Effects of the 2008 global financial crisis on population health

We compare the transmission channels through which the 2008 global financial crisis affected health. We find that postponing or skipping visits to the doctor after falling ill and stopping buying regular medication had the strongest negative effects on health, followed by a reduced consumption of staple foods, utilities being cut, being forced to move, and having to sell assets. In comparison, experiencing cuts in TV, phone, and internet services, as well as delaying payments for utilities had relatively weaker negative impacts. In contrast, having a household head or household member lose a job also had negative effects on health status, although this effect was relatively lower. Finally, a reduced flow of remittances had the weakest negative effect.     

Incidence of lower extremity amputations in diabetics

The aim of this study was to identify the incidence of lower extremity amputations (LEAs) in diabetics in Poland as background data for comparisons over time and with other communities. This was a cross-sectional study of the incidence of any non-traumatic and non-neoplastic LEAs in the population of Krakow region (1,239,703 inhabitants in its borders before 1.1.1999). It was calculated that for this population size it was sufficient to collect data for one year. The amputees had to be inhabitants of the Krakow region between 1.1.1996 and 31.12.1996. Data was collected from two sources: surgical wards and limb fitting centres. 290 non-traumatic and non-neoplastic LEAs were identified: 283 in the first source (hospital), of which 51 were found in the second (limb fitting centre) while 7 amputations were identified in the second source solely. 72.4% of LEAs were performed in males and this proportion tended to decrease with age, especially in diabetics. Mean age of the amputees was 64.7 years. Diabetics were significantly older (68.2 vs 61.5 years, p < 0.001). The number of amputations was growing with age reaching peak values between 65-74 years in diabetics and 55-64 in non-diabetics. 47.9% of LEAs were performed in diabetics. In 10.8% of cases diabetes was previously unknown. 88.7% of amputations were primary. The following amputation levels were identified: toe--15.5%, metatarsus--6.6%, ankle 1.0%, crus--20.0%, thigh--56.9%. In diabetics 21.6% of amputations were minor (metatarsus and below) comparing to 9.9% in non-diabetics. Incidence rates, calculated per 100,000/year and corrected using capture-recapture method, were as follows (95% confidence intervals in parentheses): 25.9 (10.2-41.6) in the whole population, 186.7 (125.3-248.1) in diabetics, 165.3 (110.5-220.0) primary in diabetics, and 14.4 (3.5-25.4) in non-diabetics. Comparing to data from the literature these were comparatively good results for diabetics of caucasian race. Like in other papers incidence rate in diabetics was almost 15 times higher than in non-diabetics, reaching 24 in females, which suggested that gender protection was reduced by diabetes. In an attempt to lower the rate of amputations several actions should be considered. They may include more active case finding, particularly by GPs, and more effective screening for a high risk diabetic foot.     

Socioeconomic factors and concomitant diseases are related to the risk for venous thromboembolism during long time follow-up

While the risk for arterial vascular disease has been shown to be influenced by socioeconomic status (SES), there is limited information whether SES also influences the risk for venous thromboembolism (VTE). To evaluate whether there is an association between SES and VTE incidence. In 1990, all 730,050 inhabitants (379,465 women and 350,585 men) above 25 years of age in the County of Skåne in Sweden were evaluated with regard to age, household income, marital status, country of birth, number of years of residence in Sweden, educational level, and concomitant diseases. The cohort was hereafter prospectively investigated regarding diagnosis of, or death from VTE (deep venous thrombosis or pulmonary embolism ), during 1991–2003. The association between socioeconomic data and concomitant diseases at the baseline investigation 1990 and incidence of VTE during follow-up was examined by Cox proportional hazard models. During the 13 years prospective follow-up, 10,212 women and 7,922 men were diagnosed with VTE. In both genders, age above 40 years at baseline, low income, single status, and a lower level of education were associated with an increased risk of VTE. However, both men and women born outside of Sweden have a lower risk for VTE during follow-up, however. Age above 40 years, low income, single marital status, and lower level of education were independently related to an increased risk of VTE diagnosis during 13 years of prospective follow-up.     

Wrist tourniquet: the most patient-friendly way of bloodless hand surgery

BACKGROUND: The literature is scarce on wrist tourniquets. In this study, three well-established locations of tourniquet setting including upper arm, proximal forearm, and wrist were compared on the same limb using both clinical as well as biochemical variables in paramedical volunteers. METHODS: Twenty unmedicated, healthy, paramedical, right-hand dominant volunteers participated in the study. The left upper arms were used for monitoring. Blood pressures and heart rates were monitored and recorded before (baseline) and immediately after the application of the tourniquet, every 5 minutes, and at the time the patient requested deflation. An intravenous cannula (22 G) was placed on the right hand to obtain samples, which were taken at baseline and immediately after deflation of the tourniquet to evaluate the levels of pO2, pCO2, O2 saturation, pH, bicarbonate, blood sugar, lactate, hematocrit, and electrolytes. The tourniquets were applied to the right upper arm, forearm, and wrist of each subject with 5-day intervals between each trial. Subjective discomfort and tourniquet pain levels were recorded. For each trial, tourniquet tolerance and details of discomfort were recorded. Statistical analysis was performed as appropriate. RESULTS: Twenty volunteers aged 20 to 44 years were included. For each trial, in the first 10 minutes after inflation of the tourniquet, the heart rate and systolic blood pressure were increased compared with baseline values. Diastolic blood pressure was elevated immediately after inflation and remained so until deflation in each trial. Diastolic blood pressure values were higher in the upper-arm tourniquet group compared with wrist. Then pH, pO2, and O2 saturation values were decreased and pCO2 and lactate levels were increased compared with baseline values in each trial. Blood sugar was decreased significantly in the arm group. The decrease in pH, pO2, O2 saturation, and blood sugar in the upper arm group was significantly higher compared with wrist and forearm groups. The lactate value was higher in the upper arm group compared with wrist. Visual analog scale and numerical rating scores were lower in the wrist group compared with others at all times. The longest tourniquet tolerance was in the wrist group. In the wrist group, curling was observed in all subjects but the fingers could easily be extended. CONCLUSION: The wrist tourniquet is the most comfortable technique of bloodless surgery for procedures limited to the hand region.     

