Implementing Enhanced Recovery Pathways: A Qualitative Study of Factors That Distinguished Higher Performing Hospitals

OBJECTIVE

The aim of this study was to explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success.

BACKGROUND

Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success.

METHODS

We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from 8 US hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with 9 process measures over time.

RESULTS

Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives.

CONCLUSION

We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.

Towards improving hospital workflows: An evaluation of resources to mobilize patients

AIM

To characterize resources to safely mobilize different types of hospitalized patients.

BACKGROUND

Current approaches to determine nurse-patient ratios do not always include information regarding the specific demands of patients who require extra resources to mobilize. Workflows must be designed with knowledge of resource requirements to integrate patient mobility into the daily nursing team care plan.

METHODS

Nurse-led mobility sessions were evaluated on two adult hospital units, which consisted of nurse-patient encounters focused on patient mobility only. The resources assessed for each session were time-to-mobilize patient, time-to-document, need for additional staff support, and the need for assistive devices. Mobility sessions were also categorized by patient ambulation status, level of mobility limitations (low, medium and high) and diagnosis.

RESULTS

In 212 total mobility sessions, the median time-to-mobilize and time-to-document were 7.75 and 1.27 min, respectively. Additional staff support was required for 87% and 92% of patients with medium and high mobility limitations, respectively. All patients with low mobility limitations ambulated, and only 14% required additional staff. Ambulating patients with high mobility limitations was the most time-intensive (median 12.55 min). Ambulating stroke patients required one additional staff and an assistive device in 92% and 69% of the sessions, respectively.

CONCLUSION

This study describes the resources associated with mobilizing inpatients with different levels of mobility impairments and diagnoses.

IMPLICATIONS FOR NURSING MANAGEMENT

These results could assist nursing management with facilitating appropriate daily nurse-patient ratios and justify the need for assistive devices and staff support to safely mobilize patients.

Pharmacokinetic and pharmacodynamic profile of the sodium-glucose co-transporter-2 inhibitor empagliflozin in young people with Type 2 diabetes: a randomized trial

AIMS

To assess the pharmacokinetic and pharmacodynamic profile of a single dose of empagliflozin in young people with Type 2 diabetes to identify the appropriate doses for further paediatric development.

METHODS

We conducted a single-dose, open-label, randomized, parallel-group study with empagliflozin 5 mg, 10 mg and 25 mg in young people with Type 2 diabetes aged 10-17 years.

RESULTS

Of 39 participants screened, 27 were randomized and completed the study; their mean (± sd) age was 14.1±2.0 years and body weight was 96.7±23.5 kg. Compared with similar studies in adults with Type 2 diabetes, the maximum observed plasma concentrations were slightly lower with the 10-mg and 25-mg doses, and the area under the plasma concentration-time curve was slightly lower with the 10-mg but slightly higher with the 25-mg dose. The adjusted mean increases in urinary glucose excretion were 53 g/24 h (95% CI 32,74), 73 g/24 h (95% CI 52,94) and 87 g/24 h (95% CI 68,107), and the adjusted mean decreases in fasting plasma glucose were 0.9 mmol/l (95% CI -1.6,-0.1), 0.9 mmol/l (95% CI -1.7,-0.2) and 1.1 mmol/l (95% CI -1.8,-0.5) for the 5- 10- and 25-mg doses, respectively. There were no serious adverse events and one investigator-reported drug-related event (dehydration).

CONCLUSIONS

After a single oral dose of empagliflozin, adults and young people with Type 2 diabetes had similar exposure-response relationships after adjusting for significant covariates. These data support testing 10-mg and/or 25-mg doses of empagliflozin in an upcoming paediatric phase III Type 2 diabetes trial. (ClinicalTrials.gov registration no.: NCT02121483).

Narcotics reduction, quality and safety in gynecologic oncology surgery in the first year of enhanced recovery after surgery protocol implementation

OBJECTIVES

Enhanced Recovery After Surgery (ERAS) programs are mechanisms for achieving value-based improvements in surgery. This report provides a detailed analysis of the impact of an ERAS program on patient outcomes as well as quality and safety measures during implementation on a gynecologic oncology service at a major academic medical center.

METHODS

A retrospective review of gynecologic oncology patients undergoing elective laparotomy during the implementation phase of an ERAS program (January 2016 through December 2016) was performed. Patient demographics, surgical variables, postoperative outcomes, and adherence to core safety measures, including antimicrobial and venous thromboembolism (VTE) prophylaxis, were compared to a historical patient cohort (January 2015 through December 2015). Statistical analyses were performed using t-tests, Wilcoxon rank sum tests, and Chi squared tests.

RESULTS

The inaugural 109 ERAS program participants were compared to a historical patient cohort (n=158). There was no difference in BMI, race, malignancy, or complexity of procedure between cohorts. ERAS patients required less narcotics (70.7 vs 127.4, p=0.007, oral morphine equivalents) and PCA use (32.1% vs. 50.6%, p=0.002). Despite this substantial reduction in narcotics, ERAS patients did not report more pain and in fact reported significantly less pain by postoperative day 3. There were no differences in length of stay (5days), complication rates (13.8% vs. 20.3%, p=0.17) or 30-day readmission rates (9.5 vs 11.9%, p=0.54) between ERAS and historical patients, respectively. Compliance with antimicrobial prophylaxis was 97.2%. However, 33.9% of ERAS patients received substandard preoperative VTE prophylaxis.

