Predictors and Outcomes for COVID-19 Re-Admissions in the Anticipate Cohort.

Aims To describe readmissions of hospitalised patients with COVID-19, define predictors of readmission and explore the long term outcomes using the SF-12 score compared to patients who were not readmitted and those not hospitalised. Methods A single centre retrospective in North Inner-City Dublin. Recruitment was done through a COVID follow up clinic. Predictors of readmission and SF-12 scores at two timepoints post follow up at median 3 months and 12 months. Results Seventy (45%) participants were admitted, with a median age of 49.5 years (IQR 41.3-56.9), 36(51%) of whom were female. Unscheduled readmissions at ≤30 days in COVID-19 patients were 9(12.9%) and length of stay was four days (IQR 2-5). Readmissions were due to ongoing symptoms(n=9(64.3%)) or new complications(n=5(35.7%)). Mechanical ventilation and having symptoms of nausea and vomiting on index admission were predictive of readmission. (p=0.002). SF-12 scores at one year of readmitted patients were not different to patients who were never admitted at median one year follow up, p=.089. Conclusions Most readmissions were of short duration. Early follow up of patients post MV or who had nausea and vomiting on index admission should be prioritised. Wellbeing of readmitted patients was not different to those never hospitalised, at one year.

The Value of the Combined Assessment of COPD in Accurate Characterization of Stable COPD.

There is evidence showing a tendency to upgrade COPD severity previously staged with spirometric-based GOLD (GOLD 1234) when using the new GOLD combined disease assessment (GOLD ABCD). The aim of our study was to compare the GOLD 1234 classification in a population of stable COPD patients with the GOLD ABCD classification to determine whether stable COPD was upgraded when using this new classification. After an observational study of a stable COPD cohort (n = 112), 61 patients (54.5%) had an increase in their COPD severity when moving from the old GOLD 1234 classification to the current GOLD ABCD assessment (p < 0.01). 42 patients (37.5%) had no change in severity of COPD. 9 patients COPD were assessed to be better on using GOLD ABCD. This study highlights previously missed high-risk patients when reviewing stable COPD. Continued incorporation of GOLD ABCD will translate into better evidence-based management.

Using Social Media to Increase Accessibility to Online Teaching Resources.

The key learning points of Surgical Grand Rounds (SGR) are often not accessible at times of exam revision for students. We sought to use Twitter as an online teaching repository. A SGR Twitter profile was created. 23 SGR presentations were made accessible on Twitter over a 3 month period. 93 students were invited to complete a questionnaire assessing usage of the repository. 84 (90%) in total responded, of these, 25 (80.6%) felt that the online provision of SGR through twitter was "useful". The majority (71%) felt that the online content was easily accessible. The novel use of social media is a useful adjunctive educational tool in accessing an online repository of SGR presentations.

An intrathecal catheter in a pregnant patient with idiopathic intracranial hypertension: analgesia, monitor and therapy?

Idiopathic intracranial hypertension is important for the obstetric anaesthetist as it is mostly seen in obese women of childbearing age. The incidence is likely to increase as the obesity pandemic grows. Management of labour analgesia in these patients can be complex and requires multidisciplinary input. We successfully managed labour analgesia in a parturient with idiopathic intracranial hypertension with an intrathecal catheter. The possibility of using this catheter as a cerebrospinal fluid drain and pressure monitor was considered and is discussed along with potential complications.

A controlled clinical trial of vitamin E supplementation in patients with congestive heart failure.

BACKGROUND: Oxidative stress is increased in patients with congestive heart failure and can contribute to the progressive deterioration observed in these patients. Increased oxidative stress is the result of either an increased production of free radicals or a depletion of endogenous antioxidants, such as vitamin E. OBJECTIVE: We aimed to determine whether vitamin E supplementation of patients with advanced heart failure would modify levels of oxidative stress, thereby preventing or delaying the deterioration associated with free radical injury. DESIGN: Fifty-six outpatients with advanced heart failure (New York Heart Association functional class III or IV) were enrolled in a double-blind randomized controlled trial for 12 wk. At a baseline visit and at 2 follow-up visits, blood and breath samples were collected for the measurement of indexes of heart function and disease state, including malondialdehyde, isoprostanes, and breath pentane and ethane. Quality of life was also assessed at baseline and after 12 wk of treatment. RESULTS: Vitamin E treatment significantly increased plasma concentrations of alpha-tocopherol in the treatment group but failed to significantly affect any other marker of oxidative stress or quality of life. In addition, concentrations of atrial natriuretic peptide (a humoral marker of ventricular dysfunction), neurohormonal-cytokine markers of prognosis, tumor necrosis factor, epinephrine, and norepinephrine were unchanged with treatment and were not significantly different from those in the control group. CONCLUSION: Supplementation with vitamin E did not result in any significant improvements in prognostic or functional indexes of heart failure or in the quality of life of patients with advanced heart failure.

