Somatostatin analogues for the prevention of pancreatic fistula after open pancreatoduodenectomy: A nationwide analysis.

BACKGROUND: Somatostatin analogues (SA) are currently used to prevent postoperative pancreatic fistula (POPF) development. However, its use is controversial. This study investigated the effect of different SA protocols on the incidence of POPF after pancreatoduodenectomy in a nationwide population. METHODS: All patients undergoing elective open pancreatoduodenectomy were included from the Dutch Pancreatic Cancer Audit (2014-2017). Patients were divided into six groups: no SA, octreotide, lanreotide, pasireotide, octreotide only in high-risk (HR) patients and lanreotide only in HR patients. Primary endpoint was POPF grade B/C. The updated alternative Fistula Risk Score was used to compare POPF rates across various risk scenarios. RESULTS: 1992 patients were included. Overall POPF rate was 13.1%. Lanreotide (10.0%), octreotide-HR (9.4%) and no protocol (12.7%) POPF rates were lower compared to the other protocols (varying from 15.1 to 19.1%, p = 0.001) in crude analysis. Sub-analysis in patients with HR of POPF showed a significantly lower rate of POPF when treated with lanreotide (10.0%) compared to no protocol, octreotide and pasireotide protocol (21.6-26.9%, p = 0.006). Octreotide-HR and lanreotide-HR protocol POPF rates were comparable to lanreotide protocol, however not significantly different from the other protocols. Multivariable regression analysis demonstrated lanreotide protocol to be positively associated with a low odds-ratio (OR) for POPF (OR 0.387, 95% CI 0.180-0.834, p = 0.015). In-hospital mortality rates were not affected. CONCLUSION: Use of lanreotide in all patients undergoing pancreatoduodenectomy has a potential protective effect on POPF development. Protocols for HR patients only might be favorable too. However, future studies are warranted to confirm these findings.

Unilateral temporary diaphragmatic paralysis secondary to bronchial artery embolization in a girl with cystic fibrosis and massive hemoptysis: a case report.

BACKGROUND: Massive hemoptysis is a serious complication in Cystic Fibrosis (CF), occurring commonly in older patients. Bronchial artery embolization (BAE) can be performed to stop the bleeding. BAE is generally safe and effective, but can sometimes lead to serious complications. We report the first case of temporary unilateral diaphragmatic paralysis associated to lung consolidation following BAE in a pediatric CF female patient. This complication worsened the lung function of the patient who underwent lung transplantation after 9 months. CASE PRESENTATION: A 14 years old female CF patient followed by the CF center of Florence presented low-grade fever, cough increase and recurrent episodes of major hemorrhages such as to carry out a BAE. Within 24 h the patient started to complain of severe thoracic pain in the right hemithorax, increased dyspnea and fever. A computed tomographic angiography and a dynamic fluoroscopic evaluation revealed the right diaphragmatic paralysis, not present before the procedure. After 4 days the clinical condition and radiological imaging had improved with restored mobility of the right hemidiaphragm. Nine months later, she required mechanical ventilation, and subsequently the initiation of extracorporeal membrane oxygenation (ECMO) for a pulmonary exacerbation with septic shock. Lung transplantation in ECMO was performed with success. CONCLUSION: Clinicians should be aware of the possibility of phrenic nerve injury with BAE in pediatric CF patients.

Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfort.

BACKGROUND: Maximising patient comfort during and after surgery is a primary concern of anaesthetists and other perioperative clinicians, but objective measures of what constitutes patient comfort in the perioperative period remain poorly defined. The Standardised Endpoints in Perioperative Medicine initiative was established to derive a set of standardised endpoints for use in perioperative clinical trials. METHODS: We undertook a systematic review to identify measures of patient comfort used in the anaesthetic, surgical, and other perioperative literature. A multi-round Delphi consensus process that included up to 89 clinician researchers was then used to refine a recommended list of outcome measures. RESULTS: We identified 122 studies in a literature search, which were the basis for a preliminary list of 24 outcome measures and their definitions. The response rates for Delphi Rounds 1, 2, and 3 were 100% (n=22), 90% (n=79), and 100% (n=13), respectively. A final list of six defined endpoints was identified: pain intensity (at rest and during movement) at 24 h postoperatively, nausea and vomiting (0-6 h, 6-24 h, and overall), one of two quality-of-recovery (QoR) scales (QoR score or QoR-15), time to gastrointestinal recovery, time to mobilisation, and sleep quality. CONCLUSIONS: As standardised outcomes will support benchmarking and pooling (meta-analysis) of trials, one or more of these recommended endpoints should be considered for inclusion in clinical trials assessing patient comfort and pain after surgery.

