Evaluating the hip-flask defence using analytical data from ethanol and ethyl glucuronide. A comparison of two models

AIM

Claimed intake of alcohol after a traffic incident, called the hip-flask defence, can be objectively assessed by different methods. One of them is the use of two consecutive ethanol concentrations in urine and the ratio between ethanol concentrations in urine and blood. Another one is the concentrations of ethyl glucuronide (EtG) and ethyl sulphate (EtS) in blood and their ratio to ethanol. The experimental basis for both these models is from single dose studies only. The aim of this study was therefore to describe the kinetics of ethanol, EtG and EtS after ingestion of two repeated doses of ethanol and to investigate the usefulness of the different models for the assessment of the hip-flask defence.

METHODS

Thirty-five subjects ingested a first dose of 0.51 g of ethanol per kilo body weight, and two hours later a second dose (the hip-flask drink) of 0.25, 0.51 or 0.85 g of ethanol per kilo body weight. Ten urine and 17 blood samples were collected and analysed for ethanol, EtG and EtS using fully validated methods. It was investigated if all subjects fulfilled the criteria for recent drinking, according to the two different models, when using the samples collected 180-240 minutes after start of first dose drinking. According to the first model, increase in urinary ethanol concentrations and a ratio UAC/BAC below 1.3 indicated recent drinking. According to the second model, increase in blood EtG concentrations and a ratio ethanol (g/kg)/EtG (mg/L) above 1 indicated recent drinking.

RESULTS

All subjects in the high dose group fulfilled all criteria for recent drinking. One subject in the medium dose group and nine subjects in the low dose group failed to show increasing UAC and/or a UAC/BAC ratio below 1.3. One subject in the low dose group failed to show increasing concentrations of blood EtG, but all subjects showed a ratio ethanol/EtG above 1.

CONCLUSIONS

The present study showed, by the use of experimental data, that both two models used to investigate the hip-flask defence can be used, but only when the hip-flask dose is sufficiently high.

Anxiety during magnetic resonance imaging of the spine in relation to scanner design and size

INTRODUCTION

Magnetic resonance imaging in closed-bore scanners sometimes provokes anxiety but closed-bore designs have gradually become wider and shorter. Open scanners may be easier to tolerate. The aim was to compare patient anxiety during MRI between bore diameters of 60 cm and 70 cm, and to determine the current level of patient anxiety and experience in open scanners in a clinical setrting.

METHODS

Consecutive patients referred for examination of the spine in 60 cm and 70 cm bores and one open scanner participated. Four established/validated questionnaires, answered before, directly after (N = 155) and one week after (N = 109) the MRI-examination were used, measuring anxiety, fear and depression.

RESULTS

No difference was found in the patient scores of anxiety between the 60 cm and the 70 cm scanners on the examination day. At follow-up, patients in the 70 cm bore rated their examination experience better (p < 0.025), compared to patients in the 60 cm bore. Patients in the open scanner rated higher levels of anxiety (p < 0.001) before, directly after and one week after the examination, compared to the closed bore scanners.

CONCLUSION

Scanners with a 70 cm diameter bore seem more tolerable than those with a 60 cm bore. Patients referred to the open scanner had on average a higher tendency to express anxiety. Still, patient anxiety in MRI is challenging and further research required.

IMPLICATIONS FOR PRACTICE

Patients prefer to be examined in 70 cm bore scanners compared with 60 cm. If open scanners aren't available extended support may be necessary for the most anxious patients.

Decreases in blood ethanol concentrations during storage at 4 °C for 12 months were the same for specimens kept in glass or plastic tubes

Background

The stability of ethanol was investigated in blood specimens in glass or plastic evacuated tubes after storage in a refrigerator at 4 °C for up to 12 months.

Methods

Sterile blood, from a local hospital, was divided into 50 mL portions and spiked with aqueous ethanol (10% w/v) to give target concentrations of 0.20, 1.00, 2.00 and 3.00 g/L. Ethanol was determined in blood by headspace gas chromatography (HS-GC) with an analytical imprecision of <3% (coefficient of variation, CV%). Aliquots of blood were re-analysed after 2, 7, 14, 28, 91, 182 and 364 days of storage at 4 °C.

