Driving behaviors associated with emergency service vehicle crashes in the U.S. fire service.

OBJECTIVE: Emergency service vehicle incidents are a leading cause of firefighter fatalities and are also hazardous to civilian road users. Modifiable driving behaviors may be associated with emergency service vehicle incidents. The goal of this study was to use telematics to identify driving behaviors associated with crashes in the fire service. METHODS: Forty-three emergency service vehicles in 2 fire departments were equipped with telematics devices (12 in Department A and 31 in Department B). The devices collected vehicle coordinates, speed, and g forces, which were monitored for exceptions to driving rules established by the fire departments regarding speeding, harsh braking, and hard cornering. Fire department administrative reports were used to identify vehicles involved in crashes and merged with daily telematics data. Penalized logistic regression was used to identify driving rules associated with crashes. Least absolute shrinkage and selection operator (LASSO) regression was used to generate a telematics-based risk index for emergency service vehicle incidents. RESULTS: Nearly 1.1 million km of driving data and 44 crashes were recorded among the 2 departments during the study. Harsh braking was associated with increased odds of crash in Department A (odds ratio [OR] = 2.22; 95% confidence interval [CI], 1.09-4.51) and Department B (OR = 1.55; 95% CI, 1.12-2.15). For every kilometer of nonemergency speeding, the odds of crash increased by 35% in Department A (OR = 1.35; 95% CI, 1.03-1.77) and by over 2-fold in Department B (OR = 2.09; 95% CI, 1.19-3.66). In Department B, hard cornering (OR = 1.14; 95% CI, 1.03-1.26) and emergency speeding (OR = 1.65; 95% CI, 1.06-2.57) were also associated with increased odds of crash. The final LASSO risk index model had a sensitivity of 73% and specificity of 57%. CONCLUSIONS: Harsh braking and excessive speeding were driving behaviors most associated with crash in the fire service. Telematics may be a useful tool for monitoring driver safety in the fire service.

Intensive multifactorial intervention improves modelled coronary heart disease risk in screen-detected Type 2 diabetes mellitus: a cluster randomized controlled trial.

AIMS: To compare the effects of intensive multifactorial cardiovascular risk intervention with standard care in screen-detected Type 2 diabetes. METHODS: Twenty general practices randomly invited 30 950 adults without diagnosed diabetes for screening (World Health Organization, 1999). In a cluster randomized controlled trial, screen-detected cases were assigned by practice allocation to receive intensive protocol-driven cardiovascular risk management (n = 146) or standard care (n = 199) according to local guidelines. Intensive intervention was designed to achieve an HbA(1c) of 48 mmol/mol (6.5%), blood pressure < 130/80 mmHg and total cholesterol < 3.5 mmol/l. Primary outcome was modelled 5-year coronary heart disease risk (UKPDS-CHD). Analysis was via intention to treat. RESULTS: After 1.1 years 339 (98%) individuals were still participating. There were significant reductions in HbA(1c) , blood pressure and total cholesterol from baseline in both groups [mean change for total study population -27.7 mmol/mol (-0.62%), -11.64/10.01 mmHg, -1.11 mmol/l]. After adjustment for baseline and clustering, significant inter-group differences were observed in mean changes from baseline for HbA(1c) {-28.5 mmol/mol [-0.7% (1.4)] vs. -27.5 mmol/mol [-0.6% (1.6)], P = 0.001}, blood pressure [systolic -16.2 (19.6) vs. -8.4 (18.6) mmHg, P < 0.001], total cholesterol [-1.3 (1.3) vs. -1.0 (1.2) mmol/l, P < 0.001] and weight [-3.8 (5.5) vs. -2.2 (5.5) kg, P = 0.01] in favour of intensive treatment. UKPDS 5-year coronary heart disease risk was reduced by 3.2% and 2.3%, respectively (P < 0.0001). Intensive intervention was associated with more lipid-lowering and anti-hypertensive but not hypoglycaemic medication use [odds ratios 2.5 (1.4-4.4), 5.5 (2.4-11.5), 1.6 (0.8-2.3); compared with standard care, P < 0.001, P = 0.003, P = 0.65]. Treatment satisfaction responses were superior with intensive intervention, with no increase in self-reported hypoglycaemia. CONCLUSION: Intensive intervention in patients with diabetes identified through systematic non-risk-factor-based screening significantly reduces modelled coronary heart disease risk. This is achieved predominantly with lipid-lowering and anti-hypertensive treatments with no adverse effect on quality of life or hypoglycaemia.

Cost effectiveness of clinically appropriate decisions on alternative treatments for angina pectoris: prospective observational study.

