Insufflation vs intubation during esophagogastroduodenoscopy in children

Objectives: We compared adverse airway events during esophagogastroduodenoscopy (EGD) in children managed with insufflation vs intubation. Background: Optimum airway management during EGD in children remains undecided. Methods/materials: Following IRB approval and written informed parental consent, children between 1 and 12 years of age presenting for EGD were randomized to airway management with insufflation (Group I), intubation/awake extubation (Group A), or intubation/deep extubation (Group D). All subjects received a standardized anesthetic with sevoflurane in oxygen. Using uniform definitions, airway adverse events during and after EGD recovery were recorded. Categorical data were analysed with Chi‐square contingency tables or Fisher’s exact test as appropriate. Results: Analyzable data were available for 415 subjects (Group I: 209; Group A: 101; Group D: 105). Desaturation, laryngospasm, any airway adverse event, and multiple airway adverse events during EGD were significantly more common in subjects in Group I compared to those in Groups A and D. Complaints of sore throat, hoarseness, stridor, and/or dysphagia were more common in subjects in Groups A and D. Analysis of confounders suggested that younger age, obesity, and midazolam premedication were independent predictors of airway adverse events during EGD. Conclusions: Insufflation during EGD was associated with a higher incidence of airway adverse events, including desaturation and laryngospasm; intubation during EGD was associated with more frequent complaints related to sore throat. As our results show that insufflation during EGD offers no advantage in terms of operational efficiency and is associated with more airway adverse events, we recommend endotracheal intubation during EGD, especially in patients who are younger, obese, or have received midazolam premedication.     

Molecular epidemiology of hepatitis C in Australia

The aim of this study was to determine the distribution of hepatitis C virus (HCV) genotypes in Australian patients with hepatitis C and to identify factors associated with particular genotypes. Serum isolates of HCV-RNA were genotyped using a commercial oligonucleotide hybridization (line probe) assay. Relationships between demographic factors, mode of HCV transmission and HCV genotype were assessed by logistic regression analysis. Among 463 patients with hepatitis C, 425 tested positive for HCV-RNA and a single HCV genotype was identified in 420 cases. The patients' places of birth were Australia or New Zealand (62%), Asia (13%), Europe (12%), Mediterranean (6%), Middle East (6%) and other countries (<1%). The most common genotypes were type 1 (52%) or type 3 (32%); type 2 (9.3%), type 4 (5.5%) and type 6 (1.7%) were less common. Patients with genotype 1b were older (48 ± 13 years, P < 0.001) and patients with genotype 3 were younger than the remaining patients (37 ± 11 years vs 42 ± 12 years, P < 0.001). Among type 1 isolates, 1b was more common for patients born outside Australia compared with those born in Australia (50%vs 13%, P < 0.001) whereas non-1b subtypes were more common among Australian-born patients. Likewise, 21 of 23 (91%) patients with type 4 were from Egypt and six of seven (86%) with type 6 were from Vietnam. The relative importance of parenteral risk factors for HCV also varied according to geographic origin. Thus, a definite risk factor for HCV acquisition was identified in > 95% of Australian-born patients, but in only 33% of Asian or Mediterranean-born patients. Logistic regression analysis indicated that region of birth and risk factor (intravenous drug use or not) would allow 98% of type 4 cases and 76% of type 1b cases to be identified correctly. In summary, region of birth, patterns of migration over time and risk factors for transmission of HCV interact to determine the distribution of HCV genotypes in a multi-racial community like Australia.     

Toward a Transdisciplinary Model of Evidence-Based Practice

Context: This article describes the historical context and current developments in evidence-based practice (EBP) for medicine, nursing, psychology, social work, and public health, as well as the evolution of the seminal "three circles" model of evidence-based medicine, highlighting changes in EBP content, processes, and philosophies across disciplines.
Methods: The core issues and challenges in EBP are identified by comparing and contrasting EBP models across various health disciplines. Then a unified, transdisciplinary EBP model is presented, drawing on the strengths and compensating for the weaknesses of each discipline.
Findings: Common challenges across disciplines include (1) how "evidence" should be defined and comparatively weighted; (2) how and when the patient's and/or other contextual factors should enter the clinical decision-making process; (3) the definition and role of the "expert"; and (4) what other variables should be considered when selecting an evidence-based practice, such as age, social class, community resources, and local expertise.
Conclusions: A unified, transdisciplinary EBP model would address historical shortcomings by redefining the contents of each model circle, clarifying the practitioner's expertise and competencies, emphasizing shared decision making, and adding both environmental and organizational contexts. Implications for academia, practice, and policy also are discussed.     

