Atrial reentry in chronic repetitive supraventricular tachycardia

Atrial reentrance as a mechanism of the tachycardia was demonstrated in a 28-year-old patient suffering from chronic repetitive supraventricular tachycardia. Criteria for diagnosis included the following: (1) Repetitive supraventricular tachycardia was induced and terminated by properly timed atrial extrastimuli. (2) Return cycles of all atrial extrastimuli not abolishing the tachycardia were fully compensatory. (3) A-H prolongation was not a prerequisite to induce the tachycardia. (4) The contours of P and A waves during tachycardia differed from those in sinus rhythm, but atrial activation remained antegrade. (5) A concealed anomalous pathway could not be proved.     

Comparison of costs of percutaneous transluminal coronary angioplasty and coronary bypass surgery for patients with angina pectoris

To determine the costs of a procedure, the total costs of the department that provides the service must be considered and, in addition, the direct cost of the specific procedure. Applying this principle to the cost accounting of angioplasty and bypass surgery results in a direct, i.e. procedural, cost, including the initial hospital stay, of respectively 8694 Dfl and 20,987 Dfl. A review of the follow-up data for the first year after the original intervention revealed a 2% reintervention rate for bypass surgery, while this percentage was 29% for angioplasty. Adding the first year costs involved with reinterventions to the procedural costs results in a 1-year cost of angioplasty and bypass operation of 13,625 Dfl and 21,363 Dfl, respectively. It is concluded that because of reinterventions in the first year, a mark up of 57% on the procedural cost of angioplasty must be added to cover 1-year costs, while for bypass surgery this is only 1%. Nevertheless, the 1-year cost for angioplasty is still 36% less than for bypass surgery. As reinterventions after PTCA may stay considerably higher than for CABG for several years, the mark-up percentages will be substantially higher for longer time spans. This may tend to equalize the total costs of PTCA and CABG over time spans of perhaps 5-8 years. Sufficient data are not available to verify this statement. Clinicians must realize that choosing the most appropriate procedure is not only a matter of medical assessment but also a matter of cost effectiveness. CABG can be seen as an 'investment decision' while PTCA tends to become a decision with characteristics of 'maintenance planning'!     

Using an office system intervention to increase breast cancer screening

OBJECTIVE: To evaluate an innovative approach to continuing medical education, an outreach intervention designed to improve performance rates of breast cancer screening through implementation of office systems in community primary care practices. DESIGN: Randomized, controlled trial with primary care practices assigned to either the intervention group or control group, with the practice as the unit of analysis. SETTING: Twenty mostly rural counties in North Carolina. PARTICIPANTS: Physicians and staff of 62 randomly selected family medicine and general internal medicine practices, primarily fee-for-service, half group practices and half solo practitioners. INTERVENTION: Physician investigators and facilitators met with practice physicians and staff over a period of 12 to 18 months to provide feedback on breast cancer screening performance, and to assist these primary care practices in developing office systems tailored to increase breast cancer screening. MEASUREMENTS AND MAIN RESULTS: Physician questionnaires were obtained at baseline and follow-up to assess the presence of five indicators of an office system. Three of the five indicators of office systems increased significantly more in intervention practices than in control practices, but the mean number of indicators in intervention practices at follow-up was only 2.8 out of 5. Cross-sectional reviews of randomly chosen medical records of eligible women patients aged 50 years and over were done at baseline (n=2,887) and follow-up (n=2,874) to determine whether clinical breast examinations and mammography, were performed. Results for mammography were recorded in two ways, mention of the test in the visit note and actual report of the test in the medical record. These reviews showed an increase from 39% to 51% in mention of mammography in intervention practices, compared with an increase from 41% to 44% in control practices (p=.01). There was no significant difference, however, between the two groups in change in mammograms reported (intervention group increased from 28% to 32.7%; control group increased from 30.6% to 34.0%, p=.56). There was a nonsignificant trend (p=.06) toward a greater increase in performance of clinical breast examination in intervention versus control practices. CONCLUSIONS: A moderately intensive outreach intervention to increase rates of breast cancer screening through the development of office systems was modestly successful in increasing indicators of office systems and in documenting mention of mammography, but had little impact on actual performance of breast cancer screening. At follow-up, few practices had a complete office system for breast cancer screening. Outreach approaches to assist primary care practices implement office systems are promising but need further development. Presented in part at the 19th annual meeting of the Society of General Internal Medicine, Washington, DC, May 1996. This research was supported under grant CA 54343-02 from the National Cancer Institute.     

