Risk factors for a medically inappropriate admission to a Department of Internal Medicine

OBJECTIVE: To identify patient- and admission-related risk factors for a medically inappropriate admission to a department of internal medicine. METHODS: Cross-sectional study of a systematic sample of 500 admissions to the department of internal medicine of an urban teaching hospital. The appropriateness of each admission and reasons for inappropriate admissions were assessed using the Appropriateness Evaluation Protocol. Risk factors included the time (day of week and holidays) and manner (through emergency department or direct admission) of admission, patient age and sex, health status of patient and spouse, living arrangements, formal home care services, and informal support from family or friends. RESULTS: Overall, 76 (15.2%) hospital admissions were rated as medically inappropriate by the Appropriateness Evaluation Protocol. In multivariate analysis, the likelihood of an inappropriate admission was increased by better physical functioning of the patient (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.1-2.1 [for 1 SD in Physical Functioning scores]), lower mental health status of the patient's spouse (OR, 2.6; 95% CI, 1.3-5.6), receipt of informal help from family or friends (OR, 3.3; 95% CI, 1.5-7.2), and hospitalization by one's physician (OR, 3.6; 95% CI, 1.7-7.5). Receiving formal adult home care was not associated with inappropriateness of hospitalization. CONCLUSIONS: Inappropriate admissions to internal medicine wards are determined by a mix of factors, including the patient's health and social environment. In addition, the private practitioners' discretionary ability to hospitalize their patients directly may also favor medically inappropriate admissions.     

Contraindications to metformin therapy in patients with NIDDM

OBJECTIVE: Treatment with metformin is occasionally associated with the development of severe lactic acidosis. However, this is usually observed in patients with major contraindications to the drug. In this study, we aimed to determine the prevalence of conditions currently regarded as either contraindications or cautions to the use of metformin in patients with NIDDM. RESEARCH DESIGN AND METHODS: The case notes of metformin-treated NIDDM patients (mean age 62 years) attending a United Kingdom university hospital diabetes clinic over a 3-month period were reviewed according to criteria reflecting a pragmatic view of current prescribing recommendations. RESULTS: Of 89 consecutive patients whose notes could be evaluated in detail, only 41 (46%) had no contraindications or cautions to metformin whatsoever. Concomitant chronic disorders associated with a potentially increased risk of hyperlactatemia were renal impairment (n = 2; plasma creatinine concentrations 1.7 and 2.3 mg/dl, respectively), cardiac failure (n = 2), and chronic liver disease (n = 2). Other potentially relevant disorders included ischemic heart disease (n = 20), clinical proteinuria (n = 14), peripheral vascular disease (n = 22), and pulmonary disease (n = 7). Multiple conditions (i.e., two, three, or four) were present in eight, five, and one patient(s), respectively. CONCLUSIONS: More than half the patients in our series had concomitant conditions or complications conventionally regarded as cautions or contraindications to metformin; approximately 10% had a multiplicity of such conditions. Regular surveillance is necessary to detect the development of complications such as renal impairment. Vigilance is also required in view of the increased risk of major intercurrent illnesses, which may independently disturb lactate metabolism in patients with NIDDM. Metformin should be withdrawn promptly under such circumstances.     

In situ bypass and diabetes

From 1986 through to 1990 a total of 483 in situ bypass procedures were performed in 444 patients. Preoperative risk-factors were equally distributed among diabetic (DM) and non-diabetic (NDM) patients, except for smoking habits (DM:48%, NDM:64%, p = 0.002) and cardiac disease (DM:45%, NDM:29%, p = 0.005). Critical limb-ischaemia was more often present in diabetic than non-diabetic patients (DM:57%, NDM:36%, p = 0.0002). Diabetic patients had a significantly lower distal anastomosis than non-diabetic patients (p = 0.00001). There were no differences among diabetic and non-diabetic patients regarding three years primary and secondary patency (58% and 64% respectively), and regarding major amputations. However, the rate of minor amputations was higher in insulin-dependent compared with non-insulin-dependent diabetics, who in turn had a higher rate than non-diabetics (p < 0.00001). A markedly decreased survival rate was found in diabetics (p < 0.00005). We found the in situ bypass technique very useful in the treatment of critical ischaemia of the lower limb in diabetic patients. The overall results in diabetic patients, whether insulin-dependent or not, were equal to those in non-diabetic patients.     

