The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission

Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.

The One-Stop Aortic Surveillance Clinic

Background

The principle of interval ultrasound surveillance of small abdominal aortic aneurysms (AAA) is well established. The fundamental principle of surveillance is that repair of AAA is a serious undertaking and the risk of the operation outweighs the risk of rupture in aneurysms less than 5.5 cm. Surveillance is well established but requires multiple visits to both the surgical clinic and the ultrasound department.

Report

This report presents a system whereby the vascular surgeon is trained in the process of aortic sonography with a view to one-stop clinic assessment. After training of the main investigators in aortic sonography, the surgeons performed scans on the aortas of 80 consecutive patients and compared the scan result with the subsequent formal scan.

Discussion

Surgical and radiographer scans correlate very closely. It is believed that the one-stop aortic surveillance model is safe, accurate, and improves both the patient journey and clinic throughput.

Early clinical experience with the Anaconda re-deployable endograft in 106 patients with abdominal aortic aneurism: the west of Scotland Anaconda registry

Endovascular repair of abdominal aortic aneurysm is a common procedure and not without complications. The aim of this study was to evaluate the early results of the Anaconda endograft (Vascutek Ltd., Inchinnan, Scotland, UK) in 106 patients in three hospitals in the west of Scotland. A prospective registry of 106 consecutive patients undergoing endoluminal repair of their abdominal aortic aneurysms using the Anaconda device was set up to record the clinical outcomes, with a mean follow-up of two years. There was no 30-day perioperative mortality in the 106 patients. Only type II endoleaks were detected on serial computed tomography scanning at follow-up. Technical success was achieved in 99% (105/106) in this study; one patient was converted to open surgical repair. Two cases of proximal device migration (>1 cm) were detected at one month and 19 months, respectively, with no associated endoleak or sac enlargement. Five cases of endograft limb thrombosis were noted in this study. Our early clinical experience with the Anaconda endograft compares favourably with other commercially available endografts in the treatment of abdominal aortic aneurysms. The main advantages of this device are that it is re-deployable and that it has a magnetic wire system which makes it easy to implant.

Early clinical experience with color three-dimensional intravascular ultrasound in peripheral interventions

PURPOSE

To report early clinical experiences with color 3-dimensional intravascular ultrasound (3-D IVUS) in assisting peripheral interventions.

TECHNIQUE

A 3.5-F, 20-MHz IVUS catheter that utilizes ChromaFlo computer software to demonstrate blood flow in color was evaluated in over 100 peripheral interventions. ChromaFlo captures up to 30 conventional IVUS frames every second and generates "real-time" imaging. The software compares sequential axial IVUS images and interprets any differences in the position of echogenic blood particles, which are displayed as colorized flow in axial or 3-D renderings.

CONCLUSIONS

ChromaFlo-enhanced IVUS demonstrates colorized blood flow inside the vessel lumen, which is helpful in distinguishing echolucent disease from luminal blood flow and can also be used to perform peripheral interventions in patients with renal failure or allergy, avoiding the use of contrast media.

Pain treatment satisfaction in spinal cord injury

STUDY DESIGN

A survey on pain satisfaction was mailed to 300 individuals with spinal cord injury. Eighty-eight completed surveys were returned, and the results were analyzed.

OBJECTIVES

The survey queried the respondents on characteristics of their pain, treatments received, the impact of pain on multiple, life activities and functions and the satisfaction with treatment received to reduce pain.

SETTING

Subjects for the study were selected from the Spinal Cord Injury Registry from the Commonwealth of Virginia in the US.

METHODS

Information was obtained from a survey sent to the subjects who were chosen randomly with respect to age and gender. At least 1 year had elapsed from the time of injury for each individual.

RESULTS

Respondents were typically dissatisfied with the results of the treatments received to manage their pain.

CONCLUSION

Pain in individuals with spinal cord injury needs to be addressed in a thorough fashion to reduce the adverse impact on life activities.

The primates of the Baly Bay area, north-western Madagascar

Primate surveys were conducted in isolated primary west Malagasy decidous forest blocks around Baly Bay, north-western Madagascar. Eight species of primate were found, including Microcebus c.f. myoxinus, Hapalemur griseus occidentalis and Phaner furcifer. Two species were found only in Namoroka Strict Nature Reserve, which may mean that other forest blocks in the area have experienced primate extinctions. The record of M. c.f. myoxinus came from mangrove, the first confirmed record of a lemur from this habitat. The pelage of female Eulemur fulvus rufus was atypical.

