Measurement of extravascular lung water to diagnose severe reperfusion lung injury following pulmonary endarterectomy: a prospective cohort clinical validation study.

The measurement of extravascular lung water is a relatively new technology which has not yet been well validated as a clinically useful tool. We studied its utility in patients undergoing pulmonary endarterectomy as they frequently suffer reperfusion lung injury and associated oedematous lungs. Such patients are therefore ideal for evaluating this new monitor. We performed a prospective observational cohort study during which extravascular lung water index measurements were taken before and immediately after surgery and postoperatively in intensive care. Data were analysed for 57 patients; 21 patients (37%) experienced severe reperfusion lung injury. The first extravascular lung water index measurement after cardiopulmonary bypass failed to predict severe reperfusion lung injury, area under the receiver operating characteristic curve 0.59 (95%CI 0.44-0.74). On intensive care, extravascular lung water index correlated most strongly at 36 h, area under the receiver operating characteristic curve 0.90 (95%CI 0.80-1.00). Peri-operative extravascular lung water index is not a useful measure to predict severe reperfusion lung injury after pulmonary endarterectomy, however, it does allow monitoring and measurement during the postoperative period. This study implies that extravascular lung water index can be used to directly assess pulmonary fluid overload and that monitoring patients by measuring extravascular lung water index during their intensive care stay is useful and correlates with their clinical course. This may allow directed, pre-empted therapy to attenuate the effects and improve patient outcomes and should prompt further studies.

The effect of high-flow nasal oxygen on hospital length of stay in cardiac surgical patients at high risk for respiratory complications: a randomised controlled trial.

There has been increased interest in the prophylactic and therapeutic use of high-flow nasal oxygen in patients with, or at risk of, non-hypercapnic respiratory failure. There are no randomised trials examining the efficacy of high-flow nasal oxygen in high-risk cardiac surgical patients. We sought to determine whether routine administration of high-flow nasal oxygen, compared with standard oxygen therapy, leads to reduced hospital length of stay after cardiac surgery in patients with pre-existing respiratory disease at high risk for postoperative pulmonary complications. Adult patients with pre-existing respiratory disease undergoing elective cardiac surgery were randomly allocated to receive high-flow nasal oxygen (n = 51) or standard oxygen therapy (n = 49). The primary outcome was hospital length of stay and all analyses were carried out on an intention-to-treat basis. Median (IQR [range]) hospital length of stay was 7 (6-9 [4-30]) days in the high-flow nasal oxygen group and 9 (7-16 [4-120]) days in the standard oxygen group (p=0.012). Geometric mean hospital length of stay was 29% lower in the high-flow nasal group (95%CI 11-44%, p = 0.004). High-flow nasal oxygen was also associated with fewer intensive care unit re-admissions (1/49 vs. 7/45; p = 0.026). When compared with standard care, prophylactic postoperative high-flow nasal oxygen reduced hospital length of stay and intensive care unit re-admission. This is the first randomised controlled trial examining the effect of prophylactic high-flow nasal oxygen use on patient-centred outcomes in cardiac surgical patients at high risk for postoperative respiratory complications.

The association between borderline pre-operative anaemia in women and outcomes after cardiac surgery: a cohort study.

