How well do we monitor patient satisfaction? Problems with the nation-wide patient survey

AIM

To outline and assess the accuracy and usefulness of the quarterly nation-wide patient survey of all New Zealand hospitals.

METHOD

Data generated by an improved patient survey at South Auckland Health (SAH) was used to examine some of the problems and issues pertaining to this survey: i.e. the format of the questionnaire; unintended consequences of the specific methodology employed and the usefulness of the obtained information.

RESULTS

Evidence is provided to show that the inpatient sample is not representative of the SAH patient population and that patients across different socio-demographic groups have different satisfaction rates. Additional research projects undertaken by the authors at SAH suggest that different methods of completing the questionnaire can significantly influence the results.

CONCLUSION

The nation-wide patient survey is in need of revision, if it is to be used as an effective management tool within hospitals and for the sector as a whole.

The SynerGraft valve: a new acellular (nonglutaraldehyde-fixed) tissue heart valve for autologous recellularization first experimental studies before clinical implantation

The durability of current bioprosthetic heart valves is diminished by glutaraldehyde-associated leaflet calcification or by the associated absence of a cellular component capable of repair of wear-related damage. As a novel tissue engineering approach to improving replacement heart valve durability, we have developed a decellularization process to replace the use of cross-linking to limit xenograft antigenicity. The effectiveness of this process was assessed in a weanling sheep right ventricular outflow tract reconstruction model where valve function, calcification, and recellularization were examined. Porcine aortic valves were decellularized by a process designed to remove all histologically demonstrable leaflet cells. Stentless, bioprosthetic valves were fabricated from acellular tissues, cryopreserved, sterilized, and then implanted as pulmonary valve replacements in 4- to 6-month old female Suffolk sheep. Sheep aortic valves were implanted as allograft control subjects. After 150 days, the grafts were explanted and assessed histologically and by atomic absorption spectrophotometry for calcium content. All valves were hemodynamically functional at explant. Histological examination showed intact leaflets with in-growth of host fibroblastoid cells in all explanted porcine valves and no evidence of calcification. Porcine leaflet calcium content was unchanged over the duration of the implant (1.0+/-1.2 vs 1.5+/-1.8 mg/g dry weight, P = ns). Decellularization can stabilize xenogenic heart valves. Lack of calcification of acellular aortic leaflets suggests that prolonged durability of such valves is attainable without the use of cross-linking agents. The repopulation of the leaflet matrix offers additional promise of durability based on revitalization of the graft in vivo.

System memory in violent incidents: evidence from patterns of reoccurrence

For 20% of a sample of 1,078 violent incidents reported in British bars and pubs, another incident was reported at the same premises within 6 months. Log-survival analysis revealed nonrandom sequences that demonstrate a system memory effect separate from any biases involving particular venues. The rate of reoccurrence was not constant during the 6 months following incidents but was significantly higher for Weeks 1-4, approximated to the mean value for Weeks 5-12, and declined for Weeks 13-26. Reoccurrence was particularly likely in the first 3-4 days after an incident. Risk of reoccurrence was further increased for incidents that involved either threats or the exit and return of the assailants within that original incident. Results support the view that "violence breeds violence" and demonstrate the need for increased staff vigilance for up to 12 weeks following a violent incident, and particularly during the first few days and weeks.

Appendix: education and information resources in hyperbaric medicine

A comprehensive listing of hyperbaric medicine resources is provided. These resources serve the educational and information needs of those who wish to enter this medical specialty, as well as those who practice it. A selected hyperbaric specific bibliography is included, as is the methodology to stay current with the scientific and technological advances of this field.

The management of epilepsy in a hospital for people with a learning disability

The study examined changes in the use of antiepileptic drugs (AEDs) in a large hospital for people with a learning disability over a 2 year period, the use of investigations, and the presence of medication side-effects. The surveys were carried out in 1993 and 1995/6. In 1993, 27% of patients were being treated for epilepsy and in 1995/6, 30.1%. Ninety percent and 82.4% of patients, respectively, were receiving one or two AEDs. In the second survey there were fewer prescriptions for phenobarbitone (5.8% vs. 12.5%) and an increase in the use of lamotrigine (21.6% vs. 5%), gabapentin (5.8% vs. 0) and vigabatrin (3.9% vs. 2.5% in 1993). Side-effects were recorded in 6 (11.8%) patients. Seven (21.2%) patients receiving carbamazepine were found to have hyponatraemia. Of the 54 electroencephalograms (EEGs) requested, 41 (76%) were reported as abnormal. Six CT brain scans had been conducted, of which five were abnormal. People receiving antipsychotic drugs had fewer seizures than average.

