Outpatient ureteric stent removal following kidney transplantation.

During a kidney transplant, a plastic tube (stent) is placed in the ureter, connecting the new kidney to the bladder, in order to keep the new join open during the initial phase of transplantation. The stent is then removed after a few weeks via a camera procedure (cystoscopy), as it is no longer needed. The present study compared performing this in the operating theatre or in clinic for transplanted patients using a new single-use type of camera with an integrated grasper system. The results have shown that it is safe and cost-effective to do this in clinic, despite patients being susceptible to infection after transplantation.

The uncertainty of thyroid dose estimate in chest CT.

Dose to the thyroid from helical chest CT can vary significantly due to the random tube start point, pitch factor, thyroid position relative to the isocenter, and beam width. We used optically stimulated luminescence dosimeters (OSLDs) and an adult anthropomorphic phantom to investigate the uncertainty of thyroid dose estimate. Maximum gap or overlap in the helical beam was estimated using the above factors. Using the maximum gap/overlap over the thyroid, different possible scenarios were simulated and the degree of missed thyroid tissue by the primary beam was estimated. Results showed a variation of >30% in the average thyroid dose, and >50% if a single dosimeter was used to determine dose to the thyroid. Furthermore, measured doses were compared to those calculated by Monte Carlo simulation software, which automatically matches the anatomy of the localizer radiograph with the stylized computational phantom used for dose calculation. The difference was significant: the dose given by the Monte Carlo software was ∼50% lower than the average dose measured with the phantom in all three chest protocols. In addition, the software does not take the effect of the random tube start angle into account.

Impact of piperacillin-tazobactam shortage on meropenem use: implications for antimicrobial stewardship programs.

Drug shortages pose a clear detriment to antimicrobial stewardship (AS) efforts. Our objective was to evaluate the effect of a piperacillin-tazobactam shortage on meropenem use, related costs, and associated changes in AS activity. A quasi-experimental quality improvement review compared adult patients receiving meropenem ≥72h three months pre-shortage and three months during the shortage. 320 patients were included (pre-shortage: 103; shortage: 217). Baseline characteristics were similar, but the length of stay was slightly longer in pre-shortage [19 (11-32) days] versus shortage [16 (11-32) days] (p=0.094). In pre-shortage and shortage, median days of therapy and estimated meropenem cost were 7 (5-11) and 7 (5-10) and $309.93 ($173.60-$507.03) and $255.30 ($204.24-$424.31), respectively (p=0.411 and p=0.050). Frequency of ID consultation was similar (16.8% in pre- and 25.3% in shortage, p=0.091). AS interventions increased during the shortage period (99 in pre-shortage and 205 in shortage). De-escalation occurred in 19.4% versus 32.7% of the patients in pre-shortage and shortage (p=0.014). The piperacillin-tazobactam shortage was associated with a 111% increase in meropenem prescriptions despite active AS, but was not associated with changes in mortality, length of therapy, or meropenem costs. AS should be aware that shortages may require proactive countermeasures to avoid inappropriate antimicrobial use during shortage periods.

Cost-benefit and effectiveness analysis of rapid testing for MRSA carriage in a hospital setting.

A cost-effectiveness analysis was conducted comparing the polymerase chain reaction assay and traditional microbiological culture as screening tools for the identification of methicillin-resistant Staphylococcus aureus (MRSA) in patients admitted to the pediatric and surgical intensive care units (PICU and SICU) at a 722 bed academic medical center. In addition, the cost benefits of identification of colonized MRSA patients were determined. The cost-effectiveness analysis employed actual hospital and laboratory costs, not patient costs. The actual cost of the PCR assay was higher than the microbiological culture identification of MRSA ($602.95 versus $364.30 per positive carrier identified). However, this did not include the decreased turn-around time of PCR assays compared to traditional culture techniques. Patient costs were determined indirectly in the cost-benefit analysis of clinical outcome. There was a reduction in MRSA hospital-acquired infection (3.5 MRSA HAI/month without screening versus 0.6/month with screening by PCR). A cost-benefit analysis based on differences in length of stay suggests an associated savings in hospitalization costs: MRSA HAI with 29.5 day median LOS at $63,810 versus MRSA identified on admission with 6 day median LOS at $14,561, a difference of $49,249 per hospitalization. Although this pilot study was small and it is not possible to directly relate the cost-effectiveness and cost-benefit analysis due to confounding factors such as patient underlying morbidity and mortality, a reduction of 2.9 MRSA HAI/month associated with PCR screening suggests potential savings in hospitalization costs of $142,822 per month.