Anaemia is common before cardiac surgery and is associated with increased morbidity and mortality. The World Health Organization (WHO) definition of anaemia is lower for women than for men by 10 g.l-1 , potentially putting women at a disadvantage compared with men with regard to pre-operative optimisation. Our hypothesis was that women with borderline anaemia (defined by us as haemoglobin concentration 120-129 g.l-1 ) would have a higher rate of red cell transfusion, morbidity and mortality than non-anaemic women (haemoglobin ≥ 130 g.l-1 ). This retrospective observational study included all adult patients admitted for elective cardiac surgery from January 2013 to April 2016. During the study period, 1388 women underwent cardiac surgery. Pre-operatively, 333 (24%) had a haemoglobin level < 120 g.l-1 ; 408 (29%) 120-129 g.l-1 ; and 647 (47%) ≥ 130 g.l-1 . Compared with non-anaemic women, women with borderline anaemia were more likely to be transfused (68.6% vs. 44.5%; RR 1.5, 95%CI 1.4-1.7; p < 0.0001) and were transfused with more units of red cells, mean (SD) 1.8 (2.8) vs. 1.3 (3.0); p < 0.0001. Hospital length of stay was significantly longer in the borderline anaemia group compared with non-anaemic women, median (IQR [range]) 8 (6-12 [3-45]) vs. 7 (6-11 [4-60]); p = 0.0159. Short- and long-term postoperative survival was comparable in both groups. Borderline anaemia is associated with increased red cell transfusion and prolonged hospital stay. Future research should address whether correction of borderline anaemia results in improved outcomes.

Blood conservation in cardiac surgery.

This article aims at reviewing the currently available evidence about blood conservation strategies in cardiac surgery. Pre-operative anaemia and perioperative allogeneic blood transfusions are associated with worse outcomes after surgery. In addition, transfusions are a scarce and costly resource. As cardiac surgery accounts for a significant proportion of all blood products transfused, efforts should be made to decrease the risk of perioperative transfusion. Pre-operative strategies focus on the detection and treatment of anaemia. The management of haematological abnormalities, most frequently functional iron deficiency, is a matter for debate. However, iron supplementation therapy is increasingly commonly administered. Intra-operatively, antifibrinolytics should be routinely used, whereas the cardiopulmonary bypass strategy should be adapted to minimise haemodilution secondary to circuit priming. There is less evidence to recommend minimally invasive surgery. Cell salvage and point-of-care tests should also be a part of the routine care. Post-operatively, any unnecessary iatrogenic blood loss should be avoided.

Complex regional pain syndrome following protracted labour*.

Obstetric nerve palsies are common and long-term sequelae are fortunately rare. The development of a complex regional pain syndrome is an unusual and less reported complication of labour-related neuropathy. A 28-year-old primigravida who experienced prolonged labour and instrumental delivery under spinal anaesthesia complained of persisting weakness and numbness postpartum, affecting the left lower limb. Urgent magnetic resonance imaging demonstrated no abnormality and a common peroneal nerve injury was later confirmed by nerve conduction studies. Unfortunately, the neuropathy did not resolve as expected and oedema, burning paraesthesia and allodynia affecting the left foot developed within two weeks. She was treated with gabapentin, ibuprofen, topical capsaicin and regular physiotherapy. After six months, the foot drop had resolved and the chronic pain element was significantly diminished.

Not without my permission: parents' willingness to permit use of newborn screening samples for research.

BACKGROUND: State newborn screening (NBS) programs are considering the storage and use of NBS blood samples for research. However, no systematic assessment of parents' attitudes exists. METHODS: We conducted an Internet-based survey of a nationally representative parent sample. We examined parents' willingness (1) to permit use of their children's NBS samples for research with/without their permission and (2) to allow NBS sample storage. Using bivariate and multinomial logistic regression, we examined the association of parent and child characteristics with parents' willingness to permit NBS sample storage and use for research, respectively. RESULTS: The response rate was 49.5%. If permission is obtained, 76.2% of parents were 'very or somewhat willing' to permit use of the NBS sample for research. If permission is not obtained, only 28.2% of parents were 'very or somewhat willing'. Of parents surveyed, 78% would permit storage of their children's NBS sample. Parents who refused NBS sample storage were also less willing to permit use of the NBS sample for research. CONCLUSIONS: Three-quarters of parents would permit use of their children's NBS samples for research - if their permission is obtained. Parents not in favor of storing NBS samples often opposed the use of NBS samples for research.

