Impact of delirium and suture-less securement on accidental vascular catheter removal in the ICU.

The objectives were to describe the incidence of accidental vascular catheter removal (AVCR) in an Australian Intensive Care Unit (ICU) and evaluate whether the fixation method or patient delirium increased the risk of AVCR. This prospective observational study was based in a tertiary level ICU between April 2011 and October 2012. All vascular catheters were secured either by sutures or by a suture-less securement device (STATLOCK(™), Bard Medical, Covington, GA, USA) as per the treating clinician. Data were obtained from bedside nursing staff, with daily screening for delirium completed by the ICU medical team using the Confusion Assessment Method-ICU. 2361 patients were admitted during this period with 1032 patients screened and data available for 322 patients (452 vascular catheters). AVCR occurred in 15 patients (16 vascular catheters) (5.0%) with an incidence of AVCR of 2.77 per 100 catheter-days. Delirious patients were 13-fold more likely to have an AVCR event (odds ratio=13.3; 95% confidence interval 4.36, 40.52; P <0.0001). There was a non-significant trend to an increase in AVCR when using the suture-less securement device (odds ratio=2.6; 95% confidence interval 0.87, 7.8; P=0.09) but delirious patients were no more likely to have an AVCR episode when a suture-less securement device was used (P=0.95). In this study the use of suture-less securement did not seem to increase the risk of AVCR. However, there was a non-significant trend towards increased AVCR when using suture-less securement devices, which may reflect a ß error.

Assessing efficient patient care: should length of stay be calculated independently of local admission rates?

OBJECTIVE: To compare the length of hospitalisation for infants with bronchiolitis across the Eastern region and to assess the impact of the varying admission rates in each hospital. DESIGN: Data collection through the Hospital Episode Statistics (HES) using the ICD clinical coding for bronchiolitis across all hospitals in east of England for three winter seasons (October to March for the years 2009/10, 2010/11 and 2011/12). MAIN OUTCOME MEASURE: Length of hospital stay, corrected to adjust for local population. RESULTS: Seventeen hospitals across the east of England were included in this study. Overall admission rate (as a percentage of the population) for the region was 3.3% and consistent with national data, but rates within individual hospitals varied between 1.5% and 5.7% over the 3-year period. Bed days per 1000 population ('standardised bed days') per year varied almost fourfold, from 34.5 to 122.3 in different hospitals. Corrected length of stay showed high discordance when compared to average length of stay. CONCLUSIONS: The average length of stay is substantially affected by admission rates, with hospitals who admit a greater proportion of infants appearing to have a shorter uncorrected length of stay. We propose that a single corrected measure for length of stay should be used when assessing the efficiency of care because it is unaffected by variations in local admission rates and is adjusted for local population size.

Biopsy examination of squamous cell carcinoma of the tongue: source of significant prognostic information?

Histological analysis of tumour resection for squamous cell carcinoma (SCC) of the tongue yields prognostic information. We analysed histological slides of biopsy and tumour resection specimens using an adapted malignancy grading score and analysed variables of neck dissections. There was moderate correlation between biopsy and tumour resection using malignancy grading scores (correlation coefficient 0.45); good agreement of tumour grade (79%), tumour depth (76%), and type of invasive front (80%), but correlation was only fair to moderate (κ=0.38, κ=0.51, and κ=0.41, respectively). Correlation of the biopsy grading score and invaded nodes in the neck, extra capsular spread, and soft tissue disease was not significant.

The challenges of accurate waist and hip measurement over clothing: Pilot data.

BACKGROUND: Accurate waist and hip measurement are increasingly central to the goal of weight control and the battle against diabetes and cardiovascular disease. Protocols and methods vary widely, with little guidance on clothing. This pilot study investigated the effect of light clothing on measurement. AIMS: To determine whether light clothing and underwear make a potentially clinically significant difference of 0.5 cm to the measurement of waist and hip circumference in a group of volunteer subjects. METHODS: We measured waist circumference over light clothing and then over bare skin. We measured hip circumference over light clothing and then over underwear and with a small sub-group, on bare skin. RESULTS: 50 volunteers were measured. Potentially clinically significant differences were found in the mean values as followed (mean; 95% CI): light clothing compared to bare skin at the waist (0.50 cm; -1.54 to 2.55 cm); light clothing compared to underwear at the hip (2.58 cm; -0.75 to 5.91 cm). CONCLUSION: This study demonstrates that the effect of clothing on waist and hip measurements is not always trivial, and deserves a larger study. Waist circumference measurements should be made on bare skin whenever possible and hip circumference measurements over underwear.

Pneumonyssoides species infestation in two Pekingese dogs in the UK.

