Repair of chronic peritoneal dialysis catheter.
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BACKGROUND: Damage to the peritoneal dialysis catheter may be due to wear from long-term use, exposure to antibacterial agents (strong oxidants), and accidental injury from sharp objects. Repair of such catheter, if not associated with subsequent complications, would extend catheter life and reduce costs and patient inconvenience related to catheter replacement. OBJECTIVE AND DESIGN: Retrospective analysis of seven peritoneal catheters repaired 11 times over a 15-year period by splicing the old catheter with an extension tube using the Peri-Patch Repair Kit (Quinton Instrument Co., Bothwell, WA, U.S.A.). RESULTS: The life of these seven catheters was extended by a mean of 26 months (range 1-87 months), without increasing infection rates after splicing. The peritonitis rate after catheter splicing was 0.40 per year, not higher than the overall rate (0.76 per year) in our center during the same time period. Exit-site infections occurred in 6 patients after catheter splicing. Only one infection was related to trauma during the procedure and resulted in chronic exit infection; the catheter was eventually removed. In this patient, damage to the catheter was less than 1.5 cm from the exit site. CONCLUSIONS AND RECOMMENDATIONS: Splicing of the damaged peritoneal catheter, if properly done, is a safe procedure and can significantly prolong catheter life. We recommend that measures to prevent catheter damage, such as avoiding the use of scissors and other sharp objects, should be emphasized during the initial patient education and training. Alcohol and iodine should not be used on silicone rubber catheters. We suggest that the patient should report catheter damage immediately and come to the clinic within a few hours for catheter splicing (if possible) and prophylactic antibiotic to prevent peritonitis. Finally, we recommend that repair of the catheter should not be attempted if the breakage is less than 2 cm from the exit site, unless done as an emergency procedure if immediate catheter replacement cannot be performed. (+info)
Thrombolysis in acute myocardial infarction: the safety and efficiency of treatment in the accident and emergency department.
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OBJECTIVES: To assess the safety and efficiency with which the accident and emergency (A&E) department provides thrombolytic treatment for patients with acute myocardial infarction (AMI). METHODS: A prospective observational study based in a teaching hospital for one year. All patients who presented with the clinical and electrocardiographic indications for thrombolytic treatment were studied. Patients were grouped according to route of admission. After logarithmic transformation, the "door to needle times" of the groups were compared using a two tailed Student's t test. Arrhythmias and complications after thrombolytic treatment were noted. The appropriateness of the treatment was assessed retrospectively by review of the clinical records and electrocardiograms, judged against locally agreed eligibility criteria. RESULTS: Data from 153 patients were analysed; 138/153 (90%) patients were admitted via the A&E department. The shortest door to needle times were seen in those patients thrombolysed by A&E staff within the A&E department (mean 43.8 minutes). The transfer of A&E patients to the coronary care unit (CCU) was associated with a significant increase in the door to needle time (mean 58.8 minutes, p = 0.004). Only one malignant arrhythmia occurred during the administration of thrombolysis in the A&E department, and this was managed effectively. No arrhythmias occurred during transfer of thrombolysed patients to the CCU. In every case, the decision to administer thrombolysis was retrospectively judged to have been appropriate. CONCLUSIONS: The A&E department provides appropriate, safe, and timely thrombolytic treatment for patients with AMI. Transferring A&E patients to the CCU before thrombolysis is associated with an unnecessary treatment delay. (+info)
Enoxaparin prevents death and cardiac ischemic events in unstable angina/non-Q-wave myocardial infarction. Results of the thrombolysis in myocardial infarction (TIMI) 11B trial.
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BACKGROUND: Low-molecular-weight heparins are attractive alternatives to unfractionated heparin (UFH) for management of unstable angina/non-Q-wave myocardial infarction (UA/NQMI). METHODS AND RESULTS: Patients (n=3910) with UA/NQMI were randomized to intravenous UFH for >/=3 days followed by subcutaneous placebo injections or uninterrupted antithrombin therapy with enoxaparin during both the acute phase (initial 30 mg intravenous bolus followed by injections of 1.0 mg/kg every 12 hours) and outpatient phase (injections every 12 hours of 40 mg for patients weighing <65 kg and 60 mg for those weighing >/=65 kg). The primary end point (death, myocardial infarction, or urgent revascularization) occurred by 8 days in 14.5% of patients in the UFH group and 12.4% of patients in the enoxaparin group (OR 0.83; 95% CI 0.69 to 1.00; P=0. 048) and by 43 days in 19.7% of the UFH group and 17.3% of the enoxaparin group (OR 0.85; 95% CI 0.72 to 1.00; P=0.048). During the first 72 hours and also throughout the entire initial hospitalization, there was no difference in the rate of major hemorrhage in the treatment groups. During the outpatient phase, major hemorrhage occurred in 1.5% of the group treated with placebo and 2.9% of the group treated with enoxaparin (P=0.021). CONCLUSIONS: Enoxaparin is superior to UFH for reducing a composite of death and serious cardiac ischemic events during the acute management of UA/NQMI patients without causing a significant increase in the rate of major hemorrhage. No further relative decrease in events occurred with outpatient enoxaparin treatment, but there was an increase in the rate of major hemorrhage. (+info)
Ticlopidine and clopidogrel.
