TELEMAM: a cluster randomised trial to assess the use of telemedicine in multi-disciplinary breast cancer decision making.

AIM: The TELEMAM trial aimed to assess the clinical effectiveness and costs of telemedicine in conducting breast cancer multi-disciplinary meetings (MDTs). METHODS: Over 12 months 473 MDT patient discussions in two district general hospitals (DGHs) were cluster randomised (2:1) to the intervention of telemedicine linkage to breast specialists in a cancer centre or to the control group of 'in-person' meetings. Primary endpoints were clinical effectiveness and costs. Economic analysis was based on a cost-minimisation approach. RESULTS: Levels of agreement of MDT members on a scale from 1 to 5 were high and similar in both the telemedicine and standard meetings for decision sharing (4.04 versus 4.17), consensus (4.06 versus 4.20) and confidence in the decision (4.16 versus 4.07). The threshold at which the telemedicine meetings became cheaper than standard MDTs was approximately 40 meetings per year. CONCLUSION: Telemedicine delivered breast cancer multi-disciplinary meetings have similar clinical effectiveness to standard 'in-person' meetings.

Attitudes of breast cancer professionals to conventional and telemedicine-delivered multidisciplinary breast meetings.

We surveyed the attitudes of breast cancer professionals to standard face-to-face and future telemedicine-delivered breast multidisciplinary team (MDT) meetings. Interviews, which included the Group Behaviour Inventory, were conducted face-to-face (n = 19) or by telephone (n = 26). The mean total score on the Group Behaviour Inventory was 96 (SD 19) for 33 respondents, which indicated satisfaction with standard MDT meetings, irrespective of role and base hospital. Positive attitudes to videoconferencing were more common among participants with previous experience of telemedicine (Spearman's rank correlation 0.26, P = 0.91). Common themes emerging from the interviews about telemedicine-delivered MDTs included group leadership, meeting efficiency, group interaction, group atmosphere and technical quality of communication. Most participants were satisfied with standard breast MDTs. Nurses and allied health professionals were least supportive of telemedicine.

Effect of helmet wear on the incidence of head/face and cervical spine injuries in young skiers and snowboarders.

PURPOSE: To evaluate whether helmets increase the incidence and/or severity of cervical spine injury; decrease the incidence of head injury; and/or increase the incidence of collisions (as a reflection of adverse effects on peripheral vision and/or auditory acuity) among young skiers and snowboarders. METHODS: During one ski season (1998-99) at a world class ski resort, all young skiers and snowboarders (<13 years of age) presenting with head, face, or neck injury to the one central medical facility at the base of the mountain were identified. On presentation to the clinic, subjects or their parents completed a questionnaire reviewing their use of helmets and circumstances surrounding the injury event. Physicians documented the site and severity of injury, investigations, and disposition of each patient. Concurrently, counts were made at the entry to the ski area of the number of skiers and snowboarders wearing helmets. RESULTS: Seventy children were evaluated at the clinic following ski/snowboard related head, neck, and face injuries. Fourteen did not require investigation or treatment. Of the remaining 56, 17 (30%) were wearing helmets and 39 (70%) were not. No serious neck injury occurred in either group. Using helmet-use data from the hill, among those under 13 years of age, failure to wear a helmet increased the risk of head, neck, or face injury (relative risk (RR) 2.24, 95% confidence interval (CI) 1.23 to 4.12). When corrected for activity, RR was 1.77 and 95% CI 0.98 to 3.19. There was no significant difference in the odds ratio for collisions. The two groups may have been different in terms of various relevant characteristics not evaluated. No separate analysis of catastrophic injuries was possible. CONCLUSION: This study suggests that, in skiers and snowboarders under 13 years of age, helmet use does not increase the incidence of cervical spine injury and does reduce the incidence of head injury requiring investigation and/or treatment.

Teaching pediatric procedures: the Vancouver model for instructing Seldinger's technique of central venous access via the femoral vein.

