The Agency for Healthcare Research and Quality (formerly the Agency for Health Care and Policy Research), American College of Cardiology, American Heart Association, and European Society of Cardiology have all issued recommendations on the diagnosis and treatment of left ventricular systolic dysfunction, the most common type of heart failure. These recommendations provide a benchmark for measuring the quality of heart failure care and implementing improvements. They advise that patients with suspected or overt heart failure should undergo diagnostic testing to measure ventricular function and that those with ejection fractions <40% should receive angiotensin-converting enzyme (ACE) inhibitors. ACE inhibitors and |3-blockers should be titrated to the recommended doses to decrease mortality regardless of symptoms, while patients with concomitant atrial fibrillation should receive warfarin unless contraindicated.
Two large studies suggest that many hospitalized patients do not undergo measurement of left ventricular ejection fraction to determine the underlying cause of their heart failure, while a significant proportion of those with moderately to severely decreased left ventricular ejection fractions do not receive ACE inhibitors and P-blockers. [gallery ids=""]
Similarly, several studies show that warfarin is underused in atrial fibrillation. The reasons for underusing recommended diagnostic tests and drugs are unclear. As recently as 1990, 83% of heart failure patients were being looked after by internists or primary care physicians with no formal cardiology training, and correspondingly less informed about recent therapeutic advances. Surveys assessing the use of heart failure diagnostic and management guidelines by board-certified cardiologists and board-certified primary care physicians show differences in patient care.
The results suggest that some primary care physicians do not fully appreciate the difference between left ventricular systolic and diastolic dysfunction. This lack of understanding of heart failure pathophysiology may explain why primary care physicians differ from cardiologists in their perception of the importance of measuring the left ventricular ejection fraction. They are significantly less likely to request this parameter. Many also appear not to differentiate between the different types of heart failure.
They are more likely to prescribe digoxin when it is not indicated (diastolic dysfunction) and less likely to prescribe digoxin and ACE inhibitors when they are indicated. National guidelines have emphasized the safety and importance of ACE inhibition in patients with asymptomatic low blood pressure and those with mild renal insufficiency. The surveys suggest that primary care physicians underuse ACE inhibitors because they overestimate the risk rather than fail to appreciate the benefits. Similarly, they are significantly less likely than cardiologists to prescribe warfarin for patients with concomitant atrial fibrillation because they overestimate the risks of anticoagulation. Primary care physicians are likely to continue to manage the majority of patients with heart failure.
An improved quality of primary care should be a priority for this highly prevalent condition. Unfortunately, studies have shown that the development and dissemination of guidelines may increase knowledge and modify attitudes, but has little impact on behavior and, ultimately, on outcome. Primary care physicians need further education on heart failure pathophysiology, the safety of ACE inhibitors and [3-blockers, and the low risk of major bleeding with anticoagulation in selected patients. Antoni MR, Beyth RJ, Covinsky KE, et al.
Failure to prescribe warfarin to patients with nonrheumatic atrial fibrillation. J Gen Intern Med.1996;11. 713-720.
Baker DW, Hayes RP, Massie BM, Craig CA. Variations in family physicians' and cardiologists' care for patients with heart failure. Am Heart J.
1999;138: 826-834. Bath PM, Prasad A, Brown MM, MacGregor GA. Survey of use of anticoagulation in patients with atrial fibrillation. BMJ.
1993,307:1045. Chodoff P, Bischof RO, Nash DB, Laine C.The AHCPR guidelines on heart failure: comparison of a family medicine and an internal medicine practice with the guidelines and an educational intervention to modify behaviour.
Clin Perform Qual Health Care.1996;4: 179-185. Heart failure treatment with angiotensin-converting enzyme inhibitors in hospitalized Medicare patients in 10 large states The Large State Peer Review Organization Consortium. Arch Intern Med.
1997,157: 1103-1107. Konstarn MA, Dracup K, Baker DW, et al. Heart failure: evaluation and care of patients with left ventricular systolic dysfunction. Rjblication No.
AHCPR 94-0612. Rockville, USA: Agency for Health Care Policy and Research, 1994. Krumholz HM, Wang Y, Parent EM, Mockalis J, Petrillo M, Radford MJ.
Quality of care for elderly patients hospitalized with heart failure. Arch Intern Med.1997,157: 2242-2247 Keywords management; caregiver specialty; primary care physician; cardiologist; guideline; diagnostic test; drug The facial is not only one of the most concentrated efforts to make our faces look their best; it is also a relaxing and pleasurable process, and part of the pampering that a beauty spa offers its guests.
Although beauty spas may differ in the products they use and the treatments they provide, there are some universal features of a facial that you can expect when you sign up to have one. What to Expect As with most beauty spa services, a facial will usually begin with an in-depth consultation with the therapist, which covers a number of aspects of skin care, and the treatments you can choose to receive. It will usually also include your providing information about your diet, exercise, and skin care habits, what medications you might be taking, and what cosmetics you ordinarily use, if any.
The technician may explain the effects of environment on the skin, and how pollutants, sun, or other factors may have been playing a role in the condition of your skin. You'll be invited to talk about what changes or improvements you would like to make in the condition of your skin. During this conversation, you should be able to state what your expectations are, in terms of what you would like the facial to accomplish.
As you talk with the therapist, you will get feedback that lets you know how to keep those expectations at a realistic level. While there are certainly benefits you'll see and feel instantly after one facial, more lasting effects may require a series of visits for repeat applications, with measures you can take at home in between facials. Once you have completed your opening conversation with the therapist, your skin will be cleansed, and you’ll get an analysis of your skin’s condition. It must have been amusing for them.
Chiefy had pet hates, or more accurately, several people whom he hated even more than he hated the rest of us. One of them was a thick-necked lad with big lips and a receding chin. He was a second-termer who was known as Dong.
Dong looked stupid and he certainly wasn’t bright. Chiefy didn’t care about that though: he hated Dong because Dong was uncoordinated to the point of disability. When most people walk, they put their left leg forward and at the same time their left arm swings back; the natural gait of the homo sapien.
Dong’s natural gait was in reverse; his left arm would swing forward at the same time as his left leg went forward, making him move forward with a strange robotic motor, which drove Chiefy wild with rage. He would stand with his face two inches from Dong’s and screech abuse at him, spraying poor Dong with a blanket of spittle. Chiefy would then turn to the ranks of cadets and screech: Look at ’im! Look at ’im! He’s got two left legs! He’s a bloody cripple! March, Dong! Go on! March! And Dong would set off, shambling jerkily like a badly-built machine.