Economic evaluation of the impact of nicorandil in angina (IONA) trial.

OBJECTIVE: To estimate the net cost of adding nicorandil to usual treatment for patients with angina and to compare this with indicators of health benefit. DESIGN: Cost effectiveness analysis. SETTING: Based on results of the IONA (impact of nicorandil on angina) trial. PATIENTS: Patients with angina fulfilling the entry criteria for the IONA trial. INTERVENTIONS: In one arm of the trial nicorandil was added to existing antianginal treatment and compared with existing treatment alone. MAIN OUTCOME MEASURES: Costs were for use of hospital resources (for cardiovascular, cerebrovascular, and gastrointestinal reasons), nicorandil, and care after hospital discharge. Benefits were assessed in three ways: (1) IONA trial primary outcome (coronary heart disease (CHD) death, non-fatal myocardial infarction, or hospital admission for cardiac chest pain); (2) acute coronary syndrome (CHD death, non-fatal myocardial infarction, or unstable angina); and (3) event-free survivors at the end of the trial. RESULTS: The net cost for each additional IONA trial end point averted was -5 pounds sterling (-7 euros). The net cost for each case of acute coronary syndrome averted was -8 pounds sterling (-12 euros). The net cost for each event-free survivor was -5 pounds sterling (-7 euros). These figures are based on gastrointestinal events that were judged definitely or probably related to nicorandil. When all gastrointestinal events were included these three ratios rose to 567 pounds sterling (835 euros), 886 pounds sterling (1305 euros), and 516 pounds sterling (760 euros), respectively. CONCLUSIONS: A substantial amount of the additional cost of nicorandil is offset by reduced use of hospital services. The limited comparisons possible with other CHD interventions suggest that nicorandil compares favourably.

Mobilization of patients after spinal surgery for acute spinal cord injury.

STUDY DESIGN: A retrospective review was conducted covering records of patients who underwent spinal surgery after acute spinal cord injury. OBJECTIVE: To study the relation between time of operation and mobilization of patients. SUMMARY OF BACKGROUND DATA: No such report has existed in the literature. METHODS: Reviews were conducted for the medical records of 102 consecutive patients with acute spinal cord injury admitted to the National Spinal Injuries Center whose spines had been stabilized surgically. The surgeries had been performed either in the National Spinal Injuries Center or in hospitals of the United Kingdom or Continental Europe not specialized in comprehensive care of spinal cord injury. For the patients in three groups, the date of operation and the date of mobilization were compared. The causes for delay in mobilization were identified. RESULTS: A trend of negative correlation was found between the mean number of days from injury to operation and the mean number of days from injury to mobilization. Conversely, a trend of positive correlation was found between the mean number of days from injury to admission or transfer to the National Spinal Injuries Center and the mean number of days from injury to mobilization. Long stay in bed was associated with complications. None of the patients in Group A stayed in bed longer than 77 days, whereas 13 patients in Groups B and C combined had a longer stay. The difference was statistically significant (P = 0.02, chi2). Eight of these patients had pressure sores. CONCLUSION: To ensure early mobilization, early spinal surgery must be supported by specialized comprehensive care.

The effect of childhood spinal cord injury on skeletal development: a retrospective study.

STUDY DESIGN: Cross-sectional clinical review. OBJECTIVES: To assess the relationship between late spinal deformity in childhood onset spinal cord injury (SCI) and level of spinal cord lesion, severity of lesion, age at onset, duration of paralysis and pelvic deformities. SETTING: People with spinal cord injury (onset in childhood) treated and followed up at the National Spinal Injuries Center (identified from case notes review, contacted and agreed to participate). METHOD: One hundred and eighty-nine subjects satisfying study inclusion criteria (acute onset SCI before the 16th birthday) were identified by case note review of 8200 records. Eighty formed the group attending for clinical review including whole spine radiographs (AP and lateral). Clinical examination included neurological status and joint range of movements. Demographic data was recorded. RESULTS: Scoliosis occurred more frequently and was more severe in those injured at a younger age, 38 degrees, compared with 24 degrees in those injured later (P<0.05), in paraplegia, 33 degrees, versus tetraplegia, 17 degrees, (P<0.01) and in complete, 36 degrees, versus incomplete lesions, 18 degrees, (P<0.001). Lordosis angulation in paraplegic subjects was significantly greater than in tetraplegic subjects in both seated, 50 degrees versus 25 degrees (P<0.014) and standing subjects 78 degrees versus 59 degrees (P<0.017) respectively and for kyphosis in standing subjects, 52 degrees versus 31 degrees (P<0.01). Sagittal measurements were influenced by habitual posture (which also corresponded to the severity of the lesion). CONCLUSION: Younger age at onset was shown to be associated with more severe scoliosis, as has been reported by others. Subjects with paraplegia and complete lesions demonstrated a greater and more frequently occurring scoliosis than those with tetraplegia and incomplete lesions respectively. Lordosis was greater in those with paraplegia than with tetraplegia and in those with very incomplete lesions compared with complete lesions. However the influence of the severity of the lesion cannot be separated from the postural position when analyzing spinal deformity.

