Model-based estimates of risks of disease transmission and economic costs of seven injection devices in sub-Saharan Africa.
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OBJECTIVE: To investigate and compare seven types of injection devices for their risks of iatrogenic transmission of bloodborne pathogens and their economic costs in sub-Saharan Africa. METHODS: Risk assumptions for each device and cost models were constructed to estimate the number of new hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infections resulting from patient-to-patient, patient-to-health care worker, and patient-to-community transmission. Costs of device purchase and usage were derived from the literature, while costs of direct medical care and lost productivity from HBV and HIV disease were based on data collected in 1999 in Cote d'Ivoire, Ghana, and Uganda. Multivariate sensitivity analyses using Monte Carlo simulation characterized uncertainties in model parameters. Costs were summed from both the societal and health care system payer's perspectives. FINDINGS: Resterilizable and disposable needles and syringes had the highest overall costs for device purchase, usage, and iatrogenic disease: median US dollars 26.77 and US dollars 25.29, respectively, per injection from the societal perspective. Disposable-cartridge jet injectors and automatic needle-shielding syringes had the lowest costs, US dollars 0.36 and US dollars 0.80, respectively. Reusable-nozzle jet injectors and auto-disable needle and syringes were intermediate, at US dollars 0.80 and US dollars 0.91, respectively, per injection. CONCLUSION: Despite their nominal purchase and usage costs, conventional needles and syringes carry a hidden but huge burden of iatrogenic disease. Alternative injection devices for the millions of injections administered annually in sub-Saharan Africa would be of value and should be considered by policy-makers in procurement decisions. (+info)
Randomized evaluation of the performance of single-use laryngoscopes in simulated easy and difficult intubation.
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BACKGROUND: Single-use laryngoscopes are becoming used more widely. METHODS: We compared six types of single-use laryngoscope with the standard Macintosh laryngoscope using the Laerdal SimMan patient simulator. Twenty anaesthetists attempted to intubate the simulator with standardized airway settings allowing a full view of the vocal cords ('easy intubation'). The airway settings were then changed so that only the posterior part of the glottis was visible ('difficult intubation') and the anaesthetists were asked to intubate the simulator again. RESULTS: The time to intubate with the standard laryngoscope was less in both easy (P<0.05) and difficult (P<0.01) intubations. The performance of five laryngoscopes during easy intubation (P<0.01) and four during difficult intubation (P<0.001) was significantly worse than that of the Macintosh. There was a significant difference in Cormack and Lehane grading between the laryngoscopes tested in both easy (P<0.05) and difficult (P<0.05) intubation. The percentage of glottic opening visible (POGO score) also differed between laryngoscopes in both the easy (P<0.01) and difficult (P<0.001) groups. The highest POGO scores were obtained with the Macintosh laryngoscope. During the difficult intubation simulation, the reusable Macintosh laryngoscope needed less use of a bougie and had fewer failed intubations than the single-use laryngoscopes, but these differences did not reach statistical significance. CONCLUSIONS: Of the laryngoscopes tested, the standard reusable Macintosh laryngoscope performed best. The Europa was the best single-use laryngoscope. Some single-use laryngoscopes tested were significantly inferior to the Macintosh. This raises concern over their use in clinical practice, particularly if intubation is difficult. (+info)
An in vitro study to investigate the use of a breath-actuated, small-volume, pneumatic nebulizer for the delivery of methacholine chloride bronchoprovocation agent.