Modification of general practitioner prescribing of antibiotics by use of a therapeutics adviser (academic detailer)

AIMS

This was a pilot study of the use of a clinical pharmacist as a therapeutics adviser (academic detailer) to modify antibiotic prescribing by general practitioners.

METHODS

Following a visit by the adviser (March-May), 112 general practitioners were recruited and randomised to control or active groups. A panel of experts prepared a best practice chart of recommended drugs for upper and lower respiratory tract infections, otitis media and urinary tract infections. The adviser made a 10-15 min visit to each prescriber in the active group (June-July), gave them the chart and discussed its recommendations briefly. Doctors in the control group were not visited nor given the chart. Prescription numbers for all prescribers were obtained from the Commonwealth Health Insurance Commission for the pre(March-May) and postdetailing (August-September) periods using a three month lag time for data collection. Data for total numbers of prescriptions and for selected individual antibiotics used in these two periods were analysed using nonparametric statistics.

RESULTS

Prescribing patterns were similar for the control and active groups in the predetailing period. For both groups, there were significant (P<0.03) increases (45% for control and 40% for active) in total number of antibiotic prescriptions in the post compared with the predetailing period. This trend was anticipated on the basis of the winter seasonal increase in respiratory infections. In line with the chart recommendations for first-line treatment, doctors in the active group prescribed significantly more amoxycillin (P<0.02) and doxycycline (P<0.001) in the post vs predetailing periods. By contrast, doctors in the control group prescribed significantly more cefaclor (P<0.03) and roxithromycin (P<0.03), drugs that were not recommended. The total cost of antibiotics prescribed by doctors in the control group increased by 48% ($37 150) from the preto postdetailing periods. In the same time period, the costs for the active group increased by only 35% ($21 020).

CONCLUSIONS

We conclude that the academic detailing process was successful in modifying prescribing patterns and that it also decreased prescription numbers and costs. Application of the scheme on a nationwide basis could not only improve prescriber choice of the most appropriate antibiotic but also result in a significant saving of health care dollars.

Percutaneous techniques for endoluminal carotid interventions

PURPOSE

To describe the evolving techniques for stent implantation in the proximal and cervical carotid arteries.

METHODS AND RESULTS

Percutaneous access to proximal and cervical carotid lesions is either via direct puncture of the common carotid artery or through the more familiar retrograde common femoral (RCF) artery approach. Both techniques and their variations are described in detail, along with their benefits, disadvantages, and possible complications. Dual lesions at the arch and higher up the neck can be treated either from the RCF route or, if the cervical lesion requires endarterectomy, with open exposure at the bifurcation and stenting of the proximal lesion.

CONCLUSIONS

While the RCF route is more familiar to the majority of interventionists and provides adequate access in most situations, traversing the arch and negotiating acute angles at the ostia of the great vessels may render this method infeasible. The direct puncture technique is a useful alternative; however, it requires more expertise to prevent potentially disastrous access-site complications. One further caveat must be stated: regardless of the access approach selected, the opportunity for serious, debilitating-and lethal-complications is always present in cerebrovascular interventions. At this earliest phase in our experience with carotid stenting, cautious investigative methodologies must prevail.

Intravascular ultrasound assessment in carotid interventions

PURPOSE

To demonstrate the clinical value of intravascular ultrasound (IVUS) imaging in monitoring stent deployment in the cervical carotid arteries.

METHODS AND RESULTS

Two-dimensional (2D) and three-dimensional (3D) IVUS imaging has been used routinely in more than 100 patients following carotid stenting and the completion angiogram to detect evidence of inaccurate stent deployment. Axial 2D views were used to measure diameters and cross-sectional areas and provide the basis for 3D reconstruction. These composited images produced single-frame views of entire vascular segments, with definition of vessel wall morphology, stent placement, and angioplasty-induced defects. This information was used in the decision to apply further treatment to the area in order to maximize luminal diameter and/or correct defects.

CONCLUSIONS

IVUS imaging is an important component of carotid artery stent procedures. It more accurately visualizes stent placement and vessel wall morphology than arteriography, information critical to the intraprocedural assessment process.

Stenting in the carotid artery: initial experience in 110 patients

PURPOSE

To evaluate the feasibility, safety, and efficacy of intravascular stents in the treatment of extracranial carotid artery occlusive disease.

