Ambulatory Type Research Articles

Nasal pressure recordings to detect obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common disease. Given the costs of in-laboratory polysomnography (PSG), alternative ambulatory methods for accurate diagnosis are desirable. The objective of this study was to evaluate the performance of a simple device (SleepCheck) to identify patients with sleep apnea. A total of 30 consecutive patients with suspected OSA syndrome referred to the sleep clinic were prospectively evaluated with standard PSG and SleepCheck simultaneously during an in-laboratory, supervised full-night diagnostic study. The PSG apnea and hypopnea index (AHI) was evaluated according to standard criteria, and SleepCheck assessed the respiratory disturbance index (RDI) based on nasal cannula pressure fluctuations. Compared to the full-night PSG, SleepCheck systematically overscored respiratory events (the mean difference between SleepCheck RDI and PSG AHI was 27.4+/-13.3 events per hour). This overscoring was in part related to normal physiologic decreases in flow during rapid eye movement sleep or after an arousal. However, there was reasonable correlation between AHI and RDI (r=0.805). Receiver operating characteristic curves with threshold values of AHI of 10 and 20/h demonstrated areas under the curves (AUCs) of 0.915 and 0.910, respectively. Optimum combinations of sensitivity and specificity for these thresholds were calculated as 86.4/75.0 and 88.9/81.0, respectively. Overall, the SleepCheck substantially overscored apneas and hypopneas in patients with suspected OSA. However, after correction of the bias, the SleepCheck had reasonable accuracy with an AUC, sensitivity, and specificity similar to other ambulatory type 4 devices currently available.

Preliminary Validation of a Patient-based Self-assessment Measure of Severity of Illness in Type 2 Diabetes

Measures of case mix are needed to control for patients' clinical status in studies assessing the process and outcomes of care. The Veterans Health Study (VHS) is a longitudinal study of determinants of health outcomes in ambulatory veterans. This study assessed the validity of a case-mix measure developed to quantify severity of illness in ambulatory type 2 diabetic patients. As part of the pilot phase of the VHS, 245 veterans using 4 primary care clinics in Boston were screened for diabetes and 5 other chronic illnesses when they presented for care. Subjects screening positive for diabetes returned to complete severity of illness and outcome measures. The variables for the diabetes case-mix module were chosen based upon the principles of parsimony, duration of follow-up, and clinical validity and credibility. Variables were selected to predict function, as measured by the Medical Outcomes Study Short-Form 36 (SF-36). The diabetic patients in this study had a heavy burden of chronic illness, with an average of 3.9 comorbid conditions and a mean general health perceptions score of 48 on the SF-36 (scored from 0 to 100, with 100 indicating best health). A summary variable called DMSEV was created for "diabetes severity". This included atherosclerotic complications(stroke, transient ischemic attack or myocardial infarction; chest pain frequency; and claudication), plus any history of eye, foot, or neuropathic symptoms. DMSEV correlated with all 8 outcome scales of the SF-36, and in particular was highly associated with physical function (r=0.49, P=.0001). Least squares linear regression analysis controlling for age and comorbidity confirmed the association of DMSEV with all 8 SF-36 scales. The correlation with physical function remained highly significant (P<.0001), with an R of 0.31. This patient-based self-assessment questionnaire and the summary variable DMSEV appear to be valid measures of severity of illness in ambulatory diabetic veterans with multiple comorbidities. After further testing, this case-mix measure may be suitable for controlling for severity of illness in ambulatory-based studies of diabetic patients with multiple chronic illnesses.

Ways to reduce patient turnaround time and improve service quality in emergency departments

Recent years have witnessed a fundamental change in the function of emergency departments (EDs). The emphasis of the ED shifts from triage to saving the lives of shock-trauma rooms equipped with state-of-the-art equipment. At the same time walk-in clinics are being set up to treat ambulatory type patients. Simultaneously ED overcrowding has become a common sight in many large urban hospitals. This paper recognises that in order to provide quality treatment to all these patient types, ED process operations have to be flexible and efficient. The paper aims to examine one major benchmark for measuring service quality--patient turnaround time, claiming that in order to provide the quality treatment to which EDs aspire, this time needs to be reduced. This study starts by separating the process each patient type goes through when treated at the ED into unique components. Next, using a simple model, the impact each of these components has on the total patient turnaround time is determined. This in turn, identifies the components that need to be addressed if patient turnaround time is to be streamlined. The model was tested using data that were gathered through a comprehensive time study in six major hospitals. The analysis reveals that waiting time comprises 51-63 per cent of total patient turnaround time in the ED. Its major components are: time away for an x-ray examination; waiting time for the first physician's examination; and waiting time for blood work. The study covers several hospitals and analyses over 20,000 process components; as such the common findings may serve as guidelines to other hospitals when addressing this issue.