OBJECTIVE: To assess whether revascularisation that is considered to be clinically appropriate is also cost effective. DESIGN: Prospective observational study comparing cost effectiveness of coronary artery bypass grafting, percutaneous coronary intervention, or medical management within groups of patients rated as appropriate for revascularisation. SETTING: Three tertiary care centres in London. PARTICIPANTS: Consecutive, unselected patients rated as clinically appropriate (using a nine member Delphi panel) to receive coronary artery bypass grafting only (n=815); percutaneous coronary intervention only (n=385); or both revascularisation procedures (n=520). MAIN OUTCOME MEASURE: Cost per quality adjusted life year gained over six year follow-up, calculated with a National Health Service cost perspective and discounted at 3.5%/year. RESULTS: Coronary artery bypass grafting cost 22,000 pounds sterling (33,000 euros; $43,000) per quality adjusted life year gained compared with percutaneous coronary intervention among patients appropriate for coronary artery bypass grafting only (59% probability of being cost effective at a cost effectiveness threshold of 30,000 pounds sterling per quality adjusted life year) and 19,000 pounds sterling per quality adjusted life year gained compared with medical management among those appropriate for both types of revascularisation (probability of being cost effective 63%). In none of the three appropriateness groups was percutaneous coronary intervention cost effective at a threshold of 30,000 pounds sterling per quality adjusted life year. Among patients rated appropriate for percutaneous coronary intervention only, the cost per quality adjusted life year gained for percutaneous coronary intervention compared with medical management was 47,000, pounds sterling exceeding usual cost effectiveness thresholds; in these patients, medical management was most likely to be cost effective (probability 54%). CONCLUSIONS: Among patients judged clinically appropriate for coronary revascularisation, coronary artery bypass grafting seemed cost effective but percutaneous coronary intervention did not. Cost effectiveness analysis based on observational data suggests that the clinical benefit of percutaneous coronary intervention may not be sufficient to justify its cost.

Cardiovascular changes with the laryngeal mask airway in cardiac anaesthesia.

BACKGROUND: The laryngeal mask airway (LMA) causes fewer haemodynamic changes, particularly in mean arterial pressure (MAP) and heart rate (HR), than tracheal intubation using either laryngoscopy or the intubating LMA. There are no data for patients with coronary artery disease. METHOD: We studied 27 patients having coronary artery bypass grafting, prospectively randomized to be managed with either the LMA or tracheal intubation using either laryngoscopy or the ILMA. We used invasive monitoring to compare the haemodynamic effects in each group during induction and emergence from anaesthesia. RESULTS: Both methods of intubation caused an increase in MAP compared with the LMA (P<0.05). Mixed venous oxygen saturation increased in the intubated patients but not with the LMA (P<0.05). HR did not change at induction in the LMA group. Changes at extubation were similar in all groups but cardiac index was lower in the LMA group (P<0.05). CONCLUSION: The LMA allows airway management without hypertension and tachycardia and should be considered when anaesthetizing patients with coronary disease.

Sevoflurane versus isoflurane in patients undergoing valvular cardiac surgery.

OBJECTIVE: To determine if sevoflurane provides hemodynamic and recovery characteristics comparable to isoflurane in patients undergoing surgery for valvular heart disease. DESIGN: A prospective crossover, dose-response study using sevoflurane and isoflurane before the start of surgery, followed by randomization to sevoflurane or isoflurane for surgery with blinded assessment for recovery. SETTING: Tertiary referral cardiac center. PARTICIPANTS: Twenty-seven patients scheduled for elective valve surgery. Surgery consisted of 18 aortic valve and 12 mitral valve replacements, of which 3 patients had 2 valves replaced; 1, tricuspid repair; and 8, coronary artery bypass procedures. INTERVENTIONS: A pulmonary artery catheter was used to obtain a complete hemodynamic profile during the dose-response study before surgery. Transesophageal echocardiography was used to confirm the diagnosis, and electrocardiography monitored for myocardial ischemia. MEASUREMENTS AND MAIN RESULTS: Both agents showed similar hemodynamic effects at 0.5 and 1.0 minimum alveolar concentration. There was a tendency to decreases in heart rate, blood pressure, and cardiac output, whereas filling pressures remained stable with each volatile agent. Electrocardiography did not detect ischemic changes. Times to eye opening and extubation were similar with both agents, with sevoflurane tending to be earlier than isoflurane. CONCLUSION: Sevoflurane showed a tendency to lower heart rates and cardiac index compared with isoflurane. Eye opening and extubation were slightly earlier. These findings were not statistically significant, however.

Sevoflurane versus isoflurane in patients undergoing coronary artery bypass grafting: a hemodynamic and recovery study.

