Randomized controlled trial and cost-effectiveness analysis of silver-donating antimicrobial dressings for venous leg ulcers (VULCAN trial)

BACKGROUND

Antimicrobial silver dressings are used beneath graduated compression in the treatment of venous ulceration. There is little information on whether their use is effective. This was a prospective randomized trial and cost-effectiveness analysis of silver-donating versus non-silver low-adherence dressings in the treatment of venous leg ulcers.

METHODS

Patients were randomized between the two types of dressing. The primary outcome measure was complete ulcer healing at 12 weeks. Secondary outcomes included time to healing, quality of life and cost-effectiveness.

RESULTS

A total of 213 patients were recruited. There was no difference between the dressings in the proportion of ulcers healed at 12 weeks (59.6 per cent for silver and 56.7 per cent for control dressings). Mean utility scores for the EuroQol 5D and Short Form 6D were similar in both groups at 1, 3, 6 and 12 months. Compared with the control group the antimicrobial group had an incremental cost of pounds sterling 97.85 and an incremental quality-adjusted life year gain of 0.0002, giving an incremental cost-effectiveness ratio of pounds sterling 489 250 for the antimicrobial dressings.

CONCLUSION

No significant differences were found in either primary or secondary endpoints. There was no evidence to support the routine use of silver-donating dressings beneath compression for venous ulceration.

REGISTRATION NUMBER

ISRCTN 72485131 (http://www.controlled-trials.com).

Midgut neuroendocrine tumours with liver metastases: results of the UKINETS study

We intended to identify the prognostic factors and the results of interventions on patients with liver metastatic midgut carcinoids. Five institutions that are part of United Kingdom and Ireland neuroendocrine tumour (NET) group took part in this study. Patients were included if they had histology proven NET of midgut origin and liver metastases at the time of the study. Clinical and biochemical data were collected retrospectively from hospital charts, pathology reports, radiology reports and biochemistry records for each patient. Three hundred and sixty patients were included in the study. The median survival from date of diagnosis was 7.69 years (confidence interval (CI) 6.40-8.99) and 5.95 years (CI 5.02-6.88) from date of diagnosis of liver metastases. On univariate analysis, increasing age at diagnosis, increasing urinary hydroxyindole acetic acid levels, increasing plasma chromogranin A levels, high Ki67, high tumour volume and treatment with chemotherapy were identified as factors associated with a significantly poorer outcome. Resection of liver metastases, resection of small bowel primary, treatment with somatostatin analogue therapy and treatment with peptide receptor therapy were associated with improved prognosis. Multivariate analysis revealed that age at diagnosis (P=0.014), Ki67 level (P=0.039) and resection of primary (P=0.015) were independent predictors of survival. This is the largest study to our knowledge looking specifically at the prognosis and clinical course of patients with liver metastatic midgut NETs. For the first time, we have shown that Ki67 and resection of primary are independent predictors of survival for this group of patients.

How do different cigarette design features influence the standard tar yields of popular cigarette brands sold in different countries?

OBJECTIVES

To examine the associations among cigarette design features and tar yields of leading cigarette brands sold in the United States, Canada, Australia and the United Kingdom.

METHODS

Government reports and numbers listed on packs were used to obtain data on International Organization for Standardization (ISO)/Federal Trade Commission (FTC) yields for the tar of 172 cigarette varieties sold in the United States, Canada, Australia and the United Kingdom. We used standardised methods to measure the following 11 cigarette design parameters: filter ventilation, cigarette pressure drop, filter pressure drop, tobacco rod length, filter length, cigarette diameter, tipping paper length, tobacco weight, filter weight, rod density and filter density.

RESULTS

Filter ventilation was found to be the predominant design feature accounting for the variations between brands in ISO/FTC tar yields in each of the four countries. After accounting for filter ventilation, design parameters such as overwrap length, tobacco weight and rod density played comparatively minor roles in determining tar yields.

CONCLUSIONS

Variation in ISO/FTC tar yields are predicted by a limited set of cigarette design features, especially filter ventilation, suggesting that governments should consider mandatory disclosure of cigarette design parameters as part of comprehensive tobacco product regulations.