Diabetic nephropathy among type 2 diabetes mellitus patients in Dr. Cipto Mangunkusumo Hospital

Diabetic nephropathy has been known as one of the most serious long-term complications of diabetes mellitus (DM), which could lead to end-stage kidney failure. However, data showing the presence of diabetic nephropathy among ambulatory type 2 diabetic patients is currently not available. This cross-sectional study was conducted to find the prevalence of diabetic nephropathy among non-hospitalized type 2 diabetic patients, who came for the first time to the Metabolic and Endocrinology Clinic, Dr. Cipto Mangunkusumo Hospital, Jakarta. From December 2001 to June 2002, 100 new type 2 diabetic patients were included in the study. Forty-two of them were men and the mean age was 54 ± 9.6 years. Overt nephropathy (macroalbuminuria) was found in 11% of patients, while incipient nephropathy (microalbuminuria) was 26%, and the rest were normal (normoalbuminuria). Duration of illness of more than 5 years was significantly correlated with the degree of albuminuria. However, there is no significant correlation between the degree of albuminuria and other risk factors, i.e. patient’s age, dyslipidemia, hypertension, obesity, HbA1c level. All patients with overt nephropathy had creatinine clearance test below 75 ml/ min. (mean 45.3 mL/min), significantly lower than patients with micro- or normoalbuminuria (p=0.01). Retinopathy was found in 10 out of 11 (90%) patients with overt nephropathy. Multivariate analysis showed that the duration of illness and retinopathy was significantly correlated with the presence of diabetic nephropathy (p&lt; 0.05). We concluded that the prevalence of diabetic nephropathy (i.e. overt nephropathy with retinopathy) among non-hospitalized type 2 diabetic patients was 10%. The duration of illness was an important risk factor for the development of this complication. (Med J Indones 2004; 13: 161-5) Keywords: diabetic nephropathy, chronic kidney disease, diabetic retinopathy, albuminuria, ambulatory type 2 diabetic patients

Factores relacionados con el control glucémico de pacientes con diabetes tipo 2

To describe metabolic, lipidic and blood pressure control and to identify blood glucose control predictive factors in patients with type 2 diabetes. Retrospective cohort study. Ambulatory type 2 diabetic patients were selected from 2/1/00 to 14/11/01 if they had been visited yearly at least three years previously. They were classified into three groups: a) initial and final treatment with diet and/or oral glucose-lowering drugs; b) insulinized patients during follow-up; and c) initial and final therapy with insulin. BODY MASS INDEX: (BMI), blood pressure, HbA1c and lipid profile were determined at start and at the end of the study. A multiple regression model was used to predict mean HbA1c through follow-up. 320 patients were selected, 199 women (62.2%) and 121 men (37.8%) with mean age of 69 years (SD: 9). Mean follow-up was 5.2 years (SD: 1.1). 106 patients (33.8%) were included into A group, 70 patients (22.4%) into B group and 137 (43.8%) into C group. 63% of patients had values of HbA1c > 7.5%, 36% blood pressure > 140/85 mmHg and 8.5% LDL values > 155 mg/dl. HbA1c mean through follow-up was of 8.2% and its independent predictors were baseline HbA1c (0.37; IC 95% 0.31-0.43; p < 0.001), baseline BMI (0.023; IC 95% 0.004-0.042; p = 0.017), baseline treatment with insulin (0.67; IC 95% 0.45-0.88; p < 0.001) and insulinization during follow-up (0.46; IC 95% 0.21-0.71; p < 0.001). It's difficult to achieve an acceptable blood glucose control. Mean HbA1c predictive factors include baseline HbA1c and BMI and insulin therapy.

Hyperfibrinogenemia. An important risk factor for vascular complications in diabetes.

