Improving the quality of health care: using international collaboration to inform guideline programmes by founding the Guidelines International Network (G-I-N)

Clinical practice guidelines are regarded as powerful tools to achieve effective health care. Although many countries have built up experience in the development, appraisal, and implementation of guidelines, until recently there has been no established forum for collaboration at an international level. As a result, in different countries seeking similar goals and using similar strategies, efforts have been unnecessarily duplicated and opportunities for harmonisation lost because of the lack of a supporting organisational framework. This triggered a proposal in 2001 for an international guidelines network built on existing partnerships. A baseline survey confirmed a strong demand for such an entity. A multinational group of guideline experts initiated the development of a non-profit organisation aimed at promotion of systematic guideline development and implementation. The Guidelines International Network (G-I-N) was founded in November 2002. One year later the Network released the International Guideline Library, a searchable database which now contains more than 2000 guideline resources including published guidelines, guidelines under development, "guidelines for guidelines", training materials, and patient information tools. By June 2004, 52 organisations from 27 countries had joined the network including institutions from Oceania, North America, and Europe, and WHO. This paper describes the process that led to the foundation of the G-I-N, its characteristics, prime activities, and ideas on future projects and collaboration.

Improving the quality of health care: using international collaboration to inform guideline programmes by founding the Guidelines International Network (G-I-N)

Clinical practice guidelines are regarded as powerful tools to achieve effective health care. Although many countries have built up experience in the development, appraisal, and implementation of guidelines, until recently there has been no established forum for collaboration at an international level. As a result, in different countries seeking similar goals and using similar strategies, efforts have been unnecessarily duplicated and opportunities for harmonisation lost because of the lack of a supporting organisational framework. This triggered a proposal in 2001 for an international guidelines network built on existing partnerships. A baseline survey confirmed a strong demand for such an entity. A multinational group of guideline experts initiated the development of a non-profit organisation aimed at promotion of systematic guideline development and implementation. The Guidelines International Network (G-I-N) was founded in November 2002. One year later the Network released the International Guideline Library, a searchable database which now contains more than 2000 guideline resources including published guidelines, guidelines under development, "guidelines for guidelines", training materials, and patient information tools. By June 2004, 52 organisations from 27 countries had joined the network including institutions from Oceania, North America, and Europe, and WHO. This paper describes the process that led to the foundation of the G-I-N, its characteristics, prime activities, and ideas on future projects and collaboration.

Remifentanil vs fentanyl/morphine for pain and stress control during pediatric cardiac surgery

BACKGROUND

Remifentanil is a short acting, potent synthetic opioid that does not accumulate after infusion or repeated bolus doses. It may be rapidly titrated to the requirements of individual patients. Titrated infusion of remifentanil may be able to provide potent analgesia required for pediatric cardiac surgery and obtund the stress response in theater whilst not having the persistent respiratory depression and sedation seen with longer acting opioids.

METHODS

Twenty patients were randomized to receive a titrated infusion of remifentanil (0-1 microg x kg(-1) x min(-1)) or a standard dose of fentanyl (30 microg x kg(-1)) prebypass plus morphine (1 mg x kg(-1)) on rewarming. Blood samples for glucose and cortisol were taken at regular intervals from induction through bypass and into the first 24 h of postoperative intensive care. In addition to biochemical indicators of the stress response we recorded baseline hemodynamic parameters and any acute physiological events.

RESULTS

Ten patients received morphine, seven received remifentanil. There were no statistically significant differences between the two treatment groups in cortisol measurements, mean arterial pressure or heart rate recordings. In the last time period the remifentanil group had a larger rise in blood glucose concentration (baseline 3.9, rise 3 mmol x l(-1)) than the fentanyl/morphine group (baseline 4.2 rise 1.9 mmol x l(-1)), CI -4.3 to -0.2.

CONCLUSIONS

The only significant difference was in glucose in the postbypass time periods. Although statistically significant, this difference is insufficient evidence of increased stress in the remifentanil group. The results show that in the patients studied there was no clinically important difference between the two techniques.

Control of endemic MRSA-what is the evidence? A personal view

Although there is extensive literature on the control of MRSA, when that concerning epidemics is excluded, only a limited amount remains regarding the control of endemic MRSA. Several guidelines have been recently published recommending stringent control measures, which are often suggested based on their success in controlling MRSA outbreaks in hospitals with few MRSA or in containing MRSA cases introduced into a hospital with no MRSA. In these settings, multiple measures are usually introduced with apparently successful results. However, results may not be generalizable to other settings and we do not know the minimum effective measures required for MRSA containment. This paper aims critically to review the literature to determine whether evidence exists for the value of the infection control measures that are widely recommended in the endemic setting. Much of this literature is based on observational studies, with few randomized, controlled trials having been conducted. More well-designed studies are required before many of the principles on which we build infection control programmes can be regarded as evidence based.

