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Pulmonary oxygen uptake ([Formula: see text]) slowly increases during exercise above the anaerobic threshold, and this increase is called the slow component of [Formula: see text]. The mechanism of the increase in [Formula: see text] is assumed to be due to increasing energy cost associated with increasingly inefficient muscle contraction. We hypothesized that the increase in [Formula: see text] would be accompanied by a constant or increasing rate of accumulation of blood lactate, indicating sustained anaerobic metabolism while [Formula: see text] increased. Ten male subjects performed cycle ergometry for 3, 6, and 9 min at a power output representing 60% of the difference between lactate threshold and maximal [Formula: see text] while [Formula: see text] and blood lactate accumulation were measured. Blood lactate accumulation decreased over time, providing the energy equivalent of (mean ± SD) 1586 ± 265, 855 ± 287, and 431 ± 392 ml of [Formula: see text] during 0-3, 3-6, and 6-9 min of exercise, respectively. As duration progressed, [Formula: see text] supplied 86.3 ± 2.0, 93.6 ± 1.9, and 96.8 ± 2.9% of total energy from 0 to 3, 3 to 6, and 6 to 9 min, respectively, while anaerobic contribution decreased. There was no change in total energy cost after 3 min, except that required by ventilatory muscles for the progressive increase in ventilation. The slow component of [Formula: see text] is accompanied by decreasing anaerobic energy contribution beyond 3 min during heavy exercise.

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PURPOSE: Describe patient satisfaction and patient-reported outcomes after voluntary use of a telephone-based nurse triage service. METHODS: A random sample of symptomatic callers who contacted the triage service in 1999 was identified. A computer-assisted telephone survey was conducted, resulting in a response rate of 58.9 percent and a sample size of 35,374. SUMMARY: Overall satisfaction with the service was 90.4 percent and did not vary greatly when stratified by demographic and health status characteristics. Of all callers who reported following the triage recommendation to use self-care instructions while monitoring the condition for change (n = 12,037), 11.5 percent scheduled an office visit and 1.5 percent used hospital emergency-room (ER) services for further care. CONCLUSIONS: Overall satisfaction with telephone-based nurse triage services was high and did not vary substantially by caller characteristics.

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OBJECTIVE: To assess patient satisfaction and a health plan's return on investment associated with a telephone-based triage service. STUDY DESIGN: A pre-post study design, with medical claims data, to assess changes in medical service utilization and health plan expenditures associated with members' use of the triage service. PATIENTS AND METHODS: This study is based on data on 60,000 members of a health plan. A telephone survey was conducted to assess member satisfaction and outcomes with the triage service. The plan's medical claims and encounter data were used to calculate medical utilization rates and plan expenditures for those services. The health plan's return-on-investment was evaluated using a pre/post study design to assess changes in medical service utilization between the baseline (December 1995 through November 1996) and program (December 1996 through November 1997) periods. RESULTS: The average nurse response time to a call was just less than 50 seconds, which indicates the service provided ready access to medical advice 24 hours per day, 7 days per week. More than 90% of users were satisfied, and utilization of hospital emergency department (ED) and physician office services decreased significantly after the service was implemented. The changes in medical service utilization resulted in reductions in health plan expenditures that exceeded the plan's costs of providing the service. The plan's estimated return for every dollar invested in the nurse triage service was approximately $1.70. CONCLUSIONS: The telephone-based nurse triage service appears to be a cost-effective intervention that improves access to medical advice, thereby encouraging appropriate use of medical services. The service is associated with reductions in utilization of hospital ED and physician office services and with high levels of member satisfaction.