CONCLUSIONS

ERAS program implementation resulted in reductions in narcotic requirements and PCA use without changes in length of stay or readmission rates. Compliance should be diligently audited during the implementation phase of ERAS programs, with special attention to adherence to pre-existing core safety measures.

Review of the enhanced recovery pathway for children: perioperative anesthetic considerations

PURPOSE

Enhanced recovery after surgery (ERAS) pathways have been used for two decades to improve perioperative recovery in adults. Nevertheless, little is known about their effectiveness in children. The purpose of this review was to consider pediatric ERAS pathways, review the literature concerned with their potential benefit, and compare them with adult ERAS pathways.

SOURCE

A PubMed literature search was performed for articles that included the terms enhanced recovery and/or fast track in the pediatric perioperative period. Pediatric patients included those from the neonatal period through teenagers and/or youths.

PRINCIPAL FINDINGS

The literature search revealed a paucity of articles about pediatric ERAS. This lack of academic investigation is likely due in part to the delayed acceptance of ERAS in the pediatric surgical arena. Several pediatric studies examined individual components of adult-based ERAS pathways, but the overall study of a comprehensive multidisciplinary ERAS protocol in pediatric patients is lacking.

CONCLUSION

Although adult ERAS pathways have been successful at reducing patient morbidity, the translation, creation, and utility of instituting pediatric ERAS pathways have yet to be realized.

The Effect of Preoperative Pregabalin on Postoperative Nausea and Vomiting: A Meta-analysis

BACKGROUND

Nonopioid adjuvant medications are increasingly included among perioperative Enhanced Recovery After Surgery protocols. Preoperative pregabalin has been shown to improve postoperative pain and limit reliance on opioid analgesia. Our group investigated the ability of preoperative pregabalin to also prevent postoperative nausea and vomiting (PONV).

METHODS

Our group performed a meta-analysis of randomized trials that report outcomes on the effect of preoperative pregabalin on PONV endpoints in patients undergoing general anesthesia.

RESULTS

Among all included trials (23 trials; n = 1693), preoperative pregabalin was associated with a significant reduction in PONV (risk ratio [RR] = 0.53; 95% confidence interval [CI], 0.39-0.73; P = 0.0001), nausea (RR = 0.62; 95% CI, 0.46-0.83; P = 0.002), and vomiting (RR = 0.68; 95% CI, 0.52-0.88; P = 0.003) at 24 hours. Subgroup analysis designed to account for major PONV confounders, including the exclusion trials with repeat dosing, thiopental induction, nitrous oxide maintenance, and prophylactic antiemetics and including high-risk surgery, resulted in similar antiemetic efficacy. Preoperative pregabalin is also associated with significantly increased rates of postoperative visual disturbance (RR = 3.11; 95% CI, 1.34-7.21; P = 0.008) compared with a control.

CONCLUSIONS

Preoperative pregabalin is associated with significant reduction of PONV and should not only be considered as part of a multimodal approach to postoperative analgesia but also for prevention of PONV.

The Effect of Preoperative Gabapentin on Postoperative Nausea and Vomiting: A Meta-Analysis

BACKGROUND

Preoperative gabapentin has been shown to improve postoperative pain and limit reliance on opioid analgesia. On the basis of an alternative mechanism, our group investigated the ability of preoperative gabapentin to prevent postoperative nausea and vomiting (PONV).

METHODS

We performed a meta-analysis of trials that reported outcomes on the effect of preoperative gabapentin on PONV end points in patients undergoing general anesthesia. In our primary analysis, we calculated the pooled antiemetic effects of preoperative gabapentin in studies with PONV as the primary end point. In our secondary analysis, we calculated the pooled effects in trials involving preoperative gabapentin that reported on the side effects, nausea and vomiting.

RESULTS

Among the trials designed with PONV as a primary end point (8 trials; n = 838), preoperative gabapentin was associated with a significant reduction in PONV (risk ratio [RR] = 0.60; 99% confidence interval [CI], 0.50-0.72; P < 0.0001), nausea (RR = 0.34; 99% CI, 0.20-0.56; P < 0.0001), and vomiting (RR = 0.34; 99% CI, 0.19-0.61; P = 0.0002) at 24 hours. Among all included trials (44 trials; n = 3489) that reported on the side effects, nausea and vomiting, similar reductions were noted in PONV with preoperative gabapentin administration. Subgroup analysis of trials excluding repeat dosing, thiopental induction, and nitrous oxide maintenance and including high-risk surgery resulted in similar PONV efficacy. Preoperative gabapentin is also associated with significantly increased rates of postoperative sedation (RR = 1.22; 95% CI, 1.02-1.47; P = 0.03) compared with control.

