Estimation of the specificity of an antibody ELISA for paratuberculosis generated from a sector of the UK cattle population using results from a paratuberculosis control programme.

In the United Kingdom (UK) a voluntary programme to control paratuberculosis in cattle based on herd management and serological screening has been operating since 1998. The programme assigns a risk level to each participating herd according to the within herd seroprevalence and the confirmation of the presence of infection with Mycobacterium avium subspecies paratuberculosis (MAP) by faecal culture or polymerase chain reaction (PCR). From the outset a general concern over the specificity of the paratuberculosis antibody enzyme-linked immunosorbent assay (ELISA) resulted in the use of a faecal screen for the causal organism to negate or confirm infection in individual seropositive animals. Progress in improving the diagnostic tests has been gradual throughout the life of the programme and the under-pinning approach to using tests to determine the risk of paratuberculosis for a herd required to be re-examined. This study used a large data set of more than 143,000 test results over five years from the lowest paratuberculosis risk level category of herds to estimate the specificity of a commercially available paratuberculosis antibody ELISA for cattle. In each year of the study the estimated specificity reached or exceeded 0.998. We also examined the apparent impact that annual or more frequent application of the single intradermal comparative cervical tuberculin (SICCT) test for tuberculosis (TB), using purified protein derivatives of Mycobacterium bovis and Mycobacterium avium subspecies avium, had on specificity of the antibody ELISA for paratuberculosis. We found a statistically significant difference in three of the five years with herds that were officially tuberculosis free and not subject to frequent SICCT testing. This difference was small and considered to be of little practical importance for the paratuberculosis assurance programme. We concluded that, in the UK the mandatory TB surveillance programme of cattle herds is not a limiting factor in the use of serological testing to support herd-level assurance schemes for paratuberculosis. Furthermore, in paratuberculosis, where shedding of MAP is intermittent and the sensitivity of the commercially available PCR tests for detection MAP is highly variable, faecal screening of seropositive animals is an unreliable method for negating infection in seropositive cattle.

Longitudinal predictors of French word reading difficulties among French Immersion children.

In Canada, approximately 12% of school-aged children are enrolled in French Immersion (FI), with some provinces estimating close to 30%. FI programs are intended to produce bilingual individuals who can functionally communicate in both of Canada's official languages. Yet, we are currently underinformed as to how to identify children with French word reading difficulties in such programs. Within this context, and in the interests of informing early identification of second language reading challenges, we examined early English predictors of French word reading difficulties. We also examined potential overlap of these difficulties as well as the stability of these difficulties over time. A total of 108 children in FI participated, completing measures of English nonverbal intelligence, phonological awareness, rapid automatized naming, and receptive vocabulary in kindergarten, as well as English and French word reading in grades 1, 2, and 3. Logistic regressions revealed that kindergarten English phonological awareness and rapid automatized naming (RAN) distinguished between good and poor French word readers in grade 3, with adequate sensitivity and specificity. These results suggest that English phonological awareness and RAN may be appropriate early skills to identify children at risk of word reading challenges in bilingual programs. Chi-square analyses demonstrated significant overlap of English and French word reading challenges in grades 1, 2, and 3, highlighting the possibility that English and French word reading difficulties do not exist independently. Finally, chi-square analyses revealed retrospectively stable word reading difficulties in English and French. Interestingly, prospective stability was stronger for French than English word reading challenges. Overall, our results underscore the importance of considering the specific nature of word reading difficulties in bilingual readers.

Prevalence of Venous Thromboembolism and Anticoagulant Use in Patients with COVID-19 in Alberta, Canada.

