Shock reduction using antitachycardia pacing for spontaneous rapid ventricular tachycardia in patients with coronary artery disease.

BACKGROUND: Implantable cardioverter-defibrillators (ICDs) can terminate some ventricular tachycardias (VTs) painlessly with antitachycardia pacing (ATP). ATP has not routinely been applied for VT >188 bpm because of concerns about efficacy, risk of acceleration, and delay of definitive shock therapy. This prospective, multicenter study evaluated the efficacy of empirical ATP to terminate fast VT (FVT; >188 bpm). METHODS AND RESULTS: Two hundred twenty coronary artery disease patients received ICDs for standard indications. Empirical, standardized therapy was programmed so that all FVT episodes (average cycle length [CL] 240 to 320 ms, 250 to 188 bpm) were treated with 2 ATP sequences (8-pulse burst pacing train at 88% of the FVT CL) before shock delivery. A total of 1100 episodes of spontaneous ventricular tachyarrhythmias occurred during a mean of 6.9+/-3.6 months of follow-up. Fifty-seven percent were classified as slow VT (CL>/=320 ms), 40% as FVT (240 ms

[10 year results of preoperative radiotherapy in treatment of rectal carcinoma]. / 10-Jahres-Ergebnisse der präoperativen Radiotherapie in der Behandlung des Rectumcarcinoms.

BACKGROUND: We have previously reported improvements in survival and disease-free survival at five years using preoperative radiation in the treatment of rectal cancer. The current update was undertaken to determine if these favorable results were durable with longer follow-up. METHODS: Patients found to have resectable rectal cancer between 1972 and 1979 were treated with 40-45 Gy of preoperative radiation (40 patients) or resection alone (109 patients). Follow-up information beyond five years was obtained from the Tumor Registry, physician contact and a survey of the National Death Index. Of the 149 patients followed for five years, 144 were evaluable at ten years. RESULTS: After a median follow-up of 125 months, survival of the irradiated patients was significantly better than that of controls (77 versus 57% at 5 years and 74 versus 41% at 10 years, p = 0.0044). Disease-free survival of those patients whose resection margins were free was also superior for the irradiated group (85 versus 59% at 5 years and 80 versus 45% at 10 years, p = 0.0045). CONCLUSIONS: The results show that the survival advantage for 40 to 45 Gy preoperative radiation in the treatment of rectal cancer persist at 10 years follow-up.

Effect on physical functioning of care in adult foster homes and nursing homes.

This study tested the effects on physical functioning of substituting adult foster care (AFC) for nursing home care. Secondary data from Oregon's Medicaid agency were used to compare change in ADL functioning of 1,032 nursing home and 279 AFC residents. Maximum likelihood estimation was used to analyze selection of long-term care setting and change in functioning. One-third of surviving AFC residents would have been better off in a nursing home, whereas almost all nursing home residents were placed appropriately. Further research on outcomes that clients value most along with efforts to support functioning are needed.

The influence of local tumor ulceration on the effectiveness of endocavitary radiation for patients with early rectal carcinoma.

BACKGROUND: Endocavitary radiation therapy is an alternative to surgical therapy for some early rectal carcinomas. Careful patient selection is necessary to ensure good results. The purpose of this study was to examine the authors' experience with endocavitary radiation at their institution from 1984 to 1991 to determine which factors were associated with treatment failure to provide for better future patient selection. METHODS: Thirty-two patients with carcinoma of the rectum, not apparently involving the muscle wall, underwent 75-120 Gy of endocavitary radiation as potentially curative therapy. Treatment was given as a series of 2-4 doses of 30 Gy at three weekly intervals. Twenty-two patients had polypoid tumors, 5 sessile, and 5 ulcerated. RESULTS: After a mean follow-up of 43 months (range, 6-103 months), 4 of 5 patients (80%) with ulcerated tumors developed local recurrences, compared with only 4 of 27 (15%) with sessile or polypoid lesions. Not only was the incidence of local recurrence greater for patients with ulcerated tumors (P = 0.009), but the time to recurrence was shorter also (P = 0.0001). Tumor size, anterior or posterior location, and dose of radiation received did not affect the rate of recurrence. CONCLUSIONS: These results indicate that superficial polypoid and sessile rectal tumors can be managed successfully with endocavitary radiation. Ulcerating tumors are likely to recur locally within a short time and therefore should be considered for surgical treatment initially.

