The process of hospital discharge for medical patients: a model.

Background. The 1990 NHS Community Care Act established a requirement for hospital discharge policies and procedures in the United Kingdom to be developed in collaboration with local government authorities in order to ensure supported discharge for those in need. Aims. The aim of the study reported in this paper was to track decisions about hospital discharge in relation to outcomes for a sample of medical patients and their carers, identified as at risk of experiencing unsuccessful discharge processes. Methods. Themed unstructured interviews were conducted in three different hospitals with 30 patients identified as at risk of unsuccessful discharge and their carers pre- and postdischarge. Hospital, community and social care staff involved in the care of the patient were also interviewed. Findings. Patients and carers were constantly negotiating their social roles, seeking to juggle appropriate identities and limited resources to maintain their own and each others’ dignity and quality of life. When the negotiation process was destabilized (for example, by exacerbation of chronic disease, withdrawal of some resource, or the experience of additional stressors – not necessarily health-related), then either or both parties sought a way out. In all the cases examined the result was admission to hospital – usually, but not always, mediated by community professionals. Conclusions. The effective discharge of patients from hospital needs to move from a functional focus on symptom management to a negotiation of quality of life that seeks to promote health for all parties involved

The phenomenon of "QT stunning": the abnormal QT prolongation provoked by standing persists even as the heart rate returns to normal in patients with long QT syndrome.

Patients with long QT syndrome (LQTS) have inadequate shortening of the QT interval in response to the sudden heart rate accelerations provoked by standing-a phenomenon of diagnostic value. We now validate our original observations in a cohort twice as large. We also describe that this abnormal QT-interval response persists as the heart rate acceleration returns to baseline. To describe a novel observation, termed "QT stunning" and to validate previous observations regarding the "QT-stretching" phenomenon in patients with LQTS by using our recently described "standing test." The electrocardiograms of 108 patients with LQTS and 112 healthy subjects were recorded in the supine position. Subjects were then instructed to stand up quickly and remain standing for 5 minutes during continuous electrocardiographic recording. The corrected QT interval was measured at baseline (QTc(base)), when heart rate acceleration without appropriate QT-interval shortening leads to maximal QT stretching (QTc(stretch)) and upon return of heart rate to baseline (QTc(return)). QTc(stretch) lengthened significantly more in patients with LQTS (103 ± 80 ms vs 66 ± 40 ms in controls; P <.001) and so did QTc(return) (28 ± 48 ms for patients with LQTS vs -3 ± 32 ms for controls; P <.001). Using a sensitivity cutoff of 90%, the specificity for diagnosing LQTS was 74% for QTc(base), 84% for QTc(return), and 87% for QTc(stretch). The present study extends our previous findings on the abnormal response of the QT interval in response to standing in patients with LQTS. Our study also shows that this abnormal response persists even after the heart rate slows back to baseline

Review of direct anatomical open surgical management of atherosclerotic aorto-iliac occlusive disease.

BACKGROUND Aortofemoral bypass(AFB), iliofemoral bypass(IFB), and aortoiliac endarterectomy(AIE) are the three most common techniques for anatomical open surgical revascularisation for patients with aorto-iliac occlusive disease(AIOD), but the optimal method of reconstruction is unknown. AIMS To review and compare mortality, morbidity and short- and long-term patency rates for AFB, IFB and AIE in patients with AIOD reported in the English language literature METHODS A MEDLINE(1970-2007) and Cochrane Library search for articles relating to AFB, IFB, AIE and AIOD was undertaken. Studies were included if: a) patency rates based on life-tables were available, and b) patient/study characteristics were reported. RESULTS 29 studies(5738 patients) for AFB, 11 studies(778 patients) for IFB and 11 studies(1490 patients) for AIE were included. Operative mortality was 4.1% for AFB, 2.7% for IFB and 2.7% for AIE (p<0.0001). Systemic morbidity was 16.0% for AFB, 18.9% for IFB and 12.5% for AIE (p<0.05). Overall 5-year primary patency rates were 86.3%, 85.3% and 88.3% for AFB, IFB and AIE, respectively (p=NS). CONCLUSION Aorto-iliac endarterectomy was associated with significantly lower peri-operative morbidity and mortality rates compared with bypass grafting. All three techniques were equally effective in terms of long-term patency

Mathematical micromodeling of infilled frames:state of the art

The in-plane contribution of infill walls on the structural response of infilled frame structures is an important problem and many research initiatives, via experimental and numerical methods, have been conducted in order to investigate it thoroughly. As a result, the need to consider these research findings on the structural performance has been acknowledged in the latest generation of structural design codes. However, due to the uncertainties concerning the behavior of masonry at the material and structural level, these elements are usually ignored during practical structural analysis and design. They are overtly considered only when there is suspicion that their influence is detrimental to the overall structural response or to the behavior of individual load bearing elements or when it is necessary to justify an improvement in the overall load-carrying capacity or structural performance in general. In this paper, a thorough overview of the different micromodels proposed for the analysis of infilled frames is presented, and the advantages and disadvantages of each micromodel are pointed out (this paper follows our recent review paper on the state-of-the-art of the mathematical macromodeling of infilled frames, thus completing the overview of both macro- and micro- models in the field). Practical recommendations for the implementation of the different models are also presented