Unstable angina: specialty-related disparities in implementation of practice guidelines

BACKGROUND

The agency for Health Care Policy and Research (AHCPR) has published practice guidelines to improve the quality of care patients with unstable angina. Prior to publication, studies demonstrated that when compared with cardiologists, internists were less likely to use effective pharmacologic therapies or revascularization in patients with unstable angina.

HYPOTHESIS

The study was undertaken to determine whether the AHCPR guideline publication abolished specialty-related disparities in care.

METHODS

We performed a chart review of consecutive patients hospitalized at a university-affiliated institution with an admission diagnosis of chest pain in the absence of myocardial infarction and a noncardiac etiology. Treatment and diagnostic cardiac testing were compared between risk-stratified patients cared for by a generalist (n = 125) and those whose care was guided by a cardiologist (n = 211).

RESULTS

In those with low-risk unstable angina, generalists were less likely to prescribe recommended aspirin (71 vs. 88%, p < 0.01) and beta blockers (9 vs. 37%, p < 0.001), and heparin (20 vs. 49%, p < 0.001), and to perform a recommended diagnostic stress test or cardiac catheterization (28 vs. 60%, p < 0.001). In those with at least intermediate risk, generalists were less likely to prescribe beta blockers (19 vs. 52%, p < 0.001), heparin (19 vs. 66%, p < 0.001), and nitrates (77 vs. 96%, p < 0.001), and to refer for diagnostic testing (19 vs. 65%, p < 0.001). Generalists' care was associated with significantly lower hospital charges.

CONCLUSIONS

AHCPR guidelines for the evaluation and treatment of unstable angina are implemented more effectively, but not uniformly, by cardiologists at our institution. Further studies are necessary to evaluate the barriers to implementation of the AHCPR guidelines.

Spreading of exogenous surfactant in an airway

Using a theoretical model, we studied spreading of a bolus of insoluble surfactant deposited on a thin liquid layer of a model airway. Applications include instillation of exogenous surfactant as a treatment for neonatal respiratory distress syndrome, the use of surfactant carriers to deliver drugs via the lung, and the movement of liquid along the airway tree due to naturally occurring gradients of surface tension. The time-dependent governing equations were solved numerically for longitudinal axisymmetric surfactant spreading. We examined the influences of the resident liquid layer (thickness, viscosity, endogenous surfactant, airway radius), of the bolus (volume and surfactant content), and of gravity. The gradient in surface tension drives the flow toward the region of higher surface tension, ultimately creating a shocklike wave of nearly twice the initial lining thickness. Pressure gradients due to interfacial curvature (capillarity) have little effect on the rate of surfactant spread. The presence of an endogenous resident surfactant greatly augments the rate of spreading while inhibiting development of the shock. In all cases studied, the effect of circumferential curvature was negligible, indicating that the liquid layer can be treated as if it were spreading over a flat surface. Our results reveal that the surfactant spreads as time to the one-third power. Accordingly, a surfactant deposited in the trachea of a neonate would spread to the periphery in approximately 12 s.

The steady expiratory pressure-flow relation in a model pulmonary bifurcation

Experiments were conducted over a range of Reynolds numbers from 50 to 8000 to study the pressure-flow relationship for a single bifurcation in a multi-generation model during steady expiratory flow. Using the energy equation, the measured static pressure drop was decomposed into separate components due to fluid acceleration and viscous energy dissipation. The frictional pressure drop was found to closely approximate that for an equivalent length of curved tube with the same curvature ratio as in the model bifurcation. The sensitivity of these results to changes in airway cross-sectional shape, non-planar configuration, and flow regime (laminar-turbulent) was investigated. In separate experiments using dye visualization and hot-wire anemometry, a transition to turbulent flow was observed at Reynolds numbers between 1000 and 1500. Transition had very little effect on the pressure-flow relation.