To evaluate the determinants of elevated fibrinogen levels and the impact of hyperfibrinogenemia on vascular complications in diabetes. Plasma fibrinogen, glucose, HbA1, and lipids were measured in 116 ambulatory type I and type II diabetic patients with (n = 59) or without (n = 57) clinical evidence of micro- or macrovascular complications. In 56 of these patients, factor VII activity and CRP also were measured. Univariate and multivariate data analyses were conducted. Overall mean +/- SE fibrinogen levels in patients (339 +/- 7.3 mg/dl) were elevated markedly compared with control subjects (248 +/- 9.1 mg/dl). Fibrinogen levels were elevated disproportionately in patients with type II diabetes (P less than 0.0001), hypertension (P = 0.0001), obesity (P less than 0.0001), and vascular complications (P less than 0.0001). Fibrinogen was correlated significantly with age (P less than 0.001), cholesterol (P = 0.002), CRP (P less than 0.001), and factor VII activity (P = 0.032), but not with plasma glucose, triglycerides, HDL cholesterol, or disease duration. Stepwise multiple regression analyses revealed that type II diabetes and presence of vascular complications were major determinants of fibrinogen. For vascular complications, fibrinogen emerged as one of only three independent predictors, the other two being diabetes duration and hypertension.

12世紀,13世紀イル・ド・フランスにおける支柱組織の展開について : 6分ヴォールトの諸問題その4

The transition of the pier system in Ile-de-France from the early 12 th century to the early 13 th century is the process that heavy compound piers are replaced with slender colomns by stages. At Early Gothic the sexpartite vault was employed in order to accommodate to the remarkable alternation of the pier system witch was the result that the heavy compound piers have been replaced with slender columns on every other piers. The intermediate pier of Early Gothic sexpartite vaulting church has shafts standing on the capital, from witch terminals arches and ribs depart. I think that such a composition (column-constitution) was originally created when constructors made a trial to cover the apse of ambulatory type choir with rib vault. In this paper, I treat of the evolution of pier constitutions in the whole central space including both choir and nave. As a result, it is able to be considered that the evolution of pier-constitutions of Ile-de-France, from the early 12 th centuy to the early 13 th century, is the process that the column-constitution which was created in the apse of the ambulatory type choir spreads over the other portions of the central space gradually.

Proximal glomerulo-tubular balance in patients with Type 1 (insulin-dependent) diabetes mellitus

To evaluate the glomerulo-tubular balance of sodium and water in the proximal tubules of diabetic patients with elevated glomerular filtration rate, the renal plasma clearance of lithium and the glomerular filtration rate (51Cr-EDTA plasma clearance) were determined simultaneously in 11 ambulatory Type 1 (insulin-dependent) diabetic patients (aged 25-35 years) with no evidence of diabetic nephropathy and in 10 age-matched healthy subjects. The renal plasma clearance of lithium, which is a measure of flow from the proximal tubule into the thin descending limb of the loop of Henle, did not differ between diabetic and control subjects (28.9 +/- 4.0 versus 28.3 +/- 5.1 ml/min per 1.73 m2 surface area, mean +/- SD), whereas the glomerular filtration rate in the diabetic patients was significantly higher than in the control subjects (136 +/- 10.2 versus 108 +/- 13.6 ml/min per 1.73 m2, p less than 0.001). The same held true for the fractional reabsorption rate in the proximal tubules (78.7 +/- 3.2 versus 73.6 +/- 4.9%, p less than 0.02). The results indicate that the elevation of the glomerular filtration rate in diabetic patients is associated with a parallel increase in the proximal reabsorption rate. This type of glomerulo-tubular balance implies that the flow of water and flux of sodium to the segments distal to the proximal tubule are kept constant during variations in the glomerular filtration rate.

GLYCEMIC RECOVERY IN IV INFUSED DIABETICS RECEIVING MEALS OF DIFFERENT SIZES

Increased dietary flexibility is said to be possible in Type I diabetics treated with continuous infusions of insulin. To explore this, we studied the glycemic responses to meals of varying size in 6 ambulatory Type I diabetics aged 16-30y, treated for 3 wk periods with a portable system of IV insulin infusion. During wk 1 the patient's usual (Regular) diet was provided and an waveform of insulin infusion was defined for each meal. This resulted in diurnal normoglycemia. Subsequently, Small (50% of calories) and Large (150%) versions of the R breakfast were provided without change in the insulin infusion waveforms. R lunch was always provided and the resulting glycemic response was studied until dinner. Neither the mean FPG levels before the breakfast of different sizes nor the mean PG rise following the meal were significantly different. However, before lunch the PG level was significantly different when the S or L breakfast was provided instead of the R one. 2h later, during which time the usual augmented insulin infusion was provided, there was no longer any significant difference. Notably before dinner, the PG level was similar for all 3 meal sizes. We conclude that in Type I diabetics managed with preprogrammed IV insulin infusion, variations in caloric intake lead to changes in the time course of the glucose profile which are transient in nature and without sustained adverse glycemic consequence.

