Scale (GDS), and a global question regarding current disease activity. Stepwise multivariate analyses were conducted with the AQLQ and SF-36 scores as the dependent variables and depressive symptoms, comorbidity, asthma, and demographic characteristics as independent variables. The mean age of patients was 41 ± SD 11 years and 83% were women. The mean GDS score was 11 ± SD 8 (possible range, 0 to 30; higher scores reflect more depressive symptoms), and a large percentage of patients, 45%, scored above the threshold considered positive for depression screening. Compared with patients with a negative screen for depressive symptoms, patients with a positive screen had worse composite AQLQ scores (3.9±SD 1.3 vs 2.8±SD 0.8, P<.0001) and worse PCS scores (40±SD 11 vs 34±SD 8, P<.0001) and worse MCS scores (48±SD 11 vs 32±SD 10, P<.0001) scores. In stepwise analyses, current asthma activity and GDS scores had the greatest effects on patient-reported health-related quality of life, accounting for 36% and 11% of the variance, respectively, for the composite AQLQ, and 11% and 38% of the variance, respectively, for the MCS in multivariate analyses. CONCLUSIONS: Nearly half of asthma patients in this study had a positive screen for depressive symptoms. Asthma patients with more depressive symptoms reported worse health-related quality of life than asthma patients with similar disease activity but fewer depressive symptoms. Given the new emphasis on functional status and health-related quality of life measured by disease-specific and general health scales, we conclude that psychological status indicators should also be considered when patient-derived measures are used to assess outcomes in asthma. This project was supported by a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar’s Award to Dr. Mancuso.     

Association of Erythrocyte Aldose Reductase Activity with Diabetic Complications in Type 1 Diabetes Mellitus

Erythrocyte aldose reductase was isolated and its activity measured in 72 Type 1 (insulin dependent) diabetic patients and 21 age and sex matched non-diabetic subjects. The diabetic patients were categorized into two groups in terms of presence (n = 29) or absence (n = 43) of severe diabetic complications. Age, sex, duration of diabetes and HbA_1c levels were matched between the diabetic groups. Erythrocyte aldose reductase (mean ± SEM) was increased in patients with Type 1 diabetes compared to the non-diabetic subjects (7.22 ± 0.24 vs 5.66 ± 0.19 Ul-erythrocytes^-1, < 0.0001). There was a four-fold variation in its activity among the diabetic patients (3.38-12.23 Ul-erythrocytes^-1). The enzyme activity was significantly higher in patients with complications than those without (8.17 ± 0.39 vs 6.58 ± 0.26 Ul-erythrocytes^-1, p < 0.002). When the patients were stratified by duration of the disease, the enzyme activity was highest in patients who had developed complications with a duration of less than 20 years and lowest in those without complications for 20 years or longer (8.54 ± 0.48 vs 6.46 ±p± 0.33 Ul-erythrocytes^-1, p < 0.002). Patients who had an aldose reductase activity greater than the mean + 2SD of that seen in non-diabetic controls were four times more likely to have diabetic complications than those whose enzyme activity fell within 2SD of non-diabetic individuals (p < 0.0005). We conclude that the activity of aldose reductase varies among Type 1 diabetic patients and the differences in its activity may result in a variable susceptibility of these patients to the complications of the disease.     