METHODS

According to protocol, stent therapy was offered to symptomatic patients with > or = 70% arteriographically defined carotid stenoses or ulcerative lesions and, after September 1994, to asymptomatic patients with > or = 75% stenoses. From April 1993 to September 1995, 110 nonconsecutive patients (79 males; mean age 72 years, range 45 to 85) consented to participate in the study. The majority (79 [72%]) were asymptomatic. Lesions meeting the treatment criteria were in the proximal common (n = 3); mid common (n = 12); distal common (n = 8); internal (ICA) (n = 92); and external (n = 2) carotid arteries. Seven patients had bilateral ICA stenoses, and 17 patients were treated for postsurgical recurrent disease. The mean lesion length and diameter stenosis for all lesions were 12.4 +/- 9.2 mm and 86.5% +/- 10.6%, respectively. The procedures were performed either via direct percutaneous access to the cervical common carotid artery or through a retrograde femoral artery approach. Standard balloon dilation preceded deployment of balloon-expandable stents in most cases. No postprocedural anticoagulation was used (aspirin only).

RESULTS

In 110 patients (117 arteries) intended for treatment, 109 (99.0%) (116 arteries [99.1%]) were successfully treated with 129 stents (128 Palmaz, 1 Wallstent). One percutaneous procedure failed (0.9%) for technical reasons (stent could not be deployed) and was converted to carotid endarterectomy. Minor complications included 4 cases of spasm (successfully treated with papaverine); 1 flow-limiting dissection (stented); and 6 access-site problems. There were 7 strokes (2 major, 5 reversible) (6.4%) and 5 minor transient events (4.5%) that resolved within 24 hours. Three patients were converted to endarterectomy (2.7%) prior to discharge; 1 stroke patient expired (0.9%), and another patient died of an unrelated cardiac event in hospital. In the 30-day postprocedural period, 2 ICA stents occluded (patients asymptomatic). Clinical success at 30 days (no technical failure, death, endarterectomy, stroke, or occlusion) was 89.1% (98/110). Over a mean 7.6-month follow-up (range 2 to 31), no new neurological symptoms developed. Another stent occlusion at 2 months and one case of flow-limiting intimal hyperplasia at 7 months were detected on routine duplex scanning in asymptomatic patients. Life-table analysis shows an 89% cumulative primary patency rate.

CONCLUSIONS

Based on this early experience, carotid stenting appears feasible from a technical standpoint, with good midterm patency. However, the incidence of neurological sequelae is a serious problem. Technical enhancements and a more aggressive antiplatelet regimen may have a positive impact on these events.

The clinical value of three-dimensional intravascular ultrasound imaging

Two-dimensional (2D) intravascular ultrasound (IVUS) imaging can now be reconstructed into three dimensions from serial 2D images captured following a "pullback" of the IVUS catheter through the target site. Three-dimensional (3D) reconstructions provide "longitudinal" and "volume" images. The former is similar to an angiogram and can be examined in three dimensions by rotating the image around its longitudinal axis, providing clinically useful information during endovascular procedures. The volume view takes longer to create and is not an exact reconstruction, but it provides images that can be rotated into any spatial position. It visualizes the luminal aspect of the vessel particularly well. The clinical value of 3D IVUS is in the diagnosis of vascular disease and the assessment of endovascular interventions. Three-dimensional IVUS, which provides better, more informative images than 2D IVUS, can be particularly useful intraprocedurally in detecting inaccurate deployment of intravascular stents and endoluminal grafts.

Lessons from interpractice visits. Developing standards

The author describes a small series of interpractice visits in Perth, Western Australia, motivated by the growing need for quality assurance standards in general practice. He reviews the strengths and failures of the experience from the point of view of doctors equally inexperienced in such ventures.

Disability following head injury

Disability following head injury varies depending on injury mechanism, neuropathology, and other factors, including medical complications. Mild head injury (Glasgow Coma Scale score 13-15) has been shown to have considerable variability in outcome. Some persons experience rapid symptom resolution whereas others continue to evidence symptoms for an extended duration. A small, but clinically significant number of patients may be neuropsychologically and occupationally disabled at least up to 1 year postinjury. Methodological problems continue to plague mild head injury outcome studies. In contrast, moderate (Glasgow Coma Scale score 9-12) and severe head injury (Glasgow Coma Scale score 3-8) result in more consistent patterns of disability following injury. In general, patients who sustain moderate to severe head injury tend to experience persistent and extensive neuropsychological, psychiatric, and occupational impairment. The impact of rehabilitative interventions is variable and dependent on injury severity, intervention type, and outcome criteria.

Wechsler Memory Scale-Revised in closed head injury

This study was undertaken to determine the ability of the Wechsler Memory Scale-Revised (WMS-R) to differentiate a group of closed head injury patients from a group of controls and determine how injury severity and attentional deficits are associated with WMS-R performance. The relationship of WMS-R performance to everyday memory also was assessed. The head injured group performed more poorly than controls on all five WMS-R indices and exhibited greater impairments on tasks that measure retention. In the original sample only the Visual Memory Index correlated with injury severity; in a larger sample, all four memory indices correlated modestly with injury severity. Patients who performed more poorly on the WMS-R also received poorer ratings on an independent assessment of everyday memory.