Risk factors for acquisition of methicillin-resistant Staphylococcus aureus (MRSA) by trauma patients in the intensive care unit

In a previous study in the intensive care unit (ICU) of the Alfred Hospital, Melbourne, Australia, it was demonstrated that trauma patients were at particular risk of becoming colonized by methicillin-resistant Staphylococcus aureus (MRSA). We examined risk factors for MRSA acquisition in these patients using a cohort study comparing the 31 patients who acquired MRSA with 65 who did not. Data collected included ICU length of stay (LOS), mechanism of trauma, site of injury, type of surgery, trauma severity and antibiotic usage. Odds ratios (OR) were determined and adjusted for LOS. LOS in the ICU was a significant univariate predictor of MRSA acquisition (OR 13.7). When adjusted for LOS, mechanism of trauma (OR 10.4), laparotomy (OR 6.3) and administration of ticarcillin/clavulanic acid (OR 4.5) or glycopeptides (OR 5.9) remained significant. We confirmed our previous finding that LOS was associated with MRSA acquisition. Receipt of antibiotics correlated with reported literature. Novel associations were road trauma as a mechanism and laparotomy.

White cell scanning for inflammatory bowel disease: are biochemical markers useful referral criteria?

The aim of this study was to determine whether biochemical markers for inflammation could prove effective in identifying the most appropriate patients with suspected inflammatory bowel disease (IBD) for labelled white cell scanning. One hundred and twenty-five patients referred for 99mTc-HMPAO labelled white cell scans were investigated. The values of C-reactive protein (CRP), antichymotrypsin (ACT) and acid glycoprotein (AGP) were measured in 73 patients, AGP and CRP in 10 and CRP only in a further 42. Sensitivity and specificity of each test were calculated using the white cell scan result as the 'gold standard'. ACT had the highest specificity (1.0), but the lowest sensitivity (0.27) of the three markers. CRP (using specified limits) had the lowest specificity (0.67) and the highest sensitivity (0.79). The corresponding values for AGP are 0.87 and 0.48. The low sensitivity of ACT and AGP preclude them from being useful referral criteria. CRP (using specified limits) is the most sensitive marker, but not sensitive enough to be useful as a referral indicator. However, by lowering the upper limit of normal to 5 mg.l-1, the sensitivity of the test increases to 0.96. Using this threshold to select the patients, 30% would not have been scanned and only one patient out of the 22 with IBD would have been missed. Where there is high demand for white cell scans this may provide a useful strategy for rationalizing the requests with minimal consequence on clinical management.

The effect of clomethiazole on plasma concentrations of interleukin-6, -8, -1beta, tumor necrosis factor-alpha, and neutrophil adhesion molecule expression during experimental extracorporeal circulation

Clomethiazole (CMZ), a neuroprotective drug, has antiinflammatory actions. We investigated the effects of CMZ administration on plasma concentrations of interleukin (IL)-6, IL-8, IL-1beta, tumor necrosis factor-alpha, and neutrophil adhesion molecule expression during experimental extracorporeal circulation. Five healthy volunteers each donated 500 mL of blood, which was subsequently divided into equal portions. Identical extracorporeal circuits were simultaneously primed with donated blood (250 mL) and circulated for 2 h at 37 degrees C. CMZ was added to 1 of the circuits of each pair to achieve a total plasma concentration of 40 micro mol/L. Blood samples were withdrawn at (i) donation, (ii) immediately after addition of CMZ, and at (iii) 30, 60, 90, and 120 min after commencing circulation. Plasma concentrations of IL-6, IL-8, and tumor necrosis factor-alpha were less in the CMZ group compared with control after 60 min of circulation (2.2 [0.3] versus 3.2 [0.4], 14.9 [4.8] versus 21.9 [18.4], 63.3 [43.5] versus 132.2 [118.9] pg/mL, respectively, P < 0.05). After 120 min of circulation, neutrophils from CMZ-treated circuits showed significantly less CD18 expression compared with control (237.5 [97.4] versus 280.5 [111.5], P = 0.03). The addition of CMZ to experimental extracorporeal circuits decreases the inflammatory response. This effect may be of clinical benefit by decreasing inflammatory-mediated neurological injury during cardiopulmonary bypass.