Some features of oscillatory flow in a model bifurcation

Oscillatory flow in the lung is studied using an order-of-magnitude analysis and flow visualization experiments in a single bifurcation with lung-like geometry. The results are used to obtain a classification scheme that identifies three major flow regimes, distinguished on the basis of whether the flow is dominated by unsteadiness, viscous effects, or the effects of convective acceleration. The unsteady regime is found to exist for values of a dimensionless stroke length (L/a, i.e., stroke volume/local cross-sectional area) less than or equal to 3 and for values of a dimensionless frequency (alpha 2 = alpha 2 omega/nu, where alpha is airway radius, omega the oscillatory frequency, and nu the kinematic viscosity) less than or equal to 10 in basic agreement with previous studies. The viscous regime is found when alpha 2(L/a)(a/R)1/2 less than 10 and alpha 2 less than 10 where R is the local radius of curvature in the bifurcation; the convective regime is found when alpha 2(L/a)(a/R)1/2 greater than 10 and L/a greater than 3. This same approach yields scaling laws for the magnitude of secondary flow velocities and shows that the ratio of secondary-to-axial velocity is small everywhere outside of the convective regime where it scales with (a/R)1/2. Comparison of these results to related simple flows shows that many of the features observed can be attributed to the effects of curvature, suggesting that the influence of the flow divider and of area change may be of lesser importance than previously thought.

Numerical solutions for steady and unsteady flow in a model of the pulmonary airways

A computational model is presented for unsteady flow through a collapsible tube with variable wall stiffness. The one-dimensional flow equations are solved for inlet, outlet and external conditions that vary with time and for a tube with time-dependent, spatially-distributed local properties. In particular, the effects of nonuniformities and local perturbations in stiffness distribution in the tube are studied. By allowing the flow to evolve in time, asymptotically steady flows are calculated. When simulating a quasi-steady reduction in downstream pressure, the model demonstrates critical transitions, the phenomena of wave-speed limitation and the sites of flow limitation. It also exhibits conditions for which viscous flow limitation occurs. Computations of rapid, unsteady changes of the exit pressure illustrate the phenomena occurring at the onset of a cough, and the generation and propagation of elastic jumps.

Mathematical simulation of forced expiration

Flow limitation during forced expiration is simulated by a mathematical model. This model draws on the pressure-area law obtained in the accompanying paper, and the methods of analysis for one-dimensional flow in collapsible tubes developed by Shapiro (Trans. ASME J. Biomech. Eng. 99: 126-147, 1977). These methods represent an improvement over previous models in that 1) the effects of changing lung volume and of parenchymal-bronchial interdependence are simulated; 2) a more realistic representation of collapsed airways is employed; 3) a solution is obtained mouthward of the flow-limiting site by allowing for a smooth transition from sub- to supercritical flow speeds, then matching mouth pressure by imposing an elastic jump (an abrupt transition from super- to subcritical flow speeds) at the appropriate location; and 4) the effects of levels of effort (or vacuum pressure) in excess of those required to produce incipient flow limitation are examined, including the effects of potential physiological limitation.

Tube law for the intrapulmonary airway

A semiempirical model of a pressure-area relationship for the bronchial airways is developed. It is described by a single similarity law consistent in form with the nonlinear elastic behavior of biological tissue. The tethering effect of the parenchyma is lumped into the wall properties of the bronchi and is included in an effective wall stiffness. The model, which is fitted to the experimental data of Takishima and his associates (J. Appl. Physiol. 38: 875-881, 1975), is lung-volume dependent and is therefore suitable for the analyses of airflow at different lung volumes, especially for modeling of forced expiration.

Effect of optimization of hemodynamics on fibrinolytic activity and antithrombotic efficacy of external pneumatic calf compression

External pneumatic calf compression is effective but imperfect for antithrombotic prophylaxis in surgical patients. In preliminary studies, sequential filling of multisegmented leggings with graded pressure decreasing from ankle to knee increased venous flow velocity and wall shear stress, decreased residual venous volume, and enhanced postoperative fibrinolysis more than uniform compression. To determine if improved hemodynamics also increased antithrombotic activity, we performed a prospective randomized trial in neurosurgical patients comparing sequential application of graded pressure with uniform pressure applied to either a segmented bladder or to a single bladder. Deep vein thrombosis was diagnosed by leg scanning and impedance plethysmography and confirmed by phlebography. Venous thrombosis developed in 3 of 45 patients with graded-sequential filling, 6 of 50 with uniform compression-multiple compartments, and 3 of 41 with uniform pressure single bladder (differences not significant). These results suggest either that uniform compression offers all that can be expected of external pneumatic calf compression in prevention of venous thrombosis, or that even if a study with greater statistical power showed graded-sequential filling to be superior, the benefit/cost ratio of the more complex latter system is not likely to be large.

