A primary care cardiovascular risk reduction clinic in Canada was more effective and no more expensive than usual on-demand primary care – a randomised controlled trial

The objective of this randomised controlled trial was to compare the effects and expense of three approaches to care (1) proactive cardiovascular risk reduction (CaRR) clinic; (2) nurse telephone calls; or (3) usual care for people with cardiovascular risk factors in a Primary Care, Health Service Organisation (HSO) in Ontario, Canada. Subjects included consenting patients with an identified cardiovascular disease (CVD) risk factor identified from the HSO computerised patient information system in 2004. Patients were excluded if they were mentally incompetent, <18 years of age, in a nursing home, or not English speaking. Of 1570 eligible subjects, 523 (33.3%) verbally declined, 145 (9.2%) could not be contacted, and 249 (15.9%) were not needed. The final sample size was 653 (41.6%), 634 completed the follow-up (97%). The Cardiovascular Risk Score, Health and Social Service Utilisation, Montgomery-Asberg Depression Rating, Billings and Moos Indices of Coping, Personal Resource and Self-Efficacy Questionnaires were measured at baseline and 1-year follow-up by clinical examination and telephone interview. Cardiovascular risk scores were reduced in all treatment groups after 1 year. The proportions of subjects showing reduction in risk score greater than or equal to 10% was greatest in the CaRR group (69.2%) compared with Nurse Phone intervention (57.8%) and Usual Care (59.0%) ( M - H χ² = 4.33, df = 1, P  = 0.037, CaRR-Usual Care). Self-efficacy scores showed the greatest improvements in the CaRR clinic. This effect was achieved with no significant difference in total person per annum costs for direct and indirect health and social service utilisation between all three groups. A CaRR clinic is more effective in reducing CVD risk after 1 year compared with nurse phone intervention and usual care with no additional expense found.     

An outbreak of Serratia marcescens bacteremia after general anesthesia.

OBJECTIVE: To investigate an outbreak of Serratia marcescens bacteremia among patients after general anesthesia. DESIGN: A case-control study. SETTING: A 304-bed, pediatric teaching hospital. PATIENTS: Twenty-three pediatric patients who developed S. marcescens bacteremia within 2 weeks after general anesthesia between June 15 and September 22, 1999, were compared with 46 age-matched control-patients who had undergone procedures on the same clinical services of the hospital during the same period. RESULTS: Cases were distributed over a wide range of surgical services and were not correlated with exposure to any of the surgical, anesthesia, or nursing staff. Case-patients were significantly more likely than control-patients to have received cefazolin (odds ratio [OR], 11.1; 90% confidence interval [CI90], 1.9 to 24.3) or to have had perioperative placement of a central vascular catheter (OR, 4.2; CI90, 1.2 to 18.8). The timing of the procedures of patients who subsequently developed S. marcescens bacteremia was significantly associated with the shifts of one or more of five operating room technicians (OR, 2.9 to 6.8) who were responsible for preparing intravenous fluids used both to reconstitute perioperatively administered antibiotics and to prime central vascular catheter assemblies. CONCLUSIONS: Our findings are consistent with a pattern of intermittent contamination due to periodic breaches in sterile technique, rather than a point-source of contamination. The unique challenges that such a procedural breakdown presents to an epidemiologic investigation are discussed. This outbreak stresses the importance of providing comprehensive training in antisepsis when multifunctional personnel are incorporated into an operating room work environment.     

Inhibitory effect of streptozotocin on tumor development in transgenic mice bearing an elastase I-SV40 T-antigen fusion gene.

Transgenic mice, bearing a fusion gene of rat elastase I promoter and SV40 T-antigen, developed acinar cell tumors of the pancreas, as predicted by the model. In addition, they developed insulinomas and somatostatin (delta)-cell hyperplasia of the pancreatic islets. The insulinomas and the delta-cell hyperplasia appeared to be functional, as evidenced by changes in plasma glucose, insulin, and somatostatin. Streptozotocin, which has been shown to inhibit pancreatic carcinogenesis in the hamster model, significantly reduced the numbers of insulinomas and delta-cell hyperplasias. Streptozotocin did not cause a statistically significant reduction in exocrine tumors.     

Thyroid carcinoma

The issue of appropriate management for thyroid neoplasms remains unsettled. Confusion concerning histology and classification, controversy as to appropriate therapy, the relative indolence of most differentiated thyroid tumors, and various levels of surgical skill have contributed to the prejudice of various approaches to the management of such neoplasms. It appears unlikely that the controversy will be resolved in the immediate future. If total thyroidectomy can be performed by a skilled surgeon with minimal complications, this approach seems theoretically justifiable for the management of most differentiated tumors, facilitating follow-up postoperatively. Conclusive evidence for improved survival with this rationale is insufficient.     

A simplified algorithm for optimization of large-scale gas networks

A number of sophisticated algorithms exist for the optimization of large-scale systems. However, from a practical viewpoint one must always balance the cost of such optimization in applications with the saving that results. This paper presents a simplified algorithm for large-scale gas networks which, although yielding a suboptimal energy saving, is nevertheless simple to apply and demands only moderate back-up facilities. To illustrate the proposed method an example is chosen in which there are fifty nodes and three compressors.     

Effects of a thromboxane antagonist (BM 13·177) during endotoxin-induced pulmonary vasoconstriction in sheep

Summary. We investigated the effect of a thromboxane antagonist, BM 13·177, during endotoxin-induced pulmonary vasoconstriction in sheep. In control animals intravenous E-coli endotoxin (1 μg/kg) caused a transient increase of pulmonary artery and airway pressure paralleled by large concentration increases of TXB₂: in comparison peak plasma concentrations of 6-keto-PGFlα (a prostacyclin metabolite) were small and delayed in time. Pre-treatment with BM 13·177 (bolus 5 mg/kg), followed by 0·75 mg/kg/min intravenously) abolished the rise of pulmonary artery and airway pressure. Plasma concentrations of TXB₂ and 6-keto-PFGla were similar to controls. These and previous investigations imply that BM 13·177 specifically antagonizes TXA₂ on the putative receptor in pulmonary vascular and airway smooth muscle.     

Gamekeepers thumb: a prospective study of functional bracing

Patients with acute thumb metacarpophalangeal joint injuries were assessed by stress radiography, arthrography, and clinical examination. Arthrograms served to assess tissue injury by the extent and location of dye leaks including the differentiation of displaced (Stener lesion) from undisplaced tears of the ulnar collateral ligament. Patients were treated for a minimum of 6 weeks by use of a removable custom-fit splint and daily range of motion exercises, and followed at a minimum of 1 year. In the 32 patients available for follow-up, mean relative instability improved from 17 degrees (after injury) to 2.3 degrees (follow-up) (p = 0.0001). Functional and subjective outcomes were good or satisfactory in more than 90% of patients; outcomes for all patients with Stener lesions were satisfactory, although joint stabilization was less than in the whole group. The three failures involved persistent symptoms, that defied subsequent surgery. These cases could not be predicted from the initial clinical tests. The treatment regimen was an economical, noninvasive, and effective method for a range of acute thumb metacarpophalangeal joint injuries.