Parenteral with enteral nutrition in the critically ill.

OBJECTIVE: To determine whether nutrient intake by early enteral nutrition with parenteral nutrition improves levels of retinol-binding protein and prealbumin (primary endpoint) and reduce morbidity and mortality (secondary endpoint) in ICU patients. DESIGN: Prospective, double-blind, and randomized, placebo-controlled study. SETTING: Two intensive care units in a tertiary institution. PATIENTS AND PARTICIPANTS: 120 patients in two groups of 60. INTERVENTIONS: Patients received either enteral plus parenteral nutrition (treatment group) or enteral nutrition plus placebo (placebo group) for 4-7 days after initiation of nutritional support. MEASUREMENTS AND RESULTS: Retinol-binding protein (P = 0.0496) and prealbumin (P = 0.0369) increased significantly in the treatment group from day 0 to day 7. There was no reduction in morbidity in ICU. There was no difference in OMEGA score (263 vs. 244) and length of stay in the ICU (16.9 vs. 17.3), but a reduction in length of stay at hospital (31.2+/-18.5 vs. 33.7+/-27.7, P = 0.0022). Mortality on day 90 (17 vs. 18) and after 2 years (24 vs. 24) was identical. CONCLUSIONS: Although it enhances nutrient intake and corrects nutritional parameters such as RBP and prealbumin more rapidly, within 1 week, supplemental parenteral nutrition has no clinically relevant effect on outcome in ICU patients at the early phase of nutritional support.

HIV testing in gay sex clubs.

The purpose of this study was to evaluate a programme of human immunodeficiency virus (HIV) antibody testing at gay sex clubs. Conducting secondary analyses with 2 datasets, we evaluated HIV-testing preferences of patrons at 2 sex clubs and compared their risks to testers at a standard testing clinic. Sex club testers had significantly more partners and were significantly older than their clinic peers. Sixteen per cent of sex club testers reported that they would not test if testing were not available at the sex club. Gay sex clubs offer an opportunity to reach men at high risk for HIV, some who otherwise may not test.

[Australian Refined Diagnosis Related Groups. Formal and inherent problems of grouping with the example of stroke care]. / Australian Refined Diagnosis Related Groups. Formale und inhaltliche Problematik der Anwendung am Beispiel der Schlaganfallversorgung.

BACKGROUND AND OBJECTIVES: With the Health Reform 2000, the Australian Refined Diagnosis Related Groups (AR-DRG), Version 4.1 have been chosen as the basis for the future German costing system for hospitals. With regard to Stroke Severity (Barthel Index [BI]) we investigated to what extent the grouping according to AR-DRGs can reproduce healthcare expenditures for such patients. Options to adapt and optimize the system are discussed. PATIENTS AND METHODS: 632 patients who had suffered a cerebrovascular accident and were discharged from conservative acute care in 1999, were classified according to the AR-DRGs. For the grouping we alternatively used data from the current hospital information system and a stroke database for quality assurance. The results were also compared with the clinical profiles for the public hospital sector of the corresponding DRGs in Australia (1997-98). RESULTS: On average 0.99 additional diagnoses per case were documented in the hospital information system, compared to 3.65 in the stroke database. In the stroke database 177 cases (36.8%) were assigned to the DRG with the highest cost weight. 53.7% of these patients suffered a serious stroke (BI < 30). Grouping on the basis of hospital information system data led only to 14 cases (2.8%) assigned to the DRG with the highest cost weight. CONCLUSIONS: Type and extent of additional diagnoses are crucial for the grouping process. From a clinical and economic point of view, measures of disability and impairment should be assigned to the grouping process to improve homogeneity under both aspects. Scores can also serve for determining reliable outcome parameters. For the development of an outcome related reimbursement system, procedures must be included in the definition of medical DRGs. In future, DRGs, which cover overlapping healthcare sectors, should be developed for patients with poststroke rehabilitation.

Paediatric assessment in a residential child and adolescent psychiatry unit.

