Echocardiographic assessment of right heart size and function in dogs with pulmonary valve stenosis.

INTRODUCTION/OBJECTIVES: We sought to determine the prevalence and clinical significance of right heart remodeling and right ventricular (RV) dysfunction in dogs with pulmonary valve stenosis (PS). We also sought to evaluate repeatability of several measurements of severity of PS, right heart size, and RV function in dogs with PS. ANIMALS, MATERIALS AND METHODS: Several indices of right atrial (RA) size and RV size and function were prospectively evaluated in 48 dogs with PS. Regression analysis was used to determine if indices of right heart size and function were independently associated with maximum transpulmonary pressure gradient (max PG) and adverse clinical findings (exercise intolerance, syncope, or right heart failure). Eight dogs underwent a second echocardiogram performed by the same operator to assess repeatability of the echocardiographic indices, which was quantified by coefficient of variation (CV) and repeatability coefficient. RESULTS: Increased RA size (81%), increased RV wall thickness (83%), and decreased tricuspid annular plane systolic excursion (TAPSE [81%]) were common. Right atrial size, end-diastolic RV area, and RV wall thickness were independently associated with max PG. Decreased TAPSE was independently associated with adverse clinical findings. All indices except RA area (18.6%) and RV systolic velocity (20.7%) had CVs <15%. Repeatability coefficients are available to help distinguish a true change versus measurement variability during serially obtained exams. CONCLUSIONS: Right heart remodeling and RV dysfunction are common in dogs with PS and are associated with echocardiographic and clinical severity. Results support the quantitative assessment of right heart size and function in dogs with PS.

Echocardiographic Assessment of Right Ventricular Size and Function in Cats With Hypertrophic Cardiomyopathy.

BACKGROUND: Studies evaluating right ventricular (RV) structural and functional abnormalities in feline hypertrophic cardiomyopathy (HCM) are limited. HYPOTHESIS: Right ventricular structural and functional abnormalities are present in cats with HCM and are associated with clinical severity. ANIMALS: Eighty-one client-owned cats. METHODS: Retrospective 2-dimensional (2D) echocardiographic study. Right atrial diameter (RAD), RV free wall thickness (RVFWd), RV internal dimension (RVIDd), RV fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE) were measured in control cats (n = 26), cats with subclinical HCM (subclinical HCM; n = 31), and cats with HCM and congestive heart failure (HCM + CHF; n = 24). RESULTS: Right heart size (RAD, RVFWd, and RVIDd) and RV function (FAC and TAPSE) significantly (all P < .05) increased and decreased, respectively, in the HCM + CHF group compared with controls. In the subclinical HCM group, only RVFWd was significantly (P < .05) higher than in controls. Compared with reference intervals derived from controls, 29% of cats with HCM had increased RVFWd. Increased left ventricular free wall thickness, increased RVIDd and decreased TAPSE independently correlated with increased left atrial size. Cats with HCM and pleural effusion were significantly more likely to have increased RVFWd and had increased RAD and decreased TAPSE compared with cats without pleural effusion. CONCLUSIONS AND CLINICAL IMPORTANCE: Right ventricular remodeling and dysfunction occur in some cats with HCM and may be associated with clinical severity. Our results support involvement of RV in the pathophysiology of HCM in some cats and support echocardiographic assessment of the RV in cats with HCM.

Midwives' adoption of the reproductive life plan in contraceptive counselling: a mixed methods study.