Background: COVID-19 causes a hypercoagulable state and increases the risk of venous thromboembolism (VTE). Objectives: The primary objective was to identify VTE prevalence among patients with COVID-19 in one Canadian province. Secondary objectives were to identify the prevalence of bleeding, describe anticoagulation prescribing practices, and identify factors contributing to VTE in these patients. Methods: Adult patients admitted to Alberta hospitals between March and December 2020 with COVID-19 who had a length of stay of at least 72 hours were included in this retrospective study. VTE, bleeding events, and comorbidities were defined by International Classification of Diseases and Related Health Problems, 10th Revision codes. Cases of VTE and controls (no VTE) were matched on the basis of age older than 60 years, active cancer, and length of stay for the full cohort, as well as for a subgroup of patients with d-dimer data available, to assess for factors associated with VTE. Results: A total of 2544 patients were included. Median age was 66 years, 1461 patients (57.4%) were male, median weight was 77.7 kg, and median d-dimer level on admission was 1.00 mg/L. The prevalence of VTE was 3.7% (n = 93) and that of major and clinically relevant non-major bleeding was 4.9% (n = 125). Of the total population, 1224 patients (48.1%) had standard prophylactic-dose anticoagulation, 460 (18.1%) received only higher-dose anticoagulation, 248 (9.7%) received both prophylactic- and higher-dose anticoagulation, and 612 (24.1%) had no anticoagulation data. Logistic regression showed that only the presence of d-dimer above 3 mg/L was associated with a significant odds ratio for VTE (7.04, 95% confidence interval 2.43-20.84). Conclusions: VTE prevalence among patients with COVID-19 was higher than baseline prevalence in Alberta. Analysis of prescribing practices demonstrated that a large proportion of patients received higher-dose anticoagulation.

Contexte: La COVID-19 provoque un état d'hypercoagulabilité et augmente le risque de thromboembolie veineuse (TEV). Objectifs: L'objectif principal de cette étude consistait à identifier la prévalence de la TEV chez les patients atteints de COVID-19 dans une province canadienne. Ses objectifs secondaires consistaient, quant à eux, à identifier la prévalence des saignements, décrire les pratiques relatives à la prescription d'anticoagulants et à identifier les facteurs contribuant à la TEV chez ces patients. Méthodes: Cette étude rétrospective a été menée auprès de patients adultes atteints de COVID-19 admis dans les hôpitaux de l'Alberta entre mars et décembre 2020 avec une durée de séjour d'au moins 72 heures. La TEV, les événements hémorragiques et les comorbidités étaient définis par les codes de la Classification internationale des maladies et des problèmes de santé connexes, 10 e révision (CIM-10). Les cas de TEV et les témoins (sans TEV) ont été appariés sur les bases suivantes afin d'évaluer les facteurs associés à la TEV : âge de plus de 60 ans, cancer actif et durée de séjour pour l'ensemble de la cohorte, ainsi que pour un sous-groupe de patients dont les données sur les D-dimères étaient disponibles. Résultats: Au total, 2544 patients ont été inclus. L'âge médian était de 66 ans; 1461 patients (57,4 %) étaient des hommes; leur poids médian était de 77,7 kg et le taux médian de D-dimères à l'admission était de 1,00 mg/L. La prévalence de la TEV était de 3,7 % (n = 93) et celle des saignements majeurs et non majeurs cliniquement pertinents était de 4,9 % (n = 125). Sur la population totale, 1224 patients (48,1 %) ont reçu un anticoagulant à dose prophylactique standard; 460 (18,1 %) n'ont reçu qu'un anticoagulant à dose plus élevée; 248 (9,7 %) ont reçu à la fois un anticoagulant à dose prophylactique et à dose plus élevée; et 612 (24,1 %) ne disposaient pas de données relatives à la prescription d'anticoagualant. La régression logistique a montré que seule la présence de D-dimères au-dessus de 3 mg/L était associée à un rapport de cotes significatif pour la TEV (7,04, intervalle de confiance à 95 % 2,43­20,84). Conclusions: La prévalence de la TEV chez les patients atteints de COVID-19 était plus élevée que la prévalence de référence en Alberta. L'analyse des pratiques de prescription a montré qu'une grande proportion de patients recevait un anticoagulant à plus forte dose.

Drinking among university students with a history of reading difficulties: motivational and personality risk factors for hazardous levels of consumption.

