Cocaine-related admissions to an intensive care unit: a five-year study of incidence and outcomes

Cocaine misuse is increasing and it is evidently considered a relatively safe drug of abuse in Ireland. To address this perception, we reviewed the database of an 18-bed Dublin intensive care unit, covering all admissions from 2003 to 2007. We identified cocaine-related cases, measuring hospital mortality and long-term survival in early 2009. Cocaine-related admissions increased from around one annually in 2003-05 to 10 in 2007. Their median (IQR [range]) age was 25 (21-35 [17-47]) years and 78% were male. The median (IQR [range]) APACHE II score was 16 (11-27 [5-36]) and length of intensive care stay was 5 (3-9 [1-16]) days. Ten patients died during their hospital stay. A further five had died by the time of follow-up, a median of 24 months later. One was untraceable. Cocaine toxicity necessitating intensive care is increasingly common in Dublin. Hospital mortality in this series was 52%. These findings may help to inform public attitudes to cocaine.

Effect of pre-milking teat preparation procedures on the microbial count on teats prior to cluster application

A study was carried out to investigate the effect of six pre-milking teat preparation procedures on lowering the staphylococal, streptococcal and coliform microbial count on teat skin prior to cluster application. The teat preparations included 'Iodine', 'Chlorhexidine' teat foam, 'Washing and drying' with paper, 'No preparation', 'Chlorine' teat foam, and disinfectant 'Wipes'. Teat preparations were applied for five days to 10 cows for each treatment during two herd management periods (indoors and outdoors). Teats were swabbed on day four and five before teat preparation and repeated after teat preparation. The swabs were plated on three selective agars: Baird Parker (Staphylococcus spp.), Edwards (Streptococcus spp.), and MacConkey (coliform). Following incubation, microbial counts for each pathogen type were manually counted and assigned to one of six categories depending on the microbial counts measured. The results were analysed by logistic regression using SAS 28. The main analysis was conducted on binary improvement scores for the swabbing outcomes. There were no differences for staphylococcal, streptococcal and coliform bacterial counts between treatments, measured 'before' teat preparation. Treatments containing 'Chlorhexidine' teat foam (OR = 4.46) and 'Wipes' (OR = 4.46) resulted in a significant reduction (P < 0.01) in the staphylococcal count on teats compared to 'Washing and drying' or 'No preparation'. 'Chlorine' teat foam (OR = 3.45) and 'Wipes' (3.45) had the highest probability (P < 0.01) of reducing streptococcal counts compared to 'Washing and drying' or 'No preparation'. There was no statistical difference between any of the disinfectant treatments applied in reducing coliforms. Thus, the use of some disinfectant products for pre-milking teat preparation can have beneficial effects on reducing the levels of staphylococcal and streptococcal pathogens on teat skin.

Farm management factors associated with bulk tank somatic cell count in Irish dairy herds

The relationship between bulk tank somatic cell count (SCC) and farm management and infrastructure was examined using data from 398 randomly selected, yet representative, Irish dairy farms where the basal diet is grazed grass. Median bulk tank SCC for the farms was 282,887 cells/ml ranging from 82,209 to 773,028 cells/ml. Two questionnaires were administered through face-to-face contact with each farmer. Herd-level factors associated with bulk tank SCC were determined using linear models with annual somatic cell score (i.e., arithmetic mean of the natural logarithm of bulk tank SCC) included as the dependent variable. All herd level factors were analysed individually in separate regression models, which included an adjustment for geographical location of the farm; a multiple regression model was subsequently developed. Management practices associated with low SCC included the use of dry cow therapy, participation in a milk recording scheme and the use of teat disinfection post-milking. There was an association between low SCC and an increased level of hygiene and frequency of cleaning of the holding yard, passageways and cubicles. Herd management factors associated with bulk tank SCC in Irish grazing herds are generally in agreement with most previous studies from confinement systems of milk production.

