Predicting Post-Discharge Outcome

The ability of members of the multidisciplinary team and of elderly patients themselves to predict how patients will cope at home influences the successful outcome of discharge from hospital. Following the introduction of structured assessment of the physical, psychological and social function of patients on an acute elderly care unit, a study was undertaken to compare the predictive ability of the primary nurse, the patient and the occupational therapist.

Overall, results suggested a high level of accuracy of predictions. There was a trend for the occupational therapist to predict more accurately (83.6%) than the patient (80.7%) or the primary nurse (72.5%). Where the predictions were incorrect, the patients erred on the side of optimism (78% optimistic) whereas the nurses were more pessimistic (69% pessimistic). Further studies to look at the reliability of outcome predictions by health professionals and the patients themselves would be useful in the overall management of the discharge of elderly people from hospital.

Individualisation of time-motion analysis: a method comparison and case report series

This study compared the intensity distribution of time-motion analysis data, when speed zones were categorized by different methods. 12 U18 players undertook a routine battery of laboratory- and field-based assessments to determine their running speed corresponding to the respiratory compensation threshold (RCT), maximal aerobic speed (MAS), maximal oxygen consumption (vV˙O2max) and maximal sprint speed (MSS). Players match-demands were tracked using 5 Hz GPS units in 22 fixtures (50 eligible match observations). The percentage of total distance covered running at high-speed (%HSR), very-high speed (%VHSR) and sprinting were determined using the following speed thresholds: (1) arbitrary; (2) individualised (IND) using RCT, vV˙O2max and MSS; (3) individualised via MAS per se; (4) individualised via MSS per se; and (5) individualised using MAS and MSS as measures of locomotor capacities (LOCO). Using MSS in isolation resulted in 61% and 39% of player's % HSR and % VHSR, respectively, being incorrectly interpreted, when compared to the IND technique. Estimating the RCT from fractional values of MAS resulted in erroneous interpretations of % HSR in 50% of cases. The present results suggest that practitioners and researchers should avoid using singular fitness characteristics to individualise the intensity distribution of time-motion analysis data. A combination of players' anaerobic threshold, MAS, and MSS characteristics are recommended to individualise player-tracking data.

Short term benefits of post-operative oral dietary supplements in surgical patients

The present study was undertaken to investigate the short term clinical efficacy of oral dietary supplements administered post-operatively to patients undergoing predetermined moderate to severe gastrointestinal surgery. Trial end points for comparison included effects of oral dietary supplements on nutritional intake, nutritional status and incidence of serious complications. 54 patients who were scheduled to undergo predetermined moderate to major gastrointestinal surgical procedures entered the study. They were randomly assigned to receive a normal ward diet post-operatively or the same diet supplemented ad libitum by an oral nutritional sip feed. The study period was defined as commencing from the day patients were adjudged to be capable of ingesting 'free fluids' to the day of hospital discharge. 40 patients (20 in each group) completed the study. The mean daily energy intake (KCal/day) assessed from 7 day food diaries was significantly higher in the treatment group (1833 +/- SEM 99) than in the control group (1108 +/- 56, p < 0.0001). This increase occurred not only as a consequence of energy intake from the oral dietary supplements (470 +/- 30) but also because more energy was consumed from the ward diet by the treatment than the control patients (1353 +/- 92 vs 1108 +/- 56, p < 0.02). The mean daily protein intake g/day in the treatment group (66.0 +/- 3.4) was also greater than in the control group (52.9 +/- 29 p < 0.0001). This difference was due solely to the intake in protein from the oral dietary supplements (15.7 +/- 1.0), protein intake from the ward diet being similar in the treatment (50.1 +/- 3.2) and control (52.9 +/- 29) groups. Patients in the treatment group maintained their pre-operative weight where as control patients had lostsignificant amount of their pre-operative weight by study day 3 (4.5 +/- 12 kg and by discharge (4.7 +/- 1.2 kg, p < 0.02). Pre-operative muscle function as evidenced by grip strength dynamometry decreased to a greater extent in the control than treatment group patients by study day 3 (14.6 +/- 2.2 KPa vs 2.8 +/- 2.4 < 0.03) and by discharge (10.4 +/- 3.1 KPa vs 0.10 +/- 1.9 p < 0.03). The incidence of serious infections (pneumonia, wound infection) was significantly higher in the control group (10) than in the treatment group (3, p < 0.02). It is concluded that the prescription of oral dietary supplements on an ad libitum basis to post-operative patients undergoing moderate to major gastrointestinal surgery results in clinically significant short term benefits.

