Long-term use of acid suppression started inappropriately during hospitalization.

BACKGROUND: Practitioners routinely misuse acid suppression medications on general medical floors and inappropriately continue the drug at discharge. AIMS: To: (i) retrospectively study the appropriateness of acid suppression use on the general medical floors; (ii) characterize the patient population discharged on unnecessary acid suppression and (iii) evaluate whether patients discharged on unnecessary acid suppression continue the medicine long term. METHODS: Retrospective chart review of general medical patients admitted to an in-patient teaching service over 6 consecutive months. RESULTS: About 60% of patients lacked an indication for initiation of acid suppression and 34% of these patients were discharged on the medicine. The only independent predictor of continuation of acid suppression at discharge was longer length of stay. Multivariate analysis did not identify a characteristic distinguishing those patients discharged inappropriately on acid suppression. At 3 and 6 months of follow-up, 80% and 50% of patients, respectively, remained on acid suppression therapy without an appropriate indication. CONCLUSIONS: Our data verifies that practitioners routinely start general medical in-patients on acid suppression without an appropriate indication. Many of these prescriptions are continued at discharge for no apparent reason, leading to their long-term misuse.

Tick-borne diseases in transfusion medicine.

Ticks are effective vectors of viral, bacterial, rickettsial and parasitic diseases. Many of the tick-borne diseases (TBDs) are of significance to transfusion medicine, either because of the risks they pose to the blood supply or the necessity for blood products required in their treatment. The transmission of tick-borne pathogens via blood transfusion is of global concern. However, among transfusion medicine practitioners, experience with most of these microorganisms is limited. Transfusion transmission of TBDs has been documented largely by means of single case reports. A better understanding of the epidemiology, biology and management of this group of diseases is necessary in order to assess the risks they pose to the blood supply and to help guide effective prevention strategies to reduce this risk. Unique methods are required to focus on donor selection, predonation questioning, mass screening and inactivation or eradication procedures. The role of the transfusion medicine service in their treatment also needs to be better defined. This article reviews the growing body of literature pertaining to this emerging field of transfusion medicine and offers some recommendations for transfusionists in dealing with TBDs.

Restraint practices in Australasian emergency departments.

OBJECTIVE: The objective of this study was to estimate the use of restraint techniques and evaluate restraint policies and training in Australasian emergency departments METHOD: A survey of 116 Australasian emergency departments was conducted to determine the type, indications/contraindications, training, policies, documentation and audit requirements for restraint. RESULTS: The overall estimated rate of patient restraint is 3.3 episodes per 1000 presentations. The commonest indications for restraint are violence or threatened violence (52%), psychosis (32%) and acute brain syndrome (10%). Major contraindications are medical instability, risk of harm to staff in applying restraint and the availability of alternatives to restraint. Chemical restraint is used in all emergency departments surveyed. The commonest agents used are haloperidol (93%), midazolam (82%) and diazepam (59%). At least one benzodiazepine and one major tranquilliser are used in 97% of emergency departments. Manual restraint (87%) is frequently used as a prelude to chemical or, less frequently, mechanical restraint (69%). Seclusion restraint is used in 23% of Australasian emergency departments. Formal training is most commonly undertaken for chemical restraint, being used in 33% of departments surveyed. Less than half of the departments have written policies guiding the use of restraint, and only 11% audit their use of restraint. A specific form for restraint documentation is used in only one emergency department. CONCLUSIONS: Patient restraint is a common procedure in Australasian emergency departments. There is little formal training in, or documentation or audit of, restraint practices in Australasian emergency departments, despite the important clinical, occupational health and medical legal issues associated with the use of restraint.

Caffeine-induced cardiac arrhythmia: an unrecognised danger of healthfood products.

We describe a 25-year-old woman with pre-existing mitral valve prolapse who developed intractable ventricular fibrillation after consuming a "natural energy" guarana health drink containing a high concentration of caffeine. This case highlights the need for adequate labelling and regulation of such products.

Fulminant babesiosis treated with clindamycin, quinine, and whole-blood exchange transfusion.

