A case of intraoperative pyrexia

A 14-year-old boy was admitted via accident and emergency after a road traffic accident. Open fractures of his left radius and ulna required urgent fixation so he was assessed preoperatively. Previous surgery for correction of strabismus had been uneventful and he was otherwise well. He had eaten just before the accident and had suffered significant blood loss. Intravenous fluids and blood were infused to restore haemodynamic stability. Examination was otherwise unremarkable. His temperature was 36°C. Premedication with atropine was prescribed and rapid sequence induction planned using thiopentone and suxamethonium. Cefuroxime was given as an antimicrobial.

Canadian implantable defibrillator study (CIDS) : a randomized trial of the implantable cardioverter defibrillator against amiodarone

BACKGROUND

Patients surviving ventricular fibrillation (VF) or sustained ventricular tachycardia (VT) are at a high risk of death due to a recurrence of arrhythmia. The implantable cardioverter defibrillator (ICD) terminates VT or VF, but it is not known whether this device prolongs life in these patients compared with medical therapy with amiodarone.

METHODS AND RESULTS

A total of 659 patients with resuscitated VF or VT or with unmonitored syncope were randomly assigned to treatment with the ICD or with amiodarone. The primary outcome measure was all-cause mortality, and the secondary outcome was arrhythmic death. A total of 328 patients were randomized to receive an ICD. A thoracotomy was done in 33, no ICD was implanted in 18, and the rest had a nonthoracotomy ICD. All 331 patients randomized to amiodarone received it initially. At 5 years, 85.4% of patients assigned to amiodarone were still receiving it at a mean dose of 255 mg/day, 28.1% of ICD patients were also receiving amiodarone, and 21.4% of amiodarone patients had received an ICD. A nonsignificant reduction in the risk of death was observed with the ICD, from 10.2% per year to 8.3% per year (19.7% relative risk reduction; 95% confidence interval, -7.7% to 40%; P=0.142). A nonsignificant reduction in the risk of arrhythmic death was observed, from 4.5% per year to 3.0% per year (32.8% relative risk reduction; 95% confidence interval, -7.2% to 57.8%; P=0.094).

CONCLUSIONS

A 20% relative risk reduction occurred in all-cause mortality and a 33% reduction occurred in arrhythmic mortality with ICD therapy compared with amiodarone; this reduction did not reach statistical significance.

Development, dissemination, implementation and evaluation of a clinical pathway for oxygen therapy

BACKGROUND

Oxygen is commonly administered to patients in hospital, but prescribing and monitoring of such therapy may be suboptimal. The objective of this study was to develop, disseminate, implement and evaluate a multidisciplinary clinical pathway for the administration of oxygen.

METHODS

The authors developed a clinical pathway for the ordering, titration and discontinuation of oxygen, which was disseminated through teaching sessions, in-service training sessions and information posters in a medical clinical teaching unit (CTU). Implementation of the pathway was ensured by means of reminders and patient-centred audit and feedback to CTU nurses and house staff. During a 3-month intervention phase, consecutive patients requiring supplemental oxygen were treated according to the pathway. During a 1-month "wash-out" phase followed by a 3-month non-intervention phase, patients were treated at the discretion of the CTU team. Clinical and economic data were collected in both phases.

RESULTS

In the 2 phases, patient characteristics, the concentration and duration of oxygen prescribed, the frequency of oxygen saturation monitoring, the frequency of arterial blood gas testing and the clinical outcomes were similar. However, there were more discontinuation orders in the intervention phase (p < 0.001). In the intervention phase, costs were higher for monitoring of oxygen saturation ($44.95/patient v. $36.17/patient, p = 0.048) and for order transcription ($2.71/patient v. $1.28/patient, p < 0.001); total costs, including those for personnel, were also higher in the intervention phase ($76.93/patient v. $56.67/patient, p = 0.02). The cost of education about the oxygen pathway was $45.71/patient. When the education cost was included, the total cost of oxygen therapy during the intervention phase was $122.64/patient; this was significantly higher than the total cost of oxygen therapy during the non-intervention phase ($56.67/patient) (p < 0.001).

