Abstract Objectives To investigate associations between the rectoanal inhibitory reflex (RAIR), type of congenital anorectal malformations (ARMs), type of operation that patients with ARM had ...undergone, and objectively measured fecal incontinence and defecation problems. Methods We retrospectively included 69 pediatric patients with ARM. All underwent anorectal function tests at the University Medical Center of Groningen during the last 10 years. We assessed anorectal physiology using the Rome IV criteria and anorectal function tests. Results We found the reflex in 67% of patients and all types of ARMs. All patients who had not been operated on, and those who had undergone less extensive surgery possessed the reflex. In contrast, patients who underwent posterior sagittal anorectoplasty, 44% possessed it. We found no difference between mean rectal volumes in patients with and without the reflex (251 mL vs. 325 mL, respectively, p = 0.266). We found that over time, patients without the reflex seemed to develop significantly higher rectal volumes than patients who had it. We did not find a significant difference between the reflex and fecal incontinence; however, it seems that the absence of the reflex, resting anal sphincter pressure, and fecal incontinence are related. Conclusion The RAIR seems present in patients with ARM irrespective of their malformation type. Corrective surgery, however, may impair this reflex. Seemingly, its absence results in constipation with enlarged rectal volumes and fecal incontinence. Every effort should be made to preserve this reflex during surgery and to use extensive surgical procedures as sparingly as possible.
What is Known The presence of the rectoanal inhibitory reflex (RAIR) in patients born with different types of anorectal malformations (ARMs) has not been investigated in detail. A dysfunctional internal anal sphincter has been related to constipation and fecal incontinence. However, the outcomes are contradictory. What is New The RAIR is present in patients with ARMs irrespective of the type of malformation. Absence of RAIR seems related to corrective surgery. Absence of RAIR is related to constipation and might be related to fecal incontinence.
A family history of diabetes and family members' experiences with diabetes may influence individuals' beliefs and expectations about their own diabetes. No qualitative studies have explored the ...relationship between family history and experiences and individuals' diabetes illness representations.
Secondary data analysis of 89 exploratory, semi-structured interviews with adults with type 1 or type 2 diabetes seeking care in an urban health system. Participants had a recent diabetes-related ED visit/hospitalization or hemoglobin A1c > 7.5%. Interviews were conducted until thematic saturation was achieved. Demographic data were collected via self-report and electronic medical record review. Interviews were audio-recorded, transcribed, and coded using a conventional content analysis approach. References to family history and family members' experiences with diabetes were analyzed using selected domains of Leventhal's Common Sense Model of Self-Regulation.
Participants cited both genetic and behavioral family history as a major cause of their diabetes. Stories of relatives' diabetes complications and death figured prominently in their discussion of consequences; however, participants felt controllability over diabetes through diet, physical activity, and other self-care behaviors.
Findings supported an important role of family diabetes history and experience in development of diabetes illness representations. Further research is needed to expand our understanding of the relationships between these perceptions, self-management behaviors, and outcomes. Family practice providers, diabetes educators and other team members should consider expanding assessment of current family structure and support to also include an exploration of family history with diabetes, including which family members had diabetes, their self-care behaviors, and their outcomes, and how this history fits into the patient's illness representations.
Patients with chest pain have a high hospital admission rate, but often no cardiac cause is found. In this trial, coronary CT angiography accurately identified patients who were free from coronary ...disease and could be safely discharged from the emergency department.
Patients who present to the emergency department with signs and symptoms consistent with a possible acute coronary syndrome pose a diagnostic dilemma.
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Despite the introduction of clinical decision rules
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and the improved sensitivity of cardiac markers,
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most patients are admitted to the hospital so that an acute coronary syndrome can be ruled out, even though for most of these patients, the symptoms are ultimately found not to have a cardiac cause.
The absence of evidence of coronary disease on invasive coronary angiography is associated with a low risk of future cardiac events.
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Coronary computed tomographic angiography . . .