An increasing number of students are entering university with reading difficulties-whether they be diagnosed or self-reported. Research demonstrates that university students who self-report a history of reading difficulties (HRD) have lower academic achievement and higher anxiety about academic performance as compared to peers without this history (NRD). Here we study other aspects of HRD students' university experiences, focusing on alcohol consumption. Specifically, we investigated the drinking motives and personality characteristics likely to increase risk of hazardous alcohol consumption among HRD vs. NRD undergraduates. We identified 42 HRD and 54 NRD participants based on responses to a reading history questionnaire. Participants completed questionnaires assessing hazardous drinking, drinking motives, and alcohol-risk personality traits. Both groups reported similarly high levels of hazardous drinking. HRD students reported drinking more to conform with peers, and less to enhance positive moods, than NRD students. HRD students also scored higher in the alcohol personality risk of impulsivity. Our results support a unique pattern of motives and personality risks among HRD students, a pattern that likely puts them at increased risk for sustained hazardous drinking. Clinical implications for preventing problem drinking among HRD undergraduates are considered.

Two aspects of psychological functioning in undergraduates with a history of reading difficulties: anxiety and self-efficacy.

Reading difficulties have been associated with problems in psychological functioning, including challenges in both anxiety and self-efficacy. This study was designed to determine whether such psychological functioning problems are specific to the academic sphere or more global. First-year undergraduate students with and without a history of reading difficulties (n = 40 and 46, respectively) completed standardized questionnaires on general and academic anxiety, and social and academic self-efficacy. Students with a history of reading difficulties reported higher academic anxiety, but comparable general anxiety, relative to those with no such history. Students with a history of reading difficulties also reported lower academic self-efficacy, but comparable social self-efficacy, relative to those with no such history. These findings suggest that students with a history of reading difficulties, as compared to those without such history, experience academic-specific mental health symptoms involving heightened anxiety and low self-efficacy as they enter university. These results point to the need for focused and targeted assessments to be able to capture difficulties they experience with anxiety and self-efficacy and interventions to help them cope with these difficulties. More broadly, the findings have implications for how universities assess academic vulnerabilities and provide access to specific course accommodations.

Impact of an education and multilevel social comparison-based intervention bundle on use of routine blood tests in hospitalised patients at an academic tertiary care hospital: a controlled pre-intervention post-intervention study.

BACKGROUND: Repetitive inpatient laboratory testing contributes to waste in healthcare. We evaluated an intervention bundle combining education and multilevel social comparison feedback to safely reduce repetitive use of inpatient routine laboratory tests. METHODS: This non-randomised controlled pre-intervention post-intervention study was conducted in four adult hospitals from October 2016 to March 2018. In the medical teaching unit (MTU) of the intervention site, learners received education and aggregate social comparison feedback and attending internists received individual comparison feedback on routine laboratory test utilisation. MTUs of the remaining three sites served as control units. Number and cost of routine laboratory tests ordered per patient-day before and after the intervention was compared with the control units, adjusting for patient factors. Safety endpoints included number of critically abnormal laboratory test results, number of stat laboratory test orders, patient length of stay, transfer rate to the ICU, and 30-day readmission and mortality. RESULTS: A total of 14 000 patients were included. Pre-intervention and post-intervention groups were similar in age, sex, Charlson Comorbidity Index and length of stay. From the pre-intervention period to the post-intervention period, significantly fewer routine laboratory tests were ordered at the intervention MTU (incidence rate ratio=0.89; 95% CI 0.79 to 1.00; p=0.048) with associated costs savings of $C68 877 (p=0.020) as compared with the control sites. The variability in the ordering pattern of internists at the intervention site also decreased post-intervention. No worsening was noted in the safety endpoints between the pre-intervention and post-intervention period at the intervention unit compared with the controls. CONCLUSIONS: Combination of education and multilevel social comparison feedback significantly and safely led to cost savings through reduced use of routine laboratory tests in hospitalised patients.

The impact of inclusion, dose and duration of pyrazinamide (PZA) on efficacy and safety outcomes in tuberculosis: systematic review and meta-analysis protocol.