Atherosclerosis in the primary health care setting: A real-word data study

Introduction and ObjectivesTo characterize patients with atherosclerosis, a disease with a high socioeconomic impact, in the Lisbon and Tagus Valley Health Region.MethodsA cross-sectional observational study was carried out through the Lisbon and Tagus Valley Regional Health Administration primary health care database, extracting data on the clinical and demographic characteristics and resource use of adult primary health care users with atherosclerosis during 2016. Different criteria were used to define atherosclerosis (presence of clinical manifestations, atherothrombotic risk factors and/or consumption of drugs related to atherosclerosis). Comparisons between different subpopulations were performed using parametric tests.ResultsA total of 318 692 users were identified, most of whom (n=224 845 users; 71%) had no recorded clinical manifestations. The subpopulation with clinical manifestations were older (72.0±11.5 vs. 71.3±11.0 years), with a higher proportion of men (58.0% vs. 45.9%), recorded hypertension (78.3% vs. 73.5%) and dyslipidemia (55.8% vs. 53.5%), and a lower proportion of recorded obesity (18.2% vs. 20.8%), compared to those without clinical manifestations (p<0.001). Mean blood pressure, LDL-C and glycated hemoglobin values were lower in the subpopulation with manifestations (142/74 vs. 146/76 mmHg, 101 vs. 108 mg/dl, and 6.80 vs. 6.84%, respectively; p<0.001). Each user with atherosclerosis attended 4.1±2.9 face-to-face medical consultations and underwent 8.6±10.0 laboratory test panels, with differences in subpopulations with and without clinical manifestations (4.4±3.2 vs. 4.0±2.8 and 8.3±10.3 vs. 8.7±9.8, respectively; p<0.001).ConclusionsAbout one in three adult primary health care users with atherosclerosis have clinical manifestations. The results suggest that control of cardiovascular risk factors is suboptimal in patients with atherosclerosis.     

Real-Time Ultrasound Guidance Facilitates Transradial Access: RAUST (Radial Artery Access With Ultrasound Trial)

ObjectivesThis study sought to assess the utility of ultrasound (US) guidance for transradial arterial access.BackgroundUS guidance has been demonstrated to facilitate vascular access, but has not been tested in a multicenter randomized fashion for transradial cardiac catheterization.MethodsWe conducted a prospective multicenter randomized controlled trial of 698 patients undergoing transradial cardiac catheterization. Patients were randomized to needle insertion with either palpation or real-time US guidance (351 palpation, 347 US). Primary endpoints were the number of forward attempts required for access, first-pass success rate, and time to access.ResultsThe number of attempts was reduced with US guidance [mean: 1.65 ± 1.2 vs. 3.05 ± 3.4, p < 0.0001; median: 1 (interquartile range [IQR]: 1 to 2) vs. 2 (1 to 3), p < 0.0001] and the first-pass success rate improved (64.8% vs. 43.9%, p < 0.0001). The time to access was reduced (88 ± 78 s vs. 108 ± 112 s, p = 0.006; median: 64 [IQR: 45 to 94] s vs. 74 [IQR: 49 to 120] s, p = 0.01). Ten patients in the control group required crossover to US guidance after 5 min of failed palpation attempts with 8 of 10 (80%) having successful sheath insertion with US. The number of difficult access procedures was decreased with US guidance (2.4% vs. 18.6% for ≥5 attempts, p < 0.001; 3.7% vs. 6.8% for ≥5min, p = 0.07). No significant differences were observed in the rate of operator-reported spasm, patient pain scores following the procedure, or bleeding complications.ConclusionsUltrasound guidance improves the success and efficiency of radial artery cannulation in patients presenting for transradial catheterization. (Radial Artery Access With Ultrasound Trial [RAUST]; NCT01605292)     

Polymyalgia rheumatica in patients with a normal erythrocyte sedimentation rate

Objective. To ascertain the frequency of polymyalgia rheumatica (PMR) with a normal erythrocyte sedimentation rate (ESR; ≤30 mm/hour) and to determine any defining clinical characteristics. Methods. A retrospective chart review study of all patients meeting the clinical criteria for PMR seen over a 5-year period in a hospital and an office-based rheumatology practice. Results. We evaluated 117 patients; 26 (22.2%) had a pretreatment ESR of ⩽30 mm/hour (mean ± SD 19.8 ± 7.5 versus 74.4 ± 30.3 mm/hour for elevated ESR group; P < 0.0001). Of the 26 normal ESR patients, 15 (58%) were female compared with 74 of the 91 elevated ESR patients (81%) (P < 0.02, by Fisher's exact test). The mean hemoglobin concentration was significantly lower in the elevated ESR population (mean ± SD 1.23 ± 0.15 gm/liter versus 1.38 ± 0.11 gm/liter; P < 0.0001). The duration of symptoms prior to treatment with prednisone was significantly longer for patients with a normal ESR (149 ± 95 days versus 103 ± 95 days for elevated ESR patients; P <0.04). Conclusion. In our series, PMR with a normal ESR accounted for approximately one-fifth of all PMR patients, more commonly in men. The lack of characteristically abnormal laboratory findings may result in a delay in the proper diagnosis and management of this condition.     

