A Pilot of Digital Whiteboards for Improving Patient Satisfaction in the Emergency Department: Nonrandomized Controlled Trial

BACKGROUND

Electronic paper (E-paper) screens use electrophoretic ink to provide paper-like low-power displays with advanced networking capabilities that may potentially serve as an alternative to traditional whiteboards and television display screens in hospital settings. E-paper may be leveraged in the emergency department (ED) to facilitate communication. Providing ED patient status updates on E-paper screens could improve patient satisfaction and overall experience and provide more equitable access to their health information.

OBJECTIVE

We aimed to pilot a patient-facing digital whiteboard using E-paper to display relevant orienting and clinical information in real time to ED patients. We also sought to assess patients' satisfaction after our intervention and understand our patients' overall perception of the impact of the digital whiteboards on their stay.

METHODS

We deployed a 41-inch E-paper digital whiteboard in 4 rooms in an urban, tertiary care, and academic ED and enrolled 110 patients to understand and evaluate their experience. Participants completed a modified Hospital Consumer Assessment of Health Care Provider and Systems satisfaction questionnaire about their ED stay. We compared responses to a matched control group of patients triaged to ED rooms without digital whiteboards. We designed the digital whiteboard based on iterative feedback from various departmental stakeholders. After establishing IT infrastructure to support the project, we enrolled patients on a convenience basis into a control and an intervention (digital whiteboard) group. Enrollees were given a baseline survey to evaluate their comfort with technology and an exit survey to evaluate their opinions of the digital whiteboard and overall ED satisfaction. Statistical analysis was performed to compare baseline characteristics as well as satisfaction.

RESULTS

After the successful prototyping and implementation of 4 digital whiteboards, we screened 471 patients for inclusion. We enrolled 110 patients, and 50 patients in each group (control and intervention) completed the study protocol. Age, gender, and racial and ethnic composition were similar between groups. We saw significant increases in satisfaction on postvisit surveys when patients were asked about communication regarding delays (P=.03) and what to do after discharge (P=.02). We found that patients in the intervention group were more likely to recommend the facility to family and friends (P=.04). Additionally, 96% (48/50) stated that they preferred a room with a digital whiteboard, and 70% (35/50) found the intervention "quite a bit" or "extremely" helpful in understanding their ED stay.

CONCLUSIONS

Digital whiteboards are a feasible and acceptable method of displaying patient-facing data in the ED. Our pilot suggested that E-paper screens coupled with relevant, real-time clinical data and packaged together as a digital whiteboard may positively impact patient satisfaction and the perception of the facility during ED visits. Further study is needed to fully understand the impact on patient satisfaction and experience.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04497922; https://clinicaltrials.gov/ct2/show/NCT04497922.

57 POTENTIALLY INAPPROPRIATE MEDICATION USE AND MORTALITY IN PATIENTS WITH COGNITIVE IMPAIRMENT

Background

Potentially inappropriate medications (PIMs are associated with falls, hospitalisation, and cognitive decline. Few studies have investigated the association between PIMs related to cognitive impairment (PIMCog) and mortality in dementia or mild cognitive impairment (MCI).

Methods

This was a retrospective observational study. Patients diagnosed with MCI or dementia (DSM-IV criteria) presenting to a tertiary-referral memory clinic from 2013–2019 were eligible. The primary outcome was all-cause death. Secondary outcomes were vascular death and non-vascular death defined according to formal certification. The primary exposure variable of interest was PIMCog, defined as any medication in the Beers 2015 or STOPP criteria, classified as potentially inappropriate for patients with cognitive impairment. Anticholinergic burden was measured using the anticholinergic cognitive burden (ACB) scale. Polypharmacy was defined as ≥5 medications. Cox proportional hazard models were used to calculate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

There were 418 patients included (n = 261 dementia, n = 157 MCI). The median age was 79 (interquartile range {IQR} 74–82) and median follow-up was 809 days (IQR 552–1,571). One or more PIMCog was prescribed in 141 patients (33.4%). PIMCog use was associated with all-cause mortality after adjustment for age, sex, dementia severity, Charlson Co-morbidity Index, chronic obstructive pulmonary disease, congestive cardiac failure, and peripheral vascular disease (HR 1.96, 95% CI 1.24–3.09). PIMCog use was associated with vascular death (HR 3.28, 95% CI 1.51–7.11) but not with non-vascular death (HR 1.40 95% CI: 0.78–2.52). Neither an ACB ≥3 (HR 0.87, 95% CI: 0.46–1.64) or polypharmacy (HR 1.87, 95% CI: 0.67–5.24) were associated with death.

Conclusion

The burden of PIMCog use in patients with cognitive impairment is high. PIMCog use is independently associated with all-cause mortality and vascular death. This is a potential modifiable risk factor for death in patients with neurocognitive disorders. Further research is required to independently validate this finding.

