Feasibility of early discharge strategies for neutropenic fever: outcomes of a Victorian organisational readiness assessment and pilot.

BACKGROUND: Although Australian consensus guidelines support the use of ambulatory care strategies for management of adult patients with low-risk neutropenic fever (NF), few centres have successfully implemented viable programmes. AIMS: To study the feasibility of an early discharge programme for adult patients with low-risk NF and assess organisational factors likely to influence successful implementation across participating Victorian hospitals. METHODS: Four hospitals participated in an organisational readiness assessment preceding selection of a pilot site for programme implementation. Prospective baseline auditing of current practice (i.e. inpatient care until resolution of NF) across three hospitals preceded programme implementation and evaluation. RESULTS: Barriers and facilitators to successful implementation were identified. One hundred and seventeen NF episodes were evaluated during audit phases. The frequency of low-risk NF presentations eligible for early discharge was low (less than two episodes per week). The programme reduced median (interquartile range) duration of parenteral antibiotics and length of stay for eligible patients (n = 11) from 4 (4, 5) days at baseline to 1 (1, 2) day during pilot (P = 0.02) and 4.5 (4, 5) days (baseline) to 2 (1, 3) days (pilot) (P = 0.02) respectively. The proportion of ineligible patients stepped down to oral antibiotics was improved from 38% (baseline) to 67% (pilot). No patients failed ambulatory care requiring readmission into hospital. CONCLUSION: The ambulatory care strategy for management of NF proposed by Australian consensus guidelines has been successfully piloted at a single Victorian centre. Organisational readiness tools can be used to identify potential barriers to the implementation of evidence based practices in patients with NF.

Use of uranium isotopes as a temporal and spatial tracer of nuclear contamination in the environment.

The Fernald Feed Materials Production Center (FFMPC) was established in 1951 to process natural uranium (U) ore, enriched uranium (EU) and depleted uranium (DU). This study tests the utility of U isotopic ratios in sediment cores and lichens as indicators of the aerial extent, degree and timing of anthropogenic U contamination, using the FFMPC as a test case. An 80-cm-long sediment core was extracted from an impoundment located approximately 6.7 km southwest of the FFMPC. Elemental concentrations of thorium (2.7-6.2 µg g(-1)) and U (0.33-1.33 µg g(-1)) as well as major and minor U isotopes were analyzed in the core. The lack of measurable (137)Cs in the deepest sample as well as a natural (235)U/(238)U signature and no measurable (236)U, are consistent with pre-FFMPC activity. Anomalously elevated U with respect to Th concentrations occur in seven consecutive samples immediately above the base of the core (62-76 cm depth). Samples with elevated U concentrations also show variable (235)U/(238)U (0.00645-0.00748), and all contain measurable (236)U ((236)U/(238)U = 2.1 × 10(-6)-3.6 × 10(-5)). Correspondence between the known releases of U dust from the FFMPC through time and variations in sediment core U concentrations, (235)U/(238)U and (236)U/(238)U ratios provide evidence for distinct releases of both DU and EU. Furthermore, these relationships demonstrate that the sediment core serves as a robust archive of past environmental U contamination events. Samples in the upper 40 cm display natural (235)U/(238)U, but measurable (236)U/(238)U ((236)U/(238)U = 5.68 × 10(-6)-1.43 × 10(-5)), further indicating the continued presence of anthropogenic U in present-day sediment. Three local lichen samples were also analyzed, and all display either EU or DU signatures coupled with elevated (236)U/(238)U, recording airborne U contamination from the FFMPC.

Distribution and significance of small, artificial water bodies across the United States landscape.

At least 2.6 million small, artificial water bodies dot the landscape of the conterminous United States; most are in the eastern half of the country. These features account for approximately 20% of the standing water area across the United States, and their impact on hydrology, sedimentology, geochemistry, and ecology is apparently large in proportion to their area. These features locally elevate evaporation, divert and delay downstream water flow, and modify groundwater interactions. They apparently intercept about as much eroded soil as larger, better-documented reservoirs. Estimated vertical accretion rates are much higher, hence, inferred sedimentary chemical reactions must be different in the small features than in larger ones. Finally, these features substantially alter the characteristics of aquatic habitats across the landscape.

Anaesthesia for posterior cervical osteotomy.

We have studied 22 consecutive cases of posterior cervical osteotomy done at the Toronto East General Hospital between October 1967 and November 1973. The anaesthetic management is discussed in some detail and consists of psychological preparation of the patient, and neuroleptanalgesia with infiltration with local anaesthetic by the surgeon. The reasons for this choice of technique have been discussed in some detail. There were no deaths during operation, but one patient suffered collapse on the table, which was thought to be due to air embolism. One patient died three weeks post-operatively of pulmonary embolism. Experience in anaesthetizing patients who require operation after previous posterior cervical osteotomy is mentioned briefly and techniques are recommended for successful management of such cases.