Farm management factors associated with bulk tank total bacterial count in Irish dairy herds during 2006/07

Research has shown that total bacterial count (TBC), which is the bacterial growth per ml of milk over a fixed period of time, can be decreased by good hygiene and farm management practices. The objective of the current study was to quantify the associations between herd management factors and bulk tank TBC in Irish spring calving, grass-based dairy herds. The relationship between bulk tank TBC and farm management and infrastructure was examined using data from 400 randomly selected Irish dairy farms where the basal diet was grazed grass. Herd management factors associated with bulk tank TBC were identified using linear models with herd annual total bacterial score (i.e., arithmetic mean of the natural logarithm of bulk tank TBC) included as the dependent variable. All herd management factors were individually analysed in a separate regression model, that included an adjustment for geographical location of the farm. A multiple stepwise regression model was subsequently developed. Median bulk tank TBC for the sample herds was 18,483 cells/ml ranging from 10,441 to 130,458 cells/ml. Results from the multivariate analysis indicated that the following management practices were associated with low TBC; use of heated water in the milking parlour; participation in a milk recording scheme; and tail clipping of cows at a frequency greater than once per year. Increased level of hygiene of the parlour and cubicles were also associated with lower TBC. Herd management factors associated with bulk tank TBC in Irish grazing herds were generally in agreement with most previous studies from confinement systems of milk production.

Quantification of risk-benefit in interventional radiology

The increased use of interventional radiological procedures brings with it an increased risk of cancer induction due to the possible high radiation levels used. This risk must be balanced against any viable alternatives and should take into account the individual risks and benefits. The purpose of this study is to quantify this risk benefit in terms of quality-adjusted life years (QALYs) of a procedure and its alternatives, including the risk due to the radiation. Uterine fibroid embolisation was chosen as a model study with data collected both on the outcomes of procedures in terms of complications and quality of life in the long-term and on radiation dose delivered to the patient. Dosimetry data were obtained from University Hospital Galway. The risk was then calculated using the BEIR VII model of dose-response for low linear energy transfer (LET) radiation. In this case, it was found that the radiological technique has distinct advantages over hysterectomy and myomectomy in terms of QALYs. The increased risk due to radiation from the procedure is small when compared with the overall benefit to the patient. Probability of stochastic effects based on the average dose per procedure carries an attributable risk (fatal and non-fatal cancer and hereditary effects) of 0.4% or a relative risk of 1.09%. The method described here can readily be adapted to other interventional procedures.

Long-term functional outcome and performance status after intensive care unit re-admission: a prospective survey

BACKGROUND

Intensive care unit (ICU) re-admission identifies a high-risk group in terms of hospital mortality, length of stay, and resource utilization. Only hospital and ICU mortality are well described in the literature on critically ill patients needing re-admission.

METHODS

With ethical committee approval, from a prospectively collected database of all admissions to a combined medical and surgical ICU from January 1 to December 31, 2004, we identified all ICU re-admissions from within the hospital and analysed the factors associated with increased incidence of re-admission. At 2-3 yr after discharge, we evaluated the functional outcome of the surviving re-admitted patients as Glasgow Outcome Score (GOS) and Karnofsky index and identified determinants of both mortality and good functional outcome.

RESULTS

Seventy-three (7.4%) of the 1061 patients who survived their first ICU stay were re-admitted during the study period. Of the 73 re-admitted patients, 14 died in ICU, 17 died later in the same hospital stay, and 10 died in the interim. Thus, 32 (43.8%) were alive 2-3 yr after discharge. The median [IQR] GOS of the survivors was 4 (see Mackle and colleagues in One year outcome of intensive care patients with decompensated alcoholic liver disease.

CONCLUSIONS

Although the ICU, hospital, and subsequent mortalities are high in patients after ICU re-admission, most survivors at 2-3 yr had by then made a good functional recovery and were independent.

