Fast-track cardiac surgery: application in an Australian setting

In response to the current state of healthcare in Australia, our unit has employed a fast-track policy for low-risk cardiac surgery patients since January 2000. This study was designed to examine the safety and efficacy of this policy. From July 2001 to June 2004, 342 (23%) of 1,488 patients undergoing cardiac surgery were identified preoperatively as suitable for fast-track recovery. There was a significantly shorter median time to extubation (4 hr vs 9 hr), reduced intensive care unit stay (8 hr vs 26 hr), and a lower rate of readmission to the intensive care unit (0.6% vs 4.2%) for those fast tracked compared to the other patients. The fast-track group had a lower incidence of complications and significantly decreased median length of hospital stay (5 vs 7 days). We concluded that this policy accurately identifies the low-risk cardiac surgery patients suitable for less intensive postoperative recovery.     

Preventing diabetes in the clinical setting

OBJECTIVE: Translating lessons from clinical trials on the prevention or delay of type 2 diabetes to populations in nonstudy settings remains a challenge. The purpose of this paper is to review, from the perspective of practicing clinicians, available evidence on lifestyle interventions or medication to prevent or delay the onset of type 2 diabetes. DESIGN: A MEDLINE search identified 4 major diabetes prevention trials using lifestyle changes and 3 using prophylactic medications. We reviewed the study design, key components, and outcomes for each study, focusing on aspects of the interventions potentially adaptable to clinical settings. RESULTS: The lifestyle intervention studies set modest goals for weight loss and physical activity. Individualized counseling helped participants work toward their own goals; behavioral contracting and self-monitoring were key features, and family and social context were emphasized. Study staff made vigorous follow-up efforts for subjects having less success. Actual weight loss by participants was modest; yet, the reduction in diabetes incidence was quite significant. Prophylactic medication also reduced diabetes risk; however, lifestyle changes were more effective and are recommended as first-line strategy. Cost-effectiveness analyses have shown both lifestyle and medication interventions to be beneficial, especially as they might be implemented in practice. CONCLUSION: Strong evidence exists for the prevention or delay of type 2 diabetes through lifestyle changes. Components of these programs may be adaptable for use in clinical settings. This evidence supports broader implementation and increased reimbursement for provider services related to nutrition and physical activity to forestall morbidity from type 2 diabetes.     

Ethnicity and sex are strong determinants of diabetes in an urban Western society: implications for prevention

Aims/hypothesis This study was conducted to investigate the prevalence of diabetes and its association with ethnicity and sex, to identify subgroups at special risk.Methods We performed a population-based cross-sectional survey of 30- to 67-year-olds in an area of Oslo with low socio-economic status, and collected data using questionnaires, physical examinations and serum analyses for the 2,513 participants (attendance rate 49.3%).Results In the age group 30–59 years, mean BMI was 28.5 (95% CI: 27.5–29.6) for South Asian women, 26.1 (25.9–26.4) for Western women, 26.7 (26.1–27.4) for South Asian men and 27.2 (26.9–27.5) for Western men. The diabetes prevalence rates were 27.5% (18.1–36.9) for South Asian women, 2.9% (1.9–3.4) for Western women, 14.3% (8.0–20.7) for South Asian men and 5.9% (4.2–7.5) for Western men. The age-adjusted odds ratio (OR) for diabetes for women vs men was 1.9 (0.9–4.1) for South Asians, and 0.4 (0.3–0.6) for the Western population (p<0.001). The age-adjusted OR for diabetes for South Asians vs Westerners was 11.0 (5.8–21.1) for women and 3.0 (1.6–5.4) for men, and after adjustment for WHR the ORs were 7.7 (3.9–15.3) for women and 2.6 (1.4–4.9) for men. After additional adjustments for physical activity, education, body height and fertility for women, the OR was 6.0 (2.3–15.4) for women and 1.9 (0.9–4.0) for men.Conclusions/interpretation The alarmingly high prevalence of diabetes among South Asian women in Norway needs further investigation, as it has considerable public health implications. Ethnic differences in OR for diabetes persisted after adjustment for age, adiposity, physical activity and education. These differences were still present for women after additional adjustment for body height and fertility.     

Cost analysis and outcome of endoscopic submucosal dissection for colorectal lesions in an outpatient setting

Background and study aims

Endoscopic submucosal dissection (ESD), a minimally invasive treatment for early gastrointestinal (GI) cancer, is considered challenging and risky in the colorectum. As such, most patients undergoing ESD are hospitalized due to the perceived increased risk of adverse events. The aim of this study was to compare the costs, safety and efficacy of colorectal-ESD in an outpatient vs inpatient setting in a tertiary level center.

Periprocedural creatine kinase-MB elevations: long-term impact and clinical implications

Since the introduction of percutaneous transluminal coronary angioplasty (PTCA), percutaneous intervention with balloon catheters, stents, and atherectomy devices has become a widely accepted practice. The persistent complication of non-Q-wave myocardial infarction (MI), as evidenced by increased cardiac enzyme levels after intervention, has aroused only moderate concern because its incidence was perceived to be small and not clinically relevant. With more systematic assessments of cardiac enzymes--specifically, creatine kinase (CK) and its MB isoform--evidence has begun to clarify both the incidence and the prognosis of periprocedural non-Q-wave MI: It appears to occur nearly three times more often than is clinically evident across all device types (8 to 9% of all interventions) and is directly and continuously associated with adverse outcomes, including late death. Although directional and rotational atherectomy improve angiographic outcome compared with PTCA, periprocedural infarction occurs at least twice as often with these newer technologies; the incidence associated with stent placement is comparable to and possibly higher than that of PTCA. Factors that may cause elevated CK-MB levels include distal embolization, side branch occlusion, thrombus, and coronary spasm. Analyses of the major trials of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors, a class of potent antiplatelet agents, show striking effectiveness of these drugs in reducing the incidence of "enzyme-only" or "silent" MI and in improving long-term clinical outcomes. The findings implicate platelet mediation in the occurrence of periprocedural infarction and suggest an important role for antiplatelet therapy, particularly GP IIb/IIIa receptor inhibition, in protecting patients undergoing percutaneous intervention.     

Endothelial dysfunction in diabetes mellitus: Molecular mechanisms and clinical implications

Cardiovascular disease is a major complication of diabetes mellitus, and improved strategies for prevention and treatment are needed. Endothelial dysfunction contributes to the pathogenesis and clinical expression of atherosclerosis in diabetes mellitus. This article reviews the evidence linking endothelial dysfunction to human diabetes mellitus and experimental studies that investigated the responsible mechanisms. We then discuss the implications of these studies for current management and for new approaches for the prevention and treatment of cardiovascular disease in patients with diabetes mellitus.     

Methotrexate: long-term safety and efficacy in an Australian consultant rheumatology practice

Background: The aim of this study was to evaluate the rate and cause of methotrexate (MTX) termination in clinical practice, describe the types of toxicities noted, assess the incidence of achieving remission in rheumatoid arthritis (RA) patients and review the appropriateness of current clinical guidelines for monitoring MTX treatment.
Methods: A retrospective, case review of patients seen in a private rheumatology practice attached to a major Sydney Teaching Hospital was undertaken over an 18-year period. The primary outcome was time to cessation of MTX.
Results: Seven hundred and ninety patients satisfied the inclusion criteria. MTX was terminated in 272 patients (34.4%). Toxicity-related discontinuation occurred in 93 patients (11.8%) and due to non-adverse reactions in 179 patients. The median duration of therapy in these two groups was 2.0 and 2.9 years, respectively. There was no difference in the average maximum weekly dose of MTX. Of patients with RA, 47.5% were in remission at last follow up. Cox proportional hazards analyses showed that those of the female sex remained on treatment significantly longer than the male sex (hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.57–0.96; P  = 0.014); patients with RA remained on treatment significantly longer than patients with seronegative arthritis (HR 0.56, 95%CI 0.42–0.74; P  < 0.001). Being of the male sex aged more than 60 years and having a non-RA diagnosis predisposed to stopping MTX earlier.
Conclusion: MTX is a safe and effective medication. Notable remission rates are achievable in patients with RA with current conventional treatment protocols. MTX has a low toxicity profile and this study stresses the need to re-evaluate and revise the current monitoring guidelines.     

