Feasibility and profitability of a radiology department providing trauma US as part of a trauma alert team

RATIONALE AND OBJECTIVES

The purpose of this study was to assess the feasibility and profitability of a radiology department providing a six-point trauma ultrasound (US) examination for abdominal or pelvic free fluid as part of a trauma alert team.

MATERIALS AND METHODS

The study included 191 trauma alerts, which generated 156 US examinations. A radiologist and a departmental technologist carried beepers and responded to level I and II traumas. A departmental secretary or technologist recorded when the responding technologist exited and re-entered the department and if US was performed. If performed, the US examination evaluated the four abdominal and pelvic quadrants and the suprapubic and subxiphoid regions. For 64 patients, the responding technologist recorded the times of the trauma alert, emergency room arrival, US start and finish, and return to the radiology department.

RESULTS

Median response, wait, scan duration, and return times were 2, 8, 5, and 7 minutes, respectively. Median costs for the technician, physician, archiving, transcription, and equipment were $8.17, $30.85, $0.97, $4.80, and $41.22, respectively. Reimbursement per examination averaged $110.60. Sensitivity analyses that varied the time spent (median vs mean), US non-use rate (10%-18%), and years of depreciation (5-7 years) yielded net results ranging from a $36.60 profit to a $6.12 loss per examination.

CONCLUSION

A radiology department can profitably respond to trauma alerts and provide a six-point trauma US examination for free fluid.

The effects of multiple shunt revisions on neuropsychological functioning and memory

The focus of this study was to determine the effect of multiple shunt revisions on cognition and memory. The present study attempted to document a discrepancy in the functioning of children with hydrocephalus having numerous shunt revisions compared to those with only an initial shunt surgery. Researchers have found an increasing number of children with hydrocephalus requiring shunt revisions. In the current literature there are many conflicting views regarding the effects of hydrocephalus on cognition and memory. Many researchers report that properly treated hydrocephalus will not have a negative impact on cognitive functioning. Furthermore, researchers found that factors such as the total number of shunt revisions do not negatively impact global intellectual ability. Forty-six subjects between the ages of six and 16 years participated in the study. The subjects were recruited from the Department of Neurosurgery at an urban pediatric hospital. Specific inclusion and exclusion criteria were met. Independent variables for the study included shunt revisions, seizures, and Attention Deficit Hyperactivity Disorder (ADHD). Subject groupings were based on whether the subjects required multiple shunt revisions or single shunt placement and the presence or absence of seizures and ADHD. Dependent variables included the subject's performance on measures of cognition and memory. Measures of functioning included the Wechsler Intelligence Scale for Children--Third Edition and the Wide Range Assessment of Learning and Memory-Screener. The results of this study did not support the presence of cognitive or memory impairments as a result of multiple shunt revisions. Anecdotal findings noted that seizures were the only independent variable to significantly account for the observed variance in scores of cognition, specifically Full Scale IQ, Verbal Comprehension, and Perceptual Organization.

Fine mapping of the friend retrovirus resistance gene, Rfv3, on mouse chromosome 15

Rfv3 is a host resistance gene that operates through an unknown mechanism to control the development of the virus-neutralizing antibody response required for recovery from infection with Friend retrovirus. The Rfv3 gene was previously mapped to an approximately 20-centimorgan (cM) region of chromosome 15. More refined mapping was not possible, due to a lack of microsatellite markers and leakiness in the Rfv3 phenotype, which prevented definitive phenotyping of individual recombinant mice. In the present study, we overcame these difficulties by taking advantage of seven new microsatellite markers in the Rfv3 region and by using progeny tests to accurately determine the Rfv3 phenotype of recombinant mice. Detailed linkage analysis of relevant crossovers narrowed the location of Rfv3 to a 0.83-cM region. Mapping of closely linked genes in an interspecific backcross panel allowed us to exclude two previous candidate genes, Ly6 and Wnt7b. These studies also showed for the first time that the Hsf1 gene maps to the Rfv3-linked cluster of genes including Il2rb, Il3rb, and Pdgfb. This localization of Rfv3 to a region of less than 1 cM now makes it feasible to attempt the cloning of Rfv3 by physical methods.

