Routine use of oxygen in the treatment of myocardial infarction: systematic review

CONTEXT

International guidelines recommend the routine use of oxygen therapy in the treatment of myocardial infarction (MI).

OBJECTIVE

To undertake a systematic review and meta-analysis of randomised placebo-controlled trials of oxygen therapy in MI.

DATA SOURCES

Medline, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, EMBASE and CINHAL.

STUDY SELECTION

Randomised placebo-controlled trials of oxygen therapy in MI.

DATA EXTRACTION

The primary clinical outcome was mortality.

RESULTS

Two of 51 potential studies met the inclusion criteria. The one study with substantive clinical outcome data reported that in uncomplicated MI, high-flow oxygen was associated with a non-significant increased risk of death (risk ratio 2.9, 95% CI 0.8 to 10.3, p = 0.08) and a greater serum aspartate aminotransferase level (difference 19.2 IU/ml, 95% CI 0 to 38.4, p = 0.05) than room air.

CONCLUSION

The limited evidence that does exist suggests that the routine use of high-flow oxygen in uncomplicated MI may result in a greater infarct size and possibly increase the risk of mortality.

Meta-analysis of the risk of mortality with salmeterol and the effect of concomitant inhaled corticosteroid therapy

BACKGROUND

There is concern that long-acting beta agonist (LABA) drugs may increase the risk of asthma mortality.

METHODS

A meta-analysis was conducted of asthma deaths in randomised controlled clinical trials from the GlaxoSmithKline database that compared salmeterol with a non-LABA comparator treatment in asthma. The Peto one-step method was used to determine the risk overall (all studies) and in derived datasets based on inhaled corticosteroid (ICS) use.

RESULTS

There were 35 asthma deaths in 215 studies with 106,575 subjects. Two studies (SMART and SNS) contributed 30/35 (86%) asthma deaths, the overall findings largely reflecting the characteristics of these studies. The odds ratio for risk of asthma mortality with salmeterol was 2.7 (95% CI 1.4 to 5.3). In 54 placebo controlled studies the risk of death from asthma in patients not prescribed ICS was 7.3 (95% CI 1.8 to 29.4). In 127 studies in which patients were prescribed ICS, the risk of asthma death was 2.1 (95% CI 0.6 to 7.9). In 63 studies in which patients were randomised to receive the combination salmeterol/fluticasone propionate inhaler or ICS, there were no asthma deaths among 22,600 patients.

CONCLUSIONS

Salmeterol monotherapy in asthma increases the risk of asthma mortality and this risk is reduced with concomitant ICS therapy. There is no evidence that combination salmeterol/fluticasone propionate therapy is associated with an increased risk of asthma mortality, although this interpretation is limited by the low statistical power of available studies.

Dose-response relationship for risk of non-vertebral fracture with inhaled corticosteroids

OBJECTIVE

To determine the strength of association between the dose of inhaled corticosteroids (ICS) and risk of non-vertebral fracture in adults.

METHODS

A systematic review and meta-analysis of case-control studies of non-vertebral fractures in adults, in which at least two doses of ICS were reported as the dose of beclomethasone dipropionate (BDP) or equivalent.

RESULTS

Five case-control studies were identified, with a total of 43 783 cases and 259 936 controls. There was an association between the risk of non-vertebral fracture and increasing dose of BDP. The random-effects odds ratio of relative risk for a non-vertebral fracture was 1.12 (95% confidence interval 1.00-1.26) per 1000 microg increase in the daily dose of BDP or equivalent.

CONCLUSION

In older adults, the relative risk of non-vertebral fractures increases by about 12% for each 1000 microg/day increase in the dose of BDP or equivalent. The magnitude of this risk was considerably less than other common risk factors for fracture in the older adult.

Pre-hospital oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

High concentration oxygen is commonly administered during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The aim of this study was to determine the association between oxygen, severity markers and poor outcomes in AECOPD.

METHODS

In an audit of patients with AECOPD arriving by ambulance to the Emergency Department of Wellington Hospital, details of oxygen administration, clinical outcomes and severity markers were documented. The main outcome measure was a composite of death, assisted ventilation, or respiratory failure. Associations between oxygen therapy, severity markers and poor clinical outcomes were assessed by logistic regression.