The way in which physicians are trained to do invasive practical procedures is an ongoing challenge for educators. Percutaneous insertion of a central line via the femoral vein using the Seldinger technique is an important practical pediatric procedure, and the need for physicians to be educated in the necessary skills is recognized in current training initiatives such as Pediatric Advanced Life Support (PALS) and Advanced Pediatric Life Support. Unfortunately, the majority of instruction in central venous access techniques is theoretic. This approach does not provide the hands-on training needed to give practitioners the necessary practical experience, or confidence in their skills. Practice using simulated tissue can enable physicians to perform practical skills with greater confidence. However, although commercially available models exist for peripheral venous access, a recent cross-Canada survey of the 13 PALS program coordinators and a similar inquiry to the American Heart Association indicated that none of them had a pediatric practice model for central venous access. We describe 1) how to construct from materials readily available a pediatric model for the insertion of central venous catheters into the femoral vein using the Seldinger technique, and 2) an evaluation of the change in confidence learning with the model engendered. In our experience, this model is inexpensive (less than $50) and can be replicated readily by others for use as a teaching aid. It provides inexperienced physicians the opportunity to learn the practical elements of the technique and acquire confidence in the Seldinger method. Our hypothesis was that the confidence and skill of physicians would be increased by practical experience of central line insertion using a realistic model. The model enables trainees to be taught the technique described in the PALS manual to locate the femoral artery. They then can learn to introduce a thin-walled needle or over-the-needle catheter, one finger's breadth below the inguinal ligament and just medial to the location of the femoral artery. The needle or over-the-needle catheter then can be advanced at the correct angle if the needle is directed toward the model's umbilicus. As occurs in vivo, the model allows for a free flow of fluid to be obtained as the "vessel" is entered. If the Foley catheter simulating the vessel is transfixed, negative pressure applied as the needle is withdrawn will result in fluid being obtained as the needle tip reenters the "vessel." The syringe then can be removed from the needle, and the key elements of the procedure-correct insertion of the Seldinger guide wire and passage of the venous catheter over the guide wire into the vessel-can be practiced. If desired, instruction also can be given on the use of a dilator and techniques of taping the catheter in place and all the appropriate techniques to avoid potential air embolism. However, the model does not lend itself to instruction in suturing. The model has been used to teach the practical elements of this technique to 428 physicians (emergency physicians, 49%; pediatricians, 24%; other physicians, 20%; pediatric residents, 7%). Their success rate for cannula insertion in three or fewer attempts was 87%. The last 218 physicians were evaluated to assess the influence of learning with the model on their confidence to perform the technique successfully in an emergency. Before training they were asked, "Have you done a pediatric resuscitation course that taught this technique in theory?" and "Rate your confidence level for performing central vascular access in a patient from 0 to 5 (none, very little, some, moderate, good, complete)." This rating was repeated after the training session using the model. For 154 (71%) answering "yes" to a previous resuscitation course, mean scores were 1.52 (standard error [SE] +/- 0.91) after theoretic instruction and 4.06 (SE +/- 0.47) after practical education using our model. The 64 (29%) physicians

A comparison of intubation success for paediatric transport team paramedics using lighted vs regular tracheal tube stylets.

We conducted a prospective randomized study of success rate and time to intubation using Trachlight and Surch-Lite lighted stylets versus a regular tracheal tube stylet, in a training setting. Participants, 18 paediatric transport paramedics, performed two intubations with each of the three devices, using an airway management trainer. There was no significant difference in mean time for intubation between the three devices. The times for external confirmation of correct tube placement were comparable using the two lighted stylets. External confirmation of the tube placement using the lighted stylets was quicker than laryngoscopic visualization. In darkness, with a nonfunctioning laryngoscope, intubations were successfully performed 100% of the time with the lighted stylet, but only 11% of the time with the regular stylet. All paramedics felt that a lighted stylet would be a useful airway management adjunct for the transport environment for complicated intubations or for use in very high or low levels of ambient light.

Evaluation of the 3-drug combination, Rifater, versus 4-drug therapy in the ambulatory treatment of tuberculosis in Cape Town.

The subjective impression among clinicians that the use of Rifater was causing delayed sputum conversion and increased drug resistance was tested in a prospective study. Adults in the Cape Town municipal area with a first episode of pulmonary tuberculosis were treated either with Rifater or a regimen consisting of isoniazid, rifampicin, pyrazinamide and ethambutol. All patients who took the treatment as prescribed (67 Rifater, 39 the 4-drug regimen) converted to a negative sputum culture by the time 90 doses had been taken. The rates of inadequate compliance and of side-effects were similar in the two groups. Drug sensitivity testing of bacteria cultured from pre-treatment sputum specimens revealed an overall primary resistance rate of 4.84% in the population studied, sufficiently low to preclude any necessity for routine pre-treatment drug sensitivity testing.

