Cost-effectiveness of blood transfusion and white cell reduction in elective colorectal surgery

BACKGROUND

The use of white cell (WBC)-reduced blood in elective colorectal surgery appears to reduce the frequency of postoperative infection. The question to be addressed is whether the cost:benefit ratio justifies the recommendation that WBC-reduced blood should be used for all colorectal surgery.

STUDY DESIGN AND METHODS

Patients admitted for elective colorectal surgery (n = 197) were randomly assigned to receive transfusion consisting of whole blood or WBC-reduced whole blood. Postoperative complications, postoperative stay, and hospital charges were compared.

RESULTS

Forty-eight patients received WBC-reduced whole blood, 56 received unfiltered whole blood, and 93 received no transfusion. Postoperative infections were significantly higher (p < 0.001) in the group that received unfiltered whole blood. That group also had longer hospital stays: 17 days as compared to stays of 10 and 11 days for the group receiving no transfusion and the group receiving filtered whole blood transfusions, respectively (p < 0.01). The total hospital cost per patient receiving unfiltered whole blood was $12,347, as compared to $7,867 for those who received WBC-reduced whole blood and $7,030 for those who received no transfusion.

CONCLUSION

The use of WBC-reduced whole blood transfusions in elective colorectal surgery significantly reduces the frequency of postoperative infection, the length of hospital stay, and the total hospital charges for patients needing blood transfusion.

A double-blind comparison of moclobemide and doxepin in depressed general practice patients

A total of 56 patients attending a general practitioner for treatment of depression, most of whom met the criteria for major depression, were included in this double-blind, parallel group, 6-week study, in which the selective MAO-A inhibitor moclobemide (MOC; maximum dose 600 mg) was compared with the tricyclic antidepressant doxepin (DOX; maximum dose 250 mg). Thirty patients on MOC and 23 on DOX were assessed after treatment for at least 1 week and are included in the response evaluation. Improvement was assessed primarily with the Montgomery-Asberg Depression Rating Scale (MADRS). There were only 4 drop-outs in the MOC group and three in the DOX group after 1 week. Overall improvement measures showed a nonsignificant difference in favor of DOX. Two factors were found to have prognostic significance: (1) previous or present panic attacks (10 patients in the MOC group and--by chance--only one in the DOX group) were associated with significantly lower improvement within the MOC group. Since we had no a priori hypothesis about this effect, it could be a chance finding. (2) Improvement was negatively correlated with age; this was statistically significant in the total group as well as in the MOC group, with a nonsignificant trend in the same direction in the DOX group. Side effects differed little between the two groups; only dryness of mouth appeared with markedly higher frequency in the DOX group.

Reflectance pulse oximetry in neonates

OBJECTIVE

To test the feasibility and reliability in neonates of an in-house reflectance pulse oximetry (RPOX) system as an alternative method of non-invasive oxygen saturation monitoring when transmission pulse oximetry (TPOX) cannot be used, as in fetal scalp oxygen saturation monitoring during delivery.

STUDY DESIGN

The study population consisted of 31 intensive care neonates. The RPOX sensor was attached by suction to the forehead, cheek, occiput and back; recordings were under simultaneous TPOX control.

RESULTS

There was close agreement between RPOX and TPOX oxygen saturation and heart rate values, even in periodic breathing. RPOX signals from the back were unreliable because of breathing artifacts. Differences in mean absolute RPOX and TPOX oxygen saturation values were due to different calibrations. Both systems were equally sensitive to motion artifacts.

CONCLUSION

As a feasible and reliable method of non-invasive oxygen saturation monitoring in neonates, RPOX has potential applications in fetal scalp monitoring.