Temporal Trends in Bulk Tank Somatic Cell Count and Total Bacterial Count in Irish Dairy Herds During the Past Decade

The objective of this study was to document temporal trends in bulk tank somatic cell count (SCC) and total bacterial counts (TBC) in Irish dairy herds during the years 1994 to 2004. Three milk processors participated in the study, providing data on 2,754,270 individual bulk tank SCC and 2,056,992 individual bulk tank TBC records from 9,113 herds. Somatic cell counts decreased during the years 1994 to 2000, followed by an annual increase thereafter of more than 2,000 cells/mL. A tendency existed for TBC to decrease over time. Across all years, bulk tank SCC were the lowest in April and highest in November; TBC were the lowest in May and highest in December. The significant seasonal pattern observed in herd SCC and TBC was an artifact of seasonal calving in Ireland. In general, herds selling more milk had lower bulk tank SCC and TBC. Herds having the highest SCC (i.e., > 450,000 cells/mL) and the lowest SCC (i.e., < or = 150,000 cells/mL) both contributed substantially to the mean SCC of the milk pool collected by the milk processors. Derived transition matrices showed that between adjacent years, herds had the greatest probability of remaining in the same annual mean SCC or TBC category.

Building safer systems by ecological design: using restoration science to develop a medication safety intervention

BACKGROUND

Experts call for stronger safety cultures and transparent reporting practices to increase medication safety in today's strained healthcare environments. The field of ecological restoration is concerned with the effective, efficient, and sustainable repair and recovery of ecosystems that have been degraded, damaged, or destroyed. A study was undertaken to determine whether the lessons of restoration science can be adapted to the study of medication safety issues.

METHODS

Working with 26 practitioners, the principles of good restoration were used to design and pilot an innovative multifaceted medication safety intervention. The intervention included focus groups with practitioners, the construction and administration of a research based medication safety inventory, repeat digital photography of environmental safety issues, and targeted environmental modifications.

RESULTS

Participants were most concerned about staff education and the physical environment for medication administration. Ward staff used the research to build a healthy reporting culture, introduce regular discussions of near misses, develop education strategies, redesign delivery and storage processes, and renovate the environment.

CONCLUSIONS

Members of a busy hospital ward successfully adapted methods of restoration science to study, redesign, and strengthen medication safety practices and ward safety culture within existing resources. Further research will be conducted to test the merits of restoration science for health care.

Passivation of nitinol wire for vascular implants--a demonstration of the benefits

This study investigated a passivation process for polished nitinol wires and vascular stent components, after being given a typical shape setting heat treatment. Heat treated samples were passivated in a nitric acid solution and a series of corrosion tests, surface analysis and chemical analysis was performed. Potentiodynamic polarization tests demonstrated a significant increase in breakdown potential for passivated samples, compared to heat treated surfaces. Surface analysis indicated that the passivation reduces Ni and NiO content in the oxide and increases TiO2 content. Chemical analysis of passivation solutions suggests that the improvement in corrosion resistance is proportional to the quantity of nickel removed. Long term immersion tests demonstrate that nickel release from the surface of the material decreases with time and the quantity of nickel released is lower for passivated samples. The improved corrosion resistance is maintained after extended periods of immersion in saline solution.

Acute anterior myocardial infarction as first manifestation of acute myeloid leukemia

A 42-year-old man was admitted with heavy retrosternal pain lasting 30 min. Electrocardiography showed typical signs of acute anterior myocardial infarction. The patient reported only attacks of coughing for a couple of days, and no serious diseases. The physical examination was normal. Laboratory tests showed a white blood cell count of 45/nl, platelet count of 58/nl, and hemoglobin of 14.4 g/dl. Blood chemistry showed elevated lactic dehydrogenase (413 U/l) but no elevation in creatine phosphokinase or glutamic-oxaloacetic transaminase. Therefore no thrombolysis was administered, but coronary angiography was performed. This showed a long-distance, subtotal thrombotic occlusion of the left anterior descending artery. After percutaneous transluminal coronary angioplasty and implantation of serial stents a normal perfusion of the artery was observed. The patient's blood and bone marrow films revealed acute myeloid leukemia FAB M2. Various conditions can cause a myocardial infarction in leukemias. We discuss the clinical management and the possible reasons for a subtotal thrombotic occlusion of the coronary artery.