Incidents in obstetric anaesthesia and analgesia: an analysis of 5000 AIMS reports

We aimed to explore the first 5000 incidents reported to the Australian Incident Monitoring Study (AIMS) involving anaesthesia for obstetric patients and found 203 such incidents. Analysis and classification identified seven main incident groups; regional anaesthetic techniques (33%), anaesthetic equipment problems (13%), "wrong drug" errors (10%), other drug-related problems (16%), difficult/failed intubation (9%), problems with the endotracheal tube (9%) and other problems (10%). When compared to the incidents in the main database, obstetric cases were found to be over-represented with respect to accidental dural puncture, post dural puncture headache, failed intubation in emergency situations and the incidence of certain types of "wrong drug" error. The implications of these reports regarding safe practice of obstetric anaesthesia are discussed.

Effect of material deprivation on Epstein-Barr virus infection in Hodgkin's disease in the West Midlands

We have used Townsend scores from postcode data to compare levels of material deprivation and Epstein-Barr virus (EBV)-positivity for 223 patients diagnosed with Hodgkin's disease (HD) in the period 1981-1997. The presence of EBV in HD tumours was determined using in situ hybridization to target the abundantly expressed EBV early RNAs. EBV was detected in the malignant Hodgkin and Reed-Sternberg cells in 47/223 HD cases (21%). There was found to be a tendency for higher Townsend scores (indicative of higher levels of material deprivation) in EBV-positive HD patients, but this association was not statistically significant. When various subgroups of patients from the study were examined separately the indication of higher Townsend scores in EBV-positive patients was found to be more marked for patients with mixed cellularity disease (P = 0.09) and for females (P = 0.03). The results of this study suggest that differences in the level of material deprivation are important in determining the likelihood of EBV-positive HD in the UK, particularly for certain subgroups of patients. It is not known what specific socioeconomic factors are responsible for these differences, although alterations in the timing or rate of primary EBV infection, or decline in the level of EBV-specific immunity, may be important.

Epidural analgesia for labour and delivery in a parturient with congenital hypertrophic obstructive cardiomyopathy

We report a parturient delivering vaginally at term with symptomatic congenital hypertrophic obstructive cardiomyopathy. Epidural analgesia was used during labour and delivery and is likely to have made a useful contribution to the successful outcome. Although controversial, reported use of epidural analgesia during labour for hypertrophic obstructive cardiomyopathy parturients has been generally positive. A multi-disciplinary team approach, early anaesthetic assessment and a carefully managed epidural catheter inserted in early labour can optimize analgesia and minimize the stresses of labour and vaginal delivery provided the risks of reduced preload and afterload are minimized.

Transjugular intrahepatic portosystemic shunts compared with endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage. A randomized, controlled trial

BACKGROUND

Transjugular intrahepatic portosystemic shunts (TIPS) have widened the use of portal decompression as therapy for variceal hemorrhage. However, no controlled studies have examined the efficacy of TIPS compared with that of other treatments.

OBJECTIVE

To compare the efficacy and safety of TIPS with those of endoscopic sclerotherapy for the prevention of recurrent variceal hemorrhage.

DESIGN

Randomized, controlled trial.

SETTING

Tertiary-care academic medical center.

PATIENTS

100 patients with cirrhosis were evaluated a mean of approximately 10 days after an episode of acute variceal bleeding; 20 patients were excluded because of portal venous thrombosis (n = 6), hepatoma (n = 3), florid alcoholic hepatitis (n = 6), and refusal to give consent (n = 5).

INTERVENTIONS

TIPS (n = 41) or sclerotherapy (n = 39). The latter was performed by freehand injections of 5% Na morrhuate at 2- to 3-week intervals. Recurrent variceal hemorrhage was managed by sclerotherapy followed by angiographic assessment of TIPS and dilatation of the stents (TIPS group) or crossover to TIPS (sclerotherapy group).

MEASUREMENTS

Rebleeding and survival were the primary end points. Complications and rates of rehospitalization were secondary end points.

