Current management of patients taking herbal medicines: a survey of anaesthetic practice in the UK.

BACKGROUND AND OBJECTIVES: Increasing numbers of patients taking herbal medicine products are presenting for anaesthesia and surgery. Anaesthetists need to consider the perioperative implications of herbal medicines and should, therefore, have some knowledge of this subject. METHODS: A postal questionnaire survey was sent to a random 5% of practising members of the Association of Anaesthetists of Great Britain and Ireland residing in the UK, to identify attitudes, practice and knowledge regarding herbal medicines. RESULTS: From 341 questionnaires there were 221 replies, a 65% response rate. Ninety per cent stated that they seldom or never asked patients about herbal medicine usage, yet 65% felt that there could be potentially harmful effects of herbal medicines in the perioperative period. There was a very poor level of knowledge with respect to the current management of 10 well-known herbal medicines. However, 75% agreed that information about perioperative usage of herbal medicines is important, and 77% felt that herbal medicines should be in the undergraduate medical curriculum. Reading was the usual source of herbal medicine product information. Most (82%) felt their knowledge of herbal medicine products and the implications in patient care were inadequate. CONCLUSIONS: This sample of anaesthetists require education on herbal medicines. Suggestions for remedial action are given.

A critical evaluation of the past 25 years of perinatal nursing practice: opportunities for improvement.

Changes in perinatal nursing over the past 25 years have been abundant. Nursing advocacy has contributed to the introduction of innovations such as single-room maternity care and family-centered care, and to the end of restrictive practices such as the use of hand and leg restraints during birth, routine use of episiotomy, and routine general anesthesia for normal births. Perinatal nursing involves complex clinical interventions, intensive patient and family education, empathetic support and evaluation of family dynamics, and a wide range of opportunities to make a difference in the lives of mothers, babies, and families. The strengths and weaknesses of perinatal nursing practice at the beginning of the new century are chronicled, and suggestions for improvements are made.

High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims.

Perinatal units differ in their ability to prevent patient injury and medical malpractice litigation. Obstetrical units with favorable performance are distinguished by common organizational and clinical features. Organizationally, they resemble what behavioral scientists define as "high-reliability organizations" (i.e., the ability to operate technologically complex systems essentially without error over long periods). Clinically, practices are based on nationally recognized guidelines and/or an operational philosophy of "safety first." These organizational and clinical features are described so that physicians, nurses, and administrators might view their own clinical environments in the context of this perspective.

Photodynamic therapy of actinic keratosis with topical 5-aminolevulinic acid. A pilot dose-ranging study.

OBJECTIVE: To examine the safety and efficacy of photodynamic therapy using topical 5-aminolevulinic acid (ALA) and red light to treat actinic keratoses (AKs). DESIGN: Actinic keratoses were treated with topical ALA (concentrations of 0%, 10%, 20%, or 30%) under occlusion for 3 hours. Before photodynamic therapy, sites were examined for fluorescence. Sites were irradiated with an argon pumped dye laser (630 nm) at fluences of 10 to 150 J/cm2. SETTING: Academic medical center. PATIENTS: Forty patients with 6 clinically typical, previously untreated AKs per patient. MAIN OUTCOME MEASURE: Complete resolution and decrease in lesion area of the AK relative to baseline evaluated at weeks 1, 4, 8, and 16. RESULTS: Three hours after ALA administration, lesions showed moderate red fluorescence. Cutaneous phototoxic effects, localized erythema and edema, peaked at 72 hours. Patients experienced mild burning and stinging during light exposure. Eight weeks after a single treatment using 30% ALA, there was total clearing of 91% of lesions on the face and scalp and 45% of lesions, on the trunk and extremities. No significant differences were observed in clinical responses with treatment using 10%, 20%, or 30% ALA. All concentrations of ALA were more effective than treating AKs with vehicle and light. CONCLUSIONS: Topical photodynamic therapy with ALA is an effective treatment of typical AKs. Complete clearing of nonhypertrophic AKs can be achieved with 10%, 20%, or 30% ALA that is easily tolerated by the patient. Lesions on the face and scalp are more effectively treated than lesions on the trunk and extremities. Hypertrophic AKs did not respond effectively.

Nonsurgical management of gastric or duodenal perforation from a Wills-Oglesby-type gastrostomy tube.

PURPOSE: To describe the clinical and radiologic appearance of gastrointestinal perforation related to a Wills-Oglesby-type gastrostomy tube, as well as techniques for nonsurgical management. MATERIALS AND METHODS: Five patients with a previously placed 14-F modified Wills-Oglesby-type gastrostomy catheter experienced viscus perforation by the distal limb of the catheter during a 30-month period. RESULTS: The average interval between tube placement and perforation event was 4.3 months. Three patients had migration of the gastrostomy tube into the duodenum and subsequent duodenal perforation. One patient had posterior perforation of the stomach, and one patient developed a gastrocolic fistula. Generalized peritonitis was not present in any patient. All patients were treated successfully without surgery, and tube feedings were re-established in 4-14 days. CONCLUSIONS: Gastrostomy tube-related perforation is an uncommon, delayed complication of percutaneous gastrostomy with the modified Wills-Oglesby-type catheter. Nonsurgical management is feasible in select instances. Because of these gastrointestinal perforations, the gastrostomy tube has been modified (eliminating the distal tip), and no gastrostomy-associated gastrointestinal perforation has been experienced since.