Complications of central venous access devices in paediatric haemophilia patients.

We conducted a retrospective survey of our experience with central venous access devices (CVADs) implanted in children with haemophilia seen at the Vanderbilt Hemostasis-Thrombosis Clinic from 1986 to 2000. Following discussion with parents on the merits and risks associated with the use of CVADs for immune tolerance induction or factor prophylaxis, catheters were inserted under sterile technique in the operating room. One nurse provided demonstration and teaching about catheter care and access. Thirty central venous catheters were inserted in 22 children. Our survey revealed that the two most common complications associated with central venous catheters were bacteraemia and thrombosis. We found a sepsis rate of 0.30/1000 catheter-days or one episode of bacteraemia for every 3346 days of catheter use. The thrombosis rate of our cohort was 0.13/1000 catheter-days or one episode of thrombosis for every 7529 days of catheter use. Uncomplicated venous access is essential in children with severe haemophilia who require prophylaxis or immune tolerance induction. While infection was the most common complication observed in our series, we experienced a lower overall infection rate than several reported series. Catheter thrombosis and subsequent obstruction may occur as a result of intraluminal fibrin deposits. We conclude that the use of implantable central venous catheters is an effective method for accessing children with haemophilia. We accept that the benefits of CVADs in the treatment of paediatric haemophilia patients outweigh the previously documented risks. Future prospective studies should be designed to define all associated risks and to determine effective strategies to reduce them.

Factors affecting access to menopause information.

OBJECTIVE: As female life expectancy increases, women spend a greater proportion of their life in menopause. Menopausal women may benefit from preventive treatments, such as hormone replacement therapy, and are more likely to use medical treatments if they have access to information about menopause. The purpose of this study was to identify women's needs with respect to learning about menopause. DESIGN: A 20-question survey was administered anonymously to 116 women during outreach programs. Data were separated and evaluated by race and level of education. RESULTS: A significant association was found between access to information about menopause and both race and education level. Being African American or having less than a college education was associated with a twofold risk (p < 0.01) for not having a source of menopause information. A significant relationship was found between a woman's rating of her current knowledge of menopause and access to source of information (p = 0.03); women who did not have an information source felt the least knowledgeable about the subject. Women varied in the ways in which they are comfortable with learning about menopause. Different groups of women seemed to prefer different methods of learning about menopause. CONCLUSIONS: Both level of education and race are associated with a woman's ability to obtain information about menopause. To enhance women's understanding of health during menopause, information must be readily available. This information should be presented to women through educational programs that are designed to meet the needs of varied groups of adult women.

Attitudes of first-year medical students toward the confidentiality of computerized patient records.

OBJECTIVES: To investigate the attitudes of students entering medical school toward the confidentiality of computerized medical records. DESIGN: First-year medical students at the Vanderbilt University School of Medicine responded to a series of questions about a hypothetic breach of patient's privacy through a computerized patient record system. MEASUREMENTS: The individual authors independently grouped the blinded responses according to whether they were consistent with then-current institutional policy. These preliminary groupings were discussed, and final categorizations were made by consensus. RESULTS: While most students had a sense of what was right and wrong in absolute terms, half the class suggested at least one course of action that was deemed to be inconsistent with institutional policies. CONCLUSIONS: The authors believe that medical schools should directly address ethical and legal issues related to the use of computers in clinical practice as an integral part of medical school curricula. Several teaching approaches can facilitate a greater awareness of the issues surrounding technology and medicine.

Controlled delivery of therapeutics from microporous membranes. II. In vitro degradation and release of heparin-loaded poly(D,L-lactide-co-glycolide).

In vitro degradation and release of five types of heparin/surfactant-loaded poly(D,L-lactide-co-glycolide 50:50) (PLG) microspheres alone and also incorporated within microporous polyurethane tubes were studied over a 3-month period. Degradation was studied with scanning electron microscopy (SEM), Fourier-transform infrared spectroscopy (FTIR), gel permeation chromatography (GPC) and differential scanning calorimetry (DSC). Heparin release was characterized using a modified Azure A assay. SEM suggests that microspheres may be entrapped within polyurethane fibrils of the polyurethane tubes, thereby reducing contact with their hydrated environment. FTIR transmittance spectra confirm microsphere incorporation within the polyurethane tubes and PLG ester hydrolysis occurring over the 3-month period. A correlation was observed between decreasing molecular weights and glass transition temperatures (Tg). The microspheres alone exhibited a change in Tg but not when incorporated within the microporous tubes. Release profiles revealed a burst effect occurring during the first 4h and total release of the heparin from the microspheres by 12 weeks.