Infants' growth charts for southern Iran

Currently there are no growth charts based on local norms available for infants in Iran, and their growth is assessed by the National Centre for Health Statistics (NCHS) reference data, which is misleading. Growth charts for a cohort of 317 infants (164 girls and 153 boys) born in Shiraz (Southern Iran) in 1996 and followed for 2 years from birth are presented. All the centiles of length and weight charts are slightly above those of the NCHS charts under the age of 6 months and fall substantially below those over the age of 6 months. However, the spread is similar, so there is no suggestion that the difference is due to the prevalence of gross malnutrition. The difference shows that the use of locally based growth charts are essential for assessing the growth of children in Iran. The representativeness of our data leads us to conclude that the charts presented here are likely to be applied to the urban infant population of Iran.

Gegenwärtig stehen im Iran für Kleinkinder keine auf lokalen Normdaten basierende Wachstumsdiagramme zur Verfügung. Das Wachstum dieser Kinder wird anhand der Referenzdaten des Nationalen Zentrums für Gesundheitsstatistik (NCHS) eingeschätzt, was zu Fehleinschätzungen führt. Es werden Wachstumsdiagramme für eine Kohorte von 317 Kleinkindern (164 Mädchen und 153 Jungen) vorgestellt, die 1996 in Shiraz (Südiran) geboren wurden und nach ihrer Geburt 2 Jahre lang untersucht wurden. Alle Längen- und Gewichtszentilen liegen bis zu einem Alter von unter 6 Monaten leicht über denjenigen der NCHS-Diagramme und fallen ab einem Alter von 6 Monaten beträchtlich unterhalb diese. Allerdings ist die Spannweite ähnlich und daher gibt es kein Anzeichen dafür, dass der Unterschied auf das Vorliegen einer schweren Unterernährung zurückzuführen ist. Die Unterschiede zeigen, dass die Verwendung von lokalen Wachstumsdiagrammen für die Einschätzung des Wachstums von Kindern im Iran notwendig ist. Die Tatsache, dass unsere Daten als repräsentativ anzusehen sind, veranlasst uns zu der Schlussfolgerung, dass die hier vorgestellten Charts wahrscheinlich für die städtische Kleinkinderpopulation im Iran anwendbar sind.

On ne dispose pas actuellement en Iran de tables normatives de la croissance établies sur des données locales, si bien que la croissance des enfants iraniens est inadéquatement observéeen référence aux données du National Centre for Health Statistics (NCHS). On présente ici des courbes de croissance établies à partir d'une cohorte de 317 enfants (164 filles et 153 garçons) nés à Shiraz (Iran méridional) en 1996 et suivis pendant leurs deux premières années. Tous les centiles de taille et de poids sont légèrement supérieurs à ceux des tables NCHS avant l'âge de six mois, puis leurs deviennent nettement inférieurs par la suite. L'évolution des courbes étant similaire, il n'y a donc pas raison de suspecter que la différence est due à de la malnutrition. Cet écart entre les deux tables montre que l'utilisation de courbes fondées sur des données locales est essentielle pour le suivi de la croissance des enfants en Iran. La représentativité de nos données nous conduit à estimer que les tables présentées dans ce travail sont applicables à la population infantile urbaine en Iran.     

A Novel Similarity Learning Method via Relative Comparison for Content-Based Medical Image Retrieval

Nowadays, the huge volume of medical images represents an enormous challenge towards health-care organizations, as it is often hard for clinicians and researchers to manage, access, and share the image database easily. Content-based medical image retrieval (CBMIR) techniques are employed to facilitate the above process. It is known that a few concrete factors, including visual attributes extracted from images, measures encoding the similarity between images, user interaction, etc. play important roles in determining the retrieval performance. This paper concentrates on the similarity learning problem of CBMIR. A novel similarity learning paradigm is proposed via relative comparison, and a large database composed of 5,000 images is utilized to evaluate the retrieval performance. Extensive experimental results and comprehensive statistical analysis demonstrate the superiority of adopting the newly introduced learning paradigm, compared with several conventional supervised and semi-supervised similarity learning methods, in the presented CBMIR application.     