Paediatric traumatic out-of-hospital cardiac arrests in Melbourne, Australia

INTRODUCTION

Many consider attempted resuscitation for traumatic out-of-hospital cardiac arrest (OHCA) futile. This study aims to describe the characteristics and profile of paediatric traumatic OHCA.

METHODS

The Victorian Ambulance Cardiac Arrest Registry (VACAR) was used to identify all trauma related cases of OHCA in patients aged less than 16 years of age. Cases were linked with their coronial findings.

RESULTS

Between 2000 and 2009, EMS attended 33,722 OHCAs including 2187 adult traumatic OHCAs. There were 538 (1.6%) OHCAs in children less than 16 years of age of which n=64 were due to trauma. The median age (IQR) of paediatric traumatic OHCA was 7 (4.5-13) years and 44 were male (69%). Bystander CPR was performed in 22 cases (34.4%). The first recorded rhythm by EMS was asystole seen in 42 (66%), PEA in 14 (22%) cases and VF in 2 cases (3%). Cardiac output was present in 7 (11%) cases who subsequently had an EMS witnessed OHCA. EMS attempted resuscitation in 35 (55%) patients of whom 7 (20%) achieved ROSC and were transported, and 1 (3%) survived to hospital discharge with severe neurological sequelae; 14(40%) were transported with CPR of whom none survived. Coronial cause of death was multiple injuries in 35%, head injury in 33%, head and neck injury in 10%, chest injuries in 10% and other causes (12%).

CONCLUSIONS

Traumatic aetiology of OHCA when compared to the incidence of adult traumatic OHCAs is uncommon. Resuscitation efforts are seldom effective and associated with poor neurological outcome.

Paediatric hanging associated out of hospital cardiac arrest in Melbourne, Australia: characteristics and outcomes

INTRODUCTION

Hanging is a rare but devastating cause of out of hospital cardiac arrest (OHCA). The characteristics and outcomes of hanging associated OHCA in the paediatric age group are described.

METHODS

The Victorian Ambulance Cardiac Arrest Registry was searched for patients aged less than 18 years where the precipitant cause of OHCA was hanging. Results were cross checked with the coronial database.

RESULTS

During the years 2000-2009, there were 680 paediatric cardiac arrests of which 53 (7.8%) were precipitated by hanging with an incidence of 4.4 per million paediatric patients (<18 years) per year. Median age was 16 (IQR 14-17) years and 58.5% were males. Five were unintentional hangings; median age 3 (IQR 2-4) years. The youngest deliberate hanging associated OHCA was aged 10 years. Most hangings occurred in a house (85%) and bystander cardiopulmonary resuscitation (CPR) was performed in 30%. Asystole was the most common initial cardiac arrest rhythm seen in 50 cases (94%) while three patients had pulseless electrical activity. The emergency medical services (EMS) attempted resuscitation in 18 patients (34%), inserting an endotracheal tube in 13 patients. The majority (n=41) were not transported; seven patients were transported with return of spontaneous circulation (ROSC) and five patients were transported with ongoing CPR. Victims who had bystander CPR were more likely to have EMS attempted resuscitation (p<0.001). Only patients who had received bystander CPR achieved ROSC (p<0.001). Three patients survived to hospital discharge; two survivors suffered severe neurological injury (Cerebral Performance Category Scale 3-4).

CONCLUSION

Non-intentional hanging is rare but deliberate hanging with suicidal intent represents a significant proportion of OHCAs in patients under 18&emsp14;years of age. A focus on prevention is key, as outcomes are poor, with survivors likely to suffer a severe neurological insult.

Influence of pharmacogenetics on response and toxicity in breast cancer patients treated with doxorubicin and cyclophosphamide

Background:

Doxorubicin and cyclophosphamide (AC) therapy is an effective treatment for early-stage breast cancer. Doxorubicin is a substrate for ABCB1 and SLC22A16 transporters. Cyclophosphamide is a prodrug that requires oxidation to 4-hydroxycyclophosphamide, which yields a cytotoxic alkylating agent. The initial oxidation is catalysed by cytochrome P450 enzymes including CYP2B6, CYP2C9, CYP2C19 and CYP3A5. Polymorphic variants of the genes coding for these enzymes and transporters have been identified, which may influence the systemic pharmacology of the two drugs. It is not known whether this genetic variation has an impact on the efficacy or toxicity of AC therapy.