A cellular model of lung elasticity

The mechanics of the lung parenchyma is studied using models comprised of line members interconnected to form 3-D cellular structures. The mechanical properties are represented as elastic constants of a continuum. These are determined by perturbing each individual cell from a reference state by an increment in stress which is superimposed upon the uniform stretching forces initially present in the members due to the transpulmonary pressure. A force balance on the distorted structure, together with a force-deformation law for the members, leads to a calculation of the strain increments of the members. Predictions based on the analysis of the 3-D isotropic dodecahedron are in good agreement with experimental values for the Young's, shear, and bulk moduli reported in the literature. The model provides an explanation for the dependence of the elastic moduli on transpulmonary pressure, the geometrical details of the structure, and the stress-strain law of the tissue.

Choking phenomena in a lung-like model

A simple, continuous, one-dimensional model for the geometry and structure of the bronchial airways is used for the analysis of fluid flow patterns which have been observed in forced expiration maneuvers. Various phenomena within the conducting system associated with flow limitation are investigated: the conditions in which a "choke" (flow limitation) can occur in a compliant system; theoretical flows that are physically impossible; the possibility of having elastic jumps downstream of the choke point; perturbations in the physical parameters of the conducting system.

Selective ablation of atheromas using a flashlamp-excited dye laser at 465 nm

Ablation of human atheromas with laser pulses that had only a small effect on normal artery tissue was shown in vitro in air and under saline using 1-mu sec pulses at 465 nm from a flashlamp-excited dye laser. At this wavelength, there is preferential absorption in atheromas due to carotenoids. The threshold fluence for ablation was 6.8 +/- 2.0 J/cm2 for atheromas and 15.9 +/- 2.2 J/cm2 for normal aorta tissue. At a fluence of 18 J/cm2 per pulse, the ablated mass per unit of energy ranged from 161 to 370 micrograms/J for atheromas and from 50 to 74 micrograms/J for normal aorta tissue. Ablation products consisted of cholesterol crystals, shredded collagen fibers, and small bits of calcific material. Most debris was less than 100 micron in diameter, but a few pieces were as large as 300 micron. High-speed photography of ablation in air suggested explosive ejection of debris, caused by vapor formation, at speeds on the scale of 300 m/sec. Histological analysis showed minimal thermal damage to residual tissue. These data indicate that selective laser ablation of atheromas is possible in vitro.

Filling of partially collapsed compliant tubes

Filling of a thin-walled, highly compliant tube in a partially collapsed condition is studied. The theory, based on one-dimensional flow, takes account of friction, longitudinal tension, and the highly nonlinear pressure-area law for the tube. Various aspects of filling behavior are revealed by alternative calculations using: (i) the method of characteristics; (ii) numerical integration of the continuity, momentum, and tube-law equations; and (iii) a crude but simple lumped-element capacitance-inertance-resistance model. Varied phenomena appear. At high Reynolds number, these include dispersive wave trains associated with circumferential bending stiffness and longitudinal tension, nonlinear changes of wave form, development of highly asymmetrical wave reflections, and sloshing. At low Reynolds number, the area changes with time in a diffusivelike manner. The experiments exhibited the dispersive phenomena predicted by the theory.

CO2 elimination by high-frequency oscillations in dogs--effects of histamine infusion

Effective gas exchange can be achieved in normal dogs by ventilation at frequencies of 4-20 Hz using stroke volumes (SV) smaller than the anatomic dead space. CO2 elimination is largely a function of tracheal SV-frequency product (Vosc) in anesthetized, paralyzed dogs with normal lungs. To determine the effect of constriction of small airways on gas exchange during such high-frequency ventilation (HFV), we ventilated five anesthetized, paralyzed, and vagotomized dogs via a tracheal cannula before and during intravenous histamine infusion. Vosc was varied by varying the frequency while keeping SV constant. For low Vosc, CO2 elimination (VCO2) increased directly with Vosc during control and histamine experiments. At high Vosc, VCO2 continued to increase directly with Vosc during the control study, but during histamine infusion VCO2 was lower than control values. Eucapnia could be maintained in each dog during HFV, even during airway constriction. During histamine infusion the frequency-dependent mechanical properties of the lung influence the delivery of the HFV SV to the respiratory zone, and this may explain the lower VCO2 observed.