Considerations for the use of oral sedation in the institutionalized geriatric patient during dental interventions: a review of the literature

Some institutionalized elderly persons need a sedative prior to a dental examination or treatment because they have a disturbance due to physical illnesses, degenerative changes in the brain, and/or psychiatric disorders, associated with advanced aging. Oral administration is one of the safest methods of delivery of a sedative drug. It is almost universally acceptable, easy to administer, costs little, has a low incidence and severity of adverse reactions, and requires no additional formal specialized training for the dentist. However, theoretical and practical knowledge of sedation is essential. This paper reviews the literature on oral sedation for the geriatric patient. Benzodiazepines are most often used for oral sedation of geriatric patients. The properties of these drugs were reviewed, and recommendations were made with respect to the drugs of choice and their dosage. Generally, fast-acting benzodiazepines of short duration, with rapid rate of elimination and no active metabolites, are recommended. The drug of choice, and the dosage, may vary according to the medical history and physical condition of the patient.

The specialist registrar puzzle: do all the pieces fit?

The review of medical training by the Working Party headed by Sir Kenneth Calman culminated in the introduction of the specialist registrar (SpR) training grade. Surgery and Radiology were the vanguard specialties, with the SpR post being introduced in December 1995.

Prader-Willi syndrome and psychotic symptoms: 2. A preliminary study of prevalence using the Psychopathology Assessment Schedule for Adults with Developmental Disability checklist

The Psychopathology Assessment Schedule for Adults with Developmental Disability (PAS-ADD) checklist was used to screen for psychotic symptoms among people with Prader-Willi syndrome (PWS) aged 16 years and over. The scoring instructions for the PAS-ADD checklist were modified to take account of knowledge about the behavioural phenotype of PWS. Using modified scoring, 6.3% of the 95 people for whom checklists were completed had a possible psychotic disorder in the month before the assessment was made. The results should be treated as a crude estimate of the prevalence of psychotic symptoms associated with PWS in adult life in view of potential biases in the sample reported. These findings lend some support to the hypothesis that PWS has a non-chance association with psychotic symptoms and that the association is not entirely accounted for by the increased prevalence of psychosis associated with intellectual disability.

Prader-Willi syndrome and psychotic symptoms: 1. Case descriptions and genetic studies

Six people with Prader-Willi syndrome (PWS) who developed psychoses are described. Along with other literature reviewed in the present paper, the results imply an association between PWS and psychotic symptoms. Genetic studies were possible in five cases and SNRPN expression was examined in three cases. Maternal uniparental disomy and 15q11q13 deletions were found, demonstrating that psychotic symptoms are not associated with a single type of genetic abnormality.

Recombinant human respiratory syncytial virus (RSV) from cDNA and construction of subgroup A and B chimeric RSV

Infectious human respiratory syncytial virus (RSV) was produced from a cDNA clone that contains 15,222 nucleotides of RSV genome derived from the A2 strain of subgroup A. Recovery of infectious RSV from cDNA required cotransfection of only three expression plasmids encoding the nucleoprotein (N), the phosphoprotein (P), and the major polymerase protein (L). Inclusion of the M2-1 plasmid was not required in the transfection reaction and if included did not significantly increase the rescue efficiency. However, a single nucleotide substitution in the RSV leader region (C to G at position 4 in the antigenomic sense), greatly increased the amount of infectious virus recovered from cDNA. A recombinant RSVA2 virus that expresses an additional structural G protein derived from a subgroup B RSV was also obtained. Both A2 and B strain G glycoproteins were expressed in cells infected with the chimeric RSV. A chimeric RSV that expresses a heterologous subgroup antigen in a live attenuated vaccine candidate may be important for prevention of diseases associated with both RSV subgroup A and subgroup B infection.

Hyperbaric oxygen and thrombolysis in myocardial infarction: the 'HOT MI' randomized multicenter study

In a previous pilot study, we demonstrated that adjunctive treatment with hyperbaric oxygen (HBO) appears to be feasible and safe in patients with acute myocardial infarction (AMI) and may result in an attenuated rise in creatine phosphokinase (CPK), more rapid resolution of pain and ST changes. This randomized multicenter trial was organized to further assess the safety and feasibility of this treatment in human subjects. Patients with an AMI treated with recombinant tissue plasminogen activator (rTPA) or streptokinase (STK), were randomized to treatment with HBO combined with either rTPA or STK, or rTPA or STK alone. An analysis included 112 patients, 66 of whom had inferior AMIs (p = NS). The remainder of the patients had anterior AMIs. The mean CPK at 12 and 24 h was reduced in the HBO patients by approximately 7.5% (p = NS). Time to pain relief was shorter in the HBO group. There were 2 deaths in the control and 1 in those treated with HBO. The left ventricle ejection fraction (LVEF) on discharge was 51.7% in the HBO group as compared to 48.4% in the controls (p = NS). The LVEF of the controls was 43.4 as compared to 47.6 for those treated, approximately 10% better (no significant difference). Treatment with HBO in combination with thrombolysis appears to be feasible and safe for patients with AMI and may result in an attenuated CPK rise, more rapid resolution of pain and improved ejection fractions. More studies are needed to assess the benefits of this treatment.

