Effect of physico-chemical regimes and tropical cyclones on seasonal distribution of chlorophyll-a in the Chilika Lagoon, east coast of India

A comprehensive analysis on spatiotemporal variation in physico-chemical variables and their control on chlorophyll-a during 2013-14 was carried out in the Chilika Lagoon. Spatiotemporal variation in physico-chemical regimes significantly controlled the phytoplankton biomass of the lagoon. Further, precipitation-induced river/terrestrial freshwater influx and marine influence controlled the physico-chemical regimes of the Chilika Lagoon, such as nutrients (NH₄⁺, NO₃^-, NO₂^-, PO₄^3- and Si(OH)₄), temperature, salinity, total suspended matter and dissolved oxygen. This study revealed significant effects of tropical cyclones Phailin (2013) and Hudhud (2014) on physico-chemical regimes and in turn the phytoplankton biomass of the lagoon. Although both cyclones Phailin (2013) and Hudhud (2014) were intense, Phailin (2013) had a greater impact on the Chilika Lagoon due to the proximity of its landfall. Heavy precipitation caused an influx of nutrient-rich freshwater, both during each cyclone's passage, through rainfall, and after, through increased river flow and terrestrial run-off. The increase in nutrients, carried by the run-off, promoted phytoplankton growth, albeit in lag phase. In general, phytoplankton growth was controlled by nitrogenous nutrients. However, the addition of SiO₄ through terrigenous run-off fuelled preferential growth of diatoms. The salinity pattern (which can be considered a proxy for fresh and marine water influx) indicated injection of freshwater nutrients into the northern, southern and central sectors of the lagoon through riverine/terrestrial freshwater run-off; marine influx was restricted to the mouth of the lagoon. Present and past magnitudes of salinity and chlorophyll-a were also compared to better understand the pattern of variability. A significant change in salinity pattern was noticed after the opening of an artificial inlet, because of the resulting higher influx of marine water. The overall phytoplankton biomass (using chlorophyll-a concentration as a proxy) remained consistent in the lagoon pre- and post-restoration. Due to the wide range of salinity and temperature tolerance, diatoms remained dominant in both pre- and post-restoration periods, but the overall phytoplankton diversity increased after the artificial inlet was dredged.

The Evolution of a Process for Selecting and Prioritizing Plant Diseases for Recovery Plans

One element of the cost of dealing with invasive species in the United States is the recovery from the arrival of exotic plant pathogens. We review the development of a process used to prioritize plant diseases for the federally mandated United State Department of Agriculture National Plant Disease Recovery System. A team of university, government, and industry scientists worked together over a 10-year period to develop a science-based objective approach to the challenge of effectively preparing for recovery plans from introduced pathogens, when the timing of the introduction of any single disease is unknown. Over time, the process transitioned from ad hoc, in which recovery plans were written when the relevant experts were able to do so, to a formally organized group-prioritization effort from which emerged the concept of generic recovery plan templates for groups of pathogens and diseases that have similar biological characteristics, and therefore, similar management approaches. Key characteristics for each template were determined through a multivariate analysis for 14 plant diseases for which a recovery plan already existed. The process was validated by a larger group of 15 plant pathologists, for which results were compared with those scored by 14 subject matter experts.

Shear stress-associated acquired von Willebrand syndrome in patients with mitral regurgitation

BACKGROUND

Mitral valve regurgitation is associated with an acquired hemostatic defect.

OBJECTIVE

We sought to assess the prevalence and severity of acquired von Willebrand syndrome in patients with native valve mitral regurgitation (MR).

PATIENTS/METHODS

Fifty-three patients were prospectively observed with bleeding questionnaires and laboratory tests when undergoing an echocardiographic assessment of MR. In patients referred for mitral valve surgery, testing was repeated postoperatively.

RESULTS

Echocardiography identified 13 patients with mild MR, 14 with moderate MR, and 26 with severe MR. Among patients with mild, moderate or severe MR, loss of the highest molecular weight von Willebrand factor (VWF) multimers occurred in 8%, 64%, and 85%, respectively, median platelet function analyzer collagen ADP closure times (PFA-CADPs) were 84 s (interquartile range [IQR] 73-96 s), 156 s (IQR 104-181 s), and 190 s (IQR 157-279 s), respectively, and the ratios of VWF latex activity to antigen were 0.92 (IQR 0.83-0.97), 0.85 (IQR 0.76-0.89), and 0.79 (IQR 0.75-0.82), respectively (all P < 0.001). Nine patients reported clinically significant bleeding, and seven had intestinal angiodysplasia and transfusion-dependent gastrointestinal bleeding (Heyde syndrome), with the median number of transfusions required being 20 (IQR 10-33; range 4-50). In patients who underwent mitral valve repair (n = 13) or replacement (n = 7), all measures of VWF function reported above improved significantly.

CONCLUSION

The high-shear environment of moderate to severe MR is sufficient to produce prevalent perturbations in VWF activity. Acquired von Willebrand syndrome may occur in this setting, and appears to be reversible with mitral valve surgery.