BACKGROUND: Babesiosis is an increasingly recognized parasitic infection with manifestations that range from a subclinical or mild flu-like illness to life-threatening disease. Risk factors that may be associated with a more severe clinical course include immunosuppression, splenectomy, and advanced age. The most effective chemotherapeutic regimen, clindamycin plus quinine, is sometimes ineffective in cases of severe disease. CASE REPORT: A previously healthy, 58-year-old man was infected by Babesia microti, presumably through a tick bite. He developed fulminant disease characterized by severe hemolytic anemia, disseminated intravascular coagulation, acute renal failure, and respiratory failure. There was no history of splenectomy or immunodeficiency. He was given oral clindamycin (300 mg/4x/day) 2 days before admission. Oral quinine (650 mg/3x/day) was added upon hospitalization. There was no clinical improvement despite antibiotic therapy with clindamycin and quinine. On the second hospital day, a whole-blood exchange transfusion was performed to simultaneously lower the parasite load and replace the patient's plasma. With an automated blood cell separator, 87 percent of the patient's total blood volume was exchanged. As replacement fluid, 6.7 L of packed RBCs reconstituted with FFP (average Hct, 33%) was used. The patient's Hct increased from 26.9 percent before the exchange to 28.3 percent after the exchange. The percentage of parasitized RBCs decreased from 13.8 percent just before exchange to 4.2 percent immediately after exchange. There was rapid clinical improvement after the whole-blood exchange transfusion. The patient's subsequent clinical course was marked by a disappearance of the parasitemia and continued slow, general improvement. Therapy with clindamycin was continued for 14 days after the exchange transfusion and quinine for 17 days. CONCLUSION: In cases of severe babesiosis, prompt institution of whole-blood exchange transfusion, in combination with appropriate antimicrobial therapy, can be life-saving.

EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms.

BACKGROUND: Computerized tomography (CT), magnetic resonance imaging (MRI), and transabdominal ultrasound frequently fail to detect ampullary lesions. Endoscopic ultrasound (EUS) is a sensitive modality for detecting and staging ampullary tumors. Accurate staging may be affected by biliary stenting, which is frequently performed in these patients with obstructive jaundice. The present study assessed the accuracy of ampullary tumor staging with multiple imaging modalities in patients with and those without endobiliary stents. METHODS: Fifty consecutive patients with ampullary neoplasms from two endosonography centers were preoperatively staged by EUS plus CT (37 patients), MRI (13 patients), or angiography (10 patients) over a 3(1/2) year period. Twenty-five of the 50 patients had a transpapillary endobiliary stent present at the time of endosonographic examination. Accuracy of EUS, CT, MRI, and angiography was assessed with the TNM classification system and compared with surgical-pathologic staging. The influence of an endobiliary stent present at the time of EUS on staging accuracy of EUS was also evaluated. RESULTS: EUS was more accurate than CT and MRI in the overall assessment of the T stage of ampullary neoplasms (EUS 78%, CT 24%, MRI 46%). No significant difference in N stage accuracy was noted between the three imaging modalities (EUS 68%, CT 59%, MRI 77%). EUS T stage accuracy was reduced from 84% to 72% in the presence of a transpapillary endobiliary stent. This was most prominent in the understaging of T2/T3 carcinomas. CONCLUSIONS: EUS is superior to CT and MRI in assessing T stage but not N stage of ampullary lesions. The presence of an endobiliary stent at EUS may result in underestimating the need for a Whipple resection because of tumor understaging.

Transfusion with blood from a donor with chronic myelogenous leukemia: persistence of the bcr/abl translocation in the recipient.

BACKGROUND: Transfusion of cells harvested from patients with chronic myelogenous leukemia (CML) as a therapeutic measure for patients with granulocytopenia was popular in the 1970s, when studies examining the persistence of transfused donor cells were limited by a lack of molecular techniques. Blood samples from a patient who recently received an inadvertent transfusion of CML cells were evaluated for the presence of the bcr/abl translocation characteristic of CML. CASE REPORT: The patient, a 67-year-old man with a history of congestive heart failure, myocardial infarct, hypertension, diabetes mellitus, and chronic renal failure, was transfused for bleeding from colonic angiodysplasia. A volunteer blood donor reported that he had been diagnosed with CML 10 days after his donation. Three days after the donation, blood components from the donor with CML had been administered to the patient as nonirradiated red cells and platelets. Evaluation of donor blood by a reverse-transcriptase polymerase chain reaction showed the b3a2 transcript, indicating a bcr/abl translocation. Periodic testing of the patient's peripheral blood by the same technique demonstrated the presence of the b3a2 transcript on Days 74 and 75 after transfusion. The patient died of congestive heart failure 8 months after the transfusion. CONCLUSION: In this rare case of accidental transfusion of neoplastic cells, the findings document the persistence of the donor's neoplastic clone in the recipient for 75 days.

Perceptions and preferences of autologous blood donors.