Descriptive analysis of emergency department oxygen use in acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Inconsistencies in oxygen therapy recommendations in acute exacerbation of chronic obstructive pulmonary disease (COPD) may result in variability in emergency department (ED) oxygen management of patients with COPD. The aim of this study was to describe oxygen management in the first 4 h of ED care for patients with exacerbation of COPD. METHODS: A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were 273 adult ED patients with COPD presenting with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were physiological data, including oxygen saturation (SpO(2)), oxygen delivery devices and flow rates on ED arrival, 1 and 4 h. RESULTS: Oxygen was used in 82.0% of patients. Patients who required oxygen had higher incidence of ambulance transport (P < 0.001), triage category 2 (P = 0.006), home oxygen use (P < 0.001), and increased work of breathing on ED arrival (P < 0.001), and higher median respiratory rate (P < 0.001) and heart rate (P = 0.001). SpO(2) > 90% occurred in the majority of patients (87.5%; 96.4%; 95.6%); however, a considerable number of patients with SpO(2) < 90% were not given oxygen (61.8%; 30%; 45.5%). CONCLUSIONS: A number of patients with documented hypoxaemia were not given oxygen and there may be variables other than oxygen saturation that may influence oxygen use. Future research should focus on increasing the evidence-based supporting oxygen use and better understanding of clinicians' oxygen decision-making in patients with COPD.

Emergency department management of exacerbation of chronic obstructive pulmonary disease: audit of compliance with evidence-based guidelines.

BACKGROUND: Emergency departments (ED) play a key role in management of exacerbation of chronic obstructive airways disease (COPD). Current guidelines for management of exacerbation of COPD showed highest levels of evidence (Level A and B) were related to use of medications and non-invasive positive pressure ventilation (NIPPV). AIMS: The aim of this study was to examine compliance with high level evidence for management of exacerbation of COPD during the first 4 h of ED care. METHODS: A retrospective medical record audit was conducted at four public and one private ED in Melbourne, Australia. Participants were adult patients with COPD presenting to the ED with a primary complaint of shortness of breath from July 2006 to July 2007. Outcome measures were compliance with evidence-based recommendations regarding use of bronchodilators, methylxanthines, steroids and NIPPV. RESULTS: Of 273 patients in this study, 72.4% received short-acting beta-agonist bronchodilators, 37.8% received an inhaled short-acting anticholinergic medication and 56.6% received systemic steroid therapy. NIPPV was used in 21 patients, 15 of whom had documentation of acidosis and/or hypercapnia). CONCLUSIONS: There was variation in the use of high level evidence for the ED management of exacerbation of COPD. The highest rate of compliance was non-use of methylxanthines and the greatest deficit was poor compliance with evidence related to NIPPV. There was also scope for improvement in the use of bronchodilators and systemic steroids.

Hemithyroidectomy versus total thyroidectomy for well differentiated T1-2 N0 thyroid cancer: systematic review and meta-analysis.

BACKGROUND: Evidence for limiting the extent of surgery in patients with low-risk thyroid cancer is lacking. METHODS: A systematic search was performed according to the PRISMA and MOOSE guidelines to assess the effect of total thyroidectomy (TT) with or without radioactive iodine (RAI) treatment versus hemithyroidectomy (HT) on recurrence and overall mortality in patients with differentiated (papillary or follicular) T1-2 N0 thyroid cancer. PubMed, Embase and Cochrane databases were searched, and two authors independently assessed the articles. RESULTS: A total of ten eligible articles were identified. All were observational cohort series, representing a total of 23 134 patients, of which 17 699 were available for meta-analysis. Six studies included patients who had TT followed by RAI treatment. The pooled recurrence rate after TT ± RAI and HT was 2·3 and 2·8 per cent respectively (odds ratio (OR) 1·12, 95 per cent c.i. 0·82 to 1·53; P = 0·48). The pooled 20-year overall survival rate after TT ± RAI was 96·8 per cent, compared with 97·4 per cent for HT (OR 1·30, 0·71 to 2·37; P = 0·40). Overall, higher complication rates were found in the TT ± RAI group. CONCLUSION: Recurrence rates after HT for treatment of well differentiated T1-2 N0 thyroid cancer were similar to those after TT ± RAI, with a lower incidence of treatment-related complications.