Human granulocytes contain an opiate alkaloid-selective receptor mediating inhibition of cytokine-induced activation and chemotaxis

Human peripheral blood granulocytes previously were found to contain opioid delta 2-receptors mediating stimulation by opioid peptides of chemotaxis. Studies presented in this work indicate that granulocytes also contain opiate alkaloid-selective, opioid peptide-insensitive receptors mediating inhibition by morphine and other opiates of cytokine-induced activation and chemotaxis. Binding studies with [3H]morphine and [3H]diprenorphine ([3H]DPN) indicated the presence of receptor sites, at considerable density with affinities and selectivity for opiates comparable with those of the mu 3-receptor of human peripheral blood monocytes (macrophages). The influence of the guanosine 5'-triphosphate (GTP) analogue GppNHp on binding indicated that the granulocyte receptor was linked to a G protein. Morphine but not opioid peptides interfered with activation and/or chemotaxis of the granulocytes induced by TNF-alpha, IL-1 alpha, IL-8, and FMLP (chemotactic peptide). These effects of morphine were blocked by the antagonist naloxone. Levorphanol inhibited TNF-alpha-induced activation, and also potentiated the inhibition by morphine. Furthermore, in binding assays, levorphanol enhanced the affinity of the receptor for morphine. Dextrorphan had no effect on activation or chemotaxis, and it also had no effect on binding, indicative of stereoselectivity for the effect of levorphanol. It is concluded that human granulocytes contain opiate alkaloid-selective mu 3-receptors that mediate inhibitory effects of morphine on cellular activation by cytokines.     

三相异步电动机可靠性和经济分析

根据三相异步电动机的主要失效模型,利用概率分析和补充变量方法,求得了三相异步电动机的可靠性指标和运行的经济指标。     

Effect of maturation on alpha-adrenoceptor activity in newborn piglet mesentery

To characterize the mesenteric alpha1- and alpha2-adrenoceptor populations in newborn piglets, an extracorporeal circuit was established to control intestinal blood flow in 0- to 2-day old and 10- to 14-day old animals. In both groups, alpha-adrenoceptor activation was first documented by observing dose-dependent increases in mesenteric perfusion pressure after intramesenteric arterial injection of alpha-adrenoceptor agonists. In the 10- to 14-day old piglets, mesenteric vasoconstrictor responses to alpha1-adrenoceptor agonists (methoxamine and norepinephrine) and an alpha2-adrenoceptor agonist (BHT-933) were each blunted (P < 0.05, analysis of variance) by peripheral intravenous injections of prazosin (an alpha1-adrenoceptor antagonist) and yohimbine (an alpha2-adrenoceptor antagonist), respectively. The mesenteric vasoconstrictor responses to those agonists were not significantly attenuated by prazosin or yohimbine in 0- to 2-day old animals, nor were they blunted by YM-12617 (alpha1-adrenoceptor antagonist) or idazoxan (alpha2-adrenoceptor antagonist)--compounds that are structurally unrelated to prazosin and yohimbine, respectively. In addition, mesenteric vasoconstrictor responses to other known vasoconstrictor agents--angiotensin II, neuropeptide Y, and a thromboxane A2 mimic (U-46619)--were not effected in either age group by prazosin or yohimbine, implying these agents act independently of alpha-adrenoceptor mechanisms. These data suggest that (1) there exists functional mesenteric alpha1- and alpha2-adrenoceptor-like activity in 10- to 14-day old piglets that, in 0- to 2-day old animals, is not specifically expressed; and (2) mesenteric alpha-adrenoceptor function becomes more selective as newborn piglets mature.     

