Use of odds ratios on anaesthesia related studies

In line with other medical journals, odds ratios are increasingly being reported in anaesthesia literature. The frequency of the use of odds ratio and how well it relates to the relative risk when it is interpreted as relative risk remains unknown. We investigated the use of odds ratio, and its relationship to relative risk and the incidence of outcome in this study. We identified 60 meta-analyses and 87 original articles that reported odds ratios. While relative risk could have been reported in 79% of the studies, only a small proportion (3%) of these studies have estimated and reported the relative risk in addition to the odds ratio. There is a significant bias if odds ratio is interpreted as relative risk, especially so when the incidence of outcome is high. While odds ratio is a valid measure of treatment effect in its own right, anaesthetists and investigators should be careful not to interpret odds ratio as equivalent to relative risk.

Clinical predictors of acute renal replacement therapy in critically ill patients with acute renal impairment

OBJECTIVE

To investigate the early predictors of acute renal replacement therapy (RRT) in critically ill patients with acute renal impairment.

METHODS

A retrospective study of the clinical and laboratory records of all critically ill adult patients with acute renal impairment admitted to a 6-bed multidisciplinary intensive care unit of a general teaching hospital between 1 January 2000 and 31 December 2001 were reviewed to determine risk factors for RRT. Acute renal impairment was defined as an acute increase in plasma creatinine of > 0.12 mmol/L and urea of > 8 mmol/L or an increase in plasma creatinine of > 0.06 mmol/L from the baseline level in patients who had chronic renal impairment.

RESULTS

A cohort of 179 critically ill patients with acute renal impairment were identified. The mean APACHE II score was 23.4 and RRT was required in 11.2% of patients. The final logistic regression model showed that the requirement for noradrenaline (OR 29.0; 95% CI: 1.92 - 436.4, p = 0.015) was a positive risk factor and an increase in the average hourly urine output after intravenous frusemide (post-frusemide average hourly urine output/pre-frusemide average hourly urine output, OR 0.08; 95% CI: 0.02 - 0.32, p = 0.0004) was a negative risk factor for the requirement of RRT (area under the ROC curve = 0.88, 95% CI: 0.82 - 0.94, p = 0.001).

CONCLUSIONS

After adequate fluid resuscitation, poor urinary output response to intravenous frusemide coupled with requirement for noradrenaline predicted the requirement for RRT in critically ill patients with early acute renal impairment in our intensive care unit.

Prophylactic antibiotics for cystic fibrosis

BACKGROUND

Staphylococcus aureus causes pulmonary infection in young children with cystic fibrosis (CF). Prophylactic antibiotics are widely prescribed in the hope of preventing infection with Staphylococcus aureus and lung damage. Antibiotics also have adverse effects and long-term use might lead to chronic infection with organisms like Pseudomonas aeruginosa.

OBJECTIVES

To assess the effect of continuous oral antibiotic prophylaxis compared to no prophylaxis in people with CF, we tested these hypotheses. Prophylaxis: (1) improves clinical status, lung function and survival; (2) causes adverse effects (eg diarrhoea, skin rash, candidiasis); (3) leads to fewer isolates of common pathogens from respiratory secretions; (4) leads to the emergence of antibiotic resistance and the colonisation of the respiratory tract with organisms, e.g. Pseudomonas aeruginosa.

SEARCH STRATEGY

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group trials register, comprising references identified from comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Companies manufacturing anti-staphylococcal antibiotics were approached for unpublished data. Most recent search of the Group's register: March 2003.

SELECTION CRITERIA

Randomised trials of continuous oral prophylactic antibiotics (given for at least one year) compared to intermittent antibiotic therapy given "as required," in people with CF of any disease severity.

DATA COLLECTION AND ANALYSIS

The reviewers assessed trials for eligibility and methodological quality and extracted data.

MAIN RESULTS

Four studies, totalling 303 participants (139 boys) aged zero to seven years on enrollment, were included. Fewer children receiving anti-staphylococcal antibiotic prophylaxis had one or more isolates of Staphylococcus aureus. There was no significant difference between groups in infant or conventional lung function tests. We found no significant effect on nutrition, hospital admissions, additional courses of antibiotics or adverse effects. There is no significant difference in the number of isolates of Pseudomonas aeruginosa between groups, though there was a trend towards a lower cumulative isolation rate of Pseudomonas aeruginosa in the prophylaxis group, at two and three years and a trend towards a higher rate from four to six years. However, as the duration of the studies reviewed has been of six years or less, conclusions cannot be drawn about the long-term effects of prophylaxis.