STUDY QUESTION: How is the reproductive life plan (RLP) adopted in midwifery contraceptive counselling? SUMMARY ANSWER: A majority of midwives adopted the RLP in their counselling, had predominantly positive experiences and considered it a feasible tool for promoting reproductive health. WHAT IS KNOWN ALREADY: The RLP is a health-promoting tool recommended by the Centers for Disease Control and Prevention in the USA for improving preconception health. It was recently used in a clinical setting in Sweden and was found to increase women's knowledge about fertility and to influence women's wishes to have their last child earlier in life. STUDY DESIGN, SIZE, DURATION: An exploratory mixed methods study among 68 midwives who provided contraceptive counselling in primary health care to at least 20 women each during the study period. Midwives received an introduction and materials for using the RLP in contraceptive counselling. Three months later, in the spring of 2014, they were invited to complete a questionnaire and participate in a focus group interview about their adoption of the RLP. PARTICIPANTS/MATERIALS, SETTING, METHODS: Data collection was through a questionnaire (n = 53 out of 68; participation rate 78%) and five focus group interviews (n = 22). Participants included both younger and older midwives with longer and shorter experiences of contraceptive counselling in public and private health care in one Swedish county. Quantitative data were analysed for differences between users and non-users, and qualitative data were analysed by qualitative content analysis to explore the midwives experiences and opinions of using the RLP. MAIN RESULTS AND THE ROLE OF CHANCE: Sixty-eight per cent of midwives had used the RLP in their contraceptive counselling. Four categories emerged through the focus group interviews: (i) A predominantly positive experience; (ii) The RLP-a health-promoting tool; (iii) individual and societal factors influence the RLP counselling; and (4) long-term implementation comprises opportunities, risks and needs. The most common reason for not using the RLP was lack of information. LIMITATIONS, REASONS FOR CAUTION: There was general lack of experience of using the RLP with women from different cultural backgrounds, with non-Swedish speaking women and, when a partner was present. Due to the non-random sample, the limited knowledge about non-responders and a short follow-up period, results apply to short-term implementations and might not fully apply to long-term implementation. WIDER IMPLICATIONS OF THE FINDINGS: The use of RLP in contraceptive counselling appears a feasible way of promoting reproductive health. Results from the USA and Sweden indicate it is a promising tool for midwives and other health professionals involved in reproductive counselling, which deserves to be explored in other nations. STUDY FUNDING/COMPETING INTERESTS: Grants were received from the Medical Faculty at Uppsala University and the European Society of Contraception and Reproductive Health. There are no competing interests. TRIAL REGISTRATION NUMBER: N/A.

Introducing reproductive life plan-based information in contraceptive counselling: an RCT.

STUDY QUESTION: Can reproductive life plan (RLP)-based information in contraceptive counselling before pregnancy increase women's knowledge of reproduction, and of the importance of folic acid intake in particular? SUMMARY ANSWER: The RLP-based information increased women's knowledge of reproduction including knowledge of folic acid intake. WHAT IS KNOWN ALREADY: Many women have insufficient knowledge of reproduction, including a health-promoting lifestyle prior to conception, and highly educated women in particular postpone childbearing until an age when their fertile capacity has started to decrease. STUDY DESIGN, SIZE, DURATION: The study was an randomized controlled trial with one intervention group (IG) and two control groups (CG1, CG2). A sample size calculation indicated that 82 women per group would be adequate. Recruitment took place during 3 months in 2012 and 299 women were included. The women were randomized in blocks of three. All groups received standard care (contraceptive counselling, Chlamydia testing, cervical screening). In addition, women in the IG were given oral and written RLP-based information about reproduction. PARTICIPANTS/MATERIALS, SETTING, METHODS: A total of 299 out of 338 (88%) Swedish-speaking women visiting a Student Health Centre were included (mean age 23 years); response rate was 88%. Before the counselling, women in the IG and the CG1 completed a baseline questionnaire, including questions about lifestyle changes in connection to pregnancy planning, family planning intentions and knowledge of reproduction (e.g. the fecundity of an ovum). At follow-up 2 months after inclusion, a structured telephone interview was performed in all groups (n = 262, 88% participation rate). MAIN RESULTS AND THE ROLE OF CHANCE: There was no difference between the groups regarding the mean knowledge score at baseline. The IG scored higher at follow-up than at baseline (P < 0.001); the mean increased from 6.4 to 9.0 out of a maximum 20 points. The women in the CG1 scored no differently at follow-up than at baseline. The difference in the knowledge score between the IG and the two CGs was significant (P < 0.001), whereas no difference was shown between the two CGs. There was no difference between the groups at baseline regarding how many women could mention folic acid intake among the things to do when planning to get pregnant. At follow-up, 22% in the IG, 3% in CG1 and 1% in CG2 mentioned folic acid intake (P < 0.001). At follow-up, more women in the IG also wished to have their last child earlier in life (P < 0.001) than at baseline, while there was no difference in the CG1. LIMITATIONS, REASONS FOR CAUTION: As the study sample consisted of university students, it is possible that the effect of the intervention was connected to a high level of education and conclusions for all women of reproductive age should be drawn with caution. WIDER IMPLICATIONS OF THE FINDINGS: The provision of RLP-based information seems to be a feasible tool for promoting reproductive health. STUDY FUNDING/COMPETING INTEREST(S): Study funding was received from the Faculty of Medicine, Uppsala University, Sweden. There are no conflicts of interest. TRIAL REGISTRATION NUMBER: ClinicalTrial.gov Identifier NCT01739101.

