Health expenditures after first hospital admission for heart failure in Nova Scotia, Canada: a retrospective cohort study

BACKGROUND

Although the frequency of heart failure makes it among the costliest of illnesses, there are scant Canadian data on annual costs of treatment or the costs as the condition advances. Our objective was to estimate mean prevalence- and incidence-based direct medical costs among older adults discharged alive after a first hospital admission for heart failure.

METHODS

We conducted a retrospective cohort study using population-based administrative health databases for Nova Scotia. The cohort comprised persons 50 years of age or older with an incident hospital admission for heart failure between 2009 and 2012. We considered the costs (expressed as 2020 Canadian dollars) of hospital admissions, physician visits and, for patients 65 years of age or older, outpatient cardiac medications. We estimated costs for calendar years, longitudinally and in the last 2 years of life. We analyzed costs from the perspective of a third-party public payer.

RESULTS

The cohort consisted of 3327 patients (mean age 77.6 yr; 1605 [48.2%] women). Median survival was 2.5 and 2.2 years among men and women, respectively. Annual prevalence-based costs were about $7100. Mean incidence-based costs ranged between $65 000 and $164 000 in the year after diagnosis and decreased by 90% subsequently. Costs were 4 to 7 times higher in the year before death than in the period from 1 to 2 years before death.

INTERPRETATION

The direct medical costs of treating patients with heart failure in Nova Scotia displayed a reverse J shape, with costs highest after diagnosis, declining subsequently and then increasing during the final year of life. Strategies designed to improve the quality of care immediately after diagnosis and during more advanced stages of disease might reduce these costs.

Duration of anticoagulant therapy and VTE recurrence in patients with cancer

Purpose

Anticoagulant therapy for at least 3–6 months is currently recommended for treatment of venous thromboembolism (VTE) in patients with cancer, but the optimal duration of treatment is unknown. This study examines the association between the duration of anticoagulation treatment and VTE recurrence in cancer patients.

Methods

The Humana claims database was used to identify newly diagnosed cancer patients who had their first VTE diagnosis between January 1, 2013, and May 31, 2015, and initiated injectable or oral anticoagulant therapy. Follow-up was calculated from the index treatment initiation to the end of eligibility or end of data (June 2015). VTE recurrence was defined as a hospitalization with a primary diagnosis of VTE. Cox proportional hazards models were used to evaluate the risk of VTE recurrence by duration of therapy in patients who discontinued therapy.

Results

The study included 1158 patients. Compared to patients treated for 0 to 3 months, VTE recurrences were significantly lower among patients treated for 3 to 6, or over 6 months. After adjustment for baseline characteristics, patients treated for 3 to 6 months (HR [95%CI], 0.53; 0.37–0.76) and more than 6 months (HR [95%CI], 0.48; 0.34–0.68) were still significantly less likely to have VTE recurrences compared to patients treated for 0 to 3 months (both p < 0.01). Findings were similar using a VTE event definition that included outpatient visits.

Conclusions

Among newly diagnosed cancer patients with VTE, anticoagulant therapy lasting more than 3 months was associated with a lower risk of VTE recurrence.

Electronic supplementary material

The online version of this article (10.1007/s00520-019-4661-3) contains supplementary material, which is available to authorized users.

Observational study of characteristics and clinical outcomes of Dutch patients with tuberous sclerosis complex and renal angiomyolipoma treated with everolimus

OBJECTIVE

To compare kidney size (used as proxy for total renal angiomyolipoma [rAML] size) and kidney function outcomes between patients with tuberous sclerosis complex (TSC) and rAML treated and not treated with everolimus.

METHODS

Medical charts of adults with TSC-associated rAML followed at a specialty medical center in the Netherlands (1990-2015). Included patients treated with everolimus (n = 33, of which 27 were included in the kidney size analyses and 27 in the kidney function analyses [21 patients in both]; index date = everolimus initiation) and non-treated patients (n = 39, of which 29 were included in the kidney size analyses and 33 in the kidney function analyses [23 patients in both]; index date = one date among all dates with outcome measurement).Percent change in kidney size and kidney function from the index date to the best measurement in the two years post-index date (best response) compared between patients treated and not treated with everolimus.

