The impact of continuous haemofiltration with high-volume fluid exchange during cardiopulmonary bypass surgery on the recovery of patients with impaired renal function: a pilot randomised trial

BACKGROUND

There is widespread variability in clinical practice within cardiac surgery units worldwide on the use of haemofiltration. The clinical impact and safety of this modality is, however, unknown.

OBJECTIVES

The primary pilot trial objectives were as follows: to assess the feasibility of randomising 60 patients with impaired kidney function undergoing on-pump coronary artery bypass graft (CABG) surgery within 6 months; to assess the suitability and reliability of our chosen outcome measures; to explore issues that may impact on recruitment into a definitive trial; and to undertake an exploratory economic evaluation.

DESIGN

A pilot, single-centre, open-label randomised trial.

SETTING

Liverpool Heart and Chest Hospital NHS Foundation Trust between November 2010 and March 2012.

PARTICIPANTS

Men and women, aged > 18 years of age, undergoing on-pump CABG surgery, who had pre-operative impaired kidney function indicated by an estimated glomerular filtration rate (eGFR) of < 60 ml/minute adjusted for 1.73 m(2) of body surface area.

INTERVENTIONS

Group 1: patients who received haemofiltration during bypass (experimental group). Group 2: patients who did not receive haemofiltration during bypass (control group).

MAIN OUTCOME MEASURES

(1) Feasibility outcome measures: barriers to recruitment to a larger trial were documented as observations made during the recruitment period of the trial. Reliability of data collection methods was monitored using a 13-point case record form validation check for data entry against the patient clinical notes and the trial database. (2) The main clinical outcomes were frequency of intensive care unit (ICU) stay of duration > 3 days and the length of ICU stay days. (3) Other clinical outcomes were the need for postoperative haemofiltration in the ICU, mechanical ventilation time, hospital stay, composite of outcome of unfavourable perioperative events and eGFR values at 6 weeks' follow-up. (4) Secondary health economic feasibility outcomes.

RESULTS

Recruitment into the pilot trial was from 21 November 2010 to 30 March 2012. Thirty-seven eligible patients were consented and successfully randomised into the trial arms (30%). The main issues impacting on recruitment were the high volume of off-pump CABG surgery within the centre; recruitment being restricted to research nurses' working hours of the week; issues arising associated with the screening process for identifying prospective eligible patients based on eGFR values; protocol deviations/treatment crossovers; and unexpected outbreaks of pandemic influenza and other infectious conditions. The data collection process was sufficiently robust, with few errors detected. The length of ICU stay days was deemed a suitable primary outcome. There was an overall trend towards reduction in the length of ICU stay for patients who were given intraoperative haemofiltration, more so for those with diabetes. The economic evaluation estimated that the incremental costs per person were £1744 lower for the intraoperative haemofiltration group, while the incremental benefits per person increased by 0.11.

CONCLUSION

Given sufficient resources and broadening of the inclusion criteria, the recruitment into a larger multicentre trial is feasible and may demonstrate potential clinical and cost benefits of using intraoperative haemofiltration in this group of patients. However, owing to the small sample size in this pilot trial, no firm conclusions can be drawn from the findings at this stage. The outcomes of this pilot study are very encouraging and suggest that it is feasible to design a continuous superiority trial with the length of ICU stay days or time to tracheal extubation as the primary outcome measure, provided that guidelines for avoiding bias are implemented. An alternative primary outcome measure that avoids bias is mortality. The inclusion criteria should also be widened to include all cardiac surgery patients with impaired renal function.

TRIAL REGISTRATION

ISRCTN49513454.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 17, No. 49. See the HTA programme website for further project information.

The impact on utilities of differences in body weight among Canadian patients with type 2 diabetes

OBJECTIVE

The objective of this study was to estimate utility values for hypothetical health states that describe differences in weight and quality of life associated with type 2 diabetes mellitus (DM) from Canadians with type 2 DM. The impact on utility values was examined separately for participants with a body mass index (BMI) of 18 to less than 25 kg/m(2) ('healthy'), 25 to less than 30 ('overweight'), and 30 or more ('obese').

METHODS

The health state descriptions were modified from a published diabetes utility study. Health states included a base-case type 2 DM health state (at participants' current weight), and six health states where the weight and attendant quality of life impact varied (base case ±3%, ±5%, and ±7% weight). Utilities were elicited using the time trade-off technique. Linear regression modeling was used to estimate the utility increment or decrement associated with a one unit difference in BMI.

