Child and caregiver voices about inpatient care: What do they report as positive and as needing improvement?

PURPOSE

In pediatric healthcare, patient satisfaction queries exclude children and solicit quantitative ratings from caregivers. We sought satisfaction perspectives from hospitalized children 7 to 17 years and their caregivers by qualitatively analyzing interview responses.

DESIGN AND METHODS

English and Spanish-speaking children and their parents on five inpatient units completed two open-ended questions about their satisfaction at hospital discharge (T1, face to face) and 7 to 10 days later (T2, telephone). The questions asked about what was good and what could be better at the hospital. Responses were analyzed using descriptive semantic content analysis and consensus coding methods.

RESULTS

Patients' mean age was 11.9 years (SD = 3.17); 51% were male. At T1, 362 patients offered 833 responses; 600 parents offered 1496 responses. At T2, 252 patients offered 552 responses; 488 parents offered 1290 responses. At T1 and T2, the most frequent patient response to what was good was 'Staff took good care of me' and for caregivers was 'Staff behaving professionally'. At T1, the most frequent patient response about what could be better was 'more activities for kids', and at T2, 'Nothing' and 'More food options and better food quality'; for caregivers at T1, 'Nothing' and 'Not liking the physical space', and at T2, 'Nothing', and 'More communication and professionalism from hospital staff'.

CONCLUSIONS

Pediatric patients and their caregivers are willing and able to offer perspectives about satisfaction with care, and suggestions for improvement before discharge.

PRACTICE IMPLICATIONS

Pediatric patients and their caregivers' perspectives about care yield actionable recommendations for hospital systems.

The Impact of Demographics on Child and Parent Ratings of Satisfaction with Hospital Care

Introduction

Patient satisfaction ratings differ between minority and nonminority respondents in studies of hospitalized adults, but little is known about such differences in pediatrics. Our goal was to determine if patient satisfaction ratings completed by hospitalized children and their parents at the point of discharge differed by race/ethnicity, language, child gender, and age.

Methods

We used a mixed-methods design. English and Spanish-speaking families from 5 inpatient units at 1 pediatric hospital completed ratings, face-to-face, before scheduled hospital discharge (T1), and again by telephone after discharge (T2). Participating children and their parents completed an 8-item satisfaction survey, and parents additionally completed 7 discharge readiness items.

Results

The refusal rate was 10.7%, with 600 families enrolled; non-white families represented 66% of both study refusals and completions. The proportion of racial/ethnic groups in our study exceeded those in our standard survey sample. There were no significant differences in satisfaction ratings between non-white and white families or by child gender, age, or language.

Conclusions

The lack of rating differences by demographic characteristics, the low refusal and attrition rates, and a more racially/ethnically representative sample of both child and parent perspectives indicate this approach to measuring satisfaction is acceptable and feasible to demographically diverse families.

Endothelial activation is associated with intestinal epithelial injury, systemic inflammation and treatment regimen in children living with vertically acquired HIV-1 infection

BACKGROUND

Premature development of cardiovascular disease in children living with HIV-1 (CLWH) may be associated with compromised gut barrier function, microbial translocation, immune activation, systemic inflammation and endothelial activation. Biomarkers of these pathways may provide insights into pathogenesis of atherosclerotic disease in CLWH.

METHODS

This was a cross-sectional study of CLWH enrolled in the multicentre Early Pediatric Initiation-Canadian Child Cure Cohort (EPIC⁴ ) who were on antiretroviral therapy (ART) with undetectable viral load. Plasma biomarkers of intestinal epithelial injury [intestinal fatty acid binding protein-1 (IFABP)], systemic inflammation [tumour necrosis factor (TNF) and interleukin-6 (IL-6)] and endothelial activation [angiopoietin-2 (Ang2), soluble vascular endothelial growth factor-1 (sVEGFR1) and soluble endoglin (sEng)] were quantified by enzyme-linked immunosorbent assay. Correlation and factor analysis of biomarkers were used to examine associations between innate immune pathways.