ANTECEDENTES: No hay evidencia para limitar la extensión de la cirugía en pacientes con cáncer de tiroides de bajo riesgo. MÉTODOS: Se realizó una búsqueda sistemática siguiendo las recomendaciones PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) y MOOSE (Meta-analysis of Observational Studies in Epidemiology) para evaluar el efecto de la tiroidectomía total (TT) +/− yodo radioactivo (radioactive iodine treatment, RAI) versus hemitiroidectomía (HT) en la recidiva y en la mortalidad global en el cáncer de tiroides diferenciado (papilar/folicular) T1-T2N0. Se realizaron búsquedas en las bases de datos PubMed, Embase y Cochrane, y dos autores evaluaron los artículos de forma independiente. RESULTADOS: Se identificaron un total de 10 artículos de interés. Todos ellos eran estudios de cohortes observacionales, con un total de 23.134 pacientes, de los cuales 17.699 se incluyeron en el metaanálisis. En seis estudios, los pacientes fueron tratados mediante TT seguida de RAI. Las tasas agrupadas de recidiva tras TT +/− RAI y HT fueron 2,3% and 2,8%, respectivamente (razón de oportunidades, odds ratio, OR = 1,12, i.c. del 95% 0,82-1,54, P = 0.48). La supervivencia global a 20 años de TT +/− RAI fue del 96,8% en comparación con el 97,4% para la HT (OR = 1,30, i.c. del 95% 0,71-2,37, P = 0,40). Globalmente, se observaron más complicaciones en el grupo de TT +/− RAI. CONCLUSIÓN: Esta revisión sistemática con metaanálisis demuestra tasas de recidiva similares tras una HT para el tratamiento del cáncer de tiroides T1-2N0 bien diferenciado en comparación con TT +/− RAI, con una menor incidencia de complicaciones relacionadas con el tratamiento.

[Hypofractionated breast radiotherapy in 13 fractions, perfect tolerance or delayed early reaction? Prospective study of Curie Institute]. / La radiothérapie mammaire hypofractionnée en 13 séances, parfaite tolérance ou réaction cutanée décalée ? Etude prospective de l'institut Curie.

PURPOSE: To assess the skin toxicity of this scheme and the time to its appearance. PATIENTS AND METHODS: Eighty-one prospectively recorded patients (pts), treated in Radiotherapy Department for Breast Cancer (BC) with radiotherapy (RT) to the whole breast at the dose of 42.9Gy per 13 fractions (F) per 5 weeks have been studied. Skin reactions were monitored weekly using the National Cancer Institute-Common Toxicity Criteria scoring system, version 3. All risk factors as tobacco smoking, diabetes, obesity were also recorded. RESULTS: All 81 pts, aged from 40 to 83 years (median: 70 years) received whole breast RT 42.9Gy per 13 F without lymph node irradiation after breast conserving surgery. There were no pts with concurrent chemo- and/or hormonal therapy. Seventeen patients (21%) have been treated using decubitus dorsal (DD) technique and 64 (79%) using the previously described isocentric decubitus lateral (IDL) technique. During the RT, only 34 pts (42%) experienced grade I skin reactions and 47 pts (58%) were without. At the last day of the breast irradiation, there were 66 (81%) grade I (N=59) and II (N=7) skin reactions and 15 pts (19%) without. The early skin tolerance of this scheme was considered to be excellent. But in the 2 weeks after the RT, 20 pts (25%) asked for new clinics with their radiation oncologist as a matter of urgency due to worsening of their skin condition. All of them have been seen by their physician and/or the nurse. Of them, nine presented grade I and 11 presented grade II skin reactions, with necessity of special skin care. The analysis of these results was realized and delayed clinics were organized for all pts treated with this scheme 10-14 days after the end of the radiation treatment. CONCLUSIONS: The breast RT 42.9Gy/13 F have been previously described as an efficacious and well tolerated scheme. This prospective homogeneous group of patients showed that delayed early skin reactions could appear in some cases. Therefore complementary clinics are needed to detect and treat these reactions.

Double labelling immunohistochemical characterization of autonomic sympathetic neurons innervating the sow retractor clitoridis muscle.

