Mortality after hip fracture: regional variations in New Zealand

AIM

To determine the 35-day and one-year mortality rates following a hospital admission for hip fracture, among individuals aged 60 years or older in New Zealand.

METHODS

New Zealand Health Information Service mortality data for the years 1988 to 1992 were examined to determine the case fatality rate among individuals aged 60 years or older admitted to hospital for fractures of the neck of femur (ICD-9 N-code 820). Case fatality rates assessed at 35 days and one year after admission to hospital were examined by age, gender, year of admission, place of residence, area health board region and cause of death.

RESULTS

Between 1988 and 1992, the case fatality rate was 8% within 35 days of admission to hospital and 24% within one year of admission. Case fatality rates were found to be twice as high in men compared to women and four to five times higher in individuals aged 85 years and older, compared to people aged between 60 and 64 years. The only regional difference in hip fracture mortality was found in the Canterbury area health board region, which had a 30% higher rate of hip fracture mortality compared to all regions combined. The two main cited underlying causes of death after hip fracture were accidental falls (ICD E880-E888) and ischaemic heart disease (ICD 410-414).

CONCLUSION

Over three-quarters of individuals aged 60 years or older who are hospitalised with a hip fracture in New Zealand survive for at least one year after admission. However, significant variations in mortality exist with age and gender. These data highlight the importance of preventive strategies for hip fracture in older people and the need to identify ways of improving post-admission care.

1999 World Health Organization-International Society of Hypertension Guidelines for the management of hypertension. Guidelines sub-committee of the World Health Organization

The present Guidelines were prepared by the Guidelines Sub-Committee of the World Health Organization-International Society of Hypertension (WHO-ISH) Mild Hypertension Liaison Committee, the members of which are listed at the end of the text. These guidelines represent the fourth revision of the WHO-ISH Guidelines and were finalised after presentation and discussion at the 7th WHO-ISH Meeting on Hypertension, Fukuoka, Japan, 29th Sept-1st Oct, 1998. Previous versions of the Guidelines were published in Bull WHO 1993, 71:503-517 and J Hypertens 1993, 11:905-918.

Oral fluorescein angiography with the confocal scanning laser ophthalmoscope

OBJECTIVE

To evaluate the efficacy of oral fluorescein angiography with a confocal scanning laser ophthalmoscope (SLO) system.

DESIGN

Comparative case series.

PARTICIPANTS

The authors used a confocal SLO (Heidelberg Retina Angiograph [HRA]) to perform oral fluorescein angiography in 47 patients, 13 of whom were without any retinal disease and 34 with a variety of retinal diseases including macular holes and pucker, inflammatory diseases, retinal vascular diseases, and age-related macular degeneration. The images were also compared to images taken with a fundus camera after intravenous fluorescein injections in patients on whom both studies were done.

INTERVENTION

Color fundus photographs were taken of each eye (30 degrees fundus camera) before drinking 4 ml of 25% sodium fluorescein mixed with 60 ml of orange juice. After oral fluorescein ingestion, images of each eye were taken with a fundus camera (TriX film) and the HRA (using 512- x 512-pixel resolution). The images were repeated at 0-, 2.5-, 5-, 7.5-, 10-, 12.5-, 15-, 20-, 25-, and 30-minute intervals. Twenty of the 47 patients underwent intravenous fluorescein angiography performed with the fundus camera.

MAIN OUTCOME MEASURE

Images were analyzed by a masked reader, and foveal avascular zone visualization, branch retinal vessel identification, and image quality were scored. Statistical analysis was performed with a t test for paired data with a two-tailed test of significance (alpha = 0.05).

RESULTS

Foveal avascular zone was 100% as seen in 16 eyes (47%) in the HRA machine versus 1 eye (2%) in the conventional fundus camera (P < 0.0001). The third-order branch retinal vessels were identified in 59% of eyes in the HRA versus 26% in the fundus camera group (P < 0.0001), and the image quality was considered comparable to an intravenous angiogram in 47% with the HRA versus 9% with the conventional fundus camera (P < 0.0001).

