The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission.

STUDY OBJECTIVE: We determined the additional cost of an extended emergency department (ED) length of stay for chest pain patients awaiting non-ICU, monitored (telemetry) beds. METHODS: This was a prospective cohort study of all ED chest pain patients aged 24 years or older and admitted to a telemetry bed in an urban university hospital during a 12-month period. Structured ED data collection included demographics, chest pain presentation, medical history, and laboratory test and ECG results. Hospital course was monitored daily, followed by a 30-day telephone follow-up. Risk severity scores (Goldman, Acute Cardiac Ischemia-Time-Insensitive Predictive Instrument, and Charlson) were calculated. Hospital charges, real costs, and revenues were obtained at discharge and 2 years later. The main outcome measure was risk-adjusted additional cost to the hospital of a delayed ED admission. Clinical outcome was a secondary measure. RESULTS: Of the 817 patients with chest pain presenting to the ED during the study period, there were 904 hospitalizations. Of these, 825 patients waited more than 3 hours for their bed (91%). There were 21 patient visits with a final diagnosis of acute myocardial infarction. ED length of stay was not associated with total hospital length of stay (r =0.01), hospital costs, or hospital or professional charges, revenues, or collection rates. The annual opportunity cost in lost hospital revenue for chest pain patients was 168,300 US dollars (204 US dollars per patient waiting >3 hours for a hospital bed). CONCLUSION: Extended ED length of stay demonstrated no association with total hospital costs or revenues or total hospital length of stay but imposed substantial ED opportunity costs, with decreased potential revenue. Interventions that reduce ED delays in hospital admissions have the potential to significantly increase hospital revenues.

Improved efficiency in providing blood to surgical patients using a novel approach to preadmission testing.

Expansion of the preadmission process for same-day-admit (SDA) surgery patients through our Admissions Evaluation Center has provided an efficient and convenient means for complete patient evaluation up to 30 days in advance of surgery. Traditionally, collection of blood samples for the pretransfusion testing that is necessary to select compatible blood for transfusion occurs within 72 hours of admission, consistent with standards to ensure detection of red blood cell (RBC) alloantibodies formed as a result of recent transfusion or pregnancy. As a result, samples for many SDA patients were submitted Stat the morning of surgery, resulting in an unwieldy amount of testing and delay in blood availability. To address this problem, the time interval for collection of patient blood samples for pretransfusion testing was extended to 30 days prior to surgery. To ensure safety, this change required documentation of patient transfusion and pregnancy history at 2 specific timepoints. Input from a multidisciplinary team was vital to assess the process of blood ordering and administration and to determine the best means to accomplish these steps. Implementation of the new process resulted in a decreased number of emergent requests for compatibility testing, decreased delays in blood delivery, and elimination of canceled surgery due to cases with unexpected RBC antibodies.

ECT and intracranial vascular masses.

In 1990, the APA Task Force on ECT cited no "absolute" contraindications to ECT but "Substantial Risk" to be associated with ECT for patients with space occupying or other cerebral lesions with increased intracranial pressure and with bleeding or otherwise unstable vascular aneurysm or malformation. These findings indicate that patients with intracranial vascular masses are at increased risk for serious morbidity and mortality. Several authors have reported performing ECT in patients with intracranial vascular masses without adverse events by monitoring blood pressure both with and without pharmacologic intervention. Given the relatively recent change in practice of considering ECT for patients with intracranial vascular masses and the few number of cases thus far reported, we present a review of the existing literature and two additional cases of ECT performed with good result and no adverse events. With the cases we have presented, the literature now contains eight cases of ECT performed in patients with intracranial vascular masses, none of which had adverse outcomes. While such numbers do not establish unequivocal safety in this population, and the individual ECT practitioner must continue to make a risk/benefit analysis on a case-by-case basis, this report adds to the growing literature on the safety and efficacy of ECT for such patients.

Anti-rheumatic compound aurothioglucose inhibits tumor necrosis factor-alpha-induced HIV-1 replication in latently infected OM10.1 and Ach2 cells.

