Effect of a pathway bundle on length of stay

BACKGROUND

Pathways to guide clinical care are well accepted and used in many emergency departments. We wanted to introduce a number ("bundle") over a short space of time and involve the whole patient stay in the pathway. It was hypothesised that a more efficient process would result with an overall reduction in length of stay (LoS).

METHODS

A "bundle" of 14 evidence-based pathways of care was introduced into a medium-sized district general hospital (DGH) in late 2006/early 2007. These pathways covered emergency department care and acute medical care for a period of up to 48 h. A total of 8184 acute emergency admission episodes were audited, 3852 in the 8 months before introduction of the new pathways and 4332 in the 8 months after their introduction.

RESULTS

The overall effect of introducing the pathway bundle had a trend towards reduction in LoS by 0.2 days (95% CI -0.2 to 0.5), but this was not statistically significant (p>0.1). However, in those patients with </=2 diagnoses, the introduction of the pathway bundle had an independent effect in reducing LoS by 0.4 days (95% CI 0.04 to 0.7, p<0.01). In patients with </=2 diagnoses (63.0% of all pre-pathway cases and 63.4% of all post-pathway cases), the reduction in LoS equates to a saving of 2154 (CI 215 to 3769) bed days per annum or 5.9 (CI 0.6 to 10.3) beds saved each day. This reduced LoS represents an improvement of 2.5% (CI 0.25% to 4.38%) in medical bed usage. As this benefit occurs in the uncomplicated group of patients without multiple co-morbidities, such pathways would have the most effect in the type of patients who may be looked after by an emergency or acute physician. They are much less likely to be effective in those who require specialist intervention due to a more complicated presentation and possibly those with multiple co-morbidities.

CONCLUSION

The introduction of a bundle of evidence-based care pathways can modestly reduce LoS for certain types of acute medical patients in a DGH setting.

High serum concentrations of iron, transferrin saturation and gamma glutamyl transferase in captive black rhinoceroses (Diceros bicornis)

Iron storage disease (haemochromatosis) is thought to be the cause of many disorders unique to captive black rhinoceroses (Diceros bicornis). To establish reliable reference ranges for iron parameters, serum samples from 27 eastern black rhinoceroses (Diceros bicornis michaeli) from a translocation programme in Kenya were analysed and compared with the samples from 17 captive individuals. The transferrin saturation, serum iron concentration and gamma glutamyl transferase were significantly higher in the captive rhinoceroses, but these elevations were not evident when the results were compared with previously published data.

Graduate medical education in Ireland: a profile of the first cohort of students

BACKGROUND

The first graduate-entry programmes to Irish medicine were established at the Royal College of Surgeons in Ireland (RCSI) and the University of Limerick (UL) in 2007. There were over 400 applications across both institutions and 306 people sat a special aptitude test (GAMSAT) in Ireland in 2007. Ultimately, 61 Irish/EU students were admitted to one or other programme.

AIMS AND METHODS

We describe the demographic profile, academic background and aggregated GAMSAT performance of 306 people who sat GAMSAT in Ireland in 2007 and of the 61 people admitted to the RCSI/UL programmes.

RESULTS

While more females than males sat GAMSAT, slightly more males were admitted. Over 90% of those admitted were aged in their 20s, almost 20% had a higher degree and they came from a wide range of academic backgrounds.

CONCLUSIONS

Among others, this information should be of interest to prospective students and to government policy makers.

HIV-related knowledge and adherence to HAART

Near perfect adherence is considered essential for patients on HAART, yet adherence to medical recommendations is rarely so high. Supportive services and reminder tools may help individuals to become adherent, yet it is difficult to determine who may need such interventions. In this study, based on data from the NYSDOH/AIDS Institute Treatment Adherence Demonstration Program, we look at the association between HIV-related knowledge and adherence, hypothesizing that a better understanding of HIV and its treatment is associated with better adherence. In analyses based on 997 participants, knowledge, as measured by five true/false questions, was significantly associated with self-reported adherence. In multivariate analysis, compared to persons with four or five items answered correctly, persons with fewer correct answers were more likely to report missed doses (OR = 1.72 for 2-3 correct, p < 0.01; OR = 2.92 for 0-1 correct, p < 0.05). Our data suggest that providers should include questions focused on knowledge of HIV in their assessments of medication readiness and need for adherence support. Similarly, providers should be diligent with respect to patient education, ensuring that each patient has the information needed to support reasoned decision making and adequate adherence.

Childhood vaccination against varicella: persistence of antibody, duration of protection, and vaccine efficacy

OBJECTIVE

To document the duration of protection afforded by Oka/Merck varicella vaccine over a 7-year period.