INTERPRETATION

This multidisciplinary, multimethod oxygen pathway led to changes in oxygen-prescribing behaviour, consumed more resources than standard management and was not associated with changes in patient outcome. Appropriate management of oxygen prescribing and monitoring by physicians and nurses take time and costs money.

A comparison of papaveretum-promethazine with morphine-ondansetron for patient-controlled analgesia

BACKGROUND

Patient-controlled analgesia (PCA) with intravenous morphine is commonplace. Antiemetics are often added to reduce side-effects. In our institution an unusual combination of papaveretum-promethazine is in use.

AIMS

We set out to compare this combination with a more commonly used one (morphine-ondansetron) by auditing the records of our pain-control team assessing analgesia and control of side-effects.

METHODS

The records of two groups of 100 consecutive patients were studied. Pain scores were recorded 24 hours post-operatively on a scale of zero to ten. Also recorded were sedation scores, pruritus, emesis, and usage of breakthrough analgesia. The groups contained the work of a variety of anaesthetists and surgeons, though the majority were orthopaedic cases. All results were recorded by one pain-control nurse, using the same question, over a nine-month period.

RESULTS

Sedation scores were identical, while side-effects were few and similar in both groups. The use of breakthrough analgesia was also similar. However, the median pain-score of zero in the papaveretum group was significantly lower than that of two in the morphine group, (p < 0.001, Mann-Whitney U).

CONCLUSION

Papaveretum-promethazine appeared to be effective for PCA. This combination is also much less expensive than morphine-ondansetron. A previously described synergistic interaction between promethazine and opiates may be a factor in its success. Further evaluation of these drugs in PCA is warranted.

Economic evaluation of long-term management strategies for erosive oesophagitis

OBJECTIVE

To compare the expected costs and outcomes of alternative strategies for the management of patients with erosive oesophagitis.

DESIGN

There were 3 components to the overall analytic approach. First, a decision model was constructed to compare expected costs and outcomes of 6 management strategies. Second, principles of quantitative literature review and meta-analysis were used to determine probabilities of clinical events (i.e. oesophagitis healing and recurrence). Finally, principles of cost-effectiveness analysis were used to compare treatment alternatives in terms of dominance and incremental cost effectiveness. The viewpoint for the study was that of a provincial government payer for healthcare over a 1-year period.

MAIN OUTCOME MEASURES AND RESULTS

Healing rates were significantly higher for proton pump inhibitors (PPI) [p < 0.001]. Recurrence rates were significantly higher for intermittent therapy (placebo) and lower for regular dose PPI (p < 0.001). Maintenance prokinetic agent (PA) is dominated (i.e. more costly and less effective) and step-down maintenance PPI is dominated through principles of extended dominance. The 'efficient frontier' is represented by: maintenance H2-receptor antagonist (H2RA), intermittent PPI, step-down maintenance H2RA and maintenance PPI.

CONCLUSIONS

The price of H2RA is a key factor influencing whether step-down maintenance PPI forms part of, or is contained within, the 'efficient frontier' of long term management for erosive oesophagitis.

Venous thromboembolism prophylaxis after total hip or knee arthroplasty: a survey of Canadian orthopedic surgeons

OBJECTIVE

To determine the pharmacologic and physical modalities used by orthopedic surgeons in Canada to prevent venous thromboembolism (deep venous thrombosis and pulmonary embolism) after total hip or knee arthroplasty.

DESIGN

Mail survey sent to all members of the Canadian Orthopaedic Association.

SETTING

A nation-wide study.

METHODS

A total of 828 questionnaires, designed to identify the type and frequency of prophylaxis against venous thromboembolism that were used after hip and knee arthroplasty were mailed to orthopedic surgeons.

OUTCOME MEASURES

Demographic data and the frequency and type of thromboprophylaxis.

RESULTS

Of the 828 surveys mailed 445 (54%) were returned, and 397 were included in this analysis. Of the respondents, 97% used prophylaxis routinely for patients who undergo total hip or knee arthroplasty. Three of the 397 (0.8%) did not use any method ofprophylaxis. Warfarin was the most common agent used (46%), followed by low-molecular-weight heparin (LMWH) (36%). Combination therapy with both mechanical and pharmacologic methods were used in 39% of patients. Objective screening tests were not frequently performed before discharge. Extended prophylaxis beyond the duration of hospitalization was used by 36% of physicians.