Critically ill systemic lupus erythematosus patients referred to the intensive care unit of Fayoum University Hospital: Frequency,complications and outcome

Aim of the work

To determine the frequency of critical complications of systemic lupus erythematosus (SLE) admitted to the intensive care unit (ICU), study the risk factors and outcome.

Medical care setting is associated with survival in acute upper gastro-intestinal bleeding: A cohort study

BackgroundThere are limited data on the effect of the medical care setting on survival in patients admitted with acute upper gastrointestinal bleeding.AimsTo identify the organisational and care setting which provides the optimal survival in patients with acute upper gastrointestinal bleeding.MethodsA retrospective observational study of administrative data from a cohort of patients admitted to a Regional or Local hospital, and cared for in a gastroenterology or general ward.Primary outcome30 day survival for non-variceal bleeding and 42 day survival for variceal bleeding.ResultsOut of 3368 patients, the source of bleeding was non-variceal in 2980 (88.5%). Survival, adjusted for clinical and organisational factors, was higher in patients admitted to a gastroenterology ward vs other wards (OR = 2.02 p < 0.0006). Management in a gastroenterology ward in a Regional hospital provided a higher survival rate (95.6% ± 0.08) vs a non-gastroenterology ward in a Local hospital (92.9% ± 0.05 p < 0.01) or a non-gastroenterology ward in a Regional hospital (89.5% ± 0.01 p < 0.0001). Survival (94.0% ± 1.6) in a Local hospital with a gastroenterology ward was significantly higher than in a Regional hospital without (89.5% ± 1.1) p < 0.01.ConclusionSurvival was optimal for patients treated in a gastroenterology ward independently of Regional or Local hospital setting.     

以提高肾脏病整体预后工作组诊断标准分析脓毒症相关急性肾损伤患者的临床特点

  目的 以提高肾脏病整体预后工作组（KDIGO）诊断标准分析重症监护病房（ICU）内脓毒症相关急性肾损伤（AKI）患者的临床特征和预后。方法 应用KDIGO推荐的AKI诊断标准,收集2007年6月—2012年6月江苏省无锡市人民医院ICU收治的符合入选标准的AKI患者资料,回顾性分析脓毒症相关AKI患者的临床特征、预后和影响患者死亡的主要危险因素。结果 在收治的703例AKI患者中,脓毒症相关AKI 395例（56.2%）,脓毒症是发生AKI最主要的原因。脓毒症相关AKI患者中,AKI Ⅰ期146例（37.0%）,Ⅱ期154例（39.0%）,Ⅲ期95例（24.1%）。与非脓毒症相关AKI患者比较,脓毒症相关AKI组急性生理与慢性健康评分Ⅱ（APACHEⅡ）、序贯器官衰竭评分（SOFA）更高(25.1±4.9比20.5±6.4,12.9±2.6比10.4±4.5;P值均<0.05)。两组基础血肌酐值差异无统计学意义［(82.9±22.2)μmol/L比(83.1±30.0)μmol/L,P>0.05］,但ICU期间脓毒症相关AKI组血肌酐更高［(143.5±21.6)μmol/L比(96.2±15.5) μmol/L,P<0.05］,进展为AKI Ⅱ期和Ⅲ期的比例更高（63.0%比33.1%,P<0.05）,接受肾脏替代治疗的比例更高（22.3%比6.2%,P<0.05）,而肾功能完全恢复的患者比例更少(74.4%比82.8%,P值均<0.05)。脓毒症相关AKI患者90 d病死率高于非脓毒症相关AKI患者(52.2%比34.1%,P<0.05)。随着KDIGO分期的增加,脓毒症相关AKI患者病死率增加。Logistic回归分析显示APACHEⅡ(OR=5.451,95%CI：3.095~9.416)、SOFA(OR=2.166,95%CI：1.964~4.515)和肾脏替代治疗(OR=4.021,95%CI：2.975~6.324)均是脓毒症相关AKI患者死亡的独立危险因素。结论 脓毒症相关AKI 患者全身疾病严重程度高、肾功能差、病死率高。APACHEⅡ、SOFA和肾脏替代治疗是脓毒症相关AKI患者死亡的独立危险因素。        