Results of an exercise to estimate the costs of interpersonal violence in Jamaica / Resultados de un ejercicio para estimar el costo de la violencia interpersonal en Jamaica

This report describes the application of a draft version of the World Health Organization (WHO)/ United States Centers for Disease Control and Prevention (CDC) Manual for estimating the economic costs of injuries due to interpersonal and self-directed violence to measure costs of injuries from interpersonal violence. METHODS: Fatal incidence data was obtained from the Jamaica Constabulary Force. The incidence of nonfatal violence-related injuries that required hospitalization was estimated using data obtained from patients treated at and/or admitted to three Type A government hospitals in 2006. RESULTS: During 2006, direct medical cost (J$2.1 billion) of injuries due to interpersonal violence accounted for about 12% of Jamaica's total health budget while productivity losses due to violence-related injuries accounted for approximately J$27.5 billion or 160% of Jamaica's total health expenditure and 4% of Jamaica's Gross Domestic Product. CONCLUSIONS: The availability of accurate and reliable data of the highest quality from health-related information systems is critical for providing useful data on the burden of violence and injury to decision-makers. As Ministries of Health take a leading role in violence and injury prevention, data collection and information systems must have a central role. This study describes the results of one approach to examining the economic burden of interpersonal violence in developing countries where the burden of violence is heaviest. The WHO-CDC manual also tested in Thailand and Brazil is a first step towards generating a reference point for resource allocation, priority setting and prevention advocacy.

Este reporte describe la aplicación de una versión preliminar del Manual de Centros de Estados Unidos para el control y prevención de enfermedades (CDC)/Organización Mundial de la Salud (OMS), para estimar el costo económico de las heridas debidas a la violencia interpersonal y la violencia auto-dirigida, con el fin de evaluar los costos de las heridas por violencia interpersonal. MÉTODOS: Datos sobre las incidencias fatales fueron obtenidos de las Oficinas de la Policía de Jamaica. La incidencia de las heridas no fatales relacionadas con la violencia, pero que no obstante requirieron hospitalización, se calculó a partir de pacientes tratados o ingresados en hospitales gubernamentales del tipo A, en el año 2006. RESULTADOS: Durante el 2006, el costo médico directo (2.1 billones JMD) por heridas a causa de violencia interpersonal, representó alrededor del 12% del total del presupuesto para la salud en Jamaica, mientras que las pérdidas de productividad debido a heridas relacionadas con la violencia, representaron aproximadamente 37.5 billones JMD, o 160% del total de gastos de salud y el 4% del producto interno bruto de Jamaica. CONCLUSIONES: Disponer de datos confiables y exactos de la más alta calidad provenientes de los sistemas de información relacionados con la salud, resulta crucial a las hora de suministrar datos útiles sobre la carga de la violencia y las heridas para quienes tienen a su cargo las tomas de decisiones. Como que los Ministros de Salud desempeñan un papel dirigente en la prevención de las heridas y la violencia, la recogida de datos y los sistemas de información tienen que jugar un papel central. Este estudio describe los resultados de un enfoque para examinar la carga económica de la violencia interpersonal en los países en vías de desarrollo, en los cuales la carga de la violencia es más pesada. El manual CDC-OMS también probado en Tailandia y Brasil, es un primer paso hacia la generación de un punto de referencia para asignar recursos, establecer prioridades y defender la prevención.

Results of an exercise to estimate the costs of interpersonal violence in Jamaica.

UNLABELLED: This report describes the application of a draft version of the World Health Organization (WHO)/ United States Centers for Disease Control and Prevention (CDC) Manual for estimating the economic costs of injuries due to interpersonal and self-directed violence to measure costs of injuries from interpersonal violence. METHODS: Fatal incidence data was obtained from the Jamaica Constabulary Force. The incidence of nonfatal violence-related injuries that required hospitalization was estimated using data obtained from patients treated at and/or admitted to three Type A government hospitals in 2006. RESULTS: During 2006, direct medical cost (J$2.1 billion) of injuries due to interpersonal violence accounted for about 12% of Jamaica's total health budget while productivity losses due to violence-related injuries accounted for approximately J$27.5 billion or 160% of Jamaica's total health expenditure and 4% of Jamaica's Gross Domestic Product. CONCLUSIONS: The availability of accurate and reliable data of the highest quality from health-related information systems is critical for providing useful data on the burden of violence and injury to decision-makers. As Ministries of Health take a leading role in violence and injury prevention, data collection and information systems must have a central role. This study describes the results of one approach to examining the economic burden of interpersonal violence in developing countries where the burden of violence is heaviest. The WHO-CDC manual also tested in Thailand and Brazil is a first step towards generating a reference point for resource allocation, priority setting and prevention advocacy.