Does bathing newborns remove potentially harmful pathogens from the skin?

BACKGROUND

Newborn infants are routinely bathed after birth partly to reduce the possibility of transmitting potential pathogens to others. The extent to which a mild soap reduces the quantity and type of microbes found on the skin through normal colonization has not been reported. The objective of the study was to compare colonization rates between infants bathed in soap and water and infants bathed in plain water.

METHOD

One hundred and forty infants were randomly assigned to one group bathed in a mild pH neutral soap and water or to another group bathed in water alone. Microbiology swabs were taken on three occasions (before the first bath, 1 hour after the bath, and 24 hours after birth) from two sites (anterior fontanelle and umbilical area).

RESULTS

No difference occurred between groups on type or quantity of organisms found at each time period. Skin colonization is a function of time, and the quantity of organisms identified increased over time (Friedman A 2 = 111.379, df = 5, p < 0.001).

CONCLUSIONS

Bathing with mild soap as opposed to bathing in water alone has minimal effect on skin bacterial colonization. Skin colonization increased over time. The findings did not support the efficacy of bathing with soap and water to reduce skin colonization of bacterial pathogens. Although the incidence of potential pathogens colonizing the skin during the first day of life is low and unlikely to pose a risk to healthy newborns, health care professionals may wish to wear gloves until the infant has been bathed.

Rhodes Index of Nausea and Vomiting--Form 2 in pregnant women. A confirmatory factor analysis

BACKGROUND

Despite widespread application of Rhodes Index of Nausea and Vomiting-Form 2 (INV2) in practice and research, empirical analyses have not been consistently performed to verify the a priori factors that guided the subclass construction of the symptoms.

OBJECTIVES

To examine the dimensional structure of Rhodes INV in a sample of pregnant women.

METHOD

Data were collected from 152 pregnant women who were experiencing some degree of nausea and vomiting during early pregnancy and analyzed using structural equation modeling techniques. Five competing measurement structures were tested and compared. The structure (model) that provided the closest fit to the data was selected and relationships (factor loadings) between the constructs and indicators were established.

RESULTS

The model fitting the data the closest was a three-factor structure measuring nausea, vomiting, and retching as three separate, but correlated dimensions. The factor loadings were high (0.73-0.96) and significant (p < .001). The model treating nausea and vomiting as a one-factor concept as well as the model including two factors named symptom occurrence and symptom distress did not fit the data.

CONCLUSION

Rhodes INV2 is a valid measurement tool if subscales are formed to reflect the multidimensional structure of nausea and vomiting in pregnancy.

Coordination and management of a large multicenter screening trial: the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial

The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial is a large and complex multi-institutional, multifaceted organization with a 20-year horizon. The implementation of the trial began with the creation of an organizational structure that supports strong leadership, cooperation, and effective communication among the trial collaborators including an operational framework for the development, review, and pretest of instruments, data collection, and management procedures; the setting of high-quality standards for training of trial staff; and the development of a comprehensive assessment plan for evaluation of all trial activities. This paper describes the process and methods used in the coordination and management of the PLCO trial. These include the role of the steering committee and its subcommittees and working groups, the establishment of regular and ad hoc communications among collaborators, the training of screening center coordinators and examiners, the PLCO manual of operations and procedures, and the development and implementation of a comprehensive quality assurance plan.

