Critical incident monitoring in anaesthesia

PURPOSE OF REVIEW: Updates on developments in critical incident monitoring in anaesthesia, and assesses its role in improving patient safety. RECENT FINDINGS: Critical incident reporting has become more widely accepted as an effective way to improve anaesthetic safety, and has continued to highlight the importance of human errors and system failures. The establishment of an international database also improves critical incident reporting. Experiences from the national reporting and learning system in the UK have provided some solutions to the many problems and criticisms faced by the critical incident reporting technique. Direct observations to detect errors are more accurate than voluntary reporting of critical incidents, and may be a promising new approach. SUMMARY: Critical incident monitoring is a valuable tool in ensuring patient safety due to its low cost and the ability to provide a comprehensive body of detailed qualitative information. The qualitative information gathered can be used to develop strategies to prevent and manage existing problems, as well as to plan further initiatives for patient safety. Novel approaches should complement existing methods to achieve better results. The development of a culture which emphasises safety should go hand in hand with current audit activities.     

EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases

Objective

To develop evidence‐based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases.

Methods

The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist–epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference.

Results

The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non‐steroidal anti‐inflammatory drugs, gastroprotection and cyclo‐oxygenase‐2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment).

Conclusion

Ten key recommendations for the management of systemic GC‐therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC‐replacement) and need further research; therefore also a research agenda was composed.Since 1948, glucocorticoids (GCs) have been widely used in medicine.¹ Although GCs soon became associated with the occurrence of adverse effects (AEs), they are still the most frequently used anti‐inflammatory and immune‐suppressive drugs in rheumatic diseases. Recent studies have demonstrated the disease‐modifying potential of low‐dose GCs in rheumatoid arthritis (RA) and this has renewed the debate on the risk–benefit ratio of this treatment.² Current literature on the risk–benefit ratio of GCs is nevertheless inconsistent, and inappropriate use of GCs could lead to increased toxicity;³ this emphasises the need for clear statements on proper use of GCs. Hence, a EULAR task force on GCs, including a patient, was formed to develop evidence‐based recommendations, to provide a tool for the better use and management of GC‐therapy in rheumatic diseases.     

DNA-PKcs-dependent modulation of cellular radiosensitivity by a selective cyclooxygenase-2 inhibitor

PURPOSE: Inhibition of cyclooxygenase-2 has been shown to increase radiosensitivity. Recently, the suppression of radiation-induced DNA-dependant protein kinase (DNA-PK) activity by the selective cyclooxygenase-2 inhibitor celecoxib was reported. Given the importance of DNA-PK for repair of radiation-induced DNA double-strand breaks by nonhomologous end-joining and the clinical use of the substance, we investigated the relevance of the DNA-PK catalytic subunit (DNA-PKcs) for the modulation of cellular radiosensitivity by celecoxib. METHODS AND MATERIALS: We used a syngeneic model of Chinese hamster ovarian cell lines: AA8, possessing a wild-type DNK-PKcs; V3, lacking a functional DNA-PKcs; and V3/WT11, V3 stably transfected with the DNA-PKcs. The cells were treated with celecoxib (50 muM) for 24 h before irradiation. The modulation of radiosensitivity was determined using the colony formation assay. RESULTS: Treatment with celecoxib increased the cellular radiosensitivity in the DNA-PKcs-deficient cell line V3 with a dose-enhancement ratio of 1.3 for a surviving fraction of 0.5. In contrast, clonogenic survival was increased in DNA-PKcs wild-type-expressing AA8 cells and in V3 cells transfected with DNA-PKcs (V3/WT11). The decrease in radiosensitivity was comparable to the radiosensitization in V3 cells, with a dose-enhancement ratio of 0.76 (AA8) and 0.80 (V3/WT11) for a survival of 0.5. CONCLUSIONS: We have demonstrated a DNA-PKcs-dependent differential modulation of cellular radiosensitivity by celecoxib. These effects might be attributed to alterations in signaling cascades downstream of DNA-PK toward cell survival. These findings offer an explanation for the poor outcomes in some recently published clinical trials.     