REVIEWER'S CONCLUSIONS

Anti-staphylococcal antibiotic prophylaxis leads to fewer children having isolates of Staphylococcus aureus, when commenced early in infancy and continued up to six years of age. The clinical importance of this finding is uncertain. Further research may establish whether the trend towards more children with CF with Pseudomonas aeruginosa, after four to six years of prophylaxis, is a chance finding. Future work should explore whether choice of prophylactic antibiotic or duration of treatment might influence infection with Pseudomonas aeruginosa.

A case of childhood sarcoidosis

Cutaneous sarcoidosis is rare in children. We report a case of a 5-year-old Bangladeshi girl who presented with fever, a papular eruption on the lower limbs and trunk, malaise, anorexia and weight loss. There was multisystem involvement with marked hepatosplenomegaly, generalized lymphadenopathy, parotid fullness and chronic uveitis. Pulmonary infiltrates were seen on the chest X-ray. Histology of a skin biopsy showed naked noncaseating granulomata and PCR for Mycobacterium tuberculosis was negative. A clinical diagnosis of sarcoidosis was made. The patient was treated with oral prednisolone (2 mg/kg per day). An excellent clinical response with resolution of the rash and improvement of extracutaneous signs was noted within 3 months and she remains well on low-dose prednisolone on alternate days. We discuss the presentation and management of sarcoidosis in children, and highlight the potential difficulty in differentiating this from disseminated tuberculosis.

Effects of daily variation in outdoor particulates and ambient acid species in normal and asthmatic children

BACKGROUND

Evidence suggests that the respiratory health of children may be adversely affected by daily variation in outdoor pollutants, particularly ozone and particulates. However, data from the UK are sparse and the contribution of different particulate fractions and acid species, together with the identification of those individuals most at risk, are not clear.

METHODS

One hundred and sixty two 9 year old children were enrolled from two inner city locations and recorded daily symptoms and twice daily peak expiratory flow (PEF) over 8 week periods in the winter and summer. Their results were analysed with daily pollutant levels at appropriate lags using regression models which corrected for trends, weather, pollen, and autocorrelation.

RESULTS

Pollutant levels were generally low, especially in the summer. Multiple statistically significant associations were noted between health outcomes and pollutant concentrations, but no consistent patterns in identified effects were apparent between pollutants, lags, direction of observed effect, or location. There was no evidence to suggest that subgroups with atopy or pre-existing wheeze are more sensitive to pollutant effects.

CONCLUSION

These data do not suggest that adverse health outcomes are associated with daily variations in pollutants [corrected]. No evidence was found to indicate that particulates or individual acid and anion species are more closely related to adverse health outcomes than other pollutants.

A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists

The paper describes the type and frequency of adverse events and transicnt reactions following consultations with professional acupuncturists. In a postal survey, involving 1,848 professional acupuncturists, all of whom were members of the British Acupuncture Council and practising in the UK, details of adverse events and transient reactions following treatment were recorded on standardised self-report forms. A sample size of 30,000 treatments was sought, and piloting indicated that a four-week period was required. Practitioners also provided information on themselves, including age, sex, length of training and years of practice. A total of 574 practitioners responded. 31% of the total population. These practitioners reported on adverse events and transient reactions associated with 34,407 treatments. No serious adverse events were reported, where these were defined as requiring hospital admission, prolonging hospital stays, permanently disabling, or resulting in death (95% CI: 0 to 1.1 per 10,000 treatments). A total of 43 significant minor adverse events were reported, a rate of 1.3 per 1,000 treatments (95% CI: 0.9 to 1.7). These included severe nausea and actual fainting (12), unexpected, severe and prolonged aggravation of symptoms (7), prolonged and unacceptable pain and bruising (5) and psychological and emotional reactions (4). There were three avoidable events: two patients had needles left in by mistake, and one patient had moxa burns to the skin, also caused by practitioner error. The acupuncturists also recorded 10,920 mild transient reactions occurring in 5136 treatments. 15% (95% CI: 14.6 to 15.3) of the 34,407 total. In terms of local reactions, there were reports of mild bruising (1.7%), pain (1.2%) and bleeding (0.4%). Practitioners reported that patients experienced an aggravation of existing symptoms after 2.8% of treatments. The most common mild transient reactions to treatment were feeling relaxed (11.9%) and feeling energised (6.6%). In this prospective survey of 34,407 treatments, practitioners reported no serious adverse events. This conclusion was based on data collected from one in three members of the British Acupuncture Council. Given that the whole membership delivers between one and a half and two million treatments a year, this is important evidence on public health and safety. When compared with medication routinely prescribed in primary care, the results suggest that acupuncture is a relatively safe treatment modality.