CONCLUSION

Prophylaxis for venous thromboembolism with warfarin or LMWH has become standard care after total hip or knee arthroplasty in Canada.

Economic evaluation of outpatient treatment with low-molecular-weight heparin for proximal vein thrombosis

BACKGROUND

The safety and efficacy of taking low-molecular-weight heparin at home was previously demonstrated in a clinical trial in which patients with acute proximal deep vein thrombosis were randomized to receive either intravenous standard heparin in the hospital or subcutaneous low-molecular-weight heparin administered primarily at home. Treatment in the home has the potential to substantially reduce the cost to the health care system.

METHODS

To conduct an economic evaluation we prospectively collected data on resource use and health-related quality of life (Medical Outcomes Study Short-Form 36) on the 300 patients who formed the trial stratum presenting with proximal vein thrombosis as outpatients, of whom 151 received standard heparin and 149 received low-molecular-weight heparin. The primary viewpoint of the analysis was societal, and costs included health care costs, patient travel costs, and productivity costs as a result of time off work. Costs were assessed over a period of 3 months from randomization. Quality of life was assessed as the change in Short-Form 36 domain scores from baseline to day 7 for each treatment group. All costs are reported in 1997 Canadian dollars.

RESULTS

There were 11 recurrent thromboembolic events and 1 bleed in the 151 patients who received standard heparin; the corresponding data for the 149 patients receiving low-molecular-weight heparin were 10 and 4, respectively. The mean cost per patient who received standard heparin was Can $5323 compared with Can $2278 for low-molecular-weight heparin, a total societal cost savings per patient using low-molecular-weight heparin of Can $3045 (95% confidence interval, Can $2012-$4050). There was no difference in quality of life between the 2 groups except for the domain of social functioning, where a greater improvement from baseline to day 7 was observed for the low-molecular-weight heparin group vs the standard heparin group (P =.005).

CONCLUSIONS

For patients with acute proximal deep vein thrombosis, treatment at home with low-molecular-weight heparin is less costly than hospital-based treatment with standard heparin. The economic evidence in favor of outpatient treatment with low-molecular-weight heparin exhibits dominance; a situation of reduced cost is created with no compromise in clinical outcomes or patients' quality of life.

The Ontario Prehospital Advanced Life Support (OPALS) study Part II: Rationale and methodology for trauma and respiratory distress patients. OPALS Study Group

The Ontario Prehospital Advanced Life Support (OPALS) Study represents the largest prehospital study yet conducted, worldwide. This study will involve more than 25,000 cardiac arrest, trauma, and critically ill patients over an 8-year period (1994-2002). The current article, Part II, describes in detail the rationale and methodology for major trauma and respiratory distress patients and for an economic evaluation of Advanced Life Support (ALS) programs in the OPALS Study. The OPALS Study, using a rigorous controlled methodology and a large sample size, should clearly indicate the benefit in trauma and respiratory distress patient survival and morbidity that results from the widespread introduction of prehospital ALS programs to communities of many different sizes. [Stiell IG, Wells GA, Spaite DW, Nichol G, O'Brien B, Munkley DP, Field BJ, Lyver MB, Luinstra LG, Dagnone E, Campeau T, Ward R, Anderson S, for the OPALS Study Group: The Ontario Prehospital Advanced Life Support (OPALS) Study Part II: Rationale and methodology for trauma and respiratory distress patients.

Severity of nausea and vomiting during pregnancy: what does it predict?

BACKGROUND

Relationships between the severity of nausea and vomiting during pregnancy and selected demographic (employment status, parity, age, smoking) and pregnancy outcome (birthweight, gender) variables are described.

METHODS

Women who volunteered for a community-based clinical trial were eligible for inclusion in this study. On three occasions, 12 hours apart, during early pregnancy using a continuous measure of nausea, vomiting, and retching, women assessed the amount, duration, and severity of symptoms as they occurred. After the birth of their infants, they provided information about the duration of nausea, vomiting, and retching as well pregnancy outcome information by responding to a mailed questionnaire. Multivariate methods were used to analyze data.

RESULTS

More severe vomiting in early pregnancy was likely to continue for a longer period of time and was related to decreased infant birthweight. Gestational age, parity status, and severity of vomiting were predictors of infant birthweight and together explained 22 percent of the variance in birthweight. A significant relationship between fetal gender and severity of nausea and vomiting was not found.

