54 EMERGENCY PERIOPERATIVE FOR THE OLDER PERSON SERVICE (POPS) IN AN IRISH TERTIARY HOSPITAL: RESULTS OF 16-WEEK COMPREHENSIVE GERIATRIC ASSESSMENT INTERVENTION

Background

Evidence suggests older persons undergoing surgery benefit from Comprehensive Geriatric Assessment (CGA). The Republic of Ireland (ROI) is yet to implement formalised perioperative care services outside of Orthogeriatrics. We present data from an Emergency Perioperative for Older Person Service (POPS) utilising CGA as an intervention in an Irish Tertiary Hospital.

Methods

A geriatric medicine registrar performed CGA on patients over 75 admitted for unscheduled General or Vascular Surgery. Senior decision-makers could refer patients under 75 whom they considered frail. Data collected: demographics; clinical frailty score (CFS); identified delirium; length of stay (LOS); mortality during admission; 90-day mortality; 30-day readmission; new Acute Kidney Injury (AKI) during admission. We compared this data to the corresponding cohort of patients admitted in 2019 (Pre-COVID19 pandemic).

Results

104 patients underwent CGA over 16 weeks. 50.5% (48/104) were female. Average age was 82. 34.6% (36/104) CFS ≥5. 24.2% (23/104) had delirium on admission. 31.7% (33/104) had identifiable delirium throughout their admission. Pre-COVID19 data (n=92) vs POPS data (n=104): Average LOS: 14.6 days vs 13.3 days; AKI new/worse during admission 29% (28/92) vs 15% (16/104); Mortality during admission 8.6% (8/96) vs 7.7% (8/103); 30 day readmission 19.3% (17/88) vs 17.7% (17/96). 90 day mortality 14.1% (13/92) vs 16% (13/80 to date).

Conclusion

Our data is, to our knowledge, the first in the ROI to capture CGA intervention in an Emergency Surgical Ward. Early data demonstrate positive trends. We believe the implementation of perioperative CGA would benefit older patients undergoing emergency surgery in Ireland.

Temporal Trends in Traumatic Brain Injury

Aims Traumatic brain injury (TBI) is a leading cause of preventable mortality and morbidity. Our aim was to examine the demographics, injury characteristics and management of TBI patients treated in an intensive care unit (ICU) in an Irish tertiary-level hospital with a neurosurgical department. Methods A retrospective, longitudinal study of all TBI patients treated in ICU between 2013-2018. Results 77% (n=171) were male and median age was 46 (Q1-Q3: 28-62). The most common mechanism of injury was fall from less than two meters (<2m) followed by road traffic accident (RTA). The proportion of injuries due to RTA increased over the six-year period (p=0.006). 41.4% (n=92) of injuries had reported alcohol involvement. Patients with fall<2m had double the median age and double the rate of alcohol involvement compared to those suffering RTA (p<0.001, p<0.001). The neurosurgical intervention rate was 74% (n=165). The median duration of ICU admission and of intracranial-pressure monitoring, advanced ventilation and inotropic therapy increased over the six-year period (p=0.031, p=0.038, p=0.033, p<0.001). Discussion This study's findings could inform precise and impactful public prevention measures. The increasing duration of ICU admission and of other interventions should be examined further for their effect on patient outcome and resource consumption.

Predictive modeling of service discontinuation in transitional age youth with recent behavioral health service use

OBJECTIVE

To develop and test predictive models of discontinuation of behavioral health service use within 12 months in transitional age youth with recent behavioral health service use.

DATA SOURCES

Administrative claims for Medicaid beneficiaries aged 15-26 years in Connecticut.

STUDY DESIGN

We compared the performance of a decision tree, random forest, and gradient boosting machine learning algorithms to logistic regression in predicting service discontinuation within 12 months among beneficiaries using behavioral health services.