Safety profile of benazepril in essential hypertension.

Data from clinical trials with benazepril suggest that the safety profile of benazepril is similar to that of other angiotensin-converting enzyme (ACE) inhibitors. Treatment-related side effects occurred in 20% of benazepril-treated patients and in 18% of patients receiving placebo. The most commonly reported side effects with benazepril were headache, dizziness, and fatigue. The incidence of side effects was not affected by the degree of hypertension, age, gender, race, dosage, or the degree of renal impairment. Side effects believed to be related to the pharmacologic action of ACE inhibitors as a class include symptomatic hypotension, which occurred at a relatively low rate with benazepril, and hyperkalemia and elevation of serum creatinine, which occurred to the same extent with benazepril as has been noted with other ACE inhibitors. The mechanism of cough as an ACE inhibitor side effect is unknown; the incidence was similar to that with other ACE inhibitors. Rash and taste disturbance have occurred rarely with benazepril. The incidence of neutropenia and of proteinuria was the same in both the benazepril and placebo groups. Renal failure in hypertensive patients treated with benazepril has not been reported. Overall, benazepril is generally well tolerated by hypertensive patients. The incidence of most side effects is comparable to that with other ACE inhibitors and placebo.

The stress response to induced hypotension for cerebral aneurysm surgery: a comparison of two hypotensive techniques.

Plasma epinephrine (PE), plasma norepinephrine (PNE), plasma renin activity (PRA), mean arterial pressure (MAP) and heart rate (HR) were measured before, during and after induced hypotension in two groups of patients undergoing cerebral aneurysm surgery. In Group I isoflurane was used to maintain anaesthesia and induce hypotension. Mean PE fell significantly during hypotension and remained reduced after hypotension, mean PNE remained unchanged, while mean PRA rose slightly but not significantly during hypotension, falling again after hypotension. In Group II halothane was used to maintain anaesthesia and sodium nitroprusside to induce hypotension. During anaesthesia and surgical stimulation PNE and PRA were significantly greater compared to Group I. Mean PE, PNE and PRA all rose during hypotension and remained elevated after hypotension. The rise in PNE and PRA was statistically significant. After hypotension the MAP in Group II was significantly higher when compared to Group I. There was no significant change in HR during the study in either group. In conclusion, isoflurane-induced hypotension with isoflurane anaesthesia unlike sodium nitroprusside-induced hypotension with halothane anaesthesia attenuated the stress response.

Fatality due to massive overdose of sodium valproate.

A 40-year-old woman admitted after a massive overdose of sodium valproate was found to have a serum valproate level of 18,900 mumol/1 which is the highest ever reported. She underwent cardio-respiratory failure, bone marrow suppression and neurological depression, subsequently dying. On post-mortem there was haemorrhagic pancreatitis but no histological evidence of hepatotoxicity. Valproate levels measured in various post-portem tissues and fluids indicated a high level in bile (21,375 mumol/1) suggesting that enteral administration of activated charcoal might be of some benefit by decreasing enterohepatic circulation of the drug.

Effect of thromboxane synthetase inhibition on vulnerability to ventricular arrhythmia following coronary occlusion.

Release of thromboxane (TXA2) during acute myocardial infarction may be an important contributing factor in the genesis of ventricular fibrillation (VF). We assessed the effect of selective TXA2 inhibition on vulnerability to VF after total occlusion of the anterior descending coronary artery in chloralose-anesthetized cats. Animals were pretreated with vehicle or with CGS-13080, a TXA2 synthetase inhibitor, 3.0 or 9.0 mg/kg intravenously. There was an apparent dose-dependent protective effect following CGS-13080 administration, in which the decrease in VF threshold following coronary occlusion was attenuated. Also, the incidence of spontaneous ventricular arrhythmia in the first 30 minutes after occlusion was reduced by two thirds in the 9.0 mg/kg CGS-13080 group compared to the vehicle-treated animals. This protective effect does not appear to be due to a change in hemodynamics, effective refractory periods, or extent of ischemia. TXA2 released during coronary occlusion appears to be arrhythmogenic, and inhibiting its synthesis may be protective.

