The independent effects of left ventricular ejection fraction on short-term outcomes and resource utilization following hospitalization for heart failure

BACKGROUND

While depressed left ventricular ejection fraction is clearly associated with poor long-term outcome in heart failure (HF), the effect of ejection fraction on short-term outcomes and resource utilization following hospitalization for HF remains unclear.

HYPOTHESIS

We evaluated the independent effect of depressed ejection fraction (< or = 40%) on short-term outcomes and resource utilization following hospitalization for HF.

METHODS

The study population included 443 consecutive patients hospitalized for DRG 127 (HF and shock) with known ejection fraction. For each patient, we assessed the hospitalization cost (1995 US$), length of stay, in-hospital mortality, 30-day mortality, and 30-day readmission rates.

RESULTS

Despite similar disease severity at admission, patients with ejection fraction < or = 40% (Group 1) had longer length of stay (4.0 vs. 3.7 days; p = 0.03), a tendency toward higher hospitalization cost ($3,054 vs. $2,770; p = 0.08), more readmissions for any cause (0.4 vs. 0.3; p = 0.05) and for HF (0.2 vs. 0.1; p = 0.01), but similar in-hospital (2.5 vs. 2.6%) and 30-day mortality (4.0 vs. 4.6%) compared with patients with ejection fraction > 40% (Group 2). In multivariate analyses, Group 1 patients were more likely to have higher than median hospitalization cost [odds ratio (OR) = 1.98; 95% confidence intervals (CI) = 1.02-3.91] and longer than median hospital stay (OR = 1.68; CI = 1.08-3.91); they were also more likely to be readmitted for any cause (OR = 2.07; CI = 1.15-3.78) or for HF (OR = 5.71; CI = 1.64-21.94), and they tended to have a higher 30-day incidence of death or readmission (OR = 1.65; CI = 0.96-2.84).

CONCLUSIONS

Depressed left ventricular ejection fraction is associated with higher resource utilization and readmission rates following hospitalization for HF. Greater focus on patients with depressed ejection fraction may increase cost savings from HF disease management programs.

Unicompartmental or total knee replacement

Between 1989 and 1992 we had 102 knees suitable for unicompartmental knee replacement (UKR). They were randomised to receive either a St Georg Sled UKR or a Kinematic modular total knee replacement (TKR). The early results demonstrated that the UKR group had less complications and more rapid rehabilitation than the TKR group. At five years there were an equal number of failures in the two groups but the UKR group had more excellent results and a greater range of movement.

The cases were reviewed by a research nurse at 8, 10 and 12 years after operation. We report the outcome at 15 years follow-up. A total of 43 patients (45 knees) died with their prosthetic knees intact. Throughout the review period the Bristol knee scores of the UKR group have been better and at 15 years 15 (71.4%) of the surviving UKRs and 10 (52.6%) of the surviving TKRs had achieved an excellent score. The 15 years survivorship rate based on revision or failure for any reason was 24 (89.8%) for UKR and 19 (78.7%) for TKR. During the 15 years of the review four UKRs and six TKRs failed.

The better early results with UKR are maintained at 15 years with no greater failure rate. The median Bristol knee score of the UKR group was 91.1 at five years and 92 at 15 years, suggesting little functional deterioration in either the prosthesis or the remainder of the joint. These results justify the increased use of UKR.

Imaging characteristics of recurrent pleomorphic adenoma of the parotid gland

BACKGROUND AND PURPOSE

Pleomorphic adenoma is the most common parotid neoplasm. It has a relatively high rate of recurrence after surgery. Imaging features of recurrent parotid pleomorphic adenoma have been infrequently reported in the radiology literature. In the present study, we reviewed our institutional experience with imaging of recurrent parotid pleomorphic adenomas.

MATERIALS AND METHODS

Retrospective imaging and chart review of 24 patients (9 men, 15 women; age, 29-63 years) with recurrent pleomorphic adenoma of the parotid were performed. Images were reviewed as to the margins, site, multiplicity, signal intensity, and enhancement pattern of the recurrent lesions by 2 neuroradiologists.

RESULTS

We found a high incidence of multiple lesions in the operative bed, most of which were extremely bright on T2-weighted images; some of the lesions demonstrated a cystic appearance with peripheral enhancement. We also noted tiny lesions in the subcutaneous fat and in regions distant from the immediate operative bed.

CONCLUSION

Although recurrent disease is usually clinically apparent, sometimes prior surgical history is lacking or recurrence may be detected on routine surveillance imaging after initial surgery. The presence of solitary or multiple subcutaneous T2 hyperintense lesions in the operative bed, subcutaneous fat, and/or spaces adjacent to the parotid in patients with prior parotidectomy for pleomorphic adenoma is consistent with the diagnosis of neoplastic recurrence. The radiologist should maintain a high index of suspicion for recurrent pleomorphic adenoma with this characteristic imaging appearance.

