Thrombolytic therapy guided by a decision analysis model: are there potential benefits for patient management?

BACKGROUND

Although thrombolytic therapy improves the outcome of myocardial infarction, it is associated with increased risks of stroke and bleeding; these risks may outweigh the benefits of therapy. The risks and benefits of thrombolysis, for any individual clinical situation, can be explicitly estimated by means of decision analysis.

HYPOTHESIS

The aim of this study was to compare the actual use of thrombolytic agents for suspected acute myocardial infarction (AMI) with the management preferred by a decision analysis model.

METHODS

Admission data prospectively obtained in 262 consecutive patients admitted to a rural community hospital's coronary care unit with suspected AMI, as well as clinical decisions and outcomes, were reviewed and analyzed.

RESULTS

Seventeen deaths from AMI and no major strokes were observed, compared with 18.30 deaths and 0.85 major strokes predicted by a decision analysis model. Forty-seven of 84 patients with confirmed AMI and 3 of 178 without AMI were given a thrombolytic agent, compared with 65 patients with and 7 without AMI who had decision analysis-guided therapy. Decision analysis-guided therapy could have saved 3.7 additional lives and gained 29.6 life years, but produced 0.4 extra strokes. Changing the quality adjustment for stroke or heart failure would not have altered the treatment preferred by decision analysis in any of the 262 cases studied. Some patients were predicted to benefit considerably from thrombolysis with little extra risk of stroke and vice versa: all cases must, therefore, be assessed individually.

CONCLUSIONS

A decision analysis model can guide thrombolytic therapy by promptly defining its risks and benefits.

How to obtain excellent response rates when surveying physicians

This paper outlines ways to maximize response rates to surveys by summarizing the most relevant literature to date and demonstrating how these techniques have resulted in consistently high rates of return in family practice research. We describe the methodology used in recent surveys of physicians conducted by the Centre for Studies in Family Medicine through its Thames Valley Family Practice Research Unit, located in London, Ontario, Canada and funded by the Ontario Ministry of Health and Long-Term Care. The identification and implementation of these techniques to maximize response rates is critical, as primary health care researchers often rely on information gathered through questionnaires to study physicians' practice profiles, experiences and attitudes. Four separate and distinct mailed surveys of physicians using a modified Dillman approach were conducted from 2001 to 2004. The sampling strategies, topics, types of questions and response formats of these surveys varied. The first survey did not use any incentives or recorded delivery/registered mail and received a response rate of 48%. In sharp contrast, the other three surveys obtained responses rates of 76%, 74%, 74%, respectively, achieved through the use of gift certificates and recorded delivery/registered mail. Sending a survey by recorded delivery/registered mail tends to result in the survey package being given priority in the physicians' incoming mail at the practice. Gift certificates partially compensate physicians for time spent completing the survey and recognition of the time required is appreciated. The response rates achieved provide strong evidence to support the use of monetary incentives and recorded delivery/registered mail (along with the Dillman approach) in survey research. It is anticipated that this evidence will be used by other researchers to justify requests for funding to cover the costs associated with incentives and recorded delivery/registered mail. We recommend the use of these strategies to maximize response rates and improve the quality of this type of primary health care research.

Airborne gamma survey of the historic Sleisbeck mine area in the Northern Territory, Australia, and its use for site rehabilitation planning

An airborne gamma-survey provided information about the extent of radioactive contamination around the historic Sleisbeck mine. Quickbird satellite data were acquired to relate airborne measurements to land cover features. Enhanced equivalent uranium (eU) levels were found to be confined to the mine and low grade waste rock dumps. The average terrestrial background radiation dose rate estimated from the airborne gamma survey data was 0.10-0.14 microGy h(-1) while the area around the mine exhibited a maximum of approximately 2.3 microGy h(-1), but measurements on the ground indicate that this maximum is exceeded in some localized areas. Rehabilitation of the site is likely to result in a threefold reduction in radiation doses to people accessing the area.

Rail signallers' assessments of their satisfaction with different shift work systems

This paper describes rail employee views on shift-work systems obtained from administration of the Rail Ergonomics Questionnaire (REQUEST) to a large sample of rail professionals in Great Britain, achieving a response rate of 83%. Results from signallers, the largest occupational grouping in the survey (n = 3230), are presented. ANOVA has been used to investigate the effects of different aspects of the shift patterns (the length of shift and the speed and direction of rotation of shifts) and the effects of age on the ratings of satisfaction with the shift system. The findings from the analyses indicate preferences for the 12-h shift system over the 7-9-h rotating shift system. There were no main effects of the direction of rotation of shifts, though there were significant interactions between the direction of rotation of shifts, the numbers of consecutive shifts and the age of respondents. There is a need for clear data addressing the impact on workers of key shift-related parameters such as shift length, direction of rotation of shifts, numbers of consecutive shifts and personal factors such as age. This paper presents findings of the effects of these key shift and personal parameters and their interactions on respondents' ratings of satisfaction with the shift system, using data collected with REQUEST in a national survey of rail signallers.