STUDY DESIGN

The subjects were healthy children 1 to 12 years of age originally enrolled in clinical studies to evaluate the primary immune response to varicella vaccine 6 weeks after vaccination. Each was monitored for antibody persistence, breakthrough infection, and household exposure to varicella to produce estimates of vaccine efficacy.

RESULTS

The 6-year cumulative varicella antibody persistence rate was 99.5% (95% CI: 98.9%, 100.0%). The annual breakthrough rate through 7 years ranged from 0.2% to 2.3% per year; the estimated cumulative event rate was 6.5%. Comparison of the observed average annual breakthrough rate with the age-adjusted expected annual incidence rate of varicella in unvaccinated children corresponded to an estimated vaccine efficacy of 93.8% to 94.6%. Eighty vaccinated children were exposed to varicella in the household, resulting in 8 (10%) cases of infection. When compared with the historical attack rate of 86.8% in unvaccinated susceptible persons exposed to varicella in the household, this yields an estimated vaccine efficacy of 88.5% (95% CI: 80.9%, 96.1%). Varicella cases in vaccinated children generally were mild.

CONCLUSION

The live attenuated varicella vaccine is highly effective in inducing persistent immunity and long-term protection against breakthrough varicella infection.

Growth Hormone (GH)/GH Receptor Expression and GH-Mediated Effects During Early Bovine Embryogenesis1

Pituitary growth hormone (GH) stimulates postnatal growth and metabolism. The role of GH and its receptor (GHR) during prenatal development, however, is still controversial. As shown by reverse transcription polymerase chain reaction (RT-PCR), bovine in vitro fertilization embryos synthesized the transcript of GHR from Day 2 of embryonic life onwards. Real time RT-PCR revealed that synthesis of GHR mRNA was increased 5.9-fold in 6-day-old embryos compared with 2-day-old embryos. Using in situ hybridization, the mRNA encoding GHR was predominantly localized to the inner cell mass of blastocysts. The GHR protein was first visualized 3 days after fertilization. GH-specific transcripts were first detected in embryos on Day 8 of in vitro culture. As shown by transmission electron microscopy, GH treatment resulted in elimination of glycogen storage in 6- to 8-day-old embryos and an increase in exocytosis of lipid vesicles. These results suggest that a functional GHR able to modulate carbohydrate and lipid metabolism is synthesized during preimplantation development of the bovine embryo and that this GHR may be subject to activation by embryonic GH after Day 8.

Serum organochlorine levels and breast cancer: a nested case-control study of Norwegian women

This study investigated the potential association between organochlorine exposure and breast cancer using stored sera collected from 1973 through 1991 from the Janus Serum Bank in Norway. Breast cancer cases were ascertained prospectively from among 25,431 female serum bank donors. A total of 150 controls were matched to cases by birth dates and dates of sample collection. One g of serum per subject was analyzed for a total of 71 organochlorine compounds. For 6 pesticides [B-hexachlorocyclohexane, heptachlor epoxide, oxychlordane, trans-nonachlor, p, p'-1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene, and p, p'-2,2-bis(p-chlorophenyl)-1,1,1-trichloroethane] and 26 individual polychlorinated biphenyl (PCB) congeners there were >90% of samples over the limit of detection. There was no evidence for higher mean serum levels among cases for any of these compounds, nor any trend of increasing risk associated with higher quartiles of exposure. The remaining compounds (including dieldrin) were analyzed with respect to the proportion of cancer cases and controls having detectable levels; no positive associations were noted in these analyses. Our study did not confirm the recent findings of a Danish study of increased concentrations of dieldrin in the serum of breast cancer cases. The evidence to date on the association between serum organochlorines is not entirely consistent, but there is accumulating evidence that serum levels of p, p'-1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene and total PCBs are not important predictors for breast cancer in the general population. Studies to date have not been able to evaluate whether exposure to highly estrogenic, short-lived PCB congeners increases breast cancer risk, nor have they fully evaluated the risk associated with organochlorine exposure in susceptible subgroups or at levels above general population exposure, including women with occupational exposure.

The NIOSH/FAA Working Women's Health Study: evaluation of the cosmic-radiation exposures of flight attendants. Federal Aviation Administration

Air crew are exposed to elevated levels of cosmic ionizing radiation of galactic and solar origin and are among the more highly exposed occupational groups to ionizing radiation in the United States. Depending on flight route patterns, the annual dose may range from 0.2 to 5 mSv. By comparison, the average annual radiation dose equivalent of occupationally exposed adults in the United States is estimated to be 1.1 mSv. Cosmic-radiation dose depends primarily on altitude and geomagnetic latitude and to a lesser degree on solar activity. Although the International Commission on Radiological Protection has recommended that air crew exposures to natural radiation in-flight be treated as occupational exposures, United States flight crew exposures to natural cosmic radiation are not regulated or typically monitored. There are approximately 148,000 air crew (flight deck crew and flight attendants) in the United States.