Mapping the information resources available to patients with colorectal cancer.

The objectives of this study were to identify gaps in information provision along the colorectal cancer (CRC) treatment pathway as provided by health services within the North Eastern Metropolitan Integrated Cancer Service in Victoria Australia; to evaluate the information and recommend consistent, high quality health information resources; and to recommend strategies to improve delivery of patient information. A random sample of health professionals (n= 47) from various disciplines at eight health service sites participated in semi-structured interviews regarding the types of information they provided to CRC patients. Information items were mapped against a published CRC patient management framework and evaluated. A total of 193 information items were collected with 24 items specific to CRC. Gaps in information provision were evident in the community, at diagnosis, in clinics, when treatment was determined and when completed. The quality of information delivery to CRC patients across the public health sites was variable. Resources were often unavailable, out of date and inaccessible in other languages. Results indicate a need to improve health information availability and resource delivery to all CRC patients across different health services particularly at diagnosis and after treatment. Further research is required to determine patient preferences for information about CRC.

Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis.

OBJECTIVES: To evaluate the effectiveness and cost-effectiveness of interventions that promote or inhibit breastfeeding or feeding with breastmilk for infants admitted to neonatal units, and to identify an agenda for future research. DATA SOURCES: Electronic databases were searched (including MEDLINE and MEDLINE In-Process Citations, EMBASE, CINAHL, Maternity and Infant Care, PsycINFO, British Nursing Index and Archive, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Science Citation Index, Pascal, Latin American and Caribbean Health Sciences, MetaRegister of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessment Database, National Research Register) from inception to February 2008. Advisors identified further published or unpublished material. REVIEW METHODS: All papers fulfilled eligibility criteria covering participants, interventions, study design and outcomes. Results from primary studies were assessed and summarised in a qualitative synthesis for each type of intervention and across types of intervention. To estimate long-term cost utility, a decision tree was developed to synthesise data on enhanced staff contact, breastmilk effectiveness, incidence of necrotising enterocolitis (NEC) and sepsis, resource use, survival and utilities. RESULTS: Forty-eight studies met the selection criteria for the effectiveness review, of which 65% (31/48) were RCTs, and 17% (8/48) were conducted in the UK. Seven were rated as good quality and 28 as moderate quality. No studies met the selection criteria for the health economics review. There is strong evidence that short periods of kangaroo skin-to-skin contact increased the duration of any breastfeeding for 1 month after discharge [risk ratio (RR) 4.76, 95% confidence interval (CI) 1.19 to 19.10] and for more than 6 weeks (RR 1.95, 95% CI 1.03 to 3.70) among clinically stable infants in industrialised settings. There is strong evidence for the effectiveness of peer support at home (in Manila) for mothers of term, low birthweight infants on any breastfeeding up to 24 weeks (RR 2.18, 95% CI 1.45 to 3.29) and exclusive breastfeeding from birth to 6 months (RR 65.94, 95% CI 4.12 to 1055.70), and for the effectiveness of peer support in hospital and at home for mothers of infants in Special Care Baby Units on providing any breastmilk at 12 weeks [odds ratio (OR) 2.81, 95% CI 1.11 to 7.14; p = 0.01]. There is more limited evidence for the effectiveness of skilled professional support in a US Neonatal Intensive Care Unit on infants receiving any breastmilk at discharge (OR 2.0, 95% CI 1.2 to 3.2, p = 0.004). Multidisciplinary staff training may increase knowledge and can increase initiation rates and duration of breastfeeding, although evidence is limited. Lack of staff training is an important barrier to implementation of effective interventions. Baby Friendly accreditation of the associated maternity hospital results in improvements in several breastfeeding-related outcomes for infants in neonatal units. Limited evidence suggests that cup feeding (versus bottle feeding) may increase breastfeeding at discharge and reduce the frequency of oxygen desaturation. Breastmilk expression using simultaneous pumping with an electric pump has advantages in the first 2 weeks. Pharmaceutical galactagogues have little benefit among mothers who have recently given birth. Our economic analysis found that additional skilled professional support in hospital was more effective and less costly (due to reduced neonatal illness) than normal staff contact. Additional support ranged from 0.009 quality-adjusted life-years (QALYs) to 0.251 QALYs more beneficial per infant and ranged from 66 pounds to 586 pounds cheaper per infant across the birthweight subpopulations. Donor milk would become cost-effective given improved mechanisms for its provision. CONCLUSIONS: Despite the limitations of the evidence base, kangaroo skin-to-skin contact, peer support, simultaneous breastmilk pumping, multidisciplinary staff training and the Baby Friendly accreditation of the associated maternity hospital have been shown to be effective, and skilled support from trained staff in hospital has been shown to be potentially cost-effective. All these point to future research priorities. Many of these interventions inter-relate: it is unlikely that specific clinical interventions will be effective if used alone. There is a need for national surveillance of feeding, health and cost outcomes for infants and mothers in neonatal units; to assist this goal, we propose consensus definitions of the initiation and duration of breastfeeding/breastmilk feeding with specific reference to infants admitted to neonatal units and their mothers.

