Acute epiglottitis in adults: diagnosis and treatment in 43 patients

Epiglottitis (supraglottitis) is an acute infection involving the supraglottic larynx that usually occurs in children, but can also affect adult patients. The purpose of this study was to retrospectively analyze diagnostic and treatment methods in adults with epiglottitis seen over a 10-year period at the Winnipeg Health Sciences Centre. Forty-three epiglottitis patients over the age of 16 were treated between 1982 and 1992. Treatment was individualized according to airway status at presentation, and not based on clinical staging protocols. A total of 29 patients were treated conservatively, whereas 14 patients were intubated immediately. One expectantly managed patient had to be intubated on the ward, and one patient died from septicemia. No presenting symptom or sign reliably predicted the need for intubation. Epiglottitis is seen in adults and can be easily and safely diagnosed by either indirect or flexible laryngoscopy. Endotracheal intubation is the safest and most direct means of securing the airway in severely affected patients. Staging systems are useful for retrospective data analysis, but should not be relied on to predict the course of patients with an inherently unpredictable disease.

The effect of body heating and cooling on the ankle and toe systolic pressures in arterial disease

Although changes in body temperature alter limb blood flow, little information exists on the effect of body heating and cooling on systolic pressures in limbs with arterial disease. Ten patients with stable claudication were studied. Mean ankle systolic pressure index during body cooling (0.79 +/- 0.04) exceeded (p less than 0.01) both the value during routine test (0.69 +/- 0.03) and during heating (0.65 +/- 0.04). The individual, paired difference in ankle systolic pressure index between cooling and heating exceeded 0.15 in seven limbs and between cooling and routine test in five. Mean toe systolic pressure index during heating, but not during cooling, was lower than during routine test (p less than 0.01). There was no significant difference in the mean toe systolic pressure index between heating and cooling. However, compared with heating, toe systolic pressure index increased with cooling in 12 limbs and decreased in eight, including three with loss of measurable pressure. The paired difference in toe systolic pressure index between cooling and heating exceeded 0.15 in 10 limbs and between cooling and routine test in eight; whereas between heating and routine test the paired difference was within 0.15 in all but three limbs. The results indicate that changes in body temperature have significant effects on distal pressures in arterial disease. Preliminary warming in routine tests should improve reproducibility.

Waiting times for nursing-home placement: the impact of patients' choices

OBJECTIVE

To identify patient characteristics and characteristics of long-term care facilities that significantly affect the waiting time for transfer from hospital to nursing home.

DESIGN

Cohort study.

PARTICIPANTS

All patients designated to be transferred from four Winnipeg hospitals between June 1, 1988, and May 31, 1989. The patients were followed up until placement, death or May 31, 1990.

MAIN OUTCOME MEASURE

Length of time waiting for nursing-home placement and relative rates of placement.

RESULTS

The variable found to shorten the waiting time the most was the patient's choice of a for-profit or nonprofit secular facility; other significant variables were male sex, age of 75 to 84 years and occupancy of an acute care bed during the wait.

CONCLUSION

The province has three policy options: it can increase the proportion of secular nursing-home beds when new facilities are built; it can require that hospital patients accept an interim nursing-home placement pending transfer to the nursing home of their choice; or it can tie the sponsorship of new facilities to a formula based on the ethnoreligious distribution of the population currently aged 55 to 64 years.

The natural history of electrocardiographic preexcitation in men. The Manitoba Follow-up Study

OBJECTIVE

To examine the natural history of preexcitation occurring on the routine electrocardiogram (ECG).

DESIGN

A longitudinal cohort study of 3983 originally healthy men followed prospectively for 40 years.

SETTING

Free-living (community-dwelling) study members residing predominantly in Canada.

PARTICIPANTS

Nineteen male study members with preexcitation occurring during routine examination in the 40-year follow-up of the Manitoba Follow-up Study.

MEASUREMENTS

Routinely requested clinical examinations and ECGs, supplemented by information supplied by the study member or his physician.

MAIN RESULTS

Ten study members were found to have preexcitation at enrollment, for a prevalence of 2.5 per 1000 (95% CI, 1.2 to 4.6). A delta wave was first detected during follow-up in an additional nine study members. Seventeen of 19 study members did not have the delta wave at some later time, and preexcitation was intermittently present in most of these members. Over time there was a loss of preexcitation, with 15 of 19 study members no longer exhibiting a delta wave by the end of follow-up. Five of 11 study members with symptoms had physician confirmation of an arrhythmia. Fourteen study members remain alive, and none of the five deaths was attributed to preexcitation.