Low-dose lenograstim is as effective as standard dose in shortening neutrophil engraftment time following myeloablative chemotherapy and peripheral blood progenitor cell rescue

Granulocyte colony-stimulating factor (G-CSF) is widely used following myeloablative chemotherapy (high-dose therapy; HDT) and peripheral blood progenitor cell rescue (PBPCR) to reduce neutrophil engraftment time. The dose and duration required to gain maximum clinical and economic benefit has not been fully investigated. This double blind placebo-controlled randomised trial was performed to determine whether short course low-dose or standard-dose Lenograstim (L) would influence recovery of haematopoiesis following HDT and PBPCR. Sixty-one patients were randomised between May 1999 and November 2004, to receive standard-dose lenograstim (263 microg/d), low-dose lenograstim (105 microg/d) or placebo injections. These commenced on day +5 following PBPCR and continued until neutrophil engraftment [absolute neutrophil count (ANC)] > or = 0.5 x 10(9)/l. Patients received standard supportive care until haemopoietic recovery. Both standard- and low-dose lenograstim resulted in a significantly shorter median time to neutrophil recovery (ANC > or = 0.1 x 10(9)/l:10.0 vs. 11.0 d, P = 0.025; ANC > or = 0.5 x 10(9)/l:11.0 vs. 14.0 d, P = 0.0002) compared with placebo. There was no significant difference in blood product support, antibiotic usage, documented infection, overall survival or relapse-free survival between the groups. Short course low-dose lenograstim is as effective as standard-dose in reducing neutrophil engraftment time following HDT and PBPCR.

Breastfeeding and radiologic procedures

QUESTION

Recently, some of my patients were instructed not to breastfeed for 24 to 48 hours after magnetic resonance imaging scans. Is this based on scientific evidence?

ANSWER

No. On the contrary, evidence indicates unequivocally that the contrast media used for both magnetic resonance imaging and computed tomography scans are excreted into breast milk in such small quantities that there is no concern at all for nursing babies.

Crystallization and preliminary X-ray diffraction studies of the influenza C virus glycoprotein

Influenza C virus contains a single surface glycoprotein in its lipid envelope which is the hemagglutinin-esterase-fusion glycoprotein (HEF). HEF binds cell-surface receptors, is a receptor-destroying enzyme (a 9-O-acetylesterase), and mediates the fusion of virus and host cell membranes. A bromelain-released soluble form of HEF has been crystallized. Two different tetragonal forms have been identified from crystals with the same morphology [P(1(3))22, a = b = 154.5, c = 414.4 A, and P4(1(3))2(1)2, a = b = 217.4, c = 421.4 A]. Both crystal forms share a common packing scheme. Synchrotron data collection and flash cooling of crystals have been used for high-resolution data collection.

A randomized controlled trial of an asthma clinical pathway for children in general practice

AIMS

To evaluate the effect of the implementation of an asthma clinical pathway on asthma in children in general practice.

METHODS

A randomized, controlled trial involving 270 general practitioners. One group of general practitioners implemented the asthma clinical pathway for children (intervention group) and the control group continued with their usual asthma medical care management. The main outcome measures were admissions to hospital for asthma and attendance at the Children's Emergency Department. Compliance with the guidelines was assessed by examining asthma drug prescriptions.

RESULTS

Admissions to hospital for asthma dropped 40% in the intervention group, by 33% in the control group and by 22% in general practitioners not participating in the trial. The differences between the intervention and control and between the intervention and non-participating general practitioners were not statistically significant. The decrease in attendance at the Children's Emergency Department decreased by 25%, 30% and 19%, respectively, but this was not statistically significant. There was a significant decrease in prescriptions for oral relievers, dry powder relievers in the under 6s, mast cell stabilizers and methylxanthines in both control and intervention groups. However, only for oral relievers was there a significant difference between the intervention group and control, with the decrease larger in the intervention group (p < 0.001).

CONCLUSIONS

Admissions to hospital for asthma decreased, as did attendance at the Children's Emergency Department. Prescriptions for asthma medication changed in the direction anticipated with compliance with the asthma clinical pathway. However, we found no evidence within the study that implementation of the asthma clinical pathway by general practitioners resulted in lower morbidity than those general practitioners who did not implement the pathway. Possible explanations are that these general practitioners were already providing care according to the recommendations of the pathway, or that there was contamination of the control group by the intervention, or that the guidelines, although based on currently accepted recommendations, are ineffective.