Doctors' attitudes about prescribing and knowledge of the costs of common medications.

INTRODUCTION: Compliance with medical therapy may be compromised because of the affordability of medications. Inadequate physician knowledge of drug costs may unwittingly contribute to this problem. METHODS: We measured attitudes about prescribing and knowledge of medication costs by written survey of medical and surgical non consultant hospital doctors and consultants in two University teaching hospitals (n = 102). Sixty-eight percent felt the cost of medicines was an important consideration in the prescribing decision, however, 88% often felt unaware of the actual costs. Only 33% had easy access to drug cost data, and only 3% had been formally educated about drug costs. Doctors' estimates of the cost of a supply of ten commonly used medications were accurate in only 12% of cases, too low for 50%, and too high for 38%. CONCLUSIONS: Interventions are needed to educate doctors about drug costs and provide them with reliable, easily accessible cost information in real-world practice.

A systematic review and economic model of the effectiveness and cost-effectiveness of methylphenidate, dexamfetamine and atomoxetine for the treatment of attention deficit hyperactivity disorder in children and adolescents.

OBJECTIVES: To assess the clinical and cost-effectiveness of oral methylphenidate hydrochloride (MPH), dexamfetaminesulphate (DEX) and atomoxetine (ATX) in children and adolescents (<18 years of age) diagnosed with attention deficit hyperactivity disorder (ADHD) (including hyperkinetic disorder). DATA SOURCES: Electronic databases covering 1999--July 2004 for MPH, 1997--July 2004 for DEX and 1981--July 2004 for ATX. REVIEW METHODS: Selected studies were assessed using modified criteria based on CRD Report No. 4. Clinical effectiveness data were reported separately for each drug and by the type of comparison. Data for MPH were also analysed separately based on whether it was administered as an immediate release (IR) or extended release (ER) formulation. For all drugs, the data were examined by dose. Data for the core outcomes of hyperactivity (using any scale), Clinical Global Impression [as a proxy of quality of life (QoL)] and adverse events were reported. For crossover studies, the mean and standard deviation (SD) for each outcome were data extracted for end of trial data (i.e. baseline data were not considered). For parallel studies, change scores were reported where given, otherwise means and SDs were presented for end of trial data. In addition, mean differences with 95% confidence intervals were calculated for each study. For adverse events, self-ratings were reported when used, otherwise, parent reports were utilised. Percentages of participants reporting adverse events were used to calculate numbers of events in each treatment arm. All the clinical effectiveness data and economic evaluations (including accompanying models) included in the company submissions were assessed. A new model was developed to assess the cost-effectiveness of the alternative treatments in terms of cost per quality-adjusted life-year. To achieve this, a mixed treatment comparison model was used to estimate the differential mean response rates. Monte Carlo simulation was used to reflect uncertainty in the cost-effectiveness results. RESULTS: In total, 65 papers met the inclusion criteria. The results suggest that MPH and DEX are effective at reducing hyperactivity and improving QoL (as determined by Clinical Global Impression) in children, although the reliability of the MPH study results is not known and there were only a small number of DEX studies. There was consistent evidence that ATX was superior to placebo for hyperactivity and Clinical Global Impression. Studies on ATX more often reported the study methodology well, and the results were likely to be reliable. Very few studies made direct head-to-head comparisons between the drugs or examined a non-drug intervention in combination with MPH, DEX or ATX. Adequate and informative data regarding the potential adverse effects of the drugs were also lacking. The results of the economic evaluation clearly identified an optimal treatment strategy of DEX first-line, followed by IR-MPH for treatment failures, followed by ATX for repeat treatment failures. Where DEX is unsuitable as a first-line therapy, the optimal strategy is IR-MPH first-line, followed by DEX and then ATX. For patients contraindicated to stimulants, ATX is preferred to no treatment. For patients in whom a midday dose of medication is unworkable, ER-MPH is preferred to ATX, and ER-MPH12 appears more cost-effective than ER-MPH8. As identified in the clinical effectiveness review, the reporting of studies was poor, therefore this should be borne in mind when interpreting the model results. CONCLUSIONS: Drug therapy seems to be superior to no drug therapy, no significant differences between the various drugs in terms of efficacy or side effects were found, mainly owing to lack of evidence, and the additional benefits from behavioural therapy (in combination with drug therapy) are uncertain. Given the lack of evidence for any differences in effectiveness between the drugs, the economic model tended to be driven by drug costs, which differed considerably. Future trials examining MPH, DEX and ATX should include the assessment of tolerability and safety as a priority. Longer term follow-up of individuals participating in trials could further inform policy makers and health professionals. Such data could potentially distinguish between these drugs in a clinically useful way. In addition, research examining whether somatic complaints are actually related to drug treatment or to the disorder itself would be informative.