Colonoscopy completion rates--are we prepared for a national screening programme?

Colonoscopy is a difficult technique to learn. There are international standards regarding its completion rates. An audit of colonoscopy completion rates was carried out using computerized data in which the compliance with international standards was assessed. Of 909 patients overall crude and adjusted (excluding incompletion due to poor preparation and disease) caecal intubation rates were 88% and 94.1% respectively. Of those who were considered eligible for terminal ileal intubation, the crude and terminal ileal intubation rates were 47.3% and 50.3% respectively. The results indicated completion rated as per recommendations and were adequate for any colon screening programme to be successful.

Oral developmental toxicity study of methylsulfonylmethane in rats

Methylsulfonylmethane (MSM) is a metabolite of dimethyl sulfoxide, and occurs naturally at low levels in many foods. MSM has received wide attention as a dietary supplement to promote joint health. The objective of these studies was to determine the developmental toxicity potential of MSM when administered orally to pregnant rats during the period of major organogenesis and histogenesis. In a preliminary dose-finding study, distilled MSM microprill (i.e., microspherical pellets of MSM) was administered by oral gavage at dose levels of 0 (vehicle control), 50, 250, 500, and 1000 mg/kg/day to 8-9 sperm-positive female Sprague-Dawley rats/group/day on gestation days 6-20. No evidence of maternal or fetal toxicity was observed. For the definitive developmental study, four groups of 24-25 timed-bred primiparous female rats were administered 0, 50, 500, or 1000 mg MSM/kg/day via gavage on gestation days 6-20. Maternal feed consumption, body weight, body weight gain, uterus weight and corrected body weight/body weight gain were unaffected by treatment. No evidence of maternal toxicity, and no significant differences in litter viability, litter size, or litter body weight were detected. Fetal evaluations failed to show any biologically significant increase in the incidence of anomalies in the MSM treated groups, and no malformations were seen in any of the fetuses. No evidence of fetal mortality, alterations to growth, or structural alterations were observed in the fetuses of dams administered 50-1000 mg/kg/day. Therefore, under the conditions of this study, the no-observed-adverse-effect level (NOAEL) for maternal and developmental toxicity was 1000 mg/kg/day.

Expression of survivin and its splice variants survivin-2B and survivin-DeltaEx3 in breast cancer

Alternative splicing of survivin mRNA gives rise to multiple isoforms, that is, survivin and 3 splice variants, survivin-2B, survivin-3B and survivin-ΔEx3. The aim of this study was to compare the expression of survivin, survivin-2B and survivin-ΔEx3 in normal breast tissue, fibroadenomas, primary breast cancer and axillary nodal metastases. Survivin, survivin-2B and survivin-ΔEx3 mRNA were measured using semiquantitative RT–PCR. In the primary carcinomas, we related mRNA for each form of survivin to both survivin protein and apoptosis. For each type of breast tissue, survivin was the predominant form detected, being present in 146 out of 156 (93.6%) primary breast carcinomas, 11 out of 11 (100%) axillary nodal metastases, 21 out of 31 (67.7%) fibroadenomas and five out of 22 (22.7%) specimens of normal breast tissue. Levels of the three forms of survivin were significantly higher in the carcinomas compared to normal breast tissue (P<0.0001). Levels of both survivin-2B and survivin-ΔEx3 but not survivin were significantly higher in nodal metastases than primary carcinomas. Survivin mRNA levels correlated significantly with survivin protein. Finally, both survivin and survivin-ΔEx3 but not survivin-2B correlated positively with apoptosis. Although survivin, survivin-2B and survivin-ΔEx3 were all detected in both malignant and nonmalignant breast tissue, the predominant form was survivin. Our results suggest that the different forms of survivin may have different roles in apoptosis in breast cancer.

Increased Risk of Hemorrhagic Complications in Renal Allograft Recipients Receiving Systemic Heparin Early Posttransplantation

The aim of this paper is to document the risk of hemorrhagic complications in renal allograft recipients requiring systemic heparinisation within the first 2 weeks posttransplantation.

METHODS

A retrospective chart review of 326 RA recipients from January 1998 to July 2003 was subjected to statistics by SPIDA with P values <.05 considered significant.