Profound reduction in morphine clearance and liver blood flow in shock.

In six patients with septic shock apparent liver blood flow was significantly reduced compared with two patients restudied on recovery from shock and a group of four matched unshocked patients undergoing intensive care (287 +/- 23 ml/min vs 870 +/- 164 ml/min; mean +/- SEM). In the shocked patients the elimination half-life of morphine was significantly prolonged (13.2 +/- 3.5 h vs 5.9 +/- 1.4 h; mean +/- SEM) and the systemic clearance of morphine reduced by 53%, in comparison with the non-shocked patients. In both groups, morphine elimination was markedly delayed compared with previously reported observations in normal subjects and surgical patients. Care should be exercised with the use of drugs with a high hepatic extraction ratio in shocked patients.

High-dose intravenous IgG in the management of pregnancy in women with idiopathic thrombocytopenic purpura.

Idiopathic thrombocytopenic purpura (ITP) may develop during pregnancy or affect later pregnancies, causing serious risks of bleeding to the mother and fetus. High-dose intravenous immunoglobulin (IGIV) has caused an immediate and predictable rise in platelet count during the infusion in both adults and children with chronic or acute ITP. The rapid rise in platelet counts may be important in preparing pregnant women with ITP for surgery or delivery. We report our experience in managing two women at weeks 29 and 37 week of gestation who required splenectomy and/or cesarean section. Both patients demonstrated an increase in platelet counts, underwent surgery without excess bleeding, and had normal infants with normal platelets, and with mild thrombocytopenia at delivery.

Evaluation of signal detection theory on the effects of psychotropic drugs on critical flicker-fusion frequency in normal subjects.

Critical flicker-fusion frequency (CFF) has often been applied to psychotropic drug evaluation as a measure of cortical arousal. There are several variables that must be considered for proper conclusions to be obtained from CFF experimental data. Psychological variables such as subject response bias are especially difficult to control. We studied the effects of single oral doses of 10 mg diazepam and 10 mg amphetamine sulfate on CFF values obtained by a block up-down spatial forced-choice method on 13 healthy volunteers (seven males and six females). Signal detection theory was also used to obtain the non-parametric value P(A) as a measure of sensory function and B as a measure of the psychological function of response bias. As a group, amphetamine increased CFF (Hz) and P(A) and diazepam decreased CFF (Hz) and P(A), with the most significant effects observed at 2 and 3 h after drug administration. B scores showed more individual variation with a trend towards a low score, or a tendency to report more flicker responses after diazepam. Separated by sex, the males had a higher percentage of subjects that demonstrated a reduction of CFF after diazepam, while the females had a higher percentage that demonstrated an increase in CFF after amphetamine. The results suggest that CFF changes following diazepam and amphetamine are mostly changes in sensory function and not changes in response bias. It is possible to apply signal detection theory to flicker-fusion studies and the accounting of bias by controlling, measuring or eliminating it is essential in interpretation of CFF data.

The value of an auditory stimulatory test in antenatal fetal cardiotocography.

One hundred auditory stimulatory antenatal fetal cardiotocographic tests were compared to standard non-stress tests in patients with pregnancy hypertension. The incidence of equivocal tests was significantly reduced. The A.S.T. is a simple and reliable test for assessing fetal heart reactivity in hypertensive pregnancy.

An evaluation of tamoxifen as a partial agonist by classical receptor theory--an explanation of the dual action of tamoxifen.

Tamoxifen is known to have both agonist and antagonist properties. Classical receptor theory predicts that given the relative concentrations of a partial agonist and full agonist acting on the same receptor, the partial agonist may reduce the effect of the full agonist. The immature rat uterine model is an excellent system to evaluate the interactions of estradiol and tamoxifen by application of receptor theory. Using this model, tamoxifen demonstrates both additive and antagonistic effects to estradiol in the fashion predicted by theory. The effects of tamoxifen are additive at low doses of estradiol and antagonistic over higher estradiol doses. It is possible that the dualism of agonism and antagonism seen in other target organs and species is a function of these basic characteristics of a partial agonist.