Process evaluation of the implementation of scorecard-based antenatal risk assessment, care pathways and interdisciplinary consultation: the Healthy Pregnancy 4 All study.

OBJECTIVE: To evaluate the implementation of a complex intervention in the antenatal healthcare field in 14 Dutch municipalities. The intervention consisted of the implementation of a systematic scorecard-based risk assessment in pregnancy, subsequent patient-tailored care pathways, and consultations of professionals from different medical and social disciplines. METHODS: Saunders's seven-step method was used for the development of a programme implementation monitoring plan, with specific attention to the setting and context of the programme. Data were triangulated from multiple sources, and prespecified criteria were applied to examine the evidence for implementation. RESULTS: Six out of 11 municipalities (54%) met the implementation criteria for the entire risk assessment programme, whereas three municipalities (27%) met the criteria if the three components of implementation were analysed separately. CONCLUSIONS: A process evaluation of implementation of a complex intervention is possible. The results can be used to improve understanding of the associations between specific programme elements and programme outcomes on effectiveness of the intervention. Additionally, the results are important for formative purposes to assess how future implementation of antenatal risk assessment can be improved in comparable contexts.

Effects of restricted feeding on physiological stress parameters in growing broiler breeders.

1. In previous studies, a lack of agreement in measurements of plasma corticosterone concentrations and heterophil:lymphocyte (H/L) ratio as physiological indices of stress, caused by hunger and frustration in restricted-fed broiler breeders, was observed. It could be suggested that the differences between previous studies were caused by differences in duration of restriction and time of the day of the measurements. Therefore, in the present study the plasma corticosterone concentration and the H/L ratio were again determined in restricted- and ad libitum-fed growing broiler breeders, taking possible causes of disagreement between previous studies into account. In addition, we measured the daily rhythm in body temperature and heart rate, and the corticosterone responses to an acute stressor as physiological indices of stress. 2. Female broiler breeders (64 per treatment, housed in groups of 4 birds) were used in the experiment. Behaviour, baseline plasma corticosterone concentrations and H/L ratio were determined at 21 d of age (immediately after the start of food restriction), and at 42 and 63 d of age. Body temperature, heart rate and activity were measured by radiotelemetry for 36 h at 49 and 70 d of age. In addition, the plasma corticosterone response to acute stress (5 min manual restraint) was measured at 77 or 78 d of age. 3. Restricted broiler breeders had higher plasma corticosterone concentrations at 42 and 63 d of age, but no differences in H/L. ratio were found between restricted birds and unrestricted control birds. Restricted broiler breeders had a higher corticosterone response to 5 min manual restraint than unrestricted birds. Restricted birds displayed a clear day-night rhythm in body temperature, heart rate and activity whereas such a rhythm was blunted in ad libitum-fed birds. 4. It is discussed that some physiological differences (plasma corticosterone concentrations, body temperature and heart rate) between ad libitum-fed and restricted broiler breeders may have been caused by differences in metabolic rate as well as by differences in the level of stress. It is concluded that a combination of behavioural measurements and a wide range of physiological parameters should be used for the assessment of stress in growing broiler breeders.

High carbon dioxide tension (PCO2) and the incidence of cardiac arrhythmias in rapidly growing broiler chickens.

The purpose of this investigation was to determine whether two-week-old rapidly growing broiler chickens with high metabolic activity have an increased risk of the development of heart failure three to five weeks later. The incidence of cardiac arrhythmias was assessed in broiler chickens with either a relatively high carbon dioxide tension (PCO2) or a low PCO2 in their venous blood. Their electrocardiograms (ECGS) were measured when the birds were between five and seven weeks old by means of a biotransplant which allowed them to move freely. Premature ventricular beats were observed in all the birds, but the largest numbers were observed in birds that had had a high PCO2 when they were two weeks old.

Intraluminal shunt for the thoracic aorta: blood flow and function in chronic studies.

