Reducing Benzodiazepine Exposure by Instituting a Guideline for Dexmedetomidine Usage in the NICU

BACKGROUND

Midazolam is a benzodiazepine sedative used in NICUs. Because benzodiazepine's effects include respiratory depression and potential detrimental developmental effects, minimizing exposure could benefit neonates. Dexmedetomidine is routinely used for sedation in older pediatric populations. We implemented a quality improvement initiative with the aim of decreasing midazolam infusions by 20% through use of dexmedetomidine.

METHODS

A multidisciplinary committee created a sedation guideline that included standardized dexmedetomidine dosing escalation and weaning. Baseline data collection occurred from January 2015 to February 2018, with intervention from March 2018 to December 2019. Percentage of sedation episodes with dexmedetomidine initiated was followed as a process measure. Outcomes measures were percentage of eligible infants receiving midazolam infusions and midazolam-free days per sedation episode. Bradycardia with dexmedetomidine, unplanned extubation rates, and morphine dosage were monitored as balancing measures.

RESULTS

Our study included 434 episodes of sedation in 386 patients. Dexmedetomidine initiation increased from 18% to 49%. The intervention was associated with a significant reduction in midazolam initiation by 30%, from 95% to 65%, with special cause variation on statistical process control chart analysis. Midazolam-free days per sedation episode increased from 0.3 to 2.2 days, and patients receiving dexmedetomidine had lower midazolam doses (1.3 mg/kg per day versus 2.2 mg/kg per day, P = 5.97 × 10-04). Bradycardia requiring discontinuation of dexmedetomidine, unplanned extubation rates, and morphine doses were unchanged.

CONCLUSIONS

Implementation of a quality improvement initiative was successful in reducing the percentage of patients receiving midazolam infusions and increased midazolam-free days per sedation episode, revealing an overall reduction in benzodiazepine exposure while maintaining adequate sedation.

Biorefinery potential of sustainable municipal wastewater treatment using fast-growing willow

The use of willow plantations can be a sustainable approach for treating primary municipal wastewater, potentially reducing both the environmental and economic burdens associated with conventional treatment. However, the impact of wastewater irrigation upon the willow biorefinery potential has not yet been established. To investigate this effect, three-year-old field grown willows were harvested from plots kept as either controls or irrigated with primary municipal wastewater effluent at 29.5 million L ha^-1 yr^-1. Biomass compositional analysis, ionic liquid pretreatment and enzymatic saccharification were assessed and differential abundance of persistent extractable phytochemicals was evaluated using untargeted metabolite profiling. Glucan significantly increased by 8% in wastewater treated trees, arabinose and galactose were significantly decreased by 8 and 29%, respectively, while xylose, mannose and lignin content were unaltered. Ionic liquid pretreatment and enzymatic saccharification efficiencies did not vary significantly, releasing >95% of the cell wall glucose and recovering 35% of the lignin. From a total of 213 phytochemical features, 83 were significantly depleted and 14 were significantly enriched due to wastewater irrigation, including flavonoids and lignan derivatives. Considered alongside increased biomass yield from wastewater irrigation (+200%), lignocellulosic bioenergy yields increased to 8.87 t glucose ha^-1 yr^-1 and 1.89 t ha^-1 yr^-1 recovered lignin, while net extractives yields increased to 1.48 t ha^-1 yr^-1, including phytochemicals of interest. The maintenance of glucose accessibility after low-cost ionic liquid pretreatment is promising evidence that sustainable lignocellulose bioenergy production can complement wastewater treatment. Untargeted metabolite assessment revealed some of the phytochemical toolkit employed by wastewater irrigated willows, including accumulation of flooding and salinity tolerance associated flavonoids glabraoside A and glabrene. The extractable phytochemicals underpin a novel high biomass phenotype in willow and, alongside lignocellulosic yields, could help enhance the economic feasibility of this clean wastewater treatment biotechnology through integration with sustainable biorefinery.

High biomass yield increases in a primary effluent wastewater phytofiltration are associated to altered leaf morphology and stomatal size in Salix miyabeana

Municipal wastewater treatment using willow 'phyto'-filtration has the potential for reduced environmental impact compared to conventional treatment practices. However, the physiological adaptations underpinning tolerance to high wastewater irrigation in willow are unknown. A one-hectare phytofiltration plantation established using the Salix miyabeana cultivar 'SX67' in Saint-Roch-de-l'Achigan, Quebec, Canada, tested the impact of unirrigated, potable water or two loads of primary effluent wastewater 19 and 30 ML ha^-1 yr^-1. A nitrogen load of 817 kg N ha^-1 from wastewater did not increase soil pore water nitrogen concentrations beyond Quebec drinking water standards. The willow phytofiltration phenotype had increased leaf area (+106-142%) and leaf nitrogen (+94%) which were accompanied by significant increases in chlorophyll a + b content. Wastewater irrigated trees had higher stomatal sizes and a higher stomatal pore index, despite lower stomatal density, resulting in increased stomatal conductance (+42-78%). These developmental responses led to substantial increases in biomass yields of 56-207% and potable water controls revealed the nitrogen load to be necessary for the high productivity of 28-40 t ha^-1 yr^-1 in wastewater irrigated trees. Collectively, this study suggests phytofiltration plantations could treat primary effluent municipal wastewater at volumes of at least 19 million litres per hectare and benefit from increased yields of sustainable biomass over a two-year coppice cycle. Added-value cultivation practices, such as phytofiltration, have the potential to mitigate negative local and global environmental impact of wastewater treatment while providing valuable services and sustainable bioproducts.