Acute chorea due to ondansetron in an obstetric patient.

This case describes a 34-year-old female who developed severe chorea following intravenous administration of ondansetron after elective caesarean section under spinal anaesthesia. A course of benztropine led to a decrease in severity of the reaction which resolved on the fifth postoperative day. Ondansetron is believed to cause extrapyramidal reactions through actions on 5HT 3 receptors in the basal ganglia. Whereas isolated case reports of extrapyramidal reactions to ondansetron do exist, they have typically been associated with higher doses and have resolved within hours. We report the lengthiest extrapyramidal reaction to ondansetron yet described.

The influence of marital adjustment on 3-year left ventricular mass and ambulatory blood pressure in mild hypertension.

BACKGROUND: Of psychosocial stressors, job strain has been associated with a sustained increase in blood pressure. The impact of marital factors on blood pressure and target organ has not been explored. OBJECTIVES: To evaluate whether marital adjustment, measured at baseline by self-report (Dyadic Adjustment Scale) influences left ventricular mass index (LVMI) and ambulatory blood pressure measured over 3 years in patients with mild hypertension. METHODS: A prospective cohort study was conducted on 103 cohabiting males or females, including 72 with technically adequate echocardiograms, who at baseline were unmedicated, employed, and living with a significant other, all for a minimum of 6 months and had repeated elevated office diastolic blood pressure. MAIN OUTCOME MEASURES: Left ventricular mass by M-mode echocardiography indexed to body surface area and blood pressure were measured by ambulatory blood pressure every 15 minutes (daytime) and hourly between 11 PM and 7 AM. RESULTS: Marital adjustment, smoking, drinking, and baseline LVMI contributed significantly to the prediction of 3-year LVMI (semipartial correlation, sr(2) = 0.04, 0.07, 0.03, and 0.22; P =.03,.008,.08, and <.001, respectively) together accounting for 36% of the total variability in follow-up LVMI. Three-year ambulatory blood pressure measures were not significantly related to marital adjustment but there were correlations with Dyadic Adjustment Scale subscales. Low or high levels of spousal contact during 3-year ambulatory blood pressure monitoring were associated with an increase or decrease of 3-year, 24-hour diastolic blood pressure, consistent with the quality of marital adjustment (P =.04) or marital satisfaction (Dyadic Adjustment Scale subscale, P =.008). CONCLUSIONS: In a cohort of subjects with mild essential hypertension, marital adjustment had an influence on 3-year LVMI. Depending on the quality of marital adjustment, spousal contact at 3 years was associated with an increase or decrease of 3-year diastolic blood pressure. Confirmation of these results, including objective marital assessment and the participation of normotensive subjects, is required. Arch Intern Med. 2000;160:3453-3458.

Anger expression, gender, and ambulatory blood pressure in mild, unmedicated adults with hypertension.

The suppression of anger has been associated with the development of hypertension. This study evaluated the association between anger management style (anger-in and anger-out) and ambulatory blood pressure (ABP) in patients with repeated clinic diastolic blood pressures (DBPs) between 90-105 mmHg, unmedicated and with no known coronary artery disease. A total of 128 men (46.0 years) and 66 women (46.6 years) participated. Fourteen percent of men and 35% of women were classified as having "white coat" hypertension (daytime DBP < 85 mmHg). Mean awake and sleep DBP and systolic blood pressure (SBP) were evaluated in a repeated measures analysis of variance (ANOVA). Anger-in and anger-out scores were categorized into low, medium, and high t-scores (< 50, 50-59, > or = 60). Results indicated that in women, increasing anger-in is associated with greater SBPs while awake and sleeping, whereas no effect was found for DBP, nor any effect in men. No significant association was found between gender, anger-out, and ABP. The clinical diagnostic status of white coat hypertension was not differentially associated with anger-in or anger-out in men and women. In conclusion, in a sample of mild unmedicated adults with hypertension, suppression of anger is associated with greater ambulatory SBP in women, but not in men.