RESULTS

Among 96 participants, the mean age was 55 years and 51% were men. The mean BMI was 32 kg/m(2) and 84% wanted to lose weight. The mean (SD) utility for the base-case state was 0.911 (0.013). Mean utilities (utility decrements) were 0.907 (-0.004), 0.865 (-0.046) and 0.806 (-0.105) for the health states describing an increased weight of 3%, 5% and 7%, respectively; and 0.923 (+0.012), 0.940 (+0.029) and 0.949 (+0.038) for the health states describing a decreased weight of 3%, 5% and 7%, respectively. For every increase of 1 kg/m(2) BMI there was an associated decrease in utility of 0.0472 (95% CI: 0.0375, 0.0569) and for every decrease of 1 kg/m(2) BMI there was an associated increase in utility of 0.0171 (95% CI: 0.0103, 0.0238).

CONCLUSIONS

The preferences of Canadian patients with type 2 DM for diabetes-related health states varied according to the weight, and quality of life impact, associated with that health state. Increased weight had a greater effect on utilities than decreased weight.

Predicting preterm birth in women with previous preterm birth and cervical length ≥ 25 mm

OBJECTIVE

To identify risk factors predicting subsequent spontaneous preterm birth or preterm prelabor rupture of membranes (PPROM) in a cohort of women with a history of spontaneous preterm birth and a cervical length of ≥ 25 mm at 20-24 weeks' gestation.

METHODS

We identified all pregnant women who attended our preterm labor clinic between January 2010 and December 2012 because of previous spontaneous preterm birth or PPROM before 34 weeks. Women with a normal cervical length (defined as ≥ 25 mm) between 20 and 24 weeks' gestation were identified and included in the analysis. Maternal characteristics, obstetric history, shortest cervical length and gestational age at shortest cervical length of women who delivered preterm (before 37 weeks) were compared with those who delivered at or after 37 weeks in the index pregnancy. Multiple regression analysis was planned to examine the relationship between significant clinical and cervical-length variables to identify significant clinical predictors of spontaneous preterm birth among high-risk patients with a normal cervix between 20 and 24 weeks' gestation.

RESULTS

Of 134 women with a normal cervix at 20-24 weeks, 28 (20.9%) delivered spontaneously or had PPROM before 37 weeks; of these 12 (9.0%) delivered before 34 weeks. None of the selected explanatory variables was predictive of recurrent preterm birth in this cohort. No correlation between absolute cervical length and gestational age at delivery was found (R = 0.01).

CONCLUSION

In high-risk women with a cervical length of ≥ 25 mm at 20-24 weeks' gestation, demographic characteristics and absolute cervical length are not useful in predicting subsequent spontaneous preterm birth.

A semi-automated method for purification of milligram quantities of proteins on the QIAcube

A growing number of studies require the purification of multiple proteins simultaneously and the development of simple economical high-throughput purification methods is essential. We have tested the purification of two related proteins in a variety of conditions to benchmark the semi-automated affinity chromatography method for the QIAcube that we have developed. We find that this new QIAcube method can successfully purify milligram quantities of proteins with minimal user involvement and performs as well as methods based on gravity. The method could easily be adapted to other chromatography resins and should prove to be a versatile method for optimizing protein expression or purification conditions for multiple proteins while obtaining sufficient amounts for subsequent biochemical analyses.

Arabic version of the Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC): a validity and feasibility study

Mental health services are far from satisfactory in the Eastern Mediterranean Region. The Global Mental Health Assessment Tool-Primary Care version (GMHAT/PC) is a semi-structured, computerized clinical assessment tool that was developed to assist health workers in making quick, convenient and comprehensive standardized mental health assessments. A study was carried out in the United Arab Emirates to evaluate the validity and feasibility of the Arabic version of the GMHAT/PC. Mental health nurses administered the GMHAT/PC Arabic version to 50 patients in mental health and rehabilitation settings and their GMHAT/PC diagnosis was compared with the psychiatrist's independent ICD-10 based clinical diagnosis on the same patients. The nurses found GMHAT/PC easy to administer in an average of 16 minutes. The GMHAT/PC-based diagnosis had a good agreement with the psychiatrist's diagnosis (kappa = 0.91) and a high sensitivity (97%) and specificity (94%).

Einfluss ungleichmäßiger Eigenspannungen in Wälzlagerringen vor dem Härten auf Formabweichungen nach dem Härten∗

Der vorliegende Beitrag beschreibt, welchen Einfluss ungleichmäßige Eigenspannungen in Wälzlagerringen vor dem Härten auf die Unrundheit bzw. Ovalität von Ringen (Werkstoff 100Cr6) nach dem Härten haben können. Insbesondere werden die Auswirkungen unterschiedlicher Herstellverfahren auf die Ausbildung von Eigenspannungen erläutert. Daneben wird ein Verfahren angegeben, wie sich der Einfluss der Herstellstufen, einschließlich des Härtens, unterscheiden lässt.