Results

The standard deviation (SD) of analysis by HS-GC was 0.0059 g/L at 0.20 g/L and 0.0342 g/L at 3.00 g/L, corresponding to CVs of 2.9% and 1.1%, respectively. The decreases in blood ethanol content were analytically significant after 14–28 days of storage for both glass and plastic tubes The mean (lowest and highest) loss of ethanol after 12 months storage was 0.111 g/L (0.084–0.129 g/L) for glass tubes and 0.112 g/L (0.088–0.140 g/L) for plastic tubes. The corresponding percentage losses of ethanol were 43–45% at a starting concentration of 0.20 g/L and 3.9–4.1% at 3.00 g/L.

Conclusion

The concentration of ethanol in blood gradually decreases during storage at 4 °C. After 12 months storage the absolute decrease in concentration was ~0.11 g/L when the starting concentration ranged from 0.20 to 3.0 g/L. Decreases in ethanol content were the same for specimens kept in glass or plastic evacuated tubes.

Adverse events are common on the intensive care unit: results from a structured record review

BACKGROUND

Intensive care is advanced and highly technical, and it is essential that, despite this, patient care remains safe and of high quality. Adverse events (AEs) are supposed to be reported to internal quality control systems by health-care providers, but many are never reported. Patients on the intensive care unit (ICU) are at special risk for AEs. Our aim was to identify the incidence and characteristics of AEs in patients who died on the ICU during a 2-year period.

METHODS

A structured record review according to the Global Trigger Tool (GTT) was used to review charts from patients cared for at the ICU of a middle-sized Swedish hospital during 2007 and 2008 and who died during or immediately after ICU care. All identified AEs were scored according to severity and preventability.

RESULTS

We reviewed 128 records, and 41 different AEs were identified in 25 patients (19.5%). Health care-associated infections, hypoglycaemia, pressure sores and procedural complications were the most common harmful events. Twenty two (54%) of the AEs were classified as being avoidable. Two of the 41 AEs were reported as complications according to the Swedish Intensive Care Registry, and one AE had been reported in the internal AE-reporting system.

CONCLUSION

Almost one fifth of the patients who died on the ICU were subjected to harmful events. GTT has the advantage of identifying more patient injuries caused by AEs than the traditional AE-reporting systems used on many ICUs.

A population-based audit of the clinical use of faecal occult blood testing in primary care for colorectal cancer

AIM

Symptoms related to colorectal cancer (CRC) are common. We investigated the value of the faecal occult blood test (FOBT), when administered in primary care, in the diagnosis of CRC.

METHOD

All patients who underwent a FOBT (Hemoccult II) at 20 public primary care centres in Sörmland County, Sweden, during 2000-2005, were included (n=9048). Linkage to the Swedish Cancer Registry identified all cases of CRC. Symptoms recorded at the time of the FOBT were retrieved from the patient records. The outcome from the FOBT to diagnosis and subsequent survival was compared between patients who were FOBT negative and patients who were FOBT positive.

RESULTS

One-hundred and sixty-one patients were diagnosed with CRC within 2 years after undergoing a FOBT in primary care. These comprised 18% of all 917 patients diagnosed with CRC in the county during the study period. In 41 (25.4%) of the 161 patients the test was negative. Symptoms related to CRC were documented for 158 (98%) patients at the time the FOBT was administered. The median investigation time from the FOBT test to the diagnosis of CRC was 91 days: 80 days for FOBT-positive patients and 188 days for FOBT-negative patients (P<0.001). This difference was significant independent of age, sex and site of tumour. The hazard ratio for FOBT negativity, 3 years after the FOBT, when adjusted for age and sex, was 1.47 (95% CI, 0.81-2.68).

CONCLUSION

Despite having suggestive symptoms, 41 (4.5%) of 917 CRC patients had a negative FOBT result in primary care. This was associated with diagnostic delay and, potentially, a worse outcome.

Family violence among psychiatric in-patients as measured by the Conflict Tactics Scale (CTS)

The aim of this study was to analyse the frequency and pattern of family (domestic) violence in a group of psychiatric in-patients by using the Conflict Tactics Scale. The study is based on a consecutive series of 55 married or cohabiting psychiatric in-patients treated at Huddinge Hospital, Stockholm, Sweden in 1994. The study shows that males and females use similar types of both violent and non-violent strategies when trying to solve marital conflicts. Depressed patients use both non-violent and violent methods less often than non-depressed patients, while the opposite is true for patients with a personality disorder, and for schizophrenics. Psychosocial stressors appear to be of limited importance in this context, while poor general functioning is associated with destructive ways of trying to solve conflicts between husband and wife. However, there have been no Scandinavian population-based studies to establish the frequency and type of violence used when trying to solve marital conflicts. Thus there is a need for such studies, and the present investigation supports the American experience that the Conflict Tactics Scale is a usable and easily administered instrument for population-based studies.