CONCLUSIONS

Oral fluorescein angiography using the HRA produces sufficiently detailed images to diagnose, treat, and follow many types of retinal pathology.

Testing a random phase approximation for bounded turbulent flow

Tractable implementation of a spectral closure requires that the modal representation of the energy satisfy a restricted random phase approximation (RRPA). This condition is exactly satisfied when the statistical system is homogeneous and the basis functions are Fourier modes. In this case, the ensemble average of the spectral covariance diagonalizes, i.e., <c(k(1))c(k(2))>=delta(k(1)+k(2))<c(k(1))c(k(2))>, where c(k,t) is a Fourier coefficient in a Galerkin representation of the velocity field. However, for inhomogeneous statistical systems in which the Fourier system is inappropriate, the RRPA requires validation. We use direct numerical simulations (DNSs) of the Navier-Stokes and truncated Euler equations to test the degree to which the RRPA is satisfied when applied to a recent representation due to Turner (LANL Unclassified Report No. LA-UR-96-3257) of a bounded turbulent rectangular channel flow with free slip, stress free walls. It is shown that a complete test of the RRPA for a fully inhomogeneous DNS with N3 grid points actually requires N3+1 members in the ensemble. The "randomness" of the phase can be characterized by a probability density function (PDF) of the modulus of the normalized spectral covariance. Results reveal that for both the Navier-Stokes and Euler systems the PDF does not change in time as the turbulence decays, and that the PDF for the Euler system is virtually identical to the one produced from an ensemble of random fields. This result is consistent with the equipartition of energy for the Euler system, in which the RRPA becomes an exact result rather than an approximation as the number of realizations approaches N3+1. The slight differences observed between the PDF produced from the random fields and the one from the Navier-Stokes system are thus shown to be entirely a result of the presence of a finite viscosity. It is also shown that there is great variation between statistics computed over the ensemble and those for a single realization.

Autistic symptoms in children with attention deficit-hyperactivity disorder

Children with the syndrome of disorders of attention, motor control and perception (DAMP) invariably fill diagnostic criteria for attention deficit hyperactivity disorder (ADHD) and commonly have symptoms of autistic spectrum disorders. This study estimates the rate of autistic symptoms in a sample of children with ADHD by using the parent-rated Autism Criteria Checklist. A high proportion of parents (between 65-80%) reported significant difficulties in social interaction (particularly in empathy and peer relationships), and communication (particularly in imaginative ability, nonverbal communication and maintaining conversation). The nature and relationship between ADHD and pervasive developmental disorders is considered, as well as implications for assessment, diagnosis and treatment.

Effect of the hemoglobin-based oxygen carrier HBOC-201 on laboratory instrumentation: cobas integra, chiron blood gas analyzer 840, Sysmex SE-9000 and BCT

As part of a clinical trial, we evaluated the effects of the hemoglobin-based oxygen-carrier (HBOC) HBOC-201 (an ultrapurified, stroma-free bovine hemoglobin product, Biopure, Cambridge, MA, USA) on our routine clinical chemistry analyzer (Cobas Integra, F. Hoffmann-La Roche Ltd, Basel, Switzerland ), blood gas analyzer (Chiron 840, Chiron Diagnostics Corporation, East Walpole, MA, USA), routine hemocytometry analyzer (Sysmex SE-9000, TOA Medical Electronics Co Ltd., Kobe, Japan), hemostasis analyzer (BCT, Dade-Behring, Marburg, Germany) and bloodbanking system (Dia-Med-ID Micro Typing System, DiaMed AG, Cressier, Switzerland). The maximum tested concentration of HBOC-201 was 65 g/l. Of the 27 routine clinical chemistry tests challenged with HBOC-201, bilirubin-direct, creatine kinase MB-fraction (CK-MB), creatine kinase (CK), gamma-glutamyltransferase (GGT), magnesium and uric acid were influenced by even low concentrations of HBOC-201. These tests were excluded from use on the plasma of patients treated with HBOC-201. Since the non-availability of the cardiac marker CK-MB may lead to problems in acute situations, we introduced the qualitative Trop T-test (Boehringer Mannheim), which was not influenced. The applicability of another nine tests was limited by the concentration of the HBOC-201 in the patients' plasma. No interference of HBOC-201 in routine hemocytometry, hemostasis-analysis and red-blood cell agglutination detection (blood-bank tests) was observed. Although immediate patient-care was not compromised, routine use of hemoglobin-based oxygen carriers will have a strong impact on logistical management. The development of robust laboratory tests free from the interference of the pigmented oxygen carriers should therefore precede its introduction into routine transfusion medicine.

