Benefit-incidence analysis of government spending on Ministry of Health outpatient services in Jordan

A benefit-incidence analysis was conducted for the year 2000 using various data sources including the Jordan healthcare utilization and expenditure survey 2000. The results illustrate that the poorest segment of the Jordanian population were the most likely to report sickness and seek treatment and were the main users of the Ministry of Health outpatient services. The poorest uninsured individuals were the main source of revenues generated through user fees. The targeting efficiency [i.e. total percentage of benefits received] for the poorest quintile was 33.8% compared with 4.0% in the richest quintile. The analysis demonstrates that the Jordanian government in-kind subsidy is reaching the poor

Prevalence and outcome of bacterial endocarditis in patients with implantable cardiac devices infections

Cardiac device infection [CDI] is a devastating complication of permanent pacemakers [PPM] or implantable cardioverter-defibrillators [lCD]. The incidence and outcome of endocarditis among patients [Pts] with CDI is not well defined. Is to report the experience in the prevalence, clinical presentations and management of bacterial endocarditis [BE] among patients with CDI in a tertiary care cardiac center over 25 years. A total of 2630 cardiac devices implanted in a cohort of 2367 patients [pts] over 25 years were studied. Out of these, 117 [4.4%] Pts presented with CDI. Clinical, bacteriologic and both transthoracic [TTE] and transoesophageal Echocardiographic [TEE] assessments were done. Of the 117 Pts with CDI [90 males, age ranging 18-82 yrs, mean=63 +/- 6 ys], 87 [74%] had redo procedures [battery replacement in 50, repositioning of leads in 12, device extrusion in 15 or evacuation of significant haematoma in 10 pts]. Of these 87 pts, 65 had re-implants on the same day of explantation. In 30 pts [26%] no apparent cause of P1 was identified. Out of the 117 Pts with CDI, 30 pts [26% of CDI and 1.1% of total procedures] had device-related BE with vegetations appeared in all pts by TEE [15 DDD, 9 VVI, 3 CRT and 3 lCD]. The clinical presentations were prolonged fever in 25 pts [83%], significant pulmonary hypertension with thrombo-embolism in 3 pts [10%], severe sepsis and multi-organ failure in 2 pts [6%]. Twenty-eight pts [93%] had positive blood cultures Istaph.aureus in 23 [77%] and enterococci in 5]. There were only 2 Pt with negative blood cultures. Device lead vegetations were evident in 20 pts [>10mm diameter in 13 pts]. Ten pts presented with only right heart valves vegetations. Out of the 30 BE pts, 28 [93%] had P1 while 2 pts had no apparent cause but frequent intravenous injections [one drug addict and one on regular haemodialysis]. Out of the 20 pts with lead endocarditis 15 had their leads removed surgically with re-implantation of either epicardial [6 pts] or endocardial leads [9 pts]. Fifteen pts had only medical treatment with proper antibiotics [5 pts with lead BE and all 10 pts with valvular BE]. Four pts [13%] died; all had their devices implanted on same day of explanation. Conclusion: Cardiac devices Redo procedures are major risk factors for CDI specially re-implantation on same day. Device related BE carries a serious morbidity and mortality yet surgical removal of the whole system is the management of choice. Blood stream bactraemia is a potential risk factor in patients with cardiac devices and warrant prophylaxis against BE

Prevalence and outcome of bacterial endocarditis in patients with implantable cardiac device infections