Resonant generation of internal waves on a model continental slope

We study internal wave generation in a laboratory model of oscillating tidal flow on a continental margin. Waves are found to be generated only in a near-critical region where the slope of the bottom topography matches that of internal waves. Fluid motion with a velocity an order of magnitude larger than that of the forcing occurs within a thin boundary layer above the bottom surface. The resonant wave is unstable because of strong shear; Kelvin-Helmholtz billows precede wave breaking. This work provides a new explanation for the intense boundary flows on continental slopes.

What happened to smokers' beliefs about light cigarettes when "light/mild" brand descriptors were banned in the UK? Findings from the International Tobacco Control (ITC) Four Country Survey

AIM

This paper examines how beliefs of smokers in the UK were affected by the removal of "light" and "mild" brand descriptors, which came into effect on 30 September 2003 for Member States of the European Union (EU).

PARTICIPANTS

The data come from the first four waves (2002-2005) of the International Tobacco Control Policy Evaluation (ITC) Four-Country Survey, an annual cohort telephone survey of adult smokers in Canada, USA, UK and Australia (15 450 individual cases).

DESIGN

The UK ban on misleading descriptors occurred around the second wave of data collection in the ITC survey, permitting us to compare beliefs about light cigarettes among adult smokers in the UK before and after the ban, with beliefs in the three other ITC countries unaffected by the ban.

RESULTS

There was a substantial decline in reported beliefs about the benefits of light cigarettes in the UK following the policy change and an associated public information campaign, but by 2005 (ie, wave 4), these beliefs rebounded slightly and the change in beliefs was no greater than in the USA, where there was no policy change.

CONCLUSIONS

The findings reveal that high levels of misperceptions about light cigarettes existed among smokers in all four countries before and after the EU ban took effect. We cannot conclude that the policy of removing some aspects of misleading labels has been effective in changing beliefs about light cigarettes. Efforts to correct decades of consumer misperceptions about light cigarettes must extend beyond simply removing "light" and "mild" brand descriptors.

Eye gaze tracking for endoscopic camera positioning: an application of a hardware/software interface developed to automate Aesop

A redesigned motion control system for the medical robot Aesop allows automating and programming its movements. An IR eye tracking system has been integrated with this control interface to implement an intelligent, autonomous eye gaze-based laparoscopic positioning system. A laparoscopic camera held by Aesop can be moved based on the data from the eye tracking interface to keep the user's gaze point region at the center of a video feedback monitor. This system setup provides autonomous camera control that works around the surgeon, providing an optimal robotic camera platform.

Frequency, severity and duration of immune reconstitution events in HIV-related tuberculosis

SETTING

Patients were enrolled in a prospective trial of rifabutin-based tuberculosis (TB) treatment for human immunodeficiency virus related TB. Antiretroviral therapy (ART) was encouraged, but not required.

OBJECTIVE

To evaluate the frequency, risk factors and duration of immune reconstitution events.

DESIGN

Patients were prospectively evaluated for immune reconstitution events, and all adverse event reports were reviewed to identify possible unrecognized events.

RESULTS

Of 169 patients, 25 (15%) developed immune reconstitution events related to TB. All 25 were among the 137 patients who received ART during TB treatment, so the frequency in this subgroup was 18% (25/137). Risk factors for an immune reconstitution event in multivariate analysis were Black race, the presence of extra-pulmonary TB and a shorter interval from initiation of TB treatment to initiation of ART. The most common clinical manifestations were fever (64%), new or worsening adenopathy (52%) and worsening pulmonary infiltrates (40%). Twelve patients (48%) were hospitalized for a median of 7 days, six underwent surgery and 11 had needle aspiration. The median duration of events was 60 days (range 11-442).

CONCLUSION

Immune reconstitution events were common among patients receiving ART during TB treatment, produced substantial morbidity and had a median duration of 2 months.

Engineering a safe landing: engaging medical practitioners in a systems approach to patient safety

BACKGROUND

Several event studies, including the Australian Safety and Quality in Healthcare Study, emphasize gaps in safety for hospitalized patients. It is now recognized that system-based factors contribute significantly to risk of adverse events and this has led to a shift in focus of patient safety from the autonomous responsibility of medical clinicians to a systems-based approach. The aim of this study was to determine medical practitioner awareness of, level of engagement in and barriers to engagement in a systems approach to patient safety and quality.

METHODS

Information from acute and subacute care medical practitioners at a metropolitan public hospital was collected within an anonymous structured electronic survey, a discussion group and key informant interviews.