Ichthyophthirius multifiliis: a model of cutaneous infection and immunity in fishes

The parasitic ciliate Ichthyophthirius multifiliis offers a useful system for the study of cutaneous immunity against an infectious microorganism. Naive fish usually die following infection, but animals surviving sublethal parasite exposure become resistant to subsequent challenge. This resistance correlates with the presence of humoral antibodies in the sera and cutaneous mucus of immune fish. A mechanism of immunity has recently been elucidated that involves antibody binding to surface proteins (referred to as immobilization antigens or i-antigens) located on the parasite cell and ciliary membranes. Antibody-mediated cross-linking of i-antigens triggers a response by the parasite resulting in its exit from the host. These effects can be observed directly on the surface of live fish. In addition to allowing the observation of effector responses in vivo, Ichthyophthirius also provides a means to study the ontogeny of the mucosal immune response. The sites of antigen capture and presentation, and the sites of antibody production, are unknown with regard to cutaneous immunity. Because the external epithelial surfaces of fish are often the points of pathogen entry, a basic understanding of the inductive immune mechanisms and immune cell interactions in the skin and gills is extremely important with regard to vaccine development. The development of Ichthyophthirius as an experimental system and how it might be used to address these issues are discussed in this review.

Folic acid, riboflavin, thiamine, and vitamin B-6 status of a group of first-time blood donors

Reference intervals for long-term status measures of folate, riboflavin, thiamine, and vitamin B-6 were determined in a select group of adults. Reference subjects had no adverse medical history and did not use tobacco, alcohol, or nutritional supplements, and their diets met > or =70% of the Australian recommended dietary intake for nutrients. Red blood cell concentrations of thiamine and folate were measured by microbiological methods. Vitamin B-6 and riboflavin status were measured on the basis of the erythrocyte aspartate transaminase activity coefficient and erythrocyte glutathione reductase activity coefficient, respectively. A survey of first-time blood donors, which was conducted in Australia in 1995, revealed a significant prevalence of low red blood cell thiamine concentrations (13%) when compared with the calculated normal reference intervals. However, the most important finding in the survey was that the group of healthy, nonanemic adults (first-time blood donors) was found to have a median red blood cell folate concentration 24% below the median concentration of the carefully selected (nonsupplemented) reference group. Plasma total homocysteine concentrations indicated folate deficiency in the reference group. Therefore, the 2.5th percentile cutoff for reference group red blood cell folate concentrations may have underestimated the prevalence of folate deficiency in the survey group. These data, coupled with the lack of Australian food-composition data for folate in particular, reinforce the need for monitoring nutritional status by both dietary and biochemical means. We recommend consideration of mandatory fortification of the Australian food supply with folic acid.

Perlman syndrome--a cause of enlarged, hyperechogenic kidneys

Perlman syndrome is a rare overgrowth syndrome, thought to be inherited in the autosomal recessive fashion. We describe the sonographic features in two cases, and review the literature.