Study objective Three large, multicenter, randomized, clinical trials have shown that coronary computed tomography (CT) angiography allows efficient evaluation and safe discharge of patients with ...low- to intermediate-risk chest pain who present to the emergency department (ED). We report 1-year event rates and resource use from the American College of Radiology Imaging Network-Pennsylvania 4005 multicenter trial. Methods Patients with low- to intermediate-risk chest pain and presenting to the ED were randomized in a 2:1 ratio to a coronary CT angiography care pathway or traditional care. Subjects were contacted by telephone at least 1 year after ED presentation. Medical record review was performed for all cardiac hospitalizations, procedures and diagnostic tests, and adverse cardiac events. Our main outcome was the composite of cardiac death and myocardial infarction within 1 year. The secondary outcome was resource use. Results One thousand three hundred sixty-eight patients enrolled and 1,285 (94%) had direct participant or proxy contact at 1 year. All others had record review or death index search. From index presentation through 1 year, there was no difference between patients in the coronary CT angiography arm versus traditional care with respect to major adverse cardiac event (1.4% versus 1.1%; difference 0.3%; 95% CI –5.5% to 6.0%). From hospital discharge through 1 year, there was also no difference in ED revisits (36% versus 38%; difference –2.1%; 95% CI –7.9% to 3.7%), hospital admissions (16% versus 17%; difference –0.9%; 95% CI –6.7% to 4.9%), or subsequent cardiac testing (13% versus 13%; difference –0.4%; 95% CI –6.2% to 5.5%). One of 640 subjects with a negative coronary CT angiography result had a major adverse cardiac event within 1 year of presentation (0.16%; 95% CI 0.004% to 0.87%). Conclusion A coronary CT angiography–based strategy for evaluation of patients with low- to intermediate-risk chest pain who present to the ED does not result in increased resource use during 1 year. A negative coronary CT angiography result is associated with a less than 1% major adverse cardiac event rate during the first year after testing.
We sought to determine the degree to which B-type natriuretic peptide (BNP) adds to clinical judgment in the diagnosis of congestive heart failure (CHF).
The Breathing Not Properly Multinational ...Study was a prospective diagnostic test evaluation study conducted in 7 centers. Of 1586 participants who presented with acute dyspnea, 1538 (97%) had clinical certainty of CHF determined by the attending physician in the emergency department. Participants underwent routine care and had BNP measured in a blinded fashion. The reference standard for CHF was adjudicated by 2 independent cardiologists, also blinded to BNP results. The final diagnosis was CHF in 722 (47%) participants. At an 80% cutoff level of certainty of CHF, clinical judgment had a sensitivity of 49% and specificity of 96%. At 100 pg/mL, BNP had a sensitivity of 90% and specificity of 73%. In determining the correct diagnosis (CHF versus no CHF), adding BNP to clinical judgment would have enhanced diagnostic accuracy from 74% to 81%. In those participants with an intermediate (21% to 79%) probability of CHF, BNP at a cutoff of 100 pg/mL correctly classified 74% of the cases. The areas under the receiver operating characteristic curve were 0.86 (95% CI 0.84 to 0.88), 0.90 (95% CI 0.88 to 0.91), and 0.93 (95% CI 0.92 to 0.94) for clinical judgment, for BNP at a cutoff of 100 pg/mL, and for the 2 in combination, respectively (P<0.0001 for all pairwise comparisons).
The evaluation of acute dyspnea would be improved with the addition of BNP testing to clinical judgment in the emergency department.
Unidirectional multi-resonant tunneling of the magnetoelectric (ME) field excitations through a subwavelength (regarding the scales of regular electromagnetic radiation) vacuum or ...isotropic-dielectric regions has been observed in two-port microwave structures having a quasi-2D ferrite disk with magnetic dipolar mode (MDM) oscillations. The excitations manifest themselves as Fano-resonance peaks in the scattering-matrix parameters at the stationary states of the MDM spectrum. The ME near-field excitations are quasimagnetostatic fields with non-zero helicity parameter: Topological phase properties of ME fields are determined by edge chiral currents of MDM oscillations. We show that while for a given direction of a bias magnetic field (in other words, for a given direction of time), the ME field excitations are considered as 'forward' tunneling processes, in the opposite direction of a bias magnetic field (the opposite direction of time), there are 'backward' tunneling processes. Unidirectional ME field resonant tunneling is observed due to the distinguishable topology of the 'forward' and 'backward' ME field excitations. We establish a close connection between the Fano-resonance unidirectional tunneling and the topology of the ME fields in different microwave structures.