Long-term (5 year) effects of transient (silent) ischaemia on left ventricular systolic function in stable angina. Clinical and radionuclide study

AIMS

(a) to assess short (1 year) and long-term (5 year) changes in left ventricular ejection fraction in patients with stable coronary disease with or without ECG evidence of transient ischaemia during daily life on routine therapy, and (b) to assess whether patients with recurrent transient ischaemic episodes have a particular propensity to gradual deterioration in left ventricular ejection fraction in the absence of infarction.

METHODS AND RESULTS

One hundred and forty eight patients (127 males; mean age 59 years), part of a natural history cohort of 172 patients who had undergone exercise testing, 48 h ambulatory ST monitoring, and resting radionuclide ventriculography at baseline, and who had not suffered any intervening cardiac event, underwent repeat radionuclide ventriculography at 1 year follow-up on identical or very similar medications. Furthermore, 56 patients (50 males; mean age 65 years) of this cohort, who had ischaemia both on exercise testing and ambulatory monitoring at baseline (n=33), or no ischaemia on either test at baseline (n=23), and who had suffered no intervening event, underwent repeat exercise testing, ambulatory monitoring and radionuclide ventriculography at a mean of 61.8 months follow-up. In 38 of these 56 cases, long-term testing mirrored baseline testing in terms of presence or absence of ischaemia (both tests +, n=25; both tests -, n=13). At one year there was no change in left ventricular ejection fraction, either for the whole group (n=148; left ventricular ejection fraction 47=11.6% - 47.13+11.07%, P=ns) or for subgroups with (n=62; left ventricular ejection fraction 48+12.1%-48.5+10.5%, P=ns) and without (n=86; left ventricular ejection fraction 46.2+10.4%-46.2+11.3%, P=ns) evidence of transient ischaemia at baseline. At 61 months, there was a small fall in mean left ventricular ejection fraction for the total study group (n=56; left ventricular ejection fraction 45.8+9.3%-42.1+8.8%, P<0.05); however, this fall was not significant for those patients with both baseline and 5 year evidence of transient ischaemia (n=25; left ventricular ejection fraction 44.9+8.7%-41.3+7.5%, P=0.056).

CONCLUSION

In medically treated stable coronary patients who do not suffer any intervening cardiac event, recurrent transient (silent) ischaemic episodes do not, in themselves, lead to gradual deterioration in left ventricular systolic function over a 1-5 year period.

Growth-related and antennular amputation-induced changes in the olfactory centers of crayfish brain

Freshwater crayfish increase in size throughout their lives, and this growth is accompanied by an increase in the length of the appendages and number of mechanoreceptive and chemoreceptive sensilla on them. We find that in the Australian freshwater crayfish Cherax destructor, neuropil volumes of the olfactory centers increase linearly with body size over the entire size range of animals found in their natural habitat. The number of cell somata of two groups of interneurons associated with the olfactory centers (projection neurons and small local neurons) also increases linearly with the size of the animals. In contrast, axon counts of interneurons that represent a nonolfactory input to the olfactory centers show that these reach a total number in the very early adult stages that then remains constant regardless of the size of the animal. Only the axon diameter of these interneurons increases linearly with body size. Amputation of the antennule and olfactory sensilla reduces the number of projection and local interneurons on the amputated side. No change in the size of the olfactory centers occurs on the unamputated side. Amputation of the olfactory receptor neurons in crayfish therefore leads not only to a degeneration of the receptor cell endings in the olfactory lobe but also to a trans-synaptic response in which the number of higher order neurons decreases. Reconstitution of the antennule and olfactory receptor neurons in small adult crayfish is accompanied by the reestablishment of the normal number of interneurons and neuropil volume in the olfactory centers.