A randomised trial of calcium alginate swabs to control blood loss in 3-5-year-old children.

OBJECTIVE: To compare the effectiveness of calcium alginate swabs and traditional cotton swabs in the control of blood loss after extraction of deciduous teeth from healthy children, aged 3-5 years, under general anaesthetic. DESIGN: Prospective, randomised clinical trial. SETTING: General anaesthetic suite in a dental teaching hospital. SUBJECTS: 101 patients were recruited to the study, comprising 50 randomised to be treated with cotton swabs and 51 with alginate swabs. INTERVENTIONS: Teeth were extracted under general anaesthesia and blood collected for measurement in order to compare blood loss using the two systems. MAIN OUTCOME MEASURES: The number of teeth extracted ranged from 1-14. The total blood loss ranged from 0.53-78.13 ml with a median of 12.9 ml. CONCLUSION: Calcium alginate swabs were not found to produce any clinical or statistical advantage over traditional cotton swabs in this surgical setting.

Blood loss following extraction of deciduous teeth under general anaesthetic.

The potential for significant blood loss following deciduous tooth extractions has been a factor in treatment planning in dental care for children. This paper reports the results of a study which aimed to quantify normal blood loss following extraction of deciduous teeth from medically fit children under general anaesthetic. Blood loss from a group of 50 children aged 3 to 5 years, having at least one molar tooth removed, was determined by comparing the amount of haemoglobin in a sample of the patient's whole blood with a known dilution of blood collected during surgery and recovery. Total blood loss ranged from 2.5 to 57 mL, with the maximum corresponding to deciduous clearance of (the removal of all deciduous teeth from) the upper arch together with the lower molars for a 3-year-old child. Clinical judgement would suggest that the maximum potential blood loss resulting from a complete dental clearance (20 teeth) from an otherwise fit child in this age group is unlikely to be greater than 100 mL. It is concluded that the risk of inducing hypovolaemic shock from this procedure is much lower than the risks of using repeated administrations of general anaesthesia to facilitate a staged dental clearance.

[Left-handedness in dental undergraduates and orthodontic specialists]. / Linkshandigheid bij studenten tandheelkunde en orthodontisten.

A questionnaire was devised involving a group of dental students (n = 70) and a group comprising all consultant orthodontists in the UK (n = 170) to investigate the prevalence and the role of handedness in dental specialisation. Subjects were classified as being pure left-, mixed- or pure right-handed according to responses to a hand preference questionnaire and the results were compared with a very similar previous study of the general population. The prevalence of sinistrality (classified by writing) was recorded as 8.6% among dental students and 17.2% among orthodontists; this compares with 7.4% among the general population. More mixed-handers presented in both the dental groups compared to the general population. This agreed with the right shift theory of laterality. No significant correlation was noted between handedness and any other variable between the two dental groups.

Left-handedness in dental undergraduates and orthodontic specialists.

A questionnaire was devised involving a group of dental students (n = 70) and a group comprising all consultant orthodontists in the UK (n = 170) to investigate the prevalence and role of handedness in dental specialisation. Subjects were classified as being pure left-, mixed- or pure right-handed according to responses to a hand preference questionnaire and the results were compared with a very similar previous study of the general population. The prevalence of sinistrality (self-classified by writing) was recorded as 8.6% among dental students and 17.2% amongst orthodontists; this compares with 7.4% among the general population. More mixed-handers presented in both the dental groups compared to the general population. This agreed with the right shift theory of laterality. No significant correlation was noted between handedness and any other variable between the two dental groups.