Illicit stimulant drug use may have a profound clinical impact in acute decompensated heart failure (ADHF). The chronic use of cocaine and methamphetamine may lead to overt cardiomyopathy and ADHF. ...The Acute Decompensated Heart Failure National Registry Emergency Module (ADHERE-EM) collected data on patients presenting to emergency departments with ADHF at 83 geographically dispersed hospitals in the United States. This registry was queried to determine the rate of self-reported illicit drug use in emergency department patients presenting with ADHF and compare these patients with those without illicit drug use. The registry enrolled 11,258 patients with ADHF with drug use data from January 2004 to March 2006. Of these patients, 594 (5.3%) self-reported current or past stimulant drug use. Compared with nonusers, these patients were more likely to be younger (median age 49.7 vs 76.1 years), to be African American (odds ratio 11.9, 95% confidence interval 9.8 to 14.4), and to have left ventricular ejection fractions <40% (odds ratio 3.4, 95% confidence interval 2.8 to 4.2). Admitted users had no difference in mortality (adjusted odds ratio 0.83, 95% confidence interval 0.25 to 2.72) compared with nonusers. In conclusion, data from ADHERE-EM suggest that a clinically important percentage of patients with ADHF report the use of illicit stimulant drugs. Although these patients are younger with a greater degree of LV dysfunction, they did not have greater risk-adjusted mortality.
Chronic phantom limb pain (PLP) is a disabling chronic pain syndrome for which regular pain treatment is seldom effective. Pain memories resulting from long-lasting preamputation pain or pain ...flashbacks, which are part of a traumatic memory, are reported to be powerful elicitors of PLP.
To investigate whether a psychological treatment directed at processing the emotional and somatosensory memories associated with amputation reduces PLP.
Ten consecutive participants (six men and four women) with chronic PLP after leg amputation were treated with eye movement desensitization and reprocessing (EMDR). Pain intensity was assessed during a two-week period before and after treatment (mean number of sessions = 5.9), and at short- (three months) and long-term (mean 2.8 years) follow-up.
Multivariate ANOVA for repeated measures revealed an overall time effect (F2, 8=6.7; P<0.02) for pain intensity. Pairwise comparison showed a significant decrease in mean pain score before and after treatment (P=0.00), which was maintained three months later. All but two participants improved and four were considered to be completely pain free at three months follow-up. Of the six participants available at long-term follow-up (mean 2.8 years), three were pain free and two had reduced pain intensity.
These preliminary results suggest that, following a psychological intervention focused on trauma or pain-related memories, substantial long-term reduction of chronic PLP can be achieved. However, larger outcome studies are required.
Claims data raises the possibility that on demand telemedicine programs might increase new utilization, offsetting the cost benefits described in some retrospective analyses.
We prospectively ...evaluated the cost of a synchronous audio-video on-demand telemedicine taking into account both what patients would have done instead of the telemedicine visit as well as the care patients received after the visit.
We conducted a prospective observational study of patients who received care from an on-demand telemedicine program. At the time of the visit, we surveyed patients about the alternative care that would have been requested, if they had not done the telemedicine visit. We also obtained information following the visit about what further care was received. Using cost data derived from the literature we performed a sensitivity analysis to determine the cost impact of the on-demand telemedicine visit.
There were 650 patients enrolled with a mean age of 37 who were 68% female; 74% had their care concerns resolved on the telemedicine visit; only 16% would have “done nothing” if they had not done the telemedicine visit, representing possible new utilization. Net cost savings per telemedicine visit was calculated to range from $19–$121 per visit.
In our on-demand telemedicine program, we found the majority of health concerns could be resolved in a single consultation and new utilization was infrequent. Synchronous audio-video telemedicine consults resulted in short-term cost savings by diverting patients from more expensive care settings.
Abstract Background Dyspnea is the most common presenting symptom in patients with acute heart failure (AHF), but is difficult to quantify as a research measure. The URGENT Dyspnea study compared 3 ...scales: (1) 10 cm VAS, (2) 5-point Likert, and (3) a 7-point Likert (both VAS and 5-point Likert were recorded in the upright and supine positions). However, the minimal clinically important difference (MCID) to patients has not been well established. Methods We performed a secondary analysis from URGENT Dyspnea, an observational, multi-center study of AHF patients enrolled within 1 h of first physician assessment in the ED. Using the anchor-based method to determine the MCID, a one-category change in the 7-point Likert was used as the criterion standard (‘minimally improved or worse’). The main outcome measures were the change in visual analog scale (VAS) and 5-point Likert scale from baseline to 6-h assessment relative to a 1-category change response in the 7-point Likert scale (‘minimally worse’, ‘no change’, or ‘minimally better’). Results Of the 776 patients enrolled, 491 had a final diagnosis of AHF with responses at both time points. A 10.5 mm (SD 1.6 mm) change in VAS was the MCID for improvement in the upright position, and 14.5 mm (SD 2.0 mm) in the supine position. However, there was no MCID for worsening, as few patients reported worse dyspnea. There was also no significant MCID for the 5-point Likert scale. Conclusion A 10.5 mm change is the MCID for improvement in dyspnea over 6 h in ED patients with AHF.
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