Process of care events in transplantation: effects on the cost of hospitalization.

Deviations in the processes of healthcare delivery that affect patient outcomes are recognized to have an impact on the cost of hospitalization. Whether deviations that do not affect patient outcome affects cost has not been studied. We have analyzed process of care (POC) events that were reported in a large transplantation service (n = 3,012) in 2005, delineating whether or not there was a health consequence of the event and assessing the impact on hospital resource utilization. Propensity score matching was used to adjust for patient differences. The rate of POC events varied by transplanted organ: from 10.8 per 1000 patient days (kidney) to 17.3 (liver). The probability of a POC event increased with severity of illness. The majority (81.5%) of the POC events had no apparent effect on patients' health (63.6% no effect and 17.9% unknown). POC events were associated with longer length of stay (LOS) and higher costs independent of whether there was a patient health impact. Multiple events during the same hospitalization were associated with the highest impact on LOS and cost. POC events in transplantation occur frequently, more often in sicker patients and, although the majority of POC events do not harm the patient, their effect on resource utilization is significant.

Severe hyperkalemia during piroxicam therapy.

Severe hyperkalemia developed in an 85-year-old man after he had been receiving piroxicam treatment for several months. At admission his serum potassium level was 9.3 mEq/L; total CO2 level, 11 mmole/L; chloride level, 122 mEq/L; serum urea nitrogen level, 54 mg/dL; and creatinine level, 2.5 mg/dL. Hyperkalemia resolved after withdrawal of the drug and polystyrene sodium sulfonate therapy and the nonanion gap acidosis subsided concomitantly. His serum urea nitrogen and creatinine levels remained unchanged. He had abnormally low plasma renin activity, which gradually returned to normal, and aldosterone concentration, which remained low. The nonsteroidal drug may have impaired renin secretion, adrenal responsiveness to angiotensin, or the action of aldosterone on the renal tubule.

Pharmacokinetic optimisation of therapy with beta-adrenergic blocking agents.

beta-Adrenergic blockade has provided one of the major pharmacotherapeutic advances of this century. The drugs in this class have the common property of blocking the binding of catecholamines to beta-adrenergic receptor sites; however, there are pharmacodynamic and pharmacokinetic differences between the individual agents which are of clinical importance. Among these differences are the completeness of gastrointestinal absorption, degree of hepatic first-pass metabolism, lipid solubility, protein binding, brain penetration, concentration within cardiac tissue, rate of hepatic biotransformation, and renal clearance of drug and/or metabolites. Long-acting formulations of existing beta-blockers are currently in use, and ultrashort-acting agents are also available. The pharmacokinetics of beta-blocking drugs can also be influenced by race, age, cigarette smoking and concomitant drug therapy. The wide interpatient variability in plasma drug concentration observed with beta-blockers makes this parameter unreliable in routine patient management. Despite the pharmacokinetic differences among the beta-blockers, these drugs should always be titrated in the individual patient to achieve the desired clinical response.

Reduction of mortality, sudden death and non-fatal reinfarction with beta-adrenergic blockers in survivors of acute myocardial infarction: a new hypothesis regarding the cardioprotective action of beta-adrenergic blockade.

Beta-adrenergic blockers have been shown definitely to reduce the incidence of total mortality, cardiovascular mortality, sudden death and nonfatal reinfarction in survivors of an acute myocardial infarction. The mechanisms to explain this protective action of beta blockers have never been elucidated conclusively, and include the antiarrhythmic and myocardial oxygen demand-reducing effects of the drugs. An antithrombotic mechanism has also been suggested. However, beta blockers have relatively weak antiplatelet activity, suggesting that their antithrombotic effects may be related to prevention of coronary artery plaque rupture and the subsequent propagation of an occlusive arterial thrombus rather than direct anticoagulant action. The therapeutic ability of beta blockers to attenuate the hemodynamic consequences of catecholamine surges, may protect a vulnerable atherosclerotic plaque from fracture, thereby reducing risk of coronary thrombosis, myocardial infarction and death.

Prevalence, incidence and prognosis of recognized and unrecognized myocardial infarction in persons aged 75 years or older: The Bronx Aging Study.