RESULTS

During a mean follow-up of approximately 1000 days, recurrent gastrointestinal bleeding resulted from variceal hemorrhage (9 patients in the TIPS group and 8 in the sclerotherapy group), portal gastropathy (1 patient in each group), and gastric lipoma (0 and 1 patients, respectively). A higher mortality rate was seen with TIPS (P = 0.03). Death resulted from variceal bleeding (5 patients in the TIPS group and 3 in the sclerotherapy group), sepsis (3 and 2 patients, respectively), liver failure (2 patients in each group), hepatoma (1 and 0 patients, respectively), and hemoperitoneum (1 and 0 patients, respectively). Encephalopathy was the most common complication in the TIPS group (n = 12), and pain developing after sclerotherapy was the most common in the sclerotherapy group (n = 10). The two groups had similar rates of rehospitalization.

CONCLUSIONS

Endoscopic sclerotherapy and TIPS are equivalent with respect to rebleeding developing over the long term. However, sclerotherapy may be superior to TIPS with respect to survival.

Proprioception after unicondylar knee arthroplasty versus total knee arthroplasty

Proprioception was measured in 2 groups of patients after successful knee arthroplasty. Twenty-eight patients had total knee arthroplasty and their results were compared with an age matched group of 10 subjects who had undergone unicondylar knee arthroplasty. The threshold to detection of passive motion was quantified as a measure of proprioception. The degree of preoperative arthritis was objectively classified according to Resnick. The anterior cruciate ligament and posterior cruciate ligament were present and preserved in all the patients who had undergone unicondylar knee arthroplasty. The anterior cruciate ligament was sacrificed and posterior cruciate ligament retained in 15 of the patients who had total knee arthroplasty and the anterior cruciate ligament and posterior cruciate ligament were sacrificed in 13 of the patients who had total knee arthroplasties. There was no difference in threshold to detection of passive motion among any of the 3 groups. Maintaining the anterior cruciate ligament and posterior cruciate ligament did not impart improved proprioception in unicondylar knee arthroplasty nor did maintaining the posterior cruciate ligament impart improved proprioception in total knee arthroplasty.

Proprioception following total knee arthroplasty with and without the posterior cruciate ligament

Proprioception was measured in two groups of patients following successful total knee arthroplasty (TKA). In one group, the posterior cruciate ligament was retained and an unconstrained cruciate-retaining total knee component was used; in the other group, the posterior cruciate ligament was excised and a cruciate-substituting design was implanted. Threshold to detection of passive motion was quantified as a measure of proprioception. The degree of preoperative arthritis was objectively classified according to Resnick and Niwoyama. There was no difference in threshold to detection of passive motion in cruciate-retaining versus cruciate-substituting TKA. In patients with a moderate grade of arthritis before surgery, the postoperative scores were virtually identical. When the grade of preoperative arthritis was severe, patients with cruciate-substituting TKAs performed significantly better than those with cruciate-retaining TKAs.

Long-term care residents' preferences for health states on the quality of well-being scale

The Quality of Well-Being Scale (QWB) quantifies health-related quality of life with a single number that represents community-based preferences for combinations of symptom/problem complexes, mobility, physical activity, and social activity. The aim of this study was to compare preferences of a long-term care population with those of the general population, determine whether preferences vary by the age of the hypothetical (target) person depicted in the health-state case description, and derive weights for new symptom/problem complexes of particular relevance to frail, older individuals. A sample of 38 female and 12 male long-term care residents with an average age of 86 years was asked to rate health-state scenarios that combined the four health domains of the QWB. This sample rates quality of life 0.10 units lower on average (on a 0-1 scale) than did the general population sample from which the QWB preferences were originally developed. Ratings of the same health state for younger versus older target persons did not differ significantly (all p values > 0.05 for t statistics). Weights derived for 11 new symptom/problem complexes were: disturbed sleep (-0.252), sit-to-stand requires maximal effort (-0.259), lonely (-0.265), walking a short distance causes extreme fatigue (-0.273), agitated (-0.284), hallucinating (-0.355), incontinent (0-359), unable to control one's behavior (-0.36), urinary catheter (-0.374), restrained in bed or chair (-0.374), and feeding tube through the nose or stomach (-0.402). These new weights increase the relevance of the QWB for cost-utility evaluations of health interventions for long-term care residents.

Effects of prompted voiding on fecal continence among nursing home residents

OBJECTIVE

To determine the effects of prompted voiding on fecal continence in nursing home residents.

DESIGN

Prospective, uncontrolled trial of prompted voiding for urinary incontinence.

