Report of experiences with bronchoscopy in a general hospital

It is reported on 50 bronchoscopies which were performed in a Berlin general hospital in a period of one year. The preliminary conditions are discussed. It is particularly dealt with 13 diagnosed tumours. According to the experiences hitherto made, in realisation of the prerequisites described the bronchoscopy can be used for the rapid establishment of the diagnosis also in general hospitals. Cooperative relations to adequate highly specialised institutions are necessary.     

Klebsiella pneumoniae bacteraemia at an urban general hospital

Of 47 patients with Klebsiella pneumoniae bacteraemia admitted to the Hillbrow Hospital, Johannesburg during a period of 18 months, 31 were males and 16 were females. Features predisposing to illness were found in 89.4% patients, chronic alcoholism, neoplastic disease and diabetes mellitus being the most common. Twenty-five infections were acquired in hospital and 22 in the community. Most patients (59.6%) had pneumonia. All isolates of K. pneumoniae were resistant to ampicillin (100%); several (42.6%) were resistant to other antibiotics also. The overall mortality rate was 55.3%. A higher mean initial blood pressure and lower concentrations of serum urea and bilirubin were found in survivors. None of the 28 patients, surviving more than 48 h who received combined therapy with an aminoglycoside and a beta-lactam antibiotic (to which the organism was susceptible) died. Among the remaining patients treated with either an appropriate beta-lactam agent alone, an appropriate aminoglycoside alone or ciprofloxacin the combined mortality rate was 83.3% (P = 0.007).     

Cardiovascular prevention in general practice: development and validation of an algorithm

OBJECTIVE: General practice visits are a unique opportunity to identify and treat individuals with a high cardiovascular (CV) risk. However, a case-finding strategy suited to the daily general practice is not provided in the CV prevention guidelines.We wanted to create, validate and test an algorithm for global CV risk assessment and management. METHODS: The algorithm was 1) developed based on evidence from epidemiological studies and clinical trials, 2) validated in a population-based cohort and 3) tested by randomly selected general practitioners (GPs) who rated its usefulness and applicability. RESULTS: 1) Screening for seven clinical risk factors (RF) allowed a quick classification of patients in four CV risk typologies: obvious high risk (previous CV event and/or type 2 diabetes) in 17%, obvious low risk (no RF) in 14%, smoking-related risk (single RF) in 6%, or undetermined risk (any other RF) to further evaluate in 63% patients. Inter-physician reproducibility for risk prediction was excellent. Overall, predicted risk was high, moderate and low in 25, 17 and 58% of the patients, respectively. 2) These risk predictions were validated in a cohort of 962 men followed over 10 years. 3) Most GPs reported that the algorithm was applicable and useful, while half of them started using it frequently in their daily practice. CONCLUSION: This algorithm is a new, pragmatic and evidence-based strategy for systematic and global CV risk management. It was validated at the population level, and shown to be applicable and useful in the daily general practice.     

Cardiovascular risk stratification in general practice

CONCLUSION: The ESC risk charts are helpful to identify high risk patients in general practice who are candidates for preventive treatment. The use of the ESC charts is one important step to initiate "evidence based medicine" in the daily practice of preventive cardiology.Cardiovascular diseases are the most important causes of premature disability and death in Germany. High risk patients however are frequently not recognized. A systematic risk stratification in general practice could identify high risk persons and allow a cost effective treatment approach. The goal of the CAD-scoring week was to identify high risk persons with the use of the ESC risk charts and to evaluate the treatment resulting from risk stratification. In addition the feasibility of the risk charts in daily office routine was to be evaluated. A total of 1122 of 20 000 (5.6%) contacted general physicians agreed to participate in the screening procedure. More than 27 000 patients (> 50 yrs) were evaluated using the ESC risk charts. 21.6% of women (n = 15 018) vs 22.2%* of men (n = 12 361) had markedly elevated blood pressure (> 150 mmHg), 29 vs. 24%* had a total cholesterol > 250 mg/dl (6.5 mmol/l), 25.5 vs 29.9%* smoked and 28.4 vs. 31.9%* had diabetes (*female vs male: p < 0.0003). Altogether 19.4% of women vs. 53% of men were newly identified as high risk patients (risk > 20% in 10 years). More than 40% of these high risk patients received drug treatment for prevention (ASA, lipid lowering drugs or ACE inhibitors). More than 70% of the participating physicians judged the risk charts to be helpful in patient management.     