Physician extenders for cost-effective management of hypercholesterolemia

OBJECTIVE: Treatment of elevated cholesterol levels reduces morbidity and mortality from coronary heart disease in high-risk patients, but can be costly. The purpose of this study was to determine whether physician extenders emphasizing diet modification and, when necessary, effective and inexpensive drug algorithms can provide more cost-effective therapy than conventional care. DESIGN: Randomized controlled trial. SETTING: A Department of Veterans Affairs Medical Center. PATIENTS: Two hundred forty-seven veterans with type IIa hypercholesterolemia. INTERVENTIONS: Patients assigned to either a cholesterol treatment program (CTP) or usual health care provided by general internists (UHC). CTP included intensive dietary therapy administered by a registered dietitian utilizing individual and group counseling and drug therapy initiated by physician extenders for those failing to achieve goal low-density lipo-protein (LDL) levels with diet alone. A drug selection algorithm for CTP subjects utilized niacin as initial therapy followed by bile acid sequestrants and lovastatin. Subjects were followed prospectively for 2 years. MEASUREMENTS: Primary outcome measurements were effectiveness of therapy defined as reductions in LDL cholesterol (LDL-C), and whether goal LDL-C levels were achieved; costs of therapy; and cost-effectiveness defined as the cost per unit reduction in the LDL-C. MAIN RESULTS: Total program costs were higher for CTP patients than for UHC patients ($659±$43 vs $477±$42 per patient, p<.001). However, at 24 months the patients in CTP were more likely to achieve LDL goal levels (65% vs 44%,p<.005), and also achieved greater reductions in LDL-C 27%±2% vs 14%±2% at 24 months,p<.001). Program costs per unit (mmol/L) reduction in the LDL-C, a measure of cost-effectiveness, was significantly lower for CTP ($758±$58 vs $1,058±$70,p=.002). CONCLUSIONS: Although more expensive than usual care, the greater effectiveness of physician extenders implementing cholesterol treatment algorithms resulted in more cost-effective therapy. Supported by Health Services Research and Delivery grant 88-127, Department of Veterans Affairs.     

BREATHING DURING SLEEP: THE RESPONSES TO ASPHYXIA and PROCHLORPERAZINE IN NORMAL SUBJECTS and PATIENTS WITH OBSTRUCTIVE SLEEP APNEA*

:The effects of sleep and prochlorperazine (12.5 mg intravenous bolus) on the ventilatory and arousal responses to asphyxia were studied in normal subjects and patients with obstructive sleep apnea (OSA). The ventilatory response to asphyxia was reduced during non-rapid eye movement sleep in the six normal subjects studied (1.93 ± 0.181 min^-1. % SaO₂ awake vs. 1.01 ± 0.10 I min^-1. ± SaO₂ asleep; rnean ± SEM; p<0.01) (SaO₂= arterial oxygen saturation). In the two normal subjects studied during sleep following prochlorperazine administration, ventilatory responsiveness was increased (p<0.05) but arousal response to asphyxia was depressed (p<0.025). Although prochlorperazine increased waking ventilatory responsiveness to asphyxia in five of six patients with OSA (2.26 ± 0.44 I min^-1.% SaO₂vs.4.77 ± 1.39 I min^-1.% SaO₂; mean ± SEM; p<0.01), the drug had no clinically significant effect on upper airway obstruction during sleep; in three patients, apnea frequency was slightly reduced but in four of six patients severity of hypoxemia during apnea was increased with drug administration. We conclude that prochlorperazine administration is unlikely to benefit patients with obstructive sleep apnea despite its ventilatory effects during wakefulness and sleep. This lack of effect may be explained by separate effects of the drug on ventilatory and arousal responses to asphyxia. (Aust NZ J Med 1983; 13: 613–620.)     