DATA EXTRACTION

We identified 33,532 transitional age youth with ≥1 claim for a primary behavioral health diagnosis in 2016 and Medicaid enrollment of ≥11 months in 2016 and ≥11 months in 2017.

PRINCIPAL FINDINGS

Classification accuracy for identifying youth who discontinued behavioral health service use was highest for gradient boosting (80%, AUC = 0.86), decision tree (79%, AUC = 0.84), and random forest (79%, AUC = 0.86), as compared with logistic regression (71%, AUC = 0.71).

CONCLUSIONS

Predictive models based on Medicaid claims can assist in identifying transitional age youth who are at risk of discontinuing from behavioral health care within 12 months, thus allowing for proactive assessment and outreach to promote continuity of care for younger persons who have behavioral health needs.

Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background

Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies.

Methods

In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality.

Findings

Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42·4% vs 44·2%; absolute difference –1·69 [–9·58 to 6·11] p=0·67; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5–8] vs 6 [5–8] cm H₂O; p=0·0011). ICU mortality was higher in MICs than in HICs (30·5% vs 19·9%; p=0·0004; adjusted effect 16·41% [95% CI 9·52–23·52]; p<0·0001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0·80 [95% CI 0·75–0·86]; p<0·0001).

Interpretation

Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status.

Funding

No funding.

85 ESTABLISHING AN EMERGENCY PERIOPERATIVE FOR OLDER PERSONS SERVICE (POPS) IN A TERTIARY HOSPITAL SETTING: EARLY DATA

Background

Evidence supports the role of geriatricians in perioperative settings. The success of orthogeriatrics has encouraged geriatric input into other surgical services. The British Geriatrics Society recommends early geriatric assessment for patients undergoing laparotomy as a means to improve older adult outcomes. We present the initial data of our Perioperative Older Person Service (POPS) that aims to standardise a clinical pathway for older adults admitted under an emergency surgical service using Comprehensive Geriatric Assessment (CGA).

Methods

We obtained an additional a whole-time equivalent geriatric registrar to facilitate establishing the POPS.

Inclusion criteria for assessment included those over 75 either admitted under an emergency surgical consultant, or awaiting a surgical assessment in the emergency department. A geriatrician performed a CGA for these patients.

We collected data including; demographics, diagnosis; premorbid frailty status (Clinical Frailty Scale (CFS) score 2 weeks prior to admission); polypharmacy; 4AT score; admission and discharge destination; procedure performed; 30-day readmission rate; ICU admission; and 90-day mortality. Extra information was gathered using free-text to identify additional geriatric interventions.

Results

At time of submission the service has assessed 15 patients over 21 days. 46% (7/15) were female, 54% (8/15) were male.

53% (8/15) of patients underwent CGA on the day of admission. 100% patients were assessed within 72 hours of their admission.

46% (7/15) had a CFS ≥4.

26% (4/15) were identified as delirious as per 4AT.

18.7% (3/16) had a procedure performed during their admission.

We identified polypharmacy in 73% (11/15).46% (7/15) were discharged with reduced medication burden.

CGA prompted new advanced care planning decisions in 40% (6/15) of patients.

Conclusion

Although the service is in its infancy, the above data is encouraging. Through early identification of frailty and timely CGA, we anticipate this service will ensure the delivery of geriatrically-attuned care to frail older people and improve outcomes.

Recent advances in the management of cutaneous malignant melanoma: our case cohort

Decades of research into the management of cutaneous malignant melanoma have proven it to be a 'tough nut to crack', and its incidence has continued to increase over the last 30 years. Surgery remains a gold standard for early-stage melanoma with five-year survival of 98% for stage I disease, and 90% for stage II. Nonetheless, patients with stage III disease are at a higher risk, resulting in local recurrence as well as distant metastasis. Research regarding the control of metastatic malignant melanoma of the head and neck has evolved. Currently the search is on to understand metastatic malignant melanoma as a heterogeneous disease both at the molecular and clinical level. This paper focuses on the latest systemic therapy for metastatic disease of the head and neck, including cytotoxic chemotherapy, immunotherapy, and target therapy. The new eighth edition of tumour staging, and the sequelae for malignant melanoma, sentinel lymph node biopsy (SLNB), surgical intervention, and its benefits and shortfalls, are discussed. Also, the outcome of our cohort series of patients with metastatic cutaneous malignant melanoma who were treated with systemic combination therapy in Dorset is presented.

