The pouch as an alternative to permanent ileostomy

Restorative proctocolectomy has become a realistic alternative to construction of a permanent stoma for patients with ulcerative colitis and familial polyposis coli. The operation restores intestinal continuity but continent patients have to open their bowels 4-5 times during the day, and over half have to rise at night to defaecate. The potential complications are considerable, but their frequency decreases with experience with the operation. This article reviews the place and results of ileoanal pouch anastomosis.     

An economic evaluation of pain therapy after hysterectomy. Patient-controlled analgesia versus regular intramuscular opioid therapy

OBJECTIVES: To assess the economics of patient-controlled analgesia (PCA) treatment versus regular intramuscular (i.m.) injections of opioid analgesia for pain management after hysterectomy. METHODS: Cost-minimization analysis was used based on the comparable pain control results achieved in the two treatment groups. Observations were taken of treatment-related events with personnel (mostly nursing) time implications during the trial. Times were then associated with these events in an independent study of personnel activity. Costs were linked by using average wage rates for the various personnel for the Montreal area during the time of the study. Drug and material costs were hospital acquisition costs for all items. The cost of the PCA pump itself was not included in the analysis. Several analyses were performed to test the sensitivity of the results to various assumptions. RESULTS: The results for total costs of the two therapies generally showed PCA to be more costly than regular i.m. injections despite no costs of the pump being included in the analyses. These results were robust with respect to changes in assumptions. Even when intentionally biasing the analysis against i.m. therapy, it was difficult to obtain results that favored PCA. CONCLUSIONS: Based upon the institutions and assumptions in this analysis, PCA offers no cost advantages over regular i.m. therapy in the pain management after hysterectomy. Regular i.m. injections provided less costly analgesia.     

Fructose as an alternative to glucose as an energy source during intravenous feeding

The metabolic effects of infusing an amino-acid solution with either a 24% solution of glucose or a 24% solution of glucose and fructrose have been investigated in 10 patients who underwent elective surgery for colo-rectal carcinoma.The serum concentrations of all measured biochemical indices and the plasma venous concentrations of individual amino-acids were similar during the infusion of glucose and the mixture of glucose and fructose. Statistically significant increases in the serum concentrations of urea, creatinine and glucose and statistically significant decreases in the serum concentrations of uric acid and bilirubin were observed during infusion of both energy substrates. A persistent increase in the plasma venous concentrations of all amino-acids was observed throughout the period of intravenous feeding.Glycosuria occurred during the infusion of both energy substrates, but the urinary loss of glucose during the infusion of glucose was statistically significantly greater than that during the infusion of glucose and fructose.It is concluded that at these rates of infusion fructose has no advantages or disadvantages over glucose as a source of non-protein energy during intravenous feeding in this type of patient.     

Human skin equivalent as an alternative to animal testing

The 3-D skin equivalent can be viewed as physiologically comparable to the natural skin and therefore is a suitable alternative for animal testing. This highly differentiated in vitro human skin equivalent is used to assess the efficacy and mode of action of novel agents. This model is generated from primary human keratinocytes on a collagen substrate containing human dermal fibroblasts. It is grown at the air-liquid interface which allows full epidermal stratification and epidermal-dermal interactions to occur. Future emphasis is the establishment of different test systems to investigate wound healing, melanoma research and infection biology. Key features of this skin model are that it can be used as an alternative for in vivo studies, donor tissue can be tailored to the needs of the study and multiple analyses can be carried out at mRNA and protein level. Driven by both ethical and economical incentives, this has already resulted in a shift of the test strategies used by the Pharmaceutical Industry in the early drug development process as reflected by the increased demand for application of cell based assays. It is also a suitable model for testing a wide variety of endpoints including cell viability, the release of proinflammatory mediators, permeation rate, proliferation and biochemical changes.     

A written test as an alternative to performance testing

Performance tests are logistically complex and time consuming. To reach adequate reliability long tests are imperative. Additionally, they are very difficult to adapt to the individual learning paths of students, which is necessary in problem-based learning. This study investigates a written alternative to performance-based tests. A Knowledge Test of Skills (KTS) was developed and administered to 380 subjects of various educational levels, including both first-year students and recently graduated doctors. By comparing KTS scores with scores on performance tests strong convergent validity was demonstrated. The KTS failed discriminant validity when compared with a general medical knowledge test. Also the identification of sub-tests discriminating between behavioural and cognitive aspects was not successful. This was due to the interdependence of the constructs measured. The KTS was able to demonstrate differences in ability level and showed subtle changes in response patterns over items, indicating construct validity. It was concluded that the KTS is a valid instrument for predicting performance scores and could very well be applied as supplementary information to performance testing. The relative ease of construction and efficiency makes the KTS a suitable substitute instrument for research purposes. The study also showed that in higher ability levels the concepts which were meant to be measured were highly related, giving evidence to the general factor theory of competence. However, it appeared that this general factor was originally non-existent in first-year students and that these competencies integrate as the educational process develops.     

