Paramedic Treatment Research Articles

Use of an impedance threshold device in spontaneously breathing patients with hypotension secondary to trauma

An impedance threshold device (ITD) intended for use in the spontaneously breathing patient has been shown to raise blood pressure in hypotensive patients. This device has not been evaluated in patients with hypotension secondary to trauma. This study focused on changes in key vital signs when the ITD was added to the paramedic treatment protocol for hypotensive patients with prehospital traumatic injury. A 6-month prospective nonrandomized observational cohort study was conducted of 200 spontaneously breathing symptomatic adult patients with prehospital hypotension due to multiple causes; the patients of primary interest experienced a traumatic injury. Upon determination of hypotension (systolic blood pressure of approximately ≤90 mm Hg), standard therapy was initiated by application of the mask-style ITD. Vital signs were documented every 2 minutes to 5 minutes after intervention. A change in mean arterial pressure (MAP) with ITD use was the primary study endpoint. Of the 200 hypotensive subjects treated, 29 (3 were excluded because of incomplete data sets and 3 patients treated with the ITD were excluded because their blood pressure did not meet inclusion criterion) were hypotensive secondary to trauma. Their MAP increased from 60 mm Hg (SD, 11 mm Hg; 95% confidence interval [CI], 8.17-15.432) to 78 mm Hg (16 mm Hg; 95% CI, 12.43-23.46) (p = 0.001), without significant change in mean heart rate. Approximately 75% of the patients reported moderate to easy tolerance. Similar increases in MAP were observed in the nontraumatic patients, from 60 mm Hg (10 mm Hg; 95% CI, 9.4-11.5) to 70 (15; 95% CI, 13.4-16.7) (p = 0.0001). In this observational cohort study of patients with hypotension secondary to trauma, the ITD was well tolerated, and MAP as well as systolic and diastolic blood pressure were improved. The patients were not overresuscitated with this intervention. On the basis of these findings, additional studies in patients with hypotension secondary to traumatic injury should be performed to better define the need and benefit of additional fluid resuscitation when the ITD is used. Therapeutic study, level IV.

Response to ‘Paramedic treatment—wherever that may be?’

Sally Boor, paramedic, East of England Ambulance Service NHS Trust responds to James Price's article on the Hazardous Area Response Team (HART), published in last month's issue of the Journal of Paramedic Practice.

Paramedic treatment—wherever that may be?

James Price is Chair of the HART National Operations Group and HART Manager for West Midlands Ambulance Service NHS Foundation Trust, explains areas of operation and types of PPE used by the programme, and the challenges in delivering clinical care within the Inner Cordon.

Addition of Impedance Threshold Device Therapy Improves Blood Pressure in the Out-of-Hospital Spontaneously Breathing Hypotensive Patient