Predictors of Behavioral Health Service Utilization in a Medicaid Enrolled Sample of Emerging Adults

Emerging adults (EA), individuals between the ages of 15-26, face many challenges in their transition to a new developmental stage, especially those with behavioral health concerns who do not receive the supports they need. Many EA drop out of services at 18, which is likely due in part to the need to transition to the adult service system and the lack of available transition support services in child/adolescent service systems. Though this is a clear disparity, research on EA service utilization, especially those enrolled in Medicaid and with co-occurring conditions, is rare. This paper begins to address this gap by examining variables at age 17 that predict the service utilization of continuously Medicaid enrolled EA at age 18. Data came from an administrative dataset. The sample had 4,548 EA and 53% were female, 50% identified with a minority group, and 19% were child-welfare involved. Exploratory logistic regression analyses were used. Minority EA had lower odds of utilizing services at age 18. EA involved with child welfare had greater odds of utilizing services at age 18. EA with at least one Substance Use Disorder (SUD) and at least one mental health disorder at 17 had a higher likelihood of service utilization at 18, the opposite was true for EA with only SUDs. These findings identified predictors of service utilization for an understudied sample-EA enrolled in Medicaid. Results provided preliminary evidence that EA with SUD diagnoses access behavioral health services differently than those without a SUD diagnosis, and that it is fruitful to examine subgroups of EA when seeking to understand their service utilization patterns. Identifying predictors of service utilization during the transition period from the child to the adult system can help inform systems interventions to retain EA in services.

Impact of Mobile Crisis Services on Emergency Department Use Among Youths With Behavioral Health Service Needs

OBJECTIVE

Youths are using emergency departments (EDs) for behavioral health services in record numbers, even though EDs are suboptimal settings for service delivery. In this article, the authors evaluated a mobile crisis service intervention implemented in Connecticut with the aim of examining whether the intervention was associated with reduced behavioral health ED use among those in need of services.

METHODS

The authors examined two cohorts of youths: 2,532 youths who used mobile crisis services and a comparison sample of 3,961 youths who used behavioral health ED services (but not mobile crisis services) during the same fiscal year. Propensity scores were created to balance the two groups, and outcome analyses were used to examine subsequent ED use (any behavioral health ED admissions and number of behavioral health ED admissions) in an 18-month follow-up period.

RESULTS

A pooled odds ratio of 0.75 (95% confidence interval [CI]=0.66-0.84) indicated that youths who received mobile crisis services had a significant reduction in odds of a subsequent behavioral health ED visit compared with youths in the comparison sample. The comparable result for the continuous outcome of number of behavioral health ED visits yielded an incidence risk ratio of 0.78 (95% CI=0.71-0.87).

CONCLUSIONS

Using comparison groups, the authors provided evidence suggesting that community-based mobile crisis services, such as Mobile Crisis, reduce ED use among youths with behavioral health service needs. Replication in other years and locations is needed. Nevertheless, these results are quite promising in light of current trends in ED use.

A Pay-for-Performance Initiative to Reduce Pediatric Psychiatric Inpatient Length of Stay

This column presents results of a pay-for-performance (P4P) initiative to reduce psychiatric inpatient length of stay for Medicaid-covered youths at eight hospitals in Connecticut in 2008 (N=715), 2009 (N=1,408), and 2010 (N=782). Compared with the 2007 baseline, average length of stay decreased by 25% (from 18.1 to 13.6 days) by the end of the P4P program, with concurrent nonsignificant decreases in 7- and 30-day readmissions. Readmitted youths tended to access postdischarge care sooner and use more community-based services during the first 180 days postdischarge. Additional research is needed, but the P4P program appears to have contributed to shortening inpatient stay without apparent adverse outcome on increases in postdischarge service use.