Cardiac device infection [CDI] is a devastating complication of permanent pacemaker [PPM] or implantable cardioverter-defibrillators [ICD]. The incidence and outcome of endocarditis among patients with CDI is not well defined. The aim of this study was to report our experience in the prevalence, clinical presentations, and management of bacterial endocarditis [BE] among patients with CDI in a tertiary care cardiac center over a 25-year period. A total of 2630 cardiac devices implanted in a cohort of 2367 patients over 25 years were studied. Of these, 117 [4.4%] patients presented with CDI. Clinical, bacteriologic and both transthoracic [TTE] and transoesophageal echocardiographic [TEE] assessment were done. Of the 117 patients with CDI [90 males, age range 18-82 yrs, mean = 63 +/- 6 yrs], 87 [74%] had redo procedures [battery replacement in 50, repositioning of leads in 12, device extrusion in 15 or evacuation of significant haematoma in 10 patients]. Of these 87 patients, 65 had -re-implants on the same day of explantation. In 30 patients [26%] no apparent cause of PI was identified. Of the 117 patietns with CDI, 30 patients [26% of CDI and 1.1% of total procedures] had device-related BE with vegetations having appeared in all patients by TEE [15 DDD, 9VVI, 3 CRT and 3 ICD]. The clinical presentations were prolonged fever in 25 patients [83%], significant pulmonary hypertension with thrombo-embolism in 3 patients [10%], severe sepsis and multi-organ failure in 2 patients [6%]. Twenty-eight patients [93%] had positive blood cultures [S aureus in 23 [77%] and enterococci in 5]. There were only 2 patients with negative blood cultures. Device lead vegetations were evident in 20 patients [>10 mm diameter in 13 patients]. Ten patients presented with only right heart valve vegetations. Of the 30 BE patients, 28 [93%] had PI while 2 patients had no apparent cause but frequent intravenous injections [one drug addict and one on regular haemodialysis]. Of the 20 patients with lead endocarditis, 15 had their leads removed surgically with re-implantation of either epicardial [6 patients] or endocardial leads [9 patients]. Fifteen patients had only medical treatment with proper antibiotics [5 patients with lead BE and all 10 patients with valvular BE]. Four patients [13%] died; all had their devices implanted on same day of explanation. Cardiac device redo procedures are major risk factors for CDI, especially with re-implantation on the same day. Device related BE carries a serious morbidity and mortality, yet surgical removal of the whole system in the management of choice. Blood stream bacteraemia is a potential risk factor in patients with cardiac devices and warrants prophylaxis against BE

Percutaneous extraction of an infected permanent pacemaker in association with superior vena cava obstruction

The procedure of lead removal has recently matured into a definable, teachable art with its own specific tools and techniques. It is now time to recognize and formalize the practice of lead removal according to the current methods of medicine and the health care industry. In this article we report the first case in the United Arab Emirates of infected pacemaker extraction after 9 years of implantation of passive fixation lead for a VVI pacemaker using a locking stylet and countertraction technique with associated superior vena cava obstruction, which had been dilated using the balloon technique with deployment of a stent

Conventional Vs non invasive ventilation in acute respiratory failure

Treatment of patients with acute respiratory failure [ARF] often involves mechanical ventilation via endotracheal intubation. Non-invasive positive pressure ventilation [NIV] using Bi-level positive airway pressure [BiPAP] can be a safe and effective means of improving gas exchange. 1] Assess non-invasive positive pressure ventilation [BiPAP] as an alternative way for ventilation in ARF, and to 2] Determine factors that can predict the successful use of BiPAP. Thirty patients with acute respiratory failure [both type I and II] were enrolled in the study and divided into two groups. Group I included 10 patients who were subjected to invasive mechanical ventilation. Group II included 20 patients were subjected to NIV using BiPAP. Both groups were compared regarding the following parameters: Arterial blood gases [ABG] on admission, 30 minutes after beginning of mechanical ventilation, 1[1/2] hour then once daily. Complications namely ventilator associated pneumonia [VAP], skin necrosis and CO[2] narcosis; static compliance and resistance were measured at day one and day two. Compared to group I, group II patients were associated with similar improvement in ABGs data at 30 minutes and at discontinuation of ventilation [Table A]. Group II patients showed significantly lower incidence in VAP [20% Vs 80%], shorter duration of mechanical ventilation [3 +/- 3 Vs 6 +/- 5 days, p=0.006], with shorter length of hospital stay [5.8 +/- 3.6 Vs 8.9 +/- 2.7 days, p=0.011] when compared to group I. Skin necrosis [50%] and CO[2] narcosis [20%] occurred in group II only. Group II patients showed significant difference change in compliance and change in resistance from day I to day II when compared to group I Table [B]. On univariate basis, parameters were analyzed to choose those who were associated with outcome in concern [successful NIV]. The following parameters were identified: Level of consciousness, pH [7.3 +/- 0.03 Vs 7.26 +/- 0.1, p=0.009] PCO[2] [69.16 +/- 13.14Vs 100.97 +/- 12.04] on admission, 1[1/2] hour after NIV, pH [7.37 +/- 0.03 Vs 7.31 +/- 0.17, p=0.005], PCO[2] [53.98 +/- 8.95 Vs 77.47 +/- 5.22, p=0.0001] in whom NIV succeeded and failed respectively. Then multivariate analysis utilizing two different techniques namely [multivariate logistic regression and discriminate analysis] was used. The variable identified was PCO[2] after 1[1/2] hour in the two models with specificity 100%. In patients with acute respiratory failure, non-invasive ventilation was as effective as conventional ventilation in improving gas exchange, associated with fewer serious complications and shorter stay in intensive care. One and half hour trial with NIV can predict success with BiPAP, as shown by an improvement in pH and PCO[2] and overall clinical picture. PCO[2] after 1[1/2] hour could be the sole predictor of successful NIV with 100% specificity