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UNLABELLED: Adenoidal hypertrophy is a common problem in pre-school children and diagnosis depends mostly on evaluation of clinical symptoms and signs. Investigative techniques to assess adenoidal size often do not add to this information. Recent reports have suggested a role for acoustic rhinometry in this situation. A total of 49 children consecutively referred to the Department of Otorhinolaryngology, University of Mainz, with evidence of adenoidal enlargement underwent acoustic rhinometry pre- and post-operatively and were compared to an age-matched control group from a local kindergarten school. Adenoidal size was visually estimated at surgery and questionnaires were completed by parents of symptomatic children. Acoustic rhinometry was not able to differentiate controls (mean nasopharyngeal cross-sectional area 1.34+/-0.47 cm2, n = 35) from symptomatic children admitted for adenoidectomy (mean nasopharyngeal cross-sectional area 1.66 +/- 0.83 cm2, n = 42, P = 0.53). Acoustic rhinometry was advantageous for patients with adenoidal hypertrophy in two situations. Firstly a sub-group of patients with complete nasopharyngeal obstruction could be identified (P = 0.03) and secondly all patients with a postnasal space less than 1.2 cm2 clinically benefited from adenoidectomy. CONCLUSIONS: Acoustic rhinometry, in general, is not suitable for assessing adenoidal size in pre-school children. Physical limitations of currently available acoustic rhinometers are likely to explain the limited clinical value of this investigative technique.

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Endoscopy of the upper airways in neonates and infants was traditionally been accomplished using rigid laryngoscopes and bronchoscopes. The laryngeal mask may be used both to control the airway for anaesthetic ventilation and to guide a fibre-optic endoscope to the laryngeal inlet and beyond. We report our experience with five neonatal and paediatric cases where fibre-optic laryngoscopy and bronchoscopy were performed through the laryngeal mask airway. All were cases in which standard rigid endoscopy had proved difficult with only a poor and restricted view of the laryngeal inlet being obtained due to the age of the infants, or abnormal anatomy of the upper airways. No problems have been encountered with maintenance of the airway or with endoscopic view obtained. In fact in neonatal patients, this technique has been found to be preferable with regard to safety and ease of use when compared to the ventilating bronchoscope. With the size 1 laryngeal mask airway it is not possible to simultaneously ventilate and endoscope the patient. Cases included, a vascular ring, Goldenhar's syndrome, laryngomalacia, supraglottis and vocal fold paresis. This technique provides a secure method of maintaining anaesthetic ventilation during airway endoscopy, and also a means of easily locating the glottis.

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The purpose of this study was to analyse national health expenditures of OECD countries relative to their age structures. Using econometric techniques designed to analyse cross-sectional time series data, the ageing of the population was found to affect health spending in several countries while having no effect in others. In addition, the effect of income on health spending was lower than that generally reported in the literature. These findings suggest that unobserved country-specific factors play a major role in determining the amount of resources allocated to health services in a country. Such factors also determine if the ageing of the population with increased health spending.

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In two studies on overcrowding and foot lesion development, claw health was monitored monthly, and behavioural activities such as lying/standing observed every 15 min for 5 consecutive days and nights each month of the housing season. In the first experiment, 35 autumn-calving heifers were housed at a 2:1 heifer to cubicle ratio immediately after calving. In the second study, 40 spring-calving heifers were housed at a 2:1 ratio for 2 months before calving and with one cubicle each after calving. Lying time was reduced to 5 h per 24 h in some of the autumn-calving animals and these animals had significantly worse foot lesion scores and clinical lameness than animals lying for 7 or 10 h per 24 h. The spring-calving animals did not show such a severe reduction in lying time and no significant correlation between haemorrhage score and lying time was detected. It is concluded that reduced lying time acts as an exacerbating factor in the development of claw lesions.

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To examine the effects of a vegetarian diet on child growth, height and weight data of 404 vegetarian children aged 4 months to 10 years who lived in a collective community in Tennessee were studied. Height for age, weight for age, and weight for height were compared with the US growth reference. Birth weights, infant feeding patterns, and parental heights were also evaluated in relation to growth. Most of the height for age, weight for age, and weight for height (n = 833) were within the 25th and 75th percentiles of the US growth reference. The mean height for age and weight for age, however, were slightly less than the median of the reference population. For different age groups, the mean height ranged from 0.2 to 2.1 cm and the mean weight ranged from 0.1 to 1.1 kg less than the reference median. The largest height difference was observed at 1 to 3 years of age and may be partly the result of intrinsic irregularities in the US growth reference at those ages. By 10 years of age, children from The Farm averaged 0.7 cm and 1.1 kg less than the reference median, representing only 0.1 and 0.3 SD from the reference. Thus, these children have adequate attained growth, even though it was modestly less than that of the reference population.