Electronic Paper Displays in Hospital Operations: Proposal for Deployment and Implementation

BACKGROUND

Display signage is ubiquitous and essential in hospitals to serve several clerical, operational, and clinical functions, including displaying notices, providing directions, and presenting clinical information. These functions improve efficiency and patient engagement, reduce errors, and enhance the continuity of care. Over time, signage has evolved from analog approaches such as whiteboards and handwritten notices to digital displays such as liquid crystal displays, light emitting diodes, and, now, electronic ink displays. Electronic ink displays are paper-like displays that are not backlit and show content by aligning microencapsulated color beads in response to an applied electric current. Power is only required to generate content and not to retain it. These displays are very readable, with low eye strain; minimize the emission of blue light; require minimal power; and can be driven by several data sources, ranging from virtual servers to electronic health record systems. These attributes make adapting electronic ink displays to hospitals an ideal use case.

OBJECTIVE

In this paper, we aimed to outline the use of signage and displays in hospitals with a focus on electronic ink displays. We aimed to assess the advantages and limitations of using these displays in hospitals and outline the various public-facing and patient-facing applications of electronic ink displays. Finally, we aimed to discuss the technological considerations and an implementation framework that must be followed when adopting and deploying electronic ink displays.

METHODS

The public-facing applications of electronic ink displays include signage and way-finders, timetables for shared workspaces, and noticeboards and bulletin boards. The clinical display applications may be smaller form factors such as door signs or bedside cards. The larger, ≥40-inch form factors may be used within patient rooms or at clinical command centers as a digital whiteboard to display general information, patient and clinician information, and care plans. In all these applications, such displays could replace analog whiteboards, noticeboards, and even other digital screens.

RESULTS

We are conducting pilot research projects to delineate best use cases and practices in adopting electronic ink displays in clinical settings. This will entail liaising with key stakeholders, gathering objective logistical and feasibility data, and, ultimately, quantifying and describing the effect on clinical care and patient satisfaction.

CONCLUSIONS

There are several use cases in a clinical setting that may lend themselves perfectly to electronic ink display use. The main considerations to be studied in this adoption are network connectivity, content management, privacy and security robustness, and detailed comparison with existing modalities. Electronic ink displays offer a superior opportunity to future-proof existing practices. There is a need for theoretical considerations and real-world testing to determine if the advantages outweigh the limitations of electronic ink displays.

484 CHANGING PRACTICES OF DECISION MAKING REGARDING DO-NOT-ATTEMPT-CARDIOPULMONARY-RESUSCITATION ORDERS AMID THE COVID-19 PANDEMIC

Introduction

The COVID-19 pandemic has brought the decision-making process regarding cardiopulmonary resuscitation into focus. This study aims to analyse Do-Not-Attempt CPR (DNACPR) documentation in older hospitalised patients before and during the COVID-19 pandemic.

Methods

This was a retrospective repeated cross-sectional study. Data including co-morbidities and resuscitation status was collected on 300 patients with COVID-19 hospitalised from March 1st to May 31 s t 2020. DNACPR documentation rates in patients aged ≥65 years with a diagnosis of COVID-19 were compared to those without COVID-19 admitted during the same period. Pre-COVID-19 pandemic DNACPR documentation rates were also examined. Factors associated with DNACPR order instatement during the first wave of the COVID-19 pandemic were identified.

Results

Of 300 COVID-19-positive patients, 28% had a DNACPR order documented during their admission. 50% of DNAR orders were recorded within 24 hours of a positive swab result for SARS-CoV-2. Of 131 patients aged 65 years or over within the cohort admitted with COVID-19, 60.3% had a DNACPR order compared to 25.4% of 130 patients ≥65 without COVID-19 (p < 0.0001). During a comparable time period pre-pandemic, 15.4% of 130 older patients had a DNACPR order in place (p < 0.0001). Independent associations with DNACPR order documentation included increasing age (Odds Ratio [O.R.] 1.12; 95% CI 1.05-1.21); nursing home resident status (O.R. 3.57; 95% CI 1.02-12.50); frailty (O.R. 3.34; 95% CI 1.16-9.61) and chronic renal impairment (O.R. 5.49; 1.34-22.47). The case-fatality-rate of older patients with COVID-19 was 29.8% versus 5.4% without COVID-19. Of older COVID-19-positive patients, 39.2% were referred to palliative care services and 70.2% survived.

Conclusion

The COVID-19 pandemic has prompted more widespread and earlier decision-making regarding resuscitation status. Although case-fatality-rates were higher for older hospitalised patients with COVID-19, many older patients survived the illness. Advance care planning should be prioritised in all patients and should remain clinical practice despite the pandemic.

Clinical Decision Support Reduces Unnecessary Tetanus Vaccinations in the Emergency Department

STUDY OBJECTIVE

Tetanus is the most common vaccination given in the emergency department; yet, administrations of tetanus vaccine boosters in the ED may not comply with the US Centers for Disease Control and Prevention's recommended vaccination schedule. We implemented a clinical decision support alert in the electronic health record that warned providers when ordering a tetanus vaccine if a prior one had been given within 10 years and studied its efficacy to reduce potentially unnecessary vaccines in the ED.

METHODS

This was a retrospective, quasi-experimental, 1-group, pretest-posttest study in 3 hospital EDs in Boston, MA. We studied adult patients for whom tetanus vaccines were ordered despite a history of vaccination within the prior 10 years. We compared the number of potentially unnecessary tetanus vaccine administrations in a baseline phase (when the clinical decision support alert was not visible) versus an intervention phase.