CONCLUSIONS

Preexcitation found on routine ECG in our originally healthy male study group did not confer excess morbidity or mortality, even in those study members who developed symptomatic arrhythmias. Most preexcitation was intermittent and disappeared over time.

Regular narrow QRS complex tachycardias in the Manitoba Follow-up Study (1948-88)

OBJECTIVE

To determine the incidence, risk factors and prognosis of regular narrow QRS complex tachycardia (NQT), which develops in the absence of pre-excitation in subjects free from ischemic heart disease in the Manitoba Follow-up Study.

DESIGN AND SETTING

The Manitoba Follow-up Study is a longitudinal cardiovascular study of 3983 initially healthy men (primarily living in Canada) followed prospectively for 40 years. Risk factors and prognosis were assessed in a nested case-control study.

MAIN RESULTS

Twenty-two individuals were diagnosed with NQT before clinical and/or electrocardiographic manifestation of ischemic heart disease (145,408 person-years of observation). Between the ages of 30 and 80, the incidence of NQT was one per 6000 person-years and increased with age. History of childhood diseases, valvular disease, smoking, elevated blood pressure and body mass index did not increase the likelihood for NQT development. NQT was diagnosed concurrently with a serious noncardiac condition in seven cases; excess mortality resulted as six of these subjects died within one year of NQT diagnosis while only two subjects without concurrent disease at NQT diagnosis died during follow-up. In comparison with 2% of control subjects, 27% of subjects with NQT subsequently developed electrocardiographical evidence of atrial fibrillation (relative risk was 12 with lower 95% confidence limit of 1.8).

CONCLUSIONS

NQT in an otherwise healthy individual is a benign condition and increases the likelihood of atrial fibrillation development.

The association between exercise blood pressure and the prevalence of ECG abnormalities

The relationship between atrial and ventricular electrocardiographic abnormalities and exercise systolic blood pressure was studied in 246 male and 183 female subjects, of whom 199 males and 158 females were normotensive (resting blood pressure below 140/90 mmHg) and 47 males and 25 females were borderline hypertensive (resting systolic blood pressure 140 to 159 and/or diastolic blood pressure 90 to 99 mmHg). Subjects were classified into three groups according to systolic blood pressure during treadmill exercise (less than or equal to 180 mmHg, 180 to 199 mmHg and greater than or equal to 200 mmHg). With respect to atrial electrocardiographic abnormalities, the prevalence of abnormal values of the P-terminal force in lead V1 increased significantly with increased levels of resting exercise systolic blood pressure in males and females. The prevalence of electrocardiographic left ventricular hypertrophy, as reflected in abnormal values of one or more RS voltage indices, increased significantly with exercise systolic blood pressure in males but not in females. Males did not show a trend of increasing electrocardiographic left ventricular hypertrophy with increased resting systolic blood pressure means. In females, the significant difference between resting systolic blood pressure means and electrocardiographic left ventricular hypertrophy did not reflect a linear progression across resting systolic blood pressure categories. The significant association of the P-terminal force in lead V1 with exercise systolic blood pressure has not previously been reported. Although an association between left ventricular hypertrophy and exercise systolic blood pressure in hypertensives has been reported by others, the association seen in normotensive and borderline hypertensive males has not been reported previously.(ABSTRACT TRUNCATED AT 250 WORDS)

Is health care use changing? A comparison between physician, hospital, nursing-home, and home-care use of two elderly cohorts

This study used log-linear survival analysis, and log-rank tests to compare 1) the characteristics of two elderly cohorts; 2) their use of physician, hospital, nursing-home and home-care services over 8.5 years; and 3) physician and bed supplies during the two periods. Both cohorts were similar in health status and in their use of hospital, nursing-home, and home-care resources despite a steady decrease in hospital beds during both periods and a shrinking supply of nursing-home beds for the later cohort. Although physician supply increased more rapidly for the first (1971) than for the second (1976) cohort, the later cohort used significantly more ambulatory care than the earlier cohort. Home care appears to substitute for year-to-year variations in nursing-home admissions but not for variations in hospital lengths of stay.

Does anesthesia contribute to operative mortality?