BACKGROUND: Aortic cross-clamping during operations on the thoracic aorta may result in paraplegia or kidney failure. METHODS: A nonshunting method of repair was compared with intraluminal shunting in two groups of young pigs: the no-shunt group, which received simple aortic cross-clamping at the ligamentum for 15 minutes; and the shunt group, which received an aortic graft with a temporary intraluminal shunt and balloon occlusion of the inferior vena cava only during shunt insertion and removal. Blood flow to the spinal cord and viscera was measured with radiolabeled microspheres on days 1, 3, 5, and 7 after operation. Renal and neurologic function and histology also were studied. RESULTS: In the no-shunt group, there was hyperemia of the lumbar cord compared with the shunt group. There were no significant differences in renal cortex blood flow or creatinine clearance. Seven of 10 animals in the no-shunt group had paraplegia, compared with none in the shunt group. Histologic studies of the lower lumbar cord showed bilateral central necrosis of gray matter in the no-shunt group, but no evidence of necrosis in the shunt group. CONCLUSIONS: An intraluminal shunt allowed thoracic aorta reconstruction without paraplegia.

Intraluminal shunt for the thoracic aorta: spinal cord and visceral blood flow in acute studies.

Aortic cross-clamping during surgery of the thoracic aorta may result in paraplegia or kidney failure. Difficulties associated with external shunts and bypasses have limited their use. Therefore we compared intraluminal shunting to the nonshunting method of repair in neonatal pigs. Blood flow to the spinal cord and viscera was measured with radiolabeled microspheres before, during, and after thoracic aortic cross-clamping or shunting. Two no-shunt groups were studied: One group was clamped distal to the left subclavian artery for 30 minutes and the other for 1 hour. In the intraluminal shunt group, a shunt was placed in the aorta just below the ligamentum arteriosum for 1 hour; it was then removed and the aorta repaired. In the no-shunt groups, there was virtually no blood flow to the lower cord and viscera during the cross-clamp period. Hyperemia of the lower thoracic and lumbar cord occurred in the no-shunt 30-minute group 15 minutes after clamp removal. In the no-shunt 60-minute group, flow initially returned to the lumbar cord but then declined; and after 1 hour of reperfusion it was significantly lower than baseline. Renal blood flow was even more severely affected in the no-shunt 60-minute group, with minimal recovery during the reperfusion period. In the intraluminal shunt group baseline spinal cord and visceral blood flow were maintained during thoracic aortic cross-clamping, without the problems associated with extracorporeal circulation.

Investigation of passive venovenous shunts during the anhepatic period of canine hepatic transplantation.

The anhepatic period of canine orthotopic hepatic transplantation is usually accompanied by cardiovascular instability due to occlusion of both the portal and inferior systemic venous systems. The present study was undertaken in order to determine some of the hemodynamic and renal alterations that occur during a 2 hour anhepatic period in the dog and to investigate the use of a passive endoportal, endocaval venovenous shunt that places both the portal and infrahepatic vena caval limbs of the shunt directly into the divided ends of these vessels. Three groups of experimental animals were studied. One group had hepatectomy without a shunt and was compared with two other groups which had hepatectomy with some form of venovenous shunting. Systemic arterial blood pressure, portal and inferior vena caval pressure, urinary output, and renal histology were all better maintained when a shunt was used.

Small bowel obstruction from an antacid bezoar: a ranitidine-antacid interaction?

A 63-year-old man had an acute small bowel obstruction while being treated with ranitidine and self-prescribed antacid. On exploration, a firm mass, chemically similar to the ingested antacid, was found impacted in the terminal ileum. We believe the effect of ranitidine on gastric secretory volume was the cause of the antacid concretion.

Survival following hepatic transplantation in the cyclosporine era.