Patients' willingness to take risks in the management of pharyngitis

Choosing a management plan for pharyngitis involves considering the risks and benefits of alternatives. Using a sick-day equivalent scale, this study examined patients' willingness to be ill with pharyngitis compared with their willingness to risk two outcomes: a penicillin reaction and rheumatic fever. On average, patients preferred 1.5 to 2.5 days of illness with pharyngitis over risking a 5-percent chance of developing a mild penicillin reaction. Willingness to risk the outcomes decreased with increasing probabilities of their occurrence. Subjects were more willing to risk a penicillin reaction than rheumatic fever. Healthy subjects receiving sick pay were more willing to risk varying probabilities of a mild penicillin reaction than subjects not receiving sick pay. Patients ill with pharyngitis, however, were not more willing to take similar risks if they received sick pay. Illness may, therefore, modify some aspects of risk-taking behavior. It is reasonable to conclude that some patients with pharyngitis would prefer early antibiotic treatment for the chance of earlier recovery over waiting for throat culture results despite the risk of a penicillin reaction.     

The use of lead positions as an alternative to the traditional manager

The use of lead employees with expanded roles and increased responsibilities gives a manager a unique opportunity to improve communications while cutting costs and lifting morale. It allows a manager to better utilize employees to schedule employees, monitor work flow, assess quality, and assign tasks that have been traditionally given to a manager. There are many different ways of viewing a task: there is the view of the employee who performs the task, the employee affected by the task, and the manager responsible for the results of the task. A good manager needs to be knowledgeable and flexible enough to see all points of view, to ensure that the job is completed in the most effective and cost-efficient manner possible while still meeting the needs of those involved. In this time of high technology and job complexity, managers must use all resources available to them while keeping costs down and getting the job done efficiently.     

Acute pain in advanced cancer: an opioid dosing strategy and illustration

Opioid dosing strategies for acute pain differ from strategies for chronic pain management. The basic principles of effective, safe dosing are rapid titration to the onset of analgesia followed by maintenance infusions based upon the titrated dose. This article presents guidelines and case histories for safe and effective dosing.     

Computerized long-menu questions as an alternative to open-ended questions in computerized assessment

To optimally avoid cueing effects and computer scoring problems in computerized examinations a computerized long-menu question (CLM) was developed. This question type was compared to open-ended questions in one treatment group and to multiple-choice questions in another treatment group. Also, scores were compared to self-perceived computer anxiety of the participants. CLMs yield comparable scores to open-ended questions, but the scores differ significantly from those on multiple-choice tests. Correlations in the first comparison (CLMs with multiple-choice) were higher than those in the second camparison (CLMs with open-ended questions). The amount of positive and negative cueing was considerably higher in the first than in the second comparison. Response times of CLMs were higher than those of multiple-choice questions and open-ended questions, differing significantly from both. Computer anxiety did not influence the mean scores in either comparison. Therefore, in computerized testing CLMs seem to offer an acceptable replacement of open-ended questions.     

Prospectives on the risks of alternative fuel cycles.

A commentary is provided on the uncertainties in the data and in qualifying the phenomena relating to the risks imposed by the various steps involved in the use of coal, oil, natural gas, hydropower, and nuclear fuels for the generation of electricity. Uncertainties appear to be extremely large for hydropower which exhibits both large scale ecological impacts and the potential for high consequence, moderate frequency events at specific sites. Major risk-related uncertainties with the use of nuclear fuels include those surrounding nuclear weapons proliferation and reactor accident frequencies and consequences. Uncertainties for coal and oil include specification of the damage function of air transported sulfates and the effects of atmospheric CO2 buildup, acid rain, and groundwater contamination from mine water runoff. Compounding these problems is the potential impact of the growing global competition for a diminishing supply of oil. In the studies reviewed herein, the assessed risks of the nuclear fuel cycle are no greater than those of the primary alternatives. Prudence suggests that we do not totally reject any particular option at this time on the basis of health effects alone; similarly, no option is an undisputed choice.     

Practical aspects in the use of passive immunization as an alternative to attenuated viral vaccines

Passive immunization as a method to protect birds has been tested for many years and shown to be effective. Its advantages over active vaccination include no use of partially virulent viruses, overcoming the gap in the level of protection at young age due to interference of maternal antibodies to raise self-immune response following active vaccination and the possible immunosuppressive effect of attenuated vaccine viruses. However, a major obstacle to its implementation is its relatively high cost which is dependent, among other things, mainly on two factors: the efficacy of antibody production, and the use of specific pathogen-free (SPF) birds for antibody production to avoid the possible transfer of pathogens from commercial layers. In this study we show efficient production of immunoglobulin Y (IgY) against four different pathogens simultaneously in the same egg, and treatment of the extracted IgY with formalin to negate the need for SPF birds. Formalin, a common registered sterilization compound in vaccine production, was shown not to interfere with the Fab specific antigen binding or Fc-complement activation of the antibody. Following injection of 1-day-old broilers with antibodies against infectious bursal disease virus, protective antibody levels were acquired for the entire period of sensitivity to this pathogen (35 days). Passive vaccination with formalin-sterilized IgY against multiple antigens extracted from one commercial egg may be a cost-effective and advantageous complementary or alternative to attenuated vaccines in poultry.