RESULTS

Among 90 CLWH, 16% of Ang2, 15% of sVEGFR1 and 23% of sEng levels were elevated relative to healthy historic controls. Pairwise rank correlations between the three markers of endothelial activation were statistically significant (ρ = 0.69, ρ = 0.61 and ρ = 0.65, P < 0.001 for all correlations). An endothelial activation index, derived by factor analysis of the three endothelial biomarkers, was correlated with TNF (ρ = 0.47, P < 0.001), IL-6 (ρ = 0.60, P < 0.001) and intestinal fatty acid binding protein-1 (ρ = 0.67, P < 0.001). Current or past treatment with ritonavir-boosted lopinavir (LPV/r) was associated with endothelial activation (odds ratio = 5.0, 95% CI: 1.7-17, P = 0.0020).

CONCLUSIONS

Endothelial activation is prevalent in CLWH despite viral suppression with combination ART and is associated with intestinal epithelial injury, systemic inflammation and treatment with LPV/r.

The Child's Voice in Satisfaction with Hospital Care

PURPOSE

Patient satisfaction is a quality improvement indicator used to evaluate care. Ratings of patient satisfaction in pediatrics exclude the child voice. We tested the feasibility and acceptability of a new model that included both child and parent satisfaction ratings.

DESIGN AND METHODS

We executed a randomized, two-arm, unblinded cohort study comparing child (aged 7-17 years) and parent reports (Arm 1) to parent report only (Arm 2) among a convenience sample of inpatients at a single urban pediatric medical center. The primary (feasibility and acceptability) and secondary outcomes were assessed at the time of discharge (T1) and approximately 10 days following discharge (T2) (standard timing).

RESULTS

Of 672 screened families, 89.3% (n = 600) enrolled in the study; 362 children and parents were randomized to Arm 1 and 238 parents to Arm 2. Patients (98.6%) and parents (99.8%) indicated preference for providing satisfaction ratings at the time of discharge. Seventy-five percent of families (n = 488) completed T1 and T2; neither child nor parent ratings differed significantly between T1 and T2 nor did parent ratings differ between the two study arms. Nurse friendliness, courtesy, and feeling well cared for were among the highest rated items at T1 and T2 by both children and parents.

CONCLUSIONS

Children 7 to 17 years of age and their parents are willing and like to provide satisfaction with care ratings prior to hospital discharge.

PRACTICE IMPLICATIONS

This measurement model could yield valid findings representative of hospitalized children and their parents, and could become the basis for a new and needed measurement approach for pediatric satisfaction with hospital care.

Rates of initial virological suppression and subsequent virological failure after initiating highly active antiretroviral therapy: the impact of aboriginal ethnicity and injection drug use

Objectives:

To compare rates of initial virological suppression and subsequent virological failure by Aboriginal ethnicity after starting highly active antiretroviral therapy (HAART).

Methods:

We conducted a retrospective cohort study of antiretroviral-naïve HIV-patients starting HAART in January 1999-June 2005 (baseline), followed until December 31, 2005 in Alberta, Canada. We compared the odds of achieving initial virological suppression (viral load <500 copies/mL) by Aboriginal ethnicity using logistic regression and, among those achieving suppression, rates of virological failure (the first of two consecutive viral loads > 1000 copies/mL) by Aboriginal ethnicity using cumulative incidence curves and Cox proportional hazards models. Sex, injection drug use as an HIV exposure category (IDU), baseline age, CD4 cell count, viral load, calendar year, and HAART regimen were considered as potential confounders.

Results:

Of 461 study patients, 37% were Aboriginal and 48% were IDUs; 71% achieved initial virological suppression and were followed for 730.4 person-years. After adjusting for confounding variables, compared to non-Aboriginals with other exposures, the odds of achieving initial virological suppression were lower for Aboriginal IDUs (odds ratio (OR)=0.33, 95% CI=0.19-0.60, p=0.0002), non-Aboriginal IDUs (OR=0.30, 95% CI=0.15-0.60, p=0.0006), and Aboriginals with other exposures (OR=0.38, 95% CI=0.21-0.67, p=0.0009). Among those achieving suppression, Aboriginals experienced higher virological failure rates ≥1 year after suppression (hazard ratio=3.35, 95% CI=1.68-6.65, p=0.0006).

Conclusions:

Future research should investigate adherence among Aboriginals and IDUs treated with HAART and explore their treatment experiences to assess ways to improve outcomes.

Renal function changes and NHS resource use in breast cancer patients with metastatic bone disease treated with IV zoledronic acid or oral ibandronic acid: a four-centre non-interventional study

AIMS

To describe renal function monitoring practice in patients with metastatic bone disease (MBD) treated with IV zoledronic acid (ZA) and oral ibandronic acid (IA), the management pathways and NHS hospital resources used.