Co-cropping with three phytoremediation crops influences rhizosphere microbiome community in contaminated soil

Human industrial activities have left millions of hectares of land polluted with trace element metals and persistent organic pollutants (POPs) around the world. Although contaminated sites are environmentally damaging, high economic costs often discourage soil remediation efforts. Phytoremediation is a potential green technology solution but can be challenging due to the diversity of anthropogenic contaminants. Co-cropping could provide improved tolerance to diverse soil challenges by taking advantage of distinct crop capabilities. Co-cropping of three species with potentially complementary functions, Festuca arundinacea, Salix miyabeana and Medicago sativa, perform well on diversely contaminated soils. Here, rhizosphere microbiomes of each crop in monoculture and in all co-cropping combinations were compared using 16S rRNA gene amplification, sequencing and differential abundance analysis. The hyperaccumulating F. arundinacea rhizosphere microbiome included putative plant growth promoting bacteria (PGPB) and metal tolerance species, such as Rhizorhapis suberifaciens, Cellvibrio fibrivorans and Pseudomonas lini. The rhizosphere microbiome of the fast-growing tree S. miyabeana included diverse taxa involved in POP degradation, including the species Phenylobacterium panacis. The well-characterised nitrogen-fixing M. sativa microbiome species, Sinorhizobium meliloti, was identified alongside others involved in nutrient acquisition and putative yet-to-be-cultured Candidatus saccharibacteria (TM7-1 group). The majority of differentially abundant rhizosphere-associated bacterial species were maintained in co-cropping pairs, with pairs having higher numbers of differentially abundant taxa than monocultures in all cases. This was not the case when all three crops were co-cropped, where most host-specific bacterial species were not detected as differentially abundant, indicating the potential for reduced rhizosphere functionality. The crops cultivated in pairs here retained rhizosphere microbiome bacteria involved in these monoculture ecosystem services of plant growth promotion, POP tolerance and degradation, and improved nutrient acquisition. These findings provide a promising outlook of the potential for complementary co-cropping strategies for phytoremediation of the multifaceted anthropogenic pollution which can disastrously affect soils around the world.

A retrospective study of neonatal case management and outcomes in rural Rwanda post implementation of a national neonatal care package for sick and small infants

Background

Despite worldwide efforts to reduce neonatal mortality, 44% of under-five deaths occur in the first 28 days of life. The primary causes of neonatal death are preventable or treatable. This study describes the presentation, management and outcomes of hospitalized newborns admitted to the neonatal units of two rural district hospitals in Rwanda after the 2012 launch of a national neonatal protocol and standards.

Methods

We retrospectively reviewed routinely collected data for all neonates (0 to 28 days) admitted to the neonatal units at Rwinkwavu and Kirehe District Hospitals from January 1, 2013 to December 31, 2014. Data on demographic and clinical characteristics, clinical management, and outcomes were analyzed using median and interquartile ranges for continuous data and frequencies and proportions for categorical data. Clinical management and outcome variables were stratified by birth weight and differences between low birth weight (LBW) and normal birth weight (NBW) neonates were assessed using Fisher’s exact or Wilcoxon rank-sum tests at the α = 0.05 significance level.

Results

A total of 1723 neonates were hospitalized over the two-year study period; 88.7% were admitted within the first 48 h of life, 58.4% were male, 53.8% had normal birth weight and 36.4% were born premature. Prematurity (27.8%), neonatal infection (23.6%) and asphyxia (20.2%) were the top three primary diagnoses. Per national protocol, vital signs were assessed every 3 h within the first 48 h for 82.6% of neonates (n = 965/1168) and 93.4% (n = 312/334) of neonates with infection received antibiotics. The overall mortality rate was 13.3% (n = 185/1386) and preterm/LBW infants had similar mortality rate to NBW infants (14.7 and 12.2% respectively, p = 0.131). The average length of stay in the neonatal unit was 5 days.

Conclusions

Our results suggest that it is possible to provide specialized neonatal care for both LBW and NBW high-risk neonates in resource-limited settings. Despite implementation challenges, with the introduction of the neonatal care package and defined clinical standards these most vulnerable patients showed survival rates comparable to or higher than neighboring countries.

Trees, fungi and bacteria: tripartite metatranscriptomics of a root microbiome responding to soil contamination

BACKGROUND

One method for rejuvenating land polluted with anthropogenic contaminants is through phytoremediation, the reclamation of land through the cultivation of specific crops. The capacity for phytoremediation crops, such as Salix spp., to tolerate and even flourish in contaminated soils relies on a highly complex and predominantly cryptic interacting community of microbial life.

METHODS

Here, Illumina HiSeq 2500 sequencing and de novo transcriptome assembly were used to observe gene expression in washed Salix purpurea cv. 'Fish Creek' roots from trees pot grown in petroleum hydrocarbon-contaminated or non-contaminated soil. All 189,849 assembled contigs were annotated without a priori assumption as to sequence origin and differential expression was assessed.

RESULTS

The 839 contigs differentially expressed (DE) and annotated from S. purpurea revealed substantial increases in transcripts encoding abiotic stress response equipment, such as glutathione S-transferases, in roots of contaminated trees as well as the hallmarks of fungal interaction, such as SWEET2 (Sugars Will Eventually Be Exported Transporter). A total of 8252 DE transcripts were fungal in origin, with contamination conditions resulting in a community shift from Ascomycota to Basidiomycota genera. In response to contamination, 1745 Basidiomycota transcripts increased in abundance (the majority uniquely expressed in contaminated soil) including major monosaccharide transporter MST1, primary cell wall and lamella CAZy enzymes, and an ectomycorrhiza-upregulated exo-β-1,3-glucanase (GH5). Additionally, 639 DE polycistronic transcripts from an uncharacterised Enterobacteriaceae species were uniformly in higher abundance in contamination conditions and comprised a wide spectrum of genes cryptic under laboratory conditions but considered putatively involved in eukaryotic interaction, biofilm formation and dioxygenase hydrocarbon degradation.

CONCLUSIONS

Fungal gene expression, representing the majority of contigs assembled, suggests out-competition of white rot Ascomycota genera (dominated by Pyronema), a sometimes ectomycorrhizal (ECM) Ascomycota (Tuber) and ECM Basidiomycota (Hebeloma) by a poorly characterised putative ECM Basidiomycota due to contamination. Root and fungal expression involved transcripts encoding carbohydrate/amino acid (C/N) dialogue whereas bacterial gene expression included the apparatus necessary for biofilm interaction and direct reduction of contamination stress, a potential bacterial currency for a role in tripartite mutualism. Unmistakable within the metatranscriptome is the degree to which the landscape of rhizospheric biology, particularly the important but predominantly uncharacterised fungal genetics, is yet to be discovered.