IMPLICATIONS

Enhancement of gamma-aminobutyric acid(A)-mediated effects by clomethiazole (CMZ) and associated neuroprotection has been established in animal models of cerebral ischemia. In an ex vivo study, we demonstrated antiinflammatory activity of CMZ in experimental extracorporeal circulation. This represents a potential neuroprotective mechanism of CMZ in patients undergoing coronary artery bypass surgery.

Intraoperative mannitol does not prevent renal failure in orthotopic liver transplantation

OBJECTIVE

To undertake a prospective randomised controlled study to investigate whether there is any beneficial renal effect in the perioperative administration of mannitol in patients undergoing orthotopic liver transplantation.

METHODS

Patients presenting in end-stage liver failure for orthotopic liver transplantation had their preoperative renal function assessed by 24 hour urinary creatinine clearance. In a randomised double-blind study they were allocated to receive either mannitol 0.5 g/kg intravenously, or an equivalent volume of 0.9% saline, after induction. All patients had central venous, peripheral and pulmonary artery catheters inserted and received intravenous fluids, blood and blood products based on central pressure measurements, thromboelastographic monitoring, and blood biochemistry. All patients also received intravenous dopamine 2.5-3.0 microg/kg/min. Intravenous fluids and urine production were recorded intraoperatively and for the first 24 hours in intensive care.

RESULTS

Twenty five patients were enrolled, 13 in the control group and 12 in the mannitol group. There was no significant difference in the preoperative creatinine clearances (control group 72.1 +/- 24.5 mL/min; mannitol group 65.1 +/- 33 mL/min, p = 0.45), total intraoperative fluid requirements (control group 10,741 +/- 4517 mL; mannitol group 13,852 +/- 11,827 mL, p = 0.38) or intraoperative urine production (control group 1323 +/- 1419 mL; mannitol group 912 +/- 493 mL, p = 0.35).

CONCLUSIONS

We conclude that intraoperative mannitol does not help preserve renal function in the patient undergoing liver transplantation.

Regulation of mitogen-activated protein kinases in cardiac myocytes through the small G protein Rac1

Small guanine nucleotide-binding proteins of the Ras and Rho (Rac, Cdc42, and Rho) families have been implicated in cardiac myocyte hypertrophy, and this may involve the extracellular signal-related kinase (ERK), c-Jun N-terminal kinase (JNK), and/or p38 mitogen-activated protein kinase (MAPK) cascades. In other systems, Rac and Cdc42 have been particularly implicated in the activation of JNKs and p38-MAPKs. We examined the activation of Rho family small G proteins and the regulation of MAPKs through Rac1 in cardiac myocytes. Endothelin 1 and phenylephrine (both hypertrophic agonists) induced rapid activation of endogenous Rac1, and endothelin 1 also promoted significant activation of RhoA. Toxin B (which inactivates Rho family proteins) attenuated the activation of JNKs by hyperosmotic shock or endothelin 1 but had no effect on p38-MAPK activation. Toxin B also inhibited the activation of the ERK cascade by these stimuli. In transfection experiments, dominant-negative N17Rac1 inhibited activation of ERK by endothelin 1, whereas activated V12Rac1 cooperated with c-Raf to activate ERK. Rac1 may stimulate the ERK cascade either by promoting the phosphorylation of c-Raf or by increasing MEK1 and/or -2 association with c-Raf to facilitate MEK1 and/or -2 activation. In cardiac myocytes, toxin B attenuated c-Raf(Ser-338) phosphorylation (50 to 70% inhibition), but this had no effect on c-Raf activity. However, toxin B decreased both the association of MEK1 and/or -2 with c-Raf and c-Raf-associated ERK-activating activity. V12Rac1 cooperated with c-Raf to increase expression of atrial natriuretic factor (ANF), whereas N17Rac1 inhibited endothelin 1-stimulated ANF expression, indicating that the synergy between Rac1 and c-Raf is potentially physiologically important. We conclude that activation of Rac1 by hypertrophic stimuli contributes to the hypertrophic response by modulating the ERK and/or possibly the JNK (but not the p38-MAPK) cascades.

Radiation protection consequences of the care of a terminally ill patient having received a thyroid ablation dose of 131I-sodium iodide

The death of a patient soon after an ablation dose of 131I-sodium iodide is a rare occurrence. We report a case of a patient who died, following emergency surgery to treat gastric bleeding, whilst still radioactive. The doses received by clinical staff involved in management of the patient were measured and were found to be within acceptable limits. However, there was an appreciable level of unsealed radioactivity in the Intensive Care Unit. The issues raised by this case are discussed in the context of legislative requirements and the worst case scenario. The event highlights the need for close liaison between the different specialities to ensure that clinical staff are properly advised and that necessary safety precautions are taken to avoid compromising the safety of staff or the care of the patient.