Intra-arterial temazepam

Images

A prospective study of 100 gelatin-sealed aortic grafts

A gelatin-sealed knitted Dacron graft has been developed which has zero porosity at implantation and does not require preclotting. Its patency rate up to 57 months and effectiveness at saving blood loss have been studied. Gelatin-sealed aortic grafts were implanted into 100 consecutive patients--77 men, 23 women. Surgery was performed for aneurysm in 36 patients (including four with rupture), intermittent claudication in 44, rest pain in 17, and gangrene in three, over an 18 month period. The patients were followed up prospectively for 57 months. Perioperative mortality was 1%. Cumulative primary graft patency was 99%. There was no measurable blood loss at implantation. Forty-seven patients required blood transfusion: mean volume transfused was 430 ml. There were no problems related to the sealant.

Early experience with intra-arterial thrombolytic therapy for peripheral arterial occlusion

The authors present their early experience with local intra-arterial thrombolytic therapy for peripheral arterial occlusions causing limb threatening ischaemia, using streptokinase or urokinase. Ten patients were treated in a period of one year. Five patients had successful recanalisation, two patients had partial success and three patients required major amputation. The indications, contraindications and results of this treatment are reviewed.

Abdominal aortic aneurysm: a preventable cause of death?

Abdominal aortic aneurysm as a cause of death may be preventable by surgery. This paper reviews current theories of aetiology, incidence and detection with particular reference to population screening for aneurysm and to reducing the operative mortality rate by detecting the correctable risk factors of surgical treatment.

Infected false aneurysms in the groin of intravenous drug abusers

The hazards of dealing with infected false femoral aneurysms resulting from intra-arterial narcotic injection are highlighted in six patients. Two patients were human immunodeficiency virus positive and three patients were hepatitis B surface antigen positive. Because of these infections exploration of groin swellings as presumed soft tissue abscesses is potentially hazardous without proper proximal vascular control. All patients underwent reconstruction following arterial ligation and five grafts became infected, with life threatening haemorrhage occurring in four patients. Five grafts have subsequently occluded or have been removed without loss of limb viability, although two patients have been regrafted. A high index of suspicion and assessment by a vascular surgeon, with angiography if indicated, is required in any intravenous drug abuser presenting with a groin swelling following injection. Because of the great risk of graft infection, it is suggested that ligation and debridement alone be carried out, with immediate arterial reconstruction only for non-viability.

Myoclonus associated with treatment with high doses of morphine: the role of supplemental drugs

OBJECTIVE

To estimate the prevalence of important side effects in patients with malignant disease who were receiving high doses of morphine as part of their palliative treatment.

DESIGN

Data on patients were collected over 12 months.

SETTING

Two palliative care units in Western Australia.

PATIENTS

19 Patients with malignant disease who were receiving morphine either subcutaneously or orally as the main analgesic. 10 Patients receiving a total daily dose of morphine of at least 500 mg orally or 250 mg parenterally were enrolled in the study. The other 9 patients were enrolled after an important problem thought to be related to the morphine had been identified. All of the patients were taking drugs to supplement the treatment.

INTERVENTIONS

The dose of morphine or route of administration, or both, was changed in three patients.

MAIN OUTCOME MEASURE

Determination of the prevalence of side effects in the patients. Assessment of the relation of any side effects with the supplemental drugs taken by the patients.

MAIN RESULTS

Plasma morphine and electrolyte concentrations were measured and a full history taken for each patient. Thirteen of the 19 patients had an important side effect; 12 of them had myoclonus and one had hyperalgesia of the skin. Plasma morphine concentrations were similar in patients with and without myoclonus, ranging from 158 to 3465 nmol/l and 39 to 2821 nmol/l respectively. Eight of the patients with side effects were taking an antipsychotic drug concurrently compared with none of those without side effects. A greater proportion of patients with side effects were taking the antinauseant drug thiethylperazine (6/13 v 2/6) and at least one non-steroidal anti-inflammatory drug (10/13 v 2/6), whereas a smaller proportion were taking a glucocorticosteroid (3/13 v 4/6). The estimated prevalence of important side effects in the total population of patients receiving palliative treatment in the two units was 2.7-3.6%.

