Rehabilitation Engineering & Assistive Technology Society (RESNA) position on the application of wheelchair standing devices: 2013 current state of the literature

This article, approved by the Rehabilitation Engineering & Assistive Technology Society of North America Board of Directors on December 23, 2013, shares typical clinical applications and provides evidence from the literature supporting the use of wheelchair standers.     

The cost of overseas visitors to an inner city accident and emergency department.

OBJECTIVE: To estimate, in a metropolitan accident and emergency (A&E) department, the annual cost of treating overseas visitors whose countries of origin do not have reciprocal arrangements with Britain. METHODS: The study was retrospective. A 24 h period (00.01 h to 24.00 h inclusive) on consecutive days in consecutive weeks (that is, Monday in week 1, Tuesday in week 2, etc) was costed over 52 weeks (1.8.92-31.7.93 inclusive) and extrapolated to 365 days. All visitors between those dates were divided into eligible (from countries with a reciprocal agreement) or non-eligible (from countries without a reciprocal agreement). Costs were calculated for medical and nursing care, investigation and treatment, and fixed costs. RESULTS: The annual St Mary's Hospital A&E budget for the study period (01/08/92 to 31/07/93) was 2,612,200 pounds; the average medical and nursing cost per major or minor case was 66.88 pounds and 20.08 pounds respectively. Investigation, treatment, and fixed costs were 16.31 pounds per patient. In total 2704 non-eligible patients (498 major and 2206 minor cases) were treated at a cost of 121,705 pounds (95% confidence interval 114,234 pounds to 129,176 pounds), which was 4.7% of the total annual budget. CONCLUSIONS: The cost of non-eligible patients to the NHS is substantial. One possible solution would be for visitors from countries which do not offer subsidised emergency treatment to British nationals to purchase health insurance compulsorily on or before entry to Britain. The revenue could be used to improve standards of care for all A&E patients.     

The natural history of nonalcoholic fatty liver disease: a population-based cohort study

BACKGROUND & AIMS: The natural history of nonalcoholic fatty liver disease (NAFLD) in the community remains unknown. We sought to determine survival and liver-related morbidity among community-based NAFLD patients. METHODS: Four hundred twenty patients diagnosed with NAFLD in Olmsted County, Minnesota, between 1980 and 2000 were identified using the resources of the Rochester Epidemiology Project. Medical records were reviewed to confirm diagnosis and determine outcomes up to 2003. Overall survival was compared with the general Minnesota population of the same age and sex. RESULTS: Mean (SD) age at diagnosis was 49 (15) years; 231 (49%) were male. Mean follow-up was 7.6 (4.0) years (range, 0.1-23.5) culminating in 3192 person-years follow-up. Overall, 53 of 420 (12.6%) patients died. Survival was lower than the expected survival for the general population (standardized mortality ratio, 1.34; 95% CI, 1.003-1.76; P = .03). Higher mortality was associated with age (hazard ratio per decade, 2.2; 95% CI, 1.7-2.7), impaired fasting glucose (hazard ratio, 2.6; 95% CI, 1.3-5.2), and cirrhosis (hazard ratio, 3.1, 95% CI, 1.2-7.8). Liver disease was the third leading cause of death (as compared with the thirteenth leading cause of death in the general Minnesota population), occurring in 7 (1.7%) subjects. Twenty-one (5%) patients were diagnosed with cirrhosis, and 13 (3.1%) developed liver-related complications, including 1 requiring transplantation and 2 developing hepatocellular carcinoma. CONCLUSIONS: Mortality among community-diagnosed NAFLD patients is higher than the general population and is associated with older age, impaired fasting glucose, and cirrhosis. Liver-related death is a leading cause of mortality, although the absolute risk is low.     

Association between intracellular infectious agents and Tourette’s syndrome

The underlying pathophysiological mechanisms in Tourette’s syndrome (TS) are still unclear. Increasing evidence supports the involvement of infections, possibly on the basis of an altered immune status. Not only streptococci but also other infectious agents may be involved. This study investigates the association between the neurotrophic agents Chlamydia, Toxoplasma and TS. 32 patients with TS and 30 healthy matched controls were included. For each individual, IgA/IgG antibody titers against Chlamydia trachomatis/pneumoniae and Toxoplasma gondii were evaluated and analyzed with Fisher’s exact test. We found a significantly higher rate of TS patients with elevated antibody titers against Chlamydia trachomatis (P = 0.017) as compared to controls. A trend toward a higher prevalence in the Tourette’s group was shown for Toxoplasma (P = 0.069). In conclusion, within the TS patients a higher rate of antibody titers could be demonstrated, pointing to a possible role of Chlamydia and Toxoplasma in the pathogenesis of tic disorders. Because none of these agents has been linked with TS to date, a hypothesis is that infections could contribute to TS by triggering an immune response. It still remains unclear whether tic symptoms are partly due to the infection or to changes in the immune balance caused by an infection.     

Renin-angiotensin blockade is associated with increased mortality after vascular surgery

Purpose

The outcome of patients with preoperative renin-angiotensin system (RAS) blockade, achieved either by angiotensin converting enzyme inhibitors or angiotensin receptor blocking agents, was assessed using 30-day mortality as a primary end point.

Methods

An observational cohort study of 883 consecutive patients undergoing elective open abdominal aortic aneurysm repair (AAA) was undertaken and analyzed using a propensity score matched study. The data collected included medical history, anesthetic techniques, and postoperative outcomes. Logistic regression analysis identified predictors of RAS blockade: hypertension, stroke, congestive heart failure, diabetes, and heart disease. A propensity score for RAS blockade was calculated for each subject using several factors: age, sex, serum creatinine, hypertension, heart disease, congestive heart failure, stroke, diabetes, and exposure to cardiovascular medications. Subjects and controls were matched using the calculated propensity score.

Results

The overall 30-day mortality rate was 3.5% (31/883 patients). The crude mortality rate in RAS blocked patients was 5.8% (21/359) vs 1.9% (10/524) in unexposed patients (odds ratio 3.2, with 95% confidence intervals [CI₉₅] 1.5-6.7; P < 0.001). Analysis of 261 propensity score matched pairs showed a 30-day mortality rate of 6.1% (16/261) in the RAS blocked group vs 1.5% (4/261) in unblocked patients (P = 0.008). The estimated odds ratio for 30-day mortality associated with RAS blockade was 5.0 (CI₉₅ 1.4-27).

Conclusions

Examination of 883 cases of AAA repair showed increased mortality associated with preoperative RAS blockade. A better understanding of perioperative pharmacology and physiology of RAS blockade is needed as well as future studies to identify causality.