The economic dimensions of interpersonal violence

It strengthens the case for investing in prevention even further by highlighting the enormous economic costs of the consequences of interpersonal violence, and reviewing the limited but nonetheless striking evidence for the cost-effectiveness of preventionprogrammes. Document in pdf format; Acrobat Reader required.

The share of suicide in injury deaths in the South African context: sociodemographic distribution.

This study describes the sociodemographic distribution of suicide deaths compared with other injury deaths in South Africa. Cross-sectional data for 26,354 cases were extracted from an injury surveillance database. These included all manners of injury death from 10 mortuaries for 1999-2000 (approximately 18-20% coverage of all injury deaths per year). They were used to examine the distribution of suicide across different sex, race and age groupings, and the relative involvement of alcohol across manners of death. The share of suicide as a cause of death was comparable for males and females, but varied considerably across races and age groups. It was twice as high for Whites as for Asians, and four times as high as for Coloureds and Blacks. For all races except Whites, suicides were concentrated in the younger age groups. Only among Whites was the proportion of alcohol-positive suicides higher or comparable with that for other manners of death. While homicides and unitentional injury deaths outnumbered suicides overall, the relative importance of suicide in some social groups is reason for concern. South Africa is a country undergoing profound transformations, and differences in the distribution of suicide across sociodemographic groups deserve attention.

The South African National Non-Natural Mortality Surveillance System--rationale, pilot results and evaluation.

BACKGROUND: While individual mortuaries have recorded data for non-natural deaths in time-limited studies, there have been no systematic efforts to draw forensic-medical services and state mortuaries into a nationwide fatal injury surveillance system. Beginning in June 1998, the National Non-Natural Mortality Surveillance System (NMSS) commenced pilot operation. OBJECTIVE: To evaluate the NMSS and illustrate its utility from sample findings. DESIGN: Data entered into the system by mortuary staff were checked against a random sample of cases for which separate forms were completed by an independent researcher. Process observations and follow-up with data users were used to assess the system's acceptability, timeliness and data usefulness. SETTING: Eighteen mortuaries in six provinces representing approximately 35,000 cases per year, or around 50% of all non-natural deaths. PARTICIPANTS: The National Departments of Health; Safety and Security; and Arts, Culture, Science and Technology; national and provincial forensic medico-legal services; the South African Police Services; universities and science research councils. MAIN OUTCOME MEASURES: Surveillance system simplicity, flexibility, acceptability, sensitivity, positive predictive value, representativeness, timeliness, data usefulness and resources. RESULTS: The NMSS was established at 10 target sites. Lack of equipment, personnel resistance, and closure of some mortuaries prevented implementation in the remaining eight mortuaries. Sensitivity was internally assessed and ranged from 65% to 95% for manner of death. Positive predictive value was also internally measured, and ranged from 74% to 80% for manner of death and from 71% to 82% for mechanism of death. Timeliness was good, and basic reports covering most items were available 6 weeks after a case had been examined. While staff found the system simple, acceptability depended on the individuals involved at different mortuaries, and the system was compromised to some extent by bureaucratic barriers. End users found the data to be of great value. NMSS set-up costs totalled approximately R26,000 per mortuary, and it is estimated that maintenance costs will be R8.00 per case registered. CONCLUSIONS: With minimal resources, the NMSS uses existing investigative procedures to describe and report the epidemiology of fatal injuries. The pilot study demonstrates the feasibility of the system, and identifies the need to remove organisational constraints and individual barriers if it is to be sustained and expanded beyond the pilot sites.