Assessment of the efficacy of sephadex filtration of buffalo spermatozoa for cryopreservation

In the present study, two experiments were conducted. The first experiment aimed to study the influence of buffalo bull semen filtration throughout different grades of sephadex columns [G-25, G-50, G-75, G-100 and G-200] on semen quality. Semen samples were collected from four buffalo bulls, diluted 1:20 with Tris buffer, loaded in different grades of sephadex columns and kept for 4-5 minutes at 37ooC. Filtered semen samples showed significantly [p<0.0001] higher individual motility [68.75 84.38%] in different grades of sephadex when compared to control samples [63.13%]. Percentages of live spermatozoa were found to be higher for filtered samples [71.38 -88.63%] than that of control samples [65.94%]. Percentages of major and minor abnormal spermatozoa were found to be decreased [2.37 4.5% and 1.56 5.12%, respectively] significantly [p< 0.0001] than that of control samples [5.56 and 6.31%, respectively]. Percentages of spermatozoa with acrosomal defects were found to be significantly [p<0.0001] lowered [1.44 3.88%] significantly [p<0.0001] in comparison with control samples [4.63%]. The loss in sperm number [0.67 to 0.99 vs 1.25 X 109 /ml] could be adequately compensated by obtaining higher values of all other important semen quality traits. The use of G-75 sephadex grade is recommended for wider use because it gives a more balanced picture of semen quality compared with other grades studied. The second experiment aimed to study the efficacy of sephadex G-75 filtration of buffalo spermatozoa for cryopreservation. Semen samples were collected from the same bulls used in the first experiment. Split samples were diluted 1:20 with Tris buffer, filtered through sephadex G-75 columns and centrifuged at 1500 rpm for 5 minutes. The supernatant was discarded and the sediments were re-diluted and frozen in Obtidyl diluent [Tris based diluent]. Filtration was found to improve semen quality after dilution, freezing and thawing. Post-dilution, filtrated sperm motility was significantly [p<0.0001] improved [86.25%] when compared with control samples [67.91%]. Post-thaw sperm motility of filtered samples was significantly [p<0.001] higher [61.25%] than that of control samples [45.83%]. Filtration was significantly enhanced sperm viability after thawing [p<0.0001], where viability indices were averaged 151.71 vs 90.83 for control samples. Percentages of spermatozoa with acrosomal defects were significantly [p<0.0001] reduced for filtered samples after dilution [1.92 vs 5.83%] and after freezing and thawing [7.75 vs 14.66%]. Bull individualities were found prominent for some parameters; post-thaw sperm motility and viability indices [p<0.05]. From the present study, filtration of semen samples through sephadex G-75 column could be recommended to improve pre- and post-thaw sperm quality of buffalo bull semen samples

Sildenafil is as effective in secondary as in primary pulmonary hypertension: impact on acute and short term haemodynamics