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Wound contamination with endogenous bacterial scalp flora plays an important role in the pathogenesis of postoperative neurosurgical infections. To assess the effect of preoperative antiseptic shampoos on the emergence of resident scalp flora during surgery and subsequent wound contamination, we randomized 151 neurosurgical procedures into four study groups: group A--preoperative shampoos with chlorhexidine, surgical scalp preparation with chlorhexidine; group B--no shampoos, surgical preparation with chlorhexidine; group C--shampoos with iodophor, surgical preparation with iodophor; group D--no shampoos, surgical preparation with iodophor. Quantitative cultures of the scalp were obtained preoperatively and at the end of surgery, and qualitative wound cultures were taken prior to wound closure. Group A had the lowest concentration of bacteria on the scalp both preoperatively and postoperatively (median range = 30 [0-5.7 x 10(5)] and 0 [0-2.5 x 10(3)] respectively). Group A also had significantly fewer positive postoperative scalp cultures (29%) than groups B (51%), C (58%), and D (53%) (P less than 0.05), as well as fewer positive wound cultures (20% v 25%, 42%, and 30% respectively). A density of bacteria on the scalp of greater than 10(2)/4cm2 best predicted the presence of bacteria in the wound. Repeated preoperative shampoos with chlorhexidine reduce intraoperative emergence of resident skin flora and subsequent contamination of the wound.

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Wound contamination with endogenous bacterial scalp flora plays an important role in the pathogenesis of postoperative neurosurgical infections. To assess the effect of preoperative antiseptic shampoos on the emergence of resident scalp flora during surgery and subsequent wound contamination, we randomized 151 neurosurgical procedures into four study groups: group A-preoperative shampoos with chlorhexidine, surgical scalp preparation with chlorhexidine; group B-no shampoos, surgical preparation with chlorhexidine; group C-shampoos with iodophor, surgical preparation with iodophor; group D-no shampoos, surgical preparation with iodophor. Quantitative cultures of the scalp were obtained preoperatively and at the end of surgery, and qualitative wound cultures were taken prior to wound closure. Group A had the lowest concentration of bacteria on the scalp both preoperatively and postoperatively (median range = 30 [0-5.7 x 10(5)] and 0 [0-2.5 x 10(3)] respectively). Group A also had significantly fewer positive postoperative scalp cultures (29%) than groups B (51%), C (58%), and D (53%) (P<0.05), as well as fewer positive wound cultures (20% v 25%, 42%, and 30% respectively). A density of bacteria on the scalp of < 10(2)/4 cm(2) best predicted the presence of bacteria in the wound. Repeated preoperative shampoos with chlorhexidine reduce intraoperative emergence of resident skin flora and subsequent contamination of the wound.

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Ninety six middle aged male patients with chronic bronchitis with relatively well preserved ventilatory function who were resident in Queensland, New South Wales, or Victoria took part in a prospective study to determine the relationship of various factors to the rate of decline of the FEV1. Thirty of the subjects withdrew, leaving 66 to be followed for four to six years. The mean rate of decline of the FEV1 was 58.6 (SD 51.4) ml/year. The subjects' ventilatory responses to bronchodilator and to methacholine (measures of bronchial lability) were significantly related to each other and to sputum eosinophilia. With a linear model for the data on 57 patients who had methacholine and skin tests the rate of decline of the FEV1 was found, after adjustment had been made for other variables, to be significantly related to State of residence, current smoking, response to bronchodilator, age, and occupational exposure to dust. Response to bronchodilator was interchangeable with response to methacholine. With the five variables in the model none of the following factors was related to the rate of decline of the FEV1:FEV1 on entry, FEV1% predicted normal, FEV1/VC%, skin test reaction, occupation on entry, history of sinusitis and rhinitis, and height. When data from all 66 subjects were introduced into the model, in addition to the five significant individual variables (FEV1/VC% X response to bronchodilator) was significantly related to the rate of decline of the FEV1. Of these prognostic indices, response to bronchodilator was independent of the initial FEV1, FEV/VC%, and FEV1% predicted. The difference between States, which was not explained by differences due to sampling or withdrawal of subjects, was due to a low rate of decline in Queensland.

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A 63-year-old man presenting with acute retention and dysuria underwent transurethral resection of the prostate for suspected benign prostatic hypertrophy. Ten days postoperatively he developed disseminated cryptococcosis. Re-examination of the prostatic chips revealed cryptococcal prostatitis. Treatment consisted of amphotericin, flucytosine and transfer factor along with wedge resection of a pulmonary toruloma. He remains well 12 months after cessation of treatment. This appears to be the first case report in Australia of cryptococcal prostatitis with dissemination after transurethral resection of the prostate.