An impedance threshold device (ITD) intended for use in spontaneously breathing patients exhibiting low blood pressure. The ITD is reported to provide therapeutic benefit through inspiratory resistance of 7cmH2O, and clinical improvement has been observed as soon as a patient begins to breathe through it. Pre-clinical and clinical studies have shown that the ResQGARD (Advanced Circulatory, Roseville, MN) increases blood pressure during hypotension from a variety of causes. This device has yet to be tested in a large urban out-of-hospital system. This pilot study sought to identify a change in vital signs following paramedic administration of the ITD. Secondary outcomes included patient tolerance and paramedic perception of patient tolerance. A six-month prospective nonrandomized observational cohort study was conducted. All paramedics received 30-45 minutes of training on patient selection and application of the ITD. This initial training was reinforced utilizing a Web-based training video, and a visual reminder (8.5 x 11 laminated sheet) of the study protocol posted inside the ambulance. The cohort was spontaneously breathing adult patients with hypotension due to dehydration, sepsis, anaphylaxis, or hypovolemia. Exclusion criteria included: unable to maintain airway, pulmonary edema, or significant respiratory distress. Upon determination of hypotension (SBP<90mmHG), standard therapy (positioning, reassurance, and intravascular fluids) was initiated and the ITD was applied in accordance with manufacturer's recommendation. The subject was coached to breathe slow and deep utilizing the mask-type device. Supplemental oxygen was supplied if deemed necessary by the paramedic. Vital signs were documented every 2-5 minutes post intervention. Patient tolerance (observed), and patient comfort (reported) were documented. Two hundred subjects were recruited with a mean initial blood pressure 78/50 (± 14/13) heart rate 87 (± 25) beats per minute and ventilatory rate of 19 (± 7) breaths per minute. After paramedic treatment, including ITD mean blood pressure 97/63 (±19/15; p=<.0001) heart rate 87 (± 25; p=.47) beats per minute and ventilatory rate of 19 (± 7; p=.002) breaths per minute, with 66% of blood pressures increased after. Of the 200 hypotensive subjects, 29 were as a result of trauma (fall, auto collisions, shootings/stabbings). The trauma population also demonstrated a significant increase in mean blood pressure from 80 to 103 systolic, and 56 to 71 diastolic (p=<.0001 and .001, respectively), and non-significant change in mean heart rate from 89 to 80 (p=.17). In all groups, 75% of patients reported moderate to easy tolerance, and only 15% of patients reporting difficult tolerance. The ITD was easily assimilated into the standard bundle of care for the treatment of hypotensive patients. A significant increase in blood pressure was observed in the overall cohort. Importantly for the trauma cohort, the ITD did not restore “normal” blood pressure, but continued to allow for permissive hypotension, and continued to be generally well tolerated.

071 SAFETY AND EFFICACY OF PARAMEDIC TREATMENT OF REGULAR SUPRAVEENTRICULAR TACHYCARDIA:

<h3>Introduction</h3> Treatment of supraventricular tachycardia (SVT) with adenosine by paramedics has been investigated and proven to be safe in the USA, but patients (pts) are transferred to hospital. We hypothesised that paramedics can safely treat and discharge pts with regular SVT without transfer to an accident and emergency department and tested this in a randomised controlled trial. <h3>Methods</h3> Pts presenting with regular narrow complex tachycardia on 12 lead ECG who were heamodynamically stable, with no history of structural or ischaemic heart disease and without contraindication to adenosine were considered for enrolment. Pts were randomised to paramedic treatment (PARA) or admission to hospital (A&amp;E). PARA pts received valsalva manoeuvre at the scene with subsequent administration of 6 mg and 12 mg of adenosine unless the SVT terminated. Pts were taken to A&amp;E if the tachycardia did not terminate, restarted, or the patient (pt) had continuing symptoms, a persistently abnormal ECG (other than T wave inversion) or was heamodynamically unstable. Prior to discharge from the ambulance pts received an information pack and a referral letter for their GP to refer them to an arrhythmia clinic. Pts randomised to A&amp;E were treated as normal and given no information other than that pertaining to the study. <h3>Results</h3> Of the 60 pts (33=F, age 52±19 years) enroled to date, 56% pts had previously attended A&amp;E with palpitations. 2 pts withdrawn as lost to follow up. Results table&nbsp;1 PARA discharge times were relatively long because 12 pts randomised to PARA were transported to A&amp;E (5 did not terminate arrhythmia, 1 abnormal observations, 4 paramedic felt ECG abnormal (confirmed as minor abnormalitites by expert panel that would not require treatment), 2 abnormal ECG requiring treatment). A panel of 2 arrhythmia experts reviewed records for all PARA pts and confirmed treatment was appropriate for all but would have further assessed 1 pt with lung disease. <h3>Conclusions</h3> Paramedic treatment and discharge of pts with regular SVT is safe, efficacious and reduces admissions. Cost effectiveness analysis is ongoing.