Meta-analysis and other approaches for synthesizing structured and unstructured data in plant pathology

The term data deluge is used widely to describe the rapidly accelerating growth of information in the technical literature, in scientific databases, and in informal sources such as the Internet and social media. The massive volume and increased complexity of information challenge traditional methods of data analysis but at the same time provide unprecedented opportunities to test hypotheses or uncover new relationships via mining of existing databases and literature. In this review, we discuss analytical approaches that are beginning to be applied to help synthesize the vast amount of information generated by the data deluge and thus accelerate the pace of discovery in plant pathology. We begin with a review of meta-analysis as an established approach for summarizing standardized (structured) data across the literature. We then turn to examples of synthesizing more complex, unstructured data sets through a range of data-mining approaches, including the incorporation of 'omics data in epidemiological analyses. We conclude with a discussion of methodologies for leveraging information contained in novel, open-source data sets through web crawling, text mining, and social media analytics, primarily in the context of digital disease surveillance. Rapidly evolving computational resources provide platforms for integrating large and complex data sets, motivating research that will draw on new types and scales of information to address big questions.

Staged revascularization in critically ill patients with coronary artery disease

BACKGROUND

Critically ill patients undergoing bypass surgery experience a higher mortality and morbidity.

HYPOTHESIS

The study was undertaken to evaluate the efficacy and value of percutaneous transluminal coronary angioplasty (PTCA) as a bridge to coronary artery bypass graft surgery (CABG) in high-risk patients with refractory unstable angina or cardiogenic shock.

METHODS

We present 11 seriously unstable patients with severe multivessel coronary artery disease undergoing culprit vessel PTCA. Angioplasty was performed not as a definitive procedure but rather as a bridge to surgical revascularization. All the patients had sustained at least one myocardial infarction prior to catheterization, all had refractory unstable angina, eight patients had only a single patent coronary artery, and five patients were in cardiogenic shock.

RESULTS

Following PTCA, all patients enjoyed a stable in-hospital period. One patient died 12 weeks after successful PTCA while awaiting second CABG. Seven patients subsequently underwent CABG and are doing well. The remaining three patients were also advised to undergo CABG, but elected to continue medical management.

CONCLUSIONS

Coronary angioplasty of the culprit vessel may play a role as a bridge to surgery in critically ill patients.

Utilization of GIS/GPS-Based Information Technology in Commercial Crop Decision Making in California, Washington, Oregon, Idaho, and Arizona

Ground-based weather, plant-stage measurements, and remote imagery were geo-referenced in geographic information system (GIS) software using an integrated approach to determine insect and disease risk and crop cultural requirements. Weather forecasts and disease weather forecasts for agricultural areas were constructed with elevation, weather, and satellite data. Models for 6 insect pests and 12 diseases of various crops were calculated and presented daily in georeferenced maps for agricultural areas in northern California and Washington. Grape harvest dates and yields also were predicted with high accuracy. The data generated from the GIS global positioning system (GPS) analyses were used to make management decisions over a large number of acres in California, Washington, Oregon, Idaho, and Arizona. Information was distributed daily over the Internet as regional weather, insect, and disease risk maps as industry-sponsored or subscription-based products. Use of GIS/GPS technology for semi-automated data analysis is discussed.

The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients

OBJECTIVE

To assess the importance of diabetes, diabetes control, hyperglycemia, and previously undiagnosed diabetes in the development of surgical-site infections (SSIs) among cardiothoracic surgery patients.

SETTING

A 540-bed tertiary-care university-affiliated hospital.

DESIGN

Prospective cohort and case-control studies.

PATIENTS

All patients having cardiothoracic surgery between November 1998 and September 1999 were eligible for participation. One thousand patients had preoperative hemoglobin A1c determinations. Seventy-four patients with SSIs were identified.

RESULTS

Diabetes (odd ratio [OR], 2.76; P<.001) and postoperative hyperglycemia (OR, 2.02; P=.007) were independently associated with development of SSIs. Among known diabetics, elevated hemoglobin A1c values were not associated with a statistically significantly increased risk of infection; the mean A1c value was 8.44% among those with infections compared with 7.80% for those without (P=.09). Forty-two (6%) of 700 patients without prior diabetes history had evidence of undiagnosed diabetes; their infection rate was comparable to that of known diabetics (3/42 [7%] vs 17/300 [6%]; P=.72). An additional 30% of nondiabetics had elevated hemoglobin A1c determinations or perioperative hyperglycemia.

CONCLUSIONS

Postoperative hyperglycemia and previously undiagnosed diabetes are associated with development of SSIs among cardiothoracic surgery patients. Screening for diabetes and hyperglycemia among patients having cardiothoracic surgery may be warranted to prevent postoperative and chronic complications of this metabolic abnormality.

Box jellyfish (Carybdea alata) in Waikiki. The analgesic effect of sting-aid, Adolph's meat tenderizer and fresh water on their stings: a double-blinded, randomized, placebo-controlled clinical trial

The study measured the analgesic effects of three popular Hawaii remedies for stings from the box jellyfish, Carybdea alata. Analysis of data showed that aerosol sprays of Sting-Aid (an aluminum sulfate solution), Aldolph's meat tenderizer dissolved in water, and fresh water neither increased nor decreased the pain of box jellyfish stings more than the control (seawater).

Box jellyfish (Carybdea alata) in Waikiki: their influx cycle plus the analgesic effect of hot and cold packs on their stings to swimmers at the beach: a randomized, placebo-controlled, clinical trial

The study measured the analgesic effect of hot and cold packs on box jellyfish (Carybdea alata) stings to Waikiki swimmers at the beach. Analysis of data showed a minimal trend toward pain relief 10 minutes after the application of hot packs, particularly when the initial pain was mild to moderate. Cold packs showed no clinically significant relief of pain, compared to the control. Data tracking shows that most box jellyfish appear in Waikiki waters on the 9th or 10th day after the full moon.

