Government health expenditures and health outcomes

This paper provides econometric evidence linking a country's per capita government health expenditures and per capita income to two health outcomes: under-five mortality and maternal mortality. Using instrumental variables techniques (GMM-H2SL), we estimate the elasticity of these outcomes with respect to government health expenditures and income while treating both variables as endogenous. Consequently, our elasticity estimates are larger in magnitude than those reported in literature, which may be biased up. The elasticity of under-five mortality with respect to government expenditures ranges from -0.25 to -0.42 with a mean value of -0.33. For maternal mortality the elasticity ranges from -0.42 to -0.52 with a mean value of -0.50. For developing countries, our results imply that while economic growth is certainly an important contributor to health outcomes, government spending on health is just as important a factor.     

Neurophobia among medical students

Objective:

To assess the attitude of medical students and junior physicians toward neurology.

Methods:

A self-administered, previously validated, questionnaire was distributed among 422 students and junior physicians at King Abdulaziz University, Jeddah, Saudi Arabia from September to December 2012. In this cross-sectional study, the questionnaire included demographic data and 12 statements to examine attitudes toward neurology using a Likert scale.

Results:

The response rate among participants was 70.3%. The mean age was 22.35 (SD+/-1.28) years. Males comprised 46.2%. While 31.3% of students had not decided regarding their future career, 11.8% selected neurology as their first possible choice. Whereas 29.6% of students were not satisfied with their neurology teaching experience, 84.4% found neurology difficult, and 42.7% of the whole group thought that their neuroscience knowledge was insufficient. Advanced clinical year students (namely, interns) were less likely to consider neurology as a career choice (p=0.001).

Conclusion:

Most of the students had an unfavorable attitude toward neurology on the Likert scale. New strategies are needed to change students’ attitude toward this demanding specialty.Neurological disorders comprise 6.4% of the global health burden, and contribute to 12% of global mortality.1 A large proportion of these disorders are chronic, outpatient based, and typically cared for in the community by general medical staff.2-6 Hence, it is important that medical students, and eventually medical doctors of different specialties, become more familiar and comfortable with dealing with these common diseases. Neurophobia, or the fear of neuroscience and clinical neurology, is well known among medical students and junior physicians.2 Neurology is considered, throughout the world, as the most difficult and the least understood medical specialty.2-5 Students, residents, and general practitioners display less confidence when dealing with neurological cases compared with other medical conditions.5,7 This has been attributed to limited patient exposure, difficult neuroanatomy, complex clinical examination, insufficient teaching, and diagnostic complexity.3,5,6,8 In Saudi Arabia, the attitude of medical students toward neurology and the extent of neurophobia is not well explored. Our study aimed to examine this issue and its extent among Saudi medical students.     

Can an iron-rich staple food help women to achieve dietary targets in pregnancy?

Habitual iron intakes during pregnancy are typically lower than dietary guidelines, a risk for iron deficiency. The aim of this study was to determine whether regular consumption of bread naturally rich in iron could help women to achieve dietary targets. Thirty-three primiparous mothers were randomized to eat 3-4 slices of iron-rich or control bread daily for 6 weeks. Two 24-h-prompted (multiple-pass) dietary recalls were completed, and validated algorithms were used to determine the amount of 'available iron' from the diet. Regular consumption of iron-rich bread helped pregnant women to achieve UK dietary recommendations; the quantity of bread consumed by the participants contributed 27% versus 9% UK Reference Nutrient Intake (RNI) (14.8 mg/d) in the intervention versus the control group. Levels of total 'available iron' were similar in both groups and correlated positively with total dietary iron (r = 0.78, P = 0.0001), vitamin C (r = 0.43, P = 0.017) and non-haem iron (r = 0.77, P = 0.0001). Findings from this study show that iron-rich staple foods can help women reach dietary targets for iron. This is an area of great potential that could be of particular benefit to low-income/ethnically diverse population groups who have some of the lowest iron intakes. Further research using fortified staple foods containing higher levels of iron is now warranted to establish physiological benefits.     