OBJECTIVE: To document the health status, comorbidity and functional impairments experienced by a group of psychiatrically disturbed children and adolescents. METHODOLOGY: A detailed study of consecutive admissions to a residential unit over a two-year period was undertaken. All admissions had a comprehensive paediatric, speech pathology and psychiatric assessment. RESULTS: Compared to the general population, there was a significant history of developmental delay and low birthweight, but only a slightly greater prevalence of antenatal problems. Clumsiness (37%), severe speech and language disorder (32%), and hearing loss (15%) were prominent. Only 25% had no history of comorbid medical or neurological disorders. CONCLUSION: Children and adolescents presenting with moderate to severe mental health morbidity may have pre-existing comorbid medical problems, as well as unrecognised difficulties and impairments in other skills areas. Multidisciplinary assessment and intervention should be an integral part of the residential programme.

Reduced atrial angiotensin receptor type 1 mRNA content in end-stage human heart failure: assessment by a novel quantitative PCR-ELISA technique.

The number of atrial angiotensin II binding sites is reduced in end-stage human heart failure. The goals of our study were the development of a quantitative polymerase chain reaction for angiotensin II receptor type 1 mRNA to determine the angiotensin receptor type 1 (AT1) mRNA content in the atria of patients with end-stage heart failure. We established a quantitative PCR based on coamplification of AT1 wild-type and an internal standard in the same PCR, followed by liquid-phase hybridization of PCR products in microtiter plates and quantitation by ELISA. Glyceraldehyde phosphate dehydrogenase mRNA in the same samples was used to relate the AT1 mRNA content to a stably expressed reference gene. Atrial samples from 11 patients with end-stage heart failure obtained at cardiac transplantation were compared with atrial samples from 11 patients with normal cardiac function undergoing routine cardiac surgery. A PCR/ELISA system with a variance of about 6% after reverse transcription and a linear measuring range was established. In the samples from 11 patients with end-stage heart failure a 58% decrease in AT1 mRNA content was found in comparison with 11 controls (heart failure: 185,680 +/- 196,912 AT1 mRNA copies/microgram RNA, controls: 440,555 +/- 268,456, P < 0.02). When AT1 mRNA content was related to glyceraldehyde phosphate dehydrogenase mRNA, a 65% decrease was detected (AT1/glyceraldehyde phosphate dehydrogenase: heart failure: 4.84 +/- 5.18; controls: 13.74 +/- 7.77; P < 0.005). Standardization of PCR resulting in a low coefficient of variance, high reproducibility, and large sample capacity is possible using optimal internal standardization and the liquid-phase hybridization/ELISA system for detection. The optimized PCR procedure indicated downregulation of atrial AT1 in end-stage human heart failure, suggesting a reduced capacity of the atria to respond to angiotensin II stimulation in end-stage heart failure.

An adaptive method for establishing a dose-response relationship.

A multistage sampling method is proposed in dose-response trials, where dose adaptions can be performed in the preplanned adaptive interim analyses. The overall test for proving a dose-response relationship is performed by Fisher's product criterion for the p-values from the separate tests of a dose effect in the disjoint samples at the different stages. Based on these p-values decision boundaries for early stopping with the rejection of the global null hypothesis of no existing dose-response relationship are introduced. The power of the adaptive two-stage procedure using a particular adaptation rule is compared with the power of the test for a linear trend under analysis of variance assumptions in extensive simulations. The bias in estimation is also quantified. This procedure could be used for establishing a dose-response relationship without including a placebo treatment.

[Criteria for biostatistical assessment in surgery of stomach cancer]. / Kriterien zur Biostatistik bei der Chirurgie des Magencarcinoms.

The problem of making valid statements about the prognosis of survival after radical operation of stomach cancer, based on retrospective or prospective studies, is investigated. Some explanations are given for contradictory or non-reproducible results in different subgroups. Especially the problem of searching for "significant" results by multiple testing of different subgroups (data snooping) is treated critically. In case of remaining open questions randomised studies appear to be inevitable.

The Case Mix System.

The Case Mix System (CMS) was developed as a broad-based decision support system for planning and managing effectiveness in the product line environment. CMS is proven in a range of hospital settings and provides the information needed to meet todays health care management challenges.