Design of the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial

The objectives of the Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial are to determine in screenees ages 55-74 at entry whether screening with flexible sigmoidoscopy (60-cm sigmoidoscope) can reduce mortality from colorectal cancer, whether screening with chest X-ray can reduce mortality from lung cancer, whether screening men with digital rectal examination (DRE) plus serum prostate-specific antigen (PSA) can reduce mortality from prostate cancer, and whether screening women with CA125 and transvaginal ultrasound (TVU) can reduce mortality from ovarian cancer. Secondary objectives are to assess screening variables other than mortality for each of the interventions including sensitivity, specificity, and positive predictive value; to assess incidence, stage, and survival of cancer cases; and to investigate biologic and/or prognostic characterizations of tumor tissue and biochemical products as intermediate endpoints. The design is a multicenter, two-armed, randomized trial with 37,000 females and 37,000 males in each of the two arms. In the intervention arm, the PSA and CA125 tests are performed at entry, then annually for 5 years. The DRE, TVU, and chest X-ray exams are performed at entry and then annually for 3 years. Sigmoidoscopy is performed at entry and then at the 5-year point. Participants in the control arm follow their usual medical care practices. Participants will be followed for at least 13 years from randomization to ascertain all cancers of the prostate, lung, colorectum, and ovary, as well as deaths from all causes. A pilot phase was undertaken to assess the randomization, screening, and data collection procedures of the trial and to estimate design parameters such as compliance and contamination levels. This paper describes eligibility, consent, and other design features of the trial, randomization and screening procedures, and an outline of the follow-up procedures. Sample-size calculations are reported, and a data analysis plan is presented.

Quality control of cancer screening examination procedures in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial

Investigators for the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial describe quality control procedures for the digital rectal examination, ovarian palpation examination, transvaginal ultrasound, chest X-ray, and flexible sigmoidoscopy. These cancer screening tests are subjective and difficult to standardize. PLCO quality control procedures aim to measure and, where possible, reduce variation, across examiner and screening center, with respect to cancer screening test performance. Initial protocols stressed examiner qualifications, experience, and training; equipment specifications; examination procedures; and definitions for positive tests. The PLCO quality assurance subcommittee developed a final quality assurance plan, which included central approval and registration of PLCO examiners, direct observation of screening test performance during periodic site visits by the National Cancer Institute and coordinating center auditors, periodic analysis of screening test data, and procedures for independently duplicating or reviewing selected examinations. For each modality, the periodic data analyses examine the test-positive and the test-inadequate proportions and aim to identify divergent centers or examiners. Procedures for duplicating examinations specify feasible sample sizes for precise estimates of agreement between examiners, at each center, for each screening test modality, and over a 1-year period. These quality control procedures will help characterize the consistency and reliability of the PLCO cancer screening tests.

Severe postoperative nausea and vomiting in a parkinsonian patient

A 74-year-old woman was reviewed 6 hours postoperatively following a mastectomy and axillary clearance as she was vomiting and feeling nauseous. She had experienced a severe episode of emesis after surgery more than 10 years previously, which, she recalled, had lasted several days.

Measuring cell proliferation in the rectal mucosa. comparing bromodeoxyuridine (BrdU) and proliferating cell nuclear antigen (PCNA) assays

Cell proliferation in the human colorectum can be measured using bromodeoxyuridine (BrdU) or proliferating cell nuclear antigen (PCNA) assays. Using data from the National Cancer Institute's Polyp Prevention Trial, these two assays are compared using correlation coefficients and variance components analysis. Adjusting for fixed as well as for the random effects of between-biopsy and scoring variation, the estimated correlation is 0.46 for the log labeling index and 0.45 for log proliferative height. This is an estimate of the highest correlation that can be achieved by taking multiple biopsies scored by multiple scorers. For single biopsies, the estimated correlation is 0.16 and 0.10, respectively. There are significant differences between the variance components for the two assays. For example, for log labeling index, PCNA has a lower variation between biopsies than BrdU, but higher variation between scorings. When used in a clinical or epidemiological setting, it is important to take multiple biopsies at multiple time points.