BACKGROUND: The public's perception of autologous blood donation and transfusion as a worthwhile alternative to allogeneic blood transfusion increased dramatically with discovery of the human immunodeficiency virus. However, new concerns are being raised about the health outcomes and cost-effectiveness of the procedure. As more restrictive guidelines for autologous blood donation evolve, opposition from patients concerned about exposure to allogeneic blood may arise. Physicians' ability to reassure patients and garner their support for more restrictive policies requires an understanding of patients' concerns. The motivations, perceptions, and preferences of patients currently participating in autologous blood donation programs were investigated in this study. STUDY DESIGN AND METHODS: Results from two questionnaire studies of 647 autologous blood donors are presented. The questionnaires assessed demographics, risk perceptions, preferences, willingness to pay, and reactions to different interventions designed to decrease patient preference for autologous blood donation. RESULTS: Patients expressed a strong preference for the availability of autologous blood and indicated that they would be willing to pay substantial amounts of money even if the procedure were not covered by insurance. Despite education about the low risks of complications from allogeneic transfusions, an aversion to allogeneic transfusion and a willingness to pay for autologous blood donation persisted. Patients were not reassured by information on better infectious disease testing or physician recommendation against autologous blood donation. CONCLUSION: Patients currently participating in autologous blood donor programs strongly prefer continued access to this procedure, primarily because they remain concerned about the complications of allogeneic transfusions. They may not be significantly reassured despite increasingly rigorous and costly improvements in donor and component screening.

Comparing a computer-based childhood vaccination registry with parental vaccination cards: a population-based study of Delaware children.

We conducted a population-based study in Delaware to examine the reliability of childhood vaccination data in a comprehensive computer-based record system versus parental vaccination cards. We sampled 1,005 children born between January, 1991, and September, 1993. We oversampled for children whose mothers received Medicaid or were uninsured at the time of delivery. Of the survey responders, 276 (56%) had access to written records, and 409 (83%) records were located in the Delaware immunization computer database. The kappa coefficient was 0.18. The observed agreement was 59.8%. When the two databases were combined, the up-to-date rate for 2-year-olds was 58.4%, an increase of 12.7% and 24.2% from the computer database and the parental records, respectively. The computer database was 78.1% sensitive and the parental records were 54.9% sensitive. These results indicate that a comprehensive computer-based record system, with adequate provider participation and proper data management, can be more reliable than parental vaccination cards.

Patients' willingness to pay for autologous blood donation.

Most cost-effectiveness analyses of autologous blood donation show very small health benefits for a substantial increase in resource utilization. However, these analyses do not consider the psychological benefits of peace of mind to patients participating in the program. In order to quantitate these benefits, we employed contingent valuation methodology to measure the willingness of patients undergoing elective surgery, to pay for autologous blood donation. The internal consistency of patient responses was investigated through correlations of willingness-to-pay values with risk perceptions and patient characteristics. Two hundred and thirty-five patients completed the self-administered questionnaire which included demographic, willingness-to-pay and risk perception questions. Median population willingness to pay for autologous blood donation was approximately $900 per patient. In multivariate analysis, willingness to pay varied significantly with dread of allogenic transfusion, perceived risk of requiring a blood transfusion and income. Patients who participate in autologous blood donation programs value the procedure highly and state they are willing to pay significant amounts out of pocket to assure themselves of available autologous blood. Willingness to pay correlated significantly with factors expected to influence value decisions.

Preapheresis peripheral blood CD34+ mononuclear cell counts as predictors of progenitor cell yield.

BACKGROUND: Peripheral blood progenitor cells, harvested by apheresis after mobilization, provide rapid hematologic recovery after high-dose chemotherapy. However, because harvesting these cells is expensive and time-consuming, there has been much interest in optimizing collection protocols. An investigation was made to determine whether, in this clinical setting, peripheral blood progenitor cell yields may be predicted from preapheresis progenitor cell counts, allowing the length of each procedure to be "fine tuned" to achieve specific target goals. STUDY DESIGN AND METHODS: Preapheresis peripheral blood CD34+ cell and total colony-forming cell counts were assessed before 78 peripheral blood progenitor cell collections from 13 consecutive patients were performed. Preapheresis counts were correlated with actual progenitor cell yields. Factors affecting this correlation were analyzed. RESULTS: With the use of linear regression analysis preapheresis progenitor cell counts were found to correlate significantly but weakly with actual yields per kg of body weight per liter of blood processed (CD34+ cells: r = 0.43; colony-forming cells: r = 0.56). Further analysis revealed two possible causes: 1) circulating progenitor cell concentrations fluctuate widely during harvest, which implies that preapheresis counts are not representative of actual concentrations during apheresis, and 2) the efficiency with which apheresis machines extract mononuclear cells varies greatly between procedures. CONCLUSION: Preapheresis CD34+ and colony-forming cell counts correlated poorly with subsequent yields in this clinical setting, which suggests that it is not practical to use such counts to predict with certainty the length of apheresis needed to achieve a target yield.