RESULTS

Of 250 patients 77 (31%) died, required assisted ventilation or were in respiratory failure. Increased oxygen flow was associated with increasing risk of death, assisted ventilation or respiratory failure with an odds ratio (OR) of 1.2 (95% CI 1.0-1.4) per 1 L/min oxygen flow. Increasing PaO(2) was associated with a greater risk of a poor outcome with an OR of 1.1 (95% CI 1.0-1.3) per 10 mmHg higher PaO(2). Home oxygen (OR 2.8, 95% CI 1.5-5.1), previous respiratory failure (OR 2.6, 95% CI 1.5-4.6), previous ventilation (OR 3.2, 95% CI 1.7-5.9) and home nebulizer use (OR 2.4, 95% CI 1.4-4.3) were associated with an increased risk of a poor outcome.

CONCLUSION

In AECOPD high flow oxygen in the ambulance is associated with poor clinical outcomes. A number of easily identified markers of chronic disease severity indicate an increased risk of a poor clinical outcome.

Adherence to antiretroviral therapy among HIV-positive children: examination of the role of caregiver health beliefs

This study examined the association between two components of the Health Belief Model (perceived vulnerability and barriers) and adherence to antiretroviral therapy (ART) among children who are HIV-infected. The parents/caregivers of 30 children (mean age = 5.21, SD = 3.18) who were HIV-infected and who were on active ART were surveyed to assess current methods of adherence assessment and educational efforts within the institution. All participants (except one) were African American and reported low monthly family incomes (M = $869.45, SD = $832.63). Assessment instruments included measures of perceived vulnerability, caregiver-reported adherence and perceived barriers, and objective measures of adherence (clinical pill count; electronic measurement). The results failed to demonstrate a significant relationship between parental perceived vulnerability, perceived barriers and adherence to antiretroviral medications. Methods of assessing adherence provided significantly discrepant estimates of adherence. Results are discussed in terms of implications for patient care and for future research in this area. The addition of behavioural and motivational components to traditional educational approaches may positively impact treatment results.

Risk of mortality associated with formoterol: a systematic review and meta-analysis

There is concern long-acting beta-agonist (LABA) drugs may increase the risk of asthma mortality. We undertook a systematic review which included the AstraZeneca Formoterol Clinical Trial Safety Database and Novartis Food and Drug Administration Formoterol Briefing Document. Randomised controlled clinical trials of duration > or = 4 weeks that compared formoterol with a non-LABA comparator treatment in asthma were included in a meta-analysis of the risk of all-cause mortality and asthma death. Simple contingency tables, Peto's one-step method and a Bayesian analysis were used. There were 42 deaths (nine from asthma) recorded in 62 studies with 49,327 subjects. The simple contingency table odds ratio for risk of all-cause mortality with formoterol was 1.1 (95% CI 0.6-2.2) and for asthma death was 2.7 (95% CI 0.5-26.7). Analyses by the other methods using both "as randomised" and "as exposed" classifications of treatment gave similar risk estimates with wide confidence and credible intervals. We conclude that there was insufficient power to determine whether formoterol increases the risk of mortality. However, the point estimates of a 2.0- to 3.2-fold increased risk of asthma death are not reassuring and add weight to evidence that LABA use in certain circumstances may increase the risk of asthma mortality.