Inhaler screw-up: A real world cystic fibrosis (CF) case

A 40-year-old male with Cystic Fibrosis developed a sudden onset choking, cough, dyspnea and hemoptysis after using his inhaler. He presented to A&E. CT scan located a foreign body in his right bronchus intermedius (RBI). Rigid bronchoscopy was performed and removed a plastic rawl plug with screw from his RBI. He made a rapid recovery. On questioning he mentioned he had stored his inhaler uncapped in the same pocket he had this screw which he found at work. Small objects can lodge in inhalers due to their design/mouthpiece uncapping. This can result in endobronchial foreign body aspiration. This case highlights the importance of replacing inhaler cap when not in use.

Knockdown of Crispld2 in zebrafish identifies a novel network for nonsyndromic cleft lip with or without cleft palate candidate genes

Orofacial development is a multifaceted process involving tightly regulated genetic signaling networks, that when perturbed, lead to orofacial abnormalities including cleft lip and/or cleft palate. We and others have shown an association between the cysteine-rich secretory protein LCCL domain containing 2 (CRISPLD2) gene and nonsyndromic cleft lip with or without cleft palate (NSCLP). Further, we demonstrated that knockdown of Crispld2 in zebrafish alters neural crest cell migration patterns resulting in abnormal jaw and palate development. In this study, we performed RNA profiling in zebrafish embryos and identified 249 differentially expressed genes following knockdown of Crispld2. In silico pathway analysis identified a network of seven genes previously implicated in orofacial development for which differential expression was validated in three of the seven genes (CASP8, FOS, and MMP2). Single nucleotide variant (SNV) genotyping of these three genes revealed significant associations between NSCLP and FOS/rs1046117 (GRCh38 chr14:g.75746690 T > C, p = 0.0005) in our nonHispanic white (NHW) families and MMP2/rs243836 (GRCh38 chr16:g.55534236 G > A; p = 0.002) in our Hispanic families. Nominal association was found between NSCLP and CASP8/rs3769825 (GRCh38 chr2:g.202111380 C > A; p < 0.007). Overtransmission of MMP2 haplotypes were identified in the Hispanic families (p < 0.002). Significant gene-gene interactions were identified for FOS-MMP2 in the NHW families and for CASP8-FOS in the NHW simplex family subgroup (p < 0.004). Additional in silico analysis revealed a novel gene regulatory network including five of these newly identified and 23 previously reported NSCLP genes. Our results demonstrate that animal models of orofacial clefting can be powerful tools to identify novel candidate genes and gene regulatory networks underlying NSCLP.

Forced Expiratory Volume in 1 Second Variability Helps Identify Patients with Cystic Fibrosis at Risk of Greater Loss of Lung Function

OBJECTIVE

To evaluate several alternative measures of forced expiratory volume in 1 second percent predicted (FEV1 %pred) variability as potential predictors of future FEV1 %pred decline in patients with cystic fibrosis.

STUDY DESIGN

We included 13,827 patients age ≥6 years from the Epidemiologic Study of Cystic Fibrosis 1994-2002 with ≥4 FEV1 %pred measurements spanning ≥366 days in both a 2-year baseline period and a 2-year follow-up period. We predicted change from best baseline FEV1 %pred to best follow-up FEV1 %pred and change from baseline to best in the second follow-up year by using multivariable regression stratified by 4 lung-disease stages. We assessed 5 measures of variability (some as deviations from the best and some as deviations from the trend line) both alone and after controlling for demographic and clinical factors and for the slope and level of FEV1 %pred.