The conduct of in vitro and in vivo drug-drug interaction studies: a Pharmaceutical Research and Manufacturers of America (PhRMA) perspective.

Current regulatory guidances do not address specific study designs for in vitro and in vivo drug-drug interaction studies. There is a common desire by regulatory authorities and by industry sponsors to harmonize approaches, to allow for a better assessment of the significance of findings across different studies and drugs. There is also a growing consensus for the standardization of cytochrome P450 (P450) probe substrates, inhibitors and inducers and for the development of classification systems to improve the communication of risk to health care providers and to patients. While existing guidances cover mainly P450-mediated drug interactions, the importance of other mechanisms, such as transporters, has been recognized more recently, and should also be addressed. This article was prepared by the Pharmaceutical Research and Manufacturers of America (PhRMA) Drug Metabolism and Clinical Pharmacology Technical Working Groups and represents the current industry position. The intent is to define a minimal best practice for in vitro and in vivo pharmacokinetic drug-drug interaction studies targeted to development (not discovery support) and to define a data package that can be expected by regulatory agencies in compound registration dossiers.

The 'family' context of HIV: a need for comprehensive health and social policies.

This paper reports on the findings from a multi-site psychosocial study of Canadian families with HIV-positive mothers. A total of 110 adults, representing 91 families across Canada participated in interviews. Qualitative analysis revealed a number of themes including: a complex web of personal, health and family concerns; the needs of children; family finances; disclosure dilemmas; and social experiences and challenges. These themes reflect an intricate and dynamic picture of parental and family life for adults and children living with HIV infection. Nowhere in the literature do we see HIV framed as a 'family infection'. Surveillance reporting reflects information on infected adults and children but not family groupings. Yet with HIV several family members and multiple generations as well as single or both parents may be infected, highlighting the importance of 'family HIV' as a framework for health policy and programme development. At issue is the problem that medical and other institutions view issues of surveillance, treatment and care through the lens of the infected individual, rather than being family focused. Often it is only in the context of identifying support, or barriers to support, for the medically diagnosed individual that biological or socially created families become a focus of concern. The failure to situate both chronic and life-threatening illnesses within the family setting has serious quality of life and planning consequences for parents and children living with HIV infection as well as other illnesses.

Trends in outcome and costs of coronary intervention in the 1990s.

Our objective was to examine trends in outcome and cost of percutaneous coronary intervention (PCI) between 1990 and 1999. PCI has become the most common form of myocardial revascularization in recent years, rivaling the more established coronary artery bypass surgery. There has been increasing interest in improving outcome of PCI while also seeking to minimize cost. A total of 21,755 patients undergoing PCI were evaluated. Clinical data were gathered from the Emory Cardiovascular Database and financial data from the UB92 formulation of the hospital bill. Charges were reduced to cost using departmental cost-to-charge ratios. Costs were inflated to 1999 dollars using medical care inflation rates. Mortality varied without a significant trend from 0.63% to 0.44% (p = 0.64). The Q-wave myocardial infarction rate decreased from 0.68% to 0.40% (p = 0.0003). Emergent coronary surgery decreased from 3.50% to 1.25% (p <0.0001). Mean hospital inflation-adjusted cost decreased from $10,478 to $8,367 (p <0.0001). Length of stay after the procedure decreased from 2.8 to 1.8 days (p <0.0001). Outcome of PCI continues to improve, with a decrease in coronary surgery and Q-wave myocardial infarction but with no significant change in mortality. This was accomplished while also decreasing costs and length of stay. Whether these favorable trends will continue remains to be seen.

Introduction of a practice guideline for penicillin skin testing improves the appropriateness of antibiotic therapy.