A novel Asp380Ala mutation in the GLC1A/myocilin gene in a family with juvenile onset primary open angle glaucoma

Glaucoma describes a clinically and genetically heterogeneous group of diseases that result in optic neuropathy and progressive loss of visual fields. A gene for juvenile onset primary open angle glaucoma JOAG) has recently been mapped to 1q21-31. Mutations in the trabecular meshwork induced glucocorticoid response gene (TIGR, also known as myocilin or the GLC1A locus) have been found to cause both juvenile and later onset primary open angle glaucoma. Family TCD-POAG1 is a Spanish kindred, which segregates JOAG in an autosomal dominant fashion. This family was found to be linked to the previously identified GLC1A locus on chromosome 1q. Direct sequencing of the TIGR/myocilin gene showed a heterozygous A to C transition in codon 380, resulting in the substitution of alanine for aspartic acid (Asp380Ala). This substitution created a StyI restriction site, which segregated with the JOAG phenotype and permitted rapid screening of all members of the family. This restriction site was not present in 60 controls.

Effect of hemoglobin- and Perflubron-based oxygen carriers on common clinical laboratory tests

Polymerized hemoglobin solutions (Hb-based oxygen carriers; HBOCs) and a second-generation perfluorocarbon (PFC) emulsion (Perflubron) are in clinical trials as temporary oxygen carriers ("blood substitutes"). Plasma and serum samples from patients receiving HBOCs look markedly red, whereas those from patients receiving PFC appear to be lipemic. Because hemolysis and lipemia are well-known interferents in many assays, we examined the effects of these substances on clinical chemistry, immunoassay, therapeutic drug, and coagulation tests. HBOC concentrations up to 50 g/L caused essentially no interference for Na, K, Cl, urea, total CO2, P, uric acid, Mg, creatinine, and glucose values determined by the Hitachi 747 or Vitros 750 analyzers (or both) or for immunoassays of lidocaine, N-acetylprocainamide, procainamide, digoxin, phenytoin, quinidine, or theophylline performed on the Abbott AxSym or TDx. Gentamycin and vancomycin assays on the AxSym exhibited a significant positive and negative interference, respectively. Immunoassays for TSH on the Abbott IMx and for troponin I on the Dade Stratus were unaffected by HBOC at this concentration. Tests for total protein, albumin, LDH, AST, ALT, GGT, amylase, lipase, and cholesterol were significantly affected to various extents at different HBOC concentrations on the Hitachi 747 and Vitros 750. The CK-MB assay on the Stratus exhibited a negative interference at 5 g/L HBOC. HBOC interference in coagulation tests was method-dependent-fibrometer-based methods on the BBL Fibro System were free from interference, but optical-based methods on the MLA 1000C exhibited interferences at 20 g/L HBOC. A 1:20 dilution of the PFC-based oxygen carrier (600 g/L) caused no interference on any of these chemistry or immunoassay tests except for amylase and ammonia on the Vitros 750 and plasma iron on the Hitachi 747.

Self-directed work teams: application to a drug information center

OBJECTIVE

To describe the transition of a drug information center from a traditionally managed center to a self-directed work team responsible for service, education, research, and drug use policy development.

SUMMARY

To adapt to economic, educational, and technologic changes, traditional management structures in healthcare organizations are being reassessed. In some instances, a team approach (using self-directed work teams [SDWTs]) is being implemented. SDWTs have the potential to provide a number of benefits to an organization, including reduced costs and greater employee motivation. The University of Illinois at Chicago Drug Information Center had functioned under a traditional management structure. For economic and professional reasons, the management structure of the center was changed to an SDWT, prompting a reevaluation of the mission and activities of the center.

DISCUSSION

Although still in transition, the center's change to a team structure has proven to be positive. The nature of the SDWT requires greater involvement by team members in all aspects of the center's operation, adding to the experience of team members. The team structure also allows for greater freedom to pursue projects of personal interest to individual team members. A number of issues still need to be resolved, such as performance-based compensation and peer- and self-evaluations.

CONCLUSIONS

SDWTs can provide many benefits. The successful implementation of an SDWT, however, has a number of requirements, the most important of which are a commitment from management and effective communication among team members and with management.