How Should Technology-Mediated Organizational Change Be Explained? A Comparison of the Contributions of Critical Realism and Activity Theory

In this paper, critical realism and theory are compared within the context of theorizing technology-mediated organizational change. An theoretic analysis of the implementation of large-scale disruptive information in a public sector setting (in particular concerning paramedic treatment of heart attack patients and ambulance dispatch work activity) is used to illustrate how theory makes a significant contribution to critical realism, by (1) locating technology within activity systems and theorizing change through contradictions and congruencies within those systems; (2) developing recent critical realism-inspired theorization of the inscription of cultural and social relations within technology; and (3) developing recent insights of critical realist researchers regarding the way in which the performance management agenda is mediated through IS.

PP242-MON DETERMINATION OF BODY MASS INDEX AND BODY COMPOSITION OF LOWER LIMB AMPUTEES

PP241-MON QUALITATIVE ANALYSIS OF BARRIERS AND FACILITATORS FOR NUTRITIONAL INTERVENTION IN HIP FRACTURE PATIENTS J. Breedveld-Peters1, P.L. Reijven2, C.E. Wyers1, A.A. Hendrikx1, A.D. Verburg3, J.M. Schols4,5, M.H. Prins1,6, T. van der Weijden7, P.C. Dagnelie1. 1Department of Epidemiology, CAPHRI School for Public Health, Maastricht University, 2Department Clinical Dietetics, Maastricht University Medical Centre, Maastricht, 3Department of Orthopaedic Surgery, Orbis Medical Centre, Sittard, 4Department of General Practice and Department of Health Service Research, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, 5Manager of the Medical and Paramedical Treatment Department, Vivre, 6Department of Medical Technology Assessment, Maastricht University Medical Centre, 7Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands

PP241-MON QUALITATIVE ANALYSIS OF BARRIERS AND FACILITATORS FOR NUTRITIONAL INTERVENTION IN HIP FRACTURE PATIENTS

PP241-MON QUALITATIVE ANALYSIS OF BARRIERS AND FACILITATORS FOR NUTRITIONAL INTERVENTION IN HIP FRACTURE PATIENTS J. Breedveld-Peters1, P.L. Reijven2, C.E. Wyers1, A.A. Hendrikx1, A.D. Verburg3, J.M. Schols4,5, M.H. Prins1,6, T. van der Weijden7, P.C. Dagnelie1. 1Department of Epidemiology, CAPHRI School for Public Health, Maastricht University, 2Department Clinical Dietetics, Maastricht University Medical Centre, Maastricht, 3Department of Orthopaedic Surgery, Orbis Medical Centre, Sittard, 4Department of General Practice and Department of Health Service Research, CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, 5Manager of the Medical and Paramedical Treatment Department, Vivre, 6Department of Medical Technology Assessment, Maastricht University Medical Centre, 7Department of General Practice, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, Netherlands

Prehospital chest emergency sonography trial in Germany

To examine the feasibility and diagnostic value of a novel prehospital chest ultrasound algorithm in patients with dyspnea. Sixty-two patients (32 men, 30 women, mean 67.1 years, range 20-90 years) with acute dyspnea prospectively underwent chest sonography with a portable ultrasound device. The algorithm included five sectional views (four-chamber subxyphoidal view, left and right laterodorsal view, left and right anterior intercostal space two to four view) screening for pleural and pericardial effusion, right heart distension, and pneumothorax. The prehospital sonographic findings were confirmed by chest radiograph, ultrasonography, and clinical follow-up in the emergency department. Prehospital chest emergency sonography trial was completed in 56 patients. Mean examination time was 2 min, and no scan took longer than 5 min. Sonography was easily integrated in the prehospital workflow alongside paramedic treatment without delay of treatment or transport. The most common diagnoses associated with acute dyspnea were (a) acute coronary syndrome (n=12, 21%), (b) decompensated congestive heart failure (CHF) (n=11, 20%), and (c) chronic obstructive pulmonary disease (COPD) (n=10, 18%). Pleural effusion was detected in 100% of CHF, 17% of acute coronary syndrome, and 20% of COPD patients, constituting a highly significant parameter in the differential diagnosis (P<0.01). Ultrasonography provided a helpful tool in n=38 (68%), and additional therapeutic consequences were drawn in n=14 (25%). Prehospital chest emergency sonography trial is a novel prehospital ultrasound algorithm for patients with dyspnea. Pleural effusion may serve as a novel prehospital marker for patients with decompensated CHF, thus facilitating the often difficult differential diagnosis between CHF and COPD.