Prevalence of anemia in clinic patients with heart failure and cost analysis of epoetin treatment

STUDY OBJECTIVES: To determine the prevalence of anemia in an outpatient heart failure clinic, describe the type of anemia in patients treated there, and evaluate the potential costs associated with epoetin therapy in this cohort. DESIGN: Single-center, retrospective cohort analysis (part 1) and a literature-based economic decision analysis (part 2). DATA SOURCE: Medical records from a multidisciplinary, outpatient, heart failure clinic, and published hospitalization and drug-use data. PATIENTS: We evaluated 170 adults with chronic heart failure who were enrolled in the clinic and for whom at least one complete blood count was recorded between January 1, 2003, and April 15, 2006. MEASUREMENTS AND MAIN RESULTS: In part 1, demographic and clinical data were extracted from electronic medical records. The overall prevalence of anemia was 47.6% or 47.1%, as based on World Health Organization or National Kidney Foundation definitions, respectively. Normocytic anemia was characterized in 75.0% of patients. In part 2, heart failure hospitalization rates and costs, drug acquisition, and drug administration were estimated by using the published literature. In a hypothetical cohort of 100 patients with heart failure and comorbid anemia, the costs associated with outpatient epoetin and intravenous iron therapy exceeded savings in hospitalization costs by $83,070. Results of 1-way sensitivity analyses generally confirmed robustness of the model. CONCLUSION: Anemia is a common comorbidity in patients with chronic heart failure treated in the outpatient clinic. Although the current evidence is insufficient to support the use of epoetin in this population, initial findings indicate that epoetin and intravenous iron therapy may be associated with positive clinical outcomes. From a pharmacoeconomic standpoint, however, a reduction in the cost of heart failure-related hospitalization does not offset the cost of epoetin and intravenous iron therapy.     

Outcomes out to 12 months after sequential use of high-dose tofacitinib following infliximab in acute severe ulcerative colitis

Acute severe colitis (ASUC) remains a significant cause of morbidity in up to 25% of patients with ulcerative colitis during their disease course. We present the outcomes out to 12 months following the use of high-dose tofacitinib, 10 mg three times daily (TDS), in patients with steroid and infliximab refractory ASUC. A total of 11 patients with ASUC who were treated with high-dose tofacitinib after failing sequential infliximab therapy between 2019 and 2021 were identified at an Australian tertiary centre. Ten of 11 patients demonstrated clinical and biochemical response to treatment during admission. Two of 11 patients required colectomy, one during the index admission and the other during re-admission 10 days after the index presentation. Nine of the initial responders had a median Mayo score of 1 (IQR 0–4) at both 6 and 12 months, and all remained colectomy-free out to 12 months. Neither venous thromboembolic events nor major infective complications were observed. Tofacitinib may be a safe and effective induction and maintenance agent in the treatment of steroid and infliximab refractory ASUC. Prospective studies with long-term follow-up are required to explore the use of tofacitinib in ASUC before it can be routinely recommended as salvage therapy.     

Rationale and design of the PRSM study: Pulmonary rehabilitation or self management for chronic obstructive pulmonary disease (COPD), what is the best approach?

Background:Pulmonary rehabilitation is only accessible by a small proportion of individuals with COPD. For the vast majority who are not able to access these programs, self management approaches may be an alternative to improve health care outcomes.Methods:The PRSM study is a three group randomised controlled trial with individual randomisation, blinded outcome assessment, 3 monthly follow-up assessments across a 12-month period and concurrent economic evaluation. The inclusion criteria are adults with COPD. The primary outcome measure is the St George Respiratory Disease Questionnaire. Secondary outcome measures include a series of questionnaires (Frenchay Activities Index, International Physical Activity Questionnaire, the Hospital Anxiety and Depression Scale and the COPD self-efficacy scale) and two physiological measures (Forced Vