Evolving Indications for Heart-Lung Transplant in Spain

BackgroundThe outcomes of heart-lung transplant (HLT) are worse than those of heart transplant (HT) and lung transplant alone; this and the availability of mechanical assistance have meant that the indications for HLT have been changing. This study aims to analyze the evolution of indications for HLT in a country of 47 million inhabitants.MethodsWe performed a retrospective observational study of all HLTs performed in Spain (performed in 2 centers) from 1990 to 2020. The total number of patients included was 1751 (HT 1673 and HLT 78). After clinical adjustment, overall survival was compared between the 2 groups. Seven etiological subgroups were considered within the HLT group: (1) cardiomyopathy with pulmonary hypertension (CM + PH);, (2) Eisenmenger syndrome, (3) congenital heart disease without Eisenmenger syndrome, (4) idiopathic pulmonary arterial hypertension (IPAH), (5) cystic fibrosis, (6) chronic obstructive pulmonary disease (COPD) and/or emphysema), and (7) diffuse interstitial lung disease.ResultsThere were a large number of differences between patients with HLT vs HT. HLT had a 2.69-fold increased probability of death in the first year compared with HT. The indications for HLT have changed over the years. In the recent period the indications are mainly congenital heart disease and Eisenmenger syndrome, with some cases of CM + PH. Other indications for HLT have virtually disappeared, mainly lung diseases (IPAH, COPD, cystic fibrosis). Median survival was low in CM + PH (18 days), diffuse interstitial lung disease (29 days), and ischemic heart disease (114 days); intermediate in Eisenmenger syndrome (600 days); and longer in IPAH, COPD and/or emphysema, and cystic fibrosis.ConclusionsHLT is a procedure with high mortality. This and mechanical assists mean that the indications have changed over the years. Etiological analysis is of utmost interest to take advantage of organs and improve survival.     

An evaluation of the District Health Information System in rural South Africa

BACKGROUND: Since reliable health information is essential for the planning and management of health services, we investigated the functioning of the District Health Information System (DHIS) in 10 rural clinics. DESIGN AND SUBJECTS: Semi-structured key informant interviews were conducted with clinic managers, supervisors and district information staff. Data collected over a 12-month period for each clinic were assessed for missing data, data out of minimum and maximum ranges, and validation rule violations. SETTING: Our investigation was part of a larger study on improving information systems for primary care in rural KwaZulu-Natal. OUTCOMES: We assessed data quality, the utilisation for facility management, perceptions of work burden, and usefulness of the system to clinic staff. RESULTS: A high perceived work burden associated with data collection and collation was found. Some data collation tools were not used as intended. There was good understanding of the data collection and collation process but little analysis, interpretation or utilisation of data. Feedback to clinics occurred rarely. In the 10 clinics, 2.5% of data values were missing, and 25% of data were outside expected ranges without an explanation provided. CONCLUSIONS: The culture of information use essential to an information system having an impact at the local level is weak in these clinics or at the sub-district level. Further training and support is required for the DHIS to function as intended.     

Evolving Indications for Active Surveillance in Low-Risk Localized Prostate Cancer

As a result of improvements in techniques for detecting prostate cancer, such as prostate-specific antigen (PSA) screening, prostate cancer is more frequently being detected while still localized within the prostate. Furthermore, the development of predictive nomograms has made it possible to estimate the risk (low, intermediate, or high) of disease progression for these patients. For some patients with low-risk, localized cancer, use of radical therapies may be inappropriate, exposing the patient unnecessarily to the traumas of surgery/radiotherapy and the concomitant complications associated with these treatment options. The protracted natural history often seen with low-risk, localized prostate cancers suggests that many of these patients may be suitable for less aggressive treatment options such as watchful waiting. Where this option is employed, a rigorous surveillance protocol is required to identify patients rapidly who are not performing well with such conservative management, and to facilitate prompt initiation of more aggressive treatment. For some patients with higher risk, non-metastatic disease, immediate hormone treatment with bicalutamide (‘Casodex’¹) 150 mg, which at 3 years’ median follow-up significantly improves progression-free survival compared with watchful waiting alone, could be considered as a treatment option.     