NF-kappaB is a potent cellular activator of HIV-1 gene expression. Down-regulation of NF-kappaB activation is known to inhibit HIV replication from the latently infected cells. Gold compounds have been effectively used for many decades in the treatment of rheumatoid arthritis. We previously reported that gold compounds, especially aurothioglucose (AuTG) containing monovalent gold ion, inhibited the DNA-binding of NF-kappaB in vitro. In this report we have examined the efficacy of the gold compound AuTG as an inhibitor of HIV replication in latently infected OM10.1 and Ach2 cells. Tumor necrosis factor (TNF)-alpha-induced HIV-1 replication in OM10.1 or Ach2 cells was significantly inhibited by non-cytotoxic doses of AuTG (>10 microM in OM10.1 cells and >25 F.M in Ach2 cells), while 25 microM of the counter-anion thioglucose (TG) or gold compound containing divalent gold ion, HAuCl3, had no effect. The effect of AuTG on NF-kappaB-dependent gene expression was confirmed by a transient CAT assay. Specific staining as well as electron microscopic examinations revealed the accumulation of metal gold in the cells, supporting our previous hypothesis that gold ions could block NF-kappaB-DNA binding by a redox mechanism. These observations indicate that the monovalent gold compound AuTG is a potentially useful drug for the treatment of patients infected with HIV.

Modelling cortical cataractogenesis XX. In vitro effect of alpha-lipoic acid on glutathione concentrations in lens in model diabetic cataractogenesis.

In previous studies stereospecific protection against lens opacity was consistent with specific reduction of R-alpha-lipoic acid(R-alpha-LA) in mitochondria of the vulnerable cells at the lens equator where the first globular degeneration is seen in glucose cataract. In this study two further possible explanations of this effect were investigated: (1) increased glucose uptake by the lens, leading to increased glycolysis and release of lactate into the incubation medium and/or (2) maintenance of glutathione levels by the R-alpha-LA. The data did not support 1, but was consistent with 2, after 24 hr incubation. The concentrations of glutathione in normal lenses or lenses incubated with R- or racemic alpha-LA were not significantly different, but the concentration of glutathione in lenses incubated with S-alpha-LA was significantly lower than the R-alpha-LA-incubated lenses.

Symptom distress and functional status changes during the first seven days after ambulatory surgery.

UNLABELLED: In this study, we describe changes in symptom distress and functional status 24 h, 4 days, and 7 days after ambulatory surgery. Adult patients aged 18-64 yr, ASA physical status I-III, were studied. The General Symptom Distress Scale was used to score 11 general symptoms; scores range from 0 (no symptoms present) to 4 (symptoms present, constant, cannot be ignored, and, in a 24-h period, remained distressing for more than half the time). The Functional Status Questionnaire was used to evaluate basic and intermediate activities of daily living. Procedure-specific analyses of covariance were performed using multiple linear regression analyses. These models were used to obtain estimates of change while adjusting for preoperative index values of age, ASA physical status, type of anesthesia, and study site. Models for hernia (n = 41) and laparoscopy (n = 59) procedures used F statistics to test the overall significance of the model. Symptom distress persisted until the 7th postoperative day after ambulatory surgery. Patients experienced decreased functional status during the first 7 postoperative days, especially after hernia repair. Older laparoscopy patients tended to have more symptom distress and decreased functional status than younger patients. Only 22% of patients had returned to full- or part-time work by the 7th postoperative day. We conclude that although major morbidity is uncommon after ambulatory surgery, symptom distress and reduced functional status are common 7 days postoperatively. IMPLICATIONS: Previous studies of patient status after ambulatory surgery have focused on mortality, major morbidity, and unanticipated hospitalization. In this study, we examined clinically significant but less life-threatening patient outcomes. Important problems in ambulatory surgery are posed by complications that occur at home. Careful assessment of discharge criteria is important to avoid these problems in this growing patient population.

Inhibition of NF-kappa B activation in human T-cell lines by anetholdithiolthione.