Properties of an experimental mouthguard material

PURPOSE

The purpose of the present study was to evaluate some important mechanical properties of an experimental silicone material (PM1) to assess its potential as a mouthguard material.

MATERIALS AND METHODS

The hardness, tear strength, tensile properties, and energy absorption properties of the silicone material were determined and compared with those of 2 commercially available materials (Bioplast, a polyvinylacetate polyethylene, and Polyshield, a silicone).

RESULTS

Bioplast was significantly harder than Polyshield and PM1. Polyshield was significantly harder than PM1. Bioplast had a significantly higher tear strength than both Polyshield and PM1. The tensile strength of Bioplast was significantly greater than that of Polyshield and PM1. PM1 had a significantly higher tensile strength than Polyshield. Bioplast had a significantly lower energy absorption capacity at 500 N than both Polyshield and PM1, with PM1 having a significantly higher value than Polyshield. At 1,000 and 1,500 N, Bioplast had a significantly higher energy absorption than both Polyshield and PM1.

CONCLUSION

It was concluded that PM1 showed better energy absorption properties than Polyshield and better energy absorption properties than Bioplast at lower impact forces. PM1 was softer and had better tear and tensile properties than Polyshield. The results of the present study suggest that the new material has a good potential for use as a mouthguard material.

Optimisation of growth hormone production by muscle cells using plasmid DNA

The production of peptide hormones by skeletal muscle tissue is a promising area of gene therapy. Skeletal muscle myogenesis can be induced in vitro, resulting in the fusion of mononucleate myoblasts to form multinucleate myotubes, and delivery vectors are first tested in vitro. C2C12 myoblasts transfected with pcDNA3-GH, which used the human cytomegalovirus (CMV) promoter, secreted immunoreactive GH with comparable biological activity to pituitary GH. Mouse myeloid leukaemia cells, which express the mouse GH receptor were used for the bioassay, and activation of these cells by GH was measured by a colorimetric microculture tetrazolium assay. Cells were incubated with a tetrazolium salt (MTS) and an intermediate electron acceptor (phenazine methosulphate, PMS), and formazan production was measured as optical density (O.D.) at 490 nm. The efficiencies of several plasmid expression vectors were compared in differentiated and non-differentiated muscle cells, as a function of bioactive GH secreted by the transfected cells. Ten-day differentiated C2C12 myotubes transfected with pcDNA3E-GH, which used the CMV promoter and a rat myosin light chain enhancer element, secreted significantly more biologically active GH than myotubes transfected with pcDNA3-GH (0.82 O.D. units+/-0.06 vs 0.57+/-0.05 respectively, P<0.001). This was consistent with reduced CMV promoter activity in myotubes. Myoblasts transfected with pcDNA3-GH secreted more bioactive GH than 10-day transfected myotubes (1.1+/-0. 1 vs 0.77+/-0.07 respectively). However, the responses were indistinguishable (both 1.0+/-0.09) if both the myotubes and myoblasts had been transfected with pcDNA3E-GH. Substitution of the vector pMHLC-GH, which used a muscle-specific truncated rabbit myosin heavy chain promoter, and the myosin enhancer resulted in a marked decrease in the responses to the conditioned medium from fused myotubes compared with the vectors pcDNA3-GH and pcDNA3E-GH (0. 24+/-0.02 vs 0.57+/-0.05 vs 0.82+/-0.06 respectively). We concluded that the combination of CMV promoter and myosin light chain enhancer in pcDNA3E-GH had the greatest expression efficiency of the several plasmid vectors which we investigated.

Using molecular epidemiology in assessing exposure for risk assessment

Quantitative estimation of health risks depends on exposure characterization, the nature of the dose response relationships, and the toxicity of the agents involved. The greatest uncertainties in risk assessment almost always arise from sparse or inadequate exposure data, inadequate understanding of exposure mechanisms, and insufficient understanding of the exposure-dose-response pathway. Additional sources of uncertainty arise when mixed or multiple exposures are implicated in the disease pathway, and as a result of variability in both exposures and responses within and between individuals. Here we consider the role of exposure assessment in the risk assessment process, the use of biological markers or molecular epidemiology to contribute to improvements in exposure assessment for risk assessment, and uncertainties associated with the use of biological markers.