The prevalence, incidence and prognosis of recognized and unrecognized Q-wave myocardial infarction (MI) was assessed in an 8-year prospective study of 390 community-based subjects (age 75 to 85 years at entry, mean 79 years). Subjects were studied at baseline and with annual follow-up electrocardiographic (ECG) exams. At baseline, 7.9% had a history of MI without ECG evidence, 6.4% had ECG evidence of Q-wave MI without clinical history, 4.1% had both clinical history and ECG evidence and 81.5% had neither history nor ECG evidence (control subjects). After an average follow-up period of 76.2 months, the total mortality rate was 5.9/100 person-years for subjects with some evidence of MI at baseline versus 3.9 in the control group (p = 0.059). The incidence of cardiovascular disease in subjects with evidence of MI was 8.8/100 person-years versus 4.7 among control subjects (p = 0.002). During the follow-up period, 115 new Q-wave MIs occurred (50 unrecognized, rate 2.4/100; 65 recognized, rate 3.2/100). There was no difference in mortality and morbidity outcome between subjects with recognized and unrecognized MIs. Those with only a history of MI at baseline had a threefold greater risk of a new MI (recognized and unrecognized) than the control group (p = 0.003). Unrecognized Q-wave MI is a common occurrence in the "old old" with subsequent morbidity and mortality prognosis comparable to that of recognized MI. History of MI alone in this age group is also associated with an increased risk of MI, suggesting the need for better diagnostic markers of myocardial ischemia in the old.

Profile of an ideal antianginal agent.

Many antianginal agents are available for the treatment of coronary artery disease. These agents act by influencing the determinants of myocardial oxygen supply and demand. The 3 main classes of agents are the nitrates, beta-adrenergic blocking agents and the calcium entry blockers. Agents from all 3 classes have shown efficacy in treating both symptomatic and asymptomatic myocardial ischaemia. However, some patients cannot be treated with these agents because of side effects or contraindications. An ideal antianginal drug should effectively treat both angina and silent ischaemia. Additionally, it should be free of side effects, allow for maintenance of physical performance and be metabolically neutral. New agents are being developed which strive for this goal.

Determinants of physician reluctance to perform mouth-to-mouth resuscitation.

OBJECTIVES: Mouth-to-mouth resuscitation (MMR) is widely taught and promoted. The purpose of this study was to better characterize the observation that health professionals are reluctant to perform MMR and to identify determinants of this reluctance. METHODS: 324 residents and faculty at a New York City teaching hospital were anonymously surveyed regarding their reluctance to perform MMR. One year later, medical staff were resurveyed. RESULTS: Reluctance varied across scenarios: 70-80% of physicians were willing to perform MMR on a newborn or child, 40-50% for an unknown man, and 20-30% for a trauma victim or potentially gay man. Physicians reported very similar percentages for each scenario in the two surveys. Factors associated with MMR reluctance were female gender (OR = 2), resident physician (OR = 2), and higher perceived risk of contracting HIV from MMR (OR = 1.4 per unit on 5-point scale). In the year before the survey, 30% of all respondents witnessed an apneic patient who required MMR for whom ventilation was not provided for at least 2 minutes. CONCLUSIONS: Many physicians are reluctant to perform MMR. Marked delays in ventilation of apneic patients are occurring.

Sustained-release verapamil formulations for treating hypertension.

Verapamil, the first calcium-channel blocker to be introduced for clinical use, is a major drug used for the treatment of systemic hypertension. During the past 10 years, the use of verapamil for hypertension has produced a considerable clinical database to support the efficacy and safety of the agent in many patients. Because of its short half-life, verapamil was originally administered 3 to 4 times daily. During the past decade, a sustained-release formulation of verapamil has been marketed in the US. This product allows for once-daily dosing up to 240 mg/d; however, when higher doses are needed, this sustained-release formulation should be administered twice daily. In addition, the medicine should be taken with food to avoid the high peak blood levels of verapamil, which appears to be related to the delivery system. A new pellet-filled capsule formulation of verapamil (Verelan, Lederle, Wayne, NJ and Wyeth-Ayerst, Philadelphia, PA) is available and provides controlled absorption, 24-hour blood pressure control, improved peak-to-trough plasma levels, and once-daily dosing regardless of dosage size. Prolonged-release verapamil can be taken without food.

Betaxolol: a new long-acting beta 1-selective adrenergic blocker.

Betaxolol (Searle, Skokie, Illinois) is a new beta 1-selective adrenergic blocker with no partial agonist action and minimal membrane stabilizing activity. Its pharmacokinetic profile is characterized by a long serum half-life and excellent oral bioavailability, with little first-pass metabolism. The mean 16-hour half-life of betaxolol has been shown to provide full 24-hour control of blood pressure and heart rate. Betaxolol has been proven to be a safe and effective antihypertensive agent, and was recently approved for clinical use in the United States for this indication.