Homicide mortality in Delaware: variations by age, race and sex.

Recently, the subject of violence and its consequences has garnered increasing media attention. Health professionals and policy makers have also expressed concern about violence in our society. There are ample scientific data that illustrate the magnitude of the problem of violent death, especially among young males, in the United States. This article presents available mortality data indicating the magnitude of the problem of violent death among Delaware residents. In specific, the discussion examines variations by age, race, and sex and reveals that Delaware mortality rates for Homicide and Legal Intervention are significantly lower than U.S. rates, especially among black males.

Fatal injury surveillance report, Delaware, 1990. Head and spinal cord injuries.

The Delaware Disabilities Prevention Program is funded through a five-year Centers for Disease Control and Prevention (CDC) grant to prevent primary and secondary disabilities associated with mental retardation and low socioeconomic status; head and spinal cord injuries; and sickle cell disease. This report focuses on fatal head and spinal cord injuries. Death certificates and autopsy reports from 1990 were the data sources used for this study. In 1990, 122 fatal head injuries and 20 fatal spinal cord injuries occurred among Delaware residents. Eight of these individuals experienced both head and spinal cord injuries. Motor vehicle crashes caused the majority of both head and spinal cord deaths. Suicides, homicides, and falls were the other major causes of fatal head injuries. Deaths are only the tip of the injury iceberg. Head and spinal cord injuries can cause lifelong disabilities affecting family, friends, and the entire community.

A framework for the development of nurse manager negotiation skills.

Effective negotiation skills have been identified as an essential component of the nurse manager role. Application of the negotiation process in today's dynamic and competitive health care environment is frequently difficult and stressful for the novice nurse manager. The authors describe a Conceptual Model for Negotiation that can be used as a management development framework for the novice nurse manager.

The role of osmolarity in renin release from afferent arterioles.

We studied the role of sodium (Na) in renin release from isolated afferent arterioles incubated in Krebs-Ringer bicarbonate solutions with the Na concentrations adjusted to 145, 135, 125, 110 and 95 mmol/l. The arterioles were incubated for three consecutive periods, with the sequence of incubations randomized. Renin release increased by 119 and 275% in the media with Na concentrations of 135 and 125 mmol/l, respectively, as compared with the renin released from arterioles incubated in the medium with Na 145 mmol/l. When the Na concentrations of the incubation media were further lowered to 110 mmol/l and 95 mmol/l, renin release continued by 118 and 216%, respectively, in comparison with that in the medium having an Na concentration of 125 mmol/l. Regression analysis showed that renin release increased by 98% for each 10 mmol/l decrement of Na concentration. When the osmolarity of the incubation medium was held constant, varying the Na concentrations did not alter the renin secretion. This suggests that renin was released from the arterioles in response to the osmotic pressure exerted by Na rather than as an ionic effect. Renin release was suppressed by the osmotic effects of sucrose and urea, although the suppressive effect of urea was weaker.

The effect of theophylline and cyclic adenosine 3',5'-monophosphate on renin release by afferent arterioles.

The effects of theophylline and cyclic adenosine 3',5'-monophosphate (cAMP) on renin release by afferent arterioles were studied. Rabbit afferent arterioles (seven to 10), obtained by a microdissection technique, were incubated for three consecutive 20 min periods in 100 microliters of Medium 199 with 0.1% bovine serum albumin (BSA). Afferent arterioles exposed to theophylline, 1 x 10(-4) mol/l, produced a greater than 100% increase in renin release (0.18 +/- 0.04 to 0.42 +/- 0.05 ng angiotensin l/h per arteriole per h incubation). The renin release stimulated by theophylline was completely abolished by indomethacin and meclofenamate. The stimulation of renin secretion was also blocked when extracellular calcium concentration was decreased to 10(-7) mol/l and the arterioles were permeabilized with calcium ionophore. Dibutyryl cAMP (db-cAMP), 1 x 10(-4) mol/l, and forskolin, 1 mumol/l or 100 mumol/l, failed to stimulate renin release by afferent arterioles. The results of this study therefore suggest that theophylline-stimulated renin release may be mediated through a prostaglandin pathway. The stimulation of renin secretion is also dependent on the extracellular concentration of calcium.