A randomized study of the safety and efficacy of reused angioplasty balloon catheters

BACKGROUND

To lower costs, many centers around the world utilize previously used, resterilized balloon catheters to perform coronary angioplasty There are no controlled trials regarding their safety and efficacy.

METHODS AND RESULTS

We performed the first randomized, double-blind, controlled, single-center clinical trial comparing the safety (clinical success) and efficacy (angiographic success) of reused versus new coronary angioplasty balloon catheters. A total of 377 procedures were included, 178 in the reused catheter arm and 199 in the new catheter arm. There were no significant differences in clinical or lesion characteristics among the two arms. The incidence of first balloon failure in the reused catheter arm was similar to that of the new catheter arm (12 cases [7%] v. 10 cases [5%], respectively). The angiographic success rate was also similar-176 cases (98.9%) in the reused catheter arm and 196 cases (98.5%) in the new catheter arm. The number of balloon catheters used per lesion, amount of contrast, and procedural and fluoroscopy time were similar in the two arms. At 30 days, the incidence of major adverse cardiac events was similar in both arms, 8 cases (4.5%) in the reused catheter arm and 10 cases (5%) in the new catheter arm. The incidence of fever was also similar.

CONCLUSIONS

When performing coronary angioplasty, reused catheters are as effective (similar angiographic success) and safe (similar clinical success) as new catheters.

Computer-assisted high-performance liquid chromatography method development with applications to the isolation and analysis of phytoplankton pigments

We used chromatography modeling software to assist in HPLC method development, with the goal of enhancing separations through the exclusive use of gradient time and column temperature. We surveyed nine stationary phases for their utility in pigment purification and natural sample analysis. For purification, a complex algal matrix was separated on an efficient monomeric column, from which partially purified fractions were collected and purified on polymeric columns that exaggerated resolution between pigments of interest. Additionally, we feature an HPLC method that is simple, fast, demonstrates excellent transferability and is ideal for quantitative analysis of pigments in dilute natural water samples.

Computer-assisted high-performance liquid chromatography method development with applications to the isolation and analysis of phytoplankton pigments

We used chromatography modeling software to assist in HPLC method development, with the goal of enhancing separations through the exclusive use of gradient time and column temperature. We surveyed nine stationary phases for their utility in pigment purification and natural sample analysis. For purification, a complex algal matrix was separated on an efficient monomeric column, from which partially purified fractions were collected and purified on polymeric columns that exaggerated resolution between pigments of interest. Additionally, we feature an HPLC method that is simple, fast, demonstrates excellent transferability and is ideal for quantitative analysis of pigments in dilute natural water samples.

Computer-assisted high-performance liquid chromatography method development with applications to the isolation and analysis of phytoplankton pigments

We used chromatography modeling software to assist in HPLC method development, with the goal of enhancing separations through the exclusive use of gradient time and column temperature. We surveyed nine stationary phases for their utility in pigment purification and natural sample analysis. For purification, a complex algal matrix was separated on an efficient monomeric column, from which partially purified fractions were collected and purified on polymeric columns that exaggerated resolution between pigments of interest. Additionally, we feature an HPLC method that is simple, fast, demonstrates excellent transferability and is ideal for quantitative analysis of pigments in dilute natural water samples.

Abolition of exercise induced positive U-wave after coronary angioplasty: clinical implication

OBJECTIVE

We prospectively studied the course of exercise induced positive U-wave before and after percutaneous transluminal coronary angioplasty (angioplasty).

BACKGROUND

Negative U-wave in ECG is known to be associated with the myocardial ischemia in the territory of the left anterior descending artery. Positive U-wave needs further evaluation to prove its diagnostic value in localization of coronary artery disease.

METHOD

Twenty patients demonstrated exercise induced positive U-wave from a cohort of 730 patients referred because of chest pain. Exercise was carried to > or =90% of target heart rate. They underwent angiography and subsequent angioplasty for stenosis of 70% or greater. The exercise test was repeated post angioplasty. Careful screening for clinical endpoints and presence of ST segment depression and positive U-wave was done during exercise and the first 3 min of the recovery phase.

RESULTS

Fifteen patients had isolated exercise induced U-wave and five had additional ST segment depression of > or =1 mm. Significant stenosis (>70% diameter reduction) of the circumflex artery was seen in 11 (55%) and of the right coronary artery in 9 (45%) patients. Coronary artery stenosis was reduced from 90+/-2% to 13+/-1% (mean+/-S.D.) P<0.001. On repeat of the exercise test U-wave and ST depression disappeared in all 20 individuals. Effort tolerance was improved after angioplasty for a mean duration of 3 min and 38 s, P<0.001.

CONCLUSION

Exercise induced positive U-wave is an infrequent but specific marker of significant single coronary (circumflex or right) artery stenosis. It may lend itself to the detection of restenosis.

Use of high-dose depot neuroleptics

Aims and methods

To identify and reduce the number of patients receiving depot neuroleptics above the British National Formulary maximum. The medical records were scrutinised and individual consultants were informed of the results.