Differential uptake of silver, copper and zinc suggests complementary species-specific phytoextraction potential

The aim of our study, conducted as a pot experiment, was to assess the potential of willow (Salix miyabeana), alfalfa (Medicago sativa), tall fescue (Festuca arundinacea), and Indian mustard (Brassica juncea) to remediate two brownfield soils differentially contaminated with Ag, Cu and Zn (up to 113.60, 47.50, and 117.00 mg kg(-1) respectively). While aboveground Ag accumulation was highest in B. juncea (4.60 ± 2.58 mg kg(-1)), lower levels were also measured in M. sativa and F. arundinacea. Cu accumulation was observed in all species, but only in underground parts, and was highest in F. arundinacea (269.20 ± 74.75 mg kg(-1)), with a bioconcentration factor of 13.85. Salix miyabeana was found to have the highest Zn aerial tissue concentration (119.96 ± 20.04 mg kg(-1)). Because of its high Ag uptake, the remediation potential of B. juncea should be evaluated more extensively on the site from which we excavated the soil for this study. Given the multiple forms of contamination on the site and the differential specie-related uptake evident in our findings, we hypothesize that an optimal plantation allowing expression of complementary remediation functions would include B. juncea for extraction of Ag, in combination with F. arundinacea for stabilization of Cu and S. miyabeana for extraction of Zn.

Differential uptake of silver, copper and zinc suggests complementary species-specific phytoextraction potential

The aim of our study, conducted as a pot experiment, was to assess the potential of willow (Salix miyabeana), alfalfa (Medicago sativa), tall fescue (Festuca arundinacea), and Indian mustard (Brassica juncea) to remediate two brownfield soils differentially contaminated with Ag, Cu and Zn (up to 113.60, 47.50, and 117.00 mg kg(-1) respectively). While aboveground Ag accumulation was highest in B. juncea (4.60 ± 2.58 mg kg(-1)), lower levels were also measured in M. sativa and F. arundinacea. Cu accumulation was observed in all species, but only in underground parts, and was highest in F. arundinacea (269.20 ± 74.75 mg kg(-1)), with a bioconcentration factor of 13.85. Salix miyabeana was found to have the highest Zn aerial tissue concentration (119.96 ± 20.04 mg kg(-1)). Because of its high Ag uptake, the remediation potential of B. juncea should be evaluated more extensively on the site from which we excavated the soil for this study. Given the multiple forms of contamination on the site and the differential specie-related uptake evident in our findings, we hypothesize that an optimal plantation allowing expression of complementary remediation functions would include B. juncea for extraction of Ag, in combination with F. arundinacea for stabilization of Cu and S. miyabeana for extraction of Zn.

The development and implementation of a newborn medicine program in a resource-limited setting

The reduction in global neonatal mortality rates remains a challenge. Internationally recognized protocols for hospital care of sick and small newborns are limited, although this specialized area lends itself to standardization. An interdisciplinary team including international and local clinical experts worked with the Rwandan Ministry of Health and Rwandan professional associations to develop and implement a neonatal care program in a rural Rwandan district hospital that was ultimately accepted as the national standard for newborn medicine. Successful features and challenges are discussed. It is realistic to develop, implement and disseminate neonatal protocols for sick newborns.

Managing the Impact of Illness: The Experiences of Men with Prostate Cancer and their Spouses

This qualitative study explored issues of support and coping for couples where the man had been diagnosed with prostate cancer. Thirty-four men with prostate cancer and their spouses were interviewed separately at three points in time: prior to surgery; 8 to 10 weeks post-surgery; and 11 to 13 months post-surgery. The core category for the couples' experience with diagnosis and treatment for prostate cancer was Managing the Impact of Illness. Five major domains emerged, including: dealing with the practicalities; stopping illness from interfering with everyday life; keeping relationships working; managing feelings; and making sense of it all. While it was clearly important for couples to manage illness and to reduce its potential intrusion into everyday life, this strategy had psychological costs as well as benefits. Men struggled to stay in control of their emotions and their lives, typically vacillating between the pulls of fierce self-reliance and fearful neediness. Women were constrained from employing their usual strategies of coping and were distressed by the complicated requirements of being supportive while also honoring their partners' need for self-reliance.

Occupational asthma: new low-molecular-weight causal agents, 2000-2010

Background. More than 400 agents have been documented as causing occupational asthma (OA). The list of low-molecular-weight (LMW) agents that have been identified as potential causes of OA is constantly expanding, emphasizing the need to continually update our knowledge by reviewing the literature. Objective. The objective of this paper was to identify all new LMW agents causing occupational asthma reported during the period 2000-2010. Methods. A Medline search was performed using the keywords occupational asthma, new allergens, new causes, and low-molecular-weight agents. Results. We found 39 publications describing 41 new LMW causal agents, which belonged to the following categories: drugs (n = 12), wood dust (n = 11), chemicals (n = 8), metals (n = 4), biocides (n = 3), and miscellaneous (n = 3). The diagnosis of OA was confirmed through SIC for 35 of 41 agents, peak expiratory flow monitoring for three (3) agents, and the clinical history alone for three (3) agents. Immunological tests provided evidence supporting an IgE-mediated mechanism for eight (8) (20%) of the newly described agents. Conclusion. This paper highlights the importance of being alert to the occurrence of new LMW sensitizers, which can elicit OA. The immunological mechanism is explained by a type I hypersensitivity reaction in 20% of all newly described LMW agents.

Brain perfusion in asphyxiated newborns treated with therapeutic hypothermia

BACKGROUND AND PURPOSE

Induced hypothermia is thought to work partly by mitigating reperfusion injury in asphyxiated term neonates. The purpose of this study was to assess brain perfusion in the first week of life in these neonates.

MATERIALS AND METHODS

In this prospective cohort study, MR imaging and ASL-PI were used to assess brain perfusion in these neonates. We measured regional CBF values on 1-2 MR images obtained during the first week of life and compared these with values obtained in control term neonates. The same or later MR imaging scans were obtained to define the extent of brain injury.

RESULTS

Eighteen asphyxiated and 4 control term neonates were enrolled; 11 asphyxiated neonates were treated with hypothermia. Those developing brain injury despite being treated with induced hypothermia usually displayed hypoperfusion on DOL 1 and then hyperperfusion on DOL 2-3 in brain areas subsequently exhibiting injury. Asphyxiated neonates not treated with hypothermia who developed brain injury also displayed hyperperfusion on DOL 1-6 in brain areas displaying injury.