Hemodynamic structure of antiorthostatic reactions: relationship of mechanical activity of the heart and arterial pressure

This paper is an update on the issue of dental student debt and provides additional data and an exploration of continued trends which were outlined by Douglass and Fein in the 1995 IOM study of The Future of Dental Education. Dental school tuitions have continued to increase at rates at or above the consumer price index. These tuition bills are increasingly being met by debt financing on the part of the students. These trends are described and then related to recent data on the future plans of dental school seniors. The second part of the paper will provide new updated date on dentists' incomes and analyze the trend in dental fees versus the consumer price index. The final section provides a summary of pay back mechanisms currently being offered to students.     

Blind adaptive interference suppression for direct-sequence CDMA

Direct sequence (DS) code division multiple access (CDMA) is a promising technology for wireless environments with multiple simultaneous transmissions because of several features: asynchronous multiple access, robustness to frequency selective fading, and multipath combining. The capacity of DS-CDMA systems is interference-limited and can therefore be increased by techniques that suppress interference. In this paper, we present developments in interference suppression using blind adaptive receivers that do not receive knowledge of the signal waveforms and propagation channels of the interference, and that require a minimal amount of information about the desired signal. The framework considered generalizes naturally to include additional capabilities such as receive antenna diversity. The most powerful application of the methods described here is for linearly modulated CDMA systems with short spreading waveforms (i.e., spreading waveforms with period equal to the symbol interval), for which they provide substantial performance gains over conventional reception. Implications for future system design due to the restriction of short spreading waveforms and directions for further investigation are discussed     

Joint noncoherent demodulation and decoding for the block fading channel: a practical framework for approaching Shannon capacity

The paper contains a systematic investigation of practical coding strategies for noncoherent communication over fading channels, guided by explicit comparisons with information-theoretic benchmarks. Noncoherent reception is interpreted as joint data and channel estimation, assuming that the channel is time varying and a priori unknown. We consider iterative decoding for a serial concatenation of a standard binary outer channel code with an inner modulation code amenable to noncoherent detection. For an information rate of about 1/2 bit per channel use, the proposed scheme, using a quaternary phase-shift keying (QPSK) alphabet, provides performance within 1.6-1.7 dB of Shannon capacity for the block fading channel, and is about 2.5-3 dB superior to standard differential demodulation in conjunction with an outer channel code. We also provide capacity computations for noncoherent communication using standard phase-shift keying (PSK) and quadrature amplitude modulation (QAM) alphabets; comparing these with the capacity with unconstrained input provides guidance as to the choice of constellation as a function of the signal-to-noise ratio. These results imply that QPSK suffices to approach the unconstrained capacity for the relatively low information and fading rates considered in our performance evaluations, but that QAM is superior to PSK for higher information or fading rates, motivating further research into efficient noncoherent coded modulation with QAM alphabets.     

A parallel systems approach to universal receivers

The problem of communication over a channel with unknown characteristics is addressed. The true channel is from a known set of channels, but the transmitter and receiver do not know which of these channels is actually in effect. The goal of a universal receiver is to provide nearly optimal demodulation regardless of the channel that is actually in effect. A parallel receiver implementation is proposed for a universal scheme to cope with such uncertainty. The parallel system consists of a finite number of receivers with the property that, for each channel in the set, the performance of at least one of the receivers will be within a specified performance range. Data verification is accomplished by an appropriate coding system. Sufficient conditions for the existence of such a universal receiver for a prescribed set of channels are established, procedures are outlined for the receiver design, and an example is given to illustrate the applicability of the theory. For M-ary signaling it is shown that, from an information-theoretic viewpoint, the data verification can be achieved at no extra cost by use of the intrinsic side information that is provided by an appropriate coding scheme that also provides error correction