An overview of types of relationships between hospitals and colleges/schools of pharmacy

Three vignettes describe the details of each of the three types of practice-education relationships in academic hospitals identified in a survey by the University HealthSystem Consortium. The educational affiliation at Penn State's Hershey Medical Center, the affiliated relationship of the Medical College of Virginia, and a fully integrated relationship at the University of Illinois at Chicago are described by the Director of Pharmacy at each institution. The advantages, disadvantages, and future goals are described.

Infant feeding practices of low-income African American women in a central city community

It is a well-established fact that nutrition is central to the growth and development of all infants. Yet it has been observed that health care professionals are frequently unfamiliar with the most typical infant feeding practices of the clients within the communities they attempt to serve. This observation was apparent during the development of a program in an inner-city community of Wisconsin to support the feeding practices of low-income African American women with low-birth-weight infants. As a result of initial encounters with prospective clients and health care and social service professionals from the targeted community, it was apparent that professionals and staff involved in this project needed to gain an understanding of common infant feeding practices of low-income African American women; a greater awareness of the values, beliefs, and health care practices of the population; and a greater understanding of the impact of poverty on the families within the targeted community. To assist the staff in gaining a better understanding of the influence of culture and economics on infant feeding practices, a study of the infant feeding practices of a select group of low-income African American women was undertaken. The study aimed to (a) gather information that could be used to describe common infant feeding practices of low-income African American women in an inner-city community of Wisconsin and (b) determine the influence of cultural and economic variables on the decisions made by low-income African American women regarding infant feeding. This article presents an analysis and summary of the data collected during the course of the study.

Estimation of fetal lung volume using enhanced 3-dimensional ultrasound: a new method and first result

OBJECTIVE

To measure fetal lung volume using a computer based, enhanced, 3-dimensional ultrasound imaging system.

DESIGN

An observational study.

SETTING

The Fetal Medicine Unit at Guys Hospital, London.

PARTICIPANTS

Twenty healthy women with a singleton pregnancy between 24 and 36 weeks of gestation were scanned on one occasion during pregnancy using an ultrasound based 3-dimensional imaging system. All delivered at term with weights above the 10th centile for gestation.

RESULTS

Total lung volume increased exponentially with gestational age. Right lung volume measured consistently greater than left lung volume.

CONCLUSIONS

The use of this new enhanced 3-dimensional imaging system allows for estimations of fetal lung volume. Preliminary data confirm that fetal lung volume, measured by a computerised 3-dimensional ultrasound imaging system increased exponentially with gestational age. The use of this system has obvious application in the further study of lung growth in utero and possible clinical application in disease states where fetal lung growth may be impaired.

Primary small-cell carcinoma of the oesophagus with spontaneous oesophageal perforation following chemotherapy

The authors describe a 66 year old woman with small-cell carcinoma of the oesophagus who developed a perforation following chemotherapy. Small-cell carcinoma of the oesophagus is a rare neoplasm, varying in appearance from a small mucosal lesion to a larger fungating mass, which in our patient presented as a bulky soft-tissue mass causing stricture. Pleural fluid collections which developed via a spontaneous oesophageal-pleural fistula were subsequently drained using percutaneously placed catheters. Radiologic management of this condition provided a successful and cost-effective means of patient care.

The inhibition of alpha-chymotrypsin predicted using theoretically derived molecular properties

The structures and molecular properties of 95 aromatic and heteroaromatic ligands previously tested as reversible inhibitors of chymotrypsin catalysis have been calculated using AMl. The properties obtained have been used as input for multiple linear regression analysis and as descriptors for a back-propagation neural network to predict the binding affinity of alpha-chymotrypsin inhibitors. Using polarizability, molecular shape, electrostatic similarity, dipole moment, ClogP, and the diagonalized quadrupole moments of the ligands, correlation coefficients between calculated and experimental affinities of 0.96 for the training set and 0.89 for the test set were obtained using a neural network. The performance of the multiple linear regression was significantly worse, although useful QSARs were also obtained.