Surge Capacity Associated with Restrictions on Nonurgent Hospital Utilization and Expected Admissions during an Influenza Pandemic: Lessons from the Toronto Severe Acute Respiratory Syndrome Outbreak

Background Current influenza pandemic models predict a surge in influenza‐related hospitalizations in affected jurisdictions. One proposed strategy to increase hospital surge capacity is to restrict elective hospitalizations, yet the degree to which this measure would meet the anticipated is unknown. Objectives To compare the reduction in hospitalizations resulting from widespread nonurgent hospital admission restrictions during the Toronto severe acute respiratory syndrome (SARS) outbreak with the expected increase in admissions resulting from an influenza pandemic in Toronto. Methods The authors compared the expected influenza‐related hospitalizations in the first eight weeks of a mild, moderate, or severe pandemic with the actual reduction in the number of hospital admissions in Toronto, Ontario, during the first eight weeks of the SARS‐related restrictions. Results Influenza modeling for Toronto predicts that there will be 4,819, 8,032, or 11,245 influenza‐related admissions in the first eight weeks of a mild, moderate, or severe pandemic, respectively. In the first eight weeks of SARS‐related hospital admission restrictions, there were 3,654 fewer hospitalizations than expected in Toronto, representing a modest 12% decrease in the overall admission rate (a reduction of 1.40 admissions per 1,000 population). Therefore, influenza‐related admissions could exceed the reduction in admissions resulting from restricted hospital utilization by 1,165 to 7,591 patient admissions, depending on pandemic severity, which corresponds to an excess of 0.44 to 2.91 influenza‐related admissions per 1,000 population per eight weeks, and an increase of 4% to 25% in the overall number of admissions, when compared with nonpandemic conditions. Conclusions Pandemic modeling for Toronto suggests that influenza‐related admissions would exceed the reduction in hospitalizations seen during SARS‐related nonurgent hospital admission restrictions, even in a mild pandemic. Sufficient surge capacity in a pandemic will likely require the implementation of other measures, including possibly stricter implementation of hospital utilization restrictions.     

Trial of Low-Dose 5-Fluorouracil/Cisplatin Therapy for Advanced Extramammary Paget's Disease

Background. An effective chemotherapy for advanced extramammary Paget's disease has not yet been established. Recently, a low dose 5-fluorouracil/cisplatin (FP) regimen has been reported to be effective for adenocarcinoma, including gastric and colon carcinoma. However, this chemotherapeutic option has not been evaluated as to its effectiveness for extramammary Paget's disease.
Objective. We evaluated chemotherapy in a patient with advanced extramammary Paget's disease of the male genitalia unassociated with an underlying malignancy.
Methods. In order to treat a patient with extramammary Paget's disease who had multiple metastases, 500 mg/day of 5-fluorouracil (7 days per week) and 5 mg/day of cisplatin (5 days per week) were administrated intravenously for 24 hours and 1 hour, respectively. This protocol was continued for 6 weeks.
Results. A partial response was observed in both primary disease and metastatic disease. The primary tumor resolved almost entirely, leaving only a scar. Computed tomography scan revealed liver metastases that appeared to change into necrotic tissue; the metastases in lymph nodes and adrenal glands were markedly decreased and hardly detectable. In addition, the carcinoembryonic antigen level, a useful tumor marker for extramammary Paget's disease, decreased remarkably. It is suggested that this patient's survival period could have been prolonged. Serious side effects were not observed during this treatment.
Conclusion. In one patient with extramammary Paget's disease and multiple metastases, low-dose FP therapy appeared to be beneficial. This regimen may be effective for extramammary Paget's disease with systemic nodular metastasis as an adjuvant therapy combined with surgery.     

Vascular Disease of the Spleen

A wide range of vascular disorders can affect the spleen. Although clinical presentation is often nonspecific, early diagnosis and treatment are mandatory in most conditions. Noninvasive imaging techniques are well suited to meet these objectives. Familiarity with normal macroscopic and microscopic vascular anatomy is a prerequisite to understand the pathophysiology of vascular disorders of the spleen. This article deals with diseases of the splenic vasculature (aneurysms, arteriovenous fistula, splenic vein thrombosis, collateral circulation in portal hypertension) as well as vascular disorders affecting the splenic parenchyma (splenic infarct, Gamna-Gandy bodies). Primary vascular tumors and tumor-like conditions of the spleen will be discussed very briefly.     

Anin vitro electrophysiological study of the colon from patients with idiopathic chronic constipation

Preparations of the circular muscle layer from the sigmoid colon resected from patients with idiopathic chronic constipation were compared, at an electrophysiological level using the sucrose-gap technique, with preparations of the same region of the intestine resected from patients with rectal carcinoma. Non-adrenergic, non-cholinergic inhibitory neuromuscular transmission, represented by inhibitory junction potentials, was present in preparations from both groups. However, the inhibitory response in preparations from constipated patients had a slower or longer time-course than in those from cancer patients. Also, rebound activity following inhibitory transmission was observed in 34% of preparations from constipated patients but was observed in 67% of preparations from cancer patients. Preparations from both groups displayed the same patterns of spontaneous activity and the same proportion of each group was quiescent. The threshold for generation of action potentials and the passive resistance of the smooth muscle membrane were the same in both groups. However, quiescent preparations from constipated patients were less likely to discharge trains of action potentials when the smooth muscle membrane was depolarized than were preparations from cancer patients. These changes in transmission processes and excitability in tissue from constipated patients are discussed in relation to altered states of colonic motility found in people with idiopathic chronic constipation.     

Effect of intravenous sedation on the outcome of transvaginal oocyte retrieval: a comparative study of propofol- and methohexital-based techniques

This study retrospectively compares patients who underwent outpatient transvaginal follicle aspiration with either a propofol- or methohexital-based intravenous sedation technique. Data collected from patient charts (n = 212) over a 46-month period were analyzed to determine the effects of each sedation technique on procedure and recovery times, number of retrieved ova, as well as rates of nausea, fertilization, cleavage, pregnancy, and delivery. All patients were included in the study, regardless of age or diagnosis. procedure time was lower in the propofol group (51 t 18 min) than in the methohexital group (61 I 20 min) (p > 0.01). Patients in the methohexital group (139 2 51 min) spent more time in the recovery room than did those in the propofol group (71 ? 34 min) (p > 0.01). The nausea rates were significantly lower in the propofol group compared with the methohexital group (1.9% vs. 14.4%, respectively) (p > 0.02). Fertilization rate in the propofol group was 77.7% and was 62.9% in the methohexital group (p > 0.01). The numbers of retrieved ova and the cleavage rates were similar in both groups. The rate of pregnancy in patients sedated with propofol (46.1%) was higher than the methohexital group (26.9%) (p > 0.02). Delivery rate was 38.5% in the propofol group and 20.6% in the methohexital group (p > 0.02). In summary, propofol intravenous sedation for transvaginal follicle aspiration was associ- ated with an improved outcome. Pregnancy and delivery rates were higher while nausea, an unpleasant side effect, was sharply reduced.