CONCLUSIONS

Myoclonus as a side effect of treatment with morphine is more likely to occur in patients taking antidepressant or antipsychotic drugs as antiemetics or as adjuvant agents or non-steroidal anti-inflammatory drugs for additional analgesia. If a patient develops myoclonus the best approach may be to change the supplemental treatment.

Ultimate tensile strength of gamma irradiated human scleral sutures

Scleral sutures were prepared by hand from the equatorial region of 53 paired donor eyes. The weakening produced by two doses of gamma Co-60 radiation (2.7 and 4.0 Mrads) was compared using measurements of tensile strength; the strength of unirradiated scleral sutures was also measured, for comparison. The three variables of tensile strength, viz. Breaking Elongation, Breaking Load, and Work of Rupture was determined for each suture. As compared to unirradiated sutures, Breaking Elongation decreased on irradiation (P less than 0.01), but the two doses of irradiation were not statistically significant (P greater than 0.05); Breaking Load increased on irradiation (P less than 0.01), but the two doses of irradiation were again not significant (P greater than 0.05). Only 4.0 Mrads irradiated scleral sutures, as compared to unirradiated ones, showed a statistically significant reduction (P less than 0.01) for Work of Rupture. No definite relationships were found by regression analysis among the tensile strength variables and the independent variables of sex and various storage times for the 4.0 Mrad data. Work of Rupture showed a negative relationship to the age of donors, though the change with age was small.

Tensile strength of fascia lata sutures following gamma radiation

Gamma radiation (Co-60) is used to sterilize biological sutures. We wished to compare the effect of gamma-radiation in doses of 2.7 and 4.0 Mrads on the tensile strength of human fascia lata sutures obtained from the same cadaver. Five variables of tensile strength viz. Breaking Elongation, Breaking Load, Yield Point Load, Work of Rupture and Elastic Stiffness were determined for each suture. For Breaking Elongation the mean strength for the 4.0 Mrad dose was 3% less than for 2.7 Mrad dose (P less than 0.05); for Breaking Load 11% less (P less than 0.01); for Yield Point Load 9% less (P less than 0.02); for Work of Rupture 14% less (P less than 0.01); and for Elastic Stiffness 8% less (P less than 0.02). Irradiation with 4.0 Mrads, does not greatly change the tensile strength characteristics of fascia lata sutures.

Excretion of inhibitors of calcification in urine Part II. Findings in patients with chronic renal failure

By means of a semiquantitative method incorporating the rachitic rat cartilage technique, the total urinary inhibitory activity with respect to calcification was compared in 11 control subjects and 20 patients with renal failure. The patients had significantly lower mean values of inhibiting units per day than did the control subjects. Both groups showed a significant positive correlation between the number of inhibiting units per day and urine volume. When urine volume was taken into account in the comparison, the numbers of inhibiting units for patients continued to be lower than the numbers for controls. These findings are consistent with the hypothesis that the increase of inhibitory activity observed in uremic serum is secondary to a decrease in excretion of the responsible factor (or factors) in the urine, and that the factor (or factors) in serum responsible for the inhibition are identical to those in the urine.

Excretion of inhibitors of calcification in urine. Part I. Findings in control subjects and patients with renal stones

The total excretion of inhibitors of in vitro calcification was measured (in inhibiting units per day) in 24-hour urine samples of 11 control subjects and 20 patients with renal calculi. A semiquantitative method incorporating the rachitic rat cartilage technique was used. In both groups there was a significant positive correlation between the number of inhibiting units per day and the daily urine volume. The mean number of inhibiting units per day was significantly (P smaller than 0.05) higher in the stone patients than in the controls. However, the stone-formers had significantly larger (P smaller than 0.01) 24-hour urine volumes. When corrections were made for urine volume there was no significant difference between the two groups. These data suggest that the underlying abnormality responsible for renal stone formation is not a persistent decrease in the total concentration of urinary inhibitors of calcification.

Vitamin C and the common cold: a double-blind trial

A large scale double-blind trial was conducted to test the claim that the intake of one gram of vitamin C per day substantially reduces the frequency and duration of "colds". It was found that in terms of the average number of colds and days of sickness per subject the vitamin group experienced less illness than the placebo group, but the differences were smaller than have been claimed and were statistically not significant. However, there was a statistically significant difference (P <0.05) between the two groups in the number of subjects who remained free of illness throughout the study period. Furthermore the subjects receiving the vitamin experienced approximately 30% fewer total days of disability (confined to the house or off work) than those receiving the placebo, and this difference was statistically highly significant (P <0.001). The reduction in disability appeared to be due to a lower incidence of constitutional symptoms such as chills and severe malaise, and was seen in all types of acute illness, including those which did not involve the upper respiratory tract.