Methicillin-Resistant Staphylococcus aureus Infection: An Independent Risk Factor for Mortality in Patients with Poststernotomy Mediastinitis

Objective

The mortality rate of patients with poststernotomy mediastinitis remains very high. The aim of this study was to identify the risk factors associated with mortality in these patients.

Subjects and Methods

Surveillance of sternal surgical-site infections including mediastinitis was carried out for adult patients undergoing a sternotomy between 2004 and 2012. Criteria from the US Centers for Disease Control and Prevention were used to make the diagnosis. All data on patients with a diagnosis of mediastinitis who were included in the study and on mortality risk factors were obtained from the hospital database and then analyzed using SPPS 16.0 for Windows.

Results

Of the 19,767 patients undergoing open heart surgery, 117 (0.39%) had poststernotomy mediastinitis; 32% of these 117 died. The independent risk factors for mortality were methicillin-resistant Staphylococcus aureus (MRSA) [odds ratio (OR) 12.11 and 95% confidence interval (CI) 3.15–46.47], intensive-care unit stays >48 h after the first operation (OR 11.21 and 95% CI 3.24–38.84) and surgery that included valve replacement (OR 6.2 and 95% CI 1.44–27.13). The mortality rate decreased significantly, dropping from 38% (34/89) between 2004 and 2008 to 14% (4/28) between 2009 and 2012 (p = 0.018).

Conclusion

In this study, elimination of MRSA from the hospital setting decreased the rate of mortality in patients with poststernotomy mediastinitis.Key Words: Poststernotomy mediastinitis, Mortality, Methicillin-resistant Staphylococcus aureus     

Coronary Flow Velocity Reserve and Carotid Intima Media Thickness in Patients with Autosomal Dominant Polycystic Kidney Disease: From Impaired Tubules to Impaired Carotid and Coronary Arteries

Background and objectives: Cardiovascular problems are a major cause of morbidity and mortality in patients with autosomal dominant polycystic kidney disease. Endothelial dysfunction, an early and reversible feature in the pathogenesis of atherosclerosis, is associated with increased vascular smooth muscle tone, arterial stiffening, and increased intima-media thickness. Coronary flow velocity reserve is a noninvasive test showing endothelial function of epicardial coronary arteries and coronary microcirculatory function. The aim of the study was to investigate the carotid intima-media thickness and coronary flow velocity reserve in patients with autosomal dominant polycystic kidney disease.Design, setting, participants, & measurements: Thirty normotensive patients with autosomal dominant polycystic kidney disease (10 male, 20 female) with well-preserved renal function and 30 healthy subjects (12 male, 18 female) were included in the study. Coronary flow velocity reserve was measured at baseline and after dipyridamole infusion by echocardiography. Coronary flow velocity reserve was calculated as the ratio of hyperemic to baseline diastolic peak velocities.Results: Carotid intima-media thickness was significantly higher in patients than in control subjects (0.80 ± 0.29 versus 0.54 ± 0.14 mm, respectively; P < 0.001). Moreover, coronary flow velocity reserve was significantly lower in patients than in control subjects (1.84 ± 0.39 versus 2.65 ± 0.68, respectively; P < 0.001).Conclusions: Normotensive patients with autosomal dominant polycystic kidney disease with well-preserved renal function have significantly increased carotid intima-media thickness and significantly decreased coronary flow velocity reserve compared with healthy subjects. These findings suggest that atherosclerosis starts at an early stage in the course of their disease in patients with autosomal dominant polycystic kidney disease.Autosomal-dominant polycystic kidney disease (ADPKD) is a hereditary renal disease that occurs in 1 of 400 to 1000 individuals (1,2). Cardiovascular problems are a major cause of morbidity and mortality in patients with ADPKD (3). Hypertension, a common finding in patients with ADPKD, often occurs before the onset of renal insufficiency and is associated with faster progression to ESRD and increased cardiovascular mortality (4,5). Activation of the renin-angiotensin-aldosterone system (RAAS) caused by cyst expansion and local ischemia has been proposed to play an important role in the development of hypertension in ADPKD (6). The RAAS is stimulated at an early stage of ADPKD, even before the onset of hypertension and clinical findings (7,8). Likewise, increased left ventricular mass indexes and biventricular diastolic dysfunction have been reported before the development of hypertension in patients with ADPKD with well-preserved renal function (9–16). Moreover, endothelial dysfunction (ED), which is an early manifestation of vascular injury, occurs in both normotensive and hypertensive patients with ADPKD, before the onset of renal failure (17).Coronary flow velocity reserve (CFVR) represents the capacity of the coronary circulation to dilate after an increase in myocardial metabolic demands (18). Although CFVR was measured invasively until recently, it can be evaluated noninvasively by using Doppler and vasodilator stress, such as dipyridamole or adenosine (19). By using this method, impairment of CFVR can be assessed before development of angiographically detectable stenosis in epicardial coronary arteries. The aim of this study was to investigate the CFVR in patients with ADPKD, with well-preserved renal function.     