Bundled Payments for Care Improvement: Health System Experience With Lower Extremity Joint Replacement at Higher and Lower Volume Hospitals

BackgroundThe Bundled Payments for Care Improvement (BPCI) initiative was introduced in 2013 to reduce Medicare healthcare costs while preserving or enhancing quality. We examined data from a metropolitan healthcare system comprised of 1 higher volume hospital and 4 lower volume hospitals that voluntarily elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2, beginning July 1, 2015. Stratifying the data by hospital volume, we determined how costs changed during the 16-month period when all 5 hospitals participated compared to the 1-year period preceding BPCI participation, where savings were achieved, and how the hospitals were rewarded.MethodsThe Medicare data included the 90-day target for each episode and actual part A and part B spending for the anchor hospitalization plus all post-acute payments including inpatient rehabilitation, skilled nursing, home health, outpatient physical therapy, and hospital readmissions.ResultsThe mean episode of care cost decreased by 11.1% (from $21,324 to $18,953) at the higher volume hospitals and by 8.3% (from $25,724 to $23,584) at the lower volume hospitals during BPCI participation compared to the preceding year. The savings were achieved by reducing the use of inpatient rehabilitation, shortening the length of stay at skilled nursing facilities, and decreasing readmission rates. Although the higher volume hospital achieved an increased mean savings of $230 per episode compared to the lower volume hospitals ($2371 vs $2141), it was penalized $490 per episode after reconciling the actual Medicare expenditures with the BPCI targets while the lower volume hospitals received a mean reward of $315 per episode.ConclusionThe BPCI initiative decreased costs and readmissions within our healthcare system. Despite substantial savings compared to the preceding year, the higher volume hospital’s low target derived from its 2009-2012 baseline costs was not achieved which resulted in a penalty and led it to withdraw from the BPCI initiative in October 2016.     

Health care provision and surgical education in South Africa

Apartheid policies have led to inequalities in the delivery of health care and the training of surgeons in South Africa. The nation's population of 33 million is comprised of 73.6% Blacks, 14.8% Whites, 8.8% Coloureds, and 2.7% Asians. Only 17% of the population are covered by medical insurance (78% of Whites, 28% of Asians, 26% of Coloureds, 4% of Blacks) that funds the private sector which accounts for 46% of the nation's total health care expenditure of 9.2156 million rand. The remainder receive care from curative state hospital based services, which consume 77% of the public expenditure on health. Preventive and promotive health services account for 23%. only 3.2% of South Africa's gross national product is spent on health care provision for 80% of the population-well short of the World Health Organization's recommendation of 5.8%. This figure translates into a per capita expenditure of 138, 340, 356, and 597 rands for Blacks, Coloureds, Asians, and Whites, respectively. Eight medical schools produce just over 900 graduates per year, 80% of whom are white. The medium of instruction is English at five (Cape Town, Witwatersrand, Natal, MEDUNSA, and Transkei) and Afrikaans at three (Pretoria, Stellenbosch, and Bloemfontein). Natal and MEDUNSA are creations of apartheid and have graduated almost all the Black South African doctors, of whom only 15 are practicing surgeons. Many universities are cognizant that dramatic change is needed to redress such imbalances, and admission policies are changing. Schools are addressing the implications of admitting many more Black African students from less privileged educational backgrounds into their medical faculties. Only then will more nonwhite graduates emerge with excellent, well monitored specialist training in surgery, which until now has been the domain of mainly white doctors.

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Resumen Las políticas del Apartheid han resultado en desigualdades en cuanto a la provisión de la atención de la salud y a la capacitación de los cirujanos en Sur Africa. La población del país está conformada por 74% de negros, 14% de blancos, 8% de color y 2% de asiáticos. Sólo el 17% de la población se halla cubierta por seguros médicos (78% blancos, 28% asiáticos, 26% de color, 4% negros) que financian el 46% del total del gasto nacional en atención de la salud, 9.215,6 millones de rand. El resto recibe atención por parte de servicios con base en hospitales que consumen 77% del gasto público en salud. Los servicios de promoción y prevención de la salud representan el 23% del gasto. Sólo 3.2% del GNB de Sur Africa se emplea en la provisión de servicios de salud para el 80% de la población, una cifra muy inferior al 5.8% que recomienda la Organización Múndial de la Salud. Esto se traduce en un gasto per cápita de 180, 340, 356 y 597 rands para los negros, de color, asiáticos y blancos, respectivamente.Ocho facultades de medicina producen algo más de 900 graduados anualmente, 80% de los cuales son blancos. El idioma de la instrucción es el inglés en cinco de ellas (Ciudad del Cabo, Witwatersrand, Natal, MEDUNSA y Transkrei) y el Afrikaan en tres (Pretoria, Stellenbosch y Bloemfontein). Natal y MEDUNSA, como creaciones de apartheid, gradúan casi exclusivamente doctores sur africanos negros, de los cuales solamente 15 son cirujanos en ejercicio.Muchas universidades son conscientes de que se requiere un cambio dramático para corregir tales desequilibrios, y ya las políticas de admisión están en proceso de modificación. Las facultades de medicina se ocupan de estudiar las implicaciones de recibir un número muy superior de estudiantes negros y africanos provenientes de los sectores menos privilegiados. Sólo entonces lograrán muchos de los graduados no blancos ascender a excelentes programas de adiestramiento especializado en cirugía, los cuales hasta ahora han sido monopolio predominante de los doctores blancos.