Angiogenesis in necrotic ulcers treated with hyperbaric oxygen

Necrotic/gangrenous wounds lack adequate blood supply and develop further vascular damage from either reperfusion injury or oxygen toxicity when exposed to oxygen at the wrong pressures. A prospective randomized study was performed to confirm the efficacy of topical hyperbaric oxygen at 1.004 to 1.013 atmospheres (THOT) in stimulating angiogenesis and healing of necrotic/gangrenous wounds. Participants included 40 inpatients (79 ulcers) recruited over 12 months who were assigned to treatment by either THOT or standard wound care (SWC). The results showed that 90% of the wounds healed in the THOT group compared to 22% in the SWC controls. Repeated measures ANOVA on log (ulcer size at 4 weeks) showed a significant group by time interaction, F(1,55) = 68.2, P < 0.0001. The size of ulcers (at 4 weeks) was significantly smaller with THOT, but larger with SWC. Capillary density/hpf (high power field) was significantly higher in THOT wounds than in SWC wounds (P < 0.001). It was concluded that THOT is effective in stimulating angiogenesis with enhanced healing of necrotic wounds.

Hippocampal volume and everyday memory in children of very low birth weight

Children born preterm and of very low birth weight have an increased incidence of learning difficulties, but little is known about the specific nature of their cognitive deficits and the underlying neuropathology. We hypothesized that their vulnerability to hypoxic, metabolic, and nutritional insults would lead to reduced hippocampal volumes and to deficits in memory because of the role of the hippocampus in this domain of cognition. Neuropsychological and magnetic resonance imaging methods were used to investigate this hypothesis in adolescents born preterm (< or = 30 wk gestation, n = 11) or full-term (n = 8). The preterm group had significantly smaller hippocampal volumes bilaterally, despite equivalent head size, and showed specific deficits in certain aspects of everyday memory, both on objective testing and as indicated by parental questionnaires. The preterm group also had a specific deficit in numeracy. The reduced hippocampal volumes and deficits in everyday memory have previously been unrecognized, but their prevalence in a group of neurologically normal children is striking.

PI-3-kinase is an essential anti-apoptotic effector in the proliferative response of primary human epithelial cells to mutant RAS

In contrast to its growth-inhibitory effect on primary mesenchymal cells, RAS oncogene activation induces a proliferative phenotype in normal human thyroid epithelial cells in vitro, consistent with its putative role in tumour initiation. Using this model, we previously showed that activation of the MAP kinase (MAPK) pathway is necessary, but not sufficient for the proliferative response to mutant (V12) H-RAS. Here we extend this work to show that another major RAS effector-- phosphatidylinositol-3-kinase (PI-3-K)--while also insufficient alone, is able to synergize with MAPK activation to mimic the effect of mutant RAS, albeit at reduced efficiency. Furthermore we show that PI-3-K is an absolute requirement for the proliferative response to RAS in these cells, acting via suppression of RAS-induced apoptosis. These data extend our understanding of RAS signalling in a clinically-relevant cell context and point to the use of PI-3-K inhibitors as potential therapeutic agents for targetting human cancers induced by RAS mutation.

Epidemiology and molecular typing of an outbreak of tuberculosis in a hostel for homeless men

AIM

To investigate a possible outbreak of tuberculosis in a hostel for homeless men using IS6110 profiling, a polymerase chain reaction (PCR) based fingerprinting technique.

METHODS

Eight cases of tuberculosis were diagnosed in residents of the hostel over a period of 28 months. To provide epidemiological data, a heminested inverse PCR (HIP) assay targeting the insertion sequence IS6110 together with its upstream flanking region was used to fingerprint the eight isolates of M tuberculosis under investigation.

RESULTS

The HIP technique gave IS6110 profiles which showed that while three isolates were clearly distinct, the remaining five strains were indistinguishable, suggesting the latter were representatives of a single outbreak strain.

CONCLUSIONS

The HIP assay proved discriminatory and facilitated repeated testing for the direct comparison of strains as more patients presented over the protracted course of this outbreak.

How do small GTPase signal transduction pathways regulate cell cycle entry?