Marital cohesion and ambulatory blood pressure in early hypertension.

One hundred thirty-four men and seventy-one women, unmedicated mild hypertensives, underwent 24-h ambulatory blood pressure (BP) monitoring (ABP) and completed standardized questionnaires measuring marital and job stress. Of these, 44.8% had daytime diastolic BP < 90 mm Hg; 96.1% had left ventricular mass index in the normal range (N = 176). Lower marital cohesion (Cohesion, subscale of the Dyadic Adjustment Scale) was related to elevated nighttime ABP (P < or = .05) and 24-h diastolic BP (P < .05). With low Cohesion (N = 83), more reported spousal contact was associated with elevated nighttime ABP (P < .031). The 7.3% of subjects with very low Cohesion demonstrated approximately 6 mm Hg elevation of all ABP variables, controlling for other significant variables (P < .05, except for nighttime SBP). This study shows an association between marital cohesion and ABP and suggests that marital factors may have a role in sustaining BP in early hypertension.

Determinants of left ventricular mass in early hypertension.

One hundred seventy-six unmedicated mildly hypertensive subjects (113 men, 63 women) underwent M-mode echocardiography to determine left ventricular mass (LVM) and relative wall thickness (RWT), 24-h ambulatory blood pressure monitoring, and completed standardized questionnaires measuring marital and job stress. Subjects were aged 46 +/- 9 years old; 45.4% had daytime diastolic blood pressure < 90 mm Hg; 96.1% of LVM results were in the normal range. We found that neither marital distress nor job strain was a determinant of LVM. However, a segmental regression approach revealed inflection points of 131 mm Hg systolic daytime blood pressure and 83 and 87 mm Hg nighttime diastolic blood pressure in the relation between LVM and RWT, respectively, and ambulatory BP. In addition, we found that the variability of LVM was best explained by indexing LVM by height, rather than body surface area.

Maternal and fetal effects of adrenaline with bupivacaine (0.25%) for epidural analgesia during labour.

The use of adrenaline added to bupivacaine during epidural analgesia for labour is controversial. The effects of epidural analgesia with bupivacaine containing adrenaline on maternal blood pressure and heart rate, uterine activity, progress of labour, fetal heart rate and Apgar scores, were assessed using visual analogue pain scores, upper level of sensory block and motor blockade in 60 parturients who were allocated randomly to receive: 10 mL of bupivacaine 0.25% plain (group I) or with adrenaline 5 micrograms mL-1 (group II) or with adrenaline 1.66 micrograms mL-1 (group III). The first stage of labour was significantly longer in group II than in group I [414 +/- 49 vs. 296 +/- 24 min (+/- SD)]. There were no other significant differences. It is concluded that adrenaline at 5 micrograms mL-1 significantly prolongs the first stage of labour. Neither adrenaline 5 micrograms mL-1 nor 1.66 micrograms mL-1 has any beneficial effect.

Canadian consensus recommendations for the measurement and reporting of diastolic dysfunction by echocardiography: from the Investigators of Consensus on Diastolic Dysfunction by Echocardiography.

Abnormalities of diastolic filling are increasingly recognized as a cause of symptoms and predictors of outcome in patients with most forms of heart disease. Noninvasive assessment of diastolic filling is possible in almost all patients, but accurate evaluation must relate echocardiographic Doppler measurements to the complex physiologic and hemodynamic factors responsible for normal and abnormal filling. This evaluation has been facilitated by recent correlation of Doppler measurement of mitral and pulmonary venous inflow with hemodynamic studies. These studies have confirmed that when a careful, integrated approach is taken, Doppler flow patterns can document a progressive pattern of abnormality in many conditions. Impaired left ventricular (LV) relaxation is seen early and is recognized by a decrease in early transmitral LV filling and an increased proportion of filling during atrial contraction. As abnormalities progress, increasing LV chamber stiffness and elevated left atrial pressure lead to a "pseudonormal" filling pattern that previously has caused considerable confusion. This can be unmasked by careful evaluation of pulmonary venous inflow and the use of the Valsalva maneuver. When marked diastolic abnormalities are present, LV filling has restrictive features characterized by rapid early filling, a very stiff left ventricle with high filling pressures, and a poor prognosis. Routine measurement of indexes of diastolic filling have been hampered by uncertainty as to what should be measured, what techniques should be used, definition of normal values, and a clear method of reporting findings. This report represents the efforts of a Canadian consensus group to define a national standard for the performance and reporting of echocardiographic Doppler studies of diastolic filling.