[Modeling long-term results of basiliximab (SIMULECT) use in patients after kidney transplantation in Great Britain]

Kidney graft survival prognosis could be performed in relation to the number of acute rejection episodes and their severity. The episodes of rejection could be modelled and based and the results obtained on this way could serve for prediction of a length of graft survival as well as for basiliximab treatment planning.

Particulate matter and daily mortality and hospital admissions in the west midlands conurbation of the United Kingdom: associations with fine and coarse particles, black smoke and sulphate

OBJECTIVES

There is considerable evidence linking ambient particles measured as particulate matter with aerodynamic diameter <10 microm (PM(10)) to daily mortality and hospital admissions but it is not clear which physical or chemical components of the particle mixture are responsible. The relative effects of fine particles (PM(2.5)), coarse particles (PM(2.5-10)), black smoke (mainly fine particles of primary origin) and sulphate (mainly fine particles of secondary origin) were investigated, together with ozone, SO(2), NO(2), and CO, on daily mortality and hospital admissions in the west Midlands conurbation of the United Kingdom.

METHODS

Time series of health outcome and environmental data were obtained for the period 1994-6. The relative risk of death or hospital admission was estimated with regression techniques, controlling for long term time trends, seasonal patterns, influenza epidemics, effects of day of the week, and temperature and humidity. Models were adjusted for any remaining residual serial correlation and overdispersion. The sensitivities of the estimates for the effects of pollution to the inclusion of a second pollutant and seasonal interactions (warm or cool) were also examined.

RESULTS

Daily all cause mortality was not associated with any gaseous or particulate air pollutant in the all year analysis, although all measures of particles apart from PM(2.5-10) showed significant positive effects of the warm season. Neither respiratory nor cardiovascular admissions (all ages) were associated with any air pollutant, and there were no important seasonal interactions. However, analysis of admissions by age found evidence for various associations-notably between PM(10), PM(2.5), black smoke, SO(2,) and ozone (negative) and respiratory admissions in the 0-14 age group. The coarse fraction, PM(2.5-10) differed from PM(2.5) in having smaller and less consistent associations (including several large significant negative associations) and a different lag distribution. The results for black smoke, an indicator of fine primary carbonaceous particles, were very similar to those for PM(2.5), and tended to be more robust in two pollutant models. The effects of sulphate, an indicator of secondary particles, also showed some similarities to those of PM(2.5).

CONCLUSIONS

Clear effects of air pollution on mortality and hospital admissions were difficult to discern except in certain age or diagnostic subgroups and seasonal analyses. It was also difficult to distinguish between different measures of particles. Within these limitations the results suggest that the active component of PM(10) resides mostly in the fine fraction and that this is due mainly to primary particles from combustion (mainly vehicle) sources with a contribution from secondary particles. Effects of the coarse fraction cannot be excluded.

The implications of contact with the mentor for preregistration nursing and midwifery students

AIM OF THE PAPER

To examine the extent to which preregistration nursing and midwifery students have contact with their named mentor, and the implications of this.

BACKGROUND/RATIONALE

Mentorship has an important part to play in enabling preregistration nursing and midwifery students to gain the maximum benefit from clinical placements. Previous research has indicated that the benefits of mentorship to learners are related to the number of occasions on which the student and mentor work together.