A variety of studies have shown that activation of the cell cycle machinery requires the participation of multiple signalling pathways. These pathways include Ras-dependent effectors such as the extracellular-signal related kinases, otherwise known as mitogen-activated protein kinases (ERKs, MAPKs), phosphatidylinositol 3 (PI3)-kinase and p21Ral pathways, as well as other signalling pathways regulated by the small GTPases p21Rho, p21Rac and p21Cdc42.

Emergency physicians versus laboratory technicians: are the urinalysis and microscopy results comparable? A pilot study

In the literature to date, there are no studies that directly evaluate microscopic urine examination results obtained by a physician compared to those of a trained laboratory technician. Our purpose in undertaking this study was to determine whether there would be comparable results obtained by these two groups. The study took place in an Emergency Medicine Department with 45,000 visits annually. Each urine sample obtained on patients presenting to the Emergency Department was divided into two lots: one was sent to the laboratory and the other was analyzed by the emergency physician. A comparison of both dipstick and microscopic results by physician and laboratory staff was then made using sensitivity, specificity, and Kappa analysis. Statistical analysis of the data revealed close agreement between the emergency physician and laboratory technician with respect to the following components of urinalysis: red blood cell urinalysis and microscopy, leukocyte esterase, and nitrite testing. Microscopy for white cells and bacteria and testing for proteinuria were not in close agreement. Urinalysis by emergency physicians is comparable to laboratory technicians for a number of the testing components. However, in this limited pilot study, emergency physicians were not able to consistently perform urinalysis for the laboratory standard.

Endothelin-1 is elevated in monocrotaline pulmonary hypertension

These studies document striking pulmonary vasoconstrictor response to nitric oxide synthase (NOS) inhibition in monocrotaline (MCT) pulmonary hypertension in rats. This constriction is caused by elevated endothelin (ET)-1 production acting on ETA receptors. Isolated, red blood cell plus buffer-perfused lungs from rats were studied 3 wk after MCT (60 mg/kg) or saline injection. MCT-injected rats developed pulmonary hypertension, right ventricular hypertrophy, and heightened pulmonary vasoconstriction to ANG II and the NOS inhibitor NG-monomethyl-L-arginine (L-NMMA). In MCT-injected lungs, the magnitude of the pulmonary pressor response to NOS inhibition correlated strongly with the extent of pulmonary hypertension. Pretreatment of isolated MCT-injected lungs with combined ETA (BQ-123) plus ETB (BQ-788) antagonists or ETA antagonist alone prevented the L-NMMA-induced constriction. Addition of ETA antagonist reversed established L-NMMA-induced constriction; ETB antagonist did not. ET-1 concentrations were elevated in MCT-injected lung perfusate compared with sham-injected lung perfusate, but ET-1 levels did not differ before and after NOS inhibition. NOS inhibition enhanced hypoxic pulmonary vasoconstriction in both sham- and MCT-injected lungs, but the enhancement was greater in MCT-injected lungs. Results suggest that in MCT pulmonary hypertension, elevated endogenous ET-1 production acting through ETA receptors causes pulmonary vasoconstriction that is normally masked by endogenous NO production.

Collaborative prototyping approaches for ICU decision aid design

When computer-based aids do not support the human users' decision-making strategies or anticipate the organizational impacts of technological change, advances in information technology may degrade rather than enhance decision-making performance. Such failures suggest the design of human-computer cooperation for problem solving and decision-making must be driven by human cognitive and organizational process requirements rather than computer technology. Decision- and user-centered development techniques involve domain experts and end-users in the earliest phases of design to evolve an understanding of requirements through iterative prototyping. This paper presents a collaborative approach to cognitive systems engineering applied to developing a clinical aid to assist respiratory care in the surgical ICU.

Evaluation of a protocol for the non-operative management of perforated peptic ulcer

BACKGROUND

The non-operative management of perforated peptic ulcer has previously been shown to be both safe and effective although it remains controversial. A protocol for non-operative management was set up in this hospital in 1989. Adherence to the guidelines in the protocol has been audited over a 6-year period with a review of outcome.

METHODS

The case-notes of patients with a diagnosis of perforated peptic ulcer were reviewed. Twelve guidelines from the protocol were selected for evaluation of compliance to the protocol.

RESULTS

Forty-nine patients underwent non-operative treatment initially. Eight patients failed to respond and underwent operation. Complications included abscess formation (seven patients), renal failure (one), gastric ileus (one), chest infection (two), and cardiac failure and stroke (one). Four deaths occurred in this group. Adherence to certain protocol guidelines was poor, notably those concerning prevention of thromboembolism, use of antibiotics, use of contrast examination to confirm the diagnosis and referral for follow-up endoscopy. Two gastric cancers were detected on subsequent endoscopy.