Segmental analysis of resting echocardiographic function and stress scintigraphic perfusion: implications for myocardial viability.

In 73 patients with coronary artery disease, we performed segmental analysis of resting two-dimensional echocardiography and stress thallium-201 single photon emission computed tomographic scintigraphy with 24-hour delayed imaging to test the hypotheses that (1) combined analysis of stress thallium-201 scintigraphy (with 24-hour redistribution) and echocardiography provides an evaluation of the viability of most myocardial segments; and (2) the severity of the scintigraphic perfusion abnormality in a given segment is equivalent to the severity of its echocardiographically determined functional impairment. Scintigraphy showed 14% of the 1168 segments analyzed to have fixed severe defects. Echocardiography showed 11% of the 1070 segments analyzed to be akinetic or dyskinetic. However, with combined analysis, only 62 (5%) segments showed no evidence of viability by either imaging technique. We conclude that in this group of patients, 95% of segments have evidence of viability by one of these two conventional imaging techniques.

Compensation equity between men and women in academic medicine: methods and implications.

BACKGROUND: Compensation inequity by gender is a problem across occupations in the United States. Most compensation-monitoring efforts in academic medicine have been informal. The authors developed an analytic method for formal, ongoing evaluation of compensation equity in academic medicine. METHOD: A historical cohort study was conducted at Michigan State University College of Medicine using data from 1990, 1991, and 1992 to (1) evaluate methods for monitoring compensation equity, (2) test the feasibility of compensation-equity monitoring as part of administrative information systems, and (3) determine whether compensation inequity existed in a case study of faculty salaries. Internal market adjustments for specialty, clinical or basic science "type," and calendar- or academic-year appointments were made before establishing a male cohort for each female faculty member. RESULTS: The method developed appears feasible for routine administrative monitoring of compensation equity. When the compensations of women of each type and rank were compared with the compensations of their male cohorts, inequities appeared to exist for basic scientists, but not clinicians, based on a criterion of the groups' compensations being 4% or more below those of their cohorts for two successive years. CONCLUSION: The authors suggest that formal monitoring of compensation equity is an important and feasible administrative undertaking to correct historical inequities. This is an area in which leadership by U.S. medical colleges is needed.

Pharmacokinetics of rocuronium bromide in paediatric patients.

Rocuronium 0.8 mg kg-1 was given to 22 children between the ages of 3 months and 8 years during anaesthesia with N2O/O2, 60:40, and halothane. Blood samples were collected for 360 min for determination of rocuronium concentrations. The pharmacokinetics were best described by a two-compartment model. Two models were fitted, one proportional to weight and the other adjusted for age. Using the first model, volumes and clearances were all proportional to weight: in the second model, only the volume of the second compartment and clearance from the central compartment were proportional to age. The results do not support the use of body surface area, rather than weight for the calculation of paediatric doses of rocuronium. In this study, the volume of the central compartment was larger than the figure obtained in an adult population.

Scintigraphic and electrocardiographic evidence of silent coronary artery disease in asymptomatic hypertension: a case-control study.

OBJECTIVES: This study was conducted to determine the incidence of physiologically significant coronary artery disease in a group of asymptomatic high risk men with essential hypertension and to assess the validity of noninvasive tests in a subset of these patients undergoing coronary arteriography. METHODS: Two hundred twenty-six asymptomatic men (mean age 61 +/- 8 years) with essential hypertension and no clinical evidence of coronary artery disease but with at least one additional coronary risk factor were studied prospectively. Fifty age- and risk factor-matched normotensive subjects were evaluated as a control group. After a minimum of 4 days without medication, subjects underwent stress thallium-201 scintigraphy, exercise and 48-h ambulatory electrocardiography, and echocardiography. Coronary angiography was performed in a subset of 34 (40%) of 84 patients with one or more positive test results. RESULTS: A positive thallium-201 scintigram (18% vs. 6%; odds ratio 3.4, confidence interval 0.95 to 10.8, p = 0.056), exercise electrocardiograms (ECGs) (37% vs. 13%; odds ratio 4.1, confidence interval 1.5 to 11.2, p < 0.003) and ambulatory ECG (15% vs. 0%, p < 0.05) were more common in the hypertensive group than in the control group. In the cohort undergoing coronary angiography, thallium-201 scintigraphy was both sensitive and specific for epicardial atherosclerotic coronary disease (90% and 79%, respectively), but positive exercise and ambulatory ECGs occurred frequently in the absence of significant coronary stenoses. In the 39% of hypertensive patients who had mild to moderate left ventricular hypertrophy, positive exercise and ambulatory ECGs occurred at a higher rate. CONCLUSIONS: These findings suggest that physiologically significant coronary artery disease occurs more frequently in asymptomatic hypertensive men than in comparable normotensive control subjects. In the subgroup undergoing coronary arteriography, reversible scintigraphic defects were both sensitive and specific for diagnosing epicardial coronary artery disease, but exercise and ambulatory ECGs appeared to yield frequent false positive results, especially when left ventricular hypertrophy was present. These results indicate that patients with "silent" coronary artery disease can be identified among high risk hypertensive patients, but the appropriate application of such screening in clinical practice remains to be determined.