CONCLUSIONS

Our data show that ASL-PI may be useful for identifying asphyxiated neonates at risk of developing brain injury, whether or not hypothermia is administered. Because hypothermia for 72 hours may not prevent brain injury when hyperperfusion is found early in the course of neonatal hypoxic-ischemic encephalopathy, such neonates may be candidates for adjustments in their hypothermia therapy or for adjunctive neuroprotective therapies.

Early versus late MRI in asphyxiated newborns treated with hypothermia

OBJECTIVE

The purposes of this feasibility study were to assess: (1) the potential utility of early brain MRI in asphyxiated newborns treated with hypothermia; (2) whether early MRI predicts later brain injury observed in these newborns after hypothermia has been completed; and (3) whether early MRI indicators of brain injury in these newborns represent reversible changes.

PATIENTS AND METHODS

All consecutive asphyxiated term newborns meeting the criteria for therapeutic hypothermia were enrolled prospectively. Each newborn underwent one or two early MRI scans while receiving hypothermia, on day of life (DOL) 1 and DOL 2-3 and also one or two late MRI scans on DOL 8-13 and at 1 month of age.

RESULTS

37 MRI scans were obtained in 12 asphyxiated neonates treated with induced hypothermia. Four newborns developed MRI evidence of brain injury, already visible on early MRI scans. The remaining eight newborns did not develop significant MRI evidence of brain injury on any of the MRI scans. In addition, two patients displayed unexpected findings on early MRIs, leading to early termination of hypothermia treatment.

CONCLUSIONS

MRI scans obtained on DOL 2-3 during hypothermia seem to predict later brain injuries in asphyxiated newborns. Brain injuries identified during this early time appear to represent irreversible changes. Early MRI scans might also be useful to demonstrate unexpected findings not related to hypoxic-ischaemic encephalopathy, which could potentially be exacerbated by induced hypothermia. Additional studies with larger numbers of patients will be useful to confirm these results.

Donation after cardiac death: the potential contribution of an infant organ donor population

OBJECTIVE

To determine the percentage of deaths in level III neonatal intensive care unit (NICU) settings that theoretically would have been eligible for donation after cardiac death (DCD), as well as the percentage of these who would have been potential DCD candidates based on warm ischemic time.

STUDY DESIGN

We conducted a retrospective study of all deaths in 3 Harvard Program in Neonatology NICUs between 2005 and 2007. Eligible donors were identified based on criteria developed with our transplantation surgeons and our local organ procurement organization. Potential candidates for DCD were then identified based on an acceptable warm ischemic time.

RESULTS

Of the 192 deaths that occurred during the study period, 161 were excluded, leaving 31 theoretically eligible donors. Of these, 16 patients had a warm ischemic time of <1 hour and were potential candidates for DCD of 14 livers and 18 kidneys, and 14 patients had a warm ischemic time of <30 minutes and were potential candidates for DCD of 10 hearts.

CONCLUSIONS

Eight percent of NICU mortalities were potential candidates for DCD. Based on the size of the potential donor pool, establishing an infant DCD protocol for level III NICUs should be considered.

Placental pathology in asphyxiated newborns meeting the criteria for therapeutic hypothermia

OBJECTIVE

We sought to describe placental findings in asphyxiated term newborns meeting therapeutic hypothermia criteria and to assess whether histopathologic correlation exists between these placental lesions and the severity of later brain injury.

STUDY DESIGN

We conducted a prospective cohort study of the placentas of asphyxiated newborns, in whom later brain injury was defined by magnetic resonance imaging.

RESULTS

A total of 23 newborns were enrolled. Eighty-seven percent of their placentas had an abnormality on the fetal side of the placenta, including umbilical cord lesions (39%), chorioamnionitis (35%) with fetal vasculitis (22%), chorionic plate meconium (30%), and fetal thrombotic vasculopathy (26%). A total of 48% displayed placental growth restriction. Chorioamnionitis with fetal vasculitis and chorionic plate meconium were significantly associated with brain injury (P = .03). Placental growth restriction appears to significantly offer protection against the development of these injuries (P = .03).

CONCLUSION

Therapeutic hypothermia may not be effective in asphyxiated newborns whose placentas show evidence of chorioamnionitis with fetal vasculitis and chorionic plate meconium.

Can induced hypothermia be assured during brain MRI in neonates with hypoxic-ischemic encephalopathy?

Until now, brain MRIs in asphyxiated neonates who are receiving therapeutic hypothermia have been performed after treatment is complete. However, there is increasing interest in utilizing early brain MRI while hypothermia is still being provided to rapidly understand the degree of brain injury and possibly refine neuroprotective strategies. This study was designed to assess whether therapeutic hypothermia can be maintained while performing a brain MRI. Twenty MRI scans were obtained in 12 asphyxiated neonates while they were treated with hypothermia. The median difference between esophageal temperature on NICU departure and return was 0.1°C (range: -0.8 to 0.8°C). We found that therapeutic hypothermia can be safely and reproducibly maintained during a brain MRI. Hypothermia treatment should not prevent obtaining an early brain MRI if clinically indicated.

A systematic review of interventions promoting clinical information retrieval technology (CIRT) adoption by healthcare professionals

PURPOSE

This paper presents the evidence on the effectiveness of interventions promoting the use of clinical information retrieval technologies (CIRTs) by healthcare professionals.

METHODS

We electronically searched articles published between January 1990 and March 2008 using following inclusion criteria: (1) participants were healthcare professionals; (2) specific intervention promoted CIRT adoption; (3) studies were randomised controlled trials, controlled clinical trials, controlled before and after studies or interrupted time series analyses; and (4) they objectively reporting measured outcomes on CIRT use.

RESULTS

We found nine studies focusing on CIRT use. Main outcomes measured were searching skills and/or frequency of use of electronic databases by healthcare professionals. Three studies reported a positive effect of the intervention on CIRT use, one showed a positive impact post-intervention, and four studies failed to demonstrate significant intervention effect. The ninth study examined financial disincentives, and found a significant negative effect of introducing user fees for searching MEDLINE in clinical settings. A meta-analysis showed that educational meetings were the only type of interventions reporting consistent positive effects on CIRT adoption.