We hypothesized that the introduction of a practice guideline for penicillin skin testing would increase the appropriateness of skin testing and reduce antibiotic costs for patients with a history of penicillin allergy who have infections caused by penicillin-susceptible pathogens. We measured the appropriateness of skin testing and daily antibiotic costs before and after the introduction of a guideline for penicillin skin testing. For patients who had negative results of skin testing and were subsequently treated with a penicillin instead of an alternative antibiotic, we calculated the difference between the actual costs and the projected costs of continuing alternative antibiotics without skin testing. After the guideline was introduced, appropriateness of skin testing increased from 17% to 64%, but daily antibiotic costs did not change. For patients who had negative results of skin testing and who were subsequently treated with a penicillin, there was no difference between actual costs and the projected costs if they had not been skin tested. We conclude that introduction of a guideline for penicillin skin testing increases the percentage of eligible patients who have a skin test, and it does so without increasing costs.

Qualitative analysis of the care of children in hospital in four countries-Part 1.

As part of a large study of the care of children in Australian, British, Indonesian, and Thai hospitals, qualitative methods were used to examine differences influenced by culture. Two groups were surveyed: parents of hospitalized children, and staff caring for them. Vignettes were used to invoke discussion, and content analysis was used to examine the data. Subjects were interviewed singly, or in focus groups. These interviews were audiotaped and transcribed verbatim. The data were explored by using content analysis to extract themes of understanding of cultural experiences. This article is the first of a two-part series, and includes a review of the literature, description of the methods used, and results of the parents' interviews. The staff results and discussion will be published in Part 2. Analysis revealed that parents in all countries were primarily concerned with treating the child's illness and the child's recovery. Parents were concerned with their work (employment), but this was a much larger consideration in Indonesia and Thailand, where no social security systems exist, than in Australia and Britain. Communication with staff was the most commonly mentioned theme for parents, indicating that irrespective of the culture in which the care was given, good communication between parents and staff was of paramount importance.

Safety of the Canadian blood supply in 1980-85: using a paediatric cohort for risk assessment of human immunodeficiency virus (HIV) infection.

The risk of HIV from transfusions in Canada in the period 1980-85 was estimated, using the information from a transfused paediatric cohort. Children who were transfused between January 1980 and November 1985 at a tertiary care paediatric hospital were contacted by letter. With this notification, HIV testing for recipients was recommended. HIV testing histories were obtained. The number tested for HIV was estimated from the questionnaire responses and from data matching with the HIV-testing laboratory. Cases of HIV infection were identified through multiple sources. In this cohort, 11,028 children were transfused a mean of 21 units. Of the 10,220 living recipients, the estimated proportion tested for HIV was 86% to 91%. Thirty-one cases of HIV infection were identified, representing 0.28% of the cohort but 0.34% of those expected to have been tested. The estimated HIV incidence per 1,000 units transfused ranged from 0.028 [95% CI 0.0007, 0.155] in 1980 to 0.445 [95% CI 0.2592, 0.712] in 1985. This suggests that the risk of HIV from transfusions in Canada continued to rise until the implementation of HIV testing of donors in November 1985.

A radiation safety infraction notification form.

The use of a well constructed form can serve as an official notification of the violation of good radiation safety practice while providing a paper trail for documentation of corrective action.

Contaminating incident investigation in medicine and biomedical research.

Regardless of how well trained, experienced and careful individuals are, if they handle radioactive materials often enough they will eventually have a contaminating incident. When the incident occurs it is imperative that the proper actions are taken to control the incident, minimize contamination and exposure, assure that proper remediation is implemented, assure that the incident remains confined, that no others become contaminated or exposed and that effective remediation is documented. This paper discusses our approach to such incidents and discusses the incident report form and our philosophy of information recording.

Child's stress hormone levels correlate with mother's socioeconomic status and depressive state.

BACKGROUND: Individuals with lower socioeconomic status report greater exposure to stressful life events and a greater impact of these events on their lives than individuals with higher socioeconomic status, and this relationship between socioeconomic status and health begins at the earliest stages of life. To extend on these results, we performed a psychoneuroendocrine study of 217 children and 139 mothers. METHODS: Salivary cortisol levels and cognitive function were assessed in children, and a semistructured phone interview measuring symptoms of stress and depression was conducted with their mothers. RESULTS: Children with low socioeconomic status present significantly higher salivary cortisol levels than children with high socioeconomic status, and this socioeconomic status effect emerges as early as age 6. We also report that a child's cortisol level is significantly correlated with his or her mother's extent of depressive symptomatology. CONCLUSIONS: These results offer a neurobiological determinant to the well-known association between socioeconomic status and health that begins early in life.