Efficacy and tolerability of the new antiepileptic drugs I: treatment of new onset epilepsy: report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society.

OBJECTIVE: To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) (gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, and zonisamide-reviewed in the order in which these agents received approval by the US Food and Drug Administration) in the treatment of children and adults with newly diagnosed partial and generalized epilepsies. METHODS: A 23-member committee, including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy, evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane library for relevant articles from 1987 until September 2002, with selected manual searches up until 2003. RESULTS: There is evidence either from comparative or dose-controlled trials that gabapentin, lamotrigine, topiramate, and oxcarbazepine have efficacy as monotherapy in newly diagnosed adolescents and adults with either partial or mixed seizure disorders. There is also evidence that lamotrigine is effective for newly diagnosed absence seizures in children. Evidence for effectiveness of the new AEDs in newly diagnosed patients with other generalized epilepsy syndromes is lacking. CONCLUSIONS: The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with newly diagnosed epilepsy and identify those seizure types and syndromes where more evidence is necessary.

Efficacy and tolerability of the new antiepileptic drugs II: treatment of refractory epilepsy: report of the Therapeutics and Technology Assessment Subcommittee and Quality Standards Subcommittee of the American Academy of Neurology and the American Epilepsy Society.

OBJECTIVE: To assess the evidence demonstrating efficacy, tolerability, and safety of seven new antiepileptic drugs (AEDs) (gabapentin, lamotrigine, topiramate, tiagabine, oxcarbazepine, levetiracetam, and zonisamide) in the treatment of children and adults with refractory partial and generalized epilepsies. METHODS: A 23-member committee including general neurologists, pediatric neurologists, epileptologists, and doctors in pharmacy evaluated the available evidence based on a structured literature review including MEDLINE, Current Contents, and Cochrane library for relevant articles from 1987 until March 2003. RESULTS: All of the new AEDs were found to be appropriate for adjunctive treatment of refractory partial seizures in adults. Gabapentin can be effective for the treatment of mixed seizure disorders, and gabapentin, lamotrigine, oxcarbazepine, and topiramate for the treatment of refractory partial seizures in children. Limited evidence suggests that lamotrigine and topiramate are also effective for adjunctive treatment of idiopathic generalized epilepsy in adults and children, as well as treatment of the Lennox Gastaut syndrome. CONCLUSIONS: The choice of AED depends upon seizure and/or syndrome type, patient age, concomitant medications, AED tolerability, safety, and efficacy. The results of this evidence-based assessment provide guidelines for the prescription of AEDs for patients with refractory epilepsy and identify those seizure types and syndromes where more evidence is necessary.

Impact of a randomized, controlled trial of liberal vs conservative hospital discharge criteria on energy, protein, and fluid intake in patients who received marrow transplants.