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BACKGROUND: Current American Thoracic Society and American Association for Respiratory Care guidelines for the delivery of aerosol agents such as methacholine chloride (MC) for bronchoprovocation testing require the use of pneumatic jet nebulizers that have well-defined droplet size and mass output. A recently developed disposable, breath-actuated nebulizer (AeroEclipse) may offer bronchoprovocation testers an alternative to existing devices. METHODS: We studied the performance of 5 AeroEclipse nebulizers with regard to mass of MC delivered with various MC solution concentrations and numbers of inhalations, using a model of adult tidal breathing. Each nebulizer was operated with compressed air (8 L/min at 50 psig) and an initial fill of 2 mL. MC solutions with mass concentrations of 0.25, 0.98, 3.85, and 15.70 mg/mL were tested. The total mass of MC delivered was determined after 5, 10, and 15 complete breathing cycles, by assaying the MC collected on a filter placed at the nebulizer mouthpiece. The aerosol droplet size distribution, fine droplet fraction (FDF) (percentage of droplets < 4.8 microm diameter), and fine droplet mass (FDM) (mass of droplets < 4.8 microm diameter) were determined by laser diffractometry, using physiologically normal saline as a surrogate for MC solution. RESULTS: The mean +/- SD FDM collected in 5 breathing cycles was 654 +/- 29 microg with the 15.70 mg/mL solution, 158 +/- 9 microg with the 3.85 mg/mL solution, 37 +/- 3 microg with the 0.98 mg/mL solution, and 7 +/- 2 microg with the 0.25 mg/mL solution. FDM showed a linear correlation (r(2) = 0.9999) with MC concentration, within the range studied. FDM also showed a linear correlation (r(2) = 0.999) with the number of breathing cycles. For instance, with the 15.70 mg/mL solution, FDM was 654 +/- 29 microg with 5 breathing cycles, 1,228 +/- 92 microg with 10 breathing cycles, and 1,876 +/- 132 microg with 15 breathing cycles. CONCLUSIONS: Although the bronchoprovocation test procedure had to be slightly modified from the guidelines to accommodate the operation of the AeroEclipse's breath-actuation feature, our measurements indicate that a predictable dose of MC, within the useful range for bronchoprovocation testing, can be delivered to an adult patient breathing tidally. The green indicator on the AeroEclipse could be used to coach the patient to inhale for a specific period, thereby controlling MC delivery per breathing cycle. (+info)
Patterns of mucin adherence to contact lenses.
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PURPOSE: Contact lens wear alters the preocular fluid through factors that include tear deposits on the lens. In the current study, lens-adherent material was extracted to assess whether contact lenses sample mucins from the preocular fluid. METHODS: Discarded extended-wear contact lenses were collected from patients with no ocular surface disease. Mucins were extracted in guanidine hydrochloride (GuHCl) with protease inhibitors. After the supernatant was removed, the extraction was repeated twice with the addition of 10 mM dithiothreitol, making a total of three extractions. Mucins were isolated by cesium chloride (CsCl) gradient centrifugation and size fractionated on Sepharose CL2B. Charge distribution was analyzed on ion-exchange chromatography with a lithium perchlorate (LiClO(4)) gradient. RESULTS: Contact lens-adherent mucins comprised soluble mucins and mucins that required solubilization by (repeated) dithiothreitol treatment. MUC1, MUC4, MUC2, and MUC5AC mucins eluted mainly at low buoyant densities in extractions from lenses worn long term without disinfection and at successively higher buoyant densities from monthly disposable contact lenses. Mucins with little negative charge, which were observed in all extractions, and very highly negatively charged species, present in the second and third extractions from contact lenses, had no equivalents in tissue-extracted mucins. CONCLUSIONS: Mucins adhering to contact lenses are altered forms of intracellular mucins. Different degrees of adherence of mucins to contact lenses may occur, either because of mucin characteristics or after mucin complexation with adherent materials. In the context of good contact lens hygiene, their presence may offer some protection from toxicants in the tear film, because mucins could function as acceptors for charged moieties such as free radicals. (+info)
Longevity of Masimo and Nellcor pulse oximeter sensors in the care of infants.
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OBJECTIVE: Pulse oximetry is a standard of care for monitoring oxygenation in neonates. Associated with the use of pulse oximetry is the cost of patient sensors, especially if the sensor is designed for single-patient use. Pulse oximetry monitoring of sick newborns is routine and often lengthy and, if the pulse oximeter sensor is short-lived, can result in a significant portion in the cost of intensive care. METHODS: We evaluated, in the NICUs of two hospitals and one step-down nursery, the useful life of disposable neonatal pulse oximeter sensors from two manufacturers: Masimo and Nellcor. The only requisites were ethics committee approval and need for monitoring. The timed of PO sensor placement and replacement were noted along with the reason for changing the sensor. The standard care practices for PO and sensor use in the respective institutions were followed. RESULTS: A total of 835.5 patient days of monitoring were accumulated with 65 infants in the Masimo group and 56 using Nellcor. The Masimo Neo sensors had over twice (2.33) the useful life of the Nellcor N-25 (9.05+/-4.4 versus 3.9+/-2.3 days (range of 7.2-11.8 and 2.5-5.8 days, respectively, p<0.05)). The magnitude of useful life between the two institutions was not significantly different in the Masimo group (2.35- versus 2.22-fold). PO sensors were replaced due to impaired adhesion (38 Masimo and 32 Nellcor) and no signal (six Masimo and four Nellcor). CONCLUSIONS: We found a more than two-fold increase in the life of Masimo versus Nellcor sensors. This difference was consistent between various caregivers in multiple settings and corroborates the experience of another, more limited study. A cost savings should result from the use of Masimo versus Nellcor disposable pulse oximeter sensors in neonatal routine care (+info)
Effects of eyelid closure and disposable and silicone hydrogel extended contact lens wear on rabbit corneal epithelial proliferation.