Retrograde neuronal tracing and immunohistochemical methods were used to define the neurochemical content of sympathetic neurons projecting to the sow retractor clitoridis muscle (RCM). Differently from the other smooth muscles of genital organs, the RCM is an isolated muscle that is tonically contracted in the rest phase and relaxed in the active phase. This peculiarity makes it an interesting experimental model. The fluorescent tracer fast blue was injected into the RCM of three 50 kg subjects. After a one-week survival period, the ipsilateral paravertebral ganglion S1, that in a preliminary study showed the greatest number of cells projecting to the muscle, was collected from each animal. The co-existence of tyrosine hydroxylase with choline acetyltransferase, neuronal nitric oxide synthase, calcitonin gene-related peptide, leu-enkephalin, neuropeptide Y, substance P and vasoactive intestinal polypeptide was studied under a fluorescent microscope on cryostat sections. Tyrosine hydroxylase was present in about 58% of the neurons projecting to the muscle and was found to be co-localized with each of the other tested substances. Within fast blue-labelled cells negative to the adrenergic marker, small populations of neurons singularly containing each of the other enzymatic markers or peptides were also observed. The present study documents the complexity of the neurochemical interactions that regulate the activity of the smooth myocytes of the RCM and their vascular components.

Orexin A in swine corpus luteum.

Orexin A (OXA) is a hypothalamic neuropeptide which acts on 2 known G-protein-coupled receptors. It has been demonstrated that OXA is a central molecular link between food intake and reproduction. More recently, its peripheral role has been investigated, and we demonstrated its involvement in regulating ovarian follicle function. The present study was undertaken to explore a potential physiological role of orexin system in swine corpus luteum, a transient ovarian endocrine organ. Our aim was, first, to analyze the localization and eventual colocalization of OXA and its 2 receptors within the different cell types composing the corpus luteum structure. Second, we wanted to explore the effects of OXA on isolated luteal cells, and finally to verify a potential involvement of OXA in angiogenesis, a crucial event in corpus luteum development. Our data demonstrate the local expression of OXA and its receptors in swine corpus luteum. Luteal cell functions were affected by treatment with OXA. In particular, progesterone production was inhibited (P < 0.05) and nonenzymatic scavenging activity was increased (P < 0.05). Moreover, OXA inhibited (P < 0.05) new vessel growth. Our results suggest that OXA could act locally to play a role in corpus luteum demise.

Orexin system in swine ovarian follicles.

Successful reproduction is strictly linked to metabolic cues. The orexins are a family of hypothalamic neurohormones, well known for their key role in the control of food intake and the involvement in several aspects of the reproductive process. The biological actions of both orexins are carried out through binding to the related Orexin 1 (OX1R) and Orexin 2 (OX2R) G-protein-coupled receptors. The purpose of this study was to investigate the presence of orexin system components in the porcine ovaries, to contribute to expand the knowledge about their pleiotropic role. First, we investigated the localization of orexin A (OXA) and its receptors by immunochemistry in different ovarian districts. Thereafter, we evaluated the expression of the prepro-orexin (PPO) gene and OXA effects on granulosa cell functions. Immunohistochemical study revealed the presence of orexinergic system components in porcine ovarian follicles. Moreover, our data show the expression of PPO messenger RNA in swine ovarian follicles >5 mm. In addition, OXA influences proliferation (P < 0.05), steroidogenic activity (P < 0.05), and redox status of granulosa cells (P < 0.05). Therefore, we hypothesize that OXA could exert a local physiological role in swine ovarian follicles even if further studies are required to deeply define the function of this pleiotropic system.

Effect of the supplementation with a blend containing short and medium chain fatty acid monoglycerides in milk replacer on rumen papillae development in weaning calves.