Cardiac catheterization in patients with end‐stage liver disease: Safety and outcomes

Introduction : Patients with end‐stage liver disease (ESLD) awaiting transplant are at increased risk of bleeding. Nevertheless, these patients routinely undergo cardiac catheterization for various indications. Safety and outcomes of cardiac catheterization in these patients are not well reported. Methods : In a case–control study 43 patients with ESLD who underwent angiography for liver transplant work‐up were compared to 43 age and gender‐matched controls with no liver dysfunction. In‐hospital outcomes and procedural variables were compared. Results : Patients with ESLD had a lower baseline hemoglobin (12.1 ± 2.1 vs. 13.7 ± 1.8, P < 0.0005), lower platelet counts (86.8 ± 66 vs. 247 ± 80, P < 0.0001) and higher international normalized ratio (INR) (1.4 ± 0.2 vs. 1.1 ± 0.2, P < 0.0001) than controls. Among ESLD group, five (11.6%) patients received platelet transfusions, one received blood transfusion, and three patients (7%) with INR > 1.6 received fresh frozen plasma (FFP) compared with none in the control group. Smaller size (four French) vascular sheaths were used more frequently in the group with ESLD (16% vs. 4%, P = 0.04). There were no significant vascular or bleeding complications in either group. Conclusions : Elective cardiac catheterization can be safely performed in patients with ESLD with outcomes (vascular and bleeding complications, length of hospital stay and in‐hospital mortality) similar to patients without liver disease despite significant thrombocytopenia and elevated INR in patients with ESLD. Practices such as platelet transfusion for platelets <60,000 μL, prophylactic FFP transfusion for INR ≥≥ 1.6, less frequent use of antiplatelet therapy and more frequent use of smaller vascular sheaths may have contributed to the safety of cardiac catheterization in ESLD patients. © 2010 Wiley‐Liss, Inc.     

Reuse of balloon catheters for coronary angioplasty: A potential cost-saving strategy?

Objectives. This study was designed to determine the effectiveness, safety and costs associated with reuse of angioplasty catheters and to compare these results with those of a contemporary center that employed a single-use strategy.Background. Coronary angioplasty is an important but expensive procedure. To overcome the financial constraints of the Canadian health care system, reuse of angioplasty catheters is routinely practiced in some institutions.Methods. In a prospective observational study, data forms were completed after each angioplasty procedure and before patient discharge over a 10-month period.Results. A total of 693 patients underwent coronary angioplasty in the two centers. Clinical and lesion characteristics were similar except for a higher incidence of unstable angina at the reuse center (p < 0.005). The angiographic success rale was identical (88%) al both centers. The reuse center utilized more balloon catheters/lesion (mean ± SD 2.4 ± 1.5 vs. 1.2 ± 0.5, p < 0.00001) and had a higher incidence of initial balloon failure (10.2% vs. 3.3%, p < 0.0001). Significant prolongation of the procedure time (81 ± 41 vs. 68 ± 32 min, p < 0.0001) and increased volume of contrast medium (201 ± 86 vs. 165 ± 61 ml, p < 0.0001) were seen in the reuse center. A higher rate of adverse clinical events (7.8% vs. 3.8%, p < 0.025) was observed in the reuse center, especially in patients with unstable angina.Conclusions. The reuse strategy was associated with a higher rate of adverse events, prolonged procedure time and increased use of contrast medium, especially in lesions that were not crossed by the initial balloon and in patients with unstable angina. Whether these differences are related to the reuse strategy or to differences in patient groups cannot be ascertained by this observational study. A multicenter randomized trial is required to further assess the safety and the cost/benefit ratio of this strategy.     