Two male, neutered, Pekingese dogs aged four years and 12 years were presented for acute-onset nasal pruritus and sneezing following a visit to a beach in northern Scotland. Routine nasal investigations revealed the presence of the canine nasal mite Pneumonyssoides both by direct visualisation and histopathologically. Resolution of clinical signs was observed following selamectin treatment. To the authors' knowledge, this report describes the first cases of Pneumonyssoides infestation in non-travelled UK dogs.

Demonstration of Ollulanus tricuspis in the stomach of domestic cats by biopsy.

Ollulanus tricuspis is a small nematode of the family Ollulanidae, found in the stomach of domestic cats and other felids. Of 131 gastric biopsy samples collected at endoscopic examination, four were shown to contain the parasite. Vomiting was the main presenting sign in three cats and weight loss in the fourth. The stomachs were grossly normal on endoscopic examination. Chronic gastritis was observed histologically in two cases, while the remaining cases were microscopically normal. The significance of the parasite remained undetermined. To our knowledge, this is the first report of O. tricuspis infection in domestic cats in which the diagnosis was made by examining routine endoscopic biopsy samples.

[Two patients with tuberculous pleurisy]. / Pleuritis tuberculosa bij 2 patiënten.

Tuberculous pleurisy was diagnosed in two patients, a 21-year-old Somali woman and a 19-year-old Surinam man. The first patient suffered from a paradoxical (immunological) reaction and the other had an infectious reaction. Both patients recovered after treatment with tuberculostatic agents and pleural drainage. The pathophysiology of the paradoxical reaction is still largely unclear. Culture continues to be the gold standard in diagnosing tuberculous pleuritis but, in many cases, bacteriological confirmation is not obtained. The (probable) diagnosis is then often made on the basis of a combination of the patient's history, estimation of the risk, physical examination, radiology and histology, and on the basis of a (trial) treatment with tuberculostatic agents. In the diagnostic process, a PCR on the Mycobacterium tuberculosis complex can be helpful. The routine determination of adenosine deaminase and interferon gamma in patients with tuberculous pleurisy is not useful in low-incidence countries such as The Netherlands. The measurement of the in-vitro T-cell reactivity against M. tuberculosis-specific antigens may be of more value in the future. The pharmacotherapy of tuberculous pleurisy is the same as that of pulmonary tuberculosis. Rinsing the pleural cavity is recommended in the case of an infectious reaction. Drainage of pleural fluid is indicated in the case of a paradoxical reaction if there are mechanical difficulties.

Sports-related brain injury research: methodological difficulties associated with ambiguous terminology.

A basic premise underlying sound methodological research is that it is based on constructs that have a sound operational definition. Failure to do so impedes comparison with other relevant literature. In sports-related brain injury research, the varied criteria and inconsistent use of the term 'concussion' and its interchangeability with other generic terms such as mild/minor head injury, and mild brain injury exemplifies such a situation. This paper will background the issues involved and provide rationale to support a call for tightening the use of terminology in the area.

US nephrologists' recommendation of dialysis modality: results of a national survey.

Selection of a dialysis modality for persons with end-stage renal disease (ESRD) has important lifestyle and occupational implications. The factors affecting modality choice remain unclear, resulting in a low rate of peritoneal dialysis (PD) in the United States compared with other countries. A national survey of 271 US nephrologists was conducted from June 1997 to June 1998 to assess the relative importance of nonclinical and clinical factors related to dialysis modality selection for patients with ESRD. Hypothetical patient scenarios were randomly assigned to nephrologists to determine their recommendation for dialytic therapy based on patient demographic, clinical, and social factors. US nephrologists were more likely to recommend PD for men with ESRD compared with women (39% versus 33%; P: < 0.05; adjusted odds ratio, 1.44; 95% confidence interval, 1.15 to 1.80), as well as for patients with good compliance (adjusted odds ratio, 11.80; 95% confidence interval, 9.29 to 15.01), weight less than 200 lb (adjusted odds ratio, 2.3; 95% confidence interval, 1.8 to 2.9), residual renal function (adjusted odds ratio, 2.14; 95% confidence interval, 1.71 to 2.70), absence of diabetes (adjusted odds ratio, 2.0; 95% confidence interval, 1.6 to 2.5), and living with family (adjusted odds ratio, 1.7; 95% confidence interval, 1.4 to 2.1). Nephrologists in practice for 11 or more years were less likely to recommend PD. The association of male sex with PD therapy suggests a potential bias or sensitivity to women's perception of body image. Race was not associated with PD recommendations after controlling for other demographic and clinical characteristics. Because the incident US ESRD population is increasingly characterized by factors associated with not selecting PD (diabetes, obesity, malnourishment, living alone, and substance abuse problems), our results suggest that PD use may decrease over time.