RESULTS

Compared with non-treated patients, significantly more everolimus-treated patients experienced a reduction in the size of their largest kidney in the two years post-index date (85.2% vs. 37.9%, p < 0.01). Also, there was a tendency towards more improvement in the estimated glomerular filtration rate (eGFR) among the everolimus-treated patients (55.6% vs. 33.3%, p = 0.08).

CONCLUSIONS

The study results suggest that everolimus is effective in controlling and even reversing the growth of the kidneys, used as a proxy for rAML size, as well as preserving or improving kidney function in patients with TSC and rAML treated in a real-world, observational setting.

Effectiveness and safety of anticoagulants for the treatment of venous thromboembolism in patients with cancer

Anticoagulation is used to treat venous thromboembolism (VTE) in cancer patients, but may be associated with an increased risk of bleeding. VTE recurrence and major bleeding were assessed in cancer patients treated for VTE with the most currently prescribed anticoagulants in clinical practice. Newly diagnosed cancer patients (first VTE 1/1/2013-05/31/2015) who initiated rivaroxaban, low-molecular-weight heparin (LMWH), or warfarin were identified from Humana claims data and observed until end of eligibility or end of data availability. VTE recurrence was a hospitalization with a primary diagnosis of VTE ≥7 days after first VTE. Major bleeding events on treatment were identified using validated criteria. Cohorts were compared using Kaplan-Meier rates at 6 and 12 months and Cox proportional hazards models. Cohorts were adjusted for their differences at baseline. A total of 2428 patients (rivaroxaban: 707; LMWH: 660; warfarin: 1061) met inclusion criteria. Patient characteristics were well balanced after weighting. There was a trend for lower VTE recurrence rates in rivaroxaban users compared to LMWH users at 6 months (13.2% vs. 17.1%; P = .060) and significantly lower at 12 months (16.5% vs. 22.2%; P = .030) [HR: 0.72, 95% CI: (0.52-0.95); P = .024]. VTE recurrence rates were also lower for rivaroxaban than warfarin users at 6 months (13.2% vs. 17.5%; P = .014) and 12 months (15.7% vs. 19.9%; P = .017) [HR: 0.74, 95% CI: (0.56-0.96); P = .028]. Major bleeding rates were similar across cohorts. This real-world analysis suggests cancer patients with VTE treated with rivaroxaban had significantly lower risk of recurrent VTE and similar risk of bleeding compared to those treated with LMWH or warfarin.

Current practice patterns and patient persistence with anticoagulant treatments for cancer-associated thrombosis

BACKGROUND

Recommended therapeutic options for the management of venous thromboembolism (VTE) in patients with cancer are burdensome, and compliance with guidelines is unknown.

OBJECTIVES

To describe current treatment patterns and to evaluate patient persistence on various anticoagulants.

PATIENTS/METHODS

Medical and pharmacy claims from the Humana Database were analyzed (01/2007-12/2014). Newly diagnosed cancer patients treated with anticoagulants were categorized into one of the following cohorts: low-molecular-weight heparin (LMWH), warfarin, and rivaroxaban. Discontinuation, switching, and persistence with the index therapy were analyzed.

RESULTS

A total of 2941 newly diagnosed patients with cancer who developed VTE and received anticoagulation in outpatient settings were identified. Of these, 97% initiated anticoagulation with LMWH (n=735; 25%), warfarin (n=1403; 47.7%), or rivaroxaban (n=709; 24.1%). Median treatment durations for the LMWH, warfarin, and rivaroxaban cohorts were 3.3, 7.9, and 7.9 months, respectively; Kaplan-Meier rates of persistence to the initial therapy were 37%, 61%, and 61% at 6 months. Warfarin and rivaroxaban users were significantly more likely to remain on initial therapy compared to LMWH (adjusted hazard ratios [HRs; 95% CI]: warfarin, 0.33 [0.28-0.38]; rivaroxaban, 0.38 [0.32-0.46]). The proportion of patients that switched from their initial treatment to another anticoagulation treatment was 22.9%, 7.9%, and 4.7% in the LMWH, warfarin, and rivaroxaban cohorts, respectively.