Feeding of neonates with artificial milk formulas is a popular trend toward early weaning of newborn dairy calves. These milk replacers (MR) should accelerate the rumen development, determining early solid feed intake and leading to better performances in cattle. Previous research demonstrated that sodium butyrate supplementation in MR can affect both small intestine and rumen development. Also acetate and propionate showed similar properties, while only a few studies indicate some potential benefit of monoglycerides on gut functions. The present study is aimed to determine the effect of the supplementation of a blend containing short and medium chain fatty acids monoglycerides (SMCFA) in milk replacer on rumen papillae development and growth performances in weaning calves. Twenty bull calves (about 2 weeks old, weighing around 43kg) were randomly allocated into two groups: control (C) and treated (T). Besides MR and starter diet, the latter offered at libitum, T calves received 0.2% SMCFA in MR. Animals were slaughtered after 56 days from the beginning of the trial. No difference was found between groups either in growth performances or in mean number of papillae/cm(2) of mucosa, total surface of papillae (mm(2))/cm(2) of mucosa or papillary size. In both groups, the morphology of the rumen epithelium was typical of parakeratosis. The cells of the stratum spinosum were directly transformed into swollen, ovoid, still nucleated keratinocytes, particularly at the papillary tip, probably as a result of unphysiological osmolarities caused by high concentrate intake. Degenerated squamous horn cells covered the "balloon like" cells forming several layers, particularly in the places of the rumen mucosa more protected from an abrasive action of solid feed. This was more evident in C animals. The squamous cells covering the papillary tip showed cytoplasmic protrusion, representing remains of the attachment sites of desmosomes, which increased the total absorptive surface and were more numerous and higher in T compared to C animals. It might be hypothesized that SMCFA supplementation in MR could better regulate epithelial cell proliferation and probably have an "emollient effect" leading to an easier "peeling" that might increase efficiency for nutrient transport across the epithelium.

Unmet needs and depression among carers of people newly diagnosed with cancer.

AIMS: The aims of this analysis were to examine levels of unmet needs and depression among carers of people newly diagnosed with cancer and to identify groups who may be at higher risk, by examining relationships with demographic characteristics. METHODS: One hundred and fifty dyads of people newly diagnosed with cancer and their carers, aged 18 years and older, were recruited from four Australian hospitals. People with cancer receiving adjuvant cancer treatment with curative intent, were eligible to participate. Carers completed the Supportive Care Needs Survey-Partners & Caregivers (SCNS-P&C45), and both carers and patients completed the Centre of Epidemiologic-Depression Scale (CES-D). RESULTS: Overall, 57% of carers reported at least one, 37% at least three, 31% at least five, and 15% at least 10 unmet needs; the most commonly endorsed unmet needs were in the domains of information and health care service needs. Thirty percent of carers and 36% of patients were at risk of clinical depression. A weak to moderate positive relationship was observed between unmet needs and carer depression (r=0.30, p<0.001). Carer levels of unmet needs were significantly associated with carer age, hospital type, treatment type, cancer type, living situation, relationship status (in both uni- and multi-factor analysis); person with cancer age and carer level of education (in unifactor analysis only); but not with carer gender or patient gender (in both uni- and multi-factor analyses). CONCLUSION: Findings highlight the importance of developing tailored programmes to systematically assist carers who are supporting patients through the early stages of cancer treatment.

Coronary angiography observations: evidence-based or ritualistic practice?

OBJECTIVE: The purposes of this study were to describe the incidence and occurrence of femoral artery bleeding during the first 6 hours after coronary angiography and to determine whether there is a relationship between current postangiogram observation protocols and the detection of complications. DESIGN: This was a prospective descriptive study. SETTING: The study was conducted in 3 university hospitals in Melbourne, Australia. PATIENTS: Subjects included 55 patients representing the complication rate of 1075 patients, mean age 61 years (SD, 12), 69% male. RESULTS: About 5.1% of patients had 1 or more incidents of bleeding requiring manual compression. In 4.2% of patients, bleeding occurred within 6 hours of angiography. Bleeding occurred a median of 2.02 hours (Q1 = 45 minutes, Q3 = 4.31 hours) after angiography. Patients without pressure bandaging bled a median of 1.32 hours (Q1 = 36.50 minutes, Q3 = 2.59 hours) after angiography. Patients with pressure bandaging bled a median of 4.75 hours (Q1 = 2.25 hours, Q3 = 7.28 hours) after angiography. In 40.6% of cases, bleeding was detected through the patient's call for assistance, and in 59.4% of cases nurses noted bleeding while checking the puncture site. Postcatheter observations were recorded 23.70 (SD, 14.60) minutes before the bleeding incident. There were no significant changes in vital signs, systolic blood pressure (P >.05), diastolic blood pressure (P >.05), or pulse (P >.05) before or during a bleeding episode. All were within normal parameters. No neurovascular assessment anomalies were detected. CONCLUSION: The use of pressure bandaging has a significant effect on the incidence and pattern of bleeding. Routine vital sign measurement has no relevance in detecting local complications after angiography. The most significant complication is bleeding that requires manual compression. Detection is through frequent puncture site observation and patient recognition and communication.