Is the context specificity of latent inhibition a sufficient explanation of learned irrelevance?

In three experiments, rats were pre-exposed either to uncorrelated presentations of a light and sucrose pellets (group CS/US) or to equivalent presentations of the light and pellets in separate sessions (control). In Experiment 1, subsequent conditioning to the light proceeded more slowly in group CS/US than in the control group, whether this conditioning was excitatory, with the light signalling the delivery of pellets, or inhibitory, with the light signalling their absence. Bonardi and Hall (1996) have argued that this learned irrelevance effect may be reducible to latent inhibition, which would be stronger in group CS/US because they are both pre-exposed and conditioned to the CS in the presence of traces of previous USs occurring in the same session. This analysis implies that group CS/US should have conditioned more rapidly to the CS than controls on the first trial of each session in Experiment 1, but this did not happen. It also implies that the learned irrelevance effect should be reversed if conditioning trials are given at a rate of one per day. Experiments 2 and 3 found no support for this prediction. We conclude that learned irrelevance effects cannot always be reduced to latent inhibition.

Tertiary Normal Faulting in the Canyon Range, Eastern Sevier Desert.

The contact between pre-Mesozoic and Tertiary rocks in the western Canyon Range, west-central Utah, has been interpreted as a large, low-angle normal fault that marks the breakaway zone of the hypothesized, basin-forming Sevier Desert detachment. Recent fieldwork suggests that the contact may in fact be depositional along much or all of its length. Deformational fabric in the supposed footwall likely traces to the Mesozoic Sevier orogeny rather than to Tertiary detachment faulting. Kinematic indicators at the range front are not generally consistent with low-angle normal-fault motion; instead, well-exposed high-angle faults are the dominant range-bounding structures. The Tertiary conglomerates of the western Canyon Range foothills, previously viewed as an evolving syntectonic deposit related to detachment faulting, are here reinterpreted as three distinct units that reflect different periods and tectonic settings. The pattern in these conglomerates, and in fault-offset gravity-slide deposits that mantle the western foothills, is consistent with block faulting and rotation along several generations of high-angle structures. Local seismic-reflection data lend qualitative support to this interpretation, and underscore the need to consider alternative working hypotheses for evolution of the Sevier Desert basin.

Payer costs of patients diagnosed with epilepsy.

PURPOSE: To identify the annual cost to a third-party payer of inpatient and outpatient services and prescription drugs for patients diagnosed with epilepsy or convulsions. METHODS: Retrospective study using administrative and claims data from a private insurer in the Northeast United States with >1.8 million covered lives. Health plan members were included if they had a claim for epilepsy or convulsions and a claim for an antiepileptic drug (AED) between January 1992 and December 1996. Annual costs and frequencies of all medical services, and of services related to epilepsy, were compared among five groups of patients defined by the most intensive procedure they received: invasive therapeutic procedure (group 1); invasive diagnostic procedure without an invasive therapeutic procedure (group 2); noninvasive diagnostic procedure without an invasive procedure (group 3); neurologist or neurosurgeon visit without an invasive procedure or noninvasive diagnostic procedure (group 4); or none of the preceding services (group 5). RESULTS: In the cohort of 9,090 patients meeting the inclusion criteria, mean age was 38 years, 53% were female, 30% had malignant disease, and 25% had cardiac disease. The mean annual cost of all medical services was $9,617. Mean annual costs of all services were $43,333, $29,847, $11,300, $4,362, and $5,855, and annual costs of inpatient and outpatient encounters coded as epilepsy plus AEDs were $24,369, $10,330, $3,127, $1,079, and $1,086, in groups 1-5, respectively. Services used to stratify patients into the groups accounted for 37% of the total costs. CONCLUSIONS: The annual costs of medical services for patients with epilepsy are high and vary considerably because of treatment of epilepsy and management of comorbidities.

Preference values for visual states in patients planning to undergo cataract surgery.

To assess how preference values that cataract surgery patients assign to their preoperative visual states relate to visual acuity and problems in specific aspects of daily life, the authors interviewed 47 patients scheduled to have cataract surgery. Using a rating-scale technique with a scale from 0 (death) to 1 (excellent health), the patients had a mean preference value of 0.68 for their preoperative vision. Patients' preference values for their preoperative vision were more closely related to problems in specific aspects of daily life (especially feelings of depression and problems interacting with people) than to visual acuity in the operative eye, better eye, or worse eye, or a weighted average of visual acuities in both eyes. These results provide a rationale for relying more on patients' views about the effects of visual impairment than on measures of visual acuity when assessing the need for cataract surgery.