RESULTS

16/326 (4.9%) recipients were initiated on intravenous (IV) heparin within the study period. Enoxaparin was subsequently used in 10/16 (62.5%) of these recipients. Intravenous heparin was instituted at a median 8 (1-14) days posttransplantation. Hemorrhagic complications occurred in 10/16 (62.5%) recipients on IV heparin versus 11/310 (3.5%) nonanticoagulated RA recipients (P = .0001). Hemorrhage occurred at a mean 9.75 (2-43) days into the course of IV heparin. The median peak APTT 24 hours prior to hemorrhage in RA recipients on heparin was 68.5 (58-180) versus a median peak APTT of 70 (50-140) among recipients on heparin who did not sustain a hemorrhagic complication (P = .30). A major intervention (predominantly surgery) was required in 6/16 (37%) recipients on IV heparin versus 7/310 (2.2%) nonheparinised RA recipients (P < .0001). Enoxaparin was instituted at a mean 22.5 (4-55) days posttransplantation. Delayed hemorrhage subsequently occurred in 4/10 (40%) recipients on enoxaparin. In conclusion, major and minor hemorrhagic complications occur more commonly among recipients requiring early post transplant IV heparin. Hemorrhage occurred despite APTT monitoring with APTT levels tending to be similar in RA recipients with versus without complications. Delayed hemorrhage was also seen with the subsequent use of enoxaparin.

A radon and meteorological measurement network for the Alligator Rivers Region, Australia

The network described in this paper has been set up to provide detailed time-series data on concentrations of 222Rn in air at various locations within the Alligator Rivers Region, over a time frame of several years. These data will be important in assessing the effects of uranium mining operations on radon levels in the region, both in providing baseline and monitoring data and in calibrating and verifying predictive models. At present, three stations are operating in the region with a fourth being commissioned. Each station logs half hourly average radon concentrations and relevant meteorological data (wind speed, direction and variability, air pressure and temperature, relative humidity, soil temperature, rain and sunshine rates). It is intended to operate the four stations at selected locations for one- or two-year intervals, at the end of which three will be moved to new locations (one station at Mudginberri will be kept as a constant control station). Sites for which extensive datasets are currently available include: Jabiru Town, Jabiru East, Djarr Djarr, East Alligator Ranger Station and Nabarlek minesite. Illustrative data from these sites are presented.

Transvenous liver biopsy via the femoral vein

AIM

To study the safety, effectiveness and diagnostic value of transvenous forceps biopsy of the liver in 54 patients with coagulopathy, gross ascites or morbid obesity and suspected liver disease in whom percutaneous liver biopsy was contraindicated.

MATERIAL AND METHODS

Forceps biopsy of the liver via the femoral vein was attempted in 54 adult patients with advanced liver disease of unknown aetiology who had coagulation disorders (41 cases), gross ascites (11 cases) or morbid obesity (two cases). In each patient two to six biopsies (average four) were taken using a radial jaw forceps inserted via the right or left femoral vein.

RESULTS

The procedure was successful in 53 cases. Hepatic vein catheterization failed in one patient. Adequate liver tissue for diagnosis was obtained in 84% of cases. One patient developed delayed haemorrhage at 12 h from a capsular leak that was undetected during the biopsy procedure. This patient required blood transfusions and laparotomy to control bleeding. There were no deaths in the 53 patients studied. Transient minor chest and shoulder pain was encountered during sheath insertion into a hepatic vein in 23 patients. Three patients developed a femoral vein haematoma, which resolved with conservative treatment.

CONCLUSION

Transvenous liver biopsy via the femoral vein is another safe, effective, simple alternative technique of biopsy when the percutaneous route is contraindicated.

Long-term efficacy of a cognitive behavioural treatment from a randomized controlled trial for patients recently diagnosed with rheumatoid arthritis

OBJECTIVES

This study examined the long-term efficacy of a cognitive behavioural intervention for patients with recent-onset, seropositive rheumatoid arthritis (RA).

METHODS

Fifty-three consecutive patients with less than a 2-yr history of classic or definite RA were recruited into the trial. All participants received routine medical management during the study, and half were randomly allocated to receive an 8-week adjunctive psychological intervention. All assessments were conducted blind to the allocation. This paper reports intention-to-treat analyses of the 18-month follow-up.

RESULTS

Consistent with short-term results, significant differences were found between the groups in depressive symptoms. The intervention group maintained improvements in joint function, although those in routine care made similar improvements over the ensuing 18 months. At follow-up, group differences emerged for disability and anxiety.

CONCLUSIONS

These results indicate that cognitive behavioural intervention offered as an adjunct to standard clinical management early in the course of RA is efficacious in producing improvements in both psychological and physical indices. Furthermore, improvements appear to increase 18 months after a brief, time-limited psychological treatment.

Low vision services for vision rehabilitation in the United Kingdom

AIM

Little is known about the distribution and methods of delivery of low vision services across the United Kingdom. The purpose of this study was to determine the type and location of low vision services within the UK.