In a series of 50 consecutive patients receiving 55 hepatic transplants, the 6-month survival was 76 per cent. Mortality was considerably higher in patients with complications of advanced liver failure (56%) than in patients that were not hospital-confined preceding the transplant procedure (10%). The causes of death were related primarily to technical errors, and uncommonly caused by rejection or uncontrollable infection. This striking change in the cause of death occurring in the cyclosporine era results from the use of more specific immunosuppression and close scrutiny of the allograft with frequent hepatic biopsy. Both of these principles diminish the reliance on high-dose corticosteroid therapy, and therefore promote wound healing and resistance to fatal infection.

Cholestatic jaundice after hepatic transplantation. A nonimmunologically mediated event.

Serial liver biopsy and close clinical monitoring in 55 consecutive hepatic allografts have disclosed a syndrome of cholestatic jaundice that simulates rejection. This syndrome is associated with distinct histologic findings and resolves spontaneously without modification of immunosuppressive management. The cause of the cholestasis is probably related to subcellular organelle damage produced by cold ischemia, and its importance stems from the confusion it creates with regard to rejection diagnosis. Recognition of this syndrome can result in decreased immunosuppression in hepatic allograft recipients, a secondary decrease in infectious complications, and improvement in the survival rate.

Autotransfusion in hepatic transplantation.

Hepatic transplantation is often accompanied by a large volume of intraoperative blood loss which may place extraordinary transfusion demands on a community blood bank. In an effort to conserve blood bank resources, intraoperative autotransfusion has recently been used in our adult patients undergoing orthotopic hepatic transplantation. A group of seven patients receiving autotransfusion was studied and compared to another group of five patients who did not receive autotransfusion. In spite of receiving more blood during the transplant procedure, the autotransfusion group required a mean of 7.9 units less banked blood. Post-transplant transfusion requirements and bleeding complications were similar in both groups. Hematocrit and total bilirubin were not adversely affected, while transient elevation of BUN and serum creatinine appeared to be unrelated to the salvage process. This procedure was found to be safe and cost-effective, while conserving blood bank resources.

Biopsy-directed immunosuppression following hepatic transplantation in man.

Patients undergoing orthotopic hepatic transplantation were studied with routinely available liver function studies and serial hepatic biopsies. Rejection was diagnosed only if confirmed histologically. Cyclosporine and a rapidly decreasing dose of corticosteroids were used for immunosuppression. Hepatic dysfunction suggesting rejection was seen in 22 instances, but acute rejection was diagnosed histologically in only 6 patients. The liver function studies used in these patients did not accurately distinguish rejection from other causes of hepatic dysfunction. We conclude that liver biopsy as performed in these patients is an accurate and safe means of assessing the adequacy of immunosuppression and minimizing the use of high dose corticosteroids.

Liver transplantation with cyclosporine and low-dose corticosteroids.

Twenty consecutive patients receiving 21 hepatic transplants were treated with cyclosporine and low-dose corticosteroids. Survival was 80 per cent at 30 days, 75 per cent at 6 months, and 65% in the 6-17 months follow-up period. Compared with earlier series, this improved survival using cyclosporine results from fewer infectious and sound healing complications. Reliance on hepatic biopsy to confirm the diagnosis of rejection may also reduce the corticosteroid exposure and help diminish the complications of excessive immunosuppression.

Cyclosporine in transplantation of the liver in the dog.

Orthotopic hepatic transplantation was performed upon 29 dogs. Four dogs received no immunosuppressant, 12 received cyclosporine and 13 received azathioprine. Dogs treated with cyclosporine at a dose of 20 milligrams per kilogram yielded histologic and functional data indistinguishable from those of the dogs in the sham transplant group. Histologic evidence of rejection consistently appeared when the dose was decreased to 10 milligrams per kilogram but was reversed upon resuming the administration of the higher dosage. Serum levels of bilirubin and hepatic enzymes, serum glutamic-oxalacetic transaminase, serum glutamic-pyruvic transaminase and alkaline phosphatase did not correlate with the development or resolution of histologic evidence of rejection in dogs receiving cyclosporine. Dogs receiving cyclosporine for 60 days had a prolonged survival when the drug was stopped, whereas the dogs receiving such therapy for less than 60 days did not have a prolonged survival period.