The effect of pressure bandaging on complications and comfort in patients undergoing coronary angiography: a multicenter randomized trial.

OBJECTIVES: To determine the effectiveness of pressure bandaging in reducing bleeding and bruising in patients undergoing coronary angiography and to investigate the contribution that pressure bandages make to patient discomfort after angiography. DESIGN: A prospective multicenter, randomized study. SETTING: Three university hospitals in Melbourne, Australia. PATIENTS: One thousand seventy-five patients undergoing coronary angiography were randomized to receive a pressure bandage (N = 556) or no bandage (N = 519) after manual compression of the right femoral artery puncture site. RESULTS: Patients without pressure bandages had a higher incidence of bleeding (P < 0.05) and bled earlier (mean 2.4 hours; SD 3.6 hours) after catheter removal (P < 0.001) than patients with bandages (mean 5.3 hours; SD 3.8 hours). The incidence of bleeding in patients without pressure bandages was 6.7%. The incidence and extent of bruising was the same for both groups. Patients with pressure bandages experienced a higher incidence of back (P < 0.05), groin (P < 0.001), and leg pain (P < 0.001), nausea (P < 0.05) and urinary difficulty (P < 0.01). CONCLUSIONS: In view of the associated increase in patient discomfort and the delay in time of onset of bleeding, pressure bandages should not be used routinely in the management of patients after coronary angiography, especially in the context of early discharge from the hospital.

Integrating cost-effectiveness evidence into clinical practice guidelines in Australia for acute myocardial infarction.

A teaching hospital is working with the Victorian State Government and universities, integrating cost-effectiveness evidence into clinical practice guidelines (CPGs), protocols and pathways for respiratory and cardiology interventions. Acute myocardial infarction (AMI) findings are reported. Results will stimulate cost-effective practice and inform medical associations, federal and state governments and international organisations developing CPGs. Published CPGs by the American College of Cardiology/American Heart Foundation for AMI in 1999 are reviewed by a large interdisciplinary hospital-based committee given cost-effectiveness evidence. Levels of evidence criteria rating on methodological rigor for effectiveness and costs are applied. National Health and Medical Research Council (NHMRC) grades of recommendation criteria for combinations of relative effectiveness versus relative costs and cut-off points are used. Extrapolating results between countries was addressed by applying the OECD's health purchasing power parity series. Recommendations for revisions to United States guidelines and for local application are formulated. United States Guidelines require updating: Regarding angioplasty, percutaneous transluminal coronary angioplasty (PTCA) is cost-effective for men aged 60 years relative to recombinant tissue plasminogen activator (tPA), with additional cost per life year saved of 274 ecu. PTCA with discharge after 3 days is cost-effective in low-risk AMI. Regarding GP IIb/IIIa drugs, Abciximab during intervention incurred equal mean hospital costs for placebo, abciximab bolus, and abciximab bolus+infusion with incremental 6-month cost for the latter treatment costing 293 US dollars per patient. Agent recouped almost all initial therapy costs with significant benefits. Incremental cost of abciximab per event prevented is 3,258 US dollars. Tirofiban was compared to placebo after high-risk angioplasty for AMI or unstable angina. Tirofiban decreased the rate of hospital deaths, myocardial infarction, revascularisation at 2 days by 36% relative to placebo (8% vs. 12%) without increased cost. Clinical benefits were similar at 30 days. Tirofiban+heparin+aspirin was compared to heparin+aspirin. Tirofiban arm resulted in net savings of 33,418 ecu per 100 patients for the first 7 days of treatment. Regarding thrombolytics, tPA is more cost-effective than streptokinase. Incremental costs for each life saved when streptokinase is substituted by recombinant tissue plasminogen are 31%, 45%, 97% higher in Germany, Italy and the United States than in the United Kingdom. Regarding anticoagulants, enoxaparin is a promising alternative to unfractionated heparin for hospitalised patients with non-Q-wave myocardial infarction or unstable angina, saving 1,485 Canadian dollars per patient over 12 months with 10% reduction in 1 year risk of death, myocardial infarction or recurrent angina. Regarding antiarrhymics, the cost-effectiveness of no amiodarone, amiodarone for patients with depressed heart rate variability (DHRV), and amiodarone for patients with DHRV plus positive programmed ventricular stimulation (PPVS) for high-risk post-AMI was investigated. Amiodarone for DHRV+PPVS patients was dominated by a blend of the two alternatives. Compared to no amiodarone, the incremental cost-effectiveness of amiodarone for DHRV patients was 39,422 US dollars per quality adjusted life year gained. Amiodarone for DHRV is the most appropriate. Other CPG updates concern serum markers, for example, cardiac troponin I assay (c-Tnl), cost advantages of ad hoc angioplasty and secondary prevention through antioxidants and pravastatin. Australian costs are reported later in the paper.