A pilot randomised controlled trial in intensive care patients comparing 7 days' treatment with empirical antibiotics with 2 days' treatment for hospital-acquired infection of unknown origin

BACKGROUND

Management of cardiac intensive care unit (ICU) sepsis is complicated by the high incidence of systemic inflammatory response syndrome, which mimics sepsis but without an infective cause. This pilot randomised trial investigated whether or not, in the ICU, 48 hours of broad-spectrum antibiotic treatment was adequate to safely treat suspected sepsis of unknown and unproven origin and also the predictive power of newer biomarkers of sepsis.

OBJECTIVE

The main objective of this pilot study was to provide preliminary data on the likely safety and efficacy of a reduced course of antibiotics for the treatment of ICU infections of unknown origin.

DESIGN

A pilot, single-centre, open-label randomised trial.

SETTING

This study was carried out in the ICU of a tertiary heart and chest hospital.

PARTICIPANTS

Patients being treated within the ICU were recruited into the trial if the intensivist was planning to commence antibiotics because of evidence of systemic inflammatory response syndrome and a strong suspicion of infection but there was no actual known source for that infection.

INTERVENTIONS

Broad-spectrum antibiotic treatment administered for 48 hours (experimental) compared with treatment for 7 days (control).

MAIN OUTCOME MEASURES

The primary outcome was a composite outcome of the rate of death or initiation of antibiotic therapy after the completion of the treatment schedule allocated at randomisation. Secondary outcomes included the duration of mechanical ventilation and ICU and hospital stay; the incidence of infection with Clostridium difficile (B. S. Weeks & E. Alcamo) Jones & Bartlett International Publishers, 2008, or methicillin-resistant Staphylococcus aureus (MRSA) (B. S. Weeks & E. Alcamo) Jones & Bartlett International Publishers, 2008; resource utilisation and costs associated with each of the two pilot arms; the ratio of patients screened to patients eligible to patients randomised; the incidence of crossover between groups; and the significance of newer biomarkers for sepsis for predicting patients' need for further antibiotics.

RESULTS

A total of 46 patients were recruited into the trial, with 23 randomised to each group. There was no significant difference between the two groups in terms of the composite primary outcome measure. The risk difference was 0.12 [95% confidence interval (CI) 0.11 to 0.13; p = 0.3]. In the 2-day group, four patients (17.4%) required further antibiotics compared with three (13%) in the 7-day group. Four patients died within the trial period and the deaths were not trial related. Patients who died during the trial period received no additional antibiotics in excess of their trial allocation. There were no documented incidences of MRSA or C. difficile infection in either group. No significant differences in adverse events were observed between the groups. Key economic findings were mean antibiotic costs per patient of £168.97 for the 2-day group and £375.86 for the 7-day group. The potential per annum cost saving for the ICU of 2-day treatment was estimated to range from £108,140 to £126,060. Patient screening was considered the biggest barrier to recruitment. There was no crossover between the two randomised groups. Data verification ascertained > 98% accuracy in data collection. Baseline procalcitonin was found to be predictive of the composite outcome (death and needing further antibiotics) (odds ratio 1.79, 95% CI 1.20 to 2.67; p = 0.005). Analysis of baseline procalcitonin also indicated a trend towards it being a predictor of restarting antibiotics, with an odds ratio of 1.45 (95% CI 1.04 to 2.02; p = 0.01).

CONCLUSIONS

Data from this pilot study suggest that there could be significant benefits of reducing broad-spectrum antibiotic use in the ICU without it undermining patient safety, with a potential cost saving in our unit of over £100,000 per year. Evidence from this pilot trial is not definitive but warrants further investigation using a large randomised controlled trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN82694288.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 36. See the HTA programme website for further project information.

The association between maternal serious psychological distress and child obesity at 3 years: a cross-sectional analysis of the UK Millennium Cohort Data

BACKGROUND

  The prevalence of child obesity is increasing rapidly worldwide. Early childhood has been identified as a critical time period for the development of obesity. Maternal mental health and early life environment are crucial factors and have been linked to adverse child outcomes. The objective of the study was to examine the relationship between maternal serious psychological distress and obesity in early childhood.

METHODS

  A cross-sectional analysis of data from the Millennium Cohort Study was conducted. Subjects consisted of all natural mothers (n= 10 465) who had complete and plausible data for Kessler-6 scores, socio-demographic and anthropometric variables, and their children for whom anthropometric measurements were completed at age 3. Maternal serious psychological distress was defined as a score of 13 or more on the Kessler-6 scale. Obesity was defined as body mass index ≥95th centile of the 1990 reference chart for age and sex in children. The data were analysed using spss 16. Maternal socio-demographic factors that are known to influence maternal mental health and child obesity were identified and adjusted using multivariate logistic regression.