RESULTS

All 5 measures of FEV1 %pred variability were predictive, but the strongest predictor was median deviation from the best FEV1 %pred in the baseline period. The contribution to explanatory power (R(2)) was substantial and exceeded the total contribution of all other factors excluding the FEV1 %pred rate of decline. Adding the other variability measures provided minimal additional value.

CONCLUSIONS

Median deviation from the best FEV1 %pred is a simple metric that markedly improves prediction of FEV1 %pred decline even after the inclusion of demographic and clinical characteristics and the FEV1 %pred rate of decline. The routine calculation of this variability measure could allow clinicians to better identify patients at risk and therefore in need of increased intervention.

Abstract T P295: Neurological Recovery Following Out-of-hospital Cardiac Arrest: Role of Hypothermia

Introduction: Every year about 70% of coronary heart disease deaths in the United States occur out of hospital, usually presenting as ‘sudden death’ due to cardiac arrest. Despite the improvement of survival with advanced cardiac interventions, mortality remains high. Therapeutic hypothermia (TH) has been shown to be neuroprotective after cardiac arrest. We explored factors associated with good recovery of neurological function following out-of-hospital cardiac arrest (OHCA).

Methods: This retrospective study included review of electronic medical records from a major healthcare system in Northeast Indiana. Individuals who suffered OHCA from January 2011 to June 2014 were included. Neurological function was evaluated by Modified Rankin Scale (mRS) at discharge. The neurological outcome was defined as good (mRS 0-3), poor (mRS 4-5), and deceased (mRS 6) to assess the association of examined variables.

Results: Among the 111 patients meeting inclusion criteria, the mortality at discharge was 68.6% in TH-treated patients and 84% in normothermia patients. For almost half (47.5%) of the patients undergoing TH who died prior to discharge, brain-related causes were the primary cause of death. 21 patients who had imaging or pathological examinations all showed evidences of ischemic brain injury. Among TH-treated survivors, patients with return of spontaneous cardiac rhythm (ROSC) within 20 minutes of onset were 1.4 times the odds more likely to have a good neurological outcome at discharge (p=0.02). Patients with ventricular fibrillation had 2 times the odds more likely retaining good neurological function at discharge after receiving TH treatment (p=0.012). The time to initiate TH (mean 2.3 ± 1.5 hours) and time to reach target temperature (mean 7.2 ± 2.3 hours) were not associated with neurological outcome at discharge.

Conclusions: Initial rhythm and time to ROSC were identified as reliable predictors of good neurological function following OHCA. TH has been found to be insufficient in preventing brain injury. This study emphasizes the need for future studies to develop new neuroprotective strategies to improve survival among OHCA patients.

Dementia care: using empathic curiosity to establish the common ground that is necessary for meaningful communication

Over the past two decades the advocates of person-centred approaches to dementia care have consistently argued that some of the negative impacts of dementia can be ameliorated in supportive social environments and they have given lie to the common but unfounded, nihilistic belief that meaningful engagement with people with dementia is impossible. This discussion paper contributes to this welcome trend by exploring how carers can use empathic curiosity to establish the common ground that is necessary to sustain meaningful engagement with people who have mild to moderate dementia. The first section of the paper gives a brief theoretical introduction to the concept of empathic curiosity, which is informed by perceptual control theory and applied linguistics. Three case examples taken from the literature on dementia care are then used to illustrate what empathic curiosity may look like in practice and to explore the potential impact that adopting an empathic and curious approach may have.

Empathic curiosity: resolving goal conflicts that generate emotional distress

The quality of the therapeutic alliance between therapist and client is consistently identified as a key component of cognitive behavioural interventions. However, relatively little is known about the causal mechanisms that generate the effects that are ascribed to the therapeutic alliance. This paper outlines how one such causal mechanism, empathic curiosity, may operate. The explanation is rooted in control theory, a theory that explains the link between our experiences and our goal-directed behaviour. Empathic curiosity is underpinned by the core skills of empathic listening and maintaining a curious attitude. From a control theory perspective, the value of this type of listening may be reinforced when speak to people about their salient concerns, as they perceive them in the current flow of their conscious thoughts. This can be facilitated by linking curious questions to the non-verbal disruptions in their body posture and conversational flow. The approach is illustrated using three case examples. In all three examples, the clients involved were able to reflect upon and re-organize conflicting goals that had been a source of significant emotional distress.