CONCLUSIONS

This real-world analysis showed that, despite guideline recommendations, warfarin and rivaroxaban are at least as equally utilized as LMWH for the treatment of cancer-associated thrombosis. LMWH was associated with significantly lower persistence, shorter duration of treatment, and more switching than warfarin and rivaroxaban.

An Evaluation of Treatment Patterns and Outcomes in Elderly Patients Newly Diagnosed With Acute Myeloid Leukemia: A Retrospective Analysis of Electronic Medical Records From US Community Oncology Practices

BACKGROUND

Many elderly patients with acute myeloid leukemia (AML) are considered ineligible for standard intensive induction therapy due to performance status and comorbidities. We analyzed treatment patterns and outcomes among elderly patients newly diagnosed with AML in the US community oncology setting.

METHODS

A retrospective observational study was conducted using patient-level data from a network of US community oncology practices provided by Altos Solutions. Patients aged ≥ 60 years, diagnosed with AML between November 2005 and February 2014, with ≥ 1 recorded visit and ≥ 6 months between diagnosis and data cutoff, were included. Only patients who received active treatment or best supportive care (BSC) per National Comprehensive Cancer Network (NCCN) AML Guidelines were analyzed.

RESULTS

Of 1139 patients meeting the inclusion criteria, 922 (median age 76 years) received NCCN-recommended treatments: standard induction (n = 5), low-intensity therapy (n = 425), BSC with hydroxyurea (HU) (n = 36), or BSC without HU (n = 455). For the low-intensity therapy cohort, median time from diagnosis to treatment initiation was 17 days; median duration of therapy was 5.1 months. Median overall survival (OS) from diagnosis in the low-intensity, BSC with HU, and BSC without HU groups was 12.3, 7.0, and 49.4 months, respectively. Median time to next therapy/death was 10.1 months in patients receiving low-intensity therapy. A higher proportion of patients receiving low-intensity therapy required transfusion or other supportive care versus those receiving BSC.

CONCLUSIONS

As expected, OS in patients receiving low-intensity therapy or BSC with HU is poor for elderly patients with AML. Remarkably, intensive induction strategies are rarely used for older patients in community oncology practice.

Adherence to iron chelation therapy and associated healthcare resource utilization and costs in Medicaid patients with sickle cell disease and thalassemia

BACKGROUND

Sub-optimal patient adherence to iron chelation therapy (ICT) may impact patient outcomes and increase cost of care. This study evaluated the economic burden of ICT non-adherence in patients with sickle cell disease (SCD) or thalassemia.

METHODS

Patients with SCD or thalassemia were identified from six state Medicaid programs (1997-2013). Adherence was estimated using the medication possession ratio (MPR) of ≥0.80. All-cause and disease-specific resource utilization per-patient-per-month (PPPM) was assessed and compared between adherent and non-adherent patients using adjusted incidence rate ratios (aIRR). All-cause and disease-specific healthcare costs were computed using mean cost PPPM. Regression models adjusting for baseline characteristics were used to compare adherent and non-adherent patients.

RESULTS

A total of 728 eligible patients treated with ICT in the SCD cohort, 461 (63%) adherent, and 218 in the thalassemia cohort, 137 (63%) adherent, were included in this study. In SCD patients, the adjusted rate of all-cause outpatient visits PPPM was higher in adherent patients vs non-adherent patients (aIRR [95% CI]: 1.05 [1.01-1.08], p < 0.0001). Conversely, adherent patients incurred fewer all-cause inpatients visits (0.87 [0.81-0.94], p < 0.001) and ER visits (0.86 [0.78-0.93], p < 0.001). Similar trends were observed in SCD-related resource utilization rates and in thalassemia patients. Total all-cause costs were similar between adherent and non-adherent patients, but inpatient costs (adjusted cost difference = -$1530 PPPM, p = 0.0360) were lower in adherent patients.