CONCLUSION

CIRT is an information and communication technology commonly used in healthcare settings. Interventions promoting CIRT adoption by healthcare professionals have shown some success in improving searching skills and use of electronic databases. However, the effectiveness of these interventions remains uncertain and more rigorous studies are needed.

Malt can cause both occupational asthma and allergic alveolitis

Specific inhalation challenge can help differentiate occupational asthma from allergic alveolitis caused by malt.

Workplace-specific challenges as a contribution to the diagnosis of occupational asthma

The diagnosis of occupational asthma can be made by exposing workers to the relevant agent either in a hospital laboratory through specific inhalation challenges (SICs) or in the workplace. As suggested by several authors, workers with negative laboratory SIC can be monitored at the workplace under supervision. The present study aims to assess the frequency of, and identify factors associated with, a positive workplace reaction in workers with negative SIC in the laboratory. The results of workplace challenges were examined in 99 workers who underwent negative SIC between 1994 and 2004. A positive reaction either in the SIC or in the workplace was defined as a sustained fall in forced expiratory volume in one second of > or =20%. In total, 22 (22.2%) workers showed positive responses at the workplace. These subjects more often had increased baseline methacholine responsiveness (90.5 versus 67.6%). They also underwent more days of SIC testing (4.9 versus 3.3 days) and were exposed more often to two or more agents (56 versus 28.4%) and for a longer period of time (363.3 versus 220.4 min) in the laboratory. The present study illustrates the usefulness of workplace monitoring of airway function in the investigation of occupational asthma and identifies factors that are more often associated with a positive reaction.

Can access to spirometry in asthma education centres influence the referral rate by primary physicians for education?

BACKGROUND AND OBJECTIVES

Asthma remains uncontrolled in a large number of asthmatic patients. Recent surveys have shown that a minority of asthmatic patients are referred to asthma educators. The objective of the present study was to assess the influence of increased access to spirometry in asthma education centres (AECs) on the rate of patient referrals to these centres by general practitioners.

METHODS

A one-year, prospective, randomized, multicentric, parallel group study was conducted over two consecutive periods of six months each, with added spirometry being offered in the second six-month period to the experimental group. Ten AECs were enrolled in the project. An advertisement describing the AECs' services was sent by mail to a total of 303 general practitioners at the start of each period, inviting them to refer their patients. Measures of the frequency of medical referrals to the AECs were assessed for each period.

RESULTS

The group of AECs randomly selected for spirometry in the second six-month period received 48 medical referrals during the first period and 32 during the second one, following proposed spirometry. AECs that had not offered spirometry received five referrals during the first period and seven during the second period. One AEC withdrew a few weeks after the study began and others encountered administrative problems, reducing their ability to provide interventions.

CONCLUSIONS

Referral to AECs is not yet integrated into the primary care of asthma and offering more rapid access to spirometry in the AECs does not seem to be a significant incentive for such referrals.

What are the questionnaire items most useful in identifying subjects with occupational asthma?

The present study assessed the usefulness of key items obtained from a clinical "open" questionnaire prospectively administered to 212 subjects, referred to four tertiary-care hospitals for predicting the diagnosis of occupational asthma (OA). Of these subjects, 72 (34%) were diagnosed as OA (53% with OA due to high-molecular-weight agents) according to results of specific inhalation challenges, and 90 (42%) as non-OA. Wheezing at work occurred in 88% of subjects with OA and was the most specific symptom (85%). Nasal and eye symptoms were commonly associated symptoms. Wheezing, nasal and ocular itching at work were positively, and loss of voice negatively associated with the presence of OA in the case of high-, but not low molecular-weight agents. A prediction model based on responses to nasal itching, daily symptoms over the week at work, nasal secretions, absence of loss of voice, wheezing, and sputum, correctly predicted 156 out of 212 (74%) subjects according to the presence or absence of OA by final diagnosis. In conclusion, key items, i.e. wheezing, nasal and ocular itching and loss of voice, are satisfactorily associated with the presence of occupational asthma in subjects exposed to high-molecular-weight agents. Therefore, these should be addressed with high priority by physicians. However, no questionnaire-derived item is helpful in subjects exposed to low-molecular-weight agents.

Exaggerated bronchoconstriction due to inhalation challenges with occupational agents

Inhalation challenges with occupational agents are used to confirm the aetiology of occupational asthma. It has been proposed that using closed-circuit equipment rather than the realistic challenge method would improve the methodology of these tests. Changes in forced expiratory volume in one second (FEV1) were examined in 496 subjects with "positive specific inhalation challenges", i.e. changes in FEVI of > or = 20% after exposure to an occupational agent, including 357 subjects exposed by the realistic method, 108 using the closed-circuit method and 31 by both methods. For immediate reactions, 18 of 95 (19%) showed changes in FEV1 of > or = 30% with the closed-circuit method, whereas a significantly larger proportion, i.e. 77 of 200 (38.5%), showed such changes using the realistic method. As regards nonimmediate reactions, changes in FEV1 of > or = 30% occurred in 16 of 43 (37%) cases with the closed-circuit method as compared to a larger proportion, i.e. 87 of 180 (48%) cases, using the realistic method. This favourable effect was significantly more pronounced in workers with higher levels of bronchial hyperresponsiveness to methacholine. It is concluded that, for agents that can be generated using the closed-circuit method, use of such apparatus results in a smaller proportion of exaggerated bronchoconstriction than does the realistic method, this being particularly true for low-molecular weight agents.

Effect of age on the conformity rate to short-acting beta-agonist use criteria in asthma

STUDY OBJECTIVES

Assess compliance to asthma guidelines and influence of age concerning inhaled short-acting beta2-agonist (SABA) utilization in 5 to 45-year-old asthmatic subjects in the province of Quebec.

DESIGN

Population-based retrospective drug utilization review using a computerized database of claims submitted to a private prescription drug insurance plan.

PATIENTS

Subjects who received at least one outpatient prescription of SABA (age range, 5 to 45 years) for the treatment of asthma between January 1996 and December 1997.

