Pneumonitis and pulmonary haemorrhage after acute myocardial infarction

A 55-year-old man presented with acute ST-elevation myocardial infarction. He received rescue angioplasty with one drug eluting stent. He developed marked breathlessness and haemoptysis two days later. Investigations led to the diagnosis of pulmonary haemorrhage, possibly from pneumonitis caused by ticagrelor. He was successfully managed with high-dose steroids and ticagrelor was replaced with clopidogrel. On stopping the steroids a month later, mild haemoptysis recurred and this was managed conservatively. Pneumonitis and pulmonary haemorrhage is rarely reported with acute myocardial infarction, but poses serious challenge to the patient and the clinician. Diagnosis may be delayed as breathlessness can occur due to myriad causes after myocardial infarction. Interrupting dual anti-platelet therapy after angioplasty could lead to devastating stent thrombosis

REFERQUAL: A pilot study of a new service quality assessment instrument in the GP Exercise Referral scheme setting

Background The development of an instrument accurately assessing service quality in the GP Exercise Referral Scheme (ERS) industry could potentially inform scheme organisers of the factors that affect adherence rates leading to the implementation of strategic interventions aimed at reducing client drop-out. Methods A modified version of the SERVQUAL instrument was designed for use in the ERS setting and subsequently piloted amongst 27 ERS clients. Results Test re-test correlations were calculated via Pearson's 'r' or Spearman's 'rho', depending on whether the variables were Normally Distributed, to show a significant (mean r = 0.957, SD = 0.02, p < 0.05; mean rho = 0.934, SD = 0.03, p < 0.05) relationship between all items within the questionnaire. In addition, satisfactory internal consistency was demonstrated via Cronbach's 'α'. Furthermore, clients responded favourably towards the usability, wording and applicability of the instrument's items. Conclusion REFERQUAL is considered to represent promise as a suitable tool for future evaluation of service quality within the ERS community. Future research should further assess the validity and reliability of this instrument through the use of a confirmatory factor analysis to scrutinise the proposed dimensional structure

Making space for experiences

Leisure and retail providers need to understand the elements of the visitor experience and the way in which they evaluate their satisfaction. This article suggests a holistic prism model of the interaction between the management and the visitor in a leisure space. This is applied to a netnographic study of visitors to a folk festival to illustrate the interconnectiveness of the different attributes causing dissatisfaction. It found that the physical and operational attributes were evaluated not through a checklist of individual features but as hindrances to the visitor's desire to make best use of the time. Visitors also evaluated the experience in the light of their own values and concerns, passing judgement on the values communicated by the management. At the heart of the experience was the enjoyment of choosing from an abundant offer and discovering something new. The main attraction is often only the pretext for enjoying the company of friends so places to meet before and chill-out afterwards are vital to the experience. The distinctiveness of the setting, the food and drink can become the sensory cues which give the event or location its uniqueness. The challenge to retail and leisure organisations is to design these elements of a memorable experience into their offerings

Emotions in business-to-business service relationships

Emotion in business-to-business service relationships regarding cargo services is explored. The service relationship is characterised by mutual trust and cooperation. Contact is mainly via telephone or e-mail with some face-to-face interactions and participants providing a complex, multi-skilled seamless service. Experience rather than training plays a vital role with long-term service relationships built up and maintained. Emotional sensitivity is acquired partly by experience and a repeat customer base but mainly through a genuine desire to help and get to know others. In contrast to the view of emotional labour bringing managerial control or adverse affects to service staff, the emotion engendered by this work is authentic expression bringing personal satisfaction

Trends in utilization of deceased donor kidneys based on hepatitis C virus status and impact of public health service labeling on discard

BackgroundKidneys from deceased donors infected with hepatitis C virus (HCV) are underutilized. Most HCV virus‐infected donors are designated as Public Health Service increased donors (PHS‐IR). Impact of PHS and HCV designations on discard is not well studied.MethodsWe queried the UNOS data set for all deceased donor kidneys between January 2015 and December 2018. The final study cohort donors (n = 38 702) were stratified into three groups based on HCV antibody (Ab) and NAT status: (a) Ab−/NAT− (n = 35 861); (b) Ab+/NAT− (n = 973); and (c) Ab±/NAT+ (n = 1868). We analyzed utilization/discard rates of these organs, the impact of PHS‐IR and HCV designations on discard using multivariable two‐level hierarchical logistic regression models, forecasted number of HCV viremic donors/kidneys by 2023.ResultsDuring the study period, (a) the number of viremic donor kidneys increased 2 folds; (b) the multilevel mixed‐effects logistic regression models showed that, overall, the PHS labeling (OR 1.20, CI 95% CI 1.15‐1.29) and HCV designation (OR 2.29; 95% CI 2.15‐2.43) were independently associated with increased risk of discard; (c) contrary to the general perception, PHS‐IR kidneys across all HCV groups, compared to PHS‐IR kidneys were more likely to be discarded; (d) we forecasted that the number of kidneys from HCV viremic donor kidneys might increase from 1376 in 2019 to 2092 in 2023.ConclusionHepatitis C virus viremic kidneys might represent 10%‐15% of deceased donor organ pool soon with the current rate of the opioid epidemic. PHS labeling effect on discard requires further discussion of the utility of this classification.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154409/1/tid13204_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154409/2/tid13204.pd