CONCLUSION

Patients adherent to ICT had less acute care need and lower inpatient costs than non-adherent patients, although they had more outpatient visits. Improved adherence may be linked to better disease monitoring and has the potential to avoid important downstream costs associated with acute care visits and reduce the financial burden on health programs and managed care plans treating SCD and thalassemia patients.

Comparison of rehospitalization rates and associated costs among patients with schizophrenia receiving paliperidone palmitate or oral antipsychotics

PURPOSE

Comparative data on rehospitalization patterns and associated institutional costs after inpatient treatment with paliperidone palmitate or oral antipsychotic therapy are reported.

METHODS

A retrospective cohort study was conducted using discharge and billing records from a large hospital database. Selected clinical and cost outcomes were compared in a cohort of adult patients who received the long-acting antipsychotic paliperidone palmitate during a schizophrenia-related index hospital stay and a cohort of patients who received oral antipsychotic therapy during their index admission. Inverse probability-of-treatment weights based on propensity scores were used to reduce confounding. Rates of all-cause and schizophrenia-related rehospitalization and emergency room (ER) use in the two cohorts over periods of up to 12 months were analyzed using a multivariate Cox proportional hazard model. Institutional costs for the evaluated postdischarge events were compared via multivariate linear regression analysis.

RESULTS

In the first 12 months after index hospital discharge, the risk of all-cause rehospitalization and ER use was significantly lower in the paliperidone palmitate cohort than in the oral antipsychotic cohort (hazard ratio, 0.61; 95% confidence interval [CI], 0.59-0.63; p < 0.0001); institutional costs during the first 6 months after discharge were significantly lower in the paliperidone palmitate cohort than in the comparator group (adjusted mean monthly cost difference -$404; 95% CI, -$781 to -$148; p < 0.0001).

CONCLUSION

The use of paliperidone palmitate therapy during patients' index hospital admission for schizophrenia was associated with a reduced risk of hospital readmission or ER use and lower postdischarge institutional costs.

What is French for déjà vu? Descriptions of déjà vu in native French and English speakers

Little is known about how people characterise and classify the experience of déjà vu. The term déjà vu might capture a range of different phenomena and people may use it differently. We examined the description of déjà vu in two languages: French and English, hypothesising that the use of déjà vu would vary between the two languages. In French, the phrase déjà vu can be used to indicate a veridical experience of recognition - as in "I have already seen this face before". However, the same is not true in English. In an online questionnaire, we found equal rates of déjà vu amongst French and English speakers, and key differences in how the experience was described. As expected, the French group described the experience as being more frequent, but there was the unexpected finding that they found it to be more troubling.

Technical note: Comparison of two methods to quantify exercise energy expenditure in trotters

This study aimed at quantifying energy expenditure during 4 specific training exercises, that is, promenade, jogging, parcours, and interval exercises, using field measurements of oxygen consumption and heart rate in trotters. Six animals performed 2 preliminary tests to determine their individual maximum velocity and to establish their individual oxygen consumption/heart rate relationship from an incremental test. Then, they undertook each of the 4 specific exercises separated by 1 wk to avoid fatigue. The intensity of the 4 exercises was expressed in percent of individual maximum velocity as well as duration and distance set according to current training practices of French trotter trainers. Throughout the incremental test and the 4 exercises, oxygen consumption and heart rate were continuously recorded using a portable respiratory gas analyzer. Energy expenditure of the 3 different phases (warm-up, exercise, and recovery) of the 4 exercises and the total energy expended during exercises (sum of energy expended during the 3 phases) were calculated from direct oxygen uptake measurements and from estimated oxygen uptake using heart rate and O caloric equivalent. The quantification of total energy expenditure from the 2 methods was not significantly different. However, estimated energy expenditure was significantly lower from estimated oxygen consumption than direct oxygen uptake method concerning the warm-up and exercise phase of parcours. Our results indicate that the estimated oxygen uptake from heart rate measurements could be used to evaluate total energy expenditure of exercises in trotters. Whereas this method requires previous establishment of an individual oxygen consumption/heart rate curve, it is easy to record using commercially available instruments under practical conditions and opens new perspectives to assess energy balance in trotters' nutrition.