Perceptions of injury causes and solutions in a Johannesburg township: implications for prevention.

As with other diseases, citizen perceptions of injury causes and solutions are important determinants of their response to the problem. This study explores qualitative responses to questions about the causes and solutions for injuries due to violence, transport, and unintentional burns, falls and other causes from 1,075 residents in six neighbourhoods of a low-income area in Johannesburg, South Africa. These included council houses, council apartment blocks and informal settlements. Data were analysed using content analytic procedures. Perceived causes of injury varied sharply between neighbourhoods. Violence was seen as an outcome of unemployment, socialisation, drug abuse and drug dealing in the formal housing areas, while in the informal settlements it was attributed to unemployment, poor housing and environmental conditions, and excessive alcohol consumption. In the formal housing areas, suggested solutions for violence emphasised increased policing and other repressive measures that contradicted the attribution of causes to environmental factors. In the informal areas, solutions were more congruent with perceived causes, emphasising housing development, education and employment. Perceived causes and solutions for transport injuries reflected the specific context of each neighbourhood, and indicated strong support for the implementation of environmental modifications to reduce the speed of motor vehicles and thus the number of pedestrian injuries. Where perceived causes and solutions for violence and transport-related injuries were located beyond the community in the broader environment, unintentional injuries due to other causes were seen as more in the sphere of potential personal control, except in the informal areas where electrification and formal housing provision were the most commonly suggested solutions. Popular constructions of the causes and solutions for major categories of injury are important in shaping injury prevention responses, and their careful assessment can increase the likelihood that safety promotion programmes will succeed.

The "Bantu Clinic": a genealogy of the African patient as object and effect of South African clinical medicine, 1930-1990.

This paper is about power, medicine and the identity of the African as a patient of western medicine. From a conventional perspective and as encoded in the current "quest for wholeness" that characterises South African biomedical discourse, the African patient--like any other patient--has always existed as an authentic and subjectified being, whose true attributes and experiences have been denied by the "mechanistic," "reductionistic" and "ethnocentric" practices of clinical medicine. Against this liberal humanist perspective on the body as ontologically independent of power, this paper offers a Foucaultian reading of the African patient as-like any other patient--contingent upon the force relations immanent within and relayed through the clinical practices of biomedicine. A quintessential form of disciplinary micro-power, these fabricate the most intimate recesses of the human body as manageable objects of medical knowledge and social consciousness to make possible the great control strategies of repression, segmentation and liberation that are the usual focus of conventional investigations into the place and function of medicine in society. Since the 1930s when the African body first emerged as a discrete object of a secular clinical knowledge, these have repeatedly transformed the attributes and identity of the African patient, and the paper traces this archaeology of South African clinical perception from then until the 1990s to show how its "quest for wholeness" is not an end point of "discovery" or "liberation," but merely another ephemeral crystallization of socio-medical knowledge in a constantly changing force field of disciplinary power.

Delivery of medication to psychiatric patients in community health services in New South Wales.

OBJECTIVE: We investigated the supply and monitoring of medication to patients who attend community mental health services in NSW. METHOD: The staff at four metropolitan and one rural community centre health service were interviewed. Information sought included policies and procedures concerning medication, the delivery of medication to patients, and staff reports concerning their knowledge and practice related to the legal requirements of the New South Wales Poisons Act 1966. RESULTS: Sixty-five (62%) of 104 coordinators, medical officers and staff who were responsible for case managing patients were interviewed. The centres all differed in their existing policies and practices and the extent to which they were supported by their local hospital and retail pharmacies. Only one centre had a designated pharmacist and this was a part-time position. CONCLUSIONS: The delivery of medication at most centres is a fairly ad hoc arrangement with staff organising medication as best as they can. At times the supply of medication to patients fails to comply with legal and New South Wales Department of Health requirements.