Sugar or salt ("SOS"): A protocol for a UK multicentre randomised trial of mannitol and hypertonic saline in severe traumatic brain injury and intracranial hypertension.

Hyperosmolar solutions are widely used to treat raised intracranial pressure following severe traumatic brain injury. Although mannitol has historically been the most frequently administered, hypertonic saline solutions are increasingly being used. However, definitive evidence regarding their comparative effectiveness is lacking. The Sugar or Salt Trial is a UK randomised, allocation concealed open label multicentre pragmatic trial designed to determine the clinical and cost-effectiveness of hypertonic saline compared with mannitol in the management of patients with severe traumatic brain injury. Patients requiring intensive care unit admission and intracranial pressure monitoring post-traumatic brain injury will be allocated at random to receive equi-osmolar boluses of either mannitol or hypertonic saline following failure of routine first-line measures to control intracranial pressure. The primary outcome for the study will be the Extended Glasgow Outcome Scale assessed at six months after randomisation. Results will inform current clinical practice in the routine use of hyperosmolar therapy as well as assess the impact of potential side effects. Pre-planned longer term clinical and cost effectiveness analyses will further inform the use of these treatments.

A comparison of ventilator-associated pneumonia rates determined by different scoring systems in four intensive care units in the North West of England.

Ventilator-associated pneumonia is a common healthcare-associated infection with significant mortality, morbidity and healthcare cost, and rates have been proposed as a potential quality indicator. We examined ventilator-associated pneumonia rates as determined by different diagnostic scoring systems across four adult intensive care units in the North West of England. We also collected clinical opinions as to whether patients had ventilator-associated pneumonia, and whether patients were receiving antibiotics as treatment. Pooled ventilator-associated pneumonia rates were 36.3, 22.2, 15.2 and 1.1 per 1000 ventilator-bed days depending on the scoring system used. There was significant within-unit heterogeneity for ventilator-associated pneumonia rates calculated by the various scoring systems (all p < 0.001). Clinical opinion and antibiotic use did not correlate well with the scoring systems (k = 0.23 and k = 0.17, respectively). We therefore question whether the ventilator-associated pneumonia rate as measured by existing tools is either useful or desirable as a quality indicator.

Interposition grafting of the lower lobe pulmonary artery with a cuff of azygous vein, following its accidental ligation and division.

A patient with a mass lesion suggestive of a bronchial carcinoma in the right upper lobe was taken to theatre for a right upper lobectomy. The lower lobe artery, which was smaller than usual, was inadvertently divided. The arterial blood supply to the lower lobe was repaired with azygous vein as an interposition graft between the stump of the right apical segment arteries and the lower lobe artery. There were no signs of reperfusion injury post-operatively. We report a method that can be safely and relatively easily performed in these rare circumstances.

A 20th century forecast of 21st century healthcare trends.

John Naisbitt, preeminent social forecaster and author of Megatrends, the New York Times 1982 number-one bestseller, has been accurately describing the future for the past three decades. This June, Naisbitt will share some his world view with individuals attending HFMA's Annual National Institute in Orlando, Florida, where he will give the opening keynote address. On December 31, 1999, while most of the world waited for the Y2K horizon to spread across the globe, Naisbitt spoke with Healthcare Financial Management about the future, particularly with respect to some of the subjects he tackles in his most recent book, HIGH TECH.high touch. Specifically, does technology free us from the constraints of the physical world, or does it tie us down to machines? Does it save time in our day-to-day lives or merely create a void we feel compelled to fill with even more tasks and responsibilities? How does it affect the delivery of health care? And with recent developments in genetic engineering now raising the possibility of a future that will someday be free of birth defects, disabilities, and disease, what then will be natural, what will be artificial, and what will it truly mean to be human?