Increased platelet responsiveness following coronary stenting. Heparin as a possible aetiological factor in stent thrombosis

AIMS

Platelet activation may be a determinant of thrombotic and restenotic complications following intracoronary stenting. In order to measure the effect of stenting on platelet activation antigen expression we used whole blood flow cytometry in 18 patients undergoing Palmaz-Schatz stenting (treated with full anticoagulation) and compared these with a group of 18 patients undergoing elective angioplasty. The effects of low molecular weight heparin and unfractionated heparin on platelet behaviour were also studied, both in vitro and in vivo to determine the contribution of prolonged heparin therapy to platelet activation following stenting.

METHODS AND RESULTS

Fibrinogen binding to activated GPIIb-IIIa, and surface expression of P-selectin, GPIb and GPIIb-IIIa antigens were measured in unstimulated peripheral blood samples (rest) and on stimulation with adenosine diphosphate (0.1-10 micromol x 1(-1)) and thrombin (0.02-0.16 U x ml(-1)). No changes were seen in resting samples following angioplasty or stenting. Agonist responsiveness was unaltered after angioplasty, but in stented patients antigen expression in response to thrombin was significantly reduced (P< or =0.04), whilst the adenosine diphosphate response was significantly increased (P=0.01). Similar effects were observed in patients with unstable angina treated with either low molecular weight heparin or unfractionated heparin in vivo. In vitro, both unfractionated and low molecular weight heparin inhibited thrombin-induced platelet activation, but stimulation of adenosine diphosphate responses was more marked with unfractionated than low molecular weight heparin.

CONCLUSIONS

There was a significant increase in platelet responsiveness to adenosine diphosphate following intracoronary stenting in patients treated with conventional anticoagulants. This was probably a consequence of treatment with heparin. Activation of platelets by heparin may explain the increased rate of stent thrombosis in patients treated with anticoagulant therapy. Low molecular weight heparins stimulate platelets less than unfractionated heparin.

Can C reactive protein or troponins T and I predict outcome in patients with intractable unstable angina?

OBJECTIVE

To determine whether a single blood test for the measurement of C reactive protein, or troponin I or T concentrations could be used to stratify patients with intractable unstable angina awaiting transfer for coronary angiography by correlating these values with coronary anatomy and transient myocardial ischaemia.

DESIGN

Prospective study.

SETTING

Tertiary cardiac unit.

PATIENTS

All patients admitted to their local hospital with ischaemic chest pain, uncontrolled by medical treatment, in whom acute myocardial infarction had been excluded by serial measurement of creatine kinase and lack of Q waves on ECG.

INTERVENTION

Coronary angiography and ST segment monitoring for 24 hours.

MAIN OUTCOME MEASURES

Concentrations of C reactive protein, troponins T and I, coronary anatomy, presence of transient myocardial ischaemia.

RESULTS

Median C reactive protein, troponin I, and troponin T concentrations were 17.1 mg/dl (4.8 to 203.9), 0.05 microgram/l (0 to 7.8), and 0.0 microgram/l (0 to 2.51), respectively. Seven patients (10%) had normal coronaries and 14, 20, and 31 had one, two, or three vessel coronary disease, respectively. Nineteen (26%) had transient myocardial ischaemia, 33 (46%) had complex lesion morphology, and six (8%) had intracoronary thrombus. Of the three markers, troponin T alone was higher in patients with multivessel disease (p < 0.05) and in those with transient myocardial ischaemia (p < 0.05), but there was no significant relation between C reactive protein, troponin T or I and lesion morphology or thrombus.

CONCLUSIONS

In patients transferred to a tertiary centre with intractable chest pain, C reactive protein and troponin I are not predictive of transient myocardial ischaemia or lesion morphology, both of which are surrogate markers of outcome. Troponin T is, however, raised in patients with multivessel disease or transient myocardial ischaemia. These serum protein assays cannot be used to stratify the risk of patients with unstable angina who are awaiting transfer to the tertiary centre.

Intra-adrenal factors are not involved in the differential control of cortisol and adrenal androgens in human adrenals

