Wound Botulism Associated with Black Tar Heroin

The incidence of wound botulism is increasing and the epidemiology of the disease is changing. The majority of new cases are associated with injection drug use, in particular, the use of Mexican black tar heroin. This case report and discussion of wound botulism illustrate the following important points: Dysphagia, dysphonia, diplopia, and descending paralysis, in association with injection drug use, should alert the treating physician to the possibility of wound botulism. In such patients, the onset of respiratory failure may be sudden and without clinically obvious signs of respiratory weakness. For the reported patient, maximum inspiratory force measurements were the only reliable indicator of respiratory muscle weakness. This is a measurement not routinely performed in the ED, but may prove essential for patients with suspected wound botulism. To minimize the effect of the botulinum toxin and to decrease length of hospital stay, antitoxin administration and surgical wound debridement should be performed early.     

Medicaid managed care in Iowa: Experiences of older adults and people with disabilities

BackgroundA growing number of states are turning to managed care arrangements to provide care to senior and disabled Medicaid beneficiaries. Despite their complex care needs, very little is known about the experience of these individuals in managed care.ObjectiveTo document experiences of a sample of aged and disabled Medicaid beneficiaries receiving long-term services and supports through managed care in Iowa and to assess whether these experiences changed over time.MethodsA purposive sample of 49 aged and disabled beneficiaries enrolled in one of seven HCBS waivers in Iowa was recruited in 2017. Telephone surveys were conducted in 2017 and 2019. A conventional content analysis was used to generate themes, which were then ranked by frequency proportions. Thematic frequencies were compared across waves among repeat respondents.ResultsContent analysis yielded seven themes in the following areas: system navigation; service approvals; provider relations; customer service; case management; perception of Iowa’s transition to managed care; and oversight. Concerns with service approvals was the most frequently reported theme and within this, issues related to changes in approved services or hours and quality of newly approved services comprised the largest number of references. Beneficiary concerns appeared to grow over time among respondents participating in both survey interview waves.ConclusionThe results of this study point to serious and persistent concerns related to access and quality of care under managed care for at least some HCBS waiver participants in Iowa, underscoring the need for a comprehensive evaluation of the program.     

Online data on opening hours of general practices in England: a comparison with telephone survey data

Background

The NHS Choices website (www.nhs.uk) provides data on the opening hours of general practices in England. If the data are accurate, they could be used to examine the benefits of extended hours.

Aim

To determine whether online data on the opening times of general practices in England are accurate regarding the number of hours in which GPs provide face-to-face consultations.

Design and setting

Cross-sectional comparison of data from NHS Choices and telephone survey data reported by general practice staff, for a nationally representative sample of 320 general practices (December 2013 to September 2014).

Method

GP face-to-face consultation times were collected by telephone for each sampled practice for each day of the week. NHS Choices data on surgery times were available online. Analysis was based on differences in the number of surgery hours (accounting for breaks) and the times of the first and last consultations of the day only between the two data sources.

Results

The NHS Choices data recorded 8.8 more hours per week than the survey data on average (40.1 versus 31.2; 95% confidence interval [CI] = 7.4 to 10.3). This was largely accounted for by differences in the recording of breaks between sessions. The data were more similar when only the first and last consultation times were considered (mean difference = 1.6 hours; 95% CI = 0.9 to 2.3).

Conclusion

NHS Choices data do not accurately measure the number of hours in which GPs provide face-to-face consultations. They better record the hours between the first and last consultations of the day.     

Deep vein thrombosis and pulmonary embolism in cirrhotic patients:Systematic review

Patients with liver cirrhosis were traditionally believed to be protected against development of blood clots.Lately,studies have shown that these patients may probably be at an increased risk of venous thrombotic complications.Although the hemostatic changes in the chronic liver disease patients and the factors that may predict bleeding vs thrombotic complications remains an area of active research,it is believed that the coagulation cascade is delicately balanced in these patients because of parallel reduced hepatic synthesis of pro and anticoagulant factors.Thrombotic state in cirrhotic patients is responsible for not only portal or non-portal thrombosis[deep vein thrombosis(DVT)and pulmonary embolism(PE)];it has also been associated with progression of liver fibrosis.The use of anticoagulants in cirrhosis patients is a challenging,and often a scary situation.This review summarizes the current literature on the prevalence of venous thrombosis(DVT and PE),risk factors and safety of prophylactic and therapeutic anticoagulation in patients with chronic liver disease.