Patterns of external chest compression

We studied the performance of external chest compression by 20 fourth year medical students on 2 study days, separated by 5-7 weeks, 4-8 months after they had been initially trained in cardiopulmonary resuscitation (CPR). Our hypotheses were (1) that a given individual would perform external chest compressions in the same manner each time CPR was performed and (2) that the pattern of performance of chest compressions would be determined, in part, by the anthropometric characteristics of the rescuer. A Laerdal Skillmeter Resusci-Anne CPR manikin chest compression transducer was interfaced with an analogue-to-digital conversion board in a Macintosh LC III computer. Each subject on each study day performed four cycles of 15 compressions and two ventilations twice, once on a table (which raised the surface of the manikin sternum to 95 cm) and once on the floor. For each individual, on each attempt, we calculated the depth and rate of compressions, duty cycle, peak compression velocity, time to peak compression velocity and time to peak compression depth. In addition, we calculated the regression slope of compression depth versus compression number for each cycle of 15 chest compressions and over four cycles of compressions. Statistically significant correlations were observed between the first and second study days in each of the variables of chest compression measured, indicating that the performance of chest compressions was constant over time for a given individual. We observed that the depth of compression, duty cycle, time to peak compression, time to peak velocity and regression slope of depth of compressions versus compression number were significantly related to the height and weight of the rescuer.

The risk of asthma mortality with inhaled long acting beta-agonists

This article reviews the available evidence as to whether inhaled long acting beta-agonists (LABA) increase the risk of asthma mortality and considers the implications for the use of this treatment in the management of asthma. Randomised controlled trials suggest that LABAs prescribed as monotherapy may increase the risk of asthma death in certain circumstances, such as the unsupervised "off-label" use without concomitant inhaled corticosteroid (ICS) treatment in patients with unstable asthma. However, there is also evidence that the use of LABAs in conjunction with ICS treatment in adult asthma as recommended in current guidelines is not associated with an increased risk of asthma mortality. The only way in which a prescriber can ensure that a patient with asthma takes LABA treatment in conjunction with ICS is through a combination ICS/LABA product, an approach which may have additional therapeutic advantages. We propose that in the management of asthma, a case can now be made to limit the availability of LABAs to combination LABA/ICS therapy.

Prolonged seated immobility at work is a common risk factor for venous thromboembolism leading to hospital admission

The role of seated immobility at work in the pathogenesis of venous thromboembolism (VTE) is uncertain. In this case series, 61 patients aged <65 years with a recent admission for deep venous thrombosis and/or pulmonary embolism completed an interviewer-administered questionnaire to obtain information regarding risk factors. Prolonged seated immobility at work in the 4 weeks before the VTE event was defined as being seated at least 8 h in a 24-h period and at least 3 h at a time without getting up, at least 10 h in a 24-h period and at least 2 h at a time without getting up or at least 12 h in a 24-h period and at least 1 h at a time without getting up. The most commonly identified risk factors were family history of VTE (21 of 61, 34%), seated immobility at work (21 of 61, 34%) and a thrombophilic state (19 of 61, 31%). We conclude that prolonged seated immobility at work may represent a common and important risk factor for VTE.

Assessing PaCO2 in acute respiratory disease: accuracy of a transcutaneous carbon dioxide device

BACKGROUND

Pulse oximetry non-invasively assesses the arterial oxygen saturation of patients with acute respiratory disease; however, measurement of the arterial partial pressure of carbon dioxide (PaCO(2)) requires an arterial blood gas. The transcutaneous partial pressure of carbon dioxide (PtCO(2) ) has been used in other settings with variable accuracy. We investigated the accuracy of a PtCO(2) device in the assessment of PaCO(2) in patients with asthma and suspected pneumonia attending the emergency department.

METHODS

Patients with severe asthma (FEV(1) < 50% predicted) or suspected pneumonia (fever, cough and respiratory rate >18/min) were enrolled. Subjects were excluded if they had a history of chronic obstructive pulmonary disease or other conditions associated with respiratory failure. Arterial blood gases were taken at the discretion of the investigator according to clinical need, and paired with a simultaneous reading from the PtCO(2) probe.

RESULTS

Twenty-five patients were studied with one set of data excluded because of poor PtCO(2) signal quality. The remaining 24 paired samples comprised 12 asthma and 12 pneumonia patients. The range of PaCO(2) was 19-64 mmHg with a median of 36.5 mmHg. Bland-Altman analysis showed a mean (SD) PaCO(2) - PtCO(2) difference of -0.13 (1.9) mmHg with limits of agreement of plus or minus 3.8 mmHg (-3.9 to +3.7).