RESULTS

Of eligible patients, 22.1% (95% confidence interval [CI] 21.8% to 22.4%) had prior tetanus vaccines within 5 years, 12.8% (95% CI 12.5% to 13.0%) within 5 to 10 years, 3.8% (95% CI 3.6% to 3.9%) more than 10 years ago, and 61.3% (95% CI 60.9% to 61.7%) had no prior tetanus vaccination documentation. Of 60,983 encounters, 337 met the inclusion criteria. A tetanus vaccination was administered in 91% (95% CI 87% to 96%) of encounters in the baseline phase, compared to 55% (95% CI 47% to 62%) during the intervention. The absolute risk reduction was 36.7% (95% CI 28.0% to 45.4%), and the number of encounters needed to alert to avoid 1 potentially unnecessary tetanus vaccine (number needed to treat) was 2.7 (95% CI 2.2% to 3.6%). For patients with tetanus vaccines within the prior 5 years, the absolute risk reduction was 47.9% (95% CI 35.5 % to 60.3%) and the number needed to treat was 2.1 (95% CI 1.7% to 2.8%).

CONCLUSION

A clinical decision support alert that warns ED clinicians that a patient may have an up-to-date tetanus vaccination status reduces potentially unnecessary vaccinations.

The Influence of Carbohydrate Structure on the Clearance of Recombinant Tissue-Type Plasminogen Activator

Modification of the carbohydrate structures of recombinant tissue-type plasminogen activator (rt-PA) can increase or decrease its rate of clearance in rabbits. When rt-PA was treated with sodium periodate to oxidize carbohydrate residues, the rate of clearance was decreased from 9.6 ± 1.9 ml min−1 kg−1 to 3.5 ± 0.6 ml min−1 kg−1 (mean ± SD, n = 5). A similar change in the clearance of rt-PA was introduced by the use of endo-β-N-acetyl- glucosaminidase H (Endo-H), which selectively removes high mannose asparagine-linked oligosaccharides; the clearance of Endo-H-treated rt-PA was 5.0 ± 0.5 ml min−1 kg−1. A mutant of rt-PA was produced with an amino acid substitution at position 117 (Asn replaced with Gin) to remove a potential glycosylation site that normally contains a high mannose structure. The clearance of this material was also decreased, similar to the periodate and Endo-H-treated rt-PA. Conversely, when rt-PA was produced in the CHO 15B cell line, which can produce only high mannose oligosaccharide structures on glycoproteins, the clearance was increased by a factor of 1.8. These results demonstrate that the removal of rt-PA from the blood depends significantly upon the nature of its oligosaccharide structures.

Particle Spallation and Plasticiser (DEHP) Release from Extracorporeal Circuit Tubing Materials

Particle spallation and plasticiser (DEHP) release from medical grade polyvinylchloride (PVC), co-extruded PVC-polyurethane (PIVIPOL)R and an experimentally produced co-extruded PVC-ethylene vinyl acetate (EVA) has been studied when used with manually occluded and self-occluding peristaltic pumps over a six hour pumping period. The shore hardness of the tubings studied were similar but the luminal coating thickness differed (0.2 mm polyurethane, 0.99 mm EVA).

The pattern of particle release was similar for all materials on the pump type used with the majority of particles released being less than 5 microns in diameter. The number of particles greater than 5 microns released was independent of the tubing material but depended on the pump type. Particle release with self-occluding pumps was significantly higher (p<0.001) than for the manually occluded pump. Scanning electron microscopy indicated that the particles released originate from the repeated compression and flexing of the insert during pumping which leads to material structural failure. The higher release observed in the case of self-occluding pumps is suggestive of over-occlusion by the springs utilised in the pump.

DEHP release (ppm) over a six hour period while perfused at 300 ml/min was significantly reduced for co-extruded tubing (0.56 ± 0.05 mg (PVC-polyurethane) and 0.12 ± 0.04 mg (PVC-EVA) compared with PVC (0.74 ± 0.05 mg).

Quantitative analysis of facial soft tissue perfusion during hypotensive anesthesia using laser-assisted indocyanine green fluorescence angiography

The aim of this study was to quantitatively evaluate the efficacy of induced hypotensive anesthesia in decreasing facial soft tissue perfusion during orthognathic surgery using laser-assisted indocyanine green fluorescence angiography. This retrospective study involved the evaluation of 16 patients who underwent orthognathic surgery. Data collection included facial tissue perfusion of the bilateral cheeks and chin at normotension and with pharmacologically induced hypotensive anesthesia. There were statistically significant differences in the facial tissue perfusion at normal and depressed levels of blood pressure (P<0.001). This study used an objective measure to demonstrate the long-standing belief that hypotensive anesthesia is efficacious in reducing tissue perfusion in the surgical field. The data suggest that pharmacologically depressing the level of mean arterial pressure by 18% may result in a 41-52% decrease in facial soft tissue perfusion. This study reports a novel method of quantitative analysis.

From distress to illness: a critical analysis of medicalization and its effects in clinical practice

This paper is precisely aimed at exposing the limits of psychiatry's scientific claim-making and exploring how psychiatric diagnoses come to be utilized in practice and affect those who become pathologized. Drawing on research findings in the field of HIV/AIDS nursing, we portray the impact of psychiatric pathologization of women who see their bodies transformed by antiretroviral therapy and subsequently, must accept that their response to these changes become the target of psychiatric labelling and interventions. In this paper, we therefore engage with the reader in a critical analysis that exposes the tensions that exist between individual experiences of distress and psychiatric pathologization. The first section of the paper is dedicated to the presentation of a theoretical framework in which we explore the medicalization process and the ontological issues regarding psychiatric diagnoses. The second section seeks to present the results from a qualitative research study in the field of HIV/AIDS nursing and serves as a case example to foster discussions on the implications of psychiatric pathologization in clinical practice.