Limitations of forehead pulse oximetry

During initial clinical tests to calibrate our reflectance pulse oximetry system, we observed serious physiologic limitations to the use of pulse oximetry in the forehead region. We present a case of simultaneous reflectance and transmission mode pulse oximetry monitoring in a child undergoing cardiac surgery for congenital cyanotic heart disease with a large intracardiac shunt. During general anesthesia, when the patient was endotracheally intubated and mechanically ventilated, the transmission mode saturation agreed well with arterial oxygen saturation measurements; but, our reflectance pulse oximeter, with the sensor applied to the forehead, displayed spuriously lower (-18%) oxygen saturations. Before and after anesthesia and surgery, there was fine agreement between reflectance and transmission mode saturation values. We suggest that the difference was caused by vasodilatation and pooling of venous blood due to compromised venous return to the heart, and a combination of arterial and venous pulsations in the forehead region. This means that the reflectance pulse oximeter measured a mixed arterial-venous oxygen saturation.

[The national patient registry. Evaluation of data quality]

The Danish National Patient Register, which includes information on all patients admitted to hospitals, has been evaluated as concerns the quality of the data included. The material examined consisted of a representative sample of 1094 patients from departments all over the country (gynaecology and obstetrics, medicine, surgery and paediatrics). Recoding of data, clinical as well as administrative, based on copies of the case records from the hospitals was carried out by two clinically working physicians (registrars). For the administrative data e.g. length of stay, satisfactory concordance was found. The validity of clinical information depended on clinical speciality and degree of diagnostic specificity. Based on the international classification the agreement on the three digit diagnostic level was better than on the five digit diagnostic level. For surgery the agreement was better than for medicine. The agreement between the diagnostic information (primary diagnosis) and the recoder in choosing primary diagnosis varied from 66-83 percent on the five digit level and between 73-89 percent on the three digit diagnostic level. If cases where the diagnosis in the registry could be regarded as an acceptable alternative were included, the agreement between the registry and recoding was 75-90%. In a subsample of the material double coding by the two coders was carried out and it was remarkable that, taken as a whole, the degree of agreement between the two coders was of the same size as between recoder and the registry. It is anticipated, however, that introduction of ICD-10 with more clear-cut rules for choice of primary diagnosis in morbidity coding will contribute to better validity and consequently improved hospital statistics.

The steroid-sparing effect of long-term plasmapheresis in pemphigus

Glucocorticoids and immunosuppressive agents can induce remission in most patients with pemphigus, but mortality remains at 5 to 15% due to complications from these drugs. We reviewed the adjunctive effect of long-term plasmapheresis in 8 patients with pemphigus. Four cases had been resistant to conventional therapy. One or two large-volume plasmapheresis treatments were given monthly for 5 to 73 months. All patients were in clinical remission within 2 months after the addition of plasmapheresis. Relapses of pemphigus seldom occurred, and the patients stayed in remission 90% (40-100%) (median and ranges) of the plasmapheresis period. In all cases the daily dose of glucocorticoid was reduced. The prednisone level could be decreased significantly from 38 (15-80) mg/day to 10 (5-35) mg/day (p = 0.008). The overall level of other immunosuppressive agents remained unchanged, except in one patient where cyclosporine was introduced. This first report of long-term plasmapheresis demonstrates clinical efficacy in pemphigus and a considerable steroid-sparing effect.

Vascular graft infections with Mycoplasma: an overlooked risk factor?

Vascular graft infection is one of the most serious complications in vascular surgery. It is associated with mortality rates ranging from 25% to 75% and with morbidity in the form of amputation in approximately 30% of patients. Staphylococcus aureus is the leading pathogen. With conventional laboratory techniques, the percentage of culture-negative yet grossly infected vascular grafts seems to be increasing and is not adequately explained by the prior use of antibiotics. We have recently reported the first case of aortic graft infection with Mycoplasma. We therefore suggest the hypothesis that the large number of culture-negative yet grossly infected vascular grafts may be due to Mycoplasma infection not detected with conventional laboratory technique.

[Endocrine effects of doping with androgenic anabolic steroids]

We describe two case histories that highlight some of the endocrine effects of doping with androgenic anabolic steroids. The main endocrine effect observed after use of androgenic anabolic steroids is the development of hypogonadotrope hypogonadism, characterized by low levels of gonadotrophins, suppression of testosterone production and azoospermia. If testosterone is used alone, or in combination with synthetic anabolic steroids, the circulating levels of testosterone are normal or high. Oestrogen levels may be elevated owing to aromatization of testosterone. The level of sex hormone binding globulin is suppressed. These endocrine parameters are of practical use in evaluating patients misusing androgenic anabolic steroids.