MEASUREMENTS

Percentages of patients whose use was appropriate according to the criteria regarding the average daily dose of SABA. Use was considered appropriate if the consumption rate corresponded to a maximum of two puffs per day (Salbutamol equivalent) in subjects who did or did not use inhaled corticosteroids (ICS) at an estimated maximum dose of 800 mcg/day of Beclomethasone (BDP) equivalent for the 5 to 11-year-olds and 1000 mcg/day for the 12 to 45-year-olds.

RESULTS

In 1996, use was found to be appropriate for 74.4% of the 394 patients who received an SABA without ICS as compared with 70.7% for 593 patients in 1997. If we consider those who received an ICS at low to moderate doses, appropriate use was found for 51% of the 375 patients in 1996 and 57.6% for 254 patients in 1997. If we exclude patients who did not renew their SABA, appropriate use drops to 46.3% for 1996 and 34.3% for 1997 for the group who receive SABA without ICS (29.4% and 37.6%, respectively, for those with ICS). There is a relationship between age and appropriateness; the percentage of appropriateness was higher for the younger ones (5 to 14-year-old group; 83% in 1996 and 86% in 1997 for the patients who received a SABA without IS and 58.5% in 1996 and 73% in 1997 for the patients who received a SABA using ICS (p < 0.05).

CONCLUSION

Our results indicate that adherence to asthma guidelines concerning SABA is poor. SABA are still overused, particularly among ICS users, which might be explained by undertreatment or poor compliance. Appropriate SABA use was significantly more common among younger groups (p < 0.05). This can be explained by better treatment in that age group, better compliance or less severe asthma.

[Evaluation of medical web sites. Interobserver and intraobserver reliability of an evaluation tool]

OBJECTIVE

To develop and test the reliability of a tool for rating websites that provide information on evidence-based medicine.

DESIGN

For each site, 60% of the score was given for content (eight criteria) and 40% was given for organization and presentation (nine criteria). Five of 10 randomly selected sites met the inclusion criteria and were used by three observers to test the accuracy of the tool. Each site was rated twice by each observer, with a 3-week interval between ratings.

SETTING

Laval University, Quebec city.

PARTICIPANTS

Three observers.

MAIN OUTCOME MEASURES

The intraclass correlation coefficient (ICC) was used to rate the reliability of the tool.

RESULTS

Average overall scores for the five sites were 40%, 79%, 83%, 88%, and 89%. All three observers rated the same two sites in fourth and fifth place and gave the top three ratings to the other three sites. The overall rating of the five sites by the three observers yielded an ICC of 0.93 to 0.97. An ICC of 0.87 was obtained for the two overall ratings conducted 3 weeks apart.

CONCLUSION

This new tool offers excellent intraobserver and interobserver measurement reliability and is an excellent means of distinguishing between medical websites of varying quality. For best results, we recommend that the tool be used simultaneously by two observers and that differences be resolved by consensus.

Women's views on the practice of prenatal perineal massage

OBJECTIVE

To determine how women who practised perineal massage during pregnancy assessed the technique.

DESIGN

Observational study within one arm of a randomised controlled trial.

SETTING

Five secondary and tertiary care hospitals in the Province of Quebec, Canada.

PARTICIPANTS

Among 763 women randomised to the massage arm of a clinical trial of perineal massage during pregnancy, 684 (90%) who completed a questionnaire after delivery.

MAIN OUTCOME MEASURES

A 20-item questionnaire completed a few days after birth. The first 18 questions elicited opinions using a 6-point Likert scale. Based on a factor analysis, 17 of these questions were classified into four categories: acceptability of perineal massage (8 items); preparation for birth (4 items); relationship with the partner (2 items); and effect of massage on delivery (3 items). Scores of each scale varied between 1 (highly negative assessment) to 6 (highly positive assessment). The last two questions asked whether women would perform the massage in their next pregnancy and whether they would recommend perineal massage to another pregnant woman. In addition, 262 also provided comments about their experience in the daily diary provided to record compliance during the trial.

RESULTS

On average, perineal massage was felt to be quite acceptable [mean (standard deviation) 4.09 (0.93)]. Pain and technical problems reported during the first week or two of massage tended to disappear after a few weeks. Women's assessment of the effect of massage on preparation for birth [4.34 (1.08)] and on delivery [4.18 (1.37)] was positive. Women's views about the effect on their relationship with their partner were either positive or negative [3.54 (1.74)] and were proportional to the partner's participation with the massage. Most women said they would massage again if they were to have another pregnancy (79%; 95% CI, 76%-82%) and would recommend it to another pregnant woman (87%; 95% CI 84%-90%).

CONCLUSION

Overall, women's assessment of prenatal perineal massage is positive.

The association between perineal trauma and spontaneous perineal tears

OBJECTIVE

We assessed whether women who had a perineal trauma (episiotomy or spontaneous tear of the second degree or higher) at the first delivery were at increased risk for spontaneous perineal tears at the next delivery, and whether the risk increases with the severity of previous perineal trauma.

DESIGN

Retrospective cohort study.

POPULATION

We included data from 1895 women who had their first and second deliveries at Saint-Sacrement Hospital, Quebec City, Canada, between 1985 and 1994. Our study was restricted to women who gave birth vaginally to a single living neonate at their first 2 deliveries and who did not have an episiotomy at the second delivery. We extracted the data from the Department of Obstetrics computerized database.

OUTCOMES MEASURED

Spontaneous perineal tears (of second degree or higher) at the second delivery.

RESULTS

Having a perineal trauma at the first delivery more than tripled the risk (relative risk=3.3; 95% confidence interval, 2.6-4.2) of spontaneous perineal tears at the second delivery. The risk of spontaneous perineal tears at the second delivery increased with the severity of previous perineal trauma at birth.

CONCLUSIONS

Our results show that the risk of spontaneous perineal tears at subsequent deliveries increases with the presence and the severity of perineal trauma at the first delivery.