CONCLUSIONS

Preoperative gabapentin is associated with a significant reduction in PONV among studies designed to investigate this end point. Preoperative gabapentin should be considered not only as part of a multimodal approach to postoperative analgesia, but also for prevention of PONV.

Patient outcomes and provider perceptions following implementation of a standardized perioperative care pathway for open liver resection

Background

Enhanced recovery after surgery (ERAS) pathways have been associated with improved perioperative outcomes following several surgical procedures. Less is known, however, regarding their use following hepatic surgery.

Methods

An evidence-based, standardized perioperative care pathway was developed and implemented prospectively among patients undergoing open liver surgery between 1 January 2014 and 31 July 2015. Perioperative outcomes, including length of hospital stay, postoperative complications and healthcare costs, were compared between groups of patients who had surgery before and after introduction of the ERAS pathway. Provider perceptions regarding the perioperative pathway were assessed using an online questionnaire.

Results

There were no differences in patient or disease characteristics between pre-ERAS (42 patients) and post-ERAS (75) groups. Although mean pain scores were comparable between the two groups, patients treated within the ERAS pathway had a marked reduction in opioid use on the first 3 days after surgery compared with those treated before introduction of the pathway (all P &lt; 0·001). Duration of hospital stay was shorter in the post-ERAS group (median 5 (i.q.r. 4–7) days versus 6 (5–7) days in the pre-ERAS group; P = 0·037) and there was a lower incidence of postoperative complications (1 versus 10 per cent; P = 0·036). Implementation of the ERAS pathway was associated with a 40·7 per cent decrease in laboratory costs (−US $333; −€306, exchange rate 4 January 2016) and a 21·5 per cent reduction in medical supply costs (−US $394; −€362) per patient. Although 91·0 per cent of providers endorsed the ERAS pathway, 33·8 per cent identified provider aversion to a standardized protocol as the greatest hurdle to implementation.

Conclusion

The introduction of a multimodal ERAS programme following open liver surgery was associated with a reduction in opioid use, shorter hospital stay and decreased hospital costs. ERAS was endorsed by an overwhelming majority of providers.

Implementation Costs of an Enhanced Recovery After Surgery Program in the United States: A Financial Model and Sensitivity Analysis Based on Experiences at a Quaternary Academic Medical Center

BACKGROUND

Despite positive results from several international Enhanced Recovery After Surgery (ERAS) protocols, the United States has been slow to adopt ERAS protocols, in part due to concern regarding the expenses of such a program. We sought to evaluate the potential annual net cost savings of implementing a US-based ERAS program.

STUDY DESIGN

Using data from existing publications and experience with an ERAS program, a model of net financial costs was developed for surgical groups of escalating numbers of annual cases. Our example scenario provided a financial analysis of the implementation of an ERAS program at a United States academic institution based on data from the ERAS Program for Colorectal Surgery at The Johns Hopkins Hospital.

RESULTS

Based on available data from the United States, ERAS programs lead to reductions in lengths of hospital stay that range from 0.7 to 2.7 days and substantial direct cost savings. Using example data from a quaternary hospital, the considerable cost of $552,783 associated with implementation of an ERAS program was offset by even greater savings in the first year of nearly $948,500, yielding a net savings of $395,717. Sensitivity analysis across several caseload and direct cost scenarios yielded similar savings in 20 of the 27 projections.

CONCLUSIONS

Enhanced Recovery After Surgery protocols have repeatedly led to reduction in length of hospital stay and improved surgical outcomes. A financial model, based on published data and experience, projects that investment in an ERAS program can also lead to net financial savings for US hospitals.

A novel intubation technique for minimally invasive longitudinal studies of rat lungs using hyperpolarized 3He magnetic resonance imaging

Hyperpolarized noble gas (HNG) magnetic resonance imaging (MRI) has been shown to be useful for studying rodent models of lung disease. Image quality can be substantially degraded by signal loss from molecular oxygen entering the airway, requiring invasive surgery to ensure a good seal between the endotracheal (ET) tube and trachea. A modified Foley catheter having an inflatable cuff near the tip provides a novel approach for ensuring image quality for HNG MRI, thereby enabling longitudinal studies and reducing animal numbers. A Foley catheter was modified for rodent intubation and to minimize dead space. Three pairs of age-matched male Sprague Dawley rats 400 (30) g were used. Two pairs were intubated using the Foley and the third with an intravenous catheter. Leak rates were measured from pressure versus time curves within each animal. The pairs were euthanized immediately or six days postrecovery to assess the effects of the procedure on animal health, as reflected by histological examination. The Foley catheter resulted in minimal leak rates (−0.20 (0.03) versus −0.16 (0.05) cmH2O/s), and were shown to be well below upper-limit leak rates of −0.5 and −0.7 cmH2O/s. Tracheal samples from rats in a separate Foley group (not mechanically ventilated) showed superficial damage six days postextubation (grade = 0). 3He imaging performed using the Foley showed good image quality. Though some technical issues remain to be solved, a modified Foley catheter used as an ET tube offers the potential to enable longitudinal studies in rodents and reduce animal numbers.