An anesthesia follow-up program (100,000 anesthetics) and vital statistics data were used to assess the role of anesthesia in operative deaths. Four factor groups (patient, surgical, anesthesia, and "other") were assessed by logistic regression analysis to ascertain which variables were predictive of seven-day mortality. Advanced age, male gender, physical status, major surgery, emergency procedure, procedures performed in 1975 to 1979, intraoperative complications, narcotic techniques, and having one or two anesthetic drugs administered were associated with increased mortality, whereas duration of anesthesia, experience of the anesthesiologist, and inhalation techniques were not. Receiver-operator characteristic curves showed no increment in prediction of operative mortality greater than that for patient plus surgical factors when "other" or anesthetic factors were added. Patient and surgical risk factors were much more important in predicting seven-day mortality than the anesthesia factors we studied.

Haemophilus influenzae meningitis in Manitoba and the Keewatin District, NWT: potential for mass vaccination

A community-based surveillance study of all central nervous system infections was carried out in Manitoba and the Keewatin District, NWT, between Apr. 1, 1981, and Mar. 31, 1984. There were 201 cases of bacterial meningitis in Manitoba over the study period, 81 (40%) caused by Haemophilus influenzae; all but one isolate tested were type b (Hib). There were nine cases of H. influenzae meningitis in the Keewatin District. The overall annual incidence rate of H. influenzae meningitis in Manitoba was 2.5/100,000; for children under 5 years the rate was 32.1/100,000. For the Keewatin District the corresponding rates were 69.6/100,000 and 530/100,000. A total of 85% and 100% of the cases of H. influenzae meningitis occurred by 24 months of age in Manitoba and the Keewatin District respectively. The age at onset was earlier in native Indian children (22 cases) and Inuit children (9 cases) than in non-native children (59 cases) (p less than 0.005); thus, vaccine prevention of Hib meningitis will likely be more difficult in native Indian and Métis children. Without evaluating the increased potential of H. influenzae vaccines to prevent nonmeningitic forms of disease, we concluded that mass childhood vaccination with polyribosylribitolphosphate (PRP) vaccine is not warranted in Manitoba or the Keewatin District. Immunogenicity studies suggest that administration of conjugated Hib vaccines such as PRP-D in infancy may prevent approximately one-third to two-thirds of cases of H. influenzae meningitis; these vaccines warrant consideration for use in mass childhood vaccination programs.

Do nursing homes reduce hospital use?

This study applies data from the Manitoba Longitudinal Study on Aging for two purposes. First examined were the hospital-utilization patterns of elderly nursing home admissions during the 2 years before and 2 years after entrance into a facility. In addition, use of the hospital by these new admissions and by long-term nursing home residents was compared with that of the use by the elderly living in the community. When age, sex, and mortality rate are taken into account, the results indicate that, although both new admissions and long-term nursing home residents are sicker than their community counterparts, they are significantly less frequently hospitalized.

The natural history of primary first-degree atrioventricular heart block

The long-term prognosis of first-degree heart block in the absence of organic heart disease has not been clearly defined. We addressed this question in a 30-year longitudinal study of 3983 healthy men. We identified 52 cases that were present on entry into the study and 124 incident cases during follow-up. The incidence rose steadily after age 40 and was 1.13 per 1000 person-years over the entire period. Two thirds of the cases had only moderate prolongation of the PR interval (0.22 to 0.23 second). We compared four age-matched controls with each case for histories of scarlet fever, rheumatic fever, diphtheria, smoking, blood pressure, and body-mass index. No significant differences (P greater than 0.05) were found. Likewise, mortality from all causes did not differ between cases and controls. Although somewhat higher rates of morbidity and mortality from ischemic heart disease were observed in the cases than in the controls, the differences were not significant. Progression to higher grades of heart block occurred in only two cases. In view of the prognostic findings and the rare occurrence of advanced degrees of heart block, we conclude that primary first-degree heart block with moderate PR prolongation is a benign condition. This conclusion may not apply, however, to persons with more marked prolongation of the PR interval, a very rare condition.