Extended Day Treatment: A Comprehensive Model of After School Behavioral Health Services for Youth

This paper describes Extended Day Treatment (EDT), an innovative intermediate-level service for children and adolescents with serious emotional and behavioral disorders, delivered in the after school hours. The current paper describes the core components of the EDT model of care within the context of statewide systems of care, including its theoretical foundations, core service components, relation to evidence-based practices, workforce composition and staff training, and data collection and reporting mechanisms. Recommendations are provided for statewide implementation, followed by discussion of model development as an approach to systems reform for the treatment of children and youth with emotional and behavioral disorders.

Tracheo-oesophageal fistula diagnosed with multidetector computed tomography

This case highlights important issues in investigation of patients with suspected tracheo-oesophageal fistula including the value of multidetector computed tomography, the importance of thorough imaging evaluation when high clinical suspicion of tracheo-oesophageal fistula exists and the value of close interaction between radiologists and intensive care physicians in the investigation of these patients.

Effect of gestational nutrition on vascular integrity in the murine placenta

Maternal undernutrition is thought to result in smaller offspring and programme disease in later life. It is not known whether gestational nutrition affects development and functioning of placental vessels. The aim of this study was to ascertain if disturbed angiogenesis and junctional integrity were features of the labyrinthine vessels of placenta taken from transgenic Tie2-GFP mice fed either 18% (control) or 9% (low protein; MLP) casein diet. MLP animals showed a significant decrease in fetal weight at E14.5 and in placental and fetal weight at E18.5, however, maternal weight and litter size remained unaffected. Stereological analyses revealed that the fraction of components of the placenta remained similar in both study groups. There was a significant reduction in labyrinthine blood vessel length but not in luminal diameter in the E18.5 MLP group. In both MLP groups, perturbation of vascular endothelial Cadherin and beta-catenin, regulators of junctional integrity, permeability and quiescence, was observed with higher percentage of vessels showing weak or no junctional immunoreactivity. The reduction in length of the labyrinthine vessels and the downregulation of the adhesion molecules suggest that gestational undernutrition causes vascular dysfunction in the murine placenta. This may play a role in the early life programming of disease risk.

Two-year trends in the use of seclusion and restraint among psychiatrically hospitalized youths

OBJECTIVES

This study examined characteristics associated with the use of seclusion and restraint among 442 psychiatrically hospitalized youths and sought to quantify changing trends in the rates of these modalities of treatment over time after the 1999 implementation of federal regulations and an institutional performance improvement program.

METHODS

Demographic and clinical data related to all 5,929 incidents of seclusion and restraint that occurred during 2000 and 2001 at a child and adolescent state psychiatric hospital were analyzed.

RESULTS

The two-year prevalence of use of seclusion was 61 percent and of restraint was 49 percent. Children and adolescents who were admitted on an emergency basis and those belonging to ethnic minority groups were more likely to undergo seclusion or restraint. Children aged 11 years and younger were more likely to undergo seclusion. The total number of episodes decreased by 26 percent and their cumulative duration decreased by 38 percent between the first quarter of 2000 and the last quarter of 2001. The decreases were the result of fewer seclusion and restraint incidents as well as shorter episodes of restraint. Over time, a concurrent increase was observed in the proportion of episodes associated with patient (but not staff) injuries and with as-needed use of medications.

CONCLUSIONS

National reforms and institutional efforts can lead to downward trends in the use of seclusion and restraint among psychiatrically hospitalized youths. The active elements of these interventions warrant further study and replication.