Evaluating the CELL-DYN® 3500 Haematology Analyser in an acute general hospital

The CELL-DYN® (CD3500) 3500 (Abbott Diagnostics Division, Santa Clara, CA, USA) is a multiparameter, automated haematology analyser system capable of producing 22 haematological parameters including a screening five-part differential. The evaluation was performed in a recently expanded acute care general hospital. Studies of linearity, carryover and precision were acceptable and within manufacturer's stated limits. Correlation of CD3500 with manual differential counts were good except for the basophil count. The white cell flagging system had a sensitivity of 83.6% and specificity of 88.9% with 85.6% agreement. The platelet flagging system also had comparable sensitivity and specificity rate of 88.4% and 94.5% and agreement rate of 92.2%. The overall false positive rate and false negative rate for both the white cell and platelet flags combined were 8.6% and 10.3%. All samples provided a differential with no rejection experienced. The MAPSS technology, together with the extended lyse mode and the investigational nine-part differential provides potential for future development in WBC differential.     

Toxoplasmosis. Clinical experiences in a cancer hospital

Twenty-four patients with toxoplasmosis were seen at Memorial Hospital for Cancer and Allied Diseases. Ten patients without underlying neoplastic disease presented with fever or lymphadenopathy. In two of these patients a misdiagnosis of lymphoma had been made. All patients had rises in, or high titers of, the Sabin-Feldman dye test (DT) or the complement fixation test (CFT). The patients' signs and symptoms subsided with (eighteen patients) and without (two patients) treatment, and the effect of therapy was difficult to evaluate.Fourteen patients had a neoplastic disease; in 13 it was a leukemia or lymphoma. In one, an infant dying of bacterial sepsis and metastatic neuroblastoma, intracerebral focal granulomas were found. Hodgkin's disease was the underlying neoplasm most commonly found (nine cases). Three patients with chronic leukemia and one with lymphosarcoma comprised the remainder. All five patients examined at autopsy had central nervous system involvement. Five patients were treated with a sulfonamide drug and pyrimethamine and four showed improvement during therapy.In immunosuppressed patients with neoplasms there is a significant frequency of Toxoplasma infection, with particular predilection with central nervous system disease. In order to increase recognition of this potentially fatal complication, routine serologic testing of such patients should be instituted. Since toxoplasmosis may be treated successfully, clinical suspicion warrants vigorous diagnostic evaluation.     

Transesophageal echocardiography in an emergency setting. A district general hospital experience.

Transesophageal echocardiography is an extremely useful technique for the study of various cardiovascular pathologies. In the particular setting of emergency, it is of great value for prompt diagnosis and appropriate therapy. It was our aim to evaluate, in our hospital, the benefits obtained by the use of transesophageal echocardiography in an emergency setting. We retrospectively studied patients who underwent transesophageal echocardiography (TEE) in an emergency setting, from June 1997 to December 2002, evaluating demographic characteristics, indication to perform TEE, benefit obtained (diagnosis or exclusion of initial diagnosis), and technique-related complications. There were 97 transesophageal echocardiograms performed in an emergency setting in the period under consideration, accounting for 19.3% of the total number of exams. Fifty-two patients (53.6%) were male, mean age 63.9 +/- 12.7. Nineteen patients (19.6%) were on assisted ventilation. The indications to perform TEE were: possible massive or submassive pulmonary thromboembolism in 32 patients (33.0%); suspected aortic dissection in 19 (19.6%); shock with inconclusive transthoracic echocardiogram in ten (10.3%); possible endocarditis in eight (8.2%); possible prosthetic valve dysfunction in seven (7.2%); intracardiac mass in six (6.2%); search for cardiac source of embolism in five (5.2%); possible mechanical complication of acute myocardial infarction in four (4.1%); pre-electrical cardioversion study in four patients with atrial fibrillation (4.1%); and suspected congenital heart disease in two (2.1%). TEE examination yielded additional information and helped in the therapeutic decision in 88 patients (90.7%), leading to a diagnosis in 49 (50.6%), which was different from the initial diagnostic hypothesis in four, and exclusion of the suspected diagnosis in 39 (40.1%). There was only one minor complication (1.0%) and no TEE-related mortality. We concluded that transesophageal echocardiography is an extremely useful and safe cardiovascular diagnostic technique in an emergency setting in a district general hospital, enabling a diagnosis to be reached or excluded in almost all patients, which is essential for implementing appropriate therapy.     