Effects of steal-prone anatomy on intraoperative myocardial ischemia. The SPI Research Group.

OBJECTIVES: Our study objective was to determine whether the presence of steal-prone anatomy conferred an increased risk in the development of intraoperative myocardial ischemia. BACKGROUND: Coronary artery steal of collateral blood flow has been demonstrated for many vasodilators, including isoflurane, the most commonly used inhalational anesthetic agent in the United States. It has been postulated that patients with steal-prone anatomy (total occlusion of one coronary artery that is supplied distally by collateral flow from another coronary artery with a > or = 50% stenosis) may be particularly at risk for the development of intraoperative myocardial ischemia when an anesthetic with a vasodilator property is being administered. METHODS: We evaluated the risk of myocardial ischemia under isoflurane anesthesia (vs. a high dose narcotic technique using sufentanil) using continuous intraoperative electrocardiography and transesophageal echocardiography in patients with and without steal-prone anatomy undergoing coronary artery bypass graft surgery. RESULTS: Sixty-two (33%) of the 186 patients had steal-prone anatomy: in 5 (8%) the collateral-supplying vessel was > or = 50% to 69% stenosed, in 24 (39%) it was > or = 70% to 89% stenosed and in 33 (53%) it was > or = 90% stenosed. The incidence of ischemia (transesophageal echocardiography or intraoperative electrocardiography, or both) was similar in patients with and without steal-prone coronary anatomy (18 [29%] of 62 patients vs. 39 [31%] of 124 patients, p = 0.87, 95% confidence interval = -0.13 to 0.17). The incidence of intraoperative ischemia was similar in patients who received isoflurane or sufentanil anesthesia (20 [32%] of 62 patients vs. 37 [30%] of 124 patients, p = 0.87). The incidence of tachycardia and hypotension was low (increases in heart rate = 9.8%, and decreases in systolic blood pressure = 10.8% of total monitoring time during the prebypass period compared with preoperative baseline values). The incidence of adverse cardiac outcome was similar in patients with and without preoperative steal-prone coronary anatomy (4 [7%] of 62 patients vs. 14 [11%] of 124 patients, p = 0.53). CONCLUSIONS: These findings demonstrate that under strict hemodynamic control the presence of steal-prone anatomy does not confer an increased risk in the development of intraoperative myocardial ischemia.

Diagnostic accuracy of exercise thallium-201 scintigraphy in men with asymptomatic essential hypertension.

Coronary artery disease is responsible for much of the morbidity and mortality in patients with essential hypertension, and these complications have proven to be relatively resistant to antihypertensive therapy. However, the diagnosis of coronary disease in the hypertensive population has been considered problematic. In the present study, 30 asymptomatic patients with mild to moderate hypertension with positive exercise electrocardiograms (ECG) or stress thallium-201 scintigrams underwent coronary angiography to determine the accuracy of these tests for coronary artery disease. The exercise ECG was positive in 25 subjects, of whom 15 had significant coronary lesions and 10 did not. Thallium-201 scintigraphy proved more accurate: 17 of 18 patients with reversible abnormalities had significant obstructive coronary disease anatomically corresponding to the defect, one patient with a fixed defect had normal coronary arteries and was found to have an idiopathic cardiomyopathy, and 9 of 11 without defects had no significant lesions. The results were similar in populations with and without echocardiographic criteria for left ventricular hypertrophy. These findings indicate that despite previous suggestions to the contrary, thallium-201 scintigraphy can accurately diagnose coronary artery disease in most patients with asymptomatic essential hypertension, and that most asymptomatic hypertensive patients with physiologic evidence of myocardial ischemia have associated coronary artery disease.