Results

For the team involved in this audit there was a significant reduction in the prescription of high-dose depot medication, but this did not generalise to other teams.

Clinical implications

Different teams should repeat the audit and a new depot card has been developed.

Clinical and angiographic features in patients under 35 years with a first Q wave acute myocardial infarction

Sixty patients less than 35 years with a first Q wave acute myocardial infarction were prospectively studied to evaluate their features, risk factors and evidence of any viral infection. Typical chest pain was present in 98.3% with Q waves and ST segment elevation in all. None had hypotension or cardiogenic shock. Smoking was the most common risk factor (81.7%). Mean total cholesterol was 5.74 (+/-1.42) mmol/l. History of a viral illness was present in 28.3%, severe emotional stress in 21.7% and exhausting physical activity in 18.3%. Mean left ventricular diastolic and end systolic volumes were increased (90.11+/-22.5 ml/m2) and (46.62+/-20.46 ml/m2), respectively. The ejection fraction was depressed (49.71+/-1.6%). Triple vessel disease was seen only in 6.8 and 26.7% had insignificant or no coronary artery disease. Left anterior descending artery was most frequently involved (66%). None had left main involvement. Coronary ectasia was present in 11.7%, intracoronary thrombus in 28.3% and 40% had collaterals. Patients with no significant disease had no diabetes, a smaller number had a raised total cholesterol or smoked and had a lower ejection fraction. Patients from the Indian subcontinent who had fewer conventional risk factors, had more severe disease than those from the Arab world suggesting that other etiological factors need investigation.

A randomised controlled trial of home-based rehabilitation versus outpatient-based rehabilitation for patients suffering from chronic schizophrenia

BACKGROUND

Outpatient-based treatments for patients suffering from chronic schizophrenia inadvertently exclude a significant proportion of subjects because they are often too poorly motivated to attend for treatment. In addition there are also concerns about whether the skills that are learnt in a hospital setting will generalize to situations when the individuals are at home. This study attempted to redress some of these potential deficiencies and followed on from an earlier local study which found that a community-based team met more of the needs of patients suffering from chronic schizophrenia.

METHOD

Seventy-five patients suffering from chronic schizophrenia were allocated randomly to receive traditional outpatient-based or home-based rehabilitation from a clinical psychologist and an occupational therapist. They were assessed before and after 9 months of treatment on a range of clinical, social and quality of life outcomes. Distress to carers was also assessed. Readmission to hospital was recorded for each subject.

RESULTS

There were significant reductions in socially embarrassing behaviour (SBS), increases in interpersonal functioning and recreational activities and a trend for quality of life to improve in the home-based group. There were fewer admissions in the home-based group but the differences, although financially substantial, were not statistically significant.

CONCLUSIONS

The home-based rehabilitation service was well received by the majority of patients suffering from chronic schizophrenia and led to some improvement in social behaviour, interpersonal functioning, recreational activities and quality of life.

Aftercare and clinical characteristics of people with mental illness who commit suicide: a case-control study

BACKGROUND

Suicide prevention is now a health priority in many countries. In the UK, there are specific targets for reducing the suicide rate in the general population and in people with mental illness. However, there is almost no evidence for the effectiveness of health services in reducing suicide, and little evidence linking suicide to any aspect of health-service care.

METHOD

We conducted a case-control study of people who committed suicide after discharge from psychiatric inpatient care. Cases were a 30-month sample of 149 people who had received an inquest verdict of suicide or open verdict in Greater Manchester, and who had a history of psychiatric admission in the 5 years before death. Controls were surviving psychiatric patients individually matched for age, sex, diagnosis, and date of last admission. Cases and controls were compared on aspects of psychiatric care, and on clinical and social variables, information being obtained from case notes.

FINDINGS

Those who took their own lives were more likely to have had their care reduced (odds ratio 3.7 [95% CI 1.8-7.6]) at the final appointment in the community before death. Suicide was also associated with a history of self-harm (3.1 [1.7-5.7]), suicidal thoughts during aftercare (1.9 [1.0-3.5]) and the most recent admission as the first illness (2.0 [1.1-3.6]). The associations reported above took account of a number of confounding factors, including the predictable risk of suicide judged from case notes. Only 34% of suicides had an identifiable key worker, the essence of the Care Programme Approach. This frequency was no higher than that for controls, reflecting the difficulty of identifying those likely to commit suicide.

INTERPRETATION

Reductions in care are strongly associated with suicide by people with mental illness, and may be contributory. The implication is that maintaining care beyond the point of clinical recovery is important in protecting high-risk individuals. Several clinical variables indicate high risk but greater risk is not generally addressed in health service provisions.

Late massive haemoptyses from bronchopulmonary collaterals in infarcted segments following pulmonary embolism

Massive, recurrent haemoptyses requiring blood transfusions occurred in a patient who had been diagnosed as having pulmonary thromboembolism 3 months earlier. To the authors' knowledge this is the first case report of this kind, in which massive haemoptyses were proved to be caused by large bronchopulmonary collaterals that had developed in the infarcted lung segments affected by embolism. Selective embolization of the collaterals proved to be therapeutic and life saving.