METHODS

Medical records of 189 patients; IA (91), ZA (98) with primary breast cancer and MBD were reviewed, and data collected on renal monitoring and hospital visits during bisphosphonate therapy. Time and motion review of resources to administer the bisphosphonates was also conducted.

RESULTS

Only 30% of patients given ZA and no patient given IA had baseline creatinine clearance (CrCl) recorded. Calculated baseline CrCl suggested impaired renal function in 33% ZA and 29% IA patients. Dose reductions were not made correctly in 29 ZA and 2 IA patients whose monitoring suggested it. ZA patients made more clinic and day care attendances than IA-treated patients, at twice the cost. Staff activity and patient time per visit was higher with ZA than IA.

CONCLUSION

Although limited by retrospective design, these results demonstrate that in many patients, CrCl is not calculated before or during treatment with bisphosphonates. Renal function deteriorated in many patients during therapy. In view of these effects, practice should be reviewed to ensure appropriate dosing.

Pulmonary zygomycosis in solid organ transplant recipients in the current era

Fifty-eight solid organ transplant recipients with zygomycosis were studied to assess the presentation, radiographic characteristics, risks for extra-pulmonary dissemination and mortality of pulmonary zygomycosis. Pulmonary zygomycosis was documented in 31 patients (53%) and developed a median of 5.5 months (interquartile range, 2-11 months) posttransplantation. In all, 74.2% (23/31) of the patients had zygomycosis limited to the lungs and 25.8% (8/31) had lung disease as part of disseminated zygomycosis; cutaneous/soft tissue (50%, 4/8) was the most common site of dissemination. Pulmonary disease presented most frequently as consolidation/mass lesions (29.0%), nodules (25.8%) and cavities (22.6%). Patients with disseminated disease were more likely to have Mycocladus corymbifer as the causative pathogen. The mortality rate at 90 days after the treatment was 45.2%. In summary, pulmonary zygomycosis is the most common manifestation in solid organ transplant recipients with zygomycosis, and disseminated disease often involves the cutaneous/soft tissue sites but not the brain.

Use of BIBW 2992, a novel irreversible EGFR/HER2 tyrosine kinase inhibitor (TKI), to treat patients with HER2-positive metastatic breast cancer after failure of treatment with trastuzumab

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Background: BIBW 2992 (Tovok) is an oral, novel, and potent, irreversible dual epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor-2 (HER2) inhibitor, with preclinical activity in trastuzumab-resistant cell lines overexpressing HER2 and phase I clinical activity. A phase II study of BIBW 2992 in patients with HER2-positive breast cancer who have failed treatment with trastuzumab is currently being conducted in the US and the UK. Methods: This is a multi-institutional open label single arm phase II study, planning to recruit 40 patients. Eligibility criteria include stage IIIB or IV HER2-positive metastatic breast cancer, progression following receipt of trastuzumab or intolerance of trastuzumab, measurable disease, Eastern Cooperative Oncology Group (ECOG) performance status of 0–2 and adequate organ function. Patients receive 50 mg BIBW 2992 once daily until disease progression. Tumor assessments are performed every two courses (one course = 28 days). The primary endpoint is objective response rate (RECIST criteria). Safety data are also collected. Results: To date, 40 patients have started treatment on the trial. Patients had received a median of three lines of prior therapy. Nine patients discontinued treatment prior to the first assessment at 8 weeks; four due to disease progression, four due to adverse events and one due to withdrawal of consent. Twenty-one patients have had tumor assessment after 8 weeks of treatment. Of these, four patients had a partial response (PR) and 10 patients had stable disease (SD). The PR has been confirmed at 16 weeks in one patient. The most frequently observed side effects to date are rash (Common Toxicity Criteria for Adverse Events [CTCAE] grade 3 in 4 patients) and diarrhea (CTCAE grade 3 in 8 patients). There were 20 dose reductions in 17 patients. Conclusions: BIBW 2992 at 50 mg/day induced responses and seems promising in HER2-positive breast cancer patients who have failed treatment with trastuzumab. Manageable cutaneous adverse events and diarrhea were the main side effects.