Utilization of professional supportive care services by women with breast cancer

This paper reports on the results of a survey of utilization of professional supportive care services by women with breast cancer, and on patterns of differential service utilization by sub-groups of patients. Study participants were women with invasive breast cancer diagnosed 23-36 months prior to contact about the study, and randomly selected from the Ontario Cancer Registry. From among 1,119 eligible women sent survey questionnaires, 731 returned completed questionnaires (65%). A total of 31% of respondents reported accessing one or more of the following professionals: social worker, psychologist, psychiatrist, dietitian, physiotherapist. Among those who responded to a question about whether they would have liked specific services, 34% reported that there was at least one professional supportive care service they would have liked to use, but were unable to access. Factors shown to be related to greater utilization of services included: younger age, higher household income, employed or student status, private health insurance coverage, and having received chemotherapy. Overall, there was a surprisingly low utilization of professional specialized supportive care services among women with breast cancer. Policy implications include finding strategies to better inform cancer patients about existing services, and ensuring that a core set of services are available to all patients.

Early postsurgery experience of prostate cancer patients and spouses

PURPOSE

The authors describe the experience of men with prostate cancer and their spouses in the early recovery period after surgery.

DESCRIPTION OF STUDY

As part of a longitudinal qualitative study, semistructured interviews were held with 34 patients who had prostate cancer and their spouses 8 to 10 weeks after surgery.

RESULTS

Five components of experience emerged from the interviews: 1) hearing news about the extent of their cancer after surgery influenced how patients viewed their cancer experience and, in many cases, their recovery; 2) men placed great emphasis on recovering their physical capacity quickly; 3) couples connected with each other through working out care routines and managing periods of irritability; 4) couples described a range of responses to surgery side effects and complications; and 5) the meaning of cancer varied for couples, with most seeing the experience as a temporary disruption.

CLINICAL IMPLICATIONS

Physicians, nurses, social workers, and other health professionals working with patients before and after prostatectomies may assist couples to prepare better for the early recovery period by being both sensitive to the men's need to recover physical capacity quickly while helping them to understand that recovery takes time. Accurate information about expected periods of irritability, side effects, and possible complications would diminish the likelihood of distress during this period.

To tell or not to tell: patterns of disclosure among men with prostate cancer

This paper draws on the results of a longitudinal, qualitative study of men with prostate cancer (treated with prostatectomy) and their spouses. Interviews were conducted separately and simultaneously with men and their spouses, at three points in time (pre-surgery, 8-10 weeks post-surgery and 11-13 months post-surgery). The primary focus in the paper is on men's responses to questions about their decisions to share information (or not) with others about their diagnosis and ongoing medical situation. Most men with prostate cancer avoided disclosure about their illness where possible, and placed great importance on sustaining a normal life. Factors related to limiting disclosure included men's low perceived need for support, fear of stigmatization, the need to minimize the threat of illness to aid coping, practical necessities in the workplace, and the desire to avoid burdening others. This study contributes to an understanding of disclosure issues related to prostate cancer, and raises issues about how best to be helpful to men, given their tendency to minimize the impact of illness, and the need for support.

Preventing perineal trauma during childbirth: a systematic review

OBJECTIVE

To review systematically techniques proposed to prevent perineal trauma during childbirth and meta-analyze the evidence of their efficacy from randomized controlled trials.

DATA SOURCES

MEDLINE (1966-1999), the Cochrane Library (1999 Issue 1), and the Cochrane Collaboration: Pregnancy and Childbirth Database (1995); and reference lists from articles identified. Search terms included childbirth or pregnancy or delivery, and perineum, episiotomy, perineal massage, obstetric forceps, vacuum extraction, labor stage-second. No language or study-type constraints were imposed.

STUDY SELECTION

Randomized controlled trials (RCTs) of interventions affecting perineal trauma were reviewed. If no RCTs were available, nonrandomized research designs such as cohort studies were included. Studies were selected by examination of titles and abstracts of more than 1,500 articles, followed by analysis of the methods sections of studies that appeared to be RCTs. INTEGRATION AND RESULTS: Eligible studies used random or quasirandom allocation of an intervention of interest and reported perineal outcomes. Further exclusions were based on failure to report results by intention to treat, or incomplete or internally inconsistent reporting of perineal outcomes. Final selection of studies and data extraction was by consensus of the first two authors. Data from trials that evaluated similar interventions were combined using a random effects model to determine weighted estimate of risk difference and number needed to treat. Effects of sensitivity analysis and quality scoring were examined. Results indicated good evidence that avoiding episiotomy decreased perineal trauma (absolute risk difference -0.23, 95% confidence interval [CI] -0.35, -0.11). In nulliparas, perineal massage during the weeks before giving birth also protected against perineal trauma (risk difference -0.08, CI -0.12, -0.04). Vacuum extraction (risk difference -0.06, CI -0.10, -0.02) and spontaneous birth (-0.11, 95% CI -0.18, -0.04) caused less anal sphincter trauma than forceps delivery. The mother's position during the second stage has little influence on perineal trauma (supported upright versus recumbent: risk difference 0.02, 95% CI -0.05, 0.09).

CONCLUSION

Factors shown to increase perineal integrity include avoiding episiotomy, spontaneous or vacuum-assisted rather than forceps birth, and in nulliparas, perineal massage during the weeks before childbirth. Second-stage position has little effect. Further information on techniques to protect the perineum during spontaneous delivery is sorely needed.

Randomized trial of perineal massage during pregnancy: perineal symptoms three months after delivery

OBJECTIVE

The aim of this study was to evaluate the effect of perineal massage performed during pregnancy on perineal symptoms 3 months after delivery.

STUDY DESIGN

Pregnant women from 5 hospitals in the province of Quebec, Canada, participated in this single-blind, randomized, controlled trial. All participants received oral and written information on the prevention of perineal trauma. Women in the experimental group were taught the perineal massage technique and were asked to perform a 10-minute perineal massage daily from the 34th through 35th weeks of pregnancy until delivery. Participants completed a self-administered questionnaire on perineal pain, dyspareunia, sexual satisfaction, and incontinence of urine, flatus, and stool at the time of enrollment and 3 months after delivery.

RESULTS

Among participants without a previous vaginal birth there were no differences between the massage (n = 283) and the control (n = 289) groups with respect to perineal pain, dyspareunia, sexual satisfaction, and incontinence of urine, gas, or stool 3 months post partum. Among women with a previous vaginal birth more women in the massage group (n = 187) than in the control group (n = 190) were free of perineal pain (93.6% vs 85.8%; P =.01) but the frequencies of dyspareunia and incontinence of urine, gas, or stool were similar in the 2 groups.

