Flumazenil in drug overdose: randomized, placebo-controlled study to assess cost effectiveness.

OBJECTIVE: To investigate cost effectiveness of administration of flumazenil to patients presenting with suspected acute drug overdose. DESIGN: Double-blind, prospective, placebo-controlled randomized study. SETTING: University teaching hospital. PATIENTS: Forty-three adults presenting with suspected drug overdose and having a Glasgow Coma Scale (GCS) score of <13. Patients with known benzodiazepine/tricyclic ingestion were excluded. INTERVENTIONS: Intravenous administration of flumazenil (up to 2 mg) or placebo. MEASUREMENTS AND MAIN RESULTS: Individual patient costs were assessed and data aggregated for each treatment group. Major diagnostic and therapeutic interventions were recorded and between group comparisons performed. Clinical response to study drug administration was assessed by obtaining pre- and post-drug GCS scores and observation of the patient for at least 180 mins for signs of resedation. Aggregate cost or number of major diagnostic and therapeutic interventions were not different between groups. Patients randomized to the flumazenil group showed a marked increase in GCS score (7.4 to 11.8) compared with those in the placebo group (8.2 to 8.6). CONCLUSION: Use of flumazenil in intentional drug overdose of unknown etiology is not cost effective.

A comparison of alternate immunization regimes for measles in vaccinated populations.

Infants today lose maternal measles antibody sooner than in the past. This is related to demographic changes in maternal immunization. Data for rates of decay of maternal antibody and seroconversion after measles vaccination for infants born to naturally immune (Group 1) or vaccinated (Group 2) mothers have been used to evaluate two vaccination schedules: Regime 1, measles-mumps-rubella (MMR) at 1 year of age and Regime 2, monovalent measles at 6 months followed by MMR at 15 months of age. Regime 2 costs less because MMR can be administered at 15 months with the last pentavalent booster. Months of protection/1000 children aged 0-15 months (child-months of protection) were estimated for infant populations ranging from 0 to 100% Group 1 for Regimes 1 and 2. Regime 1 provides more child-months of protection only for 100% Group 1 populations. For the study population Regime 2 provided at least 17% more child-months of protection than Regime 1. Regime 2 provides increased medical and financial benefits in proportion to the number of Group 2 infants in the population and thus is ever more advantageous for today's increasingly vaccinated populations.

Spatial and temporal variations of trace metals in bottom sediments of Peter the Great Bay, the Sea of Japan.

New data on trace metal distribution in bottom sediments of Peter the Great Bay (the Sea of Japan) are presented. Much higher concentrations were detected near the most likely anthropogenic sources of trace metal inputs (waste water discharges from Vladivostok and Nakhodka, and the Vladivostok coastal landfill). Sediments in these contaminated areas were up to 700 ppm in Zn, 530 ppm in Pb, 7 ppm in Cd and 3 ppm in Hg. River runoff is of minor importance as a metal source in the investigated areas. The spatial distribution of trace metals outside the areas directly influenced by sewage discharges is regulated by natural processes such as sediment sorting by grain size. Based on radiometric dating of sediment cores, increases in the trace metal content of bottom sediments near Vladivostok begun in approximately 1945.

Changing the admission process for elective surgery: an economic analysis.

This study compared the costs of an inpatient elective surgical admission process with an outpatient based same day admission programme in patients undergoing laparoscopic cholecystectomy. The effect of this process change on annual surgical volume and case flow (number of procedures performed per surgical bed) in the year before the initiation of same-day method (1989/90) and subsequent to the widespread use of the process (1992/93), was also assessed. Costs incurred by 53 patients who underwent preoperative anaesthetic and surgical assessment as outpatients and were admitted as an outpatient on the day of surgery (SD Group) were compared with those incurred by 11 patients who entered hospital on the day before surgery and underwent anaesthetic and other assessments as inpatients (IP Group). Nursing, radiology, laboratory, operating room, rehabilitation and clinic costs were obtained for each patient. The remaining costs were not amenable to individual attribution and were assigned to each group as a percentage of the allocated costs. The cost per case in the SD Group was $360 less than in the IP Group, reflecting decreased nursing costs incurred by the SD Group. Between the period 1989/90 and 1992/93, the number of surgical beds declined 15.7%; however, surgical volume decreased by only 5.4%. Total case flow improved by 12.2%, that for elective and non-elective surgery increasing by 14.1% and 9.5%, respectively. Elective surgery, where same day admission was used, showed the greatest improvement in case flow. We conclude that a same day admission process reduces cost and serves to enhance hospital productivity.

Trace metals in Gulf of Mexico oysters.

Oysters (Crassostrea virginica) from 50 to 69 locations (sites) along the Gulf of Mexico coastline, collected annually in 1986, 1987 and 1988, have been analyzed for 13 trace metals, including most of the metals of concern from an environmental quality perspective. Essentially the entire U.S. Gulf coastline was sampled, from far south Texas to far south Florida. Pooled samples of 20 oysters from three different stations at each site were analyzed by atomic absorption spectrophotometry. The concentrations found were generally less than or equal to literature values from other parts of the world thought to be uncontaminated by anthropogenic trace metal inputs. A few sites did, however, show apparent trace metal pollution and other sites gave anomalous values that cannot readily be explained by either known anthropogenic or natural causes. The range of values for the overall data set (maximum/minimum) varied from 15-fold for Mn to 624-fold for Pb, whereas the coefficient of variation (standard deviation/mean) was generally in the 50-60% range for most metals. Variations were much greater between stations than between years at a given station. Enrichments usually occurred in suites of three to four elements with Ag, Cd, Cu and Zn being the most common suite, thus several strong inter-element correlations were found. There was, however, little correlation between metal levels in oysters and in sediments from the collection sites even when sediment data were rationed to Al (sediment data are not given here). There was likewise little correlation between oyster metal levels and size, sex or reproductive stage of the oysters (data given elsewhere). Geographically, appreciably elevated (greater than 3 times average) metal levels were generally restricted to single sites within bays or estuaries, implying local control. On the other hand, regionally, Ag, Cd and Se levels were somewhat higher in Texas oysters than in those from Florida, whereas the reverse was true for As and Hg. Concentrations were lower than average for several metals in oysters from central Louisiana, especially Ag, Cd and Cu. Thus, the Mississippi River outflow and extensive offshore oil development do not seem to enrich oysters in trace metals.