BACKGROUND: Pyrazinamide (PZA) is a key component of current and future regimens for tuberculosis (TB). Inclusion of PZA at higher doses and for longer durations may improve efficacy outcomes but must be balanced against the potential for worse safety outcomes. METHODS: We will search for randomised and quasi-randomised clinical trials in adult participants with and without the inclusion of PZA in TB treatment regimens in the Cochrane infectious diseases group's trials register, Cochrane central register of controlled trials (CENTRAL), MEDLINE, EMBASE, LILACS, the metaRegister of Controlled Trials (mRCT) and the World Health Organization (WHO) international clinical trials registry platform. One author will screen abstracts and remove ineligible studies (10% of which will be double-screened by a second author). Two authors will review full texts for inclusion. Safety and efficacy data will be extracted to pre-piloted forms by one author (10% of which will be double-extracted by a second author). The Cochrane risk of bias tool will be used to assess study quality. The study has three objectives: the association of (1) inclusion, (2) dose and (3) duration of PZA with efficacy and safety outcomes. Risk ratios as relative measures of effect for direct comparisons within trials (all objectives) and proportions as absolute measures of effect for indirect comparisons across trials (for objectives 2 and 3) will be calculated. If there is insufficient data for direct comparisons within trials for objective 1, indirect comparisons between trials will be performed. Measures of effect will be pooled, with corresponding 95% confidence intervals and p values. Meta-analysis will be performed using the generalised inverse variance method for fixed effects models (FEM) or the DerSimonian-Laird method for random effects models (REM). For indirect comparisons, meta-regression for absolute measures against dose and duration data will be performed. Heterogeneity will be quantified through the I2-statistic for direct comparisons and the τ2 statistic for indirect comparisons using meta-regression. DISCUSSION: The current use of PZA for TB is based on over 60 years of clinical trial data, but this has never been synthesised to guide rationale use in future regimens and clinical trials. Systematic review registration: International Prospective Register of Systematic Reviews (PROSPERO) CRD42019138735.

Perioperative Management of Patients With Atrial Fibrillation Receiving a Direct Oral Anticoagulant.

IMPORTANCE: Patients with atrial fibrillation (AF) who use a direct oral anticoagulant (DOAC) and request elective surgery or procedure present a common clinical situation yet perioperative management is uncertain. OBJECTIVE: To investigate the safety of a standardized perioperative DOAC management strategy. DESIGN, SETTING, AND PARTICIPANTS: The Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) cohort study conducted at 23 clinical centers in Canada, the United States, and Europe enrolled and screened patients from August 1, 2014, through July 31, 2018. Participants (n = 3007) had AF; were 18 years of age or older; were long-term users of apixaban, dabigatran etexilate, or rivaroxaban; were scheduled for an elective surgery or procedure; and could adhere to the DOAC therapy interruption protocol. INTERVENTIONS: A simple standardized perioperative DOAC therapy interruption and resumption strategy based on DOAC pharmacokinetic properties, procedure-associated bleeding risk, and creatinine clearance levels. The DOAC regimens were omitted for 1 day before a low-bleeding-risk procedure and 2 days before a high-bleeding-risk procedure. The DOAC regimens were resumed 1 day after a low-bleeding-risk procedure and 2 to 3 days after a high-bleeding-risk procedure. Follow-up of patients occurred for 30 days after the operation. MAIN OUTCOMES AND MEASURES: Major bleeding and arterial thromboembolism (ischemic stroke, systemic embolism, and transient ischemic attack) and the proportion of patients with an undetectable or minimal residual anticoagulant level (<50 ng/mL) at the time of the procedure. RESULTS: The 3007 patients with AF (mean [SD] age of 72.5 [9.39] years; 1988 men [66.1%]) comprised 1257 (41.8%) in the apixaban cohort, 668 (22.2%) in the dabigatran cohort, and 1082 (36.0%) in the rivaroxaban cohort; 1007 patients (33.5%) had a high-bleeding-risk procedure. The 30-day postoperative rate of major bleeding was 1.35% (95% CI, 0%-2.00%) in the apixaban cohort, 0.90% (95% CI, 0%-1.73%) in the dabigatran cohort, and 1.85% (95% CI, 0%-2.65%) in the rivaroxaban cohort. The rate of arterial thromboembolism was 0.16% (95% CI, 0%-0.48%) in the apixaban cohort, 0.60% (95% CI, 0%-1.33%) in the dabigatran cohort, and 0.37% (95% CI, 0%-0.82%) in the rivaroxaban cohort. In patients with a high-bleeding-risk procedure, the rates of major bleeding were 2.96% (95% CI, 0%-4.68%) in the apixaban cohort and 2.95% (95% CI, 0%-4.76%) in the rivaroxaban cohort. CONCLUSIONS AND RELEVANCE: In this study, patients with AF who had DOAC therapy interruption for elective surgery or procedure, a perioperative management strategy without heparin bridging or coagulation function testing was associated with low rates of major bleeding and arterial thromboembolism.