The oro-facial manifestations of trisomy 8 mosaicism: a case report.

Trisomy 8 mosaicism is a relatively common autosomal chromosomal disorder characterized by features such as mental retardation, characteristic facies, skeletal abnormalities and congenital heart disease. The case of a 4-year-old boy is described with particular reference to the oro-facial manifestations, which included cleft palate, pronounced anterior open bite, complete reserved unilateral buccal cross-bite, slightly increased width of alveolar processes, and gingival enlargement.

Guidelines for taking radiographs of children.

Dental radiographs are required for monitoring many aspects of the dental care of children. This article reviews the current guidelines for taking dental radiographs of children, with particular reference to diagnosing caries, monitoring growth and development and managing trauma. There are a number of practical difficulties in taking radiographs of this age group, which are also discussed. The use of selection criteria to assist the clinician in choosing the optimal radiograph examination is recommended.

Neurological complications of the reduction of cervical spine dislocations.

We have studied the case records of 16 patients with dislocations of the cervical spine who deteriorated neurologically during or after reduction. The dislocations were reduced by skull traction in four patients, by manipulation in four and by operation in seven. This complication was not related to age, sex, mechanism of injury, or the level and the type of dislocation. Fourteen patients made substantial recoveries, one made a partial recovery and one patient remained totally paralysed and died three months later. The causes and prevention of spinal-cord damage at this stage of management are discussed, and the early use of MRI or CT myelography is recommended.

Joint contractures in the hemophilias.

Hemophilic contracture is seen most commonly as an equinus deformity of the ankle, or at the knee or elbow in the form of a flexion deformity. The cause is either fibrosis following intramuscular hematoma, which may be complicated by a peripheral nerve palsy causing muscle imbalance, or is associated with chronic hemophilic arthropathy following recurrent hemarthroses. The introduction of home therapy is an important preventive measure, and treatment is primarily by physiotherapy, splintage, and corrective devices. The late or severe case may require surgical correction in the form of soft tissue procedures. Arthrodesis or total arthroplasty must be carried out with meticulous hemostasis and with replacement of the appropriate blood clotting factors.

Transmission of pressure into the human limb from pneumatic splints.

The anterior compartment of the leg of 4 volunteers was used to study the transmission of externally applied pressure into a limb. The pressure from a pneumatic splint was found to be transmitted directly into the leg and was found to be added to the resting intramuscular pressure. The median inflation pressure of such a splint applied by trained ambulance personnel was 25 mm Hg (range 15-36 mm Hg). When the resting intramuscular pressure was raised experimentally, either by voluntary muscular contraction or venous engorgement, numerical addition of externally applied pressure was again observed. A moderate rise in compartment pressure commonly occurs after injury. Due care should be taken in the use of pneumatic splints or compressive dressings as the total pressure generated within a limb may be sufficient to induce ischaemia.

The slit catheter: a comparison with the wick catheter in the measurement of compartment pressure.

The slit catheter, a new instrument for the measurement of compartment pressure, has been compared with the wick catheter in experimental conditions. The two catheters were inserted into the anterior tibial compartments of 8 human legs and controlled external pressures were applied by means of an inflatable limb bag. The mean resting intramuscular pressure of 8.5 +/- 6.2 mmHg for the slit and 8.7 mmHg +/- 6.2 mmHg for the wick catheter agrees with that of other workers, and the slit catheter records a pressure at all applied external pressures not significantly different from the wick catheter (paired t test). The slit catheter provides a simple and inexpensive way of estimating compartment pressure which is as accurate as a method widely used both experimentally and clinically in North America.

Compartmental pressure changes during calcaneal traction in tibial fractures.

The effect of calcaneal traction on the compartmental pressure in the legs of five individuals with tibial fractures was studied. Mean resting pressures without traction were found to be 31.9 mmHg for the deep posterior compartment and 27.0 mmHg for the anterior compartment. For each kilogram weight of traction applied the deep posterior pressure rose by 5.7 per cent of the resting value and the anterior pressure by 1.6 per cent. It is suggested that the weight of traction should be only sufficient to render the patient comfortable and maintain alignment of the limb. Excessive traction is likely to increase the risk of compartmental ischaemia. The application of six kilograms of traction would raise the mean resting pressure by 34 per cent from 31.9 to 42.7 mmHg.