METHODS

Survey by means of a 29 point postal questionnaire, followed when necessary by a five point telephone questionnaire. All known potential providers of low vision services (n = 2539) including hospitals (n = 277), optician/optometry practices (n = 1683), social services (n = 177), voluntary groups (n = 190), specialist teachers (n = 205), and universities (n = 6) were surveyed. For each service provider, the type, magnitude, and geographical location were determined. The distribution of services across the United Kingdom and the ratio of providers to population density of people with a visual impairment were mapped using the Geographic Information System (GIS).

RESULTS

Data were obtained on 1945 (77%) service providers: 1679 (66%) responded to the postal questionnaire and 266 (11%) to the telephone questionnaire. Of all respondents, 59% (n = 1135) offer some form of help to people with a visual disability, of which 26% (n = 497) only sell magnifiers and 33% (n = 638) provide low vision services. It is estimated that in total just under 155,000 low vision consultations are offered annually, the bulk of which are provided by hospital eye departments. The distribution was geographically uneven and there appears to be scarcity in some areas.

CONCLUSION

When compared to the probable number of people with a visual impairment in the UK there are apparent inadequacies in service provision in terms of distribution, magnitude, and coordination. The results highlight a need to review current services.

The breeding season diet of wedge-tailed eagles (Aquila audax) in western New South Wales and the influence of Rabbit Calicivirus Disease

A total of 2071 individual prey items were identified from 34 active and 55 inactive wedge-tailed eagle nests following the 1995, 1996 and 1997 breeding seasons. Overall, the eagle's diet was comparable to that reported in other studies within semi-arid regions, with rabbits, reptiles and macropods accounting for 47.8, 22.6 and 13.7% of prey items, respectively. In spring 1996 rabbit calicivirus moved into the study area, resulting in a 44-78% reduction in rabbit abundance (Sharp et al. 2001). An index was developed to enable the time since death for individual prey items to be approximated and a historical perspective of the eagle's diet to be constructed. Rabbits constituted 56-69% of dietary items collected during the pre-rabbit calicivirus disease (RCD) samples, but declined to 31% and 16% in the two post-RCD samples. A reciprocal trend was observed for the proportion of reptiles in the diet, which increased from 8-21% of pre-RCD dietary items to 49-54% after the advent of RCD. Similarly, the proportion of avian prey items was observed to increase in the post-RCD samples. These data suggested that prey switching may have occurred following the RCD epizootic. However, a lack of data on the relative abundances of reptiles and birds prevented an understanding of the eagle's functional responses to be developed and definitive conclusions to be drawn. Nevertheless, the eagles were observed to modify their diet to the change in rabbit densities by consuming larger quantities of native prey species.

Work in progress. Integrating physicians' services in the home

OBJECTIVE

While increasing acuity levels and the concomitant complexity of service demand that physicians be involved in in-home care, conflicting evidence and opinions do not show how this can best be achieved.

DESIGN

A phenomenologic research design was used to obtain insights into the challenges and opportunities of integrating physicians' services into the usual in-home services in London, Ont.

SETTING

Home care in London, Ont.

PARTICIPANTS

Twelve participants included three patients, two family caregivers, two family physicians, the program's nurse practitioner, two case managers, and two community nurses.

METHOD

In-depth interviews with a maximally varied purposeful sample of patients, caregivers, and providers were analyzed using immersion and crystallization techniques.

MAIN FINDINGS

Findings revealed the potential for enhanced continuity of care and interdisciplinary team functioning. Having a nurse practitioner, interdisciplinary team-building exercises and meetings, regular face-to-face contact among all providers, support for family caregivers, and 24-hour coverage for physicians were found to be essential for success.

CONCLUSION

Integration of services takes time, money, and sustained commitment, particularly when undertaken in geographically isolated communities. Informed choice and a fair remuneration system remain important considerations for family physicians.

A blind, randomized, controlled trial of cognitive-behavioural intervention for patients with recent onset rheumatoid arthritis: preventing psychological and physical morbidity

This study examined the efficacy of a cognitive and behavioural intervention (CBT) for patients with recent onset, seropositive rheumatoid arthritis. Fifty-three participants with a diagnosis of classical or definite rheumatoid arthritis, who were seropositive and had less than 2 years of disease history were recruited into the trial. All participants received routine medical management during the study, although half were randomly allocated to receive an adjunctive psychological intervention. All pre- and post-treatment assessments were conducted blind to the allocation. Analyses were conducted of treatment completers and also by intention-to-treat. Significant differences were found between the groups at both post-treatment and 6-month follow-up in depressive symptoms. While the CBT group showed a reduction in depressive symptoms, the same symptoms increased in the Standard group. At outcome but not follow-up, the CBT group also showed reduction in C-reactive protein levels. However, the CBT group did show significant improvement in joint involvement at 6-month follow-up compared with the Standard group, indicating physical improvements above those achieved with standard care. These results indicate that cognitive-behavioural intervention offered as an adjunct to standard clinical management early in the course of RA is efficacious in producing reductions in both psychological and physical morbidity