DESIGN/METHODS

A research project commissioned by the Sheffield and North Trent College of Nursing and Midwifery (now the University of Sheffield School of Nursing and Midwifery) provided an opportunity to examine the extent to which their named mentors were available to Project 2000 students, and the implications of this. Students and their named mentors were asked to keep an activity diary for 1 week. The main objective was to collect activity data to inform an analysis of the costs and benefits of clinical placements to service providers. This cost-benefit study has been published elsewhere. However, the data also cast light on the extent to which mentors were available to students, and the implications of this, and it is these findings which are presented here.

RESULTS/FINDINGS

Students frequently worked shifts without their named mentors even though unrostered students often worked weekends, evening and night shifts in order to maximize time spent with their mentors. In the mentor's absence, other members of staff covered for some of their activities (in particular, direct and indirect supervision of students). However, students whose named mentors were absent spent significantly less time than other students working with a qualified member of staff as a partner in giving care.

CONCLUSIONS

It is suggested that the extent to which named mentors are unavailable to Project 2000 students may be detrimental to the education and professional development of those students.

Sex differences in weight perception and nutritional behaviour in adults with cystic fibrosis

INTRODUCTION

Good nutritional status in cystic fibrosis (CF) is associated with improved clinical status and survival. In some conditions where dietary and pharmacological treatment are important (e.g. diabetes), a combination of eating disorders and failure of treatment compliance has been reported. Cases of eating disorders have been reported in CF. Societal pressures on young women to remain slim may compromise optimum clinical management as women are content to remain underweight.

OBJECTIVE

To determine whether women have different perception of their weight than men with CF and whether this manifests in different nutritional behaviour.

METHODS

Confidential postal questionnaire to 1870 adults with CF in 1994 known to the Association of Cystic Fibrosis Adults (UK). Participants were asked their own weight and height, and their perception of their weight. Very underweight was defined as < 85% ideal body weight, underweight as 85-94%, normal weight as 95-104%, overweight as 105-114% and very overweight as 115% and over.

RESULTS

A significantly higher proportion of women than men who are very underweight (29% vs. 11%) or underweight (41% vs. 15%) saw themselves as being of normal weight or overweight. Conversely, a significantly higher proportion of men than women who were normal weight (42% vs. 19%) saw themselves as underweight. All P-values < 0.01. A significantly higher proportion of people who perceived themselves to be underweight were taking oral or enteral food supplements compared with those who did not (77% vs. 30%, P < 0.05). Multiple logistic regression showed that perception of self as underweight was the strongest predictor of taking oral or enteral food supplements (adjusted odds ratio 2.42), even after adjustment for age, sex, overall severity score, body mass index, and seeing a dietitian in the last year.

CONCLUSION

Young women with CF tend to overestimate their weight, and young men with CF underestimate their weight when compared with their actual body weight. Perception of self as underweight is reflected in nutritional behaviour, being a significantpredictor of taking oral and enteral food supplements. People working with young patients with CF should be aware of these sex differences in weight perception, and work with young women and young men with CF to achieve a realistic perception of body weight and realistic nutritional goals. There is a need for further research into body image, weight perception, eating behaviour and adherence to pancreatic enzyme supplementation and oral and enteral food supplementation in young patients with CF.

The cycle of homelessness in the lives of young mothers: the diagnostic phase of an action research project

This paper presents the findings of the first stage of an action research project designed to explore the experience of repeated homelessness in the lives of young women. An action research strategy was selected because it offered a framework within which to work with and for rather than on this vulnerable group of service users. The women participating in the research developed a conceptual model that captured the essence of their experience, which they named 'Our Cycle'. They also proposed a system for service delivery, 'From trauma to recovery: a non-professional model'. The diagnostic phase of the action research has thus resulted in a sound theoretical and practical framework to guide the implementation and evaluation stages of the project, currently being funded through the United Kingdom Department of Health's Health Action Zone initiative.

CD8+ T cells are capable of rejecting pancreatic islet xenografts

BACKGROUND

In this study, the capacity of CD8+ T cells to act as a potential effector mechanism in pancreatic xenograft rejection was examined.