Healthcare technology co-operatives: Innovative about innovation

Abstract

The paper provides an introduction to the National Institute for Health Research Devices for Dignity Healthcare Technology Co-operative. Embedded within the NHS, Devices for Dignity identifies areas of unmet clinical need and translates these into research and development projects to develop new medical technologies. It addresses the needs of people living with long-term conditions, helping them to live more dignified and independent lives. Through partnerships with patients, universities, the NHS and industry, Devices for Dignity has developed an innovation methodology for successful medical technology innovation.     

Integrating clinical communication with clinical reasoning and the broader medical curriculum

Objective

The objectives of this paper are to discuss the results of a workshop conducted at EACH 2012. Specifically, we will (1) examine the link between communication, clinical reasoning, and medical problem solving, (2) explore strategies for (a) integrating clinical reasoning, medical problem solving, and content from the broader curriculum into clinical communication teaching and (b) integrating communication into the broader curriculum, and (3) discuss benefits gained from such integration.

Methods

Salient features from the workshop were recorded and will be presented here, as well as a case example to illustrate important connections between clinical communication and clinical reasoning.

Results

Potential links between clinical communication, clinical reasoning, and medical problem solving as well as strategies to integrate clinical communication teaching and the broader curricula in human and veterinary medicine are enumerated.

Conclusion

Participants expressed enthusiasm and keen interest in integration of clinical communication teaching and clinical reasoning during this workshop, came to the idea of the interdependence of these skills easily, and embraced the rationale immediately.

Practice implications

Valuing the importance of communication as clinical skill and embracing the interdependence between communication and thought processes related to clinical reasoning and medical problem solving will be beneficial in teaching programs.     

Cross-cultural validation of the Patient–Practitioner Orientation Scale (PPOS)

Objectives

Translate, adapt and validate the Patient–Practitioner Orientation Scale (PPOS) for use in Brazil.

Methods

The PPOS was translated to Portuguese using a modified Delphi technique. The final version was applied to 360 participants. Reliability (test–retest and internal consistency) and construct validity (explanatory and confirmatory factor analysis) were assessed.

Results

Only two items did not reach pre-established criteria agreement in Delphi technique. In pre-testing, seven items were modified. Internal consistency (Cronbach's alpha = 0.605) and test–retest reliability (intraclass correlation coefficient = 0.670) were adequate. In explanatory factor analysis, one item did not achieve a loading factor, one item was considered factorially complex and two items were inconsistent with a priori factors. Confirmatory factor analysis provided an acceptable adjustment for the observed variables (χ²/df = 2.33; GFI = 0.91; AGFI = 0.89; CFI = 0.84; NFI = 0.75; NNFI = 0.81; RMSEA = 0.062 (p = 0.016) and SRMR = 0.065).

Conclusions

The Brazilian version PPOS (B-PPOS) showed acceptable validity and adequate reliability.

Practice implications

The use of the B-PPOS in national and cross-cultural studies may contribute to the evaluation and monitoring of the attitudes of doctors, medical students and patients toward their professional relationships in research and practice.     

Integrity in Mental Health Systems: An Expanded Framework for Managing Uncertainty in Clinical Care

This article presents a broad‐based framework for evaluating integrity, defined as the structured comparison of observed values (i.e., what did happen) with expected values (i.e., what should happen), across various domains (e.g., practices, outcomes) for the purposes of informing key questions in system contexts (e.g., Is a practice being done properly? How well is it working?). We discuss the application of integrity in serving the goals of the scientific and service systems and potential sources for observed and expected values. An expanded framework regarding integrity analysis is presented detailing multiple domains of measurement (e.g., outcomes, activities, and resources), types of analysis (e.g., across vs. within units), and levels of analysis (e.g., event, episode, multi‐episode). Other possible applications of integrity analysis in service systems and ongoing dissemination and implementation efforts are also discussed.