Variant ataxia-telangiectasia presenting as primary-appearing dystonia in Canadian Mennonites

OBJECTIVE

To compare the phenotype of primary-appearing dystonia due to variant ataxia-telangiectasia (A-T) with that of other dystonia ascertained for genetics research.

METHODS

Movement disorder specialists examined 20 Canadian Mennonite adult probands with primary-appearing dystonia, as well as relatives in 4 families with parent-child transmission of dystonia. We screened for the exon 43 c.6200 C>A (p. A2067D) ATM mutation and mutations in DYT1 and DYT6. Clinical features of the individuals with dystonia who were harboring ATM mutations were compared with those of individuals without mutations.

RESULT

Genetic analysis revealed a homozygous founder mutation in ATM in 13 members from 3 of the families, and no one harbored DYT6 or DYT1 mutations. Dystonia in ATM families mimicked other forms of early-onset primary torsion dystonia, especially DYT6, with prominent cervical, cranial, and brachial involvement. Mean age at onset was markedly younger in the patients with variant A-T (n = 12) than in patients with other dystonia (n = 23), (12 years vs 40 years, p < 0.05). The patients with A-T were remarkable for the absence of notable cerebellar atrophy on MRI, lack of frank ataxia on examination, and absence of ocular telangiectasias at original presentation, as well as the presence of prominent myoclonus-dystonia in 2 patients. Many also developed malignancies.

CONCLUSION

Ataxia and telangiectasias may not be prominent features of patients with variant A-T treated for dystonia in adulthood, and variant A-T may mimic primary torsion dystonia and myoclonus-dystonia.

What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories

BACKGROUND

Surgical patients may be at risk for medication discrepancies that may lead to medication errors because both the anesthesiologist and the surgeon write separate preoperative medication histories.

METHODS

A prospective observational study was conducted to examine the extent of medication and allergy discrepancies between surgical and anesthesia preoperative medication histories for patients admitted to two surgical intensive care units in an academic medical center.

RESULTS

Of the 79 patient records reviewed, 58 (73%) contained at least one discrepancy, 23% had different allergy information, 56% had different preoperative medications, and 43% had different doses or dosing frequencies listed in the medication histories. Of the 988 allergies, medications, and doses or dosing frequencies documented in the two histories, 456 (46%) contained discrepancies. Of these discrepancies, 20 (5%) were due to different allergies, 293 (64%) to different medications, and 143 (31%) to different doses or dosing frequencies.

CONCLUSIONS

Discrepancies in preoperative medication histories between surgical and anesthesia records occur in most patients and further work is required to help improve agreement of patient medication histories between services.

Eliminating catheter-related bloodstream infections in the intensive care unit

OBJECTIVE

To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs).

DESIGN

Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU.

SETTING

The Johns Hopkins Hospital.

PATIENTS

All patients with a central venous catheter in the ICU.

INTERVENTION

To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed.

MEASUREMENT

The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion.

MAIN RESULTS

Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU.

CONCLUSIONS

Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.

Clinical deficits in Huntington disease correlate with reduced striatal uptake on iodine-123 epidepride single-photon emission tomography

Huntington disease (HD) is characterized by severe abnormalities in neurotransmitter concentrations and neuroreceptor density. Quantitative changes in dopamine D(2) receptors occur in the early stages of HD and may be detectable with functional neuroimaging techniques. The aim of this study was to determine whether dopamine D(2) receptor imaging with single-photon emission tomography (SPET) identifies preclinical abnormalities in HD. The study population comprised 32 subjects from families affected by HD: 11 were genetically normal while 21 were genetically positive for HD (seven asymptomatic, six early, three moderate and five advanced findings). Disease severity was determined using a standardized quantitative neurological examination (QNE) and the mini-mental status examination (MMSE). Subjects underwent brain SPET imaging 120 min following intravenous injection of iodine-123 epidepride. Ratios of target (striatal) to nontarget (occipital or whole-brain) uptake were calculated from the reconstructed image data. Striatum to occiput and striatum to whole-brain count ratios correlated negatively with disease stage (P=0.002 and P=0.0002) and QNE (P<0. 002 and P=0.0002), and positively with the MMSE (P=0.001 and P<0. 001). Uptake was significantly reduced in the moderate-advanced subjects but was still normal for the asymptomatic and early symptomatic stages. It is concluded that reductions in striatal dopamine D(2) receptor density can be detected with (123)I epidepride at moderate or advanced stages of HD. In contrast to other reports, we could not identify abnormalities in clinically unaffected or early stages of HD.

Wheeled mobility device database for transportation safety research and standards

To address the issue of safely accessing and securing wheeled mobility devices in motor vehicles, more information characterizing current-production devices was needed. In a recent effort, frame characteristics of wheeled mobility devices were defined and a database developed for recording characteristics relevant to access and securement. A representative number of devices have been surveyed to measure key characteristics, and these measures have been recorded in the database. This paper details the development of the database and frame characterization scheme, the methods used to survey currently available wheeled mobility devices, and some descriptive statistics resulting from an analysis of the data. A discussion of how this information is being used in research aimed at developing technology and safety standards to ensure vehicle access and safe transportation, as well as other potential uses, is also included.