Using Systems Engineering for the Development of Decision Making Support Systems (DMSS)

Decision Making Support Systems (DMSS) can mitigate the risks involved in highly uncertain processes where novelty is high, such as NPD resource management. However such systems manipulate complex organisational information and require embedding within the business it operates within. There is a risk of poor acceptance in the business if the DMSS does not take into account a number of business related considerations. Utilising a systems approach literature was analysed, from which a set of considerations pertinent to the development of DMSS was elicited. Through the assessment of a number of System Development Methodologies (SDM), it was found that no one System Development Methodology (SDM) took into account all considerations identified. There is therefore a clear gap in current research and a real need for such a methodology which addresses the considerations identified.

Cranberry and grape seed extracts inhibit the proliferative phenotype of oral squamous cell carcinomas

Proanthocyanidins, compounds highly concentrated in dietary fruits, such as cranberries and grapes, demonstrate significant cancer prevention potential against many types of cancer. The objective of this study was to evaluate cranberry and grape seed extracts to quantitate and compare their anti-proliferative effects on the most common type of oral cancer, oral squamous cell carcinoma. Using two well-characterized oral squamous cell carcinoma cell lines, CAL27 and SCC25, assays were performed to evaluate the effects of cranberry and grape seed extract on phenotypic behaviors of these oral cancers. The proliferation of both oral cancer cell lines was significantly inhibited by the administration of cranberry and grape seed extracts, in a dose-dependent manner. In addition, key regulators of apoptosis, caspase-2 and caspase-8, were concomitantly up-regulated by these treatments. However, cranberry and grape seed extracts elicited differential effects on cell adhesion, cell morphology, and cell cycle regulatory pathways. This study represents one of the first comparative investigations of cranberry and grape seed extracts and their anti-proliferative effects on oral cancers. Previous findings using purified proanthocyanidin from grape seed extract demonstrated more prominent growth inhibition, as well as apoptosis-inducing, properties on CAL27 cells. These observations provide evidence that cranberry and grape seed extracts not only inhibit oral cancer proliferation but also that the mechanism of this inhibition may function by triggering key apoptotic regulators in these cell lines. This information will be of benefit to researchers interested in elucidating which dietary components are central to mechanisms involved in the mediation of oral carcinogenesis and progression.

Neonatal death in mice lacking cardiotrophin-like cytokine is associated with multifocal neuronal hypoplasia

Mice with null mutations of ciliary neurotrophic factor (Cntf) receptor alpha (Cntf-Ralpha), or cytokine-like factor 1 (Clf), one component of Cntf-II (a heterodimeric Cntf-Ralpha ligand), die as neonates from motor neuron loss affecting the facial nucleus and ventral horn of the lumbar spinal cord. Exposure to cardiotrophin-like cytokine (Clc), the other putative Cntf-II element, supports motor neuron survival in vitro and in ovo. Confirmation that Clc ablation induces an equivalent phenotype to Clf deletion would support a role for Clc in the functional Cntf-II complex. In this study, Clc knockout mice had decreased facial motility, did not suckle, died within 24 hours, and had 32% and 29% fewer motor neurons in the facial nucleus and lumbar ventral horn, respectively; thus, Clc is essential for motor neuron survival during development. The concordance of the Clc knockout phenotype with those of mice lacking Cntf-Ralpha or Clf bolsters the hypothesis that Clc participates in Cntf-II.

Guidelines on the diagnosis and treatment of pulmonary non-tuberculous mycobacteria infection

While the prevalence of Mycobacterium tuberculosis continues to decline in the developed world, the same cannot be said for non-tuberculous mycobacteria (NTM). These organisms are increasing in incidence and prevalence throughout the world. This is probably because of a combination of increased exposure, improved diagnostic methods and an increase in the prevalence of risk factors that predispose individuals to infection. Considerable confusion can arise in determining in the wide range of species whether an isolated NTM is in fact a contaminant or a pathogenic organism when isolated in sputum or bronchoalveolar lavage. This confusion combined with increasing requests for advice on the treatment of disease has led to the development of guidelines to assist the clinician in diagnosing and treating infection accurately.

Elevated prostate specific antigen (PSA) levels a risk factor for pathological hip fracture in metastatic prostatic carcinoma

Metastatic carcinoma of the prostate is increasing in incidence and commonly affects the proximal femur, but fracture risk is difficult to predict. Prophylactic fixation may avert the technical problems and reduce post-operative complications associated with acute pathological fracture treatment. This is a retrospective study of 14 patients who sustained a pathological fracture in the proximal femur from prostatic metastases. Risk factors for fracture were assessed, peri-operative complications highlighted and patient survival noted. At time of the initial diagnosis of prostate carcinoma, 12/14 patients (86%) had uptake in the proximal femur on isotope bone scan and 11/14 (79%) had an initial prostate specific antigen (PSA) level above 100 ng/ml. A higher initial PSA level correlated with a shorter time to fracture. The subtrochanteric region was the most common fracture location and was technically the most demanding to fix. Blood loss and transfusion requirements were high. Post-operative survival was 71%, 50% and 36% at 6, 12 and 18 months, respectively. From our findings, we suggest that patients with a greatly elevated PSA (>100 ng/ml), a positive isotope bone scan and plain X-ray changes in the proximal femur are at high risk of fracture and should be referred early for prophylactic stabilisation.

