Quality of life and exercise performance in patients in sinus rhythm versus persistent atrial fibrillation: a Veterans Affairs Cooperative Studies Program Substudy.

OBJECTIVES: The purpose of this study was to determine quality of life (QOL) and exercise performance (EP) in patients with persistent atrial fibrillation (AF) converted to sinus rhythm (SR) compared with those remaining in or reverting to AF. BACKGROUND: Restoration of SR in patients with AF improving QOL and EP remains controversial. METHODS: Patients with persistent AF were randomized double-blind to amiodarone, sotalol, or placebo. Those not achieving SR at day 28 were cardioverted and classified into SR or AF groups at 8 weeks (n = 624) and 1 year (n = 556). The QOL (SF-36), symptom checklist (SCL), specific activity scale (SAS), AF severity scale (AFSS), and EP were assessed. RESULTS: Favorable changes were seen in SR patients at 8 weeks in physical functioning (p < 0.001), physical role limitations (p = 0.03), general health (p = 0.002), and vitality (p < 0.001), and at 1 year in general health (p = 0.007) and social functioning (p = 0.02). Changes in the scores for SCL severity (p = 0.01), functional capacity (p = 0.003), and AFSS symptom burden (p < 0.001) at 8 weeks and in SCL severity (p < 0.01) and AF symptom burden (p < 0.001) at 1 year showed significant improvements in SR versus AF. Symptomatic patients were more likely to have improvement. The EP in SR versus AF was greater from baseline to 8 weeks (p = 0.01) and to 1 year (p = 0.02). The EP correlated with physical functioning and functional capacity except in the AF group at 1 year. CONCLUSIONS: In patients with persistent AF, restoration and maintenance of SR was associated with improvements in QOL measures and EP. There was a strong correlation between QOL measures and EP.     

The role of coronary angioplasty in the management of unstable angina pectoris

Using percutaneous transluminal coronary angioplasty (PTCA) as primary therapy for unstable angina is quite common. Unstable angina appears to be the indication for the procedure in approximately one third of all PTCA attempts. Considering the unstable nature of the plaque in this type of angina, and the increased risk of abrupt occlusion due to frequent intraluminal thrombus, the generally reported rate of success, approximately 85%, is highly respectable. The evidence supporting a period of pretreatment with aspirin and heparin is strong. Less certain is the value of concomitantly administering plasminogen activators. Pending data should produce important further guidelines for effective therapy. Major trials, some using fibrinolytics as well as taking an overall aggressive, interventional approach (like that taken by UNSA, TIMI-III, and others), are reaching the recruitment-completion and promulgation stages.     

Geriatric trauma: resource use and patient outcomes.

INTRODUCTION: Elderly patients who suffer trauma have a higher mortality and use disproportionately more trauma resources than younger patients. To compare these 2 groups and determine the outcomes and characteristics of elderly patients, we reviewed patients in these 2 groups admitted and treated in our tertiary care provincial trauma centre. METHODS: From the provincial trauma registry we selected a cohort of 40 geriatric patients (group 1) (> or = 65 yr of age) with an ISS of 16 or more who were admitted to and spent time in our trauma service for more than 48 hours and compared them with a similar randomly selected cohort of 44 patients (group 2) aged 20-30 years. Family physicians were contacted for follow-up of these patients 2 years after discharge. We considered length of hospital stay, complications, disposition of the patients and use of consultation services. RESULTS: Patients in group 1 had a mean age of 72.1 years (range from 65-98 yr) and a mean ISS of 27.3 (range from 17-50). Patients in group 2 had a mean age of 26.3 years (range from 22-29 yr) and a mean ISS of 26.3 (range from 17-54). Hospital stay was significantly longer in the group 1: 34.5 days (95% confidence interval [CI]: 24-44 d) versus 21.6 days (95% CI: 15-28 d). More elderly patients experienced complications (35 v. 13, p < 0.001) and required medical consultations (35 v. 26, p < 0.001). In-hospital death rates were 8% (3 of 40) and 4% (2 of 44) respectively (p = 0.3). Fewer geriatric patients could be discharged home (35% [14 of 40] v. 27% [22 of 44], p = 0.056) or to rehabilitation facilities (28% [11 of 40] v. 34% [15 of 44], p = 0.3). Five geriatric patients were discharged to nursing homes (p = 0.007). Of the geriatric patients discharged to rehabilitation facilities or home, 75% were independent 2 years after discharge. CONCLUSIONS: Aggressive care for geriatric trauma patients is warranted, and resources should be directed toward rehabilitation. Based on our findings, we expect that creating a directed care pathway for these patients, targetting complications and earlier discharge, will further improve their outcomes.     

Management of older patients presenting after a fall--an accident and emergency department audit.