Effects of two field continuous incremental tests on cardiorespiratory responses in Standardbred trotters

In humans, cardiorespiratory responses are widely evaluated from field incremental exercise tests. On the contrary, equine exercise physiology faces a huge lack of oxygen consumption measurements (VO2) in field conditions due to technical concerns. The aim of this study was to test the effects of two incremental continuous field tests on cardiorespiratory responses in Standardbred trotters. The two protocols were realized at trot and ended when horses galloped. The tests started at 4.2 m/s (T1) and 6.4 m/s (T2), with speed increments of 1.4 m/s every 3 min for T1 and 0.8 m/s every 2 min for T2. Velocity (v), heart rate (HR) and gas exchanges were recorded continuously, and blood lactate concentration [La(-)] was measured before and after tests. Values recorded at the end of the tests were considered as peak values. The vpeak values were 10.6 ± 0.3 and 10.7 ± 0.7 m/s for T1 and T2 respectively. Horses reached higher VO2peak (T1: 116.6 ± 11.5 ml/min/kg; T2: 88.9 ± 10.2 ml/min/kg; p < 0.05) and HRpeak (T1: 217 ± 5 bpm; T2: 209 ± 3 bpm; p < 0.05) during T1 compared with T2. T1 was significantly longer than T2 (17.5 ± 1.9 vs. 12.9 ± 1.6 min respectively, p < 0.01), and the number of steps entirely ran tended to be different (T1: 5.6 ± 0.6; T2: 6.2 ± 0.8, p = 0.07). Compared to T2, the design of T1 appeared easier to implement and allowed higher cardiorespiratory responses. The relationship between HR-VO2 obtained through T1 gave a better correlation between the two variables than T2. These findings suggest that T1 might be better than T2 for evaluating cardiorespiratory adaptations to exercise and for estimating aerobic energy expenditure in exercising trotters.

Training management of Standardbred trotters: a field survey in France

This study aimed to characterise the training practices of French trainers and to describe the training load undertaken by unqualified (UT) and qualified Standardbred trotters (QT). During the Paris-Vincennes 2012 meeting, 20 trainers from the Grosbois training centre were surveyed. Details of their general training practices as well as the weekly workloads for UT and QT were obtained. A nonparametric Mann-Whitney test was used to compare the UT and QT data and a principal component analysis (PCA) was carried out to examine links between trainer characteristics and particular training practices. Four main exercises used to train trotters were identified: (1) ‘promenade’ exercise: light exercise at walk and at slow trot (5.1±0.4 m/s) lasting 48±9 min; (2) ‘jogging’: moderate trot exercise (6.9±1.5 m/s) lasting 44±12 min; (3) ‘parcours’ exercise: moderate/high intensity trot session (10.3±0.9 m/s) over 2,844±1,412 meters with a final sprint; (4) ‘interval’ type exercise: fast trot sessions (10.8±0.9 m/s) over 1,010±212 meters with sprint phases. Trainers used a combination of these four exercises to train both UT and QT. Moreover, the estimated training weekly workload did not appear to differ between the two age categories, with apparently similar exercises and training loads being used to train both UT and QT. The results of the PCA suggested that as trainers become older and more successful they tend to change the composition of exercises used. They preferably used more ‘jogging’ type exercise, regardless of the horses’ age or training level. Whilst the weekly training plan varied between trainers, it seems that the individual trainer's annual programme was relatively constant, consisting of a repetition of a typical training week.