[Detection of Aedes aegypti and Aedes albopictus, in an urban zone of the municipality of Catanduva, SP, after control of a Dengue epidemic]. / Detecção de Aedes aegypti e Aedes albopictus, na zona urbana do município de Catanduva-SP, após controle de epidemia de Dengue.

After the realization of control research that had in view the transmission of dengue virus, we started to monitor two kinds of entomological vigilance, Breteau Index and ovitrap. We intended to evaluate the necessary time elapsed before Aedes sp mosquitoes were again detected at the urban area of Catanduva s town (SP). The ovitraps showed positiveness for the Aedes aegypti two months after the control research, while the Breteau Index became positive only at the fourth month after the end of the referred research.

[Pupillometry in Menière's disease]. / La pupillométrie dans la maladie de Ménière.

The autonomic dysfunction is one of the etiopathogenetic hypothesis of Ménière's disease. We have already described the presence of an anomalous pupillary contraction, induced by methacholine, during the attack stage of Ménière's disease, without cardio-vascular reflexes involving. We have now employed, in a larger number of cases, a new digital equipment with infrared lighting system, built by us. The pupillary area was measured in darkness by a personal computer in basal condition (time 0) and 10, 20, 30, 45, 60 minutes after methacholine instillation. We have observed 16 cases of Ménière's disease (during attack stage and free stage), 23 cases of other vertiginous disorders (during attack stage and free strage), 10 normal subjects (5 cases of these also during a caloric test). The pupillary contraction was always highest at 30 minutes after methacholine administration. Normal subjects didn't show anisocoria and the contraction was weak and symmetric. Caloric test modified only a little the pupillary response. We observed the same results in other vertiginous disorders. During free stage of Ménière's disease there was little basal anisocoria but the contraction was normal and symmetric. During attack stage of Ménière's disease the contraction was much more evident and higher on the affected side. Ménière's disease crisis is characterized by cholinergic pupillary hyperreactivity, that is not caused by labyrinthic reflexes. We suppose this autonomic dysfunction of central origin.

Pupillary pharmacologic test in Ménière's disease: a useful method for routine diagnosis.

The role of the parasympathetic system in Ménière's disease was investigated by a pupillary pharmacologic test (methacholine test), using a computed infrared pupillograph. The test was performed in Ménière's disease (16 cases), other vertiginous disorders (23 cases) and normal subjects (10 cases). The results confirmed the presence, during the attack stage of Ménière's disease in 75% of cases, of an abnormal sensitivity of the iris musculature to methacholine, prevalent on the affected side, and an increasing pupillary asymmetry. These features were found in 17% of the patients with other vertiginous disorders and in none of the control subjects. The parasympathetic dysfunction is interpreted as a supersensitivity of central origin and seems directly related to the disease. It is proposed that the methacholine test acts as a complement to the glycerol test in the diagnosis of Ménière's disease.

The routine of post anaesthetic observations.

Fifty registered nurses were interviewed to determine how nurses view routine post anaesthetic observations (RPAOs). A structured interview established whether nurses routinely carry out post anaesthetic observations and if they believe that routine observations are part of ward procedure or hospital policy. Nurses' beliefs about the necessity for performing these observations and the rationales they use to justify them were also explored. The results show that all the nurses sampled interpreted RPAOs to mean half hourly vital sign measurements for four hours, and believed that the regimen was prescribed by ward or hospital policy. Many believed that this frequency was necessary to detect complications of surgery or anaesthesia. A small number of nurses felt obliged to comply with perceived hospital policy despite an assessment that it was unnecessary. Procedure-driven assessment and tradition rather than individualized patient assessment appear to be directing post operative nursing actions.