CONCLUSION

This experience demonstrates that non-operative treatment can be used successfully in a general hospital. Adherence to protocol guidelines was found to be variable and the protocol has therefore been simplified. This study highlights the need for an accurate diagnosis and the importance of follow-up endoscopy.

Role of wall tension in hypoxic responses of isolated rat pulmonary arteries

The changes in force developed during 40-min exposures to hypoxia (37 +/- 1 mmHg) were recorded in large (0.84 +/- 0.02-mm-diameter) and small (0.39 +/- 0.01-mm-diameter) intrapulmonary arteries during combinations of mechanical wall stretch tensions (passive + active myogenic components), equivalent to transmural vascular pressures of 5, 15, 30, 50, and 100 mmHg, and active (vasoconstriction) tensions, stimulated by PGF2alpha in doses of 0, 25, 50, and 75% effective concentrations. Constriction was observed in all arteries during the first minute; however, at any active tension, the pattern of the subsequent response was a function of the stretch tension. At 5, 15, and 30 mmHg, the constriction decreased slightly at 5 min and then increased again to remain constrictor throughout. At 50 and 100 mmHg, the initial constriction was followed by persistent dilation. Hypoxic constrictor responses, most resembling those observed in lungs in vivo and in vitro, were observed when the mechanical stretch wall tension was equivalent to 15 or 30 mmHg and the dose of PGF2alpha was 25 or 50% effective concentration. These observations reconcile many apparently contradictory results reported previously.

Glycopeptide-induced vasculitis--cross-reactivity between vancomycin and teicoplanin

Teicoplanin has been suggested for use in patients suffering complications from vancomycin. We describe two patients who developed a vasculitic rash whilst on vancomycin with recrudescence of the rash with subsequent teicoplanin therapy.

Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review

BACKGROUND

Single-dose antimicrobial prophylaxis for major surgery is a widely accepted principle; recommendations have been based on laboratory studies and numerous clinical trials published in the last 25 years. In practice, single-dose prophylaxis has not been universally accepted and multiple-dose regimens are still used in some centres. Moreover, the principle has recently been challenged by the results of an Australian study of vascular surgery. The aim of this current systematic review is to determine the overall efficacy of single versus multiple-dose antimicrobial prophylaxis for major surgery and across surgical disciplines.

METHODS

Relevant studies were identified in the medical literature using the MEDLINE database and other search strategies. Trials included in the review were prospective and randomized, had the same antimicrobial in each treatment arm and were published in English. Rates of postoperative surgical site infections (SSI) were extracted, 2 x 2 tables prepared and odds ratios (OR) [with 95% confidence intervals (95% CI)] calculated. Data were then combined using fixed and random effects models to provide an overall figure. In this context, a high value for the combined OR, with 95% CI > 1.0, indicates superiority of multiple-dose regimens and a low OR, with 95% CI < 1.0, suggests the opposite. A combined OR close to 1.0, with narrow 95% CI straddling 1.0, indicates no clear advantage of one regimen over another. Further subgroup analyses were also performed.

RESULTS

Combined OR by both fixed (1.06, 95% CI, 0.89-1.25) and random effects (1.04, 95% CI, 0.86-1.25) models indicated no clear advantage of either single or multiple-dose regimens in preventing SSI. Likewise, subgroup analysis showed no statistically significant differences associated with type of antimicrobial used (beta-lactam vs other), blinded wound assessment, length of the multiple-dose arm (> 24 h vs 24 h or less) or type of surgery (obstetric and gynaecological vs other).

CONCLUSIONS

Continued use of single-dose antimicrobial prophylaxis for major surgery is recommended. Further studies are required, especially in previously neglected surgical disciplines.

Bowel dysfunction after bladder reconstruction

PURPOSE

Bowel function may be disturbed after intestinal segments are used in urinary reconstruction. The etiology of this condition and its incidence in different patient groups is unclear. We studied the incidence of bowel disturbance in patients who underwent bladder replacement, continent diversion, enterocystoplasty for idiopathic detrusor instability and ileal conduit diversion.

MATERIALS AND METHODS

We evaluated 71 patients after ileal conduit diversion and 82 after bladder reconstruction, including clam enterocystoplasty for detrusor instability in 28, neurogenic bladder dysfunction in 26 and nonneuropathic conditions in 28. We noted the severity of symptoms, such as frequency of defecation, nocturnal diarrhea, flatus leakage, fecal urgency, fecal incontinence and explosive diarrhea, as well as quality of life.