Admission screening by thyroid function tests in an acute general care teaching hospital.

To determine the incidence of unrecognized thyroid disease among admissions to a large acute care university teaching hospital, 364 samples taken on consecutive admissions were assayed for thyroid-stimulating hormone (TSH) and free thyroxine index (FTI). Patients with abnormal test results were further evaluated by determination of antimicrosomal and antithyroglobulin antibodies, and charts were reviewed for evidence of prior diagnosis of thyroid disease, especially severe illness, drug treatment that might affect thyroid function tests, and prior diagnosis of thyroid disease. Results of subsequent thyroid function tests performed during the patient's hospitalization were correlated with the admission serum assays, and data on subsequent testing during the following 6 months were also obtained. A total of 3.9% of patients had significantly depressed TSH, and 11.1% of values were significantly elevated. A total of 11.3% of patients had significantly low FTI values, and 1% had significantly elevated values. A total of 7.4% appeared to have the euthyroid sick syndrome, 5.8% appeared to have unrecognized or undertreated primary thyroid failure, 6% had apparent subclinical hypothyroidism, 2% were thyrotoxic, and 2.8% (all women) had suppressed TSH levels for inapparent reasons. Limiting testing to patients over 49 years of age, or to women, would have missed many individuals with abnormal test results. Considering widespread availability of tests, relative costs, and value of the information obtained, it is suggested that the FTI determination would provide an appropriate screening test for patients in a population such as this entering a large, acute care general hospital.     

Nontuberculous mycobacterial disease in a general hospital

Annual incidence of nontuberculous mycobacterial (NTM) disease has been gradually increasing in the last 10 years in Japan. It is likely to encounter this disease not only in hospitals specialized in mycobacterial diseases but also in general hospitals. NTM were isolated from 97 cases between January 1990 and June 1996 at our hospital. Out of them, 41 patients were diagnosed as NTM disease. Mycobacterium avium complex (MAC) was the most frequent pathogens (68.3%) and M. kansasii (22%) was the next. Other pathogens were M. chelonae (4.9%), M. fortuitum (2.4%) and M. szulgai (2.4%). Results obtained in our hospital were very similar to the rates which have been reported previously. Patients with MAC infection showed relatively poor prognosis (eight patients were died out of 28 patients with MAC) in this study compared with the cases reported in previous papers, and this result could be explained by the severity of illness when they were admitted to our hospital, the insufficiency of the initial treatment which should be started with the combined use of three to four antibacterial drugs including clarithromycin, and to a low dosage of clarithromycin compared with conventionally adopted dosage. Unlike tuberculosis, human to human transmission is considered to be negligible in the case of NTM disease, and general hospitals are able to provide medical care to the patients with NTM disease. Rather, if general hospitals which are located in the region near to the patients residence can play more active role in the treatment of NTM disease, it would be more beneficial to patients requiring long-term follow-up observation. Based on the result that similar therapeutic results were obtained for infections with other NTM as reported in previous papers, it is indicated that general hospitals are able to provide medical care to patients with NTM disease if therapeutic regimens recommended by specialist are sufficiently understood and applied.     

Use of neuroleptics in a general hospital

Background  

This study investigates the clinical use of neuroleptics within a general hospital in acutely ill medical or surgical patients and its relation with dementia three months after admission compared with control subjects.