Atrial septal aneurysm: a new classification in two hundred five adults.

Atrial septal aneurysm is a localized "saccular" deformity, generally at the level of the fossa ovalis, which protrudes to the right or the left atrium or both. For 39 months we prospectively analyzed 205 consecutive patients in whom atrial septal aneurysm was diagnosed echocardiographically. The direction and movement of atrial septal aneurysms were carefully studied in multiple views, and, according to our findings, we now propose a new classification: type 1R if the bulging is in the right atrium only, type 2L if the bulging is in the left atrium only, type 3RL if the major excursion bulges to the right atrium and the lesser excursion bulges toward the left, type 4LR if the maximal excursion of the atrial septal aneurysm is toward the left atrium with a lesser excursion toward the right atrium, type 5 if the atrial septal aneurysm movement is bidirectional and equidistant to both atria during the cardiorespiratory cycle. We found an incidence of 1.9%, a mean age of 63 years (25 to 97 years), a female/male ratio of 2:1, valvular regurgitation 74%, hypertension 64%, left ventricular hypertrophy 38%, coronary heart disease 32%, patent foramen ovale 32%, pulmonary hypertension 31%, stroke 20%, dysrhythmias 16%, valvular prolapse 15%, and atrial septal defect 3%. No differences were found between mobile and motionless types of atrial septal aneurysm. However, differences were found between predominantly left bulging or right bulging atrial septal aneurysm (134 versus 57 patients), as well as other variables. All types of atrial septal aneurysm have particular clinical or echocardiographic characteristics. The new classification is a complete, simple, and practical form. Atrial septal aneurysm is associated with congenital and acquired heart diseases but also can present as an isolated abnormality.

Beta-adrenergic blockade and calcium channel blockade in myocardial infarction.

Because of their hemodynamic and antiarrhythmic actions, beta-adrenergic blockers and calcium-entry blockers have been suggested for use in patients with myocardial infarction (MI) for reducing infarct size, preventing ventricular ectopy, and for prolonging life in survivors of acute MI. Experimental studies have suggested their usefulness in these areas. Clinical studies have demonstrated a role for beta-blockers in the hyperacute phase of MI, and in longterm treatment of infarct survivors. Calcium channel blockers appear to have somewhat less utility in patients with Q wave MIs, but may have an important role in therapy of the non-Q wave infarct.

Determinants of reluctance to perform CPR among residents and applicants: the impact of experience on helping behavior.

BACKGROUND: Though mouth-to-mouth resuscitation (MMR) is widely endorsed as a useful lifesaving technique, studies have shown that health care professionals are reluctant to perform it. To characterize the circumstances which facilitate this reluctance among physicians, we have surveyed current and future residency trainees regarding attitudes toward providing ventilation by this method to strangers experiencing arrest in the community. METHODS: A total of 280 categorical emergency medicine (EM) and internal medicine (IM) house officers and respective program applicants at a 655 bed Brooklyn, New York teaching hospital were anonymously surveyed regarding their willingness to attempt resuscitation in five hypothetical scenarios of cardiopulmonary arrest. RESULTS: A direct relationship was observed between residency training level and reluctance to perform MMR in each scenario. Applicants expressed greater overall willingness to perform MMR than all residents (56 versus 34%, P < 0.00001). Willingness among experienced residents was lower than for junior-level residents (29 versus 40%, P = 0.01). EM and IM physicians were statistically indifferent in their responses. There were no differences in willingness to perform MMR by age in MD applicant or resident groups. CONCLUSIONS: Many physicians and future doctors are reluctant to perform MMR on arrest victims in the community, a trend that increases in prevalence among those with more residency training. These data support the hypothesis that diminished helping behavior occurs gradually over the training period and may occur as a direct consequence of the training experience. A model for characterizing the elements that make up a rescuer's decision process is proposed.

Medical therapy of the hypertensive patient with concomitant angina pectoris.

Systemic hypertension and symptomatic ischemic heart disease are two common disorders that coexist in the same patient. A medical approach to the patient with both systemic hypertension and angina pectoris is presented in this article, and different treatment modalities are considered.

Anticoagulation in patients with valvular heart disease, atrial fibrillation, or both.