OBJECT: To determine if adult patients who received marrow transplants had faster resumption of oral energy and nutrient intake and shorter duration of intravenous (i.v.) fluid requirement if discharged from the hospital earlier than is customary. DESIGN: Randomized, controlled trial of patients remaining hospitalized because of inadequate oral intake. Consenting patients were assigned randomly to remain hospitalized (hospital group) or be discharged to an ambulatory setting (ambulatory group). SUBJECTS: Seventy-eight patients of the Fred Hutchinson Cancer Research Center who were consuming less than 33% of estimated energy requirement and requiring up to 3,000 mL of fluids per day intravenously. INTERVENTION: Participants received nutrition counseling by a registered dietitian to promote resumption of oral intake. Daily oral intake records were analyzed to determine energy and nutrient content. MAIN OUTCOME MEASURES: Days after study enrollment to consume 33% of energy and protein requirements and total number of days of i.v. fluid support were analyzed by group until discharge from the center, approximately 100 days after transplantation. STATISTICAL ANALYSES: Demographic data were defined by group means. Differences between treatment procedures were determined by Cox regression analysis. No variables were confounding. RESULTS: The hospital group took fewer days than the ambulatory group to resume oral energy intake (4.5 vs 8.0, P = .004) and to discontinue i.v. fluids (30.5 vs 48.5, P = .019). There was no difference between groups in days of parenteral nutrition support (P = .817) or days to resume oral protein intake (P = .470). APPLICATIONS/CONCLUSIONS: Oral and gastrointestinal complications delay resumption of oral energy and protein intakes after transplantation. Earlier hospital discharge can achieve cost savings but may delay resumption of oral energy intake. Because of continued high-risk nutrition status and potential for rapid change in medical status, nutrition assessment and counseling are necessary in both the hospital and ambulatory setting to promote resumption of oral intake and discontinuation of i.v. fluids.

Emergency medicine and "acute" general practice: comparing apples with oranges.

Emergency Departments (EDs) operate at the interface between the inpatient and ambulatory sectors of health care. Because of shared funding between the Commonwealth and States for ambulatory care, there has been intense focus on the ED patient population, and the potential to shift the locus of care for non-inpatients. One of the frequently cited models for the provision of after-hours GP services is the Balmain General Practice Casualty (GPC). This paper analyses the GPC model, looking in detail at casemix, clinical quality, waiting times and cost-effectiveness. It is argued that the services provided and the casemix of the patient population of GPC and EDs are distinctly different. Cost-effectiveness for GPC has not been objectively established. Health service planning should recognise the distinct but complementary roles of general practice and emergency medicine. Evaluation of alternative models of service provision should critically examine the available evidence, and comparisons should be based on a precise analysis of equivalent services.

Successfully implementing a performance-based compensation plan. The secret is in the development process.

A performance-based compensation plan can effectively turn around a troubled physician practice. While no one plan will work for all practices, a particular development and implementation process has proven successful for a number of them. The process involves an inclusive approach designed to achieve the highest possible level of consensus among the physicians, identification of appropriate performance criteria and development of incentives to produce the desired behaviors.

How bad faith lawsuits can be tailored to fit HMOs.

In January 1999, in the case of Goodrich v. Aetna, a California jury returned a record-breaking verdict of $120.5 million damages in favor of a widow as a result of Aetna's failure to act in good faith in the treatment of her terminally ill husband. The following article discusses the history and basis of this kind of lawsuit, major decisions specifically pertaining to HMOs, and the outlook for future liability in this area.

Telemedicine applications in otolaryngology.

Under suitable technical and clinical conditions, remote interactive fiber-optic NPL can be used to evaluate a range of commonly occurring pathologies with a high degree of reliability. A clinical protocol appropriate for interactive and store-and-forward fiber-optic NPL was proposed for further evaluation. Additional applications of telemedicine in otolaryngology were outlined, including otoscopy, intra-oral examination, and evaluation of external facial pathology. We envisage tele-otolaryngology taking place in a variety of ways: Interactions between rural-based PCPs and specialists (routine evaluation of hoarseness, dysphagia), using store-and-forward techniques. Consults from emergency medicine physicians at a general service hospital to a specialist (laryngeal trauma, acute peritonsillar abscess, TM perforations) using interactive means. Case discussions between specialist and sub-specialist using a combination of store-and-forward and interactive technologies. Potentially, there are at least three significant benefits from widespread acceptance of telemedicine in the field of otolaryngology, or indeed in any of the medical specialties: Saved lives and reduced medical costs due to early detection of serious pathology (in this case, head and neck cancers). Reduced unnecessary referrals to specialists, and consequent savings to the patient and health-care insurer, accompanied by more efficient usage of specialist time. Enhanced level of medical education and interaction, as the link between the referring and consulting physician is more immediate and direct [27]. For these reasons, combined with the high number of visits at the primary-care level related to issues in otolaryngology-head and neck surgery, tele-otolaryngology is poised to be a leading telemedicine application within the next few years.