Charting service quality gaps

Some of the most influential models in the service management literature (Parasuraman et al., 1985; Grönroos, 1990) focus on the concept of service quality gap (SQG). Parasuraman et al. (1985) define a pioneering model with five SQGs, the concepts of which are amplified in Brogowicz et al.’s (1990) model. The latter has five types of encompassing gaps: information and feedback-related gaps; design-related gaps; implementation-related gaps; communication-related gaps; and customers’ perceptions and expectations related gaps. Additionally to this model amplification, other authors (e.g., Brown & Swartz, 1989) have pointed to relevant SQGs that have not been considered previously. This paper integrates current models and a group of SQGs dispersed through the literature in a new comprehensive model. It draws a link between the model and the stages of a strategy process, emphasising the SQGs’ impact on the process and raising relevant research questions.FCT, FEUALG, UALG

Inorganic nitrate in angina study:A randomized double-blind placebo-controlled trial

Background--In this double-blind randomized placebo-controlled crossover trial, we investigated whether oral sodium nitrate, when added to existing background medication, reduces exertional ischemia in patients with angina. Methods and Results--Seventy patients with stable angina, positive electrocardiogram treadmill test, and either angiographic or functional test evidence of significant ischemic heart disease were randomized to receive oral treatment with either placebo or sodium nitrate (600 mg; 7 mmol) for 7 to 10 days, followed by a 2-week washout period before crossing over to the other treatment (n=34 placebo-nitrate, n=36 nitrate-placebo). At baseline and at the end of each treatment, patients underwent modified Bruce electrocardiogram treadmill test, modified Seattle Questionnaire, and subgroups were investigated with dobutamine stress, echocardiogram, and blood tests. The primary outcome was time to 1 mm ST depression on electrocardiogram treadmill test. Compared with placebo, inorganic nitrate treatment tended to increase the primary outcome exercise time to 1 mm ST segment depression (645.6 [603.1, 688.0] seconds versus 661.2 [6183, 704.0] seconds, P=0.10) and significantly increased total exercise time (744.4 [702.4, 786.4] seconds versus 760.9 [719.5, 802.2] seconds, P=0.04; mean [95% confidence interval]). Nitrate treatment robustly increased plasma nitrate (18.3 [15.2, 21.5] versus 297.6 [218.4, 376.8] μmol/L, P < 0.0001) and almost doubled circulating nitrite concentrations (346 [285, 405] versus 552 [398, 706] nmol/L, P=0.003; placebo versus nitrate treatment). Other secondary outcomes were not significantly altered by the intervention. Patients on antacid medication appeared to benefit less from nitrate supplementation. Conclusions--Sodium nitrate treatment may confer a modest exercise capacity benefit in patients with chronic angina who are taking other background medication

Disorder-specific functional abnormalities during sustained attention in youth with Attention Deficit Hyperactivity Disorder (ADHD) and with Autism

Attention Deficit Hyperactivity Disorder (ADHD) and Autism Spectrum Disorder (ASD) are often comorbid and share behavioural-cognitive abnormalities in sustained attention. A key question is whether this shared cognitive phenotype is based on common or different underlying pathophysiologies. To elucidate this question, we compared 20 boys with ADHD to 20 age and IQ matched ASD and 20 healthy boys using functional magnetic resonance imaging (fMRI) during a parametrically modulated vigilance task with a progressively increasing load of sustained attention. ADHD and ASD boys had significantly reduced activation relative to controls in bilateral striato–thalamic regions, left dorsolateral prefrontal cortex (DLPFC) and superior parietal cortex. Both groups also displayed significantly increased precuneus activation relative to controls. Precuneus was negatively correlated with the DLPFC activation, and progressively more deactivated with increasing attention load in controls, but not patients, suggesting problems with deactivation of a task-related default mode network in both disorders. However, left DLPFC underactivation was significantly more pronounced in ADHD relative to ASD boys, which furthermore was associated with sustained performance measures that were only impaired in ADHD patients. ASD boys, on the other hand, had disorder-specific enhanced cerebellar activation relative to both ADHD and control boys, presumably reflecting compensation. The findings show that ADHD and ASD boys have both shared and disorder-specific abnormalities in brain function during sustained attention. Shared deficits were in fronto–striato–parietal activation and default mode suppression. Differences were a more severe DLPFC dysfunction in ADHD and a disorder-specific fronto–striato–cerebellar dysregulation in ASD

The Marketing Firm: Retailer and consumer contingencies

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