Comparison of iodine-123-epidepride and iodine-123-IBZM for dopamine D2 receptor imaging

Although 123I-IBZM is widely used as a D2 receptor imaging agent, image quality is compromised by a relatively low target-to-nontarget ratio. Animal studies suggest that 123I-epidepride (Kd 0.024 nM) may be superior to 123I-IBZM, but this agent has not been systematically studied in humans.

METHODS

We directly compared 123I-epidepride and 123I-IBZM in five normal volunteers (age range 30-58 yr, mean 43 yr). Brain SPECT imaging was performed 2 hr after the 123I-IBZM injection (average dose 153 MBq). Iodine-123-epidepride scans were performed 1 hr (n = 3), 2 hr (n = 5) and 3 hr (n = 3) postinjection (average dose 149 MBq).

RESULTS

Both radiopharmaceuticals were well tolerated. Iodine-123-epidepride provided excellent visualization of the striatum. Percent specific striatum uptake at 2 hr (71.7 +/- 4.9%) was much greater than with 123I-IBZM (32.6 +/- 5.3%, p < 0.01).

CONCLUSION

Iodine-123-epidepride is a new D2 receptor agent that exhibits excellent neuroimaging properties and has a much higher affinity for striatal uptake than 123I-IBZM.

Shoulder belt anchor location influences on wheelchair occupant crash protection

An investigation of the effect of the shoulder belt's upper anchor point location on crash protection during wheelchair transportation was conducted using a lumped parameter crash victim simulator. While varying the upper anchor point location in each of three directions, the occupant kinematics and injury criteria of the Hybrid III test dummy were determined. Through comparison of these parameters and their associated trends, it was determined that varying the location of the anchor point has a significant effect on the crash protection of the occupant.

Responses within nonfederal hospitals in Pennsylvania to the Americans with Disabilities Act of 1990

BACKGROUND AND PURPOSE

This study described responses within nonfederal hospitals in Pennsylvania to the Americans With Disabilities Act of 1990 (ADA).

SUBJECTS

The target population consisted of all 277 nonfederal hospitals licensed by the Pennsylvania Department of Health and Department of Public Welfare.

METHODS

Questionnaires were mailed to the 270 chief administrators for the 277 hospitals.

RESULTS

One hundred seventeen questionnaires (43.3%) were returned. More facilities had trained their managers regarding the ADA versus their nonmanagerial employees. Overall, 80.3% of the hospitals had an ADA committee or coordinator. Fifty-four percent of the respondents reported that job accommodations cost less than $500. Approximately 45% of the participants cited that the percentage of new construction costs spent to increase accessibility in their hospitals was less than 4.9%. More complaints and legal matters were received by facilities regarding the employment provisions of the ADA rather than the accessibility provisions.

CONCLUSION AND DISCUSSION

The results suggest that hospitals need to monitor ADA-related expenses, more employee training is needed to ensure the ADA's success, and more representation is needed on hospital committees by rehabilitation personnel and individuals with disabilities.

A familial awake movement disorder mimicking restless legs in a sleep apnea patient

We report on a patient with sleep apnea and an unusual familial movement disorder. The movements were present only during wakefulness and nocturnal arousals caused by disordered breathing. A 27-year-old obese man was referred with sleep onset insomnia, symptoms suggesting restless legs syndrome, daytime sleepiness, loud snoring and awakening with choking sensations. He was proven to have obstructive sleep apnea (apnea hypopnea index = 60.6). He also had a daytime movement disorder that was characterized by almost continuous stereotypic tapping of one or both legs. The movements were suppressible and not associated with any unpleasant or abnormal leg sensation. Virtually identical movements were present in three generations of his family. The severity of the movements did not worsen late in the day or with supine posturing. The nocturnal movements, consisting of a visible shaking of one or both legs, occurred only during arousals secondary to the apnea, had a mean duration of 5.7 +/- 3.0 (standard deviation) seconds and could not be defined as periodic limb movements in sleep (PLMS). Successful treatment of apnea by nasal continuous positive airway pressure dramatically reduced the movements during sleep (from 88.2 to 1.9 per hour). The clinical significance and the mechanism of this movement disorder is unknown. We discuss the features inconsistent with restless legs syndrome and consider other possible phenomenology, including akathisia. We conclude that this patient may have a previously unreported familial movement disorder and in addition developed the sleep apnea syndrome related to obesity.

