EPIDEMIOLOGY IN ANAESTHESIA: I: ANAESTHETIC PRACTICE OVER 20 YEARS

The practice of anaesthesia and its outcome is compared, bymeans of the Cardiff Anaesthetic Record System, between twoperiods of 6 years, in whiph 53 541 and 108 878 anaestheticswere administered by the staff of one department. The proportionof emergency cases has increased from 10.6% to 18.7%, but themortality m hospital has declined from 1 in 35 anaestheticsto 1 in 46     

Quinine poisoning

The treatment of a case of quinine amblyopia by stellate ganglion blockade is described. The degree of restoration of vision confirms the experience of other workers and is attributable to relief of retinal vasoconstriction. The possibility is discussed that earlier and more prolonged use of the technique might improve results.     

EFFECT OF SODIUM SALICYLATE ON HORMONAL RESPONSES TO HYPOGLYCAEMIA IN TYPE II DIABETICS

Prostaglandins and prostaglandin synthesis inhibitors are known to influence the secretion of a number of hormones. More specifically, sodium salicylate is known to increase insulin secretion in Type II diabetics in response to a glucose stimulus. To challenge the hypothesis that prostaglandins may be instrumental in a generalized defect of glucose recognition in Type II diabetics, the effect of sodium salicylate on the hormonal counter-regulatory response to insulin-induced hypoglycaemia was examined. Before salicylate treatment, seven Type II diabetics had brisk increases (mean +/- SEM) in circulating adrenaline (time 0 = 50 +/- 7 pg/ml; peak = 1630 +/- 330 pg/ml), noradrenaline (time 0 = 260 +/- 46 pg/ml; peak = 770 +/- 140 pg/ml), glucagon (time 0 = 38 +/- 6 pg/ml; peak = 75 +/- 10 pg/ml) and pancreatic polypeptide (time 0 = 149 +/- 30 pg/ml; peak = 1170 +/- 180 pg/ml) in response to insulin-induced hypoglycaemia. In contrast to previous studies in normal subjects, treatment with sodium salicylate failed to augment hypoglycaemia-induced secretion of adrenaline, noradrenaline or pancreatic polypeptide in Type II diabetics. The glucagon response to hypoglycaemia was augmented by sodium salicylate when the data were expressed as the incremental area under the glucagon vs. time curve, but not when peak response was used for analysis. These results are inconsistent with a prostaglandin-related generalized defect in glucose recognition in Type II diabetics and suggest that augmentation of hormone secretion in these patients by sodium salicylate may be specific for glucose-induced insulin secretion.     

The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians

Policy Points

• One of the most important possibilities of value‐based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs.
• At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low‐income populations, but not exposure to value‐based payment.
• Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity.

ContextOne of the most important possibilities of value‐based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value‐based payment will encourage health care providers to innovate to address upstream social risks.MethodsWe used the 2017‐2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices’ participation in value‐based payment models; and (3) measures of practices’ capacity for innovation. We used multivariate regression models to examine predictors of social risk screening.FindingsOn average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices’ overall exposure to value‐based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices’ capacity for innovation.ConclusionsOur results indicate that implementation of social risk screening—an initial step in enhancing awareness of social needs in health care—is not associated with overall exposure to value‐based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.     

General practitioner and paediatrician self-reported capacity for the diagnosis and management of childhood and adolescent overweight and obesity

Aim:  The purpose of the present study was to assess and document the self-reported capacity, knowledge, skill and confidence of Central Coast general practitioners and paediatricians in the identification and management of overweight and obesity in children and adolescents, to investigate the barriers they experience in this area of practice and to consider how the local public sector nutrition service may assist.
Methods:  Forty general practitioners and three paediatricians were interviewed using a semistructured purpose-designed questionnaire.
Results:  Most participating doctors perceived that public sector dietitians are not available to assist them in managing overweight and obese paediatric patients. Few (23%) doctors reported using published guidelines and most reported significant barriers limiting their capacity to identify and manage this patient group effectively. All doctors identified at least one way in which the public health system can better support doctors in this role.
Conclusions:  The findings suggest that many doctors may benefit from increased training and a health system that better remunerates them for the time investment needed to provide management consistent with best practice. Reorientation of local public sector nutrition services may also provide them with better support when managing overweight and obese paediatric clients. Future research should examine the actual practices of doctors and how public sector dietitians can best communicate and interact with them to facilitate effective management of these patients.     

CD69 is a stimulatory receptor for natural killer cell and its cytotoxic effect is blocked by CD94 inhibitory receptor

CD69 is a differentiation antigen expressed shortly after activation on T lymphocytes and other cells of haematopoietic origin, including natural killer (NK) cells. The function of CD69 on T lymphocytes acting as a costimulatory molecule in proliferation and lymphokine secretion is well established. NK cells express CD69 after activation by different stimuli such as phorbol 12-myristate 13-acetate (PMA), interleukin (IL)-2, IL-12, interferon-alpha (IFN-alpha) or anti-CD16 monoclonal antibodies (mAbs). However, although it has been shown that CD69 triggers NK-cell-mediated cytolytic activity, its effect on other NK-cell functions has not been studied. Furthermore, the possible interaction of CD69 triggering with other C-lectin type inhibitory receptors is not known. Thus, the objective of this work is to determine whether CD69-mediated NK cytotoxicity can be regulated by CD94 inhibitory receptor and the role of CD69 on other NK-cell functions different of cytotoxicity. The results show that CD69-mediated NK cytotoxicity can be abrogated by CD94 stimulation in NK cells expressing the CD94 inhibitory form of the receptor, indicating that CD94 regulates the cytotoxic events initiated by a wide variety of NK activatory receptors. We also show that anti-CD69 mAbs, not only triggered NK cytotoxicity, but also induce NK-cell proliferation, CD25 and intracellular adhesion molecule-1 (ICAM-1) expression, TNF-alpha production and Ca2+ mobilization in preactivated NK cells. These results suggest that CD69 plays a crucial role in NK-cell function contributing to sustain NK-cell activation, as it has been previously demonstrated in T cells.