CONCLUSION

A PtCO(2) device was accurate in the assessment of PaCO(2) in patients with acute severe asthma and suspected pneumonia when compared with an arterial blood gas. These bedside monitors have the potential to improve patient care by non-invasively monitoring patients with acute respiratory disease at risk of hypercapnia.

Retrospective review of 27 European cases of fatal elephant endotheliotropic herpesvirus-haemorrhagic disease reveals evidence of disseminated intravascular coagulation

Elephant endotheliotropic herpesvirus haemorrhagic disease (EEHV-HD) is widely acknowledged as the most common cause of mortality in young Asian elephants (Elephas maximus) in captivity. The objective of the current study was to perform a blinded, retrospective pathology review of European EEHV-HD fatalities, constituting the largest systematic assessment of EEHV-HD pathology to date. Findings between viral genotypes were compared with the aim to investigate if disseminated intravascular coagulation (DIC) could be substantiated as a significant complicating factor, thereby increasing the understanding of disease pathophysiology. Immunohistochemical staining confirmed endothelial cell (EC) damage and the presence of EC intranuclear inclusion bodies, demonstrating a direct viral cytopathic effect. Microthrombi were observed in 63% of cases in several organs, including lungs, which, together with widespread haemorrhage and thrombocytopenia reported in EEHV-HD case reports, supports the presence of overt DIC as a serious haemostatic complication of active EEHV infection. Death was attributed to widespread vascular damage with multi-organ dysfunction, including severe acute myocardial haemorrhage and subsequent cardiac failure. Systemic inflammation observed in the absence of bacterial infection may be caused by cytokine release syndrome. Findings reinforce the necessity to investigate cytokine responses and haemostatic status during symptomatic and asymptomatic EEHV viraemia, to potentially support the use of anti-inflammatory treatment in conjunction with anti-viral therapy and cardiovascular support.

Effectiveness of the 2009 seasonal influenza vaccine against pandemic influenza A(H1N1)2009 in healthcare workers in New Zealand, June-August 2009

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Survey of the Royal Australasian College of Physicians examination candidates: preparation and impact on lifestyle

Candidates currently view the Royal Australasian College of Physicians' written examination as a major undertaking, knowing that approximately one-third fail on their first attempt. We anonymously surveyed New Zealand registrars who sat the written examination in 2004. We found that the majority of candidates spend long hours preparing over a several months, and that the examination had a detrimental impact on their personal lives. The results of this survey have important implications in the context of efforts to reduce the stress of doctors, and should lead to a change in either the examination itself or an increase in support provided to registrars preparing for it.

XL43 and XL75: two novel RING finger-containing genes expressed during oogenesis and embryogenesis in Xenopus laevis

This article reports on the isolation of two new Xenopus genes that encode two putative zinc finger proteins. The XL43 and XL75 proteins belong to the RBCC family, and also contains the rfp-like domain. XL43 and XL75 RNAs are found in the ovary, and myc-tagged proteins are detected in mRNA injected oocytes. Whole-mount in situ hybridization of embryos revealed that these two clones are expressed exclusively in neurectodermic and mesodermic tissues. The data suggest that XL43 and XL75 genes could play an important role in the frog's early development, perhaps as a transcription factor. This RBCC family, a subclass of the RING finger family, comprises proteins with known cellular transformation properties. All members possess, besides one RING finger motif, one or two B-boxes, each having a pair of zinc fingers, and a coiled coil domain (Borden, K.L. B. et al., 1996. Proc. Natl. Acad. Sci. USA 93, 1601-1606). Among this group, some members possess, besides the RING-B box-coiled coil (RBCC) motifs, a long C-terminal domain referred to as the rfp-like domain. Although its effective role has not been elucidated yet, this last domain could play an important role by binding a ligand (Bellini, M. et al., 1993. EMBO J. 12, 107-114).

Educating for community-based occupational therapy practice: a demonstration project

SUMMARY This paper describes a demonstration program designed by one university Occupational Therapy program to prepare graduates to work in community-based practice settings. Faculty and students are involved in a partnership with designated community agencies to learn to assess needs, plan programs, and evaluate outcomes using a variety of research methodologies. Completion of the project is tied to the completion of a required master's degree research paper. Results of the first year of the project have been largely successful and those involved look forward to continuing the project in the future. The project is described and recommendations for change based on these results are presented.

