Are general practitioner hospitals cost-saving? Evidence from a rural area of Norway

OBJECTIVE: We aimed to determine whether general practitioner GP hospitals, compared with alternative modes of health care, are cost- saving. METHODS: Based on a study of admissions (n = 415) to fifteen GP hospitals in the Finnmark county of Norway during 8 weeks in 1992, a full 1-year patient throughput in GP hospitals was estimated. The alternative modes of care (general hospital, nursing home or home care) were based on assessments by the GPs handling the individual patients. The funds transferred to finance GP hospitals were taken as the cost of GP hospitals, while the cost of alternative care was based on municipality and hospital accounts, and standard charges for patient transport. RESULTS: The estimated total annual operating cost of GP hospitals was 32.2 million NOK (10 NOK = 1 Pound) while the cost of alternative care was in total 35.9 million NOK. Sensitivity analyses, under a range of assumptions, indicate that GP care in hospitals incurs the lowest costs to society. CONCLUSION: GP hospitals are likely to provide health care at lower costs than alternative modes of care.      

Reproducibility of flow rates measured with low density gas mixtures in exercise-induced bronchospasm.

We have studied the reproducibility of the change in maximum expiratory flow rates after breathing helium/oxygen (He/O2) mixtures in 12 asthmatics at rest and after exercise. Each subject performed four identical exercise tests which caused a similar degree of exercise-induced bronchospasm (EIB) on each occasion. We compared flow rates at 50% of the vital capacity (V50) breathing He/O2 to those breathing air at rest, and with the lowest V50 on air after exercise. Those subjects showing an increase of greater than 20% in V50 with He/O2 compared to the corresponding air value were termed "responders". At rest the responder status after He/O2 was more consistent than during EIB. Six subjects were non-responders consistently on up to 12 separate measurements at rest while the other five subjects were non-responders on all but one occasion and the remaining subject a responder on seven of eight measurements. During EIB all but one subject showed a He/O2 response. A response was seen consistently in six subjects but the actual percentage change in V50 with helium varied greatly. One subject remained a non-responder after exercise and the other five were He/O2 responders after only two or three of the four test runs, and non-responders on the remainder. The lack of consistency of our data, particularly during EIB makes the interpretation of the He/O2 breathing test less useful than originally claimed.     

Intrauterine cytomegalovirus infection and glycoprotein B genotypes

Cytomegalovirus (CMV) strains display polymorphisms for the gene encoding glycoprotein B (gB; gpUL55). Recent data suggest that the gB genotype may influence the outcome of acquired CMV infections. To determine whether the gB genotype also contributes to the outcome of intrauterine infection, CMV strains were studied from 56 infants with culture-confirmed intrauterine CMV infections who were born in Iowa or Texas. CMV gB genotypes were compared with the neonatal clinical features and neurodevelopmental outcomes. Fifty-three strains (95%) could be assigned a gB genotype. The overall distribution of genotypes was as follows: type 1, 50%; type 2, 18%; type 3, 23%; and type 4, 4%. Strains with the gB 3 genotype were more common among the Iowa infants (P=.082). The gB 3 genotype was more common among infants with asymptomatic infections (P=.004), but geographic location and ascertainment biases may have accounted for these differences. The gB genotypes did not correlate with the neurodevelopmental outcome of intrauterine infection.     

The Exeter method—acetabular impaction grafting with cemented reimplantation

Objective

Restoration of acetabular anatomy and biomechanics at revision hip surgery by replacing deficient acetabular bone through impaction of allograft and/or autograft bone chips.

Indications

Aseptic loosening of the socket due to osteolysis, bone loss from infection, iatrogenic bone loss due to implant removal, and in the primary setting protrusio acetabuli, dysplasia and previous acetabular fracture.

Contraindications

Large segmental peripheral acetabular defects which cannot be contained, the presence of untreated infection, unstable acetabular fractures, previous radiotherapy to the affected hip area.

Surgical technique

Sound exposure of the acetabulum with delineation of the bony defect. Creation of a host environment suitable for bone graft and containment of segmental defects using rim mesh or porous augments. Impaction grafting using layered allograft or autograft bone chips of 0.8–1 cm³, packed using hemispherical impactors, followed by cementing of a polyethylene acetabular component with pressurisation.

Postoperative management

Partial weight bearing 6 weeks, modified depending on level of containment and intra-operative findings.

Results

A successful and reproducible technique with survival up to 87?% at 20 years for aseptic loosening in the revision setting.     