Sleepiness/alertness among healthy evening and morning type individuals

Objective: The aim of this study was to determine the level of sleepiness/alertness among different chronotypes.Background: The Horne-Ostberg Morningness-Eveningness Questionnaire (MEQ) has allowed the characterization of chronotypes that are associated with a number of biological factors including: body temperature, cortisol rhythm, sleep patterns, and architecture.Methods: Fifty-six consecutive normal volunteers underwent an 8-h polysomnogram followed by a multiple sleep latency test (MSLT). Each subject also completed the MEQ and the Sleep/Wake Activity Inventory.Results: Evening types (ET) reported significantly later bedtimes and risetimes than both morning types (MT) and neither types (NT, P<0.05). On nocturnal polysomnography, the ET documented significantly longer latencies to stage 1 and persistent sleep when compared to both the NT and MT (P<0.01). There were no significant differences in the level of sleepiness on the MSLT across the different chronotypes. However, the pattern of sleepiness differed among them. While ET and NT showed differential sleep latencies across nap opportunities, MT showed no evidence of circadian variation on their level of sleepiness.Conclusions: There were no overall differences in daytime sleepiness/alertness across chronotypes. However, a differential pattern of sleep latencies was noted on the MSLT.

Self-reported levels of sleepiness among subjects with insomnia

Objectives: To determine the prevalence of sleepiness in a cohort of insomnia subjects. We evaluated if differential levels of subjective sleepiness predict systematic differences in the polysomnographic characteristics of these subjects.Background: Insomnia is prevalent among the adult population. While it has been speculated that sleepiness may be an important daytime consequence of insomnia, this has not been demonstrated.Methods: Sixty-two subjects with complaints of insomnia for at least 6 months were polysomnographically evaluated. Subjects were asked to self-report their level of sleepiness based on their experiences for the previous 7 days. Subjects were divided into three groups based on their level of sleepiness. Sleepiness was determined using the excessive daytime sleepiness scale of the Sleep/Wake Activity Inventory (SWAI-EDS).Results: Twenty-two percent of insomnia subjects were found to be sleepy on the EDS scale of the SWAI. The level of sleepiness was also found to predict difficulty initiating sleep both on the nocturnal scale of the SWAI, and on nocturnal polysomnography.Conclusions: This study established a base rate of sleepiness among a cohort of insomnia subjects. It also demonstrated a wide spectrum of sleepiness/alertness among subjects with insomnia. Differential levels of sleepiness were found to predict nocturnal sleep latencies.

Intraoperative vs postoperative morphine improves analgesia without increasing PONV on emergence from ambulatory surgery

PURPOSE

To compare the timing of administration of morphine in patients undergoing painful ambulatory surgical procedures to determine whether there was a difference in postoperative nausea or vomiting (PONV), quality of analgesia, and recovery profile.

METHODS

In a double-blinded, placebo-controlled, prospective study, 70 ASA I-II patients were randomized to receive 0.1 mg x kg(-1) morphine intraoperatively (lop) (n=35), or postoperatively (Pop) (n=35). The severity of nausea and pain were measured using visual analog scales (VAS).

RESULTS

There was no difference between the groups in postoperative nausea scores or the incidence of PONV. Upon awakening, patients who received Pop morphine had higher pain VAS scores with movement (7.6 +/- 2 vs 5.4 +/- 3, P < 0.003) and at rest (6.9 +/- 3 vs 5.1 +/- 3, P < 0.013) than the lop morphine group. The total number of PCA attempts and analgesic requirements were similar. Patients who received Pop morphine were able to drink sooner than the lop group (90 +/- 34 vs 111 +/- 38 min, P < 0.05). All other recovery milestones were similar. Times to discharge from hospital were similar.

CONCLUSIONS

Administration of 0.1 mg x kg(-1) morphine iv intraoperatively improves postoperative analgesia upon emergence from painful ambulatory surgical procedures without increasing the incidence of PONV There was no increase in PONV when morphine was administered intraoperatively rather than postoperatively.

A comparison of midazolam, alfentanil and propofol for sedation in outpatient intraocular surgery

PURPOSE

To determine the ideal sedative regimen for intraocular surgery under peribulbar or retrobulbar block. The addition of alfentanil and or propofol to midazolam was evaluated with regard to hemodynamic variables, respiratory rate, pain, anxiety, sedation, postoperative recovery and patient satisfaction.