B24 protein stored in lampbrush spheres is involved in early cleavage in urodele amphibians

A cDNA encoding a protein (B24) belonging to the Mcm/P1 family was isolated from the newt Triturus carnifex. In eukaryotes, the members of the Mcm/P1 family are essential factors in the DNA replication process. B24 protein (TcMcm3) is present in salamandrid ovarian oocytes and early embryos; its role was tested by injecting specific anti-B24 monoclonal antibodies into the cytoplasm of one blastomere of two-cell stage embryos. The injected blastomere encountered cleavage arrest either soon after the injection or following one or two divisions; later, it degenerated. Instead, the uninjected blastomere went on developing and organizing a hemi-embryo, which does not grow beyond the tailbud stage. These results are consistent with the hypothesis that the B24 protein is involved in DNA replication at cleavage. The B24 protein studied here appears to play a specific role in early development; other variants of the Mcm3 group seem to be employed by different adult tissues.

Effectiveness of the 2009 seasonal influenza vaccine against pandemic influenza A(H1N1)2009 in healthcare workers in New Zealand, June-August 2009

There is uncertainty whether the 2009 seasonal influenza vaccination influences the risk of infection with the 2009 pandemic influenza A(H1N1) virus. This issue was investigated in 548 healthcare workers from Capital and Coast District Health Board, Wellington, New Zealand, presenting with influenza-like illness during the influenza pandemic between June and August 2009. All workers completed an assessment sheet and had a nasopharyngeal swab tested by real-time RT-PCR. The risk of pandemic influenza A(H1N1) infection associated with the 2009 seasonal inactivated trivalent influenza vaccine was determined by logistic regression, with adjustment for potential confounding variables. In 96 workers pandemic influenza A(H1N1) RNA was detected and 452 tested negative. The multivariate analysis did not show any effect of vaccination on PCR-confirmed influenza A(H1N1)2009 infection (odds ratio 1.2, 95% confidence interval 0.7–1.9, p=0.48). We conclude that 2009 seasonal influenza vaccination had no protective effect against influenza A(H1N1)2009 infection amongst healthcare workers. To protect against further waves of the current pandemic influenza or future pandemics in which the influenza virus is antigenically distinct from contemporary seasonal influenza viruses, it would be necessary to vaccinate with a specific pandemic influenza vaccine, or a seasonal influenza vaccine that includes the pandemic influenza serotype.

Rationing health care--should it be done?

1. The utilitarian view supports allocation of goods to meet the needs of the greatest number of people; Lamm contends that the only just rationing would be according to age. 2. Some theorists assume that all individuals will live relatively healthily until the end of their natural lifespan; they do not distinguish between therapeutic medications and those that alleviate suffering. 3. According to intergenerational arguments, children should receive priority in funding, with the elderly at the lower end of the scale. 4. The Advisory Panel of the Office of Technology Assessment recommends rationing based on prognosis and quality of life; however, good prognostic skills are lacking and there is no consensus on quality of life.

A comparative study of the effect of two time-alteration techniques on listener comprehension

The purpose of this investigation was to determine if listener comprehension is differentially affected by two different techniques of time alteration: the sampling method and the harmonic compression method. The Nelson-Denny Reading Test, consisting of 8 selections of scientific and literary content appropriate for college students with respect to interest and level of difficulty, was presented to 3 groups of 40 Ss each; each group was given the tape-recorded test after processing at one of the 3 speech rates, normal, half normal, or twice normal rate. Of the 8 selections on this test, 4 were processed by sampling using a VARISPEECH-I compressor/expander, and 4 were processed by harmonic compression using a Lockheed LM-312 Pitch Normalizer. There were of course some differences in listener comprehension as a function of rate, but within each of the rate conditions there were no significant differences as a function of method of time alteration. With the type of speech material used here, and within these rate conditions, these time alteration methods can be used interchangeably in such research.