The Kaiser Permanente prenatal smoking-cessation trial: when more isn't better, what is enough?

INTRODUCTION: The effectiveness of low-cost smoking interventions targeted to pregnant women has been demonstrated, although few gains in absolute cessation rates have been reported in the past decade. Under conditions of typical clinical practice, this study examined whether outcomes achieved with brief counseling from prenatal care providers and a self-help booklet could be improved by adding more resource-intensive cognitive-behavioral programs. DESIGN: Randomized Clinical Trial. SETTING: A large-group-model managed care organization. PARTICIPANTS: 390 English-speaking women 18 years of age or older who self-reported to be active smokers at their initial prenatal appointment. INTERVENTION: Participants were randomized to one of three groups: (1) a self-help booklet tailored to smoking patterns, stage of change, and lifestyle of pregnant smokers; (2) the booklet plus access to a computerized telephone cessation program based on interactive voice response technology; or (3) the booklet plus proactive telephone counseling from nurse educators using motivational interviewing techniques and strategies. No attempt was made to change smoking-related usual care advice from prenatal providers. MAIN OUTCOME MEASURE: Biochemically confirmed abstinence measured by level of cotinine in urine samples obtained during a routine prenatal visit at approximately the 34th week of pregnancy. RESULTS: Twenty percent of participants were confirmed as abstinent with no significant differences found between intervention groups. Multivariate baseline predictors of cessation included number of cigarettes smoked per day, confidence in ability to quit, exposure to passive smoke, and educational level. No differential intervention effects were found within strata of these predictors or by baseline stage of readiness to change. Cessation rates among heavier smokers were strikingly low in all intervention groups. CONCLUSION: Neither a computerized telephone cessation program nor systematic provision of motivational counseling improved cessation rates over a tailored self-help booklet delivered within the context of brief advice from prenatal providers. Innovative strategies need to be developed to increase the effectiveness of existing prenatal smoking interventions. Special attention should be paid to the needs of heavier smokers.

Cost-effective evaluation of indeterminate urinary cytology.

PURPOSE: We reviewed our management of indeterminate urinary cytologies to determine which patients warrant urological evaluation. Our goal was to develop a cost-effective evaluation scheme that detects the most cancers. MATERIALS AND METHODS: We analyzed case histories of 389 patients with indeterminate urinary cytology who had undergone complete urological evaluations. Upper urinary tract imaging and cystoscopy were required to exclude malignancy, and tissue biopsy results were recorded in all individuals diagnosed with cancer. Multivariate analysis was used to assess the significance of clinical factors that would suggest the necessity of complete urinary system evaluation. Marginal cost-effectiveness rates were applied to various clinical scenarios. RESULTS: Of 389 patients 60 (15%) had urinary tract malignancy. A history of urothelial malignancy and hematuria were the only significant factors that suggested complete evaluation was necessary. If smoking history were included 59 of the 60 malignancies would have been detected. CONCLUSIONS: Patients with indeterminate urinary cytology who are nonsmokers and have neither hematuria nor a history of urothelial cancer are at low risk for malignancy and do not warrant complete evaluation.

[GSG (Structured Health Regulation)-conforming documentation of surgical interventions in a university clinic--3 years clinical experiences 1994-1996]. / GSG-konforme Dokumentation operativer Eingriffe an einer Universitätsklinik--3 Jahre klinische Erfahrung 1994-1996.