Growth hormone treatment of obese women for 5 wk: effect on body composition and adipose tissue LPL activity

Because it has been found that growth hormone (GH) treatment of GH-deficient adults is able to reduce the total fat mass, the present study was undertaken to investigate the effect of GH treatment in obese subjects. The investigation was a double-blind placebo-controlled crossover study in which nine obese females were treated with GH (0.03 mg.kg ideal body wt-1.day-1) and placebo for 5 wk. Body composition was determined by dual-energy X-ray absorptiometry, and the quantity of intra-abdominal adipose tissue was determined by CT scan. Lipoprotein lipase (LPL) activity was determined in fat biopsies taken from the subcutaneous abdominal and gluteal region. GH treatment significantly reduced the total fat mass from 40.5 to 38.4 kg (i.e., 5% reduction of the total fat mass; P < 0.01), whereas the fat-free mass increased from 50.5 to 53.5 kg (P < 0.01). In addition, GH treatment significantly reduced the intra-abdominal adipose tissue determined by CT scan (reduction by 7 +/- 0.3%; P < 0.02). CT scan performed at the level of the femur showed a 7% reduction in adipose tissue and a 5% increase in muscle volume in the GH group (P < 0.05). Thus no clear regional differences in the GH-mediated reduction of the adipose tissue mass were observed. GH reduced the LPL activity by approximately 50% (P < 0.01) in the adipose tissue. Finally, GH treatment significantly increased the level of plasma free fatty acids (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Psyche and soma--Descartes in our hearts?]

The essay deals with the mind-body problem. The first part describes the different views held by philosophers from Plato up to modern times, stressing the standpoint of René Descartes for medical philosophy and dualism. The author outlines the new research field of psychoneuroimmunology, and asks whether this could be one of the keys to the mind-body problem. The concept of anomaly is discussed, taking placebo and nocebo as prominent examples. Finally the author outlines modern holistic thinking based on a general systems theory, with biology as a dynamic interplay of culture, ecology, mind, and body in an open non-lineary system.

Purification and partial characterization of mammalian Cu-dependent amine oxidases

Bovine serum amine oxidase, porcine kidney diamine oxidase and human placental and pregnancy serum diamine oxidases have been purified by affinity chromatography and ion exchange chromatography. The purified enzymes were subjected to peptide mapping studies with trypsin, S. aureus V8 protease and pepsin. These studies revealed similarities between the enzymes and partial sequences from the bovine serum amine oxidase were obtained. The sequences obtained showed no homology to known sequences. Immunological studies using monoclonal antibodies to the purified enzymes revealed cross reactivity between the four enzymes. These results support the view that the Cu-dependent amine oxidases constitute a closely related group (E.C. 1.4.3.6).

[Long-term treatment with octreotide of patients with acromegaly]

We bring our experiences with and results of octreotide treatment for 0.5 to seven years in 26 highly selected acromegalic patients, i.e. they had almost all been operated upon before or were for other reasons not first-choice neurosurgical candidates. Sixteen patients responded immediately to octreotide and achieved good control of symptoms and average serum growth hormone levels below 5 micrograms/l. Five additional patients responded adequately to octreotide after a renewed neurosurgical attempt, and two other patients achieved satisfactory control after successful neurosurgery. Thus we had to resort to radiation therapy in three out of these 26 patients. We should like to emphasize the fact that acromegalic patients, who initially do not respond adequately to octreotide therapy, may often do so after a renewed partial adenomectomy. Octreotide therapy has in our hands been practically without side effects, apart from gastrointestinal symptoms during the initial days of treatment. All 26 patients had an ultrasound-scan of the gallbladder and biliary tracts before and during long-term octreotide administration, and with the exception of one patient with gallbladder sediment, in whom no pretreatment scanning had been performed, we had no development of biliary tract abnormalities in these up to 65 year old patients. This may be due to composition and timing of meal intake in relation to that of octreotide. Fecal fat excretion, D-vitamin metabolites in serum and prothrombin time were similar in octreotide-treated and untreated acromegalic patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Drug therapy of depression in general practice]