RESULTS

There were 73 survey respondents (response rate 7.6%). Fifty-one (69.9%) were unaware of the Institute of Medicine report 'To Err is human'. Thirty-six (49.3%) were unaware of the Australian Quality in Healthcare Study and 12 (16.4%) had read the article. There was a positive relation identified between awareness and seniority. There was a low level of participation in systems-focused quality and safety activities and limited understanding of the role of systems in medical error causation. There was uncertainty about the changing role of medical practitioners in patient safety and perceived lack of skills to effectively engage with hospital management about safety and quality issues.

CONCLUSION

Several factors are limiting engagement of medical practitioners in a systems approach to patient safety. Increased educational support is needed and may be best focused within clinical effectiveness activities pertinent to practitioner interest and expertise.

[Pulmonary nocardiosis with trimethoprime/sulphamethoxazole-resistant Nocardia paucivorans in a patient with no signs of immunosuppression]

This is so far the first published case report of a Nocardia paucivorans infection in an immunocompetent patient. A 54-year-old farmer was hospitalised with a history of coughing and fever for a period of five months. There was no indicator of either primary of secondary immunodeficiency in the prior medical history. A chest X-ray showed pneumonic infiltrates in the right middle und lower lobes, which progressed despite of antibiotic therapy with macrolides. A transbronchial biopsy revealed unspecific granulomatous inflammation of soft tissues. N. paucivorans - grew in cultures of sputum, bronchoalveolar lavage, and transbronchial biopsy. Oral antibiotic therapy was started with trimethoprime-sulphamethoxazole (TMP/SMX) and amoxicillin plus clavulanic acid. Susceptibility testing revealed high level resistance to TMP/SMX, which was consequently replaced by ciprofloxacin. Six months later, infiltrates had completely resolved and the patient did not report any residual clinical symptoms. The present case showed once again that nocardiosis is not limited to patients with immunodeficiencies. However, conservative combination therapy with oral antibiotics seems to be sufficiently effective for nocardiosis in the immunocompetent patient. For cases of suspected nocardiosis, a step-wise, risk-based diagnostic and therapeutic procedure is proposed.

Phase II trial of pirfenidone in adults with neurofibromatosis type 1

We performed an open-label phase II trial of oral pirfenidone in 24 patients with neurofibromatosis type 1 (NF1). Tumors were monitored by three-dimensional MRI. At the end of treatment, four patients had a decrease in tumor volume by 15% or more, three had tumor progression, and 17 remained stable. Pirfenidone warrants further investigation in NF1, which has until now lacked an effective control therapy.

Increased case fatality rates following a first acute cardiovascular event in patients with rheumatoid arthritis

OBJECTIVE

Among patients with rheumatoid arthritis (RA), cardiovascular mortality is increased compared with the rate among unaffected peers. In this study, 30-day mortality rates following a first acute cardiovascular event (myocardial infarction or stroke) were compared between RA patients and the general population.

METHODS

All cases of a first acute cardiovascular event between July 1, 2001 and November 30, 2003 in Victoria, Australia were identified from hospital discharge data. Individuals were classified as having RA when an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification code for RA was recorded at the index admission or during the previous 5 years. Thirty-day mortality rates were determined from linkage to the state death registry.

RESULTS

A total of 29,924 patients experienced a first cardiovascular event during the study period, 359 (1.2%) of whom had RA. Thirty-day cardiovascular mortality was 17.6% in RA patients versus 10.8% in non-RA patients. In fully adjusted models, the odds ratio (OR) for cardiovascular death in RA patients following a first acute cardiovascular event was 1.6 (95% confidence interval [95% CI] 1.2-2.2). Analysis of index event subgroups revealed that this increased case fatality rate in patients with RA was accounted for almost entirely by excess deaths following myocardial infarction. The adjusted ORs for cardiovascular death in RA after myocardial infarction and stroke were 1.9 (95% CI 1.3-2.7) and 1.2 (95% CI 0.7-2.0), respectively.

CONCLUSION

RA patients have a substantially increased risk of 30-day case fatality following myocardial infarction, but not stroke, compared with non-RA patients. This higher case fatality rate is likely to contribute to the observed overall excess of cardiovascular deaths in RA populations.