The anatomy of the ribs and the sternum and their relationship to chest wall structure and function

As with all parts of the body, the anatomy and physiology of the chest wall are intimately intertwined. To carry out the unique functions performed by the chest wall, the anatomic structures are formed precisely for maximal efficiency. This article focuses on the unique structural characteristics in the internal thoracic diameters. It discusses the specific anatomy of the ribs and costal cartilages, along with the sternum. How these parts interrelate through joints is described also. Finally, it describes the muscles that cause the motion in the chest wall.     

Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality

Background

Deep venous thrombosis (DVT) is much less common in the upper than in the lower extremity. Furthermore, there is limited information on risk factors for and the prognosis of upper extremity (UE)DVT in the general population.

Aims

To estimate incidence, risk factors, and prognosis in UEDVT.

Material and methods

Among a total of 1203 patients with venous thromboembolism (VTE) diagnosed during 1998-2006 in the prospective population-based Malmö thrombophilia study, 63 (5%, 33 men [52%, age 54 ± 17 years], and 30 women [48%, age 55 ± 22 years]) had UEDVT and were evaluated concerning risk factors, treatment, recurrent VTE, and mortality.

Results

At diagnosis, 19(30%) patients had known malignancy and 6(10%) had VTE heredity. Among female UEDVT patients 4(13%) used hormone therapy, 1(3%) was pregnant, while none was in the postpartum period. Of all 63 UEDVT patients, 12(19%) were heterozygous, and 3(5%) homozygous for the Factor V Leiden (FVL)-mutation. Two (3%) patients were heterozygous for the prothrombin mutation, and 1 patient (1.6%) showed both heterozygous FVL-mutation and lupus anticoagulant antibodies. Phlebography had been used for diagnosis in 48(76%), ultrasonography in 16(25%), and computer tomography (CT) in 9(14%) patients. Twenty-two patients (35%) were treated in hospital, and the remaining 41(65%) as out-patients. Sixty-two (98%) was treated with low molecular weight heparin (LMH), 60(95%) with oral anticoagulants (OAC), 3(5%) with unfractionated heparin, and 3(5%) with thrombolysis. VTE recurrence rate during median 62 (range 31-117) month of follow-up was 8/63(13%). Fifteen (24%) UEDVT patients died during follow-up; 9(47%) of the 19 patients with known malignancy at diagnosis and 6(14%) of the other patients. Yearly incidence of UEDVT was 3.6/100.000 (95% confidence interval [CI], 3.3 – 4.03).

Conclusion

Malignancies and the FVL mutation were common among patients with UEDVT. Mortality during follow-up vas high.     

Early and long term outcome of rescue percutaneous coronary intervention (R-PCI): experience from a tertiary care center in Pakistan Outcome of rescue angioplasty in Pakistan

Background Thrombolysis is the standard of care for STEMI in Pakistan. Failed thrombolysis has a very high morbidity and mortality. Rescue PCI then remains the only option to salvage the myocardium. We sought to analyze the angiographic, immediate and long term clinical outcome of patients undergoing Rescue PCI at our institution in Karachi, Pakistan. Methods 58 consecutive patients who underwent rescue PCI for failed thrombolysis between 2002 and 2005 were reviewed. Clinical characteristics, angiographic and procedural details with clinical outcomes including total mortality, recurrent angina, and repeat revascularization were studied. Sources included cardiac catheterization lab database, medical records and follow up at outpatient clinics. Results Rescue PCI was performed in 58 patients with a mean age 55 ± 12 years with 47 (79%) male and 11 (21%) females. CAD risk factors were hypertension (53%), dyslipidemia (48%), smoking (34%) and diabetes (34%). 53% had anterior MI, 39% inferior and 8% had a lateral wall MI. The median time frames were: onset of chest pain to ER = 99 min, door to needle time = 35 min, ER to procedure start time = 250 min. The culprit vessels were: Left Anterior Descending (LAD) (53%), Right Coronary Artery (RCA) (32%) and Circumflex (CX) (15%). TIMI flow grades pre-procedural were 0/I = 52%, II = 34%, III = 14% and post procedure 0/I = 8%, II = 6%, III = 86%. The mean follow-up duration was 16.15 months at which 50 (86%) were alive and 43 (74.13%) had event free survival. Conclusion Procedural success, event free survival and mortality in our series of Rescue PCI from Pakistan are comparable to recent international trials and registries. It should be considered as a reasonable option for patients with failed thrombolysis.