CONCLUSIONS

It may be possible to identify women at risk for third trimester vomiting and to provide appropriate nutritional support and counseling so that their risk of having a low-birthweight infant is reduced. A larger sample would be required to assess the relationship between fetal gender and severity of nausea, vomiting, and retching.

Salmonella tel-el-kebir and terrapins

OBJECTIVES

An outbreak of Salmonella tel-el-kebir occurring over a 6-month period is described in this report. This is the first outbreak of S. tel-el-kebir in the reported literature.

METHODS

S. tel-el-kebir was isolated from human faecal samples using conventional laboratory methods.

RESULTS

Eight patients had S. tel-el-kebir isolated from faeces. All patients were owners of, or in close contact with, pet terrapins. The terrapins were purchased in the same pet shop, where they were imported from America. The epidemiological link with these pets was confirmed, as S. tel-el-kebir was isolated from cloacal swabs from the terrapins, and from terrapin water. Molecular biology studies using DNA amplification fingerprinting (DAF) gave identical fingerprint patterns for all human and terrapin isolates.

CONCLUSIONS

Salmonellosis associated with exotic pets is a re-emerging disease in the 1990s, and measures to reduce this are discussed.

Effects of stocking density and concentrate supplementation of grazing dairy cows on milk production, composition and processing characteristics

The effects on milk composition and processing characteristics of varying grass supply by changing stocking density and of offering a concentrate supplement were investigated. The experiment was conducted over 28 weeks of the lactation (April-October) using 48 spring-calved Friesian-Holstein cows. Three herds each of 16 cows were offered a restricted grass supply, a standard grass supply and a standard grass supply with a supplement of 3 kg concentrate/d. Treatment groups were grazed separately with a residence time of 3 d/paddock. Milk production, composition and processing characteristics such as renneting properties, ethanol stability and plasmin activity were measured weekly. Increasing stocking density above the standard system resulted in significant reductions in milk fat and protein yields, the concentrations of total protein, casein and whey proteins, and a deterioration in most processing characteristics. Imposing concentrate supplementation on the standard system increased total protein, casein and whey protein concentrations but generally did not improve processing characteristics except for ethanol stability. These results suggest that the standard grass supply in a rotational grazing paddock system can support efficient production of quality milk, and concentrate supplementation will not improve processing characteristics when an adequate supply of good quality herbage is available.

The relationship between method of pain management during labor and birth outcomes

This study examined the relationship between method of pain management during labor and birth outcomes. A retrospective comparative chart review of 233 primiparous deliveries was conducted and group assignment was based on method of pain control (nonnarcotic, narcotic, or epidural). Epidural analgesia or anesthesia was associated with increased rates of instrumental and cesarean delivery. Augmentation of labor using a synthetic oxytocin was reported in more charts than expected, and the length of the second stage of labor was longer in those who received epidural analgesia or anesthesia. Apgar scores for those who received early epidural analgesia or anesthesia were lower than for those who received late or no epidural analgesia or anesthesia, although Apgar scores were satisfactory across all groups. Between-groups differences were unrelated to time of epidural placement or maternal temperature. Findings are relevant for maternal child nurses who serve as a resource for families wishing to make informed decisions about pain management in labor.

G-tube site care: a practical guide

Effective care of your patient's gastrostomy site is key to her recovery--even after she's been discharged. Here we'll zero in on the prevention and treatment of skin problems and tube dislodgement, and review which anchoring device best suits your particular patient's needs.