Variations in physicians' hospitalization practices: a population-based study in Manitoba, Canada

This paper uses claims data from a universal health care system to describe physicians' hospitalization styles after adjusting for case-mix characteristics of their primary patients. Patients were uniquely assigned to that physician (general or family practitioners, internist, general surgeon, or obstetrician/gynecologist) seen most frequently over each two two-year periods (1972-74 and 1974-76). Four indices were developed including: 1) percentage of primary patients hospitalized; 2) mean number of readmissions for such patients; 3) mean length of stay; and 4) total days of hospitalization per primary care patient (a summary measure combining the first three). Rates of admission, not length of stay, were shown to be strongly related to this summary measure. Marked variations in the hospitalization indices were observed across physicians; these variations cannot be explained by the health or sociodemographic characteristics of a physician's patients. Rural physicians practicing in areas with high bed-to-population ratios and low occupancy rates were particularly high users of hospitals. The economic implications of different practice styles are shown to be large; physicians who were high users of hospitals serve 27 per cent of the patients but their patients consume 42 per cent of the hospital days.

The electrocardiogram in apparently healthy men and the risk of sudden death

The purpose of this study was to determine whether electrocardiographic abnormalities detected on a routine examination in men without clinical evidence of heart disease predicted sudden death in the absence of pre-existing clinical manifestations of heart disease. The Manitoba study consists of a cohort of 3983 men with a mean age at entry of 30.8 years who have been followed with regular examinations including electrocardiograms since 1948. During the 30 year observation period, 70 cases of sudden death have occurred in men without previous clinical manifestations of heart disease. The prevalence of electrocardiographic abnormalities before sudden death was 71.4% (50/70). The frequency of abnormalities was 31.4% (22) major ST segment and T wave abnormalities, 15.7/ (11) ventricular extrasystoles, 12.9% (nine) left ventricular hypertrophy (voltage criteria), 7.1% (five) complete left bundle-branch block, and 5.7% (four) pronounced left axis deviation. When these electrocardiographic findings in men without clinical manifestations of heart disease were related prospectively to incidence of sudden death each one except pronounced left axis deviation was a significant predictor of sudden death. Two of the variables were examined in more detail. Increased severity of primary T wave abnormalities and the association of ST segment and T wave abnormalities with increased QRS voltage further increased sudden death risk. The combination of ventricular extrasystoles with either ST-T abnormalities or left ventricular hypertrophy much increased the risk of sudden death. Thus these data indicate that electrocardiographic abnormalities detected on routine examination in men without clinical evidence of heart disease are significantly related to the occurrence of sudden death.

Relationship of blood pressure in 20-39-year-old men to subsequent blood pressure and incidence of hypertension over a 30-year observation period

The objective of this investigation was to determine the relationship of blood pressure (BP) in young men, ages 20-39 years, to their subsequent BP from the perspective of BP tracking, position in BP distribution and later evidence of hypertensive BP values. Since 1948, the Manitoba Study group has followed 3983 men, 90% of whom were 20-39 years old at entry. BP in persons not prescribed antihypertensive medications was examined at 5-year intervals during the 30-year observation period to 1978. To adjust for age, BP was examined within 5-year age groups at entry. The correlations between entry and subsequent BP at the same length of follow-up were greater for systolic than diastolic BP and increased with older ages. The correlation decreased wtih every 5-year examination after entry for all ages. Men whose BP was below the mean at entry were less likely to have a BP greater than 1 standard deviation (SD) above the mean at any of the examinations. Men with an entry BP greater than 1 SD above the mean were more likely to have BP greater than 1 SD above the mean later, but the relationship decreased considerably after 20 years, especially in 20-24-year age group. The results were similar for the probability of hypertension values (systolic BP greater than or equal to 140 or 150 mm Hg, diastolic BP greater than or equal to 90 or 95 mm Hg) at later examinations. Thus, BP in later life can be predicted from BP at ages 20-39 years and can identify groups at high or low risk for hypertension.

The natural history of right bundle branch block and frontal plane QRS axis in apparently healthy men

We examined the characteristics, long-term follow-up, and prognosis of right bundle branch block (RBBB) detected on a routine ECG in men with no apparent heart disease. During the 29-year period, 59 cases of RBBB were observed in men with a mean age of 44.4 +/- 1.9 years. Because marked right or left axis deviation may identify cases with concomitant involvement of the left bundle branch system, subsets of frontal plane QRS (A QRS) were examined. Comparisons were made with groups of similar ages who were free of RBBB. Cases with RBBB were observed for 936 person-years (mean 15.9 +/- 1.6 years per case), showing no excess ischemic heart disease incidence, no cases of progression to advanced AV block (second- or third-degree), or sudden death. Right bundle branch block was associated with a greater proportion of both right axis (greater than or equal to +90 degrees) and marked left axis (-45 degrees to -90 degrees) deviation compared with those of the same age without this conduction disturbance. In apparently healthy men, RBBB had no adverse long-term prognosis regardless of frontal plane QRS axis.