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TEXAS (Taxotere® EXperience with Anthracyclines Study) trial: mature results of activity/toxicity of docetaxel given with anthracyclines in a community setting, as first line therapy for MBC

PURPOSE

The TEXAS (Taxotere EXperience with Anthracyclines Study) study examined docetaxel in combination with an anthracycline, as first line treatment of metastatic breast cancer (MBC), in everyday practice, and compared the findings with a randomised controlled trial.

METHODS

Four hundred and seventy patients were registered on the TEXAS trial. Patients were assigned, according to treating clinician's discretion, to either doxorubicin 50 mg/m2 or epirubicin 75 mg/m2 both given day1 15 min intravenous bolus every 3 weeks, followed by docetaxel 75 mg/m2, day 1, 1 h intravenous infusion every 3 weeks.

RESULTS

The overall response rate (ORR) was approximately 61%. The main toxicity reported was neutropenia, with 75 patients (55%) in the AT group and 203 (61%) in the ET arm. Febrile neutropenia or neutropenic sepsis was reported for 32 (24%) of the AT arm and 78 (23%) of the ET arm.

CONCLUSIONS

This open access study demonstrates that AT or ET are highly active treatments for MBC, with similar response rates to those observed in a phase III clinical trial. This may be important for patients with rapidly progressive visceral disease. Side effects can be managed effectively with growth factors and/or prophylactic antibiotic.

Breaking the silence: an HIV-related educational intervention for medical students in Zimbabwe

PROBLEM

A culture of silence surrounding HIV is a major contributor to continued HIV transmission and poor care for people living with HIV/AIDS.

AIM

To encourage medical leadership in addressing stigma and fear related to HIV at individual and community levels

OBJECTIVE

To pilot a mini-course for final year medical students in Zimbabwe that demonstrates stigma-reduction knowledge and skills needed to communicate information about HIV to patients, to address ethical implications of testing versus not testing for HIV, to increase awareness of the medical and preventive benefits of knowing one's HIV status and showing people how to cope with the emotional burden of dealing with HIV everyday.

DESIGN

Methods of proven effectiveness for training medical students in ethics and communication skills were used such as presentations by well respected role models and opinion leaders, role-playing, small group discussions, accompanied by materials indicating local resources, in three afternoon teaching sessions.

SETTING

University of Zimbabwe College of Medicine.

PARTICIPANTS

60 medical students, six lecturers, two facilitators and a group of actors.

MAIN OUTCOME MEASURES

Evaluation of the course by students showed appreciation of the course as measured on a scale of one to five for content and usefulness with requests for further inputs into the curriculum; model of mini-course that can be used by other medical schools in the southern Africa region and other areas of emerging HIV epidemics.

CONCLUSIONS

A brief educational intervention can help medical students to cope with the extraordinary challenge of providing care in high HIV prevalence countries and may contribute towards better leadership in addressing HIV epidemics.

DOTS implementation in a middle-income country: development and evaluation of a novel approach

BACKGROUND

DOTS is widely accepted as the most cost-effective strategy for tuberculosis (TB) control. However, there is little published information regarding methods for implementation in middle-income countries.

METHODS

Over 3 years, the Canadian Lung Association assisted the Ecuadorian TB programme to implement DOTS for over half the nation's total population. A multilevel strategy developed by a team of Ecuadorian health professionals provided initial, in-service, replica and reinforcement training at the local level, and training at national level for specialist physicians, specialist societies and medical schools. Evaluation was based on international guidelines for case finding, treatment and laboratory quality control, and costs of all implementation activities.

RESULTS

By January 2004, DOTS training had been provided to 1954 health professionals and 199 smear microscopy technicians, and DOTS was implemented in all 496 health facilities. Case detection activities at the local level increased substantially. Cure and treatment completion improved to 83% of new cases. Overall concordance of laboratory quality control readings was 98.7%. The total cost of DOTS implementation was US dollar 3 049 585.

CONCLUSIONS

To achieve international targets for TB control, DOTS implementation in a middle-income country required intensive training at the local level and at multiple other levels.

Randomized, double-blind, placebo-controlled, multicenter trial of 6% miltefosine solution, a topical chemotherapy in cutaneous metastases from breast cancer

PURPOSE

To compare 6% miltefosine solution (Miltex; Asta Medica, Frankfurt, Germany), a new topical cytostatic drug, with placebo as palliative treatment for cutaneous metastases from breast cancer.