The cost increase in the public health sector is steadily mounting and hence politicians are forced to redefine the economic conditions for regulations. As a new quality in the area of inpatient hospital care the new German law of structural health care (GSG), valid as of January 1, 1993 replaces the principle of covering full costs. The GSG law required in our hospital an adjustment of existing EDP structures with integrated automatic remuneration estimate and the installation of a medical structure of the organisation for complete and correct documentation. Weakpoints of the prescribed obligatory ICPM codes and inadequate legal regulations result in a lack of separation or wrong integration of the lump sum payment in individual cases (FP) and special compensation (SE). The summary analysis of the compensation system with a subsequent medical control system showed a primarily inaccurate classification by 12%. There is as yet no proof for the usefulness of a lump sum payment system resulting in a selection of risks.

Contribution of cardiopulmonary indices in the assessment of patients with silent and symptomatic ischemia during exercise testing.

Cardiopulmonary and radionuclear indices were used to evaluate and compare cardiac function during exercise testing in patients with symptomatic and silent ischemia. The study comprised 58 patients aged 35-74 years, divided into three groups: Group I-20 patients (controls) with neither ST depression nor chest pain; Group II-22 patients with ST depression > 1 mm and no chest pain; Group III-16 patients with both ST depression and chest pain. All patients in Groups II and III demonstrated significant coronary artery disease. No antianginal medication was taken at least 24 h before testing. All patients underwent a cardiopulmonary exercise test and a multigated acquisition radionuclear study. The following variables were measured: oxygen consumption (VO2), CO2 output (VCO2), minute ventilation (VE), O2-pulse, ventilatory anaerobic threshold (VAT), left ventricular ejection fraction (LVEF) at rest (r) and at maximal effort (ex). Probability values were significant for all variables (P < 0.01-0.0001) except left ventricular ejection fraction-rest (P not significant between the three groups). No significant differences in extent of coronary artery disease were noted between Groups II and III. These findings suggest that during exercise testing patients with silent ischemia have better overall cardiac function than patients with symptomatic ischemia. Their value for both cardiopulmonary and radionuclear indices are closer to those of the control group than to the symptomatic group, regardless of the severity of the coronary artery disease Summary of results: (mean +/- 1 S.D.) Group VO2-max O2-Pulse max VAT (%) VAT (ml/min) LVEF-rest delta LVEF (ex-r) I 25.2 +/- 6.3 15.7 +/- 3.4 51.2 +/- 6.6 1075 +/- 289 54.7 +/- 7 5.4 +/- 4.85 II 22.4 +/- 2.8 14.5 +/- 2 47.0 +/- 5.3 854 +/- 136 52 +/- 10 1.2 +/- 6.7 III 16.0 +/- 2.5 11.4 +/- 2 41.6 +/- 7.7 683 +/- 105 51 +/- 8.5 -5.87 +/- 6.3

Invasive cervical carcinoma: role of MR imaging in pretreatment work-up--cost minimization and diagnostic efficacy analysis.

PURPOSE: To examine the cost and efficacy of diagnostic work-up in patients with invasive cervical cancer. MATERIALS AND METHODS: In 246 patients with invasive cervical cancer, all diagnostic tests performed before treatment were recorded. Patients were divided into two groups: those who underwent magnetic resonance (MR) imaging as the initial study (n = 105) and those who did not (n = 141). A list of 1995 Medicare global payments was used to measure cost. Bayesian analysis (likelihood ratios derived from a literature search) was performed for bladder, rectal, parameterial, and nodal involvement in stage Ib disease. RESULTS: Significantly fewer procedures and fewer invasive studies were performed in the MR imaging group. Net cost savings for the MR imaging group was $401 for all patients and $449 for patients with stage Ib disease. For stage Ib disease, the 0% pretest probability of bladder or rectal invasion does not justify the routine use of barium enema examination, cystoscopy, or proctoscopy. The increase in predictive values for parameterial and nodal disease was highest for MR imaging when tumor size was at least 2 cm. CONCLUSION: Guidelines for the pretreatment work-up of clinical stage Ib cervical cancer need revision. MR imaging should be used as an adjunct to clinical evaluation.