Despite the availability of anticoagulant drugs for many years, there are still controversies regarding their use in many cardiovascular conditions. In this article, the pharmacology of warfarin and heparin are reviewed, and the clinical applications of these therapies in patients with valvular heart disease, atrial fibrillation, or both, discussed.

Restrictive-type hemodynamics following valve surgery for rheumatic heart disease.

Over a six-year period three patients with rheumatic valvular disease presented with congestive heart failure due to abnormalities in myocardial diastolic function. Each patient previously had been operated for mitral stenosis; one patient had additional aortic valve replacement for aortic insufficiency. The mean time for the development of symptoms following surgery was 4.7 years. In all patients, left ventricular systolic function was normal (radionuclide or angiographic ejection fraction greater than 0.50). Abnormalities in diastolic function involved the left ventricle in all patients. Biopsy material from right (one patient) and left (one patient) ventricles was nonspecific in its histologic appearance. Other disease processes, such as constrictive pericarditis and diabetic cardiomyopathy were considered to be clinically unimportant in these patients. Restrictive-type hemodynamics in patients with postoperative rheumatic heart disease may comprise a newly recognized entity.

Angina pectoris and silent ischemia in the elderly: a management update.

Coronary artery disease accompanied by symptomatic and asymptomatic myocardial ischemia is a common entity in older patients. The pathophysiology of myocardial ischemia is related to an imbalance in myocardial demand and coronary perfusion. Treatment strategies for symptomatic myocardial ischemia include correction of aggravating medical conditions (eg, anemia or hypertension) and the use of nitrates, beta-adrenergic blockers, salicylates, and calcium-entry blockers, alone or in combination. Silent myocardial ischemia is also a prevalent condition in older individuals, with and without angina pectoris. Treatment regimens are similar to those used in symptomatic patients.

Calcium channel blockers in patients with both hypertension and angina pectoris.

Systemic hypertension is a risk factor for cardiovascular disease development and an aggravating factor once symptomatic coronary artery disease occurs. Some drugs that reduce high blood pressure may increase cardiovascular disease risk by altering serum electrolyte levels and/or plasma lipids. beta-Adrenergic blockers are useful agents for treating patients with both hypertension and angina pectoris, but their use may be limited by adverse reactions and/or contraindications to this type of therapy. Calcium entry blockers are a useful alternative to beta-blockers. In a placebo run-in, randomized, double-blind, crossover trial, propranolol and verapamil were found to be equally effective in reducing angina attacks and nitroglycerin consumption, while improving exercise tolerance. In another study with a similar design, both nifedipine and diltiazem were shown to be effective antianginal and antihypertensive drugs, with no differences in efficacy between them. Both calcium entry blockers and beta-blockers are effective treatments for patients with both angina and hypertension. The choice of a specific treatment will depend on the clinical and hemodynamic requirements of the individual patient.

A bronchodilator action of glucagon.

We evaluated the effect of glucagon on eight patients with asthma. After withholding bronchodilators for 12 hours, patients received either 2 units of intravenous glucagon or 2 ml of saline after a double-blind crossover protocol. Glucagon significantly improved the FEV1 (17.5% +/- 5.5 SEM) and the peak expiratory flow rate (14.2% +/- 4.9), compared to placebo (-2.4% +/- 2.9, p less than 0.02; 4.5% +/- 4.1, p less than 0.25, respectively). Seven patients had an excellent response to glucagon (40% to 105% of the response to inhaled isoproterenol), but four patients had no significant response. We conclude that glucagon, through its pharmacologic actions, can have a bronchodilator effect in selected patients with asthma.

Acute hyperglycaemic effect of anaesthetic induction with thiopentone.

The acute effects of thiopentone on plasma glucose concentration and regulation in humans have not been well described. We therefore examined the effect of a single dose (6 mg/kg) of thiopentone on plasma glucose, insulin, glucagon, adrenaline and noradrenaline in 16 healthy women undergoing elective abdominal surgery. To assess involvement of the neuroendocrine system in the response to thiopentone, half of the patients received labetalol prior to induction of anaesthesia. Thiopentone injection resulted in a 50% increase in plasma glucose levels (P < 0.001) in both labetalol-treated and non-treated patients 90 s following its administration. This was associated neither with significant increases in plasma glucagon, adrenaline and noradrenaline nor with a decline in plasma insulin. We conclude that acute hyperglycaemia following thiopentone is most likely the consequence of a non-adrenergically-mediated increase in hepatic glucose release.