PARTICIPANTS

One hundred sixty-five nursing home residents who completed a 9 to 10-week trial.

MEASUREMENTS

Trained research aides performed physical checks for urinary and fecal incontinence hourly from 8 AM to 6 PM for 3 days (total of 33 checks) at baseline, for the last 3 days of a 1-week trial of prompted voiding, and after 9 to 10 weeks of prompted voiding.

RESULTS

After 9 to 10 weeks of prompted voiding, there was no significant change in the frequency of incontinent bowel movements per resident (1.1 [95% CI.83, 1.4] to .87 [95% CI.67, 1.1]; P = 0.140). There was a significant increase in the number of continent bowel movements per resident (.17 [95% CI.10, .24] to .62 [95% CI.45, .80]; P = .000). This increase occurred in residents whose urinary incontinence responded well to prompted voiding as well as those whose urinary incontinence did no respond. The percentage of bowel movements that were continent also increased significantly from 18% (95% CI 8,29) at baseline to 45% (95% CI 32,57) after 9 to 10 weeks of intervention (P = .000). In addition to these findings, we noted a marked increase in the total frequency of bowel movements after the first week of prompted voiding. This may have resulted from the relief of fecal impactions caused by the increased toileting, mobility, and fluid intake that occurred with prompted voiding.

CONCLUSION

Prompted voiding did not change the frequency of incontinent bowel movements significantly in this sample of nursing home residents. However, the number of continent bowel movements and the percentage of bowel movements that were continent did increase. Our data must be interpreted cautiously because our study was designed primarily as an intervention for urinary, not fecal, incontinence and the design was neither blinded nor controlled. Trials of systematic toileting schedules specifically directed at fecal incontinence, with attention to fecal impaction, diet, fluid intake and laxative use, should be conducted.

A cost and value analysis of two interventions with incontinent nursing home residents

OBJECTIVE

More than half of nursing home residents suffer from urinary incontinence. These residents typically have long stays and, because of comorbid cognitive and physical impairments, have little hope of living again in a noninstitutional environment The value of interventions to change functional status of this chronically institutionalized population is often questioned. This paper explores this value issue in the context of two incontinence management interventions that have been shown to improve functional status: (1) Functional Incidental Training (FIT), and (2) Prompted Voiding (PV). The relative value of the different interventions for the nursing home population was estimated using paired preferences.

DESIGN

The cost of two interventions (FIT and PV) that target incontinent nursing home residents was related to the value of these interventions as perceived by consumers of nursing home services. Both interventions decrease incontinence frequency, and one intervention also improves mobility endurance.

PARTICIPANTS

Ninety incontinent nursing home residents received the intervention; 37 older nondemented board and care residents and 31 family members of the nursing home residents provided estimates of the intervention's value.

MEASUREMENT

The staff-time allocations involved in implementing both interventions were documented in more than 85 resident care episodes. These time data were converted to labor cost based on the cost of nursing aides who would actually implement the intervention. The value of each intervention was assessed by asking consumers to make choices between the intervention and its associated outcomes (such as increased dryness) and other nursing home services of known cost (e.g., moving to a private room).

RESULTS

Both interventions had labor costs that were greater than "usual care" costs. The additional cost was estimated to be $4.31 per resident per day for PV and $6.42 per resident per day for FIT if these programs were implemented from 7 AM to 7 AM. Consumer preference data indicated that consumers preferred the FIT and PV outcomes to more expensive alternative services, calculated to cost $10.00 per day, often marketed to consumers,

CONCLUSION

Consumers may prefer the FIT and PV interventions relative to the typical services often marketed to the nursing home consumer. The analysis completed in this paper suggests that both interventions have value for frail residents likely to live out their lives in a nursing home.

From paradigm to method in interpretive action research

It is generally accepted in many areas of research, including nursing research, that decisions about research methods should be informed by the nature of the research question; that the research question will indicate what approach and methods should be used. However, it is arguable that this over-simplifies the process of decision-making. It is suggested that the axiom that question determines approach and method overlooks the influence of the researcher's personal worldview in such decisions. This paper seeks to examine some of the elements of the process of moving from underlying philosophy to research design and strategies, by exploring the concept of paradigm, features of this researcher's worldview, and the principles and processes which influence decisions about the research. The process is illustrated by reference to features of a study into the work of community psychiatric nurses in relation to the quality of life and social networks of their clients with enduring mental health problems.