OBJECTIVE: To determine if sevoflurane provides comparable hemodynamics and recovery characteristics to isoflurane in cardiac anesthesia. DESIGN: A prospective, crossover, dose-response study using sevoflurane and isoflurane before the start of surgery, followed by randomization to sevoflurane or isoflurane for surgery with blinded assessment for recovery. SETTING: Tertiary referral cardiac clinic and intensive care. PARTICIPANTS: Sixteen elective patients scheduled for coronary artery bypass grafting. INTERVENTIONS: A pulmonary artery catheter was used to obtain a complete hemodynamic profile during the dose response study before surgery. Transesophageal echocardiography (TEE) and an electrocardiogram (ECG) were used to assess myocardial ischemia. MEASUREMENTS AND MAIN RESULTS: Both agents showed similar hemodynamic effects at 0.5 and 1.0 minimum alveolar concentration (MAC). There was a tendency toward decreases in heart rate, blood pressure, vascular resistance, and cardiac output with a rise in central pressures. Ischemic changes were not detected by TEE or ECG. Times to eye opening and extubation were similar for both agents. CONCLUSION: At MAC equivalent doses, sevoflurane showed comparable hemodynamics to isoflurane. Both agents when used as the primary anesthetic showed similar recovery characteristics, with no statistical difference between them at any stage of the study.

Disc failure in a Björk-Shiley mitral prosthesis.

The case of a 50-year-old man is presented who underwent reoperation for a malfunctioning Björk-Shiley spherical valve which had been inserted 14 years previously. The patient made a satisfactory recovery after surgery. Examination of the explanted valve revealed that a segment of the pyrolytic carbon disc was missing. There was no evidence of embolization.

Radiopharmaceutical uptake as a marker of sternal blood supply following internal mammary artery harvesting.

To evaluate the impact of internal mammary artery harvesting on sternal blood supply after open heart surgery, a conventional bone scan was performed 7 days after operation in 30 patients. After administration of 370 MBq of technetium 99 m-medronic acid complex, imaging was carried out at the level of the sternum and including the humerus as a reference. A quantitative analysis of uptake (sternum/humerus uptake index) was performed and compared in three different groups of patients: group A, ten patients who had only vein grafts or valve surgery; group B, ten patients with single internal mammary artery harvesting; and group C, ten patients with bilateral internal mammary artery harvesting. These results were compared with 24 non-surgical subjects as a control (group D). Although intervention had a significant influence in raising the uptake index of the surgical groups (A = 3.34; B = 3.09 and C = 3.48) when compared with normal subjects (D = 2.45) (P < 0.01), there was not a statistically significant difference among the three surgical groups (P > 0.05). It was concluded that the vascular supply of the sternum is not entirely dependent upon the internal mammary arteries and that mobilization of both vessels does not cause per se additional serious impact to the bone vascularization after midline sternotomy, at least beyond day 7 after operation.

Pleural abrasion: a new method of pleurodesis.

Sixty patients (48 male, 12 female; median age 32 (range 16-72) years) underwent pleural abrasion for persistent or recurrent pneumothorax. Fifty patients had recurrent pneumothorax and 10 persistence of a first pneumothorax despite conservative treatment; two had bilateral pneumothoraces. Pleural abrasion was carried out with a domestic nylon scouring pad and blebs or bullae were ligated or stapled and excised. Intercostal drainage was discontinued after a median time of two days, median serosanguinous loss was 250 ml, and the median postoperative stay in hospital was four days. During the median follow up period of 32 (range 19-52) months pneumothorax has recurred in one patient.

Oesophageal resection after instrumental perforation.

Between 1981 and 1987, 11 patients underwent oesophageal resection following endoscopic perforation of the oesophagus. They had a median age of 67 years with a range of 36 to 88 years. They all were managed either by one- or two-stage oesophageal resections. Six patients were perforated at other hospitals, 5 on site. Seven had carcinoma of the middle or lower third of the oesophagus, 2 of these were perforated at attempted palliative intubation. Four had benign peptic strictures perforated during dilatation. Seven were resected within the first 24 hours and 4 between 2 and 10 days after perforation. All 4 patients with benign disease survived but 4 of the 7 patients with cancer died giving an operative mortality of 36.3%. Respiratory complications were the most common postoperative problem: all deaths were attributed to respiratory failure. Perforation of the thoracic oesophagus carries a high mortality. Resection after perforation in benign strictures may be life saving in a potentially lethal condition but resection after perforation, even in operable cancer, still carries a high mortality.

Palliative intubation of malignant oesophageal strictures.

A 6-year experience (1981-1987) of palliative intubation of irresectable malignant oesophageal strictures is reported in 110 patients with a mean age of 70.3 (range 41-90) years. Pulsion intubation was performed on 71 patients, 11 (15.5%) of whom died, and traction intubation on 39 with 6 (15.4%) deaths. Seven deaths resulted from instrumental perforation, but six other patients survived perforation and left the hospital in satisfactory condition. Mean in-patient stay was 8 (range 1-26) days. Non-fatal tube-related complications were more common in pulsion intubation, but was found to be highly effective in relieving dysphagia, with shortened hospital stay (mean 6 days) and acceptable morbidity and mortality rates. These results indicate the trend towards, and the increased safety of, pulsion intubation.