Antegrade locked intramedullary nailing in humeral shaft fractures

Thirty-three humeral nailings were carried out using the Russell-Taylor nail. Twenty-two acute fractures and one non-union united, gave an overall union rate of 70%. Eighteen patients (56%) experienced pain in the shoulder or at the fracture site. Thirteen patients (41%) had poor shoulder function. Only 17 (51%) of the patients were satisfied with the outcome. Fourteen patients (42%) needed further surgery. We conclude that antegrade intamedullary nailing of humeral shaft fractures leads to a substantial risk of non-union and impairment of shoulder function. There was no significant correlation between fracture comminution and fracture healing in our study.

Is vaginal birth after cesarean safe? Experience at a community hospital

OBJECTIVE

We sought to evaluate the effectiveness and safety of promoting a trial of labor after prior cesarean birth in a community hospital.

STUDY DESIGN

A 4-year prospective cohort study was conducted of all patients who had prior cesarean births (N = 1481). A comparison of outcomes was performed between those who elected repeat cesarean delivery (n = 727) and those who attempted a trial of labor after previous cesarean(s) (n = 754).

RESULTS

We found that the vaginal birth after cesarean attempt rate was 50.9% and declined significantly during the last 2 years of the study. The elective repeat cesarean rate was 49.1% and increased significantly during the last 2 years of the study. In addition, we found that neonatal outcomes were similar, with the exception of 2 neonatal deaths caused by uterine rupture. Twelve uterine ruptures occurred (1.6%), and 11 of the 12 ruptures involved either induction or augmentation of labor, or both.

CONCLUSIONS

A trial of vaginal birth after cesarean is safe provided that induction of labor is not used. The uterine rupture rate of 1.6% is higher than reported in the literature; this may reflect underreporting by community hospitals.

RANK is the intrinsic hematopoietic cell surface receptor that controls osteoclastogenesis and regulation of bone mass and calcium metabolism

We have generated RANK (receptor activator of NF-kappaB) nullizygous mice to determine the molecular genetic interactions between osteoprotegerin, osteoprotegerin ligand, and RANK during bone resorption and remodeling processes. RANK(-/-) mice lack osteoclasts and have a profound defect in bone resorption and remodeling and in the development of the cartilaginous growth plates of endochondral bone. The osteopetrosis observed in these mice can be reversed by transplantation of bone marrow from rag1(-/-) (recombinase activating gene 1) mice, indicating that RANK(-/-) mice have an intrinsic defect in osteoclast function. Calciotropic hormones and proresorptive cytokines that are known to induce bone resorption in mice and human were administered to RANK(-/-) mice without inducing hypercalcemia, although tumor necrosis factor alpha treatment leads to the rare appearance of osteoclast-like cells near the site of injection. Osteoclastogenesis can be initiated in RANK(-/-) mice by transfer of the RANK cDNA back into hematopoietic precursors, suggesting a means to critically evaluate RANK structural features required for bone resorption. Together these data indicate that RANK is the intrinsic cell surface determinant that mediates osteoprotegerin ligand effects on bone resorption and remodeling as well as the physiological and pathological effects of calciotropic hormones and proresorptive cytokines.

Primary care group commissioning of services: the differing priorities of general practitioners and district nurses for palliative care services

BACKGROUND

General practitioners (GPs) have become more responsible for budget allocation over the years. The 1997 White Paper has signalled major changes in GPs' roles in commissioning. In general, palliative care is ranked as a high priority, and such services are therefore likely to be early candidates for commissioning.

AIM

To examine the different commissioning priorities within the primary health care team (PHCT) by ascertaining the views of GPs and district nurses (DNs) concerning their priorities for the future planning of local palliative care services and the adequacy of services as currently provided.

METHOD

A postal questionnaire survey was sent to 167 GP principals and 96 registered DNs in the Cambridge area to ascertain ratings of service development priority and service adequacy, for which written comments were received.

RESULTS

Replies were received from 141 (84.4%) GPs and 86 (90%) DNs. Both professional groups agreed that the most important service developments were urgent hospice admission for symptom control or terminal care, and Marie Curie nurses. GPs gave greater priority than DNs to specialist doctor home visits and Macmillan nurses. DNs gave greater priority than GPs to Marie Curie nurses, hospital-at-home, non-cancer patients' urgent hospice admission, day care, and hospice outpatients. For each of the eight services where significant differences were found in perceptions of service adequacy, DNs rated the service to be less adequate than GPs.

CONCLUSION

The 1997 White Paper, The New NHS, has indicated that the various forms of GP purchasing are to be replaced by primary care groups (PCGs), in which both GPs and DNs are to be involved in commissioning decisions. For many palliative care services, DNs' views of service adequacy and priorities for future development differ significantly from their GP colleagues; resolution of these differences will need to be attained within PCGs. Both professional groups give high priority to the further development of quick-response clinical services, especially urgent hospice admission and Marie Curie nurses.