Management of infectious waste in the home care setting

Adaptation of infection control into practical protocol for the home care setting continues to present a challenge for home care nurses. Most information published on the management of infectious waste in home care is based on hospital protocols, and does not apply to home practice. Reasonable practices for disposal of infectious waste are not addressed by any authoritative resources. This presentation will identify principles of infection control, requirements, laws of regulating bodies, and steps that are measured chronologically to write administrative waste control policies.

Visuospatial information processing in intoxicated, recently detoxified, and long-term abstinent alcoholics

Visuospatial information processing has been shown to be particularly sensitive to acute alcohol intoxication and chronic alcohol abuse. This study extended previous studies by determining if recently detoxified alcoholics recover visuospatial processing after long-term abstinence. If visuospatial function returns to the level displayed by intoxicated alcoholics, then the deficit displayed by recently detoxified alcoholics may represent a short-term adjustment due to the removal of alcohol. However, if the visuospatial deficit remains in long-term abstinent alcoholics, then the superior processing of the intoxicated alcoholic could reflect a normalization of processing produced by alcohol ingestion. Twenty active and 40 recovering alcoholic male volunteers participated. The active alcoholics were seen intoxicated at the time of admission into a 21-day alcohol detoxification and treatment program. Of the recovering alcoholics, 20 were designated as recently detoxified alcoholics and had just completed the same treatment program. The remaining 20 long-term abstinent alcoholics had completed alcohol treatment several years previously with no relapse. Participants selected were similar in general demographic status, alcohol treatment histories, and psychomotor ability. Two main effects emerged from the results: First, the intoxicated alcoholics displayed visuospatial learning that was superior to the learning of alcoholics recently detoxified or abstinent for several years; a second principal finding was nearly identical visuospatial learning displayed by recently detoxified and long-term abstinent alcoholics.

Appearance, body image and distress in facial dysmorphophobia

Compared with surgical patients awaiting rhinoplasty and control subjects, dysmorphophobic patients were more dissatisfied with facial appearance, more anxious, more depressed, more neurotic and less extrovert. Morphanalysis, an objective measure of facial appearance, was applied to the first 11 dysmorphophobic and first 11 surgical subjects. The dysmorphophobic group had a variety of abnormal features that were not identified by medical practitioners or the patient. These subtle anomalies were often unrelated to the focus of dissatisfaction which was usually normal. A panel of lay judges rated the appearance of the dysmorphophobic group as being intermediate between the control and surgical groups but not significantly different from either.

Spatial learning deficits in preschool children of alcoholics

When compared with nonalcoholics, chronic alcoholics and their children show significant deficits in the processing of visuospatial information. The literature supports two possible explanations of a visuospatial processing deficit in the child of an alcoholic (COA) when compared with the child of a nonalcoholic (NCOA). Either the COA may suffer cognitive disruptions produced by personal and social development within an alcoholic family, or the COA may inherit or very early develop alterations in central nervous system substrates of neurocognitive operations. The present study was designed to continue our examinations of visuospatial information processing differences and the source of these differences in COAs. An evaluation of very young subjects not only assisted in providing a more complete view of visuospatial processing across the COA's life span, but also helped explain why the deficit occurs. Thirty matched male and female preschool children, aged 35.8-51.6 months, served as participants. Fifteen children were COAs from families in which the biological father and two other relatives had an alcoholism history. The other group of 15 children were NCOAs. Each child performed a visuospatial learning task similar to the task used in previous studies of older COAs. The visuospatial learning performance of the preschool COAs was inferior to that displayed by preschool NCOAs. The patterns of correct, error, and nonresponses emitted by the preschool COAs and the interrelationships of these data closely resembled the data from our previous studies of older children, adolescent, and adult COAs.(ABSTRACT TRUNCATED AT 250 WORDS)

Distribution of Body Mass Index in Indian patients with coronary artery disease

To study the distribution of overweight and obesity among Indian patients with coronary artery disease (CAD), a cross-sectional analysis of computerized data on patients, proved to have CAD by selected coronary arteriography, was carried out. There were 1078 patients, with 1052 males (mean age +/- SD:50 +/- 7.5) and 26 females (mean age +/- SD:47.7 +/- 8). Of these, 22 percent had single vessel disease, 38 percent two vessel and 40 percent three vessel disease. The Body Mass Index (BMI) was calculated from the height and weight data. BMI over 27 kg/m2 was defined as overweight and that over 30 kg/m2 as obese. Data analysis revealed that only 8.2 percent of patients with CAD were overweight, of whom 2.2 percent were obese. CAD was seen in Indians with BMI from 15 kg/m2 onwards. The BMI in the risk factor groups of smoking, diabetes and hypertension was not different when compared to those without the risk factors. However, the BMI was higher in those with a positive family history (p < 0.01). BMI was higher in the businessmen and executives but did not qualify for overweight or obesity group. BMI did not correlate with the various lipid fractions studied. It is concluded, that in Indian patients, angiographically proved coronary artery disease can be seen with low BMI.

Propranolol for pulmonary oedema in mitral stenosis

We report the case of a young adult with mitral stenosis and pulmonary oedema who did not respond to conventional antifailure therapy, but improved with intravenous propranolol and later underwent successful balloon mitral valvotomy. Intravenous beta blockade, though contraindicated in most cases of pulmonary oedema, may benefit patients with mitral stenosis and tachycardia.