The differential control of adrenal androgens and cortisol may be due to intra-adrenal factors, which may be age- or sex-related, or due to extra-adrenal factors, such as circulating hormones. The purpose of this study was to identify any intrinsic differences that may exist in steroidogenic production occurring within adrenals obtained from males and females, and any maturational differences that may evolve with age. Using human adrenals from 48 transplant donors (32 males, 16 females; ages 5-60 years), the influences of age and sex on basal production of and ACTH-stimulated cortisol, androstenedione and dehydroepiandrosterone (DHEA) were examined in freshly prepared adrenal cell suspensions. Basal and ACTH-stimulated cortisol, androstenedione and DHEA production were similar in adrenals from males and females and did not correlate significantly with age when the whole group was examined. When steroidogenesis in male and female adrenals was examined separately against age, a significant correlation was observed only for basal and ACTH-stimulated androstenedione in adrenals from males in the younger age group, 5-30 years (basal: r=0.84, P=0.0001; ACTH-stimulated: r=0.52, P=0.007). Examination of the relationships between the steroids disclosed that the basal and ACTH-stimulated cortisol/androgen ratios did not correlate significantly with age, but the androstenedione/DHEA ratio showed a significant direct relationship with age in males only (basal: r=0.53, P=0.006; ACTH-stimulated: r=0.5, P=0.01). These data suggest that the influences of sex and age are minor in the modulation of adrenal steroidogenesis and support the concept that extra-adrenal factors dominate in the differential modulation of adrenal androgens and cortisol. The relationship between the androstenedione/ DHEA ratio and increasing age in men is consistent with the recently reported stimulatory effect of testosterone on adrenal steroidogenesis by induction of the conversion of DHEA to androstenedione.

Long-term prognosis in unstable angina. The importance of early risk stratification using continuous ST segment monitoring

AIMS

To assess the ability of clinical characteristics, admission ECG and continuous ST segment monitoring in determining long-term prognosis in unstable angina.

METHODS

Two hundred and twelve patients with unstable angina (mean age 59 years), presenting within 24 h of an acute episode of angina were recruited at three hospitals and treated with standardized medical therapy. All patients kept chest pain charts and underwent ST segment monitoring for 48 h. The occurrence of death, myocardial infarction, and need for revascularization was assessed over a median follow-up of 2.6 years.

RESULTS

The risk of death of myocardial infarction was greatest in the first 6-8 weeks after admission. Admission ECG ST depression and the presence of transient ischaemia predicted increased risk of subsequent death or myocardial infarction, whereas a normal ECG predicted a good prognosis. In 14 patients, ST segment monitoring provided the only evidence of recurrent ischaemia, and 72% of this group suffered an adverse event. Transient ischaemia and a history of hypertension were the most powerful independent predictors of death or myocardial infarction.

CONCLUSIONS

Adverse events in unstable angina occur early after admission and can be predicted by clinical and ECG characteristics, and by the presence of transient ischaemia during ST segment monitoring. Risk stratification by these simple assessments can identify patients with unstable angina at high risk.

Temporal architecture of violent incidents

Five hundred five reports of violent incidents in British pubs and bars were studied by using logical pathway modeling to provide information on the processes underlying work-related violence. Logical pathway modeling is innovative in examining and mapping sequences in real incidents at a population level. The data reveal the most common pathway to be misbehavior by customers, intervention by staff (before any physically violent act), physical attack on staff, and injury to staff. The data also highlight the likelihood of further action after assailants have exited and identify stages in incidents at which most staff and customer injuries and damage to property occur. Results assist in the design of strategies to reduce the risk from future violence, particularly by training staff to recognize and to handle potentially violent situations and to maintain vigilance and security following problem incidents.

Altered platelet function detected by flow cytometry. Effects of coronary artery disease and age

Platelet activation state and responsiveness to physiological agonists were measured in 65 patients with documented coronary artery disease (54 male and 11 female; mean age, 58 years). Twelve patients (mean age, 52 years), selected at random from the male cohort, were compared with 12 age-matched male control subjects (mean age, 52 years) and with 10 normal, young male subjects (mean age, 25 years). Whole-blood flow cytometry was used to measure platelet activation status ex vivo and platelet responsiveness to physiological agonists in vitro. Peripheral blood samples were analyzed for bound fibrinogen and expression of P-selectin, GPIb, and GPIIb-IIIa at rest and in response to ADP (0.1 to 10 mumol/L) and thrombin (0.02 to 0.32 mu/mL). No significant differences were seen in the basal levels of fibrinogen binding between any of the groups, but P-selectin expression was significantly lower in patients compared with age-matched control subjects (P = .0005). When stimulated with agonists, patients' platelets had significantly decreased fibrinogen binding (P < .03) but no difference in P-selectin expression compared with the age-matched group. Both agonist-induced fibrinogen binding and P-selectin expression were, however, higher in the young subjects compared with either the older control group or the patients (P < .05). GPIb and GPIIb-IIIa expression were lowest in the patients with angina and highest in the young control subjects, with levels in the age-matched control subjects falling between these values. Data from the total patient cohort (n = 65) were identical to those in the smaller cohort (n = 12). In conclusion, atherosclerosis impairs platelet aggregatory responses (fibrinogen binding) over and above the decreased response seen with age. Platelet degranulation (P-selectin expression) is also impaired in patients with coronary artery disease, but only in comparison with younger subjects, not age-matched controls.