The COSTAR wheelchair study: a two-centre pilot study of self-propulsion in a wheelchair in early stroke rehabilitation. Collaborative Stroke Audit and Research

OBJECTIVE

It is uncertain whether self-propulsion in a wheelchair should be encouraged or discouraged in the early stages of stroke rehabilitation.

DESIGN

A two-centre pilot study to assess the feasibility of performing a multicentre randomized controlled trial on this subject.

SETTING

Clatterbridge and Aintree Stroke Rehabilitation Units, Merseyside, UK.

SUBJECTS

Forty early stroke patients (mean age 67 years) in whom it was uncertain whether self-propulsion in a wheelchair should be encouraged were studied.

INTERVENTION

A central randomization service at Newcastle University was used to determine the policy about wheelchair provision and use for each patient. They were allocated to either an 'encouraged to self-propel' or a 'discouraged from self-propulsion group'. OUTCOME MEASURES USED: Independent outcome assessment was performed by postal questionnaire and telephone interview using the Barthel ADL Scale, Nottingham Extended ADL Scales and the shortened General Health Questionnaire (GHQ-12) at 3 and 12 months. Patient's length of stay and their Ashworth tone score were also measured either at three months or when they were discharged from hospital.

RESULTS

After considerable preparation time it was possible to conduct a trial on self-propulsion in early stroke rehabilitation in the two-pilot centres. No major differences were found between the pilot groups for any of the outcome measures.

CONCLUSIONS

A multicentre randomized controlled trial to assess this question is feasible but further work is being conducted before proceeding, to satisfy the concerns expressed to our group regarding the appropriateness of the intervention and the outcome measures.

Cisapride does not alter gastric volume or pH in patients undergoing ambulatory surgery

PURPOSE

To evaluate the efficacy of 20 mg cisapride p.o. in reducing residual gastric volume and pH in adult ambulatory surgical patients.

METHODS

Using a prospective randomised double-blind controlled design, we administered either 20 mg cisapride p.o. or placebo preoperatively to 64 ASA 1-2 ambulatory surgical patients. Following induction of anesthesia we measured volume and pH of residual gastric contents, using blind aspiration through an orogastric tube. Parametric data were analysed using unpaired, one tail Students' t test. Non-parametric data were analysed using Fishers Exact test and Chi square analysis. Statistical significance was accepted at the probability level of < 0.05.

RESULTS

Residual gastric volumes were similar in the two groups (19.5 +/- 23.8, 23.9 +/- 24.4 ml), in the cisapride and placebo groups respectively, P=0.24). Data shown are mean (+/- SD). The proportions of patients with a residual gastric volume exceeding 0.4 ml x kg(-1) were similar in the two groups (4 of 28, and 8 of 23 patients in the cisapride and placebo groups respectively, P=0.09). The pH of the residual gastric contents were similar in the cisapride and placebo groups (1.6 +/- 0.5, 1.4 +/- 0.5, respectively, P=0.26). The proportions of patients with pH < 2.5 was also similar in the cisapride and placebo groups (21 of 25, and 20 of 21 patients respectively, P=0.2).

CONCLUSIONS

Preoperative administration of 20 mg cisapride p.o. to patients scheduled for outpatient surgery does not alter either the volume or the pH of gastric contents. Its use in this setting is of no apparent clinical benefit.

Topical amethocaine (Ametop) is superior to EMLA for intravenous cannulation. Eutectic mixture of local anesthetics

PURPOSE

A eutectic mixture of local anesthetics (EMLA) is commonly used to provide topical anesthesia for intravenous (i.v.) cannulation. One of its side effects is vasoconstriction, which may render cannulation more difficult. A gel formulation of amethocaine (Ametop) is now commercially available. The aim of this study was to compare EMLA and Ametop with regard to the degree of topical anesthesia afforded, the incidence of vasoconstriction and the ease of i.v. cannulation.