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The thienopyridines ticlopidine and clopidogrel are inhibitors of platelet function in vivo. Their mode of action has not been defined, but it appears that they require conversion to as yet unidentified metabolites that are noncompetitive antagonists of the platelet ADP receptor. Inhibition of platelet aggregation with these compounds is delayed until 24 to 48 hours after administration. Maximum inhibition occurs after 3 to 5 days, and recovery is slow after drug withdrawal. Ticlopidine is effective in preventing cardiovascular events in cerebrovascular, cardiovascular, and peripheral vascular disease, with an efficacy that is similar to aspirin. However, its use is associated with significant and sometimes fatal adverse reactions, specifically neutropenia and bone marrow aplasia. Gastrointestinal side effects and skin rashes are common and result in discontinuation of therapy in up to 10% of patients. Clopidogrel is at least as effective as aspirin in preventing cardiovascular events in patients with a history of vascular disease. It appears to be safer than ticlopidine, although its efficacy in acute coronary syndromes or post-coronary-stent insertion has not been reported. Important outstanding issues are whether clopidogrel adds to the benefit of aspirin and whether the combination of these agents is safe. If so, this combination may become the standard for antithrombotic therapy in cardiovascular disease. (+info)
Fit of bicycle safety helmets and risk of head injuries in children.
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BACKGROUND: Although bicycle helmets are effective in preventing head and brain injury, some helmeted individuals nevertheless sustain head injury. One of the possible reasons may be poor fit of the helmet on the head. This study was undertaken to examine the relationship between helmet fit and risk of injury. METHODS: 1718 individuals who were helmeted riders in a crash were queried on helmet fit and position. A sample of 28 children 2-14 years of age who sustained a head injury while wearing a bicycle helmet and 98 helmeted individuals of the same age treated in the same hospital emergency departments for injuries other than to the head, underwent anthropometric measurements of helmet fit. Measurements were made of the child's head, the helmet, and on a cast made of the child's head. RESULTS: Individuals whose helmets were reported to fit poorly had a 1.96-fold increased risk of head injury compared with those whose helmets fit well. Children with head injuries had helmets which were significantly wider than their heads compared with children without head injuries. Helmet fit was poorer among males and among younger children. CONCLUSIONS: Poor fit of helmets may be associated with an increased risk of head injury in children, especially in males. Helmets may not be designed to provide optimal protection. (+info)
Design and interpretation of vaccine field studies.
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There are many different effects to consider when evaluating vaccines in the field. In this review, we have covered some of the various measures and issues related to study design and interpretation of the different measures. We emphasize that in designing and understanding vaccine studies, it is necessary to be specific about what the effect of interest is and about the assumptions underlying the interpretation of the results. Halloran et al. (81) present design, analysis, and interpretation of vaccine studies in more detail. (+info)
Safety of the limited open technique of bone-transfixing threaded-pin placement for external fixation of distal radial fractures: a cadaver study.
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OBJECTIVE: To examine the safety of threaded-pin placement for fixation of distal radial fractures using a limited open approach. DESIGN: A cadaver study. METHODS: Four-millimetre Schanz threaded pins were inserted into the radius and 3-mm screw pins into the second metacarpal of 20 cadaver arms. Each threaded pin was inserted in the dorsoradial oblique plane through a limited open, 5- to 10-mm longitudinal incision. Open exploration of the threaded-pin sites was then carried out. OUTCOME MEASURES: Injury to nerves, muscles and tendons and the proximity of these structures to the threaded pins. RESULTS: There were no injuries to the extensor tendons, superficial radial or lateral antebrachial nerves of the forearm, or to the soft tissues overlying the metacarpal. The lateral antebrachial nerve was the closest nerve to the radial pins and a branch of the superficial radial nerve was closest to the metacarpal pins. The superficial radial nerve was not close to the radial pins. CONCLUSION: Limited open threaded-pin fixation of distal radial fractures in the dorsolateral plane appears to be safe. (+info)
Safety and efficacy of fertility-regulating methods: a decade of research.
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An international venture was launched in 1985 to fill a recognized gap in post-marketing surveillance of fertility-regulating methods. For this purpose a new task force was set up by the Special Programme of Research, Development, and Research Training in Human Reproduction, which is cosponsored by the United Nations Development Programme, the United Nations Population Fund, the World Bank, and WHO. Research priorities were chosen and epidemiological studies inaugurated, involving a total of 47 countries--mostly from the developing world. Important progress has been made, especially in helping to define the beneficial and possible adverse effects of oral contraceptives on the risk of neoplasia; in showing that the injectable contraceptive depot-medroxyprogesterone acetate protects against endometrial cancer and does not increase the overall risk of breast cancer, in clarifying which groups of women are susceptible to the rare cardiovascular complications of oral contraceptives (myocardial infarction, stroke, and venous thromboembolism); and in establishing the long-term effectiveness and safety of intrauterine devices. The research has already made a significant impact on family planning policies and practice. Critical appraisal of this venture, which has been modestly funded, confirms the value of mission-oriented research. It also illustrates the potential of collaboration that bridges the global divide between developing and developed countries. (+info)