Predictors for Persistent Neuropathic Pain – A Delphi Survey

Background: Chronic neuropathic pain has a major effect on quality of life. In order to prevent neuropathic pain from becoming chronic and improve neuropathic pain care, it is important to identify predictors associated with the persistence of neuropathic pain. Objective: To identify potential predictors associated with the persistence of neuropathic pain. Study Design: A 2-round Delphi study. Setting: University Medical Center and Pain Management Research Center Methods: A 2-round Delphi study was conducted among 17 experts in the field of neuropathic pain. Selection of the panel was based on the citation index ranking for neuropathic pain-related research and/or membership in the neuropathic pain special interest group of the International Association for the Study of Pain (IASP), complemented with experts with demonstrated field knowledge. Potential predictors were categorized according to the International Classification of Functioning, Disability and Health model. Participants were asked to identify important predictors, suggest new predictors, and grade the importance on a 0-10 scale. For the second round, predictors were considered important if the median score was ≥ 7 and the interquartile range (IQR) ≤ 3. Results: In the first round, 20 predictors were selected and 58 were added by the experts (patient characteristics [15], environmental factors [25], functions &amp; structure [4], participation &amp; health related quality of life [14]). In the second round, 12 predictors were considered important (patient characteristics [4; e.g., depression, pain catastrophizing], environmental factors [surgery as treatment for neuropathic pain], functions &amp; structure [6; e.g., allodynia, duration of the complaints], participation &amp; trait anxiety/depression as a part of health related quality of life). Presence of depression and pain catastrophizing were considered the most important predictors for chronic neuropathic pain (median ≥ 8;IQR ≤ 2). Limitations: The study design did not include plenary discussion among the experts. The meaning of the individual topics used in this study could have been subject to interpretation bias. Conclusions: Overall, psychological factors and factors related to sensory disturbances were considered important predictors for persistence of neuropathic pain. Activity related factors and previously received paramedical and alternative treatment were considered to be less important. The list of possible predictors obtained by this study may serve as a basis for development of a clinical prediction rule for chronic neuropathic pain. Key words: Neuropathic pain, chronic pain, persistence, Delphi study, opinion, predictors, ICF model.

Paramedical treatment in primary dystonia: A systematic review

Dystonia is a disabling movement disorder with a significant impact on quality of life. The current therapeutic armamentarium includes various drugs, botulinum toxin injections, and occasionally (neuro)surgery. In addition, many patients are referred for paramedical (including allied health care) interventions. An enormous variation in the paramedical treatment is provided, largely because evidence-based, accepted treatment regimes are not available. We have conducted a systematic review of studies that explored the effect of various paramedical interventions in primary dystonia. Only studies that have used clinical outcome measures were included. There were no class A1 or A2 studies and therefore, level 1 or 2 practice recommendations for a specific intervention could not be deducted. Many papers were case reports, mostly with a very limited number of patients and a clear publication bias for beneficial effects of a particular paramedical intervention. Some potentially interesting interventions come from class B studies, which include physical therapy in addition to botulinum toxin injections (BoNT-A) in cervical dystonia; sensorimotor training and transcutaneous electrical nerve stimulation (TENS) in writer's cramp; and speech therapy added to BoNT-A injections in laryngeal dystonia. Good quality clinical studies are therefore warranted, which should have the aim to be generally applicable. A design in which the paramedical intervention is added to a current gold standard, for example, BoNT-A injections in cervical dystonia, is recommended.

Effects of therapy in oropharyngeal dysphagia by speech and language therapists: a systematic review.