PREPARED: Preparation for Angiography in Renal Dysfunction: a randomized trial of inpatient vs outpatient hydration protocols for cardiac catheterization in mild-to-moderate renal dysfunction

BACKGROUND

IV hydration before and after cardiac catheterization is effective in preventing contrast-associated renal dysfunction for patients with mild-to-moderate renal insufficiency, but necessitates overnight hospital admission. We tested an outpatient oral precatheterization hydration strategy in comparison with overnight IV hydration.

METHODS

We randomized 36 patients with renal dysfunction (serum creatinine > or = 1.4 mg/dL) undergoing elective cardiac catheterization to receive either overnight IV hydration (0.45 normal saline solution at 75 mL/h for both 12 h precatheterization and postcatheterization; n = 18) or an outpatient hydration protocol including precatheterization oral hydration (1,000 mL clear liquid over 10 h) followed by 6 h of IV hydration (0.45 normal saline solution at 300 mL/h) beginning just before contrast exposure. The predefined primary end point was the maximal change in creatinine up to 48 h after cardiac catheterization.

RESULTS

The inpatient and outpatient groups were well matched for baseline characteristics and contrast volume. By protocol design, the outpatient group received a greater volume of hydration, although the net volume changes were comparable in the two groups. The maximal changes in serum creatinine in the inpatient (0.21+/-0.38 mg/dL; 95% confidence interval [CI], 0.02 to 0.39 mg/dL) and outpatient groups (0.12+/-0.23 mg/dL; 95% CI, 0.01 to 0.24 mg/dL) were comparable (p = not significant). There were no instances of protocol intolerance.

CONCLUSIONS

A hydration strategy compatible with outpatient cardiac catheterization is comparable to precatheterization and postcatheterization IV hydration in preventing contrast-associated changes in serum creatinine. Hospital admission for IV hydration is unnecessary before elective cardiac catheterization in the setting of mild-to-moderate renal dysfunction.

Personal use of drug samples by physicians and office staff

CONTEXT

Pharmaceutical samples are commonly used in ambulatory care settings. There is limited research on their use or impact on health care providers and patients.

OBJECTIVE

To determine the extent of personal use of drug samples over a 1-year period by physicians and medical office staff.

DESIGN, SUBJECTS, AND SETTING

An anonymous cross-sectional survey of all physicians, resident physicians, nursing staff, and office staff in a family practice residency.

MAIN OUTCOME MEASURE

Quantity of drug samples taken for personal or family use.

RESULTS

Of 55 surveys issued, 53 (96%) were returned. A total of 230 separate drug samples were reported taken in amounts ranging from 1 dose to greater than 1 month's supply. Two respondents reported no use of drug samples, while 4 respondents reported taking more than 10 different samples.

CONCLUSION

Drug samples are commonly taken by physicians and office staff for personal and family use. The ethical implications of this practice warrant further discussion.

Accelerated healing of distal radial fractures with the use of specific, low-intensity ultrasound. A multicenter, prospective, randomized, double-blind, placebo-controlled study

A multicenter, prospective, randomized, double-blind, placebo-controlled clinical trial was conducted to test the efficacy of a specifically programmed, low-intensity, non-thermal, pulsed ultrasound medical device for shortening the time to radiographic healing of dorsally angulated fractures (negative volar angulation) of the distal aspect of the radius that had been treated with manipulation and a cast. Sixty patients (sixty-one fractures) were enrolled in the study within seven days after the fracture. The patients used either an active ultrasound device (thirty fractures) or a placebo device (thirty-one fractures) daily for twenty minutes at home for ten weeks. The two types of devices were identical except that the placebo devices emitted no ultrasound energy. Clinical examination was performed and radiographs were made at one, two, three, four, five, six, eight, ten, twelve, and sixteen weeks after the fracture by each site investigator. The time to union was significantly shorter for the fractures that were treated with ultrasound than it was for those that were treated with the placebo (mean [and standard error], 61 +/- 3 days compared with 98 +/- 5 days; p < 0.0001). Each radiographic stage of healing also was significantly accelerated in the group that was treated with ultrasound as compared with that treated with the placebo. Compared with treatment with the placebo, treatment with ultrasound was associated with a significantly smaller loss of reduction (20 +/- 6 per cent compared with 43 +/- 8 per cent; p < 0.01), as determined by the degree of volar angulation, as well as with a significant decrease in the mean time until the loss of reduction ceased (12 +/- 4 days compared with 25 +/- 4 days; p < 0.04). We concluded that this specific ultrasound signal accelerates the healing of fractures of the distal radial metaphysis and decreases the loss of reduction during fracture-healing.

Acceleration of tibia and distal radius fracture healing in patients who smoke

A low intensity ultrasound device was investigated as an accelerator of cortical and cancellous bone fracture healing in smokers and nonsmokers. Statistically significant reductions in healing time for smokers and nonsmokers were observed for tibial and distal radius fractures treated with an active ultrasound device compared with a placebo control device. The healing time for a tibial fracture was reduced 41% in smokers and 26% in nonsmokers with the active ultrasound device. Similarly, distal radius fracture healing time was reduced by 51% in smokers and 34% in nonsmokers with the active device. Treatment with the active ultrasound device also substantially reduced the incidence of tibial delayed unions in smokers and nonsmokers. The use of the active ultrasound device accelerates cortical and cancellous bone fracture healing, substantially mitigates the delayed healing effects of smoking, speeds the return to normal activity, and reduces the long-term complication of delayed union.