A beginning exploration of text generation abilities in university students with a history of reading difficulties.

There is a fundamental lack of understanding of how university students with a history of reading difficulties perform on various demanding literacy tasks. We compared the text generation skills, measured with timed summary writing and proofreading tasks, of university students with a history of reading difficulties to those of students with no such history. We further examined whether between-group differences in text generation skills remained after controlling for transcription skills (spelling and handwriting fluency), word reading, and reading comprehension. Forty-six university students with a history of reading difficulties were matched on age, gender, and non-verbal intelligence to 46 students without this history. We found that the students with a history of reading difficulties performed poorer on both measures of text generation than students without this history. When differences in transcription skills, word reading, and reading comprehension were controlled, we found that only differences in timed summary writing remained significant. These results suggest that students with a history of reading difficulties experience challenges with specific aspects of text generation that are beyond what one would expect from their difficulties with transcription and word reading. We suggest that, if not addressed, text generation deficits are likely to create obstacles for academic success.

The Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) Study for Patients on a Direct Oral Anticoagulant Who Need an Elective Surgery or Procedure: Design and Rationale.

Background The perioperative management of patients who take a direct oral anticoagulant (DOAC) for atrial fibrillation and require treatment interruption for an elective surgery/procedure is a common clinical scenario for which best practices are uncertain. The Perioperative Anticoagulant Use for Surgery Evaluation (PAUSE) study is designed to address this unmet clinical need. We discuss the rationale for the PAUSE design and analysis plan as well as the rationale supporting the perioperative DOAC protocol. Methods PAUSE is a prospective study with three parallel cohorts, one for each DOAC, to assess a standardized but patient-specific perioperative management protocol for DOAC-treated patients with atrial fibrillation. The perioperative protocol accounts for DOAC type, patient's renal function and surgery/procedure-related bleeding risk. The primary study aim is to demonstrate the safety of the PAUSE protocol for the perioperative management of each DOAC. The secondary aim is to determine the effect of the pre-procedure interruption on residual anticoagulation when measured by the dilute thrombin time for dabigatran and anti-factor Xa levels for rivaroxaban and apixaban. The study hypothesis is that the perioperative management protocol for each DOAC is safe for patient care, defined by expected risks for major bleeding of 1% (80% power to exclude 2%), and for arterial thromboembolism of 0.5% (80% power to exclude 1.5%) in each DOAC group. Conclusion The PAUSE study has the potential to establish a standard-of-care approach for the perioperative management of DOAC-treated patients. The PAUSE management protocol is designed to be easily applied in clinical practice, as it is standardized and also patient specific.

The incidence of proximal deep vein thrombosis after elective hip arthroscopy: a prospective cohort study in low risk patients.