Suicide among psychiatric in-patients in the Wellington region

To identify risk factors for in-patient suicide, a case-control study of in-patient suicide was conducted in the Wellington Area Health Board region between 1984 and 1989 on 27 cases and 86 controls. The risk of in-patient suicide was increased among individuals who had been compulsorily admitted, suffered from schizophrenia, had a past history of deliberate self harm, had been in hospital for more than a month, or were unmarried. Notably, there was no relationship with physical health, a history of substance abuse, number of psychiatric admissions and time since the last known episode of deliberate self harm. These characteristics can assist clinical assessment of individual suicidal risk. Further evaluation of the relation of compulsory admission to suicide is required.

The oral examination: a study of academic and non-academic factors

The oral examination in psychiatry for final-year medical students at Wellington and Dunedin School of Medicine, University of Otago, was studied. Between December 1989 and April 1990, 40 medical students were videorecorded during such an examination. The transcripts of the recording of each oral, and at a later date the videorecordings, were individually scored by a panel of six research psychiatrists who were experienced examiners. In addition verbal and non-verbal behaviour was rated using visual analogue scales and the students completed personality and anxiety questionnaires. There was a low level of agreement between research psychiatrists in the allocation of oral marks. The oral score was positively associated with the level of confidence of the student and negatively with anxiety in men.

A "biofeedback" approach to the treatment of chronic polydipsia

A novel behavioral method is described for the treatment of psychogenic polydipsia in a patient suffering from chronic schizophrenia. The patient was given feedback on serum sodium concentration, likely physical consequences, and the value of reducing fluid intake. An ABAB single-case design was used, with changes in sodium concentration (charted by the patient during the treatment phases) as the dependent variable. The patient showed substantially increased sodium concentration, which was maintained despite the withdrawal of feedback. This behavioral method appears promising in settings where restriction of fluid intake is not practical or ethical.

Psychiatric morbidity and compulsory admission among UK-born Europeans, Afro-Caribbeans and Asians in central Manchester

Psychiatric admissions in Central Manchester of Europeans, Afro-Caribbeans, and Asians (within three age-bands) were studied over four years. Among the Afro-Caribbean group there were more single or unemployed persons than in either the Asian or European groups, which suggested greater socio-economic disadvantage. Rates for first admissions and readmissions among Afro-Caribbeans were greater; among Asians they were similar except for the 16-29-year age-group, who tended to have lower rates than Europeans. A higher proportion of Afro-Caribbeans and Asians were psychotic. In the Afro-Caribbean group, the raised rates of admission were largely attributable to increased rates of schizophrenia. The highest rate occurred in second-generation (UK-born) Afro-Caribbeans and was nine times that among Europeans. The police were more frequently involved in the admissions of Afro-Caribbeans compared with Europeans or Asians. Higher proportions of Afro-Caribbeans and Asians who were readmitted were detained under the Mental Health Act 1983, when compared with Europeans.

Sizing of balloons in balloon mitral valvotomy

In twenty six consecutive patients who underwent balloon mitral valvotomy (BMV) by the transseptal double balloon technique, the mitral valve area (MVA) increased from 0.78 +/- 0.1 cm2 to 1.80 +/- 0.3 cm2, (p < 0.001). Effective balloon dilating area (EBDA) of each combination of balloons used was calculated using a standard formula. Patients were classified into 4 subgroups with approximate EBDAs of 3.3, 4.0, 4.9 and 5.7 cm2 and they had mean post-BMV MVAs of 1.28, 1.78, 1.89 and 1.98 cm2 respectively (ANOVA F = 3.32, p < 0.05). Patients were reclassified after normalisation of EBDA and post-BMV MVA to square metre of body surface area. Three subgroups with mean normalised EBDAs of 2.32, 2.96 and 3.62 cm2/m2 had mean normalised post-BMV MVAs of 0.99, 1.17 and 1.40 cm2/m2 respectively (ANOVA F = 6.85, p 0.01). A trend towards increasing mitral regurgitation with increasing balloon size was noted. Three cases of mitral regurgitation including one case of severe mitral regurgitation occurred in the subgroup of 9 patients with largest normalised EBDAs. The overall correlation between normalised EBDAs and normalised post BMV MVA was strong r = 0.67, p < 0.01). The optimal normalised EBDA for Indian patients undergoing BMV is around 3.6 cm2/m2. Balloons used should be sized accordingly.

Assessment of impaired left ventricular diastolic function in patients with coronary artery disease, using radionuclide angiography

Left ventricular (LV) diastolic filling at rest was assessed in 76 patients with coronary artery disease (CAD) and 16 healthy subjects using radionuclide angiography. Peak LV filling rate (PFR), expressed in end diastolic volume per second (EDV/sec), was subnormal in CAD patients (1.95 +/- 0.51 as compared to the normal 3.11 +/- 0.36, P < 0.001) and time to PFR (TPFR) was prolonged (171.1 +/- 79 msec versus 106.6 +/- 25 msec normal, P < 0.001). These indices were also abnormal in 60 patients with normal resting LV ejection fraction (PFR 2.17 +/- 0.48 EDV/sec, TPFR 163.9 +/- 68 msec). Abnormal LV filling at rest (PFR EDV/sec or TPFR 160 msec) was found in 88 percent of all patients with CAD, 85 percent of patients with normal resting LV ejection fraction, and 83 percent of patients without Q waves on resting electrocardiogram. Thus, LV diastolic filling, evaluated non invasively by radionuclide angiography, appears to be abnormal in a high percentage of patients with CAD independent of LV systolic function or previous myocardial infarction.