Site-directed hydroxyl radical probing of 30S ribosomal subunits by using Fe(II) tethered to an interruption in the 16S rRNA chain

Two in vitro transcripts, one corresponding to the 5' and central domains (residues 1-920) of 16S rRNA and the other corresponding to its 3' domain (residues 922-1542), assemble efficiently in trans with 30S ribosomal proteins to form a compact ribonucleoprotein particle that cosediments with natural 30S subunits. Isolated particles are similar in appearance to natural 30S subunits with electron microscopy and contain a full complement of the small subunit ribosomal proteins. The particles have a reduced ability to bind tRNA (attributable to the location of the discontinuity in a conserved region of the rRNA) near features that have been implicated in tRNA binding. Association of these two halves of 16S rRNA in trans must be stabilized by either previously unidentified RNA-RNA contacts or interactions mediated by ribosomal proteins because there are no known direct interactions between them. The trans construct was used to probe the three-dimensional RNA neighborhood around position 922 of 16S rRNA by generating hydroxyl radicals from Fe(II) tethered to the 5' end of the 3' transcript. Hydroxyl radical-induced cuts in the 16S rRNA chain were localized by primer extension to nucleotides 923-929 and 1192-1198, providing evidence for the mutual proximity of the 920 and 1192 regions.

Use of indigenous explanations and remedies to further understand nausea and vomiting during pregnancy

Professional and indigenous midwives are rich and appropriate sources of information about antenatal comfort measures. Midwives from a variety of geographic and cultural areas were interviewed to further our understanding of the phenomenon of nausea and vomiting during pregnancy (NVP). The midwives offered general physiological, psychological, and socioeconomic etiological theories that were, at times, inconsistent with their recommended remedies. The remedies generally included alterations in maternal nutrition, activity, and environment. Commonalities in the midwives theories of etiology and treatment were found across culturally and geographically diverse groups. Much of the variation that was noted in the midwives recommendations for treatment was related to (a) availability of a specific remedy and (b) the midwife's willingness to either support or discourage intuitive responses that women have to their pregnancies (e.g., encourage either additional rest or exercise and productive activity; social withdrawal or usual social interaction; and pica and food cravings or a balanced diet with high nutritive value).

Willingness to pay and the valuation of programmes for the prevention and control of influenza

In this paper, we consider the role of willingness to pay (WTP) as a method for measuring the impact of healthcare programmes on population well-being. Alternative methods of outcome valuation, such as quality-adjusted life-years (QALYs), measure values through individuals' willingness to trade off a particular commodity, future life. Moreover, the method of valuation fails to incorporate several dimensions of benefit relevant to measuring well-being that are particularly important in programmes aimed at the prevention and control of influenza. In contrast, WTP provides a broad method of valuation based on individuals' willingness to trade off a much wider range of commodities. In addition, WTP incorporates externalities and uncertainty within individual valuations. We show that the main limitations of the WTP approach are not avoided by adoption of the QALY approach.

First International Pharmacoeconomic Conference on Alzheimer's Disease: report and summary

The First International Pharmacoeconomic Conference on Alzheimer's Disease (AD) was held in Amsterdam in July 1998. The meeting was held under the auspices of the International Working Group for Harmonization of Dementia Drug Guidelines (http://dementia.ion.ucl.ac.uk/harmon), bringing together academics, clinicians, purchasers, and representatives from industry. Presentations were given on the methodology of pharmacoeconomic studies in AD, particularly focusing on caregiver burden, quality of life (QOL), and resource utilization. Three economic models of AD were presented based on data from the United States, Canada, and the United Kingdom. In two studies, these data were then used to model the cost-effectiveness and effect on cost of treatment with donepezil. Both studies suggested a possible cost advantage for the use of donepezil, when compared with no placebo or treatment, particularly when donepezil is used appropriately in mild-to-moderate AD. These data need to be interpreted with care, as none of the cost or utility information were collected during the clinical trials. Additional data from a 2-year clinical trial of selegiline and vitamin E suggest that cognitive measures may be poor predictors of economic outcome, which is better measured directly. Both economic models of donepezil rely on short-term cognitive data to predict long-term outcome, a methodf that may not be useful in predicting economic savings. The issues facing pharmacoeconomists, researchers, clinicians, and families in the future were addressed in a series of workshops using a method of strategic futuring. The workshops attempted to see 7 years into the future for a range of areas, including consumer and caregiver use of pharmacoeconomic data; early detection and prevention; Japanese perspectives; activities of daily life and what will be daily life activities; caregiver burden; QOL at the end of life; new uses for new information and communication technology in clinical research; and physicians' use of pharmacoeconomic data. A range of exciting futures were predicted, although common themes that arose when considering barriers to achieving these futures included cost, education, political will, confidentiality, privacy, and ethics. The first conference was deemed to have been a success, having attracted more than 160 delegates and many distinguished speaker. A second conference is planned for the year 2000. Over the next 2 years, research needs to be broadened particularly in the methodological areas of resource utilization, QOL, and caregiver burden. Data from clinical trials with relevant economic and QOL outcomes will be needed by purchasers if drug treatments for dementia are to gain widespread use. It is also hoped that the models described at the meeting may become more freely available to politicians, purchasers, clinicians, and caregivers to help them make better decisions about treatment.