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PURPOSE: To examine the rabbit corneal epithelial cell proliferation rate after extended wear of disposable or silicone hydrogel contact lenses or prolonged eyelid closure. METHODS: One randomly chosen eye of 40 New Zealand White rabbits was assigned to silicone hydrogel contact lens wear (n = 15, SH), disposable hydrogel contact lens wear (n = 6, DH), eyelid suturing (n = 15, SUT), or no intervention (n = 4). Contralateral eyes served as the control. After 24 hours or 1 week of lens wear, 5-bromo-2-deoxyuridine (BrdU) was injected intravenously to label dividing corneal epithelial cells, and animals were killed 24 hours after injection. Corneas were stained with monoclonal anti-BrdU antibody and FITC-conjugated secondary antibody. A series of continuous digital images of the wholemounted epithelium were collected from the superior to inferior limbus, and the number of BrdU-labeled cell pairs was counted. RESULTS: SH, DH, and SUT caused a significant decrease in BrdU-labeled pairs of cells over the entire corneal epithelium at day 2 compared with the number in contralateral control eyes (P < 0.001). One week of SUT or SH caused a significant increase centrally in BrdU-labeled cells (P < 0.01). BrdU labeling at the limbus in all groups was not significantly different from the control. Unexpectedly, the proliferation rate of the control corneas was also significantly affected by contralateral lens wear and suturing. CONCLUSIONS: Short-term overnight SH, DH, and SUT all significantly suppressed the cell proliferation rate in the rabbit corneal epithelium. However, adaptation, with central hyperproliferation of cells, appeared to occur at 8 days. The effects of lens wear and eyelid suturing on the cell proliferation rate in contralateral control eyes suggests a central mechanism that regulates corneal epithelial proliferation. (+info)
Ensuring injection safety during measles immunization campaigns: more than auto-disable syringes and safety boxes.
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Measles immunization campaigns are effective elements of a comprehensive strategy for preventing measles cases and deaths. However, if immunizations are not properly administered or if immunization waste products are not safely managed, there is the potential to transmit bloodborne pathogens (e.g., human immunodeficiency virus and hepatitis B and hepatitis C). A safe injection can be defined as one that results in no harm to the recipient, the vaccinator, and the surrounding community. Proper equipment, such as the exclusive use of auto-disable syringes and safety boxes, is necessary, but these alone are not sufficient to ensure injection safety in immunization campaigns. Equally important are careful planning and managerial activities that include policy and strategy development, financing, budgeting, logistics, training, supervision, and monitoring. The key elements that must be in place to ensure injection safety in measles immunization campaigns are outlined. (+info)
Surgeon-led initiatives cut costs and enhance the quality of endoscopic and laparoscopic procedures.
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BACKGROUND: Public perception depicts surgical cost control and quality of care as polar opposites. We describe a program led by practicing surgeons that demonstrates that quality can be maintained, and often improved, while substantial cost reductions are realized. METHODS: A set of evidence-based protocols was developed, revised, and followed for 42 procedures in general, otolaryngologic, urologic, and orthopedic surgery. Each protocol consists of surgeon-initiated guidelines on operative indications, preoperative testing, preadmission planning, length of stay, resource utilization, convalescence, and pharmacy services. Information was collected for 24 months from July 1998 to July 2000 by 62 surgeons in Kentucky and Indiana. Data were obtained for 4302 cases, among them colonoscopy (1145), esophagogastroduodenoscopy (714), laparoscopic cholecystectomy (418), endoscopic retrograde cholangiopancreatography (235), and laparoscopic fundoplication (87). RESULTS: Specific cost reductions occurred in laparoscopic cholecystectomy by limiting the administration of perioperative antibiotics. Sixty-seven percent of patients did not receive antibiotics. Outpatient cholecystectomy was the norm (60%), due primarily to preadmission planning through discussion with the patients and their family. Interestingly, when surgeons were educated on the costs of certain instruments and medications, their practices changed. The avoidance of a particular postoperative antiemetic, which was more than tenfold more expensive than other choices, was rapidly adopted by all surgeons when the costs were discovered. One participating teaching hospital used its own financial data and predicted that if all surgeons at their facility followed the protocols and had similar results, a savings of dollar 1.1 million per quarter would be obtained. (+info)