Improved wettability of an experimental silicone rubber denture soft lining material

The purpose of this study was to improve the wettability of an experimental silicone rubber soft lining material (Sildent) to increase patient comfort. Sildent was modified by the addition of polyalkylene oxide poly(dimethylsiloxane) surfactants. The various surfactants were added directly to the polymeric matrix in the quantities 5, 10, 20% w/w. The surfactants were also added to a one part silicone sealant, which was then painted onto the surface of already cured Sildent. Contact angle measurements were made on samples using a dynamic contact angle analyzer. Results showed that incorporation of surfactants A (Silwet L7600) and B (Silwet L7607) effectively improved the wettability of Sildent. This improvement was still evident after 6 months storage in distilled water at 37 degrees C suggesting retention of the surfactants matrix via physio-chemical bonding. Formulations with surfactants added directly to the matrix showed unacceptable water absorption after 2 months in distilled water. Samples with surfactant charged sealant painted on the surface showed a lower water absorption. In conclusion, Sildent formulations modified with polyalkylene silicone surfactants showed improved wettability compared to unmodified Sildent. Further work is needed to reduce water uptake and determine the effect on key mechanical properties.

Up-regulation of growth hormone receptor immunoreactivity in human melanoma

Growth hormone (GH) exerts its regulatory functions in controlling metabolism, balanced growth and differentiated cell expression by acting on specific receptors, which trigger a phosphorylation cascade resulting in the modulation of numerous signalling pathways, and dictate gene expression. Immunohistochemical techniques were used to demonstrate the presence of growth hormone receptors in 126 formalin-fixed, paraffin-embedded melanocytic tumours comprising melanocytic naevi, superficial spreading melanoma, nodular melanoma, lentigo maligna melanoma and metastatic melanomas. The relative proportion of positive cells and intensity of staining was higher in neoplastic cells, compared to normal cutaneous cells. Of the 76 cases of common melanocytic naevi (CMN) studies, 46 were weakly reactive with MAb 263. Heterogeneity of immunoreactivity was found in primary melanoma lesions with a variable range of positive cells. Of 37 cases studied, 34 were moderately to strongly positive. Immunoreactivity showed subcellular localization of the GH-receptor in cell membranes, was predominantly cytoplasmic, but strong nuclear immunoreaction was also apparent in many instances. The nuclear localization of immunoreactivity is the result of nuclear GH-receptor/binding protein, identically to the cytosolic and plasma growth hormone binding protein. Intense immuno-reactivity was also observed in the cellular Golgi area of established cell lines and cultured tissue-derived cells in exponential growth phase, indicating cells are capable of GH-receptor synthesis. In the primary lesions, dermal tumour cells tended to be more immunoreactive relative to those seen in the dermal region. Metastatic lesions in various organs also expressed growth hormone receptors in secondary tumour cells and all of the metastatic cases were positive. The expression of GH-receptors in human melanoma cells means that these cells are directly responsive to GH action and that GH may stimulate local production of IGF-I, which then acts in an autocrine mechanism.

Immunochemotherapy with interferon-gamma and multidrug therapy for multibacillary leprosy

Treatment for multibacillary leprosy is presently performed with a multidrug therapy (MDT) scheme maintained for 2 years. Leprosy treatment however can benefit from the reduction of length. The lack of interferon-gamma (IFN-gamma) production by lepromatous leprosy (LL) patients' lymphocytes lead us to use this cytokine in the treatment of multibacillary leprosy associated with MDT in the treatment of multibacillary leprosy, and monitor several clinical and immunological parameters during the course of treatment. A total of 20 multibacillary leprosy patients were evaluated, 10 treated with MDT alone, and 10 treated with MDT + 10 daily doses of 2 x 10(6) international units (IU) of recombinant human IFN-gamma/m2 followed by 10 daily doses of 10(7) IU IFN-gamma/m2, intramuscularly, during the first 20 days of MDT. IFN-gamma was well tolerated and did not cause any increase in the rate of leprosy reactions development during treatment. Decrease of bacillary load, fall of anti-Mycobacterium leprae IgG serum antibodies, changes of histological pattern, as well as changes in lymphocyte proliferation assay in response to mitogens (PHA or PWM), M. leprae antigen or PPD was similar in both groups of patients. Among several soluble immunological markers measured before and 30 days after beginning of treatment, levels of soluble IL-2R receptor increased in patients treated with MDT plus IFN-gamma whereas decreased in patients treated with MDT alone. Soluble ICAM-1 levels decreased in the MDT group but did not change in the MDT + IFN-gamma treated patients. Soluble CD4 and soluble CD8 markers did not change significantly in either group of patients. Neopterin, a marker of macrophage activation, increased in all but one patient treated with MDT + IFN-gamma but in none treated with MDT alone, indicating that IFN-gamma was active in vivo. Our findings indicate that despite being able to promote macrophage activation in multibacillary leprosy patients a short course of systemically administered IFN-gamma is not able to change the clinical course of a long standing disease such as leprosy.