New Zealand suicides 1984-8

AIMS

to determine regional differences in suicide with special attention to inpatients and prisoners.

METHODS

all cases of suicide 1984-8 were identified from coroners' register and age, sex, method of suicide, date of death, place of inquest, occupation and prisoner or inpatient status were recorded.

RESULTS

between 1984 and 1988 there were 2019 suicides. Subjects were usually male and hanging was the commonest method of achieving death. Northland-Auckland had the highest regional suicide rate and the highest prison suicide rate; and Wellington-Wairarapa had the lowest regional suicide rate, the lowest prison suicide rate but the highest inpatient suicide rate of the five regions studied.

CONCLUSIONS

the high regional and prison rates of suicide in Northland-Auckland were probably because the largest city in New Zealand lies within its boundaries. The high inpatient suicide rate in Wellington-Wairarapa could not be explained by the regional rate, nor by controlling for the number of admissions. This pointed to regional differences in the delivery of psychiatric care.

Videothoracoscopy: improved technique and expanded indications

Current videoendoscopic technology and percutaneous techniques of exposure and dissection have been successfully applied to abdominal surgery with favorable results. Application of this technology to our practice of thoracoscopy is the basis of this report. Videothoracoscopy has been performed in 39 patients for the following indications: chronic pleural effusion, interstitial lung disease, mediastinal lymphadenopathy in lung cancer, persistent air leak after decortication, mediastinal mass, recurrent spontaneous pneumothorax, hydropneumothorax with persistent air leak, and pleural-based mass. The technique we employ includes lateral decubitus positioning and double-lumen endotracheal intubation with ipsilateral lung collapse. The videoscope, retractors, and instruments are introduced through separate 10-mm incisions. Percutaneous manipulation of instruments and the videoscope is guided by images produced on television screens without dissection, and if resection is performed, the incision is enlarged to allow specimen retrieval. Procedures performed using this technique include pleural biopsy, partial pleurectomy, lysis of adhesions, lung biopsies, staging lymph node biopsy, lung nodule biopsy, pleural-based mass resection, and mediastinal mass biopsy and resection. This videoendoscopic technique greatly improves visualization of thoracic anatomy, facilitating thoracoscopy and enhancing exploration of the chest. It is preferred over conventional thoracoscopy and, in some patients, reduces the magnitude of operation by avoiding thoracotomy.

Tetralogy of Fallot with absent pulmonary valve: diagnostic features and management

Tetralogy of Fallot with absent pulmonary valve is a rare congenital malformation. The diagnostic features and surgical management in ten patients with this malformation have been described. There were five male and five female patients, (age 3 1/2 to 26 years). The common symptoms were recurrent respiratory tract infection and cyanosis. Examination revealed hyperdynamic precordial pulsations, single second heart sound and an early diastolic murmur along the left sternal border in all. Electrocardiograms were indistinguishable from typical tetralogy of Fallot. Chest X-ray revealed cardiomegaly, prominent pulmonary conus and dilated pulmonary arteries in all cases, lung vascularity being variable. Echocardiographic findings were diagnostic and are discussed in detail. Cardiac catheterization and angiocardiography revealed annular stenosis in all, along with aneurysmal dilatation of main and branch pulmonary arteries. Eight patients underwent intracardiac repair. There was no perioperative mortality. All patients have been followed up for 350 months (mean 29 months).

Reliability of the draft diagnostic criteria for research of ICD-10 in comparison with ICD-10 and DSM-III-R

The reliability and ease of use of DSM-III-R and the clinical and research versions of ICD-10 were assessed by 5 psychiatrists working in pairs. They diagnosed 60 patients. All 3 systems showed similar and high interrater and intersystem agreement for major diagnostic categories but not for subcategories. A number of implications of these results are discussed.

Prophylaxis of atrial fibrillation with magnesium sulfate after coronary artery bypass grafting

Ninety-nine consecutive consenting patients were prospectively entered into a randomized, double-blind, placebo-controlled trial to determine the efficacy of postoperative magnesium therapy on the incidence of cardiac arrhythmias after elective coronary artery bypass grafting. No patient had documented or suspected arrhythmias preoperatively. Forty-nine patients received 178 mEq of magnesium given over the first 4 postoperative days, and 50 patients received only placebo. The clinical characteristics of both groups were similar. The preoperative mean serum magnesium concentration was similar in both study (1.90 mEq/L) and placebo (1.90 mEq/L) groups. The mean postoperative serum magnesium concentration in study patients was significantly elevated over postoperative days 1 through 4 when compared with preoperative levels (p less than 0.001). The postoperative mean serum magnesium concentration in control patients declined and remained significantly depressed through postoperative day 3 (p less than 0.001), but increased to preoperative levels by postoperative day 4. The mean serum magnesium concentration was significantly greater in the study patients as compared with the control patients over postoperative days 1 through 4 (p less than 0.001). Although there was no significant difference between groups with respect to episodes of ventricular arrhythmias, there was a significant decrease in the number of episodes of atrial fibrillation in the group receiving magnesium therapy (p less than 0.02). There were no recognized adverse effects of magnesium therapy. Prophylactic magnesium administration seems to lessen the incidence and severity of atrial fibrillation after coronary artery bypass grafting.