Medical and paramedical treatments should be evaluated according to current standards of evidence-based medicine. Evaluation of therapy in oropharyngeal dysphagia fits into this growing interest. A systematic review is given of the literature on the effects of therapy in oropharyngeal dysphagia carried out by speech therapists. Thus, the review excludes reports of surgical or pharmacological treatments. The literature search was performed using the electronic databases PubMed and Embase. All available inclusion dates up to November 2008 were used. The search was limited to English, German, French, Spanish, and Dutch publications. MESH terms were supplemented by using free-text words (for the period after January 2005). Fifty-nine studies were included. In general, statistically significant positive therapy effects were found. However, the number of papers was rather small. Moreover, diverse methodological problems were found in many of these studies. For most studies, the conclusions could not be generalized; comparison was hindered by the range of diagnoses, types of therapies, and evaluation techniques. Many questions remain about the effects of therapy in oropharyngeal dysphagia as performed by speech and language therapists. Although some positive significant outcome studies have been published, further research based on randomized controlled trials is needed.

A systematic review of controlled studies: do physicians increase survival with prehospital treatment?

BackgroundThe scientific evidence of a beneficial effect of physicians in prehospital treatment is scarce. The objective of this systematic review of controlled studies was to examine whether physicians, as opposed to paramedical personnel, increase patient survival in prehospital treatment and if so, to identify the patient groups that gain benefit.MethodsA systematic review of studies published in the databases PubMed, EMBASE and Cochrane from January 1, 1990 to November 24, 2008. Controlled studies comparing patient survival with prehospital physician treatment vs. treatment by paramedical personnel in trauma patients or patients with any acute illness were included.ResultsWe identified 1.359 studies of which 26 met our inclusion criteria. In nine of 19 studies including between 25 and 14.702 trauma patients in the intervention group, physician treatment increased survival compared to paramedical treatment. In four of five studies including between nine and 85 patients with out of hospital cardiac arrest, physician treatment increased survival. Only two studies including 211 and 2.869 patients examined unselected, broader patient groups. Overall, they demonstrated no survival difference between physician and paramedical treatment but one found increased survival with physician treatment in subgroups of patients with acute myocardial infarction and respiratory diseases.ConclusionOur systematic review revealed only few controlled studies of variable quality and strength examining survival with prehospital physician treatment. Increased survival with physician treatment was found in trauma and, based on more limited evidence, cardiac arrest. Indications of increased survival were found in respiratory diseases and acute myocardial infarction. Many conditions seen in the prehospital setting remain unexamined.

CVA-patiënten die aangewezen zijn op langdurige verpleeghuiszorg.

Many patients who suffer from an acute stroke, will need long-term nursing home care. We are poorly informed about the demographic and clinical characteristics and about the care problems and received care of these patients. This study aims to provide a first description of these characteristics in this group of patients.Data on demographic and health-related characteristics, social participation and received care were collected with the Minimum Data Set of the Resident Assessment Instrument, from january 2004-march 2007, in patients who needed long-term nursing home care. Data were collected in eight nursing homes at admission and six months after admission.Many patients were functionally impaired, suffered from depressive symptoms and pain, and were cognitively impaired. In addition, decisional capacity was frequently diminished. The majority of patients were residing at somatic wards, even when severe cognitive impairment was present, such as dementia. Several forms of restraints were frequently used, also at somatic wards. About 40% of the patients, mostly residing at somatic wards, received paramedical treatment. Social engagement was low and was correlated with functional impairment.Stroke patients who need long-term nursing home care suffer from problems in several domains. The high prevalence of cognitive impairment in stroke patients residing at somatic wards, combined with the ample use of restraints on these wards, raises questions about the appropriateness of the currently delivered care to these patients, considering the problems they have.