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In a laboratory simulation of foraging conditions, pigeons maintained ad lib weight by treadle pressing for lengthy periods of access to grain in a 24-hr live-in environment. Localized visual signals produced by treadle pressing evoked approach and pecking behavior if they signaled impending food presentation (Pavlovian first-order conditioning) or the presentation of an established signal for food (Pavlovian second-order conditioning). These findings imply a role for associative mechanisms in the control of foraging.

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The occurrence of sputum eosinophilia was investigated in 115 patients with chronic bronchitis and asthma. They were clinically divided into four groups; those with asthma only, those with asthma of equal or greater duration than chronic bronchitis, those with chronic bronchitis recently complicated by asthma and those with chronic bronchitis only. Although sputum eosinophilia was more common in the asthmatic groups there was no significant difference between the groups in the degree of sputum eosinophilia. When the groups were subdivided on the basis of methacholine and isoprenaline response (asthma subgroup, greater than or equal to 20% response to isoprenaline or greater than or equal to 40% response to methacholine; chronic-bronchitis subgroup, less than 10% response to isoprenaline plus less than 20% response to methacholine), there was a significant difference between the groups in the degree of sputum eosinophilia. However, sputum eosinophilia still occurred in the chronic bronchitics. In the asthmatic patients, there appeared to be no difference in the degree of sputum eosinophilia in those with positive skin tests, or on steroid medication, compared with those with negative skin tests or not on steroids.¿

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Inspiratory muscle strength and the flow and elastic pressure opposing inspiration were measured in seven patients with severe airways obstruction who found inspiration difficult at rest. A comparison was made of measurements obtained from seven normal subjects and five patients with airways obstruction not experiencing inspiratory dyspnoea at rest. Measurements were also obtained when inspiratory dyspnoea was induced in the normal subjects by adding an inspiratory resistance or by voluntarily increasing lung volume. Compared with the controls the inspiratory muscle strength of the patients was reduced but was not significantly less than that of the patients without inspiratory dyspnoea. The pressure required to produce inspiratory flow was significantly greater when inspiratory dyspnoea was present (P = 0-01). However, there was considerable overlap in the pressures of those with and without inspiratory dyspnoea. A better relationship was obtained when muscle strength was considered. The ratio of inspiratory muscle strength to the pressure required to produce flow was 0-24 +/- 0-07 (mean +/- SD) in patient with inspiratory dyspnoea, 0-10 +/- 0-03 in patients without inspiratory dyspnoea, and 0-033 +/- 0-019 in normal subjects. There was no overlap between the two patient groups. The ratios of the normal subjects were increased when inspiratory dyspnoea was induced and, with the exception of two cases, were all above those obtained when inspiratory dyspnoea was absent. Inspiratory dyspnoea was experienced with lower ratios in the normals than in the patients with airways obstruction.

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Chest physiotherapy, including posturing the patient head downwards while the chest is percussed and vibrated, was used in the treatment of patients with an exacerbation of chronic bronchitis. In seven patients the mean FEV declined from 1.38 litres plus or minus 0.39 to 1.25 litres plus or minus 0.37 after postural drainage and percussion (P less than 0.001). Twenty minutes later the FEV rose to 1.37 litres plus or minus 0.33. The mean decline in the FEV1 was prevented by prior administration of salbutamol. The fall in the FEV1 did not occur in 10 patients who received the postural tipping without chest percussion. Also it was not induced by coughing every two minutes during posturing. It was considered that the fall in FEV1 after chest physiotherapy was due to bronchoconstriction caused by the chest percussion or vibration, particularly in patients with bronchoconstriction under basal conditions. The induced bronchoconstriction counter-balanced any improvement of the FEV due to freeing the airways of sputum, but in two patients with moderate to copious sputum an improvement of the FEV1 was repeatedly obtained in measurements made 20 minutes after the physiotherapy when the bronchoconstriction had presumably subsided. Although the immediate decline in FEV1 was not large, it is considered inadvisable to employ chest percussion and vibration in sick patients unless a bronchodilator is administered previously.

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