Nuclear factor (NF)-kappa B is a redox sensitive cytosolic transcription factor. Redox regulation of NF-kappa B has been implicated in the activation of the human immuno-deficiency virus (HIV). Therefore, inhibition of NF-kappa B activation may be an effective strategy for acquired immunodeficiency syndrome therapy. Anetholdithiolthione (ADT, 5-[p-methoxyphenyl]-3H-1,2-dithiol-3-thione) is an antioxidant which has been used to protect against acetaminophen- and CCl4-induced hepatotoxicity, lipid peroxidation, radiation injury, and also has been used clinically as an anti-choleretic agent. The present study examined the effect of ADT pretreatment on NF-kappa B activation in response to a variety of stimuli such as H2O2, phorbol myristate acetate (PMA) or tumor necrosis factor alpha (TNF alpha). PMA and TNF alpha induced activation of (NF)-kappa B in human Jurkat T-cells was partially inhibited by ADT (0.1 mM) pretreatment. ADT (0.1 mM) also inhibited H2O2 induced activation of the transcription factor in the peroxide sensitive human Wurzburg T-cells. Furthermore, ADT treated Wurzburg cells had significantly higher glutathione levels as compared with untreated cells. H2O2 induced lipid peroxidation in Wurzburg cells was remarkably inhibited by ADT pretreatment. ADT, a pro-glutathione antioxidant, was observed to be capable of modulating NF-kappa B activation.

Anaesthetic management for caesarean section in a patient with uncorrected truncus arteriosus.

We describe the successful management of a 25-yr-old primigravida with uncorrected truncus arteriosus, requiring an urgent Caesarean section for delivery of a live infant and we discuss the rationale of using the chosen drug combination and the importance of adequate monitoring in selecting an anaesthetic technique based on the pathophysiology of the congenital cardiac lesion.

Adjustment of the myelin sheath to axonal atrophy in the rat spinal root by the formation of infolded myelin loops.

Atrophy of the L4 dorsal and ventral spinal roots was experimentally induced by unilateral sciatic neurectomy in groups of young (2 and 4 months) and older (12 months) albino rats. During the 4 months following neurectomy, the occurrence of infolded myelin loops (IMLs) was quantitatively examined in transverse sections prepared using perfusion fixation with glutaraldehyde and embedding in epoxy resin. The number of IMLs was higher on the operated side and increased with the time of survival and the age of the animals. The formation of IMLs is a characteristic early response of a large-caliber myelin sheath to axonal atrophy, probably reflecting the presence of redundant myelin.

Effects of isoflurane on myocardial blood flow, function, and oxygen consumption in the presence of critical coronary stenosis in dogs.

Because isoflurane has been reported to produce coronary steal, we studied 12 open chest, anesthetized (pentobarbital) dogs with critical stenosis (CS) of the left circumflex coronary artery (LCA). Sonomicrometers were implanted to measure systolic wall thickening, myocardial blood flow (MBF) was measured with microspheres (15 microns diameter), and regional venous sampling was performed to estimate regional oxygen extraction and myocardial oxygen consumption (MVO2). Anesthetic concentrations of isoflurane reduced arterial blood pressure dramatically, resulting in a maldistribution of MBF distal to the CS consistent with the pattern characterizing a transmural coronary steal effect. Elevation of arterial blood pressure with phenylephrine during high concentration isoflurane (1.7 +/- 0.1%) augmented MBF, but the maldistribution distal to the CS persisted. Despite the maldistribution, however, there was no indication of ischemia in the LCA region because systolic wall thickening, oxygen extraction, and MVO2 were not significantly different between the LCA and left anterior descending coronary artery (LAD) (control) areas. Because wall thickening, oxygen extraction, and MVO2 were markedly reduced by isoflurane in both the LCA and control areas, it was concluded that isoflurane substantially reduced myocardial oxygen requirements by inducing myocardial depression, reducing heart rate, and decreasing afterload. Consequently, the apparent maldistribution of LCA blood flow (coronary steal) was due to the hemodynamic and vasodilatory effects of isoflurane, but did not result in ischemia because the level of blood flow was at or above the requirements of the myocardium.