Prehospital Noninvasive Ventilation: A Viable Treatment Option in the Urban Setting

Objective. To determine the viability of prehospital noninvasive ventilation (NIV) as a prelude to a definitive clinical trial. Methods. This was a retrospective observational study of patients (aged > 55 years, severe shortness of breath) transported to a tertiary emergency department (10/5/03–12/28/04). Data were extracted from paramedic andhospital medical records. The primary outcome measure was the number of patients who could potentially benefit from prehospital NIV. They were defined as “conscious upon paramedic arrival andwho required ventilatory support (bag/valve/mask ventilation [BVM], NIV or endotracheal intubation) during transport or within 30 minutes of arrival at the emergency department (ED).” The secondary outcome measures were the effectiveness of existing paramedic treatment regimens andparamedic management times. Results. Two hundred sixty-four patients were enrolled (mean age 75.5 ± 8.7 years, 59.1% male). Sixty-seven patients (25.4%, 95% CI: 20.3–31.2) met the primary outcome measure: 31 (11.7%, 95% CI: 8.2–16.4) received prehospital BVM, an additional 35 (13.3%, 95% CI: 9.5–18.1) received NIV in the ED andone (0.4%, 95% CI: 0.0–2.4) was intubated in the ED. Prehospital treatment resulted in significant (p < 0.001) improvements in systolic blood pressure (151.2 dropping to 144.2 mmHg), respiratory rate (29.4 dropping to 26.3 breaths/minute), andoxygen saturation (92.3% rising to 96.2%). Median paramedic management time was 33 minutes (IQR 29–40). Conclusion. Prehospital treatment significantly improved patient vital signs. However, a considerable proportion of patients still required ventilatory support either prehospital or early in their ED course. Further research is indicated to determine if these patients would benefit from prehospital NIV.

Physical and Occupational Therapies in Complex Regional Pain Syndrome Type I

ABSTRACTIn patients with CRPS-I there are varying manifestations in the development and progression of the syndrome. It may lead to minimal impairment (i.e., loss of strength or pain with exposure to cold) or it may lead to major impairment, resulting in chronic invalidism. In extreme cases CRPS-I may even lead to amputation. There is a lack of knowledge in the efficacy of most treatments, time dependent symptoms of CRPS-I, natural course, prognostic factors and psychological and psychosomatic aspects of CRPS-I. In general the scientific background for therapy and for paramedical treatment particular is lacking. It may appear strange that without much evidence rehabilitation has such an important emphasis in these guidelines. The fact of the matter is that there are essentially no evidence-based therapies, and to not treat patients until ‘hard science’ is available is nihilistic. The rehabilitation method, especially physical and occupational therapies (PT and OT), provide a varied and balanced empirical ...

Characteristics of patient and healthcare service utilization associated with inappropriate hospitalization days

This paper is a report of a study to examine the number of inappropriate days of hospitalization and to identify the characteristics of patient and healthcare service utilization associated with inappropriate hospital stays. Inappropriate hospitalization stays are recognized as an important indication of the misuse of healthcare services, but the published literature shows inconsistent findings on factors influencing this. A descriptive, correlational study was carried out in September 2005, with a patient survey and a review of patient records. Data were collected for 383 patients discharged from eight general nursing care units in a tertiary teaching hospital in Korea. Inappropriate hospitalization days were defined as inpatient days not requiring continuous and active medical, nursing or paramedical treatment provided by hospital services, and were judged using the Korean version of the Appropriate Evaluation Protocol. Univariate and multiple regression analyses were performed to determine factors associated with inappropriate hospitalization days. A total of 3076 hospitalization days were reviewed. The average proportion that were inappropriate was 5.1% (+/-16.0) per patient, and 14.1% of patients were determined to have had at least one inappropriate hospitalization day. The most common reason judged as appropriate was need for nursing/life support services. Statistically significant factors associated with inappropriate stay included gender, age, primary disease, length of stay and ward bed occupancy level during the patient's hospitalization. Managers should take into account patient and clinical characteristics to promote better utilization of hospital resources.