BACKGROUND: It is common for older patients to present to accident and emergency (AE) departments after a fall. Management should include assessment and treatment of the injuries and assessment and correction of underlying risk factors in order to prevent recurrent falls. OBJECTIVES: To determine management of older patients presenting after a fall to the AE department of Groote Schuur Hospital in Cape Town, South Africa. METHOD: Hospital records were reviewed for a random sample of 100 patients aged 65 years and older presenting to the AE department after a fall, between December 2001 and May 2002. RESULTS: The mean age of the sample was 78.6 years (range 65-98 years); 72% of subjects were female. History of a previous fall, and history of drug or alcohol intake, were recorded in less than 20% of cases. Blood pressure and pulse rate were recorded in approximately 90% of cases, and pulse rhythm and postural blood pressure in 2%. Examination of the musculoskeletal system was done in 86% of cases and that of other systems in less than 50%; cognitive assessment was conducted in less than 30%. Radiological investigations were performed in 89% of cases, glucose and haemoglobin in 32%, renal profile and electrocardiogram in 5%, and urinalysis in 4%. Three-quarters of the patients were referred for further management: 52% to orthopaedic surgery, 12% to other surgical subspecialties, 6% to the general medical department, and 6% to other hospitals and clinics. No referrals were made to geriatric medicine, physiotherapy or occupational therapy. CONCLUSIONS: In managing elderly patients after a fall, the AE department focused on injuries sustained. Little effort was made to establish and manage risk factors, hence to prevent recurrent falls. Guidelines are needed for the management of such patients in AE departments.     

To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects.

The anterolateral thigh (ALT) flap has achieved popularity recently for free-flap reconstruction of intraoral defects following excision of squamous cell carcinoma. We have assessed the feasibility of the ALT flap as a free flap for oral lining and the potential use of the thinned ALT flap in a one-stage reconstruction. We used the ALT flap to reconstruct the oral cavity in 18 consecutive patients between December 2000 and December 2001 following intraoral resection of squamous cell carcinoma. Twelve patients underwent reconstruction using a standard ALT flap, four patients received a thinned ALT flap in a one-stage procedure, one patient received a standard ALT flap in combination with a fibula flap and one patient received a combination of a standard ALT flap and vascularised iliac bone. There were no complications in any of the 14 cases in which a standard ALT flap was used. Two of these flaps were thinned subsequently as secondary procedures. Of the four thinned ALT flaps, one flap failed completely and two flaps experienced partial necrosis. In all but one case the donor site was closed directly with minimal donor-site morbidity. The ALT flap is a versatile flap that can be used in combination with other flaps for more complex defects with minimal donor-site morbidity and is a useful alternative in the armamentarium of the head and neck surgeon. Thinning of the flap is best performed as a secondary procedure, should it be required.     

Safety of GM-CSF in Patients with AIDS: A Review of the Literature

We performed a literature search for all clinical studies reporting outcomes in patients with the acquired immunodeficiency syndrome (AIDS) receiving granulocyte-macrophage colony-stimulating factor (GM-CSF) for any indication. Safety outcomes included human immunodeficiency virus replication, immune status, and frequency of opportunistic infections and neoplasms. Data were synthesized qualitatively. We identified 22 studies (274 patients): 12 addressed AIDS neutropenia, 8 AIDS cancer therapy, and 2 opportunistic infections. Viral burden was assessed by serum p24Ag in 15 studies. Nine reported no change in levels, three net decreases, and three net increases. All studies showing net increases involved patients receiving GM-CSF without a concurrent antiretroviral. The CD4 counts were unchanged in 5 studies, increased in 3, and not reported in 14. The incidence of neoplasms or new opportunistic infections was low. The literature suggests no increased risk of viral replication or clinical deterioration in patients with AIDS who take GM-CSF concurrently with zidovudine.     

Efficacy of Bupivacaine Delivered by Wound Catheter for Post-Caesarean Section Analgesia

Summary: A prospective, randomized, double-blind trial was conducted to assess contribution to postoperative analgesia of intermittent instillation of 0.25% bupivacaine beneath the rectus sheath in 70 women delivered by lower uterine segment Caesarean section. The operations were performed via a Pfannenstiel incision under spinal anaesthesia. Background intravenous narcotic analgesia was provided with a patient controlled analgesia system (PCAS) using a standard morphine regimen.
Overall (44 hr) mean morphine consumption was significantly greater in the placebo (saline) group compared to the treatment group (84.2 mg versus 63.3 mg. Two tailed t test p<0.001). The most significant intergroup differences in narcotic use were found in the first 4 hours and between 24 and 36 hours after commencing PCAS (Two tailed t test p=0.014 and 0.003 respectively).
Subjective pain scores were assessed with a 10 cm visual analogue scale (VAS). The mean peak VAS score was greater in controls (5.37) than the treatment group (4.25) between 18 and 24 hours postoperatively (Mann-Whitney U=424, p=0.027). There were no intergroup differences in pain scores for any other time period. The overall incidence of nausea was lower in the treatment group compared to the control group (Chi squared with Yates' correction p=0.046) and a lower degree of sedation was seen in those receiving bupivacaine between 4 and 8 hours after commencing PCAS (Mann-Whitney U=427, p=0.028). No differences in other narcotic related side-effects (vomiting and pruritus) were shown between groups.
Regular instillation of 0.25% bupivacaine beneath the rectus sheath of women delivered by Caesarean section reduces their morphine requirements by 25% in the 44 hours after operation, with an associated reduction in both nausea and early sedation.     

Prevalence of Legionella in pharyngeal secretions of patients with pharyngitis

A serological investigation has suggested that Legionella pneumophila may be associated with sore throat in adults. In a study of 177 adults and children with acute pharyngitis, Legionella species were not isolated from pharyngeal cultures, which utilized selective and nonselective buffered charcoal-yeast extract media. Group A beta-hemolytic streptococci were isolated from 14 percent of the 177 symptomatic patients. Throat cultures from 88 asymptomatic control subjects were negative for Legionella and beta-hemolytic streptococci. Further studies are needed to determine if Legionella species are associated with acute pharyngitis.