Mortality in a sample of convicted drinking drivers

Mortality rates for 639 drinking drivers were calculated. The sample consisted of all individuals convicted of a second offence in two Ontario cities (Oshawa and North Bay) between 1973 and late 1978. There were 53 deaths (51 males, 2 females) in the sample prior to the end of 1986. Among males, significant excess total mortality was observed (Standardized Mortality Ratio = 1.7); similar trends were observed among females. Age-related excess mortality and excess mortality by cause were strikingly similar to mortality patterns observed among alcoholics.     

Calcium Carbimide in Alcoholism Treatment. Part 1: a placebo-controlled,double-blind clinical trial of short-term efficacy⋆

A randomized, double-blind, placebo-controlled single cross-over study of the alcohol sensitizing drug, calcium carbimide (CC), was conducted in 128 patients with alcohol dependence. Seventy-one (55%) completed the 4-month study. Patients reported drinking and pill-taking behaviour, and submitted urines (for analysis of alcohol and the tablet marker riboflavin) on 97%, and 91% of treatment days, respectively. All of the 69 analyzable computers were abstinent on at least 85% of days, and 58% (40) were alcohol-free during the study. Medications were taken on at least 85% of days. Symptoms and adverse clinical findings were not increased in frequency during CC, compared to placebo. Seventy-eight per cent of the patients believed they had received CC throughout the study, suggesting that CC exerts a strong psychological deterrent effect. Alcohol consumption was significantly reduced to the same extent with CC and placebo, compared to pre-treatment levels.     

Description of a Home Follow-up Program for Childbearing Families

Over the years, nurses have identified the need for home follow-up of postpartum families after discharge from the hospital. In the current health-care environment, the need for follow-up care is greater than ever. This article reviews the rationale for a follow-up program and describes a model, in existence since 1987, that makes postpartum follow-up an integral part of the total nursing care that childbearing families receive from the institution. The purpose, objectives, components, organization, documentation, funding, and evaluation of the program are described.     

SPECTROSCOPIC STUDY OF THE CONFORMATIONS OF PROLINE-CONTAINING OLIGOPEPTIDES IN THE CRYSTALLINE STATE AND IN SOLUTION

A conformational study has been carried out on a series of linear proline-containing oligopeptides (ZGP, ZGPL, ZGPLG and ZGPLGP) in both the crystalline state and in DMSO-d₆, solution, using Raman and n.m.r. spectroscopy. The amide I and HI bands in the Raman spectra of the crystalline forms indicate the presence of a type I β-bend conformation in ZGPLG and ZGPLGP, but not in ZGP and ZGPL. This result is in agreement with X-ray data on these mole cules. The Raman spectra of these peptides in solution indicate that more than one conformation is present, i.e. that the β-bend structure of the solid form of ZGPLG and ZGPLGP is destabilized by DMSO-d₆. ¹³C and ¹H n.m.r. data also demonstrate the presence of more than one conformation in ZGP, ZGPL, ZGPLG and ZGPLGP in DMSO-d₆ solution. These isomers differ in their con formation (cis and trans) about their Gly-Pro peptide bonds and possibly about the Cα-C' bond of the C-terminal proline in ZGPLGP. For ZGP, ZGPL, ZGPLG and ZGPLGP, the ensemble of conformations in DMSO-d₆ includes C₅ and C₇ hydrogen-bonded rings; in addition, ZGPLGP may contain a small percentage of a β-bend conformation (at Pro₂-Leuj₃) with trans peptides in both Gly-Pro moieties.