Joint regulation of cell size and cell number in the wing blade of Drosophila melanogaster

We used Drosophila melanogaster to test for compensatory control of cell area and cell number in the regulation of total wing area. In two random bred wild-type base stocks collected from different geographic locations we found a negative association between the area and the number of cells in the wing blade. Three replicate lines were selected for increased or decreased wing area, with cell area maintained at the same level as in the three controls. After eight generations of selection, despite a large and highly significant difference in wing area between the large, control and small selection lines, cell area did not differ significantly between them. Rather, the difference in wing area between selection regimes was attributable to differences in cell number. Over the course of selection, the initially significant negative correlation between cell area and cell number in the wing increased, providing evidence for compensatory regulation of cell area and cell number. As a result of the increasingly negative association between the two traits, the variance in wing area declined as selection proceeded. It will be important to discover the mechanisms underlying the compensatory regulation of cell area and cell number.

Knowledge of lymphoedema among primary health care teams: a questionnaire survey

Lymphoedema usually develops following surgery or radiotherapy for cancer, but can also occur in advanced malignant disease or be primary in origin. Lower limb lymphoedema may present particular difficulties in diagnosis, treatment and management. All types of lymphoedema can seriously impair quality of life for those affected. This study aimed to determine the level of knowledge among primary health care team members concerning the identification and management of patients at risk of developing lymphoedema, the current treatment options available for patients with established lymphoedema, and the awareness of local services available within the Cambridge Health District. A postal questionnaire survey obtained an 84.3% response rate. Many primary health care professionals were not aware of some important issues in the prevention and management of lymphoedema. This information proved useful in enabling the specialist service to develop appropriate educational initiatives.

A psychiatric day hospital program in an HMO

A model Psychiatric Day Hospital program developed in an HMO is described. The HMO and the Day Hospital program's function within the spectrum of adult psychiatric services of the organization are discussed. This program has enhanced the quality of the clinical care provided. Three measurements demonstrate the success of the program. Such a program is ideally suited to the needs of an HMO.

A prospective study comparing SPET with MRI and CT as prognostic indicators following severe closed head injury

Ten patients were studied prospectively afer severe closed head injury to determine the relationship between long-term clinical outcome and abnormalities detected by single photon emission tomography (99Tcm-HMPAO SPET), CT and MRI obtained within 60 days of injury. The ability of SPET to detect abnormalities not visualized by CT or MRI after cerebral trauma by the results of this study. Changes detected by SPET [global cerebral blood flow (gCBF) and number of regional cerebral blood flow (rCBF) deficits] soon after trauma were shown to be more closely correlated with long-term outcome than changes detected by MRI or CT. Templates were used to classify lesions by site and a multivariate analysis was undertaken to establish the importance of defect position in predicting clinical outcome. The results suggest that lesions in the temporal lobes, frontal lobes and basal ganglia are related to poor prognosis, and that SPET yields more useful prognostic data than the other methods.

A study of frictional forces between orthodontic brackets and archwires

The differences in magnitude of static and kinetic frictional forces generated by 0.022 x 0.030-inch stainless steel (Dentaurum) and polycrystalline ceramic (Transcend) brackets in combination with archwires of different sizes (0.018 inch and 0.019 x 0.025 inch) and materials (stainless steel, nickel-titanium, and beta-titanium) at a constant ligature force were investigated. A friction-testing assembly using the Instron machine was used. In all cases, the static frictional force was greater than the kinetic frictional force. There were no significant differences in the frictional forces generated by stainless steel and polycrystalline ceramic brackets. Beta-titanium archwires produced greater frictional forces than the other two materials. Increasing the archwire diameter increased the frictional force.

The role of bone scintigraphy with pinhole collimation in the evaluation of symptomatic paediatric hips

Sixty-two children with signs and symptoms of hip pathology underwent bone scintigraphy with pinhole collimation of the hip joints. Three distinct patterns of isotope uptake were observed: a normal uptake of isotope, a focal increase or decrease of isotope uptake and a mild diffuse increase of isotope uptake. Forty-four children had normal isotope scans, an average hospital stay of 6.8 days and no significant pathology on follow-up. Ten children had a focal increase or decrease of isotope uptake, an average hospital stay of 21 days and on follow-up all had significant pathology. Eight children had a mild diffuse increase of isotope uptake, an average hospital stay of 8.75 days and no significant pathology on follow-up. We conclude: (1) Normal isotope hip scintigrams with pinhole collimation indicate an excellent prognosis in symptomatic paediatric hips; (2) Focal scintigraphic abnormalities are indicative of significant pathology; (3) A mild diffuse increase in isotope uptake on both sides of the joint is not associated with significant pathology; (4) There is a good correlation between scintigrams and the length of hospital stay; (5) Scintigraphy is at least twice as sensitive at the time of presentation as plain radiographs in the detection of pathology.