RESULTS

Of the patients who underwent bladder reconstruction 24% had symptoms of bowel dysfunction preoperatively and 42% of those who were asymptomatic preoperatively described new bowel symptoms postoperatively. These symptoms were most common and severe in 54% of patients after clam enterocystoplasty for detrusor instability compared to 26% with neuropathy, 14% with a nonneuropathic condition and 15% with an ileal conduit. Compared to those in other groups patients who underwent enterocystoplasty for detrusor instability had a significantly higher incidence of nocturnal bowel movements (18 versus less than 4%, p <0.01), flatus leakage (29 versus less than 8%, p <0.01), fecal urgency (39 versus less than 12%, p <0.001) and fecal incontinence (32 versus less than 16%, p <0.001). The length of ileum used for clam enterocystoplasty was only slightly greater than that used for ileal conduit operations (25 versus 18 cm.). Of the patients who underwent enterocystoplasty for detrusor instability 29% regretted undergoing the procedure due to subsequent bowel symptoms.

CONCLUSIONS

After enterocystoplasty for detrusor instability patients are at risk of significant bowel symptoms. The development of new bowel symptoms was associated with poor patient satisfaction.

Improved oxygenation with prostaglandin F2alpha with and without inhaled nitric oxide in dogs

Dogs of mixed breed (n = 7) were anesthetized, right lung atelectasis was established, and the cyclooxygenase pathway was blocked with ibuprofen. Measurements of pulmonary gas exchange were performed (fractional concentration of inspired O2 = 0.95) after infusions of prostaglandin F2alpha (PGF2alpha; 2 microg . kg-1 . min-1), ventilation with nitric oxide (NO; 40 ppm), or both (PGF2alpha + NO) in random order. The arterial PO2 (PaO2) under control conditions was 117 +/- 16 Torr (shunt = 33 +/- 2.5%), was unchanged with NO alone (PaO2 = 114 +/- 17 Torr; shunt = 35.7 +/- 3. 1%), but was significantly improved with PGF2alpha alone (PaO2 = 180 +/- 28 Torr; shunt = 23.2 +/- 2.8%) and with the combination of PGF2alpha + NO (PaO2 = 202 +/- 30 Torr; shunt = 20.9 +/- 2.5%). The addition of NO did not significantly enhance the effectiveness of the PGF2alpha on PaO2. Simulation of these data in a computer model, combining pulmonary gas exchange and pulmonary blood flow, reproduced the results on the basis that vasoconstriction with PGF2alpha was maximal under hypoxia in the atelectatic lung and reduced by hyperoxia in the ventilated lung, consistent with the hypothesis of O2 dependence of PGF2alpha vasoconstriction.

Improvement in oxygenation by phenylephrine and nitric oxide in patients with adult respiratory distress syndrome

BACKGROUND

Inhaled nitric oxide (NO), a selective vasodilator, improves oxygenation in many patients with adult respiratory distress syndrome (ARDS). Vasoconstrictors may also improve oxygenation, possibly by enhancing hypoxic pulmonary vasoconstriction. This study compared the effects of phenylephrine, NO, and their combination in patients with ARDS.

METHODS

Twelve patients with ARDS (PaO2/FIO2 <le> 180; Murray score <me> 2) were studied. Each patient received three treatments in random order: intravenous phenylephrine, 50-200 micrograms/min, titrated to a 20% increase in mean arterial blood pressure; inhaled NO, 40 ppm; and the combination (phenylephrine+NO). Hemodynamics and blood gas measurements were made during each treatment and at pre- and posttreatment baselines.

RESULTS

All three treatments improved PaO2 overall. Six patients were "phenylephrine-responders" (delta PaO2 > 10 mmHg), and six were "phenylephrine-nonresponders." In phenylephrine-responders, the effect of phenylephrine was comparable with that of NO (PaO2 from 105 +/- 14 to 132 +/- 14 mmHg with phenylephrine, and from 110 +/- 14 to 143 +/- 19 mmHg with NO), and the effect of phenylephrine+NO was greater than that of either treatment alone (PaO2 from 123 +/- 13 to 178 +/- 23 mmHg). In phenylephrine-nonresponders, phenylephrine did not affect PaO2, and the effect of phenylephrine+NO was not statistically different from that of NO alone (PaO2 from 82 +/- 12 to 138 +/- 28 mmHg with NO; from 84 +/- 12 to 127 +/- 23 mmHg with phenylephrine+NO). Data are mean +/- SEM.