Improving the Transfer of Care to General Practice for People With Intellectual Disabilities: Development of a Guideline

Abstract In the Netherlands, a public policy shift has led to a movement of people with intellectual disabilities (ID) from residential congregate care facilities to normative housing in their communities. Along with these physical transfers, medical care has also been transferred from specialty intellectual disability physicians (IDPs) associated with the residential facilities to general practitioners (GPs) native to the community. To facilitate these changes, the authors created a set of guidelines for the transfer of ID medical care. In developing these guidelines, the authors queried: (1) What elements have to be included in the draft guidelines? (2) What are the barriers to using the draft guidelines in practice and how can these barriers be overcome? and (3) What elements have to be included in the final form of the guidelines? Data for the draft guidelines were drawn from information gathered during interviews and discussions with physicians and allied workers. The guidelines call for a feasible working agreement between IDPs and GPs regarding handing over patient files containing problem lists and histories and arrangements of out‐of‐hours house calls, practice visits, medication delivery, and paramedical treatments. Inherent barriers to the implementation of the guidelines might be communication difficulties among persons involved in the transfer of care and governmental rules that fail to overcome organizational barriers.

Primary Prevention and Health Services Delivery

Stroke remains the third leading cause of death in the US and other Western countries,1 and at least 1 population-based study found that the incidence of stroke was greater than that of acute coronary syndromes.2 Although there have been substantial falls in stroke incidence in some countries over the last 2 decades,3 a large US study found that the advances in stroke prevention during the 1990s were not associated with decreases in the rate of stroke hospitalizations or in case-fatality rates between 1993 and 1999.4 Moreover, based solely on demographic changes in the population of selected countries within the European Union, the World Health Organization predicts a 27% increase in stroke events between the years 2000 and 2025.5 The proportion of deaths attributed to stroke is even higher in Asian countries.6 Although much of stroke risk may be related to socioeconomic factors, more effective prevention strategies are critical. Several studies have contributed to the body of knowledge related to primary stroke prevention over the last year. Numerous studies support an association between elevated homocysteine levels and atherosclerotic disease.7 The B vitamins (folic acid, B12, and B6) reduce homocysteine serum levels raising the hope that treatment would be associated with reduced risk. That hope was diminished with publication of results of the Vitamin Intervention for Stroke Prevention (VISP) trial in 2004.8 Although a secondary rather than a primary stroke prevention trial, VISP had compared high- and low-dose B-vitamin supplementation and found no treatment effect on the risk of recurrent stroke (risk ratio [RR] 1.0; 95% CI, 0.8 to 1.3), or in the combined risk of any stroke, coronary heart event, or death (RR, 1.0; 95% CI, 0.8 to 1.1). The difference in homocysteine levels between treatment groups, however, was small …

The cost of treating patients with COPD in Denmark - A population study of COPD patients compared with non-COPD controls

This paper describes a population-based study of health care resource use of patients with chronic obstructive pulmonary disease (COPD) compared to non-COPD controls. Through a screening of the Danish Patient Registry for patients admitted with COPD diagnoses for a 5-year period, 1998-2002, 66,000 individuals with COPD still alive at the beginning of 2002 were identified. Their use of health care resources in 2002 were compared with equivalent data, stratified for age, sex and mortality rates, for a control population without COPD based on data for the 300,000 remaining patients on the Danish Patient Registry in 2002. Results indicated that the gross cost of treating patients with COPD in the Danish somatic hospital and primary health care sector corresponded to 10% of the total cost of treating patients of 40 years or more. The net cost for COPD patients was 1.9 billion DKK (256 million euro), 6% of the total annual costs of treating the population of 40 years or more. The gross cost related to any disease and the net cost reflected the resource use which could be attributed to COPD and its related diagnoses. The incidence of inpatient hospital admissions was almost four times higher in the COPD population than in the control group. COPD patients contacted their general practitioner 12 times more per year than non-COPD controls, but for specialist and paramedic treatment in the primary care sector there was no significant difference between COPD patients and non-COPD controls. Only one third of the COPD costs were due to treatment of COPD as the primary diagnosis. The remaining two-thirds of the COPD-related costs were mainly due to admissions for other diseases such as cardio-vascular diseases, other respiratory diseases, and cancer.