METHODS

The fate of pancreatic islet xenografts was studied in mice deficient in MHC class II molecules and CD4+ T cells. Fetal pig pancreas (FPP) or Wistar rat islets (RI) were transplanted into nondiabetic or streptozotocin-induced diabetic I-A knock-out (CII K/O) mice.

RESULTS

CII K/O mice were capable of rejecting both RI and FPP grafts. RI graft survival was not prolonged compared with wild type C57BL/6 controls. However, FPP grafts did survive longer in CII K/O recipients than in C57BL/J6 mice. Both RI and FPP graft rejection were CD8+ T-cell phenomena in CII K/O mice, as anti-CD8 monoclonal antibody prolonged graft survival, there were increased CD8+ T cells in the grafts and spleens of CII K/O recipients, and cell-mediated cytotoxicity was a CD8+ T-cell phenomenon associated with activation of the perforin/granzyme B system. By contrast, RI and FPP graft rejection was a CD4+ T cell-dependent phenomenon in wild type C57BL/6 mice with graft survival prolonged by anti-CD4 monoclonal antibody. There were increased numbers of CD4+ T cells, and cell-mediated cytotoxicity was a CD4+ T-cell phenomenon associated with activation of the Fas/FasL lytic pathway.

CONCLUSIONS

The results demonstrate that, in the absence of CD4+ T cells, CD8+ T cells were capable of rejecting both rat and pig pancreatic islet xenografts.

Costs and benefits of community postnatal support workers: a randomised controlled trial

OBJECTIVES

This study aimed to measure the effect and the total cost per woman of providing postnatal support at home, based on a Dutch model. The research hypothesis was furnished by some existing evidence that postnatal support could reduce the risk of postnatal depression and encourage breastfeeding.

DESIGN

The randomised controlled trial aimed to measure differences in health status in a group of women who were offered postnatal support from a community midwifery support worker (SW) compared with a control group of women who were not offered this support. Women were followed-up by postal questionnaire at 6 weeks and 6 months postnatally.

SETTING AND SUBJECTS

All women who delivered a baby at the recruiting hospital were eligible to take part in the trial if they lived within the study area, were aged 17 years or over, and could understand English.

INTERVENTION

The intervention consisted of the SW offering practical and emotional support and to help women rest and recover after childbirth. The SW offered ten visits in the first 28 days postnatally, for up to 3 hours per day. The SW's activities included housework, talking with the mother, and care for the baby or other siblings. The service was provided in addition to routine visits by the community midwife.

MAIN OUTCOME MEASURES

The primary outcome was the general health perception domain of the Short Form-36 at 6 weeks. Secondary outcomes were mean Edinburgh Postnatal Depression Scale (EPDS), Duke Functional Social Support (DUFSS) scores and breastfeeding rates.

RESULTS

The 623 randomised women were well-matched by group with a good response to follow-up. At 6 weeks there was no evidence of a significant difference between the two groups for the primary outcome. There was a non-significant trend for the control group to have better mean DUFSS and EPDS scores at 6 weeks. Breastfeeding rates were not significantly different at follow-up. At 6 months, both groups had similar health status. Satisfaction with the service was higher than for all other services received. The incremental cost of introducing the service comprised setting up and running the service. There were no differences between the groups in other resource use (general practitioner contacts, hospital services, prescriptions or medicines bought for mothers and babies) to 6-month follow-up. The total mean NHS cost to 6-month follow-up for the intervention group was pound180 per woman greater than for the control group (confidence interval, pound79.60, pound272.40).

CONCLUSIONS

Although women valued the service, there was no evidence of any health benefit at the 6-week or 6-month follow-up, no difference in use of NHS services, and the additional cost of the service provision would be around pound 180 per woman.

Costs and effectiveness of community postnatal support workers: randomised controlled trial

OBJECTIVES

To establish the relative cost effectiveness of postnatal support in the community in addition to the usual care provided by community midwives.

DESIGN

Randomised controlled trial with six month follow up.

SETTING

Recruitment in a university teaching hospital and care provided in women's homes.

PARTICIPANTS

623 postnatal women allocated at random to intervention (311) or control (312) group.

INTERVENTION

Up to 10 home visits in the first postnatal month of up to three hours duration by a community postnatal support worker.