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Résumé La politique de l'arparthéid a considérablement influencé l'administration des soins et l'enseignement des chirurgiens en Afrique du Sud. La population de la nation est de 33 millions d'habitants, dont 74% sont noirs, 14% sont blancs, 8% de peau rouge et 2% sont des asiatiques. Seulement 17% de la population a une couverture médicale (78% sont des Blancs, 28% sont des Asiatiques, 26% sont des peaux rouges, 4% sont des noirs), assurée par une contribution de fonds privés qui correspond à 46% du total des coûts de la nation, et qui s'élève à quelques 9215.6 millions de rands. Le restant de la population reçoit des soins dans les hôpitaux de l'état qui sont responsbles de 77% des dépenses de santé de la nation. Les services de santé préventifs et éducatifs dépensent 23% des fonds. Seulement 3.2% du produit national brut de l'Afrique du Sud est dépensé pour soigner 80% de la population, bien moins que les 5.8% recommandés par l'O.M.S. Ceci veut dire que les dépenses par habitant sont respectivement de 138, 340, 356, et 597 pour les Noirs, les Rouges, le Asiatiques et les Blancs. Huit écoles de Médecine sont responsables de la formation de 900 diplômés par an, parmi lesquels 80% sont blancs. L'enseignement est fait en Anglais dans cinq écoles (Cape, Witwatesrand, Natal, MEDUNSA et Transkei) et en Afrikaans dans trois (Pretoria, Stellenbosch, et Bloemfontein). Les écoles de Natal et MEDUNSA sont des créations de l'Apartheid et fournissent pratiquement tous les diplômés en médecine noirs. Parmi ceux-là, seulement 15 sont des chirurgiens qui exercent réellement leur métier. La plupart des universités sont conscients qu'il faut réviser cette politique et des changements sont en train de se faire. Plusieurs écoles de médecine étudient acketuellement comment elles peuvent recevoir d'avantage d'étudiants noirs provenant des milieux moins favorisés. A ce monment-là, seulement, verra-t-on sans doute d'avantage de diplômés non blancs provement des écoles de chirurgie dont les enseignants sont reconnus comme spécialistes, postes jusqu'à maintenant reservés aux seuls médecins blancs.

     

Treatment for Critical Lower Limb Ischemia in Elderly Patients

Background

Critical limb ischemia (CLI) has a poor outcome when left untreated. The benefits of revascularization in the very elderly might be limited because of co-morbidities and short life expectancy. Therefore, optimal management of CLI in the elderly is not straightforward. We analyzed treatment results for elderly patients with CLI (Rutherford 4 or 5/6) in our clinic.

Methods

Hospital charts of all patients >70 years of age diagnosed with Rutherford stage 4–6 peripheral arterial disease between January 2006 and December 2009 were reviewed. We divided patients into two age groups (70–79 and ≥80 years) to compare treatment results. Primary interventions were defined as conservative, endovascular, reconstructive surgery, and amputation. Outcome measures were mortality, reintervention, and major amputation rates.

Results

There were 191 patients [99 (52 %) were women], median age 78.4 years, range 70–98 years. Altogether, 119 (62 %) patients were aged 70–79 years, and 72 (38 %) were ≥80 years. The primary intervention was equally divided over the two age groups (p = 0.21). Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC II) classifications of aortoiliac lesions were not significantly different regarding intervention (p = 0.62) or age (p = 0.39). TASC II classification of femoropopliteal lesions was significantly different relative to intervention (p < 0.01) but not different between age groups (p = 0.68). Mortality rate after reconstructive surgery was significant higher in the oldest age group (p < 0.01). After conservative treatment, endovascular treatment, or amputation, the mortality rates were not significantly different between the two age groups (respectively, p = 0.06, p = 0.33, p = 0.76). Reintervention rate was 51 % in the 70- to 79-year group compared to 32 % in the ≥80-year group. After initial treatment, major amputations were performed in 10 % in the 70- to 79-year group compared to 13 % in the ≥80-year group.