Improvements in preventive care and communication for deaf patients

OBJECTIVE: To test the hypothesis that profoundly deaf persons would have better preventive care compliance and improved physician communication if enrolled in a primary care program providing American Sign Language (ASL) interpreters. DESIGN: A case-cohort community-based study. The authors had ASL-fluent research assistants interview 90 randomly selected patients (the cases) enrolled in a unique primary care program for the deaf (Deaf Services Program), which provided full-tune ASL interpreters and subsidized health care costs for some patients. Eighty-five deaf controls were friends of the cases drawn from the community. RESULTS: The cases were poorer and less often married than were the controls, but other baseline characteristics were similar. The cases were more likely (p<0.05) to report receiving within the preceding three years Pap tests (90% vs 72%), mammography (86% vs 53%), and rectal examinations (72% vs 25%), but not breast examinations (76% vs 71%, p=0.7). The cases were more likely than the controls to report receiving counseling in ASL for psychiatric and substance abuse problems (49% vs 5%, p<0.001). Although only 18% of the controls were fluent in written English, 67% of them used written notes to communicate with their physicians. Twenty percent of the controls used ASL interpreters compared with 84% of the cases (p<0.001). More cases than controls were moderately or extremely satisfied with communication with their physicians (92% vs 42%, p<0.001). CONCLUSION: Deaf persons enrolled in a primary care program that included full-time interpreters were more likely to use ASL, were more satisfied with physician communications, and had improved preventive care outcomes. Presented in part at the annual meeting of the Midwest Region of the Society of General Internal Medicine, September 18. 1992, Chicago, Illinois.     

Highlights and comments on EHRA/HRS/APHRS/LAHRS expert consensus on risk assessment in cardiac arrhythmias: use the right tool for the right outcome

Background

Intracardiac echocardiography (ICE) use during catheter ablation of atrial fibrillation (AF) provides real-time information to guide transseptal access, for monitoring the ablation and recognition of pericardial bleed. We describe trends of ICE use, impact on complications, and its in-hospital outcomes.

Methods

The national in-patient sample database was queried from 2001 to 2014 for diagnosis of AF based on ICD-9-CM 427.31 with a catheter ablation procedure code (37.34) in the same hospitalization and its associated complications. ICE was identified using ICD-9-CM procedure code (37.28). Statistical Analysis System (SAS) was used for analysis.

Results

There was an estimated total 299,152 patients who underwent AF ablation from 2001 to 2014 of which ICE was used in 46,688 (15.6%) patients. The use of ICE significantly increased from 0.08% in 2001 to 15.7% in 2014. In-hospital mortality was significantly lower in patients in whom ICE was used (0.11% vs 0.54%, p?<?0.0001). Complications were 52% lower in procedures using ICE vs without ICE (HR [95%CI]; 0.48 [0.44–0.51]). The rate of cardiac complications was also lower in ICE users (3.67% vs 4.51%; p?=?0.025). The use of ICE during AF ablation resulted in significantly higher cost of hospitalization ($98,436?±?597 vs $81,300?±?310; p?<?0.0001), but this was offset by a decreased length of hospital stay (2.1?±?0.02 vs 4?±?0.02 days; p <?0.0001).

Conclusions

The use of ICE during AF ablation has increased over the years and is associated with lower in-hospital mortality and procedural complications, shorter LOS but an increased cost of hospitalization.

     