Internal mammary artery graft at reoperation: risks, benefits, and methods of preservation

To determine the effect of a prior internal mammary artery (IMA) graft on coronary artery bypass reoperation (CABR), we reviewed our experience with 410 consecutive patients: 313 received only saphenous vein grafts at initial coronary artery bypass grafting (CABG), and 97 received at least one IMA graft at CABG. Cardiac catheterization data before CABG were available in 110 patients (56 received only saphenous vein grafts, 54 received at least one IMA graft), allowing comparison of left ventricular function at CABG and CABR. Injury of the IMA graft occurred in 5 patients (1 death), but presence of an IMA graft was not an independent predictor of morbidity or mortality. Overall, the incidences of complications and deaths were higher in patients with saphenous vein grafts than in patients with IMA grafts, though not significantly so. Internal mammary artery grafts better preserved cardiac function: patients with IMA grafts had worse left ventricular function before CABG but better left ventricular function before CABR than patients with saphenous vein grafts. Left ventricular function deterioration from before CABG to before CABR was significantly less in patients with IMA grafts. We conclude that the risk of CABR is not increased by a previously constructed IMA graft and that left ventricular function is better preserved at CABR when an IMA graft was constructed at the initial operation.

Association between cigarette smoking and coronary arterial disease in patients in India: how quantitative is it? An assessment by selective coronary arteriography

With a view to study the association between smoking and coronary arterial disease, and to identify any quantitative relationship, we undertook a cross sectional analysis of 1105 consecutive male patients investigated by selective coronary arteriography to confirm or exclude coronary arterial disease. Pattern and distribution of disease were evaluated in 3 groups of patients who never smoked; who smoked less than 5 cigarettes per day; and who smoked 6 to 60 or more cigarettes per day. Suitable statistical tests, including adjusting for confounders, were carried out. The prevalence of disease was higher amongst smokers even after adjustment for confounders. The number of cigarettes smoked, and whether the smokers had quit, made no difference to the angiographic appearance or extent of disease. There was no difference in the distribution and severity of disease amongst smokers and non-smokers. Rate ratio of disease amongst smokers in India was higher in those patients between 26 and 45 years of age than in other age groups. Smoking could be identified as a risk marker/risk factor that accelerated the disease process in those prone to develop the disease. It may be advantageous to initiate public health and preventive measures directed specifically at the group aged between 26 to 45 years, and later to address all others who smoke.

Phase analysis of radionuclide ventriculograms in patients with coronary artery disease

Phase analysis of radionuclide ventriculograms were performed in eighty patients with coronary artery disease (CAD) and in sixteen healthy subjects. The phase image in the normal group revealed a homogeneous pattern and a narrow bell shaped histogram. In forty one patients with CAD whose Left ventriculogram showed hypokinetic segments, phase image was abnormal in twenty six revealing well demarcated areas of contraction abnormality and a histogram showing broad base with multiple peaks. The mean phase angle and the standard deviation (S.D.) of phase histogram of the abnormal segments was significantly different from normal. Eighteen patients with CAD had akinetic segments. Phase analysis was abnormal in all. Six patients with CAD had dyskinetic segments. It is concluded that phase image analysis is very useful in detecting segmental wall motion abnormalities.

Organic manic syndrome associated with advanced uraemia due to polycystic kidney disease

Mania secondary to advanced uraemia caused by polycystic disease of the kidneys in a 62-year-old woman involved a complex interplay of physical, psychological and social factors. Psychotherapy and thioridazine led to full recovery.

Dipyridamole radionuclide ventriculography for localisation of coronary artery disease

Nineteen consecutive patients who had coronary arteriography underwent dipyridamole stress testing with 0.14 mg/kg/min infusion over 4 minutes during computer assisted radionuclide ventriculography. Global ejection fraction, diastolic function and regional ejection fraction were calculated by a semiautomatic method. There were 17 patients with severe left anterior descending disease of which 12 involved the proximal segment of the LAD, 15 patients with left circumflex disease and 13 patients with right coronary artery disease. Abnormalities in resting or stress induced regional ejection fraction was used for localisation of severe coronary artery disease. The overall sensitivity was 75 per cent with a specificity of 75 per cent, a positive predictive value of 90 per cent and a negative predictive value of 45 per cent. For LAD disease the sensitivity was 94 per cent with a 100 per cent specificity while proximal segment of LAD had a sensitivity of 100 per cent and a specificity of 57 per cent. Identification of left circumflex disease had a sensitivity of 47 per cent and a 100 per cent specificity and right coronary artery had a 85 per cent sensitivity and a 50 per cent specificity. Four patients developed ST changes, 6 developed chest discomfort and 1 patient developed giddiness. All 7 were promptly reversed with intravenous aminophylline. Thus dipyridamole radionuclide ventriculography is a highly sensitive and specific method for localisation of CAD.

Achieving a competitive advantage through referral management

The physician remains the primary referral source in medical service. Referral patterns, in turn, reflect interactions between referring physicians and consultants which relate to quality of care, costs, and personal factors such as age and common training. Referrals initiated by patients relate to the desire to seek a second opinion and are heavily influenced by other family members. Alterations in the referral process are emerging due to cost escalation, the emergence of large payor groupings and aggregation of physicians into larger group settings. Strategies to manage the referral process include enhanced communications using new telecommunication technology and joint ventures with hospitals.