Patterns of hospital care and physician perspectives from an Italian, Japanese, and USA hospital.

Many studies have compared different countries' health care systems at the macro level. Less has been done to analyze care provided for patients with specific diseases and to compare physician attitudes concerning factors that influence patient care. This study compares severity of illness and length of hospital stay for patients admitted for diabetes mellitus, cholecystitis, or appendicitis at three teaching hospitals in Italy, Japan, and the United States. Physicians caring for patients with these diseases were surveyed to assess their opinions of the adequacy of resources available at their hospital, perceived administrative pressures concerning resource use, and interactions with patients and their families that relate to admission and discharge decisions. The severity of the patient mix was consistently higher in the U.S. hospital than in the Italian or Japanese hospitals. Controlling for diagnosis, severity of illness, surgery, age, and presence of co-morbid conditions, the U.S. hospital consistently had the shortest stays and the Japanese hospital the longest. Japanese physicians were more likely than U.S. or Italian physicians to report insufficient resources, such as nurses, to provide quality care, but less likely to report administrative pressures interfering with patient care. Differences in hospital utilization may reflect variation in clinical practices, availability of resources, barriers to access to care, organizational differences at the national and hospital level, and patient and family preferences.

[A comparative study on long-term care facilities for the aged in Japan].

Presently in Japan, care for the aged who are bedridden, afflicted with dementia or other conditions, is provided by hospitals, skilled nursing homes (providing a certain amount of medical care) and special nursing homes (for those needing ADL assistance). Facilities for long term care of the aged are insufficient, and there are many problems in matching care needs to the services supplied in these facilities. In October 1990, a survey was conducted to collect data for helping define the optimum services needed for the aged in long term care facilities. The subjects consisted of 1,262 persons in 12 facilities: 314 in three general hospitals (average age: 78.5); 391 in three hospitals for the aged (80.8); 410 in four skilled nursing homes (81.2); 147 in two special nursing homes (81.3). Results of the survey are as follows: 1. The proportion of "seriously demented" and "very seriously demented" subjects, (according to Karasawa's scale.), was 17.5% in general hospitals, 28.7% in hospitals for the aged, 16.4% in skilled nursing homes, and 22.6% in special nursing homes. 2. For ADL, "mobility" with whole assistance was required for 40.5% of the subjects in general hospitals, 58.7% in hospitals for the aged, 22.9% in skilled nursing homes, and 37.5% in special nursing homes. 3. During the month preceding the survey, medical examinations were conducted on 98.4% in general hospitals, 99.5% in hospitals for the aged, 23.0% in skilled nursing homes, and 59.4% in special nursing homes. These examinations consisted mostly of urine and blood analyses. ECGs and x-ray tests were also performed on more than 70% of subjects in the two types of hospitals.

Sudden fatal cardiac arrest in a child with an unrecognized anterior mediastinal mass.

We report a case of sudden fatal cardiac arrest in a 3-year-old boy. The arrest occurred when he was placed in the supine position by force for a venipuncture. Autopsy revealed a large anterior mediastinal mass. The death was attributed to the airway obstruction and cardiac compression by the mass. Postural change to supine position by force was believed to have triggered compression of the cardiopulmonary system by an unrecognized anterior mediastinal mass, resulting in cardiac arrest.

[A case of effusive-constrictive epicarditis found by electrocardiogram at a school health examination].

An effusive-constrictive pericarditis confined to the epicardium is extremely rare in childhood. We report case of a 7-year-old boy with such a condition. During an annual school health examination, he was found to have low voltage activities on electrocardiogram. On admission, physical examination showed markedly distended abdomen due to ascites and hepatomegaly. Two-dimensional echocardiography revealed small ventricular cavities, extremely dilated inferior vena-cava, and a moderate amount of pericardial fluids. Pericardial and epicardial thickening were also suspected. Retrospectively, epicardial thickening was suspected on computed tomogram as well. Cardiac catheterization showed a typical diastolic dip and plateau pattern on the right ventricular pressure tracing, and deep x and y descents on that of the right atrium, suggesting that not pericardial effusion, but pericardial thickening mainly contributed to the cardiac dysfunction. Pericardiocentesis did not improve the clinical symptoms and high central venous pressure. On thoracotomy, we unexpectedly found intact pericardium and fibrotic epicardium covering the whole heart, so epicardiectomy was performed. Despite the fact that most of the fibrotic epicardium was removed, there were no immediate responses such as decrease in central venous pressure within the first 5 days after the surgery. Furthermore, it was not until two months later that all symptoms and hemodynamic parameters returned to normal levels. There have been several case reports of isolated epicardial constriction associated with pericardial effusion in English literature. However, we are unaware of such a report n Japanese. We concluded that it is important to evaluate the hemodynamics before and after pericardiocentesis, and to detect peri-and/or epicardial thickening by serial echocardiography and CT scan.(ABSTRACT TRUNCATED AT 250 WORDS)

Oesophageal lung with systemic arterial blood supply.

An adolescent girl with congenital bronchopulmonary-foregut malformation (BPFM) is reported. The patient had a hypoplastic, non-functioning right lung with the main bronchus originating from the oesophagus. The pulmonary artery of the "oesophageal lung" was supplied by systemic circulation from the descending aorta, and the venous flow drained through a hypoplastic right pulmonary artery (RPA) into the large left pulmonary artery (LPA). This case was a rare type of left-to-right shunt and demonstrates that oesophagography, pulmonary angiography and aortography are important in demonstrating the haemodynamics involving this malformation.