Prospectively assess the incidence of deep venous thrombosis (DVT) using Doppler Ultrasound, in patients receiving elective hip arthroscopy without pharmacologic/mechanical prophylaxis. One hundred and fifteen consecutive patients (mean 35.4 years, SD = 10.3) underwent elective hip arthroscopy. Patients with previous major risk factors for DVT were excluded. Signs/symptoms of DVT/pulmonary embolism were assessed at 2-week post-operatively. A bilateral whole leg Duplex color (Doppler) Ultrasonography was scheduled between 10- and 22-day post-op. The primary outcome was frequency of DVT. Secondary outcomes assessed surgical risk factors. One hundred and ten patients (mean = 34.3 years, SD = 10.1) did not get a DVT. Five patients (mean = 43.8 years, SD = 12.1) were diagnosed with a DVT, 2- to 22-day post-operatively. All DVT patients received arthroscopy in the supine position (n = 76), versus no patients in the lateral position (n = 39). Average traction time was 38 (SD = 4) and 61 (SD = 4) minutes for patients with and without a DVT, respectively. All other a priori defined risk factors were similar. Four out of five patients presented with symptoms of a DVT, confirmed by ultrasound. One patient was without symptoms/clinical findings. Four patients had a DVT restricted to the calf veins; one patient had involvement of the popliteal vein. No patients had proximal extension into the thigh or pelvis. No pulmonary emboli were suspected or occurred. The incidence of deep venous thromboembolism is 4.3%. The majority of patients had symptomatic and distal venous thromboembolic events. This study provides supportive evidence that routine prophylaxis and/or screening may not be necessary in low risk patients undergoing elective hip arthroscopy.

Evaluation of an electronic warfarin nomogram for anticoagulation of hemodialysis patients.

BACKGROUND: Warfarin nomograms to guide dosing have been shown to improve control of the international normalized ratio (INR) in the general outpatient setting. However, the effectiveness of these nomograms in hemodialysis patients is unknown. We evaluated the effectiveness of anticoagulation using an electronic warfarin nomogram administered by nurses in outpatient hemodialysis patients, compared to physician directed therapy. METHODS: Hemodialysis patients at any of the six outpatient clinics in Calgary, Alberta, treated with warfarin anticoagulation were included. Two five-month time periods were compared: prior to and post implementation of the nomogram. The primary endpoint was adequacy of anticoagulation (proportion of INR measurements within range ± 0.5 units). RESULTS: Overall, 67 patients were included in the pre- and 55 in the post-period (with 40 patients in both periods). Using generalized linear mixed models, the adequacy of INR control was similar in both periods for all range INR levels: in detail, range INR 1.5 to 2.5 (pre 93.6% (95% CI: 88.6% - 96.5%); post 95.6% (95% CI: 89.4% - 98.3%); p = 0.95); INR 2.0 to 3.0 (pre 82.2% (95% CI: 77.9% - 85.8%); post 77.4% (95% CI: 72.0% - 82.0%); p = 0.20); and, INR 2.5 to 3.5 (pre 84.3% (95% CI: 59.4% - 95.1%); post 66.8% (95% CI: 39.9% - 86.0%); p = 0.29). The mean number of INR measurements per patient decreased significantly between the pre- (30.5, 95% CI: 27.0 - 34.0) and post- (22.3, 95% CI: 18.4 - 26.1) (p = 0.003) period. There were 3 bleeding events in each of the periods. CONCLUSIONS: An electronic warfarin anticoagulation nomogram administered by nurses achieved INR control similar to that of physician directed therapy among hemodialysis patients in an outpatient setting, with a significant reduction in frequency of testing. Future controlled trials are required to confirm the efficacy of this nomogram.

A multicenter disease management program for hospitalized patients with heart failure.

BACKGROUND: Despite the availability of proven therapies, outcomes in patients with heart failure (HF) remain poor. In this 2-stage, multicenter trial, we evaluated the effect of a disease management program on clinical and economic outcomes in patients with HF. METHODS AND RESULTS: In Stage 1, a pharmacist or nurse assessed each patient and made recommendations to the physician to add or adjust angiotensin-converting enzyme (ACE) inhibitors and other HF medications. Before discharge (Stage 2), patients were randomized to a patient support program (PSP) (education about HF, self-monitoring, adherence aids, newsletters, telephone hotline, and follow-up at 2 weeks, then monthly for 6 months after discharge) or usual care. In Stage 1 (766 patients) ACE inhibitor use increased from 58% on admission to 83% at discharge (P < .0001), and the daily dose (in enalapril equivalents) increased from 11.3 +/- 8.8 mg to 14.5 +/- 8.8 mg (P < .0001). In Stage 2 (276 patients) there was no difference in ACE inhibitor adherence, but a reduction in cardiovascular-related emergency room visits (49 versus 20, P = .030), hospitalization days (812 versus 341, P = .003), and cost of care (2,531 Canadian dollars less per patient) in favor of the PSP. CONCLUSION: Simple interventions can improve ACE inhibitor use and patient outcomes.