Beyond labels: nursing home care for Alzheimer's disease in and out of special care units.

OBJECTIVE: To compare dementia special care units (SCUs) with their non-SCU counterparts in terms of unit and facility characteristics. DESIGN: Cross-sectional telephone survey and secondary database. SETTING: 1247 units in 436 Minnesota nursing homes. MEASUREMENTS: Specialized dementia care practices (e.g., staffing, environmental design and programming features) and organizational characteristics (e.g., size, geographic location, type of ownership, proportion dementia, case-mix and percentage Medicaid). RESULTS: Comparing unit level data for all units in 436 facilities, we found that 75 SCUs offered more dementia-specific features than did the 1122 units not designated as SCUs, but most units offered some dementia-specific features similar to those of SCUs. The designation of SCU did not automatically translate into richer or more tailored services for dementia compared with units without the designation. Facilities with designated SCUs are more likely to be rural, larger and divided into more units, have a higher proportion of residents with dementia, and have fewer residents at higher levels of acuity. CONCLUSION: Presence of a SCU in a facility may be related to care of dementia in the rest of the nursing home in complex ways; some dementia-specific features were less likely to be found in regular units of nursing homes with designated SCUs.

The effect of admission to long-term care program on utilization of health services by the elderly in British Columbia.

Utilization patterns of elderly clients admitted to the British Columbia Long Term Care (LTC) program were recorded and analysed. Patients were either located at home or in facilities and were classified into one of five levels of care. Data on GP and specialist contacts, acute care hospital admissions and hospital length of stay were analysed for each client (N = 7251) for two consecutive years, one before and one after admission to the program. There was only a slight decline or no change in utilization of ambulatory health services following admission to the program but a more pronounced reduction in utilization of hospital related services particularly by clients located in facilities (60-70%). When utilization rates were controlled for peak levels in the period around admission, more moderate trends evolved. Yet, clients located in facilities showed a 20% decrease in hospital admission rates and a 40% decrease in GP hospital visits in the period following admission. The data suggests that admission to LTC may reduce acute hospital utilization and consequent physician utilization among clients who are cared for in an institution.

Long-term results and complications of preoperative radiation in the treatment of rectal cancer.

A retrospective study of 149 patients with rectal cancer diagnosed between 1972 and 1979 was undertaken to compare survival, disease-free survival, recurrence sites, and long-term complications of 40 patients who received 4000 to 4500 rads of preoperative adjuvant radiotherapy (radiation group) with those of 109 patients treated by resection alone (control group). After a mean follow-up of 84 months and 99 months, respectively, survival of the irradiated patients was significantly better than that of controls (68% versus 52%, p less than 0.05). Disease-free survival of those patients rendered free of disease by treatment was also superior for the irradiated group (84% versus 57%, p less than 0.005). Local recurrence without signs of distant metastases developed only one-third as often in irradiated patients (6% versus 18%). Distant metastases, alone or in combination with local recurrence, were also less common after radiation (12% versus 27%). Second primary tumors developed in 15% and 10% of the respective groups, a difference that was not statistically significant. When we consider the survival benefit of preoperative radiation therapy, long-term complications were relatively mild. Delayed healing of the perineum was noted in two irradiated patients. Persistent diarrhea was severe enough to warrant treatment in only one case, and one patient required a colostomy for intestinal obstruction from pelvic fibrosis.

Client transfers in long-term care: five years' experience.

This paper reports the home-facility and level of care changes, discharges, and deaths over a five-year period for 1,653 clients newly admitted in 1978 to a long-term care program in British Columbia, Canada. Five years after admission, of clients initially admitted to care at home (N = 1241), 34.3 per cent were still in the program (14.5 per cent unchanged; 6.7 per cent at home but at a higher level of care, and 11.7 per cent in facilities). Of the remainder, 38.9 per cent had died and 26.8 per cent had been discharged. Findings for those initially admitted to care in facilities (N = 412) are remarkably similar. After five years, 28.4 per cent of these clients were still in the program; 39.3 per cent had died. Moves from facility to home care were few (2.4 per cent). Despite their advanced age at admission (mean = 74.7, S.D. 14.6), one-third were still in the program five years later, some with status virtually unchanged.