PATIENTS AND METHODS

In a double-blind, placebo-controlled, multicenter phase III study, a total of 52 patients with inoperable progressive skin lesions from histologically or cytologically confirmed breast cancer, not manageable by radiotherapy or systemic treatment, with superficial or flat skin lesions (estimated depth of invasion < or = 1 cm) were randomized to receive either 6% miltefosine solution or placebo. The solution was applied at the dose of 2 drops/10 cm(2), once daily during the first week and twice daily thereafter until treatment failure.

RESULTS

Treatment groups were well balanced for patient characteristics at study entry except for a small difference in age. Time to treatment failure (TTF), the primary parameter of this study, showed miltefosine solution to be significantly superior to placebo (P = .007); the median TTF in the miltefosine solution group was nearly three times longer than that in the placebo group (56 days v 21 days). The rate of response based on intention to treat patients was 33.3% for miltefosine solution compared with 3.7% for placebo (P = .006). Cutaneous reactions were seen mainly in the miltefosine group, with the type and frequency similar to those observed in previous studies.

CONCLUSION

6% Miltefosine solution is confirmed as an effective palliative treatment option for cutaneous metastases from breast cancer. Skin reactions, when present, are well tolerated and only occasionally require cessation of treatment.

Challenge of managing interventional cardiology patients over a decade

Using an outcomes management approach, St. Luke's Episcopal Hospital has achieved positive outcomes in the interventional cardiology patient population. In this article the authors describe a decade of experiences related to the processes they implemented and the outcomes achieved in this patient population.

A case of Histoplasma capsulatum causing granulomatous liver disease and Addisonian crisis

A 56-year-old man with persistently elevated liver enzyme levels, fatigue, lethargy and a 9.0 kg weight loss over six months underwent a percutaneous liver biopsy that demonstrated multiple granulomas. Screening serologies were positive for histoplasmosis, and he was started on itraconazole treatment. He returned to hospital the same night with coffee-ground emesis and in Addisonian crisis requiring parenteral steroids and intensive care unit support. An abdominal computed tomography scan revealed bilaterally enlarged, nonenhancing adrenal glands suggestive of infarcts, presumed secondary to histoplasmosis. Treatment was initiated with amphotericin B, and Histoplasma capsulatum was cultured from his urine and cerebrospinal fluid. A serum immunodiffusion test was also positive for both H and M bands, indicating active infection with Histoplasmosis species. His serum and urine samples were also weakly positive for the antigen. Despite complications of renal failure, pneumonia and congestive heart failure, he recovered with medical therapy and was discharged home to complete a prolonged course of itraconazole therapy. While hepatic granulomas often reflect an occult disease process, the cause may remain undiscovered in 30% to 50% of patients despite exhaustive investigations. H capsulatum is an uncommon cause of granulomatous liver disease, and with its protean clinical presentation, a high index of suspicion is needed to make the diagnosis and avoid the potentially high fatality rate associated with disseminated infection.

Reflections on a decade of outcomes management in women's services

Outcomes management was theorized as a strategy for redesigning and continually enhancing interdisciplinary health care processes through the use of outcomes measurements. Regardless of the rapidly changing and oftentimes turbulent health care environment, this strategy successfully facilitated positive outcomes in one women's service for 10 years. Outcomes affected during these years included reduction in cost per case, length of stay, infant prematurity, and cesarean delivery rates.

Failure of cidofovir therapy in progressive multifocal leukoencephalopathy unrelated to human immunodeficiency virus

We describe the first reported human immunodeficiency virus (HIV)-seronegative patient treated with cidofovir for progressive multifocal leukoencephalopathy (PML). Marked clinical and radiological progression of PML occurred during cidofovir therapy. The improvement observed during cidofovir therapy of HIV-infected patients may be due to the effect of concomitant antiretroviral therapy rather than cidofovir.

A study of the value of p53, HER2, and Bcl-2 in the prediction of response to doxorubicin and paclitaxel as single agents in metastatic breast cancer: a companion study to EORTC 10923

This study assesses the potential value of the tumor markers p53, HER2, and Bcl-2 in predicting the clinical response to doxorubicin and paclitaxel as single agents in the treatment of metastatic breast cancer. The primary tumors of 114 patients in the European Organization for Research and Treatment of Cancer 10923 trial were assessed by immunohistochemistry using monoclonal antibodies; the results were correlated with clinical response to therapy. HER2 was positive in 24% of patients, p53 was positive in 25% of patients, and Bcl-2 was positive in 49% of patients. There was no correlation between the expression of any of the markers and the clinical response to either agent. Although methodologically limited, this study does not support the use of p53, HER2, or Bcl-2 to assist the selection of anthracycline versus taxane in metastatic breast cancer.