METHODS

Eighty two patients aged between 50 and 85 were recruited into this prospective, randomised, double blind study. Patients, in four groups, received 0.015 mg x kg(-1) midazolam, 5 microg x kg(-1) alfentanil and 0.15 mg x kg(-1) propofol; 0.015 mg x kg(-1) midazolam and 0.15 mg x kg(-1) propofol; 0.015 mg x kg(-1) midazolam and 5 microg x kg(-1) alfentanil or 0.015 mg x kg(-1) midazolam alone. Blood pressure, heart rate, respiratory rate, pain, anxiety and sedation scores were measured. Times to discharge from the Post Anesthesia Care Unit (PACU) and Day Surgery Unit (DSU) were documented. A 24 hr telephone interview was carried out to determine patient satisfaction.

RESULT

Systolic blood pressure of patients in groups that had received alfentanil was 6% lower than that of patients who had not (P<0.05) at the time of insertion of intraocular block. Patients in the alfentanil groups also had lower respiratory rates during the first 15 min after drug administration, but all patients were given supplemental oxygen therefore oxygen saturation was unaffected. Pain scores of patients who had been given alfentanil were lower during the first postoperative hour than those who had not.

CONCLUSION

The addition of alfentanil to midazolam is advantageous in providing sedation for insertion of intraocular block.

[Clinical case management of severely mentally ill homeless people.]

The aim of this clinical case management project was to improve the health and quality of life of homeless mentally ill people and to help them use more appropriately health and welfare services. During a descriptive study that lasted 12 months, data was collected concerning the case manager's intervention as well as the assessment of these interventions on the clients' health and behavior and on community resources' services. Although limited in scope and length, the project shows some positive results. Recommendations are made concerning essential collaboration between all health and welfare professionals working with this population.

Tracheal resection and reconstruction

PURPOSE

To review the literature on tracheal and carinal resection and reconstruction, and to report the general approach to these patients, as well as the general guidelines for the safe administration of anesthesia. The airway management is extensively reviewed.

SOURCE

Articles obtained from a Medline search (1960 to October 1997; keywords: tracheal surgery, carinal surgery, airway management). Textbook literature including the bibliographies were also consulted.

PRINCIPAL FINDINGS

Benign or malignant tracheal and carinal pathology causing obstruction can be managed in several ways but resection and reconstruction are the treatment of choice for most patients with tracheal stenosis or tumour. Surgery of the trachea is a special endeavour where the airway is shared by the surgeon and the anesthesiologist. The principal anesthetic consideration is ventilation and oxygenation in the face of an open airway. Ventilation can be managed in different ways, including manual oxygen jet ventilation, high frequency jet ventilation, distal tracheal intubation, spontaneous ventilation, and cardiopulmonary bypass.

CONCLUSION

The management of anesthesia for tracheal surgery presents many challenges to the anesthesiologist. Knowledge of the various techniques for airway management is crucial. Meticulous planning and communication between the anesthesia and surgical teams are mandatory for the safe and successful outcome of surgery for patients undergoing this procedure.

The detection of brief daytime sleep episodes

INTRODUCTION

In the present study we evaluated the characteristics of sleep-onset detection (during daytime nap opportunities) as a function of differing sleep lengths among healthy, asymptomatic subjects.

METHODS

Twenty subjects were randomized into a Latin square design in which each subject received 1, 5, 10, and 20 minutes of sleep during an MSLT. Subjects were asked after each nap if they fell asleep. The rate of sleep detection was analyzed as a function of sleep duration.

RESULTS

Three subjects detected sleep onset after 1 minute of sleep, 7 subjects after 5 minutes of sleep, 10 subjects after 10 minutes of sleep, and 14 after 20 minutes of sleep (chi 2 = 9.63, p < .05).

CONCLUSIONS

The present data indicate the importance of sleep duration in an individual's ability to detect the occurrence of sleep. Importantly, only three subjects detected sleep after 1 minute of sleep, emphasizing the dangerous nature of brief sleep episodes in the context of public safety.

Unanticipated admission after ambulatory surgery--a prospective study

PURPOSE

To determine the incidence, the reasons, and the predictive factors for unanticipated admission after ambulatory surgery.

METHODS

Preoperative, intraoperative, and postoperative data were collected prospectively on 15,172 consecutive ambulatory surgical patients during a 32-month period. The data were built into a statistical model, and predictive factors were identified and classified.