Concentrations of acetone in venous blood samples from drunk drivers, type-I diabetic outpatients, and healthy blood donors

Headspace gas chromatography (HSGC) was used to measure the concentrations of acetone in samples of venous whole blood from drunk drivers (n = 500), hospital outpatients with type-I diabetes mellitus (n = 250), and healthy blood donors (n = 288). The standard deviation (SD) of blood-acetone determination by HSGC was 0.048 mg/L at a mean concentration of 2.34 mg/L (2.1%). The concentration of acetone in blood did not change significantly when the samples were stored at 4 degrees C for eight days. The ratio of the concentrations of acetone in plasma and whole blood was 1.23:1 (SD 0.229, n = 22). The frequency distributions of blood-acetone concentrations were markedly skewed to the right. The median concentration of acetone in blood from drunk drivers was 2.03 mg/L and the 2.5 and 97.5 percentiles were 0.80 and 12.8 mg/L, respectively. In patients with type-I diabetes mellitus, the median blood-acetone concentration was 1.90 mg/L and the 2.5 and 97.5 percentiles were 0.40 and 11.1 mg/L, respectively. In healthy blood donors, the median blood-acetone level was 1.26 mg/L and the 2.5 and 97.5 percentiles were 0.37 and 4.69 mg/L, respectively. The concentrations of acetone in blood did not differ appreciably among these three groups of subjects.

Beta-adrenoceptor stimulation and cyclic AMP levels in bovine tracheal muscle of old and young animals

The relationship between cyclic AMP levels and mechanical activity after exposure to isoprenaline was studied in tracheal smooth muscle. It was found that the basal cyclic AMP content decreased with age. The relaxing effects of isoprenaline, theophylline and papaverine were tested on muscles contracted by histamine, acetylcholine or carbacholine. Isoprenaline completely relaxed histamine contracted tracheas, but not those contracted by acetylcholine or carbacholine. Theophylline and papaverine completely relaxed the tracheas irrespective of whether the contracting agent was histamine, acetylcholine or carbacholine. Isoprenaline increased the cyclic AMP content of bovine trachea; this effect was stronger in muscles with spontaneous tension than in histamine contracted muscles. In muscles contracted by carbachol, isoprenaline increased the cyclic AMP level after 5 min. The correlations between the changes in the cyclic AMP levels and the tension in tracheal smooth muscle support the hypothesis that this nucleotide plays a role in the relaxation process.

Studies on the mechanism of flush induced by nicotinic acid

Flush is a common side effect of nicotinic acid therapy in patients. The effect is present as long as the level of nicotinic acid increases in the plasma. The mechanism of flush after nicotinic acid has been studied in the ears of guinea-pigs in vivo. The threshold dose of nicotinic acid (1-3 mg/kg) to raise the skin temperature of the ears and to increase the cyclic AMP level of this tissue was similar. Indomethacin and acetylsalicylic acid which inhibit the synthesis of prostaglandins markedly reduce the duration and intensity of the flush. In isolated slices from guinea-pig ears, nicotinic acid increased the level of cyclic AMP; this effect was inhibited by indomethacin. The stimulating action of prostaglandin E1 on the cyclic AMP level of the ear slices was not inhibited by indomethacin. Since administration to man of both cyclic AMP and prostaglandin E1 produces flush it is suggested that nicotinic acid may induce flush by the formation of some prostaglandin which then increases the formation of cyclic AMP.

Adrenergic beta-receptor activity and cyclic AMP metabolism in vascular smooth muscle; variations with age

The relaxing effect of isoproterenol on aortic strips from rats decreases and disappears with increasing age of the animal. In aortas from young rats (1 month) the cAMP level increases after stimulation with isoproterenol (3.6 muM), whereas in old aortas (6 months) the cAMP level was unchanged. Basal and NaF stimulated adenyl cyclase activities are increased in aortas from rats 6 months of age compared with those one month old. The phosphodiesterase activities decrease with increasing age both low (10-7M) and high (10-4M) substrate concentration.