METHODS

Thirty two ASA I adult volunteers had a #16 gauge i.v. cannula inserted on two separate occasions using EMLA and Ametop applied in a double blind fashion for topical anesthesia. Parameters that were recorded after each cannulation included visual analogue pain scores (VAPS), the presence of vasoconstriction and the ease of cannulation, graded as: 1 = easy, 2 = moderately difficult, 3 = difficult and 4 = failed.

RESULTS

The mean VAPS +/- SD after cannulation with Ametop M was 12+/-9.9 and with EMLA was 25.3+/-16.6 (P = 0.002). Vasoconstriction occurred after EMLA application on 17 occasions and twice after Ametop (P = 0.001). The grade of difficulty of cannulation was 1.44+/-0.88 following EMLA and 1.06+/-0.25 with Ametop (P = 0.023).

CONCLUSIONS

Intravenous cannulation was less painful following application of Ametop than EMLA. In addition, Ametop caused less vasoconstriction and facilitated easier cannulation. Its use as a topical anesthetic agent is recommended, especially when i.v. access may be problematic.

Computerised augmentative communication devices for people with dysphasia: design and evaluation

Recent developments in low-cost computer technology suggest that substantial improvements are possible in communication aids for dysphasic patients. This study describes a recently developed communication aid and reports a case study of one application. The software (EasySpeaker for Windows) provides an easily customized and flexible icon-based communication aid, which does not require the ability to read text, but which automatically records in detail the use being made of the device. The aid was given to a dysphasic patient in his own home for 4 weeks. Regular activity sessions were held throughout the period and data obtained from these sessions to identify learning and improvement on the device. Although improvements were found in speed and accuracy of operation, the use made of the aid for real communication by this patient was limited. Several possible reasons are identified for this and, in particular, the importance of illustrating specifically how such a system can be of benefit is emphasised.

BACUP--the first two years: evaluation of a national cancer information service

The cancer information service of the British Association of Cancer United Patients (BACUP) was launched in October 1985 as a national service to patients and their relatives, the public, and health professionals. Information is provided by telephone and letter by seven nurses trained in oncology. In the first two years over 30,000 inquiries were received: 23,527 (80%) were from women; 9445 (32%) were from cancer patients 11,574 (39%) from relatives of patients, and 2869 (10%) from health professionals. Inquiries came from all over the United Kingdom and from all sections of society but users were predominantly middle class, aged between 30 and 49, and living in south east England. Information about specific cancer sites, treatment, and how to cope was most commonly sought. Nearly a third of all inquiries were related to breast cancer. Though the service is used more by particular groups focusing on particular diseases, clearly there is a need for a cancer information service in the UK.

Gifts, exchanges and the political economy of health care. Part I: should blood be bought and sold?

Should blood be bought and sold is in crude terms the question asked and answered by Richard Titmuss in his recent book The Gift Relationship. Dr Raymond Plant, a lecturer in philosophy at Manchester University, analyses Titmuss' arguments in a paper which we are printing in two parts. Titmuss has taken the provision of blood as his example of the gift relationship--and by extension that of health care generally. Dr Plant considers in turn each of Titmuss' arguments that blood should not be a marketable commodity, the moral objections to which seem to be the erosion of freedom and of truth telling, the separation of society through the cash nexus, and its converse that the provision of health care is a means for the integration of society. Dr Plant also examines the views of other commentators on the Titmuss' theory of the value of a 'free' blood transfusion service and other medical care as a means of integration in society, and ends with his promise that in the second part of his paper he will examine Titmuss' principles not in terms of the market but rather as related to the principle of social justice.

Patient anxiety in the dentist's office

Patient anxiety during three phases of a dental appointment indicated that subjectively experienced anxiety increased as treatment approached and dramatically decreased after treatment. The amount of anxiety change was different for men and women. Implications for anxiety reduction in the dentist's office are discussed.