44Sacral extracorporeal magnetic stimulation is an effective treatment for pelvic floor dyssynergia; Comparative study with biofeedback therapy

Background: Recent development of extracorporeal magnetic stimulation (ECMS) which uses current‐changing magnetic fields allows the induction of electrical stimulation in the desired deep tissue. Recent study showed the sacral nerve stimulation reduces corticoanal excitability that may play a functional role in anal continence mechanisms. Preliminary study shows that ECMS of sacral nerve can modify pelvic floor function and expel rectal balloon in patients with pelvic floor dyssynergia (PFD). Aims: To evaluate the effect of ECMS compared with biofeedback therapy (BF) in patients with PFD. Methods and Materials: Thirty‐eight patients who fulfilled Rome II criteria for PFD by colon transit time and anorectal function tests, were randomly treated with 8 sessions of ECMS (2/weeks; n = 19) at prone position or BF (2/weeks; n = 19) at sitting position. Stimulation parameters were set at 50–80% of maximum intensity, 10 and 50 Hz frequency, 3 s burst length with 3 and 6 s off using arm‐typed stimulator (BioCom‐1000, Mcube Co., Korea). Symptom scores for constipation with/without anorectal function test were repeatedly measured after each treatment. Response was defined as 50% or more decreased symptom score after treatment (partial response: 30–50%, poor: <30%). Results: Fifteen patients (age 49.1 ± 13.4 years, mean ± SD; 4 men) completed 8 session of BF and 14 patients (54.5 ± 17.6 years, 3 men) completed 8 session of ECMS. Four patients of BF group discontinued treatment due to unsatisfactory therapeutic effect (n = 1) and withdrew consent (n = 3) and 5 patients of ECMS group discontinued treatment because of same reasons (n = 1, 4). Total symptom scores were significantly decreased after treatment of 8 session in both treatment groups (13.4 ± 6.6 vs. 4.3 ± 4.0 for BF, p = 0.009; 14.9 ± 5.6 vs. 3.4 ± 4.0 for ECMS, p < 0.001). Bowel movements per week were also significantly increased after treatment in both groups (median 2 vs. 7 for BF, p = 0.035; median 2 vs. 7 for ECMS, p = 0.008). Thirteen out of 15 patients showed response in BF group and 12 out of 14 showed good response in ECMS group. No adverse effects in both groups. Conclusions: ECMS is as effective as BF for the treatment of PFD. Long‐term effect of ECMS for the patients with pelvic floor dyssynergia need to be evaluated in the near future.     

5-HYDROXYTRYPTAMINE-INDUCED CONTRACTION OF THE MARMOSET AORTA IS MEDIATED BY A 5-HT1-LIKE RECEPTOR

1. 5-Hydroxytryptamine (5-HT) exerts both contractile and relaxant effects in the marmoset isolated aorta, actions that are unaffected by the 5-HT₂ antagonist ketanserin. The aim of the present study was to define the receptors mediating the contractile activity of 5-HT in the marmoset aorta.
2. Contractile responses were elicited in aortic rings that were either: (i) precontracted submaximally with the thromboxane A₂ agonist U44069 in order to amplify the responses; or (ii) exposed to N ^ω-nitro- L -arginine (100 μmol/L) plus LY 53857 (0.1 μmol/L; a 5-HT₂ receptor antagonist shown previously to inhibit relaxation). The effect of 5-HT on adenosine 3',5'-cyclic monophosphate (cAMP) formation was also investigated.
3. The effects of agonists and antagonists comprised: (i) agonist potencies in the order 5-carboxamidotryptamine > 5-HT > sumatriptan > 8-hydroxy-2-(di- n -propylamino)tetralin; (ii) inhibition of contractile action of 5-HT by the 5-HT_1D antagonist GR 127935; (iii) a contractile response to methysergide; (iv) a lack of effect of tropisetron, an antagonist of 5-HT₃ and 5-HT₄ receptors; and (v) inhibition of forskolin-stimulated cAMP formation by 5-HT (in the presence of LY 53857), indicative of negative coupling to adenylate cyclase.
4. The above effects fulfil the criteria for a 5-HT₁-like receptor. In view of the previous finding that this contractile response is insensitive to ketanserin, it is concluded that the contractile effects of 5-HT in the marmoset aorta are mediated exclusively by a 5-HT₁-like receptor.     

Patterns of recovery of airflow obstruction in severe acute asthma

The speed and patterns of recovery of airflow obstruction were analysed in 209 patients receiving a standard therapeutic regime for severe acute asthma. Initial rates of recovery were rapid. Three-quarters of the patients had achieved 50% of their total improvement in peak expiratory flow rate (PEFR) within 24 hr. The time taken to reach eventual maximum PEFR was very much longer, 50% of the patients taking one week or more. Diurnal variation of moderate or severe degree was seen in 78% of patients. Length of history of asthma, time of deterioration and other measures of the severity of attack on admission did not differ in faster and slower responders. The rise of PEFR within 4 hr of starting treatment was highly significantly correlated with a higher PEFR at 24 hr and a shorter time to full recovery. Although the mean arterial PCO₂ was higher (P<0·01) in the slower responding group and they were slightly older (P<0·05) and had lower mean FEV₁ (P<0·02) and FVC (P<0·05) these differences were less helpful in predicting which patients responded fastest.