An approach to estimating future manpower requirements in physical and occupational therapy.

This paper reports the approach used in a physical therapy (PT) and occupational therapy (OT) manpower requirements study conducted in British Columbia, Canada. A total of 426 questionnaires were mailed to likely employers of PTs and OTs, and to PTs in private practice. After telephone reminders and a second mailing, the overall response rate was 83.3%. The results of the survey indicated that, by 1986, respective PT and OT department heads were anticipating a 60% increase in demand for PTs and a 102% increase for OTs, while agency administrators were suggesting a 76% increase for PTs and a 142% increase for OTs. Although a variety of factors--all largely beyond the control of both respondents and researchers--will determine the degree to which these estimates actually reflect the future demand for these manpower groups, it should be noted that, for both disciplines, the anticipated increase was substantially greater than the level experienced in the five years preceding the survey. The estimation approach used in this study considers nonrespondents; it is a procedure which permits investigators to offer a more accurate picture of the current manpower situation while using a more realistic base on which to estimate future requirements. The development of the requirement side in the supply/requirement equations of manpower studies may be well served in the future with this approach.

Placement changes in long-term care: three years' experience.

This paper describes the place and level of care of an urban and a semi-rural health unit for which 1,653 clients began their experience in British Columbia's Long-Term Care (LTC) program and where they were one and three years later. Three years after admission, 54 per cent of 759 clients initially admitted at home to the lowest level of care were still active clients: 25.8 per cent unchanged, 11.3 per cent at home but at a higher level of care, 16.9 per cent had moved to facilities, 25.4 per cent had died; the remainder of this group had been discharged from LTC. A similar proportion of the 184 clients admitted to the lowest level of care in facilities were still in the program at the end of three years. In contrast, 25 per cent of those admitted to the highest level of care at home (N = 60) and 14.1 per cent of those admitted to the highest level in facilities (N = 64) remained in the program after three years. The potential of the study data for planning purposes is suggested.

Manpower planning, fiscal restraint, and the "demand" for health care personnel.

During 1979 and 1980, widely circulated newspaper stories in British Columbia reported nurse shortages in the province and warned of dire consequences from what was perceived to be a worsening situation. Because the reports were unsupported by empirical evidence, we undertook to directly monitor net requirements for health care personnel in the province. Focusing on difficult-to-fill positions, we found that geographic location and size of facility figured prominently in the distribution of vacancies, but that public-sector cost containment policies had a dominant impact in reducing vacancies in the health care sector. Health manpower planning may thus depend as much on predicting the size and disposition of the revenue base as on quantifying the perceived need for health care services.

Acute-care hospitalizations and long-term care: an examination of transfers.

A Long-term Care Program was introduced throughout British Columbia, Canada, on January 1, 1978. This comprehensive community-based program emphasizes home care. A longitudinal study was started of all persons (N = 3518) admitted to the program that year in two health districts, one urban and one semirural. An examination of the relationship between acute-care hospitalization and long-term care (LTC) involved determining (1) the number of admissions (N = 364) to LTC directly from acute-care settings versus the number (N = 1287) entering directly from the community, (2) the number of LTC persons who were hospitalized at least once in the first 12 months after admission to LTC, and (3) the outcomes of these hospitalizations. Persons from the urban area who entered the LTC Program from an acute-care hospital were much more likely to be institutionalized than were those from the semirural area. In the LTC facility group, 388 persons (19.9 per cent) experienced at least one acute-care hospitalization during the first year of the program. More than 50 per cent of those transferred to an acute-care hospital for the first time returned to the same location and level of care afterward; 14 per cent died. These descriptive analyses may be of interest to health-care planners and to those who care for the LTC elderly either at home or in a facility.