Nursing competencies: ground work in aged and extended care

Competencies have been formulated for entry level nurses. Specialist and generic advanced nursing competencies are also being developed. This paper describes exploratory groundwork on aged and extended care nursing competencies derived from interviews with nurses, allied health staff, residents and their families from one setting. Critical Incident Technique1 was used to guide semistructured interviews with 29 participants. A thematic analysis of the data suggests that the Australian Nursing Council Inc.2 competencies make a useful but incomplete contribution to understanding the perceived role of nursing in aged and extended care. A conceptual framework developed from the data illustrates the interdependence of competencies with the context in which they are observed. The framework proposes a number of elements which have the potential to offer a means to better interpret nursing competence (critical aspects) in aged and extended care contexts.

Valuing outcomes in health care: a comparison of willingness to pay and quality-adjusted life-years

Quality-adjusted life-years (QALYs) and willingness to pay (WTP) are two preference-based measures of health-related outcomes. In this article, we compare these two measures in eliciting individuals' preferences for health outcomes associated with shingles. To collect the necessary preference data, we administered computer-interactive interviews to a sample of 65- to 70-year-olds. We found no significant correlation between QALYs and WTP across individuals. We discuss our findings and argue that our results raise questions about whether QALYs and WTP are equivalent preference-based measures of health outcomes.

An evaluation of rectal mucosal proliferation measure variability sources in the polyp prevention trial: can we detect informative differences among individuals' proliferation measures amid the noise?

We assessed components of total variability of bromodeoxyuridine (BrdUrd) and proliferating cell nuclear antigen (PCNA) assays of rectal mucosal proliferation in a subset of 390 participants from the U. S. National Cancer Institute's multicenter Polyp Prevention Trial. Biopsies were blindly double-scored by two technicians. For those participants for whom at least one evaluable biopsy was obtained, a mean of 2.0 and 2.6 biopsies, and 6.2 and 8.7 crypts/biopsy were evaluated, respectively, with the BrdUrd and PCNA assays. Factors such as clinical center, scorer, and month of biopsy collection significantly affected the observed values of the labeling index (LI) and proliferative height (PH). Therefore, it is essential to control or adjust for these variables in proliferation studies. Sources of random variation for LI and PH measures remaining after the aforementioned factors include between-participant variation and several sources of within-participant variation, including variation over time, between biopsies, and between multiple measurements on the same biopsy. Both LI and PH measurements exhibited substantial variability over time, between biopsies, and from reading-to-reading of the same biopsy. When other sources of variability have been accounted for, the PCNA LI seems to have little between-participant variation. This brings into question its utility as a marker in colorectal cancer studies. The PCNA PH showed significant between-participant variability and may hold some promise as a useful marker in colorectal cancer studies. Results for BrdUrd were less conclusive. The BrdUrd LI showed marginally significant between-participant variation, whereas the corresponding variation for PH was nonsignificant.

Older men's concerns about their urological health: a qualitative study

While there has been widespread recent interest in men's health issues, and prostate cancer in particular, there have been few studies to determine which issues are important from the viewpoint of men themselves. This study was undertaken to identify genitourinary issues of concern to older men. A series of 19 focus groups involved 137 men and 14 women from a broad demographic background. Men expressed consistent concern about urinary symptoms, prostate cancer and sexual function. They revealed misunderstanding and a desire for more information about all issues. Urinary symptoms had a high impact on quality of life that could be made worse by environmental constraints such as working conditions and availability of toilets. Prostate cancer was a concern in all groups, even those at low risk, and men believed that screening for prostate cancer should be offered. Men believed sexuality was not recognised as an issue of concern to older people. Potential barriers to health action included stoicism, not talking about health issues and poor relationships with doctors. The study suggests a substantial need for community and professional education and for health promotion focused on preventable morbidity.