Innovative strategies to improve diabetes outcomes in disadvantaged populations.

Diabetes disproportionately affects disadvantaged populations. Eighty percent of deaths directly caused by diabetes occurred in low- and middle-income countries. In high-income countries, there are marked disparities in diabetes control among racial/ethnic minorities and those with low socio-economic status. Innovative, effective and cost-effective strategies are needed to improve diabetes outcomes in these populations. Technological advances, peer educators and community health workers have expanded methodologies to reach, educate and monitor individuals with diabetes. In the present manuscript we review the outcomes of these strategies, and describe the barriers to and facilitators of these approaches for improving diabetes outcomes.

Childless and single-childed women in early twentieth-century America.

Over the course of this century, there have been marked fluctuations in the extent of childlessness and single child fertility. In this article, data from the 1960 U.S. Census are used to examine cohort trends in childlessness and single child motherhood among women born in the years 1891-1925. A marked rise in low parity fertility is found among women who reached prime reproductive ages during the 1930s; cohorts born prior to or after these women had much lower levels of childlessness and single child fertility. This rise and fall in low parity fertility is examined in the light of theories that see its cause as due to changes in 1) demographic composition across cohorts, 2) health levels that affect fecundity and hence fertility, 3) normative prescriptions to bear children and countervailing norms, and 4) economic conditions that affect the degree to which women limit reproduction. A log linear analysis of changes in the composition of cohorts in race, age at marriage, marital history, and education shows that sociodemographic changes do not explain the upturn in low parity fertility. Through an analysis of health statistics and the medical literature, the theory that changing health levels are responsible for the rise and fall in low parity fertility is rejected. The normative and economic theories are found to be most useful in explaining trends in low parity fertility. It is argued that over the course of this century, an interaction between economic conditions and reproductive ideology has both necessitated women limiting their childbearing in times of economic depression and provided justification for this.

Report of the Anaesthetic Mortality Committee of Western Australia 1990-1995.

The structure and function of the Anaesthesia Mortality Committee of Western Australia are described. Reports of 500 deaths from 1990 to 1995 are analysed and discussed. The Committee determined that, in 21 cases, anaesthesia played a significant part in the death of the patient. These cases are further analysed. Deaths due mainly to anaesthetic factors are estimated to occur once in every 40,000 operations in Western Australia. One or two otherwise healthy people die each year in Western Australia from an anaesthetic mishap.

Radial artery cannulation.

The status of radial artery cannulation is reviewed. The technique of percutaneous puncture, equipment in use, and known complications are discussed. Recommendations are made for precautionary measures to reduce the complication rate. It is concluded that radial artery cannulation is a safe and useful procedure in certain anaesthetic and intensive care situations.

The continuation of education after marriage among women in the United States: 1970.

Data from the 1970 National Fertility Study are used to assess the extent and determinants of post-nuptial education among women in the United States. Over one-fifth of all women have attended high school or college since marriage; over one-third either have returned to school or anticipate returning to an academic institution sometime in the future. This phenomenon is apparently increasing since women married less than five years have already attended school in as great a proportion as women married 15-19 years. Examination of differentials reveals for both blacks and whites that post-nupital education is higher among women who: (1) attended college before marriage, (2) married early, (3) are currently separated or divorced, (4) support egalitarian sex-role attitudes, or (5) whose most recent occupation is in the professional, managerial, or administrative category. Post-nuptial trends in education undoubtedly reflect the much broader social phenomenon of changing sex-role perceptions.

The rapid transit system for patients with fractures of proximal femur.

The rapid transit system for patients with fractures of the proximal femur consists of immediate internal fixation or replacement of the fractured bone under spinal anaesthesia, without any sedation. Patients are mobilised within hours of surgery and sent home as soon as they can walk. They are supervised at home by both an experienced physiotherapist and a visiting nurse. Sixty nine patients admitted to a metropolitan teaching hospital were considered for the system and 50 were accepted. Their age distribution and level of general ill health were comparable with those in other series. The rapid transit system resulted in 90% of patients accepted being discharged to their homes within the first five days, with a lower morbidity and a mortality at three months of 7%. Using the rapid transit system rehabilitation in the original environment is difficult only if the patient lives alone, and even then temporary support is often enough to allow them to return home.

Comparison of the Finapres blood pressure monitor with intra-arterial manometry during induction of anaesthesia.

The Finapres (Ohmeda, Madison, U.S.A.) is a non-invasive device which continuously measures the arterial blood pressure in a finger and produces a real-time display of the arterial pressure wave. It consists of a finger cuff with an infra-red transmission plethysmograph, a servo control box and a monitor unit. The device was compared with intra-arterial pressure monitoring in twenty patients during induction of anaesthesia for elective neurosurgical procedures. The differences between the two methods were considerable, ranging from -40 mmHg to +26 mmHg for mean pressure. While the Finapres has potential as a non-invasive continuous blood pressure monitor, the current model Finapres, as supplied, displays too great a variability for it to be used as an alternative to intra-arterial pressure monitoring.

Continuous flush system for radial artery cannulation.

A prospective study of 50 radial artery cannulations was carried out using the Intraflo continuous flushing device. Functional patency was maintained in all cannulations. No serious complications were seen. It is concluded that this method of continuous flushing is preferable to intermittent manual flushing.

Arterial oxygen saturation in anaesthetised patients during transfer from induction room to operating room.

There is no published study that examines oxygenation of anaesthetised patients during transport from anaesthesia induction room to operating room. Arterial oxygen saturation (SaO2) was measured in twenty-five anaesthetised patients before and during transfer to an adjacent operating room and continuously recorded on a calibrated chart recorder. A telemetry ECG recorder was used to detect cardiac dysrhythmias. All anaesthetists followed their usual anaesthetic practice. Patients ventilated via face-mask and via endotracheal tube were studied. During transfer patients were either apnoeic (n = 8) or breathing room air spontaneously (n = 17). Mean SaO2 before induction was 95.4 (SD 2.5)%, was higher after induction of anaesthesia, 98.5 (SD 1.4)% and fell after transfer, 95.7 (SD 2.6)%. A fall in SaO2 was recorded for 21 patients. No SaO2 value below 90% was seen. The decrease in SaO2 was related to the time taken to transfer the patients and spontaneous ventilation (Multiple regression analysis); it was not related to the body mass index although two of the greatest decreases were seen in obese patients. Transfer time averaged 51 seconds (range: 24-97 s). No changes in cardiac rhythm were seen. Transfer of anaesthetised patients was accompanied by variable falls in SaO2 which related to duration of transfer and spontaneous breathing of room air and which were not associated with new dysrhythmias.

Case report: pheochromocytoma. Aspects of management.

The management of a patient with Pheochromocytoma is reported. Consideration of pre-operative preparation, hazards of beta-blocking agents in the absence of alpha blockade, potential hazards of butyrophenones, control of arterial blood pressure with sodium nitroprusside and the usefulness of continous pulmonary artery wedge pressure monitoring are discussed.

Fulminant hepatic failure and fatal encephalopathy associated with Epstein-Barr virus infection.

A case of fulminant hepatic failure, associated with infectious mononucleosis, in a previously healthy 14-year-old girl is reported. Despite intensive therapy, which included the use of acyclovir, charcoal haemoperfusion, and measures to control her raised intracranial pressure (guided by serial EEG and auditory brainstem-evoked response recordings), the outcome was fatal.