Use of a portable ultrasound device to measure post-void residual volume among incontinent nursing home residents

OBJECTIVE

To determine the accuracy of a portable ultrasound device for the assessment of post-void residual (PVR) volume among incontinent nursing home (NH) residents.

DESIGN

Prospective, clinical series.

SETTING

Seven community-based nursing homes.

STUDY POPULATION

Two hundred one consecutively assessed incontinent NH residents who were participating in a larger clinical trial.

MEASUREMENTS

PVR volumes measured by trained research associates using a portable ultrasound device and by in-and-out catheterization were compared. The accuracy of the ultrasound was calculated using the volume obtained by catheterization as the gold standard.

RESULTS

The ultrasound demonstrated excellent test-retest and interrater reliability. For low PVRs, the device was highly sensitive (.90) for PVR < 50 mL and .95 for PVR < 100 mL) and moderately specific (.71 for PVR < 50 mL and .63 for PVR < 100 mL). For PVRs of more than 200 mL (n = 26), the ultrasound had a sensitivity of .69 and a specificity of .99.

CONCLUSION

The portable ultrasound we used was reliable and reasonably accurate for assessing PVR in a representative sample of incontinent NH residents. Because the sensitivity for clinically significant urinary retention (PVR > 200 mL) was only .69, repeated measurements may be necessary to exclude high PVR in individual NH residents. Recent changes in ultrasound design should improve its ease of use and accuracy. Although measuring PVR by ultrasound is much easier and more comfortable than catheterization for both NH residents and staff, the cost of the device may be a barrier to its widespread use in the NH setting.

Quality of life in community mental health care--a review

There has been growing interest in the concept and measurement of quality of life in recent years, originally in the field of general health care, and more recently in community mental health. Measures designed to assess quality of life have been used to assess individual clients' problems, to assess the needs of a particular population, or for research purposes. However there is no generally agreed definition of quality of life itself, or of its associated constructs. As a result of this many ways are used to assess quality of life, ranging from those measures which are generally 'objective', using checklists or rating scales, to those which assess quality of life with little or no predetermined structure for the results. The purpose of this selective review is to focus on some of the range of definitions and concepts of quality of life and approaches to its measurement, with a view to illuminating the most appropriate approaches (both for clinical and research purposes) in the field of community care of those with enduring psychiatric illness.

Social networks: their relevance to mental health nursing

Research into social networks has been advancing over several decades, originally in relation to the general population and more recently in relation to their influences on health and mental health. The recent full implementation of the Community Care Act, with its stress on the role of carers and networks, reinforces the need for mental health nurses to be aware of these issues. This selective review examines some of the ways in which social networks can be analysed, explores the relationship between social networks and social support, and considers the effects of social networks and social support on mental health. Research into the social networks of people with long-term mental ill-health is discussed, and implications for mental health nursing in all care settings are addressed.

The dark side of incontinence: nighttime incontinence in nursing home residents

OBJECTIVE

To describe the characteristics of nighttime urinary incontinence in a sample of nursing home (NH) residents.

DESIGN

Prospective descriptive study of a convenience sample of incontinent NH residents.

SETTING

Four NHs.

PARTICIPANTS

136 incontinent NH residents.

MEASUREMENTS

Frequency and volume of incontinent and continent voids for three 10-hour daytime and three 10-hour nighttime data collection periods.

RESULTS

The frequency of nighttime incontinence was the same as during the day, but the volume of nighttime incontinent voids and total nighttime volume were higher than during the day. There was substantial between- and within-subject variability in volumes, but the distribution of ratios of night/total volumes approximated a normal curve. Diuretic use was associated with relatively low nighttime volumes.

CONCLUSION

About one-quarter of the NH residents we studied produced substantially more urine at night than during the day. Several medical, behavioral, and environmental approaches should be considered for reducing the frequency and volume of nighttime incontinence in this population.