CONCLUSIONS

Perineal massage during pregnancy neither impairs nor substantially protects perineal function at 3 months post partum.

Nurses' perspectives on unconventional therapies

Unconventional therapies have become increasingly popular with health care consumers in recent years. As patients seek information and attempt to make decisions about unconventional therapies, they often turn to nurses, asking the nurse's opinion about certain therapies. The nurse's attitudes and beliefs about unconventional therapies quite likely will influence the response to the patient's inquiries. This article represents the findings of interviews with 20 nurses regarding their perspectives on unconventional therapies. Without exception, all nurses who were interviewed emphasized that information regarding unconventional therapies needs to be available readily for both patients and health care professionals. Other themes identified in the interviews included the following: Various people use unconventional therapies; people seek unconventional therapies for a variety of reasons; communication about unconventional therapies needs to be open, and a place should be found for unconventional therapies. The interviewees saw a clearly defined role for nurses regarding unconventional therapies.

Presurgery experiences of prostate cancer patients and their spouses

PURPOSE

In this article, the authors describe the experiences of men with prostate cancer and their spouses between diagnosis and surgery.

DESCRIPTION

As part of a longitudinal qualitative study, semistructured interviews were held with 34 prostate cancer patients who were waiting for surgery. Separate interviews were held with their spouses.

RESULTS

Six main components of experience were evident from the analysis of transcripts related to the presurgery period: 1) the news of a diagnosis of prostate cancer came initially as a shock for both partners, the impact of which lessened over time; 2) the new reality of illness necessitated readdressing the marital relationship, most often resulting in a sense of renewed connection and commitment; 3) the illness crisis precipitated a search for information to guide decisions about treatment; 4) there was a need for couples to decide who to inform about the cancer diagnosis and how much to say about it; 5) couples attempted to seek a semblance of normality in their lives, especially after treatment decisions had been made; and 6) despite attempts to minimize the potential impact of upcoming surgery, anxiety was typically experienced at least intermittently by one or both partners.

CLINICAL IMPLICATIONS

Physicians, nurses, social workers, and other health professionals need to facilitate attempts by the patient to gather and synthesize information. Cancer specialists can play a positive role in reducing distress in couples, and, thus, the attention of the specialists to communication issues is critical. The strain of waiting for surgery must be considered when treatment recommendations are made; watchful waiting protocols require further study from a psychological perspective. Clinicians need to be alert to the balance between being positive and carrying on as normal, and acknowledging and dealing with the distress that arises.

A randomized controlled trial of nonpharmacologic approaches for relief of low back pain during labor

BACKGROUND

Low back pain is common during labor. Our randomized controlled trial compared the effectiveness of 3 nonpharmacologic approaches for relief of back pain.

METHODS

A total of 34 women suffering from low back pain during labor were randomly assigned to receive 1 of 3 treatments: (1) intracutaneous sterile water injections (ISW); (2) transcutaneous electrical nerve stimulation (TENS); and (3) standard care, including back massage, whirlpool bath, and liberal mobilization. Women self-evaluated both intensity and affective dimensions of pain using visual analog scales. Their evaluations of control and satisfaction were assessed using adapted versions of the Labour Agentry Scale and the Labor and Delivery Satisfaction Index.

RESULTS

Women in the ISW group rated the intensity and unpleasantness of pain during the experimental period significantly lower than women in the standard care group or the TENS group, (P = .001 and P = .003, respectively). Similar results were observed for intensity (P = .01) and unpleasantness (P = .03) of pain assessed just before delivery or request for an epidural. Mean pain intensity at 15 and 60 minutes after randomization was significantly reduced in the ISW group compared with the 2 other groups. There was no significant difference in the 3 groups in the level of control and satisfaction with labor and delivery, but less women in the ISW group indicated that they would like to receive the same treatment for back pain during another delivery.

CONCLUSIONS

Intracutaneous sterile water injections are more effective than standard care (back massage, bath, and mobilization) or transcutaneous electrical nerve stimulation for relieving low back pain during labor.

Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy

OBJECTIVE

The aim of the study was to evaluate the effectiveness of perineal massage during pregnancy for the prevention of perineal trauma at birth.

STUDY DESIGN

Pregnant women with (n = 493) and without (n = 1034) a previous vaginal birth from 5 hospitals in the province of Québec, Canada, participated in this single-blind, randomized, controlled trial. All participants received oral and written information on the prevention of perineal trauma. Women in the experimental groups were requested to perform a 10-minute perineal massage daily from the 34th or 35th week of pregnancy until delivery.

RESULTS

Among participants without a previous vaginal birth, 24.3% (100/411) from the perineal massage group and 15.1% (63/417) from the control group were delivered vaginally with an intact perineum, for a 9.2% absolute difference (95% confidence interval 3.8%-14.6%). The incidence of delivery with an intact perineum increased with compliance with regular practice of perineal massage (chi2 for trend 13.2, P = 0.0003). Among women with a previous vaginal birth, 34.9% (82/235) and 32.4% (78/241) in the massage and control groups, respectively, were delivered with an intact perineum, for an absolute difference of 2.5% (95% confidence interval -6.0% to 11.0%). There were no differences between the groups in the frequency of sutured vulvar and vaginal tears, women's sense of control, and satisfaction with the delivery experience.

CONCLUSION

Perineal massage is an effective approach to increasing the chance of delivery with an intact perineum for women with a first vaginal delivery but not for women with a previous vaginal birth.

Oncology nurses' perspectives on unconventional therapies

Unconventional therapies have become increasingly popular with health care consumers in recent years. As patients seek information and attempt to make decisions about unconventional therapies, they often turn to nurses, asking their opinion about certain therapies. The nurse's attitudes and beliefs about unconventional therapies very likely will influence the response to the patient's inquiries. This work represents the findings of interviews with 48 nurses regarding their perspectives on unconventional therapies. Without exception, all nurses interviewed emphasized the need for information regarding unconventional therapies to be readily available for patients and health care professionals. The other themes identified in the interviews included the following: various people use unconventional therapies; people seek unconventional therapies for a variety of reasons; communication about unconventional therapies needs to be open; and conventional and unconventional practitioners ought to work collaboratively. The participants interviewed saw a clearly defined role for nurses regarding unconventional therapies.