The authors advocate use of the Montgomery-Asberg Depression Rating Scale in general practice as a screening instrument for depression. A score of 20 and above for more than two weeks indicates a need for treatment with antidepressant drugs. The treatment should continue with full dosage for at least two months after the patient has been cured. In order to maintain the patient's quality of life, reduce risk of drug-related toxicity and improve compliance, we recommend alfa-2-receptor blocker, a selective 5HT-re-uptake inhibitor or a selective monoamino-oxidase A inhibitor as the first drug choice for treatment of depression by general practitioners. Monitoring serum levels of the drug may be helpful, especially in persons who do not respond to treatment.

Long-term efficacy and tolerability of octreotide treatment in acromegaly

Twenty-five acromegalic patients were studied during 6 years of treatment with octreotide, with a particular focus on the following parameters: (1) Administration schedule: in 10 patients, continuous subcutaneous (SC) octreotide infusion was compared with injections of octreotide at three dose levels (100, 250, and 1,500 micrograms/24 h) and was found to induce a greater and less-fluctuating 24-hour growth hormone (GH) suppression. (2) Carbohydrate tolerance: average 24-hour blood glucose levels were unaffected by octreotide, regardless of administration schedule. Oral carbohydrate tolerance and intravenous (IV) glucose tolerance were unaffected by continuous octreotide infusion. However, octreotide injection given shortly before the tests reduced carbohydrate tolerance. (3) Thyroid function: octreotide and somatostatin acutely reduce the response of thyroid-stimulating hormone (TSH) to thyrotropin-releasing hormone (TRH). After a few days of treatment, it was demonstrated that octreotide slightly inhibits iodothyronine deiodination and induces a transient reduction in serum triiodothyronine (T3), rapidly compensated for by a persistent slight elevation of serum TSH. (4) Fat absorption was estimated as 24-hour fecal fat content and found to be in the same high-normal range before and after octreotide treatment. Vitamin K and D absorption were unaffected by octreotide. The incidence of gallstone formation was not greater than in the general Danish population, possibly due to the schedule used for octreotide injections. (5) Foot volume was regularly estimated and found to decrease with time, on average by 12% during the first 18 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term growth hormone treatment in growth hormone deficient adults

Growth hormone treatment in GH-deficient adults has proved beneficial in recent short-term trials, but long-term results have not yet been reported. Thirteen GH-deficient adults (4 females, 9 males; mean (SEM) age 26.4 (1.7) years), who had completed 4 months of GH therapy in a double-blind placebo-controlled cross-over study were followed, for further 16.1 (0.8) months of uninterrupted GH therapy in an open design. A significant mean increase of 1.3 cm in linear height was recorded, whereas body mass index remained unchanged. Mean muscle volume of the thigh, estimated by computerised tomography, increased significantly compared with that of the initial placebo period (p = 0.01), and a slight decrease was recorded in adipose tissue volume of the thigh (p = 0.10) and subscapular skinfold thickness (p = 0.10). Still, the muscle to fat ratio of the thigh was significantly lower compared with that of normal subjects (72.6/27.4 vs 77.9/22.1) (p less than 0.01). The mean isometric strength of the quadriceps muscles increased significantly during long-term GH therapy (p less than 0.01), but remained lower compared with that of normal subjects (1.66 (0.10) vs 2.13 (0.11) Nm/kg body weight). Exercise capacity performed on a bicycle ergometer increased significantly after long-term therapy (p less than 0.05), but still did not reach the values seen in normal subjects (22.5 (3.4) vs 37.4 (4.2) watt.min.kg-1. No adverse reactions were recorded during long-term therapy and hemoglobin A1c remained unchanged. These data suggest that long-term GH replacement therapy in GH-deficient adults has beneficial effects on several physiological features which are subnormal in these patients.