Uptake of new treatment strategies for deep vein thrombosis: an international audit.

OBJECTIVE: Study of the uptake of new medical technologies provides useful information on the transfer of published evidence into usual practice. We conducted an audit of selected hospitals in three countries (Canada, France, and Switzerland) to identify clinical predictors of low-molecular-weight (LMW) heparin use and outpatient treatment, and to compare the pace of uptake of these new therapeutic approaches across hospitals. DESIGN: Historical review of medical records. SETTING AND PARTICIPANTS: We reviewed the medical records of 3043 patients diagnosed with deep vein thrombosis (DVT) in five Canadian, two French, and two Swiss teaching hospitals from 1994 to 1998. Measures. We explored independent clinical variables associated with LMW heparin use and outpatient treatment, and determined crude and adjusted rates of LMW heparin use and outpatient treatment across hospitals. RESULTS: For the years studied, the overall rates of LMW heparin use and outpatient treatment in the study sample were 34.1 and 15.8%, respectively, with higher rates of use in later years. Many comorbidities were negatively associated with outpatient treatment, and risk-adjusted rates of use of these new approaches varied significantly across hospitals. CONCLUSION: There has been a relatively rapid uptake of LMW heparins and outpatient treatment for DVT in their early years of availability, but the pace of uptake has varied considerably across hospitals and countries.

A comparison of patient satisfaction with conventional and nurse led outpatient follow-up after grommet insertion.

OBJECTIVE: The need to reduce costs while providing a first class service has led to the expansion in the role of nurses in otolaryngology practice in the National Health Service (NHS) in recent years. The aim of this study was to compare patient satisfaction with conventional and nurse led follow-up after grommet insertion. The hypothesis was that patient satisfaction is much greater with doctor led conventional follow-up as compared with nurse led out-patient follow-up. METHODS: The study was performed using a questionnaire survey using a validated patient satisfaction questionnaire. RESULTS: Our results indicate that there is no statistically significant difference in the mean factorial scores for interpersonal skills and technical competence, physical surroundings, and convenience between the conventional and nurse led follow-up clinic. The overall patient satisfaction was higher with nurse led grommet follow-up clinic than with conventional doctor led out-patient follow-up. This was statistically significant (Mann-Whitney U = 1357.50, Z = 02.39, P = 0.01). The waiting time in out-patients was also significantly less in the nurse led grommet clinic. CONCLUSIONS: We conclude that nurses provide a high quality service resulting in high patient satisfaction. Nurse led grommet follow-up clinic has the potential for substantial reduction in outpatient access times in the NHS.

Hyperlipemic pancreatitis and pseudocyst formation in late pregnancy.

Hyperlipemic pancreatitis and pseudocyst formation late in pregnancy is a rare event. We report a case of hyperlipemic pancreatitis occurring in a G1P0 oriental woman at 32 weeks gestation. The initial serum lipase level was 1070 U/L, serum cholesterol level was 38.50 mmol/L and triglyceride level was > 57 mmol/L. She was treated conservatively with fasting, narcotic analgesia, and fluid resuscitation. Her symptoms resolved rapidly and lipase returned to normal within 2 days. During the first week in hospital she developed peripancreatic fluid collections and became symptomatic from a collection that extended down into the right pelvis. One week after admission she developed pre-term labor and delivered a healthy infant vaginally. There was an excellent outcome for both mother and infant. Serum lipid levels returned to near normal by 6 weeks post delivery.