Bioengineering studies of periodic external compression as prophylaxis against deep vein thrombosis-part II: experimental studies on a stimulated leg

In this companion paper to "Part I: Numerical Simulations, " we report in vitro experimental studies performed on a simple model leg consisting of a "vein" of thin-walled latex tubing surrounded by "tissue" of open-pore foam rubber. Three modes of periodic external compression, were investigated: i) uniform compression; (ii) graded compression, decreasing from ankle to knee; and (iii) sequential compression, progressing from ankle to knee. The modes are compared on the basis of three hemodynamic criteria: degree of vessel collapse, level of fluid velocity, and level of shear stress. In uniform compression these measures of merit are distributed very nonuniformly along the length of the leg: they are high near the proximal end of the cuff but low elsewhere, a result due to the formation proximally of a partially occlusive throat. The latter does not form in either graded or sequential compression, with the consequence that favorable values of the three measures of merit occur more uniformly along the length of the pressurized region. It is concluded that either the graded or sequential mode of compression, or perhaps a combination of the two, would be more effective than uniform compression as a prophylaxis against deep vein thrombosis.

Effects of frequency, tidal volume, and lung volume on CO2 elimination in dogs by high frequency (2-30 Hz), low tidal volume ventilation

Recent studies have shown that effective pulmonary ventilation is possible with tidal volumes (VT) less than the anatomic dead-space if the oscillatory frequency (f) is sufficiently large. We systematically studied the effect on pulmonary CO2 elimination (VCO2) of varying f (2-30 Hz) and VT (1-7 ml/kg) as well as lung volume (VL) in 13 anesthetized, paralyzed dogs in order to examine the contribution of those variables that are thought to be important in determining gas exchange by high frequency ventilation. All experiments were performed when the alveolar PCO2 was 40 +/- 1.5 mm Hg. In all studies, VCO2 increased monotonically with f at constant VT. We quantitated the effects of f and VT on VCO2 by using the dimensionless equation VCO2/VOSC = a(VT/VTo)b(f/fo)c where: VOSC = f X VT, VTo = mean VT, fo = mean f and a, b, c, are constants obtained by multiple regression. The mean values of a, b, and c for all dogs were 2.12 X 10(-3), 0.49, and 0.08, respectively. The most important variable in determining VCO2 was VOSC; however, there was considerable variability among dogs in the independent effect of VT and f on VCO2, with a doubling of VT at a constant VOSC causing changes in VCO2 ranging from -13 to +110% (mean = +35%). Increasing VL from functional residual capacity (FRC) to the lung volume at an airway opening minus body surface pressure of 25 cm H2O had no significant effect on VCO2.

Effective pulmonary ventilation with small-volume oscillations at high frequency

At high oscillation frequencies (4 to 30 hertz), effective alveolar ventilation can be achieved with tidal volumes much smaller than the anatomic dead space. An explanation of this phenomenon is given in terms of the combined effects of diffusion and convection and in terms of data consistent with the hypothesis. Theory and experimental results both show that the significant variable determining the effectiveness of gas exchange is the amplitude of the oscillatory flow rate independent of the individual values of frequency and stroke volume.

Effects of family density and mothers' education on preschoolers' motor skills

Individual comparisons were used in an epidemiological framework to determine the effects of two neighborhoods, family density, and mother's education on 58 ethnically varied 3-yr.-olds in Israel. Measures included verbal IQ, gross motor skills, and fine motor skills. Significant sex differences were found in that high densities and low maternal schooling alone and in interaction related to poor motor performance for the boys. It was suggested that mothers who have at least finished primary school may act to neutralize the detrimental effects of a crowded home. Fathers' income and occupation were little associated with crowding and this seemed to reflect greater economic homogeneity within this Israeli sample.

Gesell speech norms and Israeli children

The validity of Gesell language norms for 111 Israeli children, aged 2 to 6 yr., was checked by using their Gesell language levels to predict their home backgrounds. Speech retardation accurately predicted which groups came from poorer homes at all age levels. Gesell speech norms thus appear to be valid for Hebrew.