Early assessment of the efficacy of digital infrared thermal imaging in pediatric extremity trauma

Young children or those with intellectual disability with trauma to an extremity often undergo radiographs of the whole limb. The objective of the study was to assess the efficacy of digital infrared thermal images (DITI) in pediatric extremity trauma. We hypothesized fractures to be associated with local hyperthermia, detectable with DITI, which could direct focused radiographs. In this exploratory study, patients seen over a 2-month period in a pediatric emergency department for limb trauma were included if an extremity radiograph was taken on the same day. Patients had DITI of symptomatic and contralateral limbs. The warmest area of each image was compared to the site of pain and/or fracture on the radiograph. Fifty-one patients were enrolled. DITI matched 73% of pain sites. Fractures were seen in 11 patients. DITI matched 7 of 11 (64%) fracture sites. DITI performance in pinpointing the site of injury, although suboptimal, is encouraging for further evaluation.     

Reversible posterior leukoencephalopathy in the course of Goodpasture syndrome

Reversible posterior leukoencephalopathy syndrome (RPLS) is characterized by headache, altered consciousness, seizures, and cortical blindness. The most frequent etiological factors are hypertension, kidney diseases, and immunosuppressive drugs such as steroids and cyclophosphamide. Herein we present a case of a 22-year-old female patient presented with alveolar hemorrhage and acute renal failure necessitating hemodialysis. In renal biopsy, necrotizing crescentic glomerulonephritis and immunofluorescence pattern compatible with Goodpasture syndrome were found. Anti-glomerular basement membrane antibody result was positive. At follow-up, respiratory failure ensued, steroid pulse treatment was started, and she was transferred to intensive care unit (ICU). In the ICU, she had visual disturbances and blindness together with seizures. Cranial magnetic resonance imaging (MRI) revealed irregular T2- and fluid-attenuated inversion recovery (FLAIR)-weighted lesions in bilateral occipital lobes. On clinical and radiological grounds, RPLS was diagnosed. With the supportive and anti-hypertensive treatment, RPLS was resolved without a sequela. Subsequent cranial MRI was totally normal. In the literature, RPLS associated with Goodpasture syndrome was reported only once. Hypertension and methylprednisolone might be the responsible etiologies in this case.     

Cardiovascular mortality patterns in Turkey: What is the evidence?

In Turkey, reliable cause-specific mortality data are not available. It is thus unknown whether ischaemic heart disease (as in western Europe and the US) or stroke (as in the Far East) is the prevailing cause of cardiovascular death. This information, however, is required for planning cardiovascular prevention programmes. We analyse available Turkish national cause-of-death data as well as patterns of cardiovascular mortality in a hospital in Ankara and among Turkish migrants in Germany. According to national statistics, the ischaemic heart disease-to-stroke ratio would be 0.3 among men aged 45–64 years, lower than that in Japan. Hospital and migrant data show this ratio to be 2–4. We demonstrate the implausibility of the national data by assessing the precision of cause-of-death assignment. We then discuss to what degree mortality experience among migrants is representative for their country of origin. Our findings suggest that the pattern of cardiovascular mortality in Turkey is closer to that in western Europe and the US than to that in the Far East. Finally, we discuss options for improving cardiovascular surveillance in Turkey.