Compliance with dietary prescriptions in children and adolescents with insulin-dependent diabetes mellitus

This study investigated the relationship between compliance with a prescribed diabetic diet and metabolic control of insulin-dependent diabetes mellitus (IDDM). The study sought to determine the degree to which patients translated food exchange prescriptions into appropriate food choices and to identify correlations between metabolic control (as measured by glycosylated hemoglobin level) and compliance with prescribed food exchanges, body mass index (BMI), and intake of energy and fat. Subjects were 40 inpatients and 29 outpatients aged 4 to 18 years with IDDM. Records of the inpatients' food selections for 3 days and 3-day food records collected from the outpatients (or their parents) were analyzed. For all 69 subjects, the mean daily deviation from the prescribed food exchanges was 23.8%, which indicates that subjects added or deleted approximately one of four prescribed exchanges. Records of actual food intake revealed that both patient groups had greater mean energy intakes than had been prescribed: 196 additional kcal for inpatients and 372 additional kcal for outpatients; fat sources accounted for 92% and 68% of the greater energy intake, respectively. No correlation was found between glycosylated hemoglobin level and BMI, energy intake, or fat intake.

Chlamydial antibodies in farmers in north-west England

Because of recent reports of abortion in farmers' wives following infection with ovine strains of Chlamydia psittaci during pregnancy, the distribution of chlamydial antibodies was studied in rural populations in north-west England, where endemic chlamydial infection with abortion is common in sheep. Immunoperoxidase assays with C. trachomatis and ovine C. psittaci showed no significant differences in either the frequency or titres of antibodies between sheep farmers and other types of farmer or non-farming adults living in the same areas. The frequency and titres of antibodies in farmers' wives were no greater than in farmers, and were unrelated to their previous obstetric history or type of farming. Overall, 62/255 (24%) of this rural population had antibody detected by C. trachomatis antigen and only 30/255 (13%) detected by C. psittaci antigen. The possible significance of these findings is discussed. This survey does not suggest that the risk of infection with C. psittaci is especially high in people working with sheep, but the complications following infection during pregnancy deserve the specific instructions that have been given to pregnant women to avoid exposure, especially during lambing, in farming and veterinary work.

Ciprofloxacin treatment of chlamydial infections of urogenital tracts of women

Ciprofloxacin was evaluated in chlamydial infections of the urogenital tracts of women treated with a dosage regimen of 500 mg orally twice a day for seven days. Of the 40 women evaluated, 30 were infected with Chlamydia trachomatis only, two were infected with Neisseria gonorrhoeae only, and a further eight had combined gonococcal and chlamydial infections. Ten were found to be harbouring Chlamydia trachomatis in the urethra as well as the cervix. Neisseria gonorrhoeae was eradicated from all patients with or without concomitant chlamydial infection. The overall chlamydial reisolation rates were 14% (5/35) four weeks after treatment and 23% (6/26) 11 weeks after treatment. The organism was not reisolated from the urethra of any of the patients after treatment. Ciprofloxacin was effective against Mycoplasma hominis, but almost completely ineffective against Ureaplasma urealyticum.

Morbidity after termination of pregnancy in first trimester

The outcome of termination of pregnancy was observed in relation to the preoperative clinical and microbiological findings in 167 women attending a day care abortion unit in Liverpool. Before termination, Chlamydia trachomatis was isolated from the cervix of 19 (11%) of the patients and high counts (greater than 10(4) colour changing units (ccu) per ml of specimen) of mycoplasmas were found in 30 (18%). Coexistent infections with chlamydiae and high counts of mycoplasmas occurred in only seven (4%) women. Trichomonas vaginalis, yeasts, or pathogenic bacteria were found in vaginal swabs from 30 (18%) women. After undergoing termination, seven (4%) women developed pelvic inflammatory disease (PID), five (71%) of whom had yielded C trachomatis before undergoing termination. A further 13 (8%) patients developed minor morbidity of the upper genital tract; high count mycoplasmal infection had been found in seven (54%) and chlamydial infection in three (23%) of these women before termination. In contrast, C trachomatis had been isolated from only 11 (8%) and high counts of mycoplasmas from 23 (16%) of the 147 women who had uneventful recoveries after undergoing termination. No correlation was apparent between the presence of vaginal pathogens before termination and the development of untoward sequelae postoperatively. Neither the history nor clinical examination before termination would have indicated that chlamydial or mycoplasmal infections were present, or that postoperative complications were likely to occur. Abnormal cervical cytology, however, was found in 86 (52%) of women overall, including 15 (79%) of the 19 women with chlamydial infection.

Evaluation of a seven day course of oxytetracycline in women with chlamydial cervicitis

In an urban clinic for sexually-transmitted diseases, 270 women with cervical swabs culture positive for Chlamydia trachomatis were treated with 250 mg oxytetracycline orally four times daily for 7 days. Chlamydial infection was found again in 17 of 220 (7.3%) women examined one month after treatment, and in 12 of 113 (9.7%) women reexamined three months after treatment. Even in cases where reinfection seemed unlikely, only 177 of 198 (89%) were cured. Most post-treatment infections were not clinically apparent, and laboratory follow-up was essential for evaluation of chemotherapy.