Prevalence of nasal colonization with methicillin-resistant Staphylococcus aureus in selected patient populations

Methicillin-resistant Staphylococcus aureus nasal colonization was investigated in patients arriving for elective cardiovascular surgery, renal patients admitted for arteriovenous graft surgery, and patients transferred to our hospital from other institutions. Renal patients were significantly more likely to be colonized and represent a potential source of MRSA to our institution.

Nitrogen dioxide and particle pollution near trunk roads and in towns of the south Midlands in England

Nitrogen dioxide (NO2) and particulate emissions play an important role in atmospheric pollution and might be a major cause of human respiratory problems in urban areas. This report provides an overview of traffic-related emissions monitored on several trunk roads and towns of the South Midlands of England between 1996 and 1999. NO2 pollution on major trunk roads frequently exceeded British and European Union air quality standards, while particle pollution was lower. The possible effects of traffic diversion activities in the research area are discussed. Bypasses of busy trunk roads might reduce NO2 pollution between 30 and 40% in urban centres and improve air quality for inhabitants in those areas.

Paclitaxel versus doxorubicin as first-line single-agent chemotherapy for metastatic breast cancer: a European Organization for Research and Treatment of Cancer Randomized Study with cross-over

PURPOSE

To compare the efficacy of paclitaxel versus doxorubicin given as single agents in first-line therapy of advanced breast cancer (primary end point, progression-free survival ¿PFS) and to explore the degree of cross-resistance between the two agents.

PATIENTS AND METHODS

Three hundred thirty-one patients were randomized to receive either paclitaxel 200 mg/m(2), 3-hour infusion every 3 weeks, or doxorubicin 75 mg/m(2), intravenous bolus every 3 weeks. Seven courses were planned unless progression or unacceptable toxicity occurred before the seven courses were finished. Patients who progressed within the seven courses underwent early cross-over to the alternative drug, while a delayed cross-over was optional for the remainder of patients at the time of disease progression.

RESULTS

Objective response in first-line therapy was significantly better (P =.003) for doxorubicin (response rate ¿RR, 41%) than for paclitaxel (RR, 25%), with doxorubicin achieving a longer median PFS (7.5 months for doxorubicin v 3.9 months for paclitaxel, P <.001). In second-line therapy, cross-over to doxorubicin (91 patients) and to paclitaxel (77 patients) gave response rates of 30% and 16%, respectively. The median survival durations of 18.3 months for doxorubicin and 15.6 months for paclitaxel were not significantly different (P =.38). The doxorubicin arm had greater toxicity, but this was counterbalanced by better symptom control.

CONCLUSION

At the dosages and schedules used in the present study, doxorubicin achieves better disease and symptom control than paclitaxel in first-line treatment. Doxorubicin and paclitaxel are not totally cross-resistant, which supports further investigation of these drugs in combination or in sequence, both in advanced disease and in the adjuvant setting.

From Livingstone to ecotourism. What's new in travel medicine?

OBJECTIVE

To review recent developments in the field of travel medicine and to outline the knowledge and resources family physicians need for providing health advice to travelers headed for tropical or developing countries.

QUALITY OF EVIDENCE

Personal files; references from review articles and from a recent textbook of travel medicine; current guidelines on pretravel advice; and a review of the 1996 to 1999 MEDLINE database using "travel medicine" as a term and subject heading, "trave(l)lers' diarrhea" as a text word and subject heading, "immunization + travel," and "malaria + chemo prevention" were used as information sources. Priority was given to randomized controlled trials and recommendations of expert or national bodies.

MAIN MESSAGE

Some elements of travel medicine, such as malaria chemoprophylaxis, have become more complex. Some valuable new preventive measures, such as hepatitis A vaccine, treated bed nets, and antimalarial drugs, have become available. Some health risks, such as cholera, have been overemphasized in the past, whereas others, such as tuberculosis and sexually transmitted diseases, have been underemphasized. Information sources relevant for providing travel health advice have improved and expanded. Canadian evidence-based guidelines addressing most important travel health issues are now available.

CONCLUSIONS

Travel medicine is a rapidly evolving field. Physicians intending to provide health advice to travelers to high-risk parts of the world should be well prepared and have access to good, up-to-date information.