Heart failure in diabetes mellitus: clinical features and prognostic implications

We defined the prevalence and impact on survival of clinical bedside variables in 385 patients with symptomatic congestive heart failure (CHF), of whom there were 176 with and 209 without diabetes mellitus. Patients were consecutively hospitalized and admitted for various acute conditions. Following discharge all-cause mortality was recorded. Prevalence and association of various variables with mortality were statistically analyzed. Prevailing in the diabetics versus nondiabetics were younger age (p < 0.05), pulmonary edema on admission (p = 0.002), using furosemide > 80 mg/day (p < 0.01) for > 1 year (p < 0.01) and hyponatremia (p = 0.01). Less prevalent were chronic lung disease (p < 0.01) and cardiac arrhythmias (p = 0.001). On follow-up extending up to 60 months, diabetic patients, especially those with fasting blood glucose levels on admission > or = 180 mg/dl, survived for a shorter period of time than nondiabetics (p = 0.02). Associated with increased mortality in the diabetic group were female gender (p = 0.04), furosemide > or = 80 mg/day (p < 0.001) and renal dysfunction (RD; p = 0.04). The respective variables in the nondiabetics were advanced age (p < 0.001) and RD (p = 0.002). Although they were younger, diabetic patients presented more severe CHF. It is recommended that special attention should be given to diabetic females, those using higher furosemide dosages and those suffering from RD.     

Cost analysis of chronic obstructive pulmonary disease in a tertiary care setting in Taiwan

Background and objective: The prevalence of COPD in the Western Pacific is increasing. The present study determined the total direct health‐care costs for the management of COPD patients with differing degrees of disease severity. The study also aimed to find the key cost drivers in the management of COPD. Methods: COPD patients were recruited from a tertiary care hospital during April 2002 and March 2003. One‐year costs were identified by applying cost data to medical information obtained by review of medical records. Costs included those for medications, oxygen therapy, laboratory and diagnostic tests, clinic visits, emergency room visits and hospital stays. Results: There were 160 patients recruited. Patients were categorized by COPD severity: moderate A COPD (50 ≤ FEV₁% < 80; n = 54), moderate B COPD (30 ≤ FEV₁% < 50; n = 54) and severe COPD (FEV₁% < 30; n = 52). Patients with moderate A, moderate B and severe COPD had an average of 0.82, 2.6 and 3.5 exacerbations per year, respectively. Average numbers of emergency room visits were 0.41 ± 0.94, 1.20 ± 1.39 and 1.73 ± 2.44 per year in moderate A, moderate B and severe COPD patients, respectively. The mean total direct costs were New Taiwan dollars 288 825, 149 031 and 38 203 for severe COPD, moderate B COPD and moderate A COPD, respectively. The total annual cost was correlated with the disease severity. Hospitalization contributed the major portion of cost and also correlated with disease severity. Conclusions: There is a correlation between the cost of COPD and disease severity with hospitalization owing to disease exacerbation being a major contributor to cost. The keys to reducing health‐care costs lie with reducing the frequency of exacerbations and the disease severity.     

Prevalence and clinical implications of hypocalcemia in acutely ill patients in a medical intensive care setting

The incidence and the clinical implications of hypocalcemia were evaluated in acutely ill patients admitted to the Medical Intensive Care Unit of the Detroit Receiving Hospital. Total and ionized calcium levels were prospectively evaluated upon admission for all patients over a three-month interval. A high proportion of patients (62 of 88, 70 percent) were found to have decreased levels of both total and ionized calcium. Known causes of hypocalcemia could be identified in only 28 patients (45 percent). These included hypomagnesemia (17, 28 percent), renal insufficiency (five, 8 percent), alkalosis (four, 6 percent), and acute pancreatitis (two, 3 percent). In the remaining 34 patients (55 percent), no readily identifiable cause could be found. These 34 patients had a lower mean albumin level than did the 23 normocalcemic patients (p less than 0.01), but there were no differences in age, pH, serum creatinine, magnesium, or phosphate between the two groups. Serum albumin correlated directly with ionized calcium levels (n = 82, r = 0.33, p less than 0.01), as well as with total calcium levels (n = 76, r = 0.70, p less than 0.01). There was a strong association between sepsis and hypocalcemia. Patients who survived the hospitalization had higher mean ionized calcium, total calcium, and albumin values than did nonsurvivors, but there were no differences in age, serum creatinine, magnesium, and phosphate between the two groups. The mortality of the hypocalcemic patients (44 percent) was significantly greater (p less than 0.05) than the mortality of the normocalcemic patients (17 percent). These findings suggest that hypocalcemia is a very common abnormality in acutely ill patients and is associated with a poor prognosis.