Conclusions

In patients aged ≥80 years, surgical revascularization resulted in a significant higher mortality rate in our clinic, whereas primary conservative, endovascular treatment and amputation resulted in similar mortality in both age groups. When considering surgical revascularization in the very elderly, surgeons should focus on careful patient selection.     

三种下肢静脉穿刺置管方法效果比较

目的 寻找下肢静脉最佳的穿刺置管方法.方法 将经下肢化疗的85例肿瘤患者分为三组.外周深静脉组23例,选择内踝大隐静脉起始处或小腿内侧,以15°～30°角进针行静脉穿刺,置入16 G PICC导管至大隐静脉末段或股静脉,经X线拍片证实导管尖端位置正确后接通输液装置输液;股静脉组41例,选择股动脉搏动最明显部位的内侧0.5 cm处,针头指向患者头部、与皮肤呈30°～45°角穿刺,王入16 G单腔中心静脉导管输液;外周留置针组21例,采用18～22 G贝朗留置针,选择下肢浅静脉行静脉穿刺王管输液.结果 三组一次置管成功率及操作平均耗时、化疗性静脉炎发生率总体比较差异有统计学意义(P<0.05,P<0.01),股静脉组成功率最低且耗时最多,外周留置针组化疗性静脉炎发生率最高;外周深静脉组导管平均留置时间显著短于股静脉组(P<0.05),两组并发症发生率比较差异无统计学意义(P>0.05),但股静脉组发生严重感染1例.结论 为预防化疗性静脉炎,应避免使用外周静脉而选择深静脉给药.外周深静脉置管与股静脉穿刺王管比较,操作简单、一次操作成功率高、耗时少,无严重并发症,是下肢深静脉置管较理想的方式.     

腔镜在下肢静脉性溃疡治疗中的应用

目的探讨腔镜在下肢慢性静脉功能不全(CVI)并发静脉性溃疡中的临床治疗经验与疗效。方法回顾性分析2004年5月至2011年4月期间我院应用腔镜治疗78例(88条患肢)下肢CVI并发静脉性溃疡患者的临床资料,患者均行大隐静脉高位结扎+腔内激光治疗(EVLT)+腔镜深筋膜下交通静脉离断术(SEPS)。结果所有患者手术顺利。SEPS手术时间15～30min,平均20min;术中出血量1～5ml,平均2ml;术后住院时间2～8d,平均5d。术后肢体酸胀感和曲张浅静脉消失,色素沉着区缩小。术后筋膜下血肿3例,皮下气肿2例,小腿胫前区及足靴区麻木感3例。所有患者4～6周溃疡愈合,随访0.5～5年,平均3.5年,仅1例复发,是由于足靴区交通静脉残留。结论 SEPS是治疗CVI并发静脉性溃疡的首选方法,具有创伤小、出血少、手术时间短、恢复快、并发症少、疗效显著等特点。     

A Powered Lower Limb Orthosis for Providing Legged Mobility in Paraplegic Individuals

This paper presents preliminary results on the development of a powered lower limb orthosis intended to provide legged mobility (with the use of a stability aid, such as forearm crutches) to paraplegic individuals. The orthosis contains electric motors at both hip and both knee joints, which in conjunction with ankle-foot orthoses, provides appropriate joint kinematics for legged locomotion. The paper describes the orthosis and the nature of the controller that enables the SCI patient to command the device, and presents data from preliminary trials that indicate the efficacy of the orthosis and controller in providing legged mobility.     

A methodology for resource allocation in health care for South Africa. Part IV. Application of South African Health Resource Allocation formula

The primary concern of this concluding article in a series is the application of the South African Health Resource Allocation (SAHRA) formula proposed in the previous article (SAMJ 1990; 77: 456-459). Target allocations based on this formula are compared with current budgets to estimate the extent of geographical maldistribution of health care resources. Under the present health service structure, the direction of redistribution of these resources should be from the provinces to 'homelands'. A number of refinements to the crude formula, such as the introduction of a more rational regionalisation policy and accounting for the teaching commitments of academic hospitals, are considered and their effects illustrated. Despite data deficiencies and the wide range of possible technical modifications to SAHRA, the concept of basing resource allocation decisions on an internationally applied formula is worthy of public debate.