RESULTS

The overall incidence of unanticipated admission was 1.42%. Admitted patients were more likely to be older, male, and ASA status II or III. Duration of anaesthesia was longer, and surgery was more likely to be completed after 3 pm. Length of stay in the Postanaesthesia Care Unit and the Ambulatory Surgery Unit was longer. Surgical reasons were cited in 38.1% of admitted patients; anaesthesia-related reasons were cited in 25%; social reasons accounted for 19.5%, and medical reasons for 17.2%. Ear, nose and throat (ENT) patients had the highest unanticipated admission rate (18.2%), followed by urology (4.8%) and chronic pain block (3.9%). Gynaecological patients had the lowest rate (0.4%). Among the predictive factors found were male, ASA status II and III, long duration of surgery, surgery finishing after 3 pm, postoperative bleeding, excessive pain, nausea and vomiting, and excessive drowsiness or dizziness.

CONCLUSION

Earlier operating time for certain surgical procedures, screening for proper support at home, and implementation of clinical pathways to deal aggressively with problems such as pain, nausea and vomiting should decrease the incidence of unanticipated admission.

Development of an ostomy competency

Staff educators and staff nurses developed an ostomy competency, with the guidance and expertise of the advanced practitioner and enterostomal nurse at a large teaching hospital. The competency improved the quality of care for surgical ostomy patients. Care was standardized and staff nurses' clinical knowledge was enhanced. Following the sessions, staff nurses verbalized increased confidence in working with patients with ostomies and demonstrated increased autonomy and problem-solving abilities. No variances in educational aspects of care were noted on clinical pathways.

The chronic efficacy of midazolam

The chronic efficacy of midazolam 15.0 mg was studied in 2 male and 10 female subjects. Only subjects with a complaint of sleep latency insomnia which was verified by polysomnography were included in the study. Following a screening and adaptation period, subjects spent 3 consecutive nights in the laboratory during the weeks of the study. Placebo was administered 15 min before lights out on the initial 8 and final 2 nights, and midazolam for the intervening 35 nights. Midazolam significantly reduced sleep latency parameters and significantly increased total sleep time the entire 5 weeks of nightly administration. No within-night rebound insomnia, residual daytime effects, or rebound effects upon discontinuation appeared.

Parathyroid hormone receptor in human placental syncytiotrophoblast brush border and basal plasma membranes

The syncytiotrophoblast of the placenta is the site of exchange of nutrients and minerals between the mother and fetus. We have recently demonstrated that PTH influences, in vitro, phosphate transport through the placenta brush border membranes (BBM) and increases cAMP accumulation in placental tissue. To demonstrate the site of binding of PTH in the cytoplasmic membrane, we have purified two polar membranes: the first located on the apical side, the BBM, and the second, on the fetal side, the basal plasma membrane (BPM). BBM were enriched 24-fold in alkaline phosphatase (marker for BBM), and the BPM was enriched 37-fold in binding of [3H] dihydroalprenolol (marker for BPM) compared to homogenate. Both placental membranes contain binding sites (maximum binding = 0.550 +/- 0.032 and 0.298 +/- 0.065 pmol/mg protein for BBM and BPM, respectively) with similar affinities (Kd = 2.05 +/- 0.23 and 1.78 +/- 0.19 nM, respectively) for 125I-[Nle8,Nle18,Tyr34] bovine (b) PTH-(1-34) amide. The three bovine preparations [bPTH-(1-34), its analog [Nle8,Nle18,Try34]bPTH-(1-34) amide, and the antagonist bPTH-(3-34)] were equipotent in binding to both placental membranes. In contrast, human PTH-(1-84) was more effective in displacing the bovine radioligand in BBM. Thyrocalcitonin and insulin, two non-PTH peptides, did not significantly displace the radioligand in BBM and BPM. Adenylate cyclase activity, located exclusively in BPM, was stimulated by PTH. Since the enzyme is absent from BBM, it is probable that the binding of the hormone to this membrane activates another system of messengers.