Relationship of ventricular ectopy in men without apparent heart disease to occurrence of ischemic heart disease and sudden death

The purpose of this investigation was to determine whether ventricular ectopic beats, or ventricular premature beats (VPBs), on routine electrocardiograms in men without apparent heart disease predict the later occurrence of clinical manifestations of ischemic heart disease (IHD). The Manitoba Study cohort consisted of 3983 men predominantly between 25 and 34 years of age and free of IHD at entry. During the 29-year observation period, 401 persons without clinical evidence of heart disease had VPBs on an electrocardiogram at a routine examination. They were followed 10.8 +/- 0.5 (SEM) years and 13.5% (54 men) later manifested IHD. Age-specific total IHD incidence was significantly (p less than 0.05) greater for men 40 to 59 years of age at VPB occurrence compared to men of the same age without VPBs. The clinical manifestation with the strongest association with VPBs was sudden death. VPB characteristics of frequency, configuration, coupling interval, and postextrasystolic T-wave change did not distinguish those who developed IHD. Prematurity index (R-R'/QT) showed a trend toward an association of late coupled ectopic beats (R-R'/QT greater than 1.6) and IHD risk. However, faster basic ventricular rate plus VPBs significantly correlated with greater IHD probability. Thus ventricular ectopic beats on a routine electrocardiogram in men over 40 years of age without apparent heart disease identify those at high risk for a clinical IHD event, especially sudden death.

The relationship of marked left axis deviation to the risk of ischemic heart disease

The purpose of this study was to examine the value of marked left axis deviation in men without apparent heart disease in the assessment of ischemic heart disease risk. In the Manitoba Study, a cohort of 3983 men who were predominantly between 25 to 34 yr of age at entry in 1948, 247 cases of marked left axis deviation (mean frontal plane QRS vector of -45 degrees to -90 degrees) were identified at a mean age of 46.1 +/- 0.7 (+/- 1 SEM) yr with a mean follow-up of 12.1 +/- 0.6 yr. The results were that the development of left axis deviation in men 40 to 59 yr of age, independent of blood pressure is a significant predictor of ischemic heart disease events that are usually manifest 5 to 10 yr after the onset of this electrocardiographic abnormality. Subsets of QRS variables examined to identify cases with different degrees of ischemic heart disease risk revealed that neither Q waves in leads I or aVL, or QRS duration or actual frontal plane QRS vector identified groups with different ischemic heart disease risk. However, subsets of age (less than 40 and 60 yr or greater) perhaps reflecting different etiologies of marked left axis deviation and previous electrocardiographic findings (S1S2S3 pattern) identify a low risk group.

Chronobiology of cardiac sudden death in men

Daily variation in occurrence of sudden cardiac death was examined in 3,983 men observed since 1948. For men without previous clinical evidence of ischemic heart disease, an excess proportion of sudden cardiac deaths occurred on Mondays. For men with previous clinical evidence of ischemic heart disease, sudden cardiac death occurred more uniformly throughout the week. By comparison there was no significant daily variation in cancer mortality or in day of occurrence of myocardial infarction. Thus, for men without clinically manifest heart disease, the warning "beware on Monday" should stimulate further investigation.

Natural history of left bundle-branch block

The purpose of this study was to examine factors associated with the development of complete left bundle-branch block and the prognosis in a group of people not in hospital, who had no clinical evidence of ischaemic or valvular heart disease. Twenty-nine cases of left bundle-branch block without clinical evidence of ischaemic heart disease were noted in the Manitoba cohort of 3983 men under observation since 1948. The most frequent electrocardiographic finding before development of left bundle-branch block was a normal electrocardiogram; left ventricular hypertrophy though infrequent, was the only abnormality significantly more common than in the rest of the group. The development of left bundle-branch block was associated with distinct leftward shift of the frontal plane mean QRS axis. The most frequent clinical cardiovascular event observed after development of the block was sudden death without previous clinical evidence of ischaemic heart disease. The five-year incidence of sudden death as the first manifestation of heart disease was 10 times greater in men with left bundle-branch block than in those without it.