The quick relaxation technique: effect on pain associated with chest tube removal

Documentation shows that conventional methods used to prepare patients for chest tube removal (CTR) are not effective in reducing pain associated with this procedure. The quick relaxation technique (QRT) was used on 24 primary aorta-coronary bypass surgical patients. Subjects rated their pain on the visual analog scale immediately following CTR and 30 minutes later. Results indicated that men > or = 70 years of age who received QRT in conjunction with analgesics reported less than half the amount of pain experienced by those who did not receive QRT. In comparison, women 70 years old or older reported much higher pain intensity scores when QRT was used. Preliminary results suggest that for most patients, the combination of analgesics and relaxation exercises is not more effective in decreasing pain during CTR than when analgesics are administered without relaxation exercises.

Immune mediated 'HAART' attack during treatment for tuberculosis. Highly active antiretroviral therapy

Highly active antiretroviral therapy (HAART) suppresses viral replication and improves immune function. However the inflammatory component of immune restoration can have clinically deleterious effects on previously asymptomatic infections. We report the development of acute respiratory failure in a patient after the institution of HAART, following 2 months of appropriate therapy for pulmonary tuberculosis. Necrotizing granulomas with acid-fast bacilli were found on lung biopsy, but cultures were negative for Mycobacterium tuberculosis and no other pathogens were isolated. Polymerase chain reaction of lung biopsy tissue for all mycobacterial species was positive only for M. tuberculosis. Rapid clinical improvement followed corticosteroid therapy. After initiating HAART, clinicians should be aware of the possibility of an inflammatory response to a previously quiescent tuberculous infection, even while on antituberculosis therapy.

Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome

BACKGROUND

There is controversy regarding the application of transfusion triggers in cardiac surgery. The goal of this study was to determine if lowering the hemoglobin threshold for red cell (RBC) transfusion to 8 g per dL after coronary artery bypass graft surgery would reduce blood use without adversely affecting patient outcome.

STUDY DESIGN AND METHODS

Consecutive patients (n = 428) undergoing elective primary coronary artery bypass graft surgery were randomly assigned to two groups: study patients (n = 212) received RBC transfusions in the postoperative period if the Hb level was < 8 g per dL or if predetermined clinical conditions required RBC support, and control patients (n = 216) were treated according to individual physician's orders (hemoglobin levels < 9 g/dL as the institutional guideline). Multiple demographic, procedure-related, transfusion, laboratory, and outcome data were analyzed. Questionnaires were administered for patient self-assessment of fatigue and anemia.

RESULTS

Preoperative and operative clinical characteristics, as well as the intraoperative transfusion rate, were similar for both groups. There was a significant difference between the postoperative RBC transfusion rates in study (0.9 +/- 1.5 RBC units) and control (1.4 +/- 1.8 RBC units) groups (p = 0.005). There was no difference in clinical outcome, including morbidity and mortality rates, in the two groups; group scores for self-assessment of fatigue and anemia were also similar.

CONCLUSIONS

A lower Hb threshold of 8 g per dL does not adversely affect patient outcome. Moreover, RBC resources can be saved without increased risk to the patient.

Regional changes in the expression of neurotrophic factors and their receptors following acute traumatic brain injury in the adult rat brain

We have analyzed the effect of severe traumatic brain injury (TBI) on the levels of mRNA expression of neurotrophic factors (NTFs): brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF), ciliary neurotrophic factor (CNTF) and their respective receptors: trkB, trkA and CNTFRalpha. The expression was examined in the region of the lesion as well as a region remote from the lesion at 12, 24, and 36 h following the injury. Our data suggest that after the brain injury, the expression of NGF and BDNF mRNAs were early, transiently and significantly upregulated while that of CNTF was a slow and less amplified response in both areas of the brain. We also found that trkA mRNA expression was only upregulated significantly in the remote area; trkB mRNA showed no significant change in either area except an upregulation at 12 h in the remote area. CNTFRalpha was downregulated significantly by 24-36 h in the lesion area and by 24 h in the remote area. These changes suggest that TBI regulates the expression of NTFs and their receptors. These alterations in expression may be involved in modulating the neuronal response after brain injury.

Economic implications of an early postoperative enteral feeding protocol

OBJECTIVE

To study the cost-effectiveness of an early postoperative feeding protocol for patients undergoing bowel resections.