Mental health, race and ethnicity: a retrospective study of the care of ethnic minorities and whites in a psychiatric unit

A retrospective case-note study of 152 discharged psychiatric patients (77 subjects of ethnic minority origin and 75 whites) examined for details of follow-up arrangements on discharge, compliance rate with out-patient appointments and details on length of stay, status on admission, employment status, record of illicit drug taking and diagnosis. The results show that in the areas of diagnosis, possible illicit drug involvement, status on admission and length of stay, there are significant differences between Afro-Caribbean subjects and others.

Dental health status of recipients of community dental health services

A new information system was used routinely to monitor clinical dental services. Data on 20,729 courses of treatment support the validity and usefulness of continuously collected information about dental health status. Patients who had not attended a community clinic within the year before examination did not need courses of treatment that differed appreciably from those for patients who had attended within the previous year. Patients who attended without scheduled appointments had a lower prevalence of caries free primary dentitions than those with such appointments. Dentists with patients having more caries free permanent dentitions provided a higher number of courses of treatment a year.

Effect of oral hygiene instruction on brushing skills in preschool children

This study provides new information on the assessment of toothbrushing skills in preschool children. 420 children aged 2-4 years were given a single lesson on toothbrushing. Their levels of toothbrushing skills, in terms of the locations of the tooth surfaces brushed, were recorded before and after the lesson. The number of skills per child possessed before the lesson (innate skills) and the number acquired from the lesson, both increased with age. A high correlation was found between the proportion of children innately possessing a particular skill and the proportion who subsequently learned it from the lesson. An effectiveness index was devised to help compare the relative difficulty and utility of teaching different skills at different ages.

Effects of injected sympathomimetic amines on plasma catecholamines and circulatory variables in man

We measured blood pressure, heart rate (HR), and plasma catecholamine responses to a 5-minute infusion of 0.3 mg/kg d-amphetamine (d-A) and to graded bolus injections of tyramine (Tyr) to a similar increment in systolic pressure (BPs), in 9 and 7 healthy people, respectively. Both sympathomimetic agents dramatically increased BPs (mean increases peaking at 39 and 36 mm Hg for d-A and Tyr), associated with increased plasma norepinephrine (NE) (224 and 149 pg/ml) but unassociated with changes in plasma epinephrine or HR. The time course of BPs and NE responses to Tyr was much shorter than to d-A, but the pattern was similar. The results are consistent with the hypotheses that both agents increase BPs via increased synaptic cleft NE, and that circulating plasma NE reflects "spillover" from the cleft into the general circulation.

An effective method for measuring salivary lithium in patients on anticholinergic drugs

The parotid salivary response to citric acid and cholinergic agonist and antagonist was assessed in normal volunteers. Gustatory stimulation by circulation of citric acid in the mouth evoked reproducible parotid salivary burst. The salivary response to citric acid was minimally affected by anticholinergic drugs. Analysis of citric acid-evoked parotid saliva revealed a linear relationship between saliva and serum lithium concentrations in affectively ill patients treated with lithium only, or with lithium in combination with anticholinergic drugs. We suggest that parotid saliva lithium levels can be used to guide lithium therapy in patients for whom phlebotomy is not practical.

Red cell ouabain-sensitive Na+-K+-adenosine triphosphatase: a state marker in affective disorder inversely related to plasma cortisol

Ouabain-sensitive Na+-K+-stimulated ATPase was measured in red cell membranes using a spectrophotometric assay. The mean enzyme level in patients in the depressed state (1.2 nM/mg protein per min +/- 0.18 SEM) was lower lower than that in well-state patients (2.0 +/- 0.26) and hypomanic patients (2.4 +/- 0.31). Lithium treatment itself did not alter ATPase levels. Levels in patients in the well state were not significantly different from controls and thus ATPase does not constitute a "trait" marker for affective illness. Plasma cortisol level was higher in well-state patients (15.9 micrograms/dl +/- 1.46) than in controls (11.5 +/- 0.75). There were no significant differences in cortisol in these single morning samples during different mood states. Cortisol level correlated negatively with ATPase level in the total group of patients (r = 0.42, p less than 0.005), especially in those who were euthymic. These data indicate a relationship between cortisol and ATPase levels in affectively ill patients. Ouabain-sensitive NaK ATPase may be useful as an indicator of state in affective illness; plasma cortisol may be continuously elevated in some individuals with affective disorder.