Dysfunction of tubular phosphate reabsorption related to glomerular filtration and blood glucose control in diabetic children.

The renal handling of inorganic phosphate was studied by measuring the urinary excretion rate of phosphate (UPO4V), phosphate-(Cr51) EDTA clearance ratio (CPO4/GFR) and maximal tubular reabsorption of phosphate per litre glomerular filtrate (TmPO4/GFR) during fasting in 26 ambulatory Type 1 (insulin-dependent) diabetic children without clinical signs of microangiopathy (age: 7-14 years; duration of disease: 3-14 years). Similar measurements were made in 28 healthy schoolchildren (age: 8-14 years). UPO4 V and CPO4/GFR were significantly enhanced in the diabetic children (p less than 0.001) and correlated with the degree of hyperglycaemia (p less than 0.005). TmPO4/GFR was significantly suppressed in the diabetic children (1.23 versus 1.73 mmol/l, p less than 0.001). This disturbance was neither related to changes in serum parathyroid hormone nor to growth hormone concentrations but was inversely correlated with the degree of hyperglycaemia (r = -0.61, p less than 0.001) and with tubular reabsorption of glucose (r = -0.53, p less than 0.01). In spite of the markedly lowered TmPO4/GFR in the diabetic subjects, the mean maximal (TmPO4) and absolute tubular phosphate reabsorption rates were equal to those of the 28 healthy subjects. Both in the diabetic and healthy subjects, these parameters were positively correlated with glomerular filtration rate which was significantly elevated in the diabetic children (138 versus 109 ml/min per 1.73 m2, p less than 0.01). The study demonstrates a dysfunction in tubular phosphate reabsorption in diabetic children which is related to glycaemic regulation.

Improvement of high-density lipoprotein-cholesterol levels. Ambulatory type I diabetics treated with the subcutaneous insulin pump

Improvement of high-density lipoprotein-cholesterol levels. Ambulatory type I diabetics treated with the subcutaneous insulin pump

Utilization of Nonaccepted Premedical Students

To the Editor.— The, EDITORIALS, "The Medical Manpower Shortage" and "Americans in Foreign Medical Schools" ( 217 :1857, 1971), and the article, "Foreign Medical Schools" ( 217 :1845, 1971), reveal an unexploited medical manpower pool of 14,000 "nonaccepted" medical students, 53.85% of the 26,000 applicants in 1971. Many of these disappointed, better-than-average third- and fourth-year university and college students warrant a chance to earn the right to become a physician. The field of opportunity is on the civilian medical firing line of perimeter medicine. Young physician replacements for the older primary physician are practically non-existent in these areas of greatest need. Present efforts to produce doctors and allied health personnel for the innumerable areas in need of adjunctive community medical care services for the ambulatory type of patients are of token proportions. Primary medical care is the focal point for early diagnosis coupled with adequate treatment to provide the foundation for prevention

COMPOUND FRACTURE THERAPY AT THE BOSTON CITY HOSPITAL

In 1937 I published a paper on the treatment of compound fractures. 1 That paper was based on the work done during the period from 1924 to 1934, whereas this paper covers the work done exclusively in the bone and joint service of the Boston City Hospital during the period from 1934 to 1939. Naturally, a considerable part of the earlier paper is incorporated in this one. During the five year period from July 1, 1934 to July 1, 1939, there were 12,230 patients with fracture admitted to the Boston City Hospital as requiring house care. This number does not include the many hundreds of patients with fractures of the immediate ambulatory type treated on the accident floor or in the outpatient department. Of the 12,230 hospitalized patients, the bone and joint service treated 4,491, of whom 398 had the open, or compound, type of fracture. It is the management

The Ambulatory Type of Case in Mediterranean or Malta Fever

The Ambulatory Type of Case in Mediterranean or Malta Fever