CONCLUSIONS

Phenylephrine alone can improve PaO2 in patients with ARDS. In phenylephrine-responsive patients, phenylephrine augments the improvement in PaO2 seen with inhaled NO. These results may reflect selective enhancement of hypoxic pulmonary vasoconstriction by phenylephrine, which complements selective vasodilation by NO.

Pulmonary artery NADPH-oxidase is activated in hypoxic pulmonary vasoconstriction

An NADPH-oxidase complex containing at least two protein components (gp91-phox and p22-phox) and a unique low redox potential (-245 mV) cytochrome b-245 is the source of superoxide generated for bacterial killing in neutrophils and has been suggested as the oxygen sensor in the carotid body. In pure cultures of smooth muscle cells from calf small pulmonary arteries (300 microns diameter) the presence of the 91 kD protein specific to this cytochrome was demonstrated by Western blot analysis with monoclonal antibody 48. Low-temperature-difference spectrophotometry of homogenates of these cells demonstrated the characteristic cytochrome b-245 spectrum when titrated between redox potentials of -152 and -345 mV, consistent with the low redox potential form. When these same cells were exposed to hypoxia (approximately 40 mmHg), superoxide production increased significantly from 1.4 +/- 0.2 to 73 +/- 12 nmoles.min-1 mg-1 protein. Hypoxic generation of superoxide was inhibited by the NADPH-oxidase inhibitor diphenyleneiodonium (DPI: 10 microM) but not by the mitochondrial inhibitor myxathiazole (10 microM). The hypoxic superoxide increase was significantly greater than that observed from smooth muscle cells from large pulmonary arteries or from large or small systemic arteries. Fluorescence immunocytochemistry revealed the presence of the NADPH-oxidase protein in the walls of pulmonary arteries in rat lung slices, and confocal microscopy showed the complex to be widely distributed in the vicinity of the arterial smooth muscle walls. In hypoxia or norepinephrine (NP)-induced vasoconstriction of pulmonary artery rings from cats, the sensitivity to inhibition by DPI was observed to be significantly greater for hypoxia (ED50 = 0.8 microM) than for NP-induced (ED50 = 13.4 microM) constriction. Together these observations demonstrate that the unique cytochrome b-245 containing NADPH-oxidase is present in pulmonary artery smooth muscle and that an NADPH-oxidase or NADH-oxidoreductase complex is activated to release superoxide by hypoxic conditions. It is concluded that a trans-membrane NADPH-oxidase is the most likely and that activation of this system may be involved in the initiation of hypoxic pulmonary vasoconstriction.

Mucinous adenocarcinoma in the abomasum of a cow

A cow with mucinous adenocarcinoma of the abomasum presented to the teaching hospital with a markedly distended abdomen from which 80 liters of fluid was drained during trocharization. An exploratory laparotomy allowed removal of an additional 80 liters of fluid from the peritoneal cavity and revealed a diffusely thickened parietal peritoneum and a palpable cranial abdominal mass. The cow was euthanatized. At necropsy, the abomasum was diffusely thickened and firm. The peritoneal and pleural surfaces were covered with numerous coalescing, firm white nodules. Microscopically, the thickened abomasum was multifocally effaced by aggregates, cords, and acini of neoplastic cells separated by amphophilic, foamy to wispy periodic acid-Schiff- and alcian blue-positive material. Cell boundaries were indistinct and large, clear, colorless intracytoplasmic vacuoles were common.

Injuries related to car crime: the joy-riding epidemic

'Joy-riding' is the term used, somewhat inappropriately, for the offence of taking a vehicle without the owner's consent. In certain areas, mainly deprived inner-city estates, there has been an increase in this crime. The aim of this study was to investigate its impact on the workload of an inner-city teaching hospital's busy accident and orthopaedic departments. In this prospective study, all patients admitted to hospital as a result of road-traffic accidents (RTAs) were identified during a 9 month period. A total of 1576 patients were admitted to the trauma unit. One hundred and fifty-two admissions were as a result of RTA and 20 (13 per cent) of these patients had injuries as a result of car crime. Of this group, eight were severely injured (ISS > 16) and six of these were innocent bystanders. Three patients (one joy-rider and two innocent bystanders) died as a result of car crime. The average length of hospital stay was 12 days (1-62 days) and the hospital in-patient costs were estimated to be at least 5200 pounds per patient. Injuries related to car crime results in a significant amount of work and financial cost to the National Health Service.