DESIGN

A nonrandomized, prospective, clinical trial. Surgeons elected to participate in the treatment arm before the study's outset.

SUBJECTS/SETTING

Treatment (n = 66) and control (n = 159) patients were admitted to a nonprofit general teaching hospital in the Texas Medical Center for similar diagnoses and subsequent bowel resections during an 18-month period.

INTERVENTION

Treatment patients who met specific inclusion criteria had a jejunal feeding tube placed during surgery. Tube feedings were initiated within 12 hours after surgery. Control patients who met the same inclusion criteria received usual care.

OUTCOMES

A successful outcome was defined as a patient developing no postoperative infection. The average cost of a nosocomial infection is presented. Variable direct and total costs (fixed plus variable) are compared between patient groups.

STATISTICAL ANALYSIS

Mean cost was adjusted for rate of success in each patient group according to an analytic model. The mean cost difference between groups was analyzed by independent-samples t tests. Nonparametric Mann-Whitney rank sum tests were used to determine the cost significance of a nosocomial infection.

RESULTS

The average variable direct cost savings per successful treatment patient was $1,531, which required an additional variable cost of $108.30 for the dietitian's time. The protocol resulted in a total cost savings of $4,450 per success in the treatment group.

CONCLUSION

An early postoperative enteral feeding protocol as part of an outcomes management program for patients undergoing bowel resection is cost-effective.

Cost effectiveness of Streetworks' needle exchange program of Edmonton

OBJECTIVE

To conduct a cost-effectiveness analysis of the Edmonton Streetworks needle exchange program, in terms of the additional cost per HIV infection averted. The main outcome measures were needle use with and without Streetworks, HIV cases averted, and program costs.

METHODS

We conducted interviews and HIV saliva tests on a sample of street-involved intravenous drug users (IDU) who are regular Streetworks' clients. Outcomes were used in a cost-effectiveness model.

RESULTS

It is projected that the program has a cost-effectiveness of $9,500 (Canadian) per HIV infection delayed for one year.

CONCLUSIONS

The discounted cost per case averted is less than the cost of a case of AIDS. Continuing the program is a dominant strategy.

Managing the outcome of infection: nosocomial infection initiative

Outcomes management provides a mechanism to foster development of patient-driven services through revision of practice and measurement of outcomes. This article shares an outcome initiative that focused on reducing the incidence of nosocomial pneumonia in a hospital setting. Strategies used such as a case-control study, risk tool development and protocol implementation are discussed. Both process and outcome data are provided to demonstrate the positive impact of the initiative.

Linking outcomes management and practice improvement. Structured care methodologies: evolution and use in patient care delivery

Structured care methodologies are tools that provide a comprehensive approach to patient care delivery. These tools have evolved in their application and purpose over the years. In many situations, multiple tools are needed to obtain the best outcomes for a patient. The presence of a SCM does not preclude clinical judgment. On the contrary, the fundamental purpose of any SCM is to assist practitioners in implementing practice patterns associated with good clinical judgment, research-based interventions, and improved patient outcomes. These tools support smooth operation and appropriate use of resources, establish a means of patient management across the continuum of care, facilitate collaboration among disciplines, reflect patient outcomes, and provide outcomes data. Data from SCMs permit benchmarking, comparison of pre-implementation and post-implementation outcomes, development of action plans for quality enhancement, identification of high-risk patients, identification of issues and problems in the system that require interventions, and the development of research protocols and studies. Structured care methodology development and implementation can be challenging, rewarding, and at times frustrating. When used appropriately, these tools can have a major impact on the standardization of care and the achievement of desired outcomes. However, individual patient needs may supersede adherence to a tool. The challenge then becomes one of balancing the unique needs of each patient and appropriate use of SCMs. Change comes slowly, but persistence pays off.

Linking outcomes management and practice improvement. The link between outcomes management and JCAHO functions

Staff participating in the CABG outcomes management program continue to examine the effectiveness and efficiency of care processes and to redesign care to improve patient and organizational outcomes. In fact, this quality enhancement program is neverending as we strive continually to improve the care of CABG patients. The success, measured through improved process and outcome variables, has promoted the implementation of similar programs for other patient populations. Using foresight in the development of outcomes management programs to ensure inclusiveness of regulatory body or agency criteria encourages comprehensive programs that yield positive outcomes for both patients and organizations.