Regulation of the citrate synthase (gltA) gene of Escherichia coli in response to anaerobiosis and carbon supply: role of the arcA gene product

As an enzyme of the tricarboxylic acid cycle pathway, citrate synthase participates in the generation of a variety of cellular biosynthetic intermediates and in that of reduced purine nucleotides that are used in energy generation via electron transport-linked phosphorylation reactions. It catalyzes the condensation of oxaloacetate and acetyl coenzyme A to produce citrate plus coenzyme A. In Escherichia coli this enzyme is encoded by the gltA gene. To investigate how gltA expression is regulated, a gltA-lacZ operon fusion was constructed and analyzed following aerobic and anaerobic cell growth on various types of culture media. Under aerobic culture conditions, expression was elevated to a level twofold higher than that reached under anaerobic culture conditions. ArcA functions as a repressor of gltA expression under each set of conditions: in a delta arcA strain, gltA-lacZ expression was elevated to levels two- and eightfold higher than those seen in a wild-type strain under aerobic and anaerobic conditions, respectively. This control is independent of the fnr gene product, an alternative anaerobic gene regulator in E. coli. When the richness or type of carbon compound used for cell growth was varied, gltA-lacZ expression varied by 10- to 14-fold during aerobic and anaerobic growth. This regulation was independent of both the crp and fruR gene products, suggesting that another regulatory element in E. coli is responsible for the observed control. Finally, gltA-lacZ expression was shown to be inversely proportional to the cell growth rate. These findings indicate that the regulation of gltA gene expression is complex in meeting the differential needs of the cell for biosynthesis and energy generation under various cell culture conditions.

Acceleration of tibial fracture-healing by non-invasive, low-intensity pulsed ultrasound

Sixty-seven closed or grade-I open fractures of the tibial shaft were examined in a prospective, randomized, double-blind evaluation of use of a new ultrasound stimulating device as an adjunct to conventional treatment with a cast. Thirty-three fractures were treated with the active device and thirty-four, with a placebo control device. At the end of the treatment, there was a statistically significant decrease in the time to clinical healing (86 +/- 5.8 days in the active-treatment group compared with 114 +/- 10.4 days in the control group) (p = 0.01) and also a significant decrease in the time to over-all (clinical and radiographic) healing (96 +/- 4.9 days in the active-treatment group compared with 154 +/- 13.7 days in the control group) (p = 0.0001). The patients' compliance with the use of the device was excellent, and there were no serious complications related to its use. This study confirms earlier animal and clinical studies that demonstrated the efficacy of low-intensity ultrasound stimulation in the acceleration of the normal fracture-repair process.

ED management of acute congestive heart failure in renal dialysis patients

This is a descriptive report of the management techniques used effectively in the emergency department (ED) treatment of acute congestive heart failure (CHF) in renal dialysis patients. Study design included a prospective case series of consecutive renal dialysis patients who presented to the ED of a regional dialysis center in acute CHF. Clinical presentation, ED management, and outcome were recorded. Forty-six patients (38 hemodialysis and 8 peritoneal dialysis) were included in this study. Presentation classifications for these patients were minimal distress (13 patients), moderate distress (16 patients), and severe distress (17 patients). In addition to supplemental oxygen, treatment focused on pharmacological preload and afterload reduction. Patients received sublingual nitroglycerin (NTG) (30 patients), transdermal NTG (36 patients), captopril sublingual (10 patients) nifedipine oral (nine patients), nitroprusside (four patients), morphine sulfate (one patient), NTG infusion (one patient), and clonidine (one patient). There were no deaths in the study group, and 32 of the patients were able to be dialyzed and discharged, including seven patients in the severe group. Six patients required intubation, one of whom was extubated and discharged from the ED after dialysis. Intravascular access was obtained in 29 patients but was used in only six. All patients on nitroprusside drips were weaned during the course of their dialysis. Effective ED management of acute CHF in renal dialysis patients can be accomplished through preload reduction with nitrates and afterload reduction with captopril, nifedipine, and, in severe cases, nitroprusside.

An analysis of the diagnostic accuracy of endoscopic biopsy and cytology in the detection of oesophageal malignancy

The role of combined cytohistological examination in the differentiation of benign from malignant oesophageal mucosal lesions was studied in 331 patients. Malignancy was confirmed by specimen histopathology in 58 patients. Both endoscopic biopsy and cytology were positive in 41 (71%) patients. Endoscopic biopsy alone suggested malignancy in 10 cases (17%) while cytology was positive after negative biopsy in seven (12%). Cytology yielded four false positive and 10 false negative results giving a sensitivity level of 81%, a specificity of 98% and a positive predictive value for oesophageal malignancy of 92%. Histology on the other hand yielded one false positive and seven false negative results providing a sensitivity of 87%, a specificity of 99% and a positive predictive value of 96%. No patients were left undiagnosed using both diagnostic modalities; cytology increased the diagnostic yield from 87% to 100%. Exfoliative cytology was most valuable in the diagnosis of tumours of the lower one-third of the oesophagus where seven of 31 malignancies (23%) were identified by this method alone (P less than 0.05). Neither the histological type of the tumour nor the morphological appearance was found significantly to affect the diagnostic yield (P greater than 0.05). We conclude that cytological examination should be standard practice in the investigation of oesophageal lesions.