Cardiovascular risk in overweight/obese and lean hypertensive patients

IntroductionObesity and hypertension have been identified as independent risk factors for cardiovascular disease. Nevertheless, the role of obesity in the development and progression of target-organ disease in hypertensive patients is controversial. The objective of this study was to assess the impact of body weight on cardiovascular risk factors, target-organ disease and global cardiovascular risk in hypertensive patients in a primary care setting.MethodsA cross-sectional observational study was carried in Vila Nova de Gaia, Portugal (n=150). A detailed medical and personal history was obtained and a physical examination was performed. Venous blood and 24-hour urine samples were collected, and an electrocardiogram was performed. Cardiovascular risk was assessed using the Framingham score. The statistical analysis was performed using SPSS^®. A p-value <0.05 was considered statistically significant.ResultsThe sample was 71.8% female, with a mean age of 74.3±10.8 years. The prevalence of obesity was 29.5%. Overweight/obese subjects presented lower mean HDL cholesterol (51.2±13.9 mg/dl vs. 65.4±35.2, p<0.005), higher triglycerides (137.8±70.4 mg/dl vs. 111.5±68.8 mg/dl, p<0.001), higher fasting glucose (111.9±32.8 mg/dl vs. 98.4±13.1 mg/dl, p<0.011) and more frequent mild valve disease (57.9% vs. 29.6%, p=0.021). Global cardiovascular risk was also significantly higher (10.9±7.7 vs. 6.5±5.7, p<0.001).ConclusionOverweight and obesity appear to be related to a less favorable lipid and blood glucose profile and higher cardiovascular risk in hypertensive patients. On the basis of our findings we suggest strict metabolic monitoring and improved education on weight reduction and control at primary health care clinics.     

Emotional distress is associated with poor self care in type 2 diabetes mellitus

Background: The aim of the present study was to evaluate possible clinical and psychosocial variables that influence diabetes self‐care management in patients with type 2 diabetes mellitus (T2DM). Methods: A total of 150 individuals with T2DM who had had diabetes for at least 6 months were recruited to this cross‐sectional study. Levels of self‐care and psychosocial status were determined using the Self‐Care Inventory (SCI) and Problem Areas in Diabetes (PAID) scale. The PAID scores were calculated using a five‐point Likert scale with options ranging from 0 (not a problem) to 4 (serious problem). Data were evaluated using non‐parametric and parametric tests as appropriate. Results: The mean age of the study participants was 69.97 ± 8.68 years. Cronbach’s α for SCI and PAID scores was 0.85 and 0.98, respectively. People with poor glycemic control had significantly higher mean (±SD) total PAID scores than individuals with good glycemic control (29.5 ± 30.9 vs 16.7 ± 26.9, respectively; P = 0.012). There was a significant relationship between PAID scores and glycemic control (r = 0.2; P = 0.012). Conclusions: The present study demonstrates that psychosocial factors directly influence glycemic control and diabetes self‐care habits. In addition, diabetes‐specific distress in study population was unrelated to the duration of diabetes, the age of the patients and anthropometric indices.     

Serum ribonuclease activity in the diagnosis of pancreatic disease

The present study evaluated serum ribonuclease activity (SRA) in patients with inflammatory and neoplastic pancreatic diseases. RNase determination was carried out using t-RNA (T) fromE. coli MRE 600 at pH 7.4 and polycytidylic acid (poly-C) (P) at pH6.6 as RNA substrates with RNase A from bovine pancreas as reference enzyme. Healthy volunteers had a SRA of T: 160±12 and P: 482 ±24 ngeq/mL (mean±SEM(n)). In patients with acute interstitial pancreatitis (AIP), SRA was similar to healthy controls (T: 166 ±14; P: 474 ±30 ngeq/mL). Patients with acute necrotizing pancreatitis (ANP) had increased SRA (T: 278 ±49; P: 791 ± 145 ngeq/mL,p 0.01, compared to controls). SRA values were also increased in patients with chronic pancreatitis (CP) with T: 224± 15 ngeq/mL (p<0.01) and in patients with pancreatic carcinoma (PCA) with T: 331 ±35(p 0.001 vs controls, p<0.01 vs CP). Increased SRA was detected in patients with renal insufficiency (T: 2576± 195 ngeq/mL, p<0.001). Diagnostic discrimination between AIP and ANP was achieved in 69% using T-SRA (sensitivity 31%, specificity 88%), and in 78% using P-SRA (sensitivity 54%, specificity 92%). Discrimination between CP and pancreatic carcinoma was possible in 68% (sensitivity 67%, specificity 71%). The diagnostic value of serum RNase is limited because of its low sensitivity, but increased T-SRA above a cutoff of 250 ngeq/mL and increased P-SRA above a cutoff of 620 ngeq/mL are specific for detecting pancreatic necrosis in the absence of renal impairment. The kidney is a major site for SRA clearance.