Intracerebral infection of mice with ovine strains of Chlamydia psittaci: an animal screening test for the assay of vaccines

Intracerebral inoculation of mice with the A22 strain of ovine C. psittaci gave a reproducible non-lethal infection; multiplication of the inoculum could be quantitated by titration of mouse brain extracts in tissue culture. Mice which had recovered from infection, or which had been inoculated subcutaneously with living organisms of A22 strain, showed solid resistance to intracerebral challenge infection. However, subcutaneous inoculation of formalin-inactivated chlamydia showed little protective effect unless given in very high dosage. Inactivated vaccines of the heterologous ZC113 strain gave better, but still incomplete, protection against A22 challenge infection than did the homologous inactivated vaccine. The implication of these findings is discussed. The mouse intracerebral protection test appears to be a suitable laboratory procedure for assessing the potency of vaccines against enzootic ewe abortion and for comparing the immunological cross-protection between the various strains of C. psittaci currently found in the natural disease in sheep.

Evaluation of ciprofloxacin 500 mg twice daily for one week in treating uncomplicated gonococcal chlamydial, and non-specific urethritis in men

Ciprofloxacin, a quinolone antibacterial, was evaluated in the treatment of gonococcal, chlamydial, gonococcal and chlamydial, and non-gonococcal non-chlamydial urethritis. The dosage regimen used was 500 mg orally twice a day for seven days. Of the 56 patients evaluated 22 had gonococcal infection only, 13 were infected with Chlamydia trachomatis only, seven had combined infection, and 14 were harbouring neither of these organisms. Neisseria gonorrhoeae was cleared in all the 29 patients with or without chlamydial infection. Of those who denied having sexual intercourse during the follow-up period, post gonococcal urethritis (PGU) developed in 12 (63%) out of 19, C trachomatis was isolated again from 11 (78%) out of 14, and urethritis recurred in five (55%) out of nine patients with non-gonococcal non-chlamydial infection. There was also evidence that the dosage regimen used was only partially effective against Ureaplasma urealyticum.

Chlamydial infections of the urethra in women

Cervical and endourethral swabs from 360 untreated women attending a sexually transmitted disease (STD) clinic were cultured for Chlamydia trachomatis and other genitourinary pathogens. The patients included contacts of men with non-gonococcal urethritis, women with gonorrhoea, and those in whom symptoms suggestive of urinary tract infection were the main reasons for their attendance. Chlamydial infection of the urethra was less common than, and seldom occurred in the absence of, cervical chlamydial infection; it was frequently silent, producing no signs or symptoms of urethritis. Only 33/96 women with evidence of urethritis gave chlamydia positive urethral swabs, and 14 of them had other concurrent infections of the genitourinary tract. Chlamydia trachomatis thus does not appear to be a major cause of the signs and symptoms of urethritis commonly found in women attending STD clinics, and there seems to be no indication for taking routine urethral swabs to aid in the diagnosis of chlamydial infection in women.

Lack of effect of highly purified subunit influenza vaccination on theophylline metabolism

Plasma concentrations of theophylline, and urinary recovery of theophylline and its metabolites [1, 3-dimethyluric acid, 3-methyl xanthine and 1-methyluric acid] were measured before and after highly purified subunit influenza vaccination in seven healthy subjects, and five subjects with chronic obstructive bronchitis. No cases of theophylline toxicity were seen, and there was no increase in mean plasma theophylline concentration or significant decrease in urinary metabolite concentration after vaccination. An antibody response to vaccination was demonstrated in all subjects. Highly purified subunit influenza vaccination may be given with safety to patients on theophylline.

An in-vitro investigation of synergy and antagonism between antimicrobials against Chlamydia trachomatis

Chequerboard titrations of antimicrobials were carried out against Chlamydia trachomatis in vitro to assess possible synergy or antagonism. None of the antimicrobial pairs produced any detectable antagonism. Penicillin and ciprofloxacin showed independent activity. Tetracycline and penicillin, tetracycline and erythromycin, tetracycline and chloramphenicol, erythromycin and penicillin, and erythromycin and chloramphenicol showed additive inhibitory activity and limited synergy. Trimethoprim and sulphamethoxazole was the only combination to produce clear synergistic activity against Chlam. trachomatis in vitro.

A comparison of the in-vitro activity of antimicrobials against Chlamydia trachomatis examined by Giemsa and a fluorescent antibody stain

Minimum concentrations for the inhibition of normal chlamydial inclusions (MICN) and abnormal inclusions (MICA) were obtained for a range of antimicrobials titrated against Chlamydia trachomatis in McCoy cell cultures. Each antibiotic titrated produced an MICN which was the same whether examined by Giemsa or fluorescent antibody staining methods (rifampicin 0.007 mg/l, tetracycline, erythromycin and penicillin 0.062 mg/l, chloramphenicol and spiramycin 0.25 mg/l, ciprofloxacin 1.0 mg/l, and cycloserine 250 mg/l). With the exception of penicillin the MICA (Giemsa) was between two- and four-fold higher than the MICN, and the MICA (fluorescent antibody) a further two-fold higher. Penicillin was alone in the wide concentration range over which abnormal inclusions were detected (0.0062 mg/l to 5 g/l).