Patients with pulmonary hypertension [PH] usually present with limited exercise tolerance, heart failure, and diminished life expectancy. Vasodilators might cause hypotension and deterioration in gas exchange. Sildenafil, a selective phosphodiestrase inhibitor [PDEI-type 5] has been used as an alternative to prostacyclin and nitric oxide in primary PH with reports of early success. Our aim was to assess the acute and short term effects of Sildenafil in patients [pts] with pulmonary hypertension due to different etiologies. Ten pts have been studied [7 females, 3 males, mean age 37 +/- 10 y, range=23-56ys.]. They included 4 pts with primary PH, 2 with Eisenmenger syndrome, 2 with thromboembolic and 2 with Bilharzial PH. Following clinical evaluation and functional class assessment [NYHA], all pts were subjected to Swan-Ganz catheterization whereby mean pulmonary artery pressure [mPAP], pulmonary vascular resistance [PVR] and mixed venous oxygen saturation [mVo2] were invasively measured. Echocardiography where right ventricular diameter [RVD] in short axis view, left ventricular stroke volume [SV] and cardiac output [COP] were evaluated. Readings were recorded before, 3 days and 3 months after start of oral Sildenafil therapy [25 mg 6 hourly] for all pts. Out of the 10 pts, 8 [including 3 with PPH] showed significant clinical, hemodynamic and echocardiographic improvement 3 days after therapy. Two pts failed to show improvement [one primary and one Eisenmenger PH]. The former 8 pts showed improvement of NYHA class [from IV to III], a substantial reduction of mPAP [95 to 76 mmHg, p<0.01] of mean PVR [1797 to 1128 dynes. sec cm-5, p<0.01] with insignificant rise in mVo2 [53 to 57 Torr]. All hemodynamic changes occurred without change of arterial BP or heart rate. Echocardiography showed insignificant mild reduction in mean RVD [6.6 to 6.4 cm] with marginally significant rise in SV [44 to 51 Ml, p<0.05], and COP [3.7 to 3.9 L/min, P < 0.01]. Follow up three months later showed sustained improvement in 7 out of the latter 8 pts [one Bilharzial pt died suddenly after discharge] clinically [NYHA-III to II], further reduction of mPAP [from 77 to 67 mmHg, p<0.05], mean PVR [from 1128 to 958 dynes sec. cm -5, p<0.01] with further rise in mVo2 [from 57 to 61 Torr, P<.01]. Echocardiography showed continued significant reduction of the RVD to 4.1 cm [P<0.01] with further rise in SV to 56 ml [P<0.05], and COP to 4.1 L/min [P < 0.01]. 1] Sildenafil proved to be effective in the acute and short term conditions both subjectively and objectively and in both primary and secondary PH. 2] In Bilharzial PH, sildenafil looks promising, however larger number of Bilharzial PH pts should be studied.3] Sildenafil and other selective PDE5 inhibitors with improved selectivity and longer half-lives merit further therapeutic studies in pulmonary hypertension

Viral hepatitis in malignant lymphoma

This study included 25 newly diagnosed non-Hodgkin's lymphoma [NHL] patients who fulfilled the criteria for inclusion in the study. Hepatitis profile was done for NHL patients at the time of diagnosis and after three months of chemotherapy and for ten healthy persons who were selected as a control group. In addition to the routine lab investigations, lactate dehydrogenase [LDH], B2 microglobulin and hepatitis markers were done before each cycle of chemotherapy. The study revealed a high percentage of NCV infection in patients with NHL [36%] in comparison with the control group [10%]. Patients with positive serological markers were liable to hepatic dysfunction and hepatitis reactivation during and after the end of chemotherapy. The presence of the hepatitis infection did not affect the response to chemotherapy in this group of patients. However 3/5 of the relapsed patients were HCV +ve. The results of serum gamma transferase [GGT] before treatment with chemotherapy in patients who were positive and negative to HCV showed very highly significant difference

Percutaneous dilational tracheostomy in critically ill patients

This study was performed on 18 critically ill surgical or medical ICU patients [10 males, mean age 32.8 +/- 17 years] in a tertiary university hospital requiring tracheostomy for airway control or prolonged mechanical ventilation. It aimed to evaluate the safety and cost-effectiveness of the bedside percutaneous dilatational tracheostomy [PDT] in the critically ill patients and to compare two different methods of PDT; namely, the progressive and the single dilatation techniques. The patients were randomized to undergo PDT by either the multiple progressive dilatation method [group A, eight patients] or single dilatation method [group B, ten patients]. The study concluded that PDT is a relatively safe and fast procedure in the ICU-critically ill patients. The single dilatation method is even more rapidly performed bedside method than the progressive dilatation one

radiological appearance of the chest in sickle cell anemia

The radiological picture of the chest in sickle cell disease has not been widely reported in the literature. The following study concerns the chest findings in thirteen consecutive patients, encountered during 14 months in the Radiological Department of a Private Hospital