RESULTS

  Of the 10 465 mother-child dyads, 3.5% of mothers had serious psychological distress and 5.5% of children were obese at 3 years of age. Logistic regression analysis showed that maternal serious psychological distress was associated with early childhood obesity (P= 0.01; OR 1.62, 95% CI 1.11, 2.37). After adjusting for potential confounding factors using multivariate logistic regression, maternal serious psychological distress remained significantly associated with early childhood obesity (P= 0.01; OR 1.59, 95% CI 1.08, 2.34).

CONCLUSIONS

  The results show that maternal serious psychological distress is independently associated with early childhood obesity.

What is the evidence for radical surgery in the management of localized embryonal bladder/prostate rhabdomyosarcoma?

As survival outcomes for bladder/prostate rhabdomyosarcoma have improved over the last 40 years, the emphasis has shifted to minimizing treatment related morbidity. We undertook a critical review of the current literature to examine the role of radical pelvic surgery to achieve local control. We illustrate that there appears to be no difference in overall survival or event free survival when comparing differing modalities utilized in local disease control, microscopic disease clearance does not correlate with improved outcomes, and the morbidity associated with radical surgery for BP RMS is significantly greater than for a conservative method of local control.

SMART phones and the acute respiratory patient

Definition of Respiratory Failure using PaO2 alone is confounded when patients are commenced on oxygen therapy prior to arterial blood gas (ABG) measurement. Furthermore, classification of Respiratory Failure as Type 1 or Type 2 using PaCO2 alone can give an inaccurate account of events as both types can co-exist. 100 consecutive presentations of acute respiratory distress were assessed initially using PaO2, and subsequently PaO2/FiO2 ratio, to diagnose Respiratory Failure. Respiratory Failure cases were classified as Type 1 or Type 2 initially using PaCO2, and subsequently alveolar-arterial (A-a) gradient. Any resultant change in management was documented. Of 100 presentations, an additional 16 cases were diagnosed as Respiratory Failure using PaO2/FiO2 ratio in place of PaO2 alone (p = 0.0338). Of 57 cases of Respiratory Failure, 22 cases classified as Type 2 using PaCO2 alone were reclassified as Type 1 using A-a gradient (p < 0.001). Of these 22 cases, management changed in 18.

A genome-wide association study identifies susceptibility loci for Wilms tumor

Wilms tumor is the most common renal malignancy of childhood. To identify common variants that confer susceptibility to Wilms tumor, we conducted a genome-wide association study in 757 individuals with Wilms tumor (cases) and 1,879 controls. We evaluated ten SNPs in regions significantly associated at P < 5 × 10(-5) in two independent replication series from the UK (769 cases and 2,814 controls) and the United States (719 cases and 1,037 controls). We identified clear significant associations at 2p24 (rs3755132, P = 1.03 × 10(-14); rs807624, P = 1.32 × 10(-14)) and 11q14 (rs790356, P = 4.25 × 10(-15)). Both regions contain genes that are plausibly related to Wilms tumorigenesis. We also identified candidate association signals at 5q14, 22q12 and Xp22.

The use of computerised tomography guided percutaneous fine needle aspiration in the evaluation of solitary pulmonary nodules

The evaluation of a solitary pulmonary nodule (SPN) has changed over the years with increased access to percutaneous computerised tomography (CT) guided fine needle aspiration (FNA), where bronchoscopy is unhelpful. The aim of our study was to evaluate the sample adequacy, diagnostic and complication rate of CT-FNA of a SPN at our academic teaching hospital over an 18 month period. CT-FNA was performed by a radiologist, with a cytopathologist in attendance to confirm the adequacy of the sample obtained. The size of the nodule, sample material and adequacy, diagnosis and complications were recorded. A total of 101 patients were included, 54 male and the mean age was 68 +/- 11 years. The mean size of the SPN was 2.3 cm (range 1-11 cm). 56 (56%) patients had a right SPN, 45 (45%) had a left SPN. CT-FNA was diagnostic in 80 (80%) patients and non-diagnostic in 21 (20%) patients. The sample was insufficient for immunocytochemistry, although the morphological appearance was diagnostic in 20 (25%) of the 80 patients. Pneumothorax occurred in 26/101 (26%) patients post CT-FNA, of these 7 (27%) required chest drain insertion, while 19 (73%) were managed conservatively. CT FNA is a useful tool for the diagnosis of a SPN, with our diagnostic accuracy comparable to that reported in the literature. However, CT-FNA may not provide adequate sample volume to perform ancillary testing and has a moderate complication rate.