Abortion due to infection with Chlamydia psittaci in a sheep farmer's wife

A farmer's wife who had helped with lambing aborted spontaneously in March after a short febrile illness in the 28th week of her pregnancy. She developed disseminated intravascular coagulation post partum with acute renal failure and pulmonary oedema. Recovery was complete after two weeks of hospital care. A strain of Chlamydia psittaci, probably of ovine origin, was isolated from the placenta and fetus. The patient's serum showed rising titres of antibody against chlamydia group antigen; the placental and fetal isolates; and a known ovine abortion, but not a known avian, strain of C psittaci. IgG against both ovine abortion and enteric strains of C psittaci was detected, but IgM against only an abortion strain was detected. Histological examination showed pronounced intervillus placentitis with chlamydial inclusions in the trophoblast but no evidence of fetal infection or amnionitis. Laboratory evidence of chlamydial infection was found in an aborting ewe on the farm in January and in remaining sheep and lambs in July. Doctors should recognise the possible risk to pregnant women in rural areas where chlamydial infections in farm animals are widespread.

Genital infections with Chlamydia trachomatis in women attending an antenatal clinic

Cervical swabs for isolation of C. trachomatis and serum for anti-chlamydial antibodies were taken from 252 pregnant women on their first visit to an urban antenatal clinic. Chlamydial infection was found in 18 (7%) women, and antibody at titres greater than 1/32 in 48 (19%); of the 18 infected women only 10 (56%) showed antibody. The likelihood of infection could not have been predicted by urogenital symptoms, the social or medical history or serology. Hypertrophic cervical ectopy and mucopus were significantly more common in infected than in uninfected women but underestimate the true rate of infection. The consorts of 10 infected women had signs of non-gonococcal urethritis but were asymptomatic; C. trachomatis was isolated from the urethra of one man. The indications for routine screening of antenatal patients for chlamydial infections is discussed.

Activity of ciprofloxacin against genital tract pathogens

The in vitro activity of the quinolone carboxylic acid, ciprofloxacin, against a variety of genital tract pathogens was examined. Each of 35 isolates of Neisseria gonorrhoeae, including some beta-lactamase producing strains and strains resistant to tetracycline, was inhibited at a concentration of 0.01 mg/l. Most (13 of 20) strains of Gardnerella vaginalis were inhibited at 1 mg/l but three isolates had minimum inhibitory concentrations (MICs) of 8 mg/l or more. Each of seven strains of Chlamydia trachomatis was completely inhibited at a concentration of 2 mg/l. Prolonged (72 hours) exposure of the chlamydiae to ciprofloxacin was required for inhibition at this concentration.

Intravenous lorazepam in neuroleptic-induced catatonia

Presented here are four cases of catatonic reactions which were felt to be neuroleptic induced. Intravenous lorazepam was rapidly effective in reversing the catatonia and attendant symptoms. Lorazepam's previous uses and pharmacological profile are discussed. Reviewed briefly are catatonia and its neuroleptic-induced forms. Possible mechanisms responsible for the therapeutic effect of intravenous lorazepam in these cases are then examined.

Effects of chloramphenicol on Chlamydia trachomatis infection in neonatal conjunctivitis and in McCoy cell cultures

It was found that 26 of 127 infants with chlamydial conjunctivitis had previously received chloramphenicol eye drops. This treatment had delayed the onset and reduced the degree of oedema, congestion and discharge compared with infected infants with no 'first-line' chemotherapy, but eye swabs remained positive in 22 (85%) of the chloramphenicol treated infants. The problems of designing laboratory tests which might accurately forecast the clinical value, or lack of value of antibiotics in chlamydial infections were investigated. The minimum inhibitory concentration (MIC) of chloramphenicol, against Chlamydia trachomatis in McCoy cell cultures varied widely according to the antibiotic preparation used, the timing and duration of its exhibition in relation to the single step growth cycle of C. trachomatis, and, in particular, the method of examination of infected tissue cultures for residual chlamydial growth after incubation with chloramphenicol.

Effect of cycloheximide on the infective yield of a genital strain of Chlamydia trachomatis in McCoy cells

The yield of infectious progeny of a genital strain of Chlamydia trachomatis in cycloheximide-treated McCoy cell cultures was 11-fold lower than that in untreated monolayers.

Persistence of chlamydial infection after treatment for neonatal conjunctivitis

A high incidence of pharyngeal infection was found in babies with isolation-positive chlamydial conjunctivitis. Chlamydia trachomatis was isolated from the pharynx of 12 (52%) of 23 babies before treatment, and was reisolated from the eyes of 4 (12%) of 34 and from the pharynx of 14 (41%) of 34 after treatment. C trachomatis was reisolated significantly more often from babies treated only with topical tetracycline for 4 weeks (75%) than from those treated with both topical tetracycline and oral erythromycin for 2 weeks (32%). Reisolation from the eyes was associated with only minor clinical signs. Radiological signs of an inflammatory lesion in the chest were found in 2 of 8 babies examined because of persistent cough. These signs were not associated with high or rising titres of serum chlamydial antibody.