MAIN OUTCOME MEASURE

General health status as measured by the SF-36 and risk of postnatal depression. Breast feeding rates, satisfaction with care, use of services, and personal costs.

RESULTS

At six weeks there was no significant improvement in health status among the women in the intervention group. At six weeks the mean total NHS costs were pound 635 for the intervention group and pound 456 for the control group (P=0.001). At six months figures were pound 815 and pound 639 (P=0.001). There were no differences between the groups in use of social services or personal costs. The women in the intervention group were very satisfied with the support worker visits.

CONCLUSIONS

There was no health benefit of additional home visits by community postnatal support workers compared with traditional community midwifery visiting as measured by the SF-36. There were no savings to the NHS over six months after the introduction of the community postnatal support worker service.

High-dose growth hormone does not affect proinflammatory cytokine (tumor necrosis factor-alpha, interleukin-6, and interferon-gamma) release from activated peripheral blood mononuclear cells or after minimal to moderate surgical stress

High-dose GH therapy, with GH doses 10-20 times the normal replacement dose for GH-deficient adults, has been used as an anti-catabolic agent in a number of different patient groups. A recent study, however, has shown an increase in mortality in critically ill patients treated with high-dose GH. The increased mortality was associated with multiorgan failure, septic shock, and uncontrolled infection, suggesting that GH may have altered the immune response. The GH receptor and GH are both expressed in peripheral blood mononuclear cells (PBMCs); thus, GH could act as either an endocrine or an autocrine modulator of the immune response. We have examined the hypothesis that high-dose GH therapy may induce proinflammatory cytokines, which are implicated in septic shock. To do this we measured cytokine production by PBMCs incubated in conditions that simulated high-dose GH therapy, and we measured cytokine levels in patients undergoing laparoscopic cholecystectomy who were randomized to receive either high-dose GH therapy (13 IU/m2 x day) or placebo. To confirm the biological activity of GH in our cell culture system we used a Stat5 functional assay. In this assay GH induced a bell-shaped curve, with a maximal response at GH levels between 100-1,000 ng/mL. PBMCs from healthy volunteers were incubated with GH in doses from 1-1,000 ng/mL for 6-72 h under resting conditions and after activation with endotoxin and the mixed lymphocyte reaction. Studies were repeated with PBMCs from six individuals using a GH dose of 100 ng/mL (the level of GH found after high-dose GH therapy) and an endotoxin dose that gave a submaximal response (0.01 ng/mL). GH had no effect on cell proliferation or the production of tumor necrosis factor-alpha (TNFalpha), interleukin-6 (IL-6), or interferon-gamma (IFNgamma). In patients undergoing laparoscopic cholecystectomy there was a time-related effect of surgery on cytokine levels. There was a rise in IL-6 and a fall in TNFalpha at 24 h after surgery; however, high-dose GH therapy had no effect on the cytokine response. We considered the possibility that endogenous GH production by PBMCs could influence the cytokine response in activated PBMCs; however, incubation of PBMCs in the presence of the GH receptor antagonist, B2036, had no effect on TNFalpha, IL-6, or IFNgamma production by PBMCs in either the mixed lymphocyte reaction or when activated by endotoxin. These results suggest that high-dose GH therapy does not alter the proinflammatory cytokine response to surgery or endotoxin. The results do not exclude an effect of GH on the immune response, but they suggest that the mortality seen in critically ill patients may be due to factors other than immune modulation.

General practitioners' perceptions of store-and-forward teledermatology

We studied the views of 26 general practitioners (GPs) towards store-and-forward tele-dermatology before its introduction into their practices. A postal questionnaire was developed using Likert-type questions with respondents able to explain their answers in free text. Questions related to the GPs' knowledge, perceptions and expectations of tele-dermatology, as well as their attitudes towards being part of a research trial. Most of the GPs had limited prior knowledge of tele-dermatology. They perceived its role to relate to quicker access to specialist opinions, decreased referrals, increased convenience for patients, diagnosis, and education and teaching. There was an overwhelming view that any system needed to be quick, easy to use, efficient and reliable. Concerns were expressed about being part of the clinical trial, using new technology and an increased workload. The future of tele-dermatology was thought to depend on the clinical adequacy of the system.