Methods:

Germ line DNA samples from 230 patients with breast cancer on AC therapy were genotyped for the following SNPs: ABCB1 C1236T, G2677T/A and C3435T, SLC22A16 A146G, T312C, T755C and T1226C, CYP2B6^*2, ^*8, ^*9, ^*3, ^*4 and ^*5, CYP2C9^*2 and ^*3, CYP3A5^*3 and CYP2C19^*2. Clinical data on survival, toxicity, demographics and pathology were collated.

Results:

A lower incidence of dose delay, indicative of less toxicity, was seen in carriers of the SLC22A16 A146G, T312C, T755C variants. In contrast, a higher incidence of dose delay was seen in carriers of the SLC22A16 1226C, CYP2B6^*2 and CYP2B6^*5 alleles. The ABCB1 2677A, CYP2B6^*2, CYP 2B6^*8, CYP 2B6^*9, CYP 2B6^*4 alleles were associated with a worse outcome.

Conclusion:

Variant alleles in the ABCB1, SLC22A16 and CYP2B6 genes are associated with response to AC therapy in the treatment of breast cancer.

Should we be 'pushing meds'? The implications of pharmacogenomics

Medication continues to be the most widely prescribed treatment in the NHS for mental health problems. It has been known for many years that individuals differ in the way they respond to a given pharmaceutical therapy, and one reason for this lies in the genetic variation between individuals. This paper recognizes the impact that pharmacogenomics and pharmacogenetics are having in the field of mental health. Variants in genes that code for the drug metabolizing enzymes in the liver have been found to influence the way in which these enzymes handle psychotropic medication. Individuals can be classified as poor, moderate or extensive metabolizers when standard regimes are used, and this can lead to huge differences in therapeutic effect and toxicity. There are now genotyping tests available which provide information on the individual's ability to metabolize psychotropic medication. One author provides an account of the effects of medication on her son's physical and psychological well-being. Genotyping provided evidence for his poor metabolism of psychotropic medication, and his life is now changing as he is being very gradually weaned off this medication. This emerging field of work has implications for the way in which practitioners consider medication adherence.

Ureteral spindle cell sarcoma in a dog

A five-year-old, female spayed Labrador retriever was presented for further investigation of an intra-abdominal mass. Abdominal exploration showed a large mass arising from the right ureter and a ureteronephrectomy was performed. Histopathology of the ureteral mass was consistent with a spindle cell sarcoma. The patient recovered well, but five months later was diagnosed with another tumour, this time in her left abdominal wall. The owners decided not to pursue further treatment and euthanasia was performed a month later.

[Infant bronchiolitis point of care by physicians in the Ile-de-France bronchiolitis network]

OBJECTIVE

The Ile-de-France bronchiolitis network assessment gave us the opportunity to carry out a survey regarding the customary handling of acute bronchiolitis by physicians involved in this network. The aim of this study was to retrieve results relating to season 2003-2004 and to compare them with the September 2000 French consensus conference recommendations.

METHODS

The practitioners engaged using a special form subsequently transmitted to network joint committee collected the clinical and therapeutic data of the patients included in the Network. We analysed 342 exploitable forms.

RESULTS

Analysis of the physicians medications for patients classified as bronchiolitis showed that their behavior was on the whole keeping with the official recommendations. The nearly systematic prescription of specific respiratory physiotherapy (increase in expiratory flow) satisfies the expectations of the French consensus conference. Likewise, treatments such as bronchodilator or corticoids that are not recommended were prescribed only in approximately 1/4 of cases. Abstention from all medical treatment was found in only 41% of cases classified as bronchiolitis. However, in considering only the first episode of acute bronchiolitis, this rate increased to 54,3%. Short-acting bronchodilator usage may appear legitimate as a therapeutic test of reversibility. In our study, 1/3 of patients with bronchiolitis treated by bronchodilator underwent a second episode and 80% of them were older than 6 months.

CONCLUSION

Analysis of the practices of physicians participating in the Bronchiolite Ile-de-France Network proves very positive in light of the comparison with studies prior and subsequent to the consensus conference. In recognition of this, it is necessary to consider the importance of the network's training programs. Beyond the need to go on with the diffusion of the recommendations, it seems desirable to extend them to clinical situations not yet considered, especially recurrent bronchiolitis and infant asthma. Finally, this type of study should be repeated in order to measure the future evolution of medical practices, as well as extended to a larger scope than the Ile-de-France bronchiolitis Network.