Medical treatment of octogenarians with chronic heart failure: data from CHECK-HF

Background: Elderly heart failure (HF) patients are underrepresented in clinical trials, though are a large proportion of patients in real-world practice. We investigated practice-based, secondary care HF management in a large group of chronic HF patients aged ≥ 80 years (octogenarians). Methods: We analyzed electronic health records of 3490 octogenarians with chronic HF at 34 Dutch outpatient clinics in the period between 2013 and 2016 , 49% women. Study patients were divided into HFpEF [LVEF ≥ 50%; n = 911 (26.1%)], HFrEF [LVEF < 40%; n = 2009 (57.6%)] and HF with mid-range EF [HFmrEF: LVEF 40–49%; n = 570 (16.3%)]. Results: Most HFrEF patients aged ≥ 80 years received a beta blocker and a renin–angiotensin system (RAS) inhibitor (angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker), i.e. 78.3% and 72.8% respectively, and a mineralocorticoid receptor antagonist (MRA) was prescribed in 52.0% of patients. All three of these guideline-recommended medications (triple therapy) were given in only 29.9% of octogenarians with HFrEF, and at least 50% of target doses of triple therapy, beta blockers, RAS inhibitor and MRA, were prescribed in 43.8%, 62.2% and 53.5% of the total group of HFrEF patients. Contraindications or intolerance for beta blockers was present in 3.5% of the patients, for RAS inhibitors and MRAs in, 7.2% and 6.1% Conclusions: The majority of octogenarians with HFrEF received one or more guideline-recommended HF medications. However, triple therapy or target doses of the medications were prescribed in a minority. Comorbidities and reported contraindications and tolerances did not fully explain underuse of recommended HF therapies. Graphic abstract: [Figure not available: see fulltext.]

Gestión del modelo de desinstitucionalización de adultos con alteraciones mentales en el sistema público de la Provincia de Buenos Aires

La alteración de la salud mental constituye un problema socio-sanitario. Las ciencias de la salud consideran modelos de causalidad multifactoriales con determinantes sociales. No se observa en esta investigación la inclusión de la Ciencia Administrativa como interdisciplina. Su incorporación permitiría integrar conocimientos administrativos para un eficaz y eficiente desempeño en las organizaciones de salud mental. Las fallas de planificación como proceso central en la formulación de estrategias constituyen un común denominador de los modelos descriptos. Los resultados encontrados, como indicadores del valor giro programa, 5 años de permanencia (rango 1 – 20); y producto del análisis cualitativo (respuestas a entrevistas) 6 años (máxima permanencia 26-27 años) afirman un bajo rendimiento de los programas existentes. Se observó contradicción en los modelos para compatibilizar el control del rendimiento con la autonomía de las diferentes divisiones, sistemas cerrados instrumentales de la sede central, responsables de las actividades dependientes de más de un coordinador con desempeño simultáneo en subproyectos sin conseguir resultados aceptables. La propuesta del nuevo modelo de gestión es una intervención de tipo social fragmentaria, sistematizada e incremental. Propone un rediseño de los procesos con la revisión de los recursos disponibles para alcanzar aumento del valor giro-paciente para la externación con reinserción social.Facultad de Ciencias Económica

Cost modelling of PACS

In a contribution to the Medical Imaging,II conference 1988 the design and construction of a package for PACS cost modelling was advocated. In this paper the main features of such a package are described. A first version of the package, called CAPACITY, is ready and experiences are being collected. The package produces as its main results a comparison oftotal cost differences of a PACS configuration and a film-based system as a function of time. The user has to describe the PACS configuration, the technical characteristics of the various components together with the estimated price (as a function of time). Also for the film based system the costs of the various components have to be defined by the user. The production volume of the hospital and the radiology department is input and used in the critique module that checks the input data supplied against a number of rules of thumb (to be defined by experts). At present the package is being used experimentally within our group. At the next EUROPACS meeting (March 1989) it will be demonstrated and other groups will be invited to use it. It is expected that discussions on the results of the package and analysis of the input data supplied will contribute to convergence of the widely varying opinions about the costs of PACS and the moment PACS will be cost justified (both within the radiology department and in the clinic)

Bumblebees and other pollinators

Aspects determining the risk of pesticides to wild bees: risk profiles for focal crops on three continents

Cost Modelling Of PACS

In a contribution to the Medical Imaging,II conference 1988 the design and construction of a package for PACS cost modelling was advocated. In this paper the main features of such a package are described. A first version of the package, called CAPACITY, is ready and experiences are being collected. The package produces as its main results a comparison oftotal cost differences of a PACS configuration and a film-based system as a function of time. The user has to describe the PACS configuration, the technical characteristics of the various components together with the estimated price (as a function of time). Also for the film based system the costs of the various components have to be defined by the user. The production volume of the hospital and the radiology department is input and used in the critique module that checks the input data supplied against a number of rules of thumb (to be defined by experts). At present the package is being used experimentally within our group. At the next EUROPACS meeting (March 1989) it will be demonstrated and other groups will be invited to use it. It is expected that discussions on the results of the package and analysis of the input data supplied will contribute to convergence of the widely varying opinions about the costs of PACS and the moment PACS will be cost justified (both within the radiology department and in the clinic)

Clinical utility of two-dimensional magnetic resonance angiography in detecting coronary artery disease

Aims: The accuracy of magnetic resonance angiography in detecting proximal coronary artery stenoses is unclear. We postulated that fast magnetic resonance angiography is capable of (1) imaging proximal coronary arteries, and (2) detecting stenoses of ≤ 50% of their luminal diameter. Methods and results: Thirty-five patients, referred for analysis of angina pectoris, underwent both conventional angiography and magnetic resonance angiography of coronary arteries. A fast k-space segmented gradient-echo technique was used during breath-holds. Two observers, blinded to the results of conventional angiography, independently analysed the magnetic resonance studies for (1) length of visualized segments, and (2) presence of signal voids indicative of stenoses. From 140 proximal arteries, 15 (11%) were excluded because of incomplete imaging or degraded image quality. Mean length of the visualized segments was 9 ± 4 mm for the left main, 62 ± 16 mm for the left anterior descending, 21 ± 9 mm for the left circumflex and 89 ± 32 mm for the right coronary artery. Sensitivity for detecting ≤ 50% luminal diameter stenoses was 0.00 for the left circumflex, 0.53 for the left anterior descending coronary artery, 0.71 for the RCA and 1.00 for the left main artery. Specificity varied from 0.73 for the left anterior descending coronary artery to 0.96 for the left circumflex. Inter-observer agreement was 0.90. Conclusion: Thus, segmented magnetic resonance angiography is capable of non-invasive imaging of proximal coronary anatomy. Its good accuracy in detecting left main coronary artery disease, intermediate accuracy in detecting right coronary artery and left anterior descending coronary artery stenoses, and low accuracy in detecting left circumflex lesions fit within a range of sensitivities and specificities found by others. Further technical advances are necessary to make the technique clinically robust

Magnetic resonance angiography of anomalous coronary arteries: A new-gold standard for delineating the proximal course?

Background: The clinical significance of anomalously originating coronary arteries depends on their proximal course. Diagnosis of this course by conventional x-ray coronary angiography alone may be equivocal. We postulated that with fast magnetic resonance (MR) angiography, accurate detection of anomalous coronary arteries and unambiguous delineation of their proximal course is feasible. Methods and Results: In a selected group of 38 patients, 19 of them having an anomalously originating coronary artery, a fast MR angiographic technique was used to study the proximal coronary anatomy. Blinded analysis of randomly ordered MR studies was performed independently by two observers. Both origin and proximal course of the coronary arteries were defined. Two cardiologists reviewed all x-ray coronary angiograms. After the separate analyses, a final consensus result was defined for each patient. In 37 patients, successful MR coronary angiography could be performed. Interobserver agreement for determining both origin and proximal course was 100%. An x-ray coronary angiogram was available in 36 patients. In 3 patients (all with an anomalous left main coronary artery originating from the right aortic sinus), there was disagreement about the proximal course between the results of MR and x-ray coronary angiography had unambiguously visualized the proximal coronary artery course, whereas the results of x-ray angiography had been equivocal. Thus, sensitivity and specificity for detecting anomalous coronary arteries and delineating their proximal course were 100%. Conclusions: These data suggest that fast MR angiography is highly accurate in determining the origin and delineating the proximal course of anomalous coronary arteries, even in those cases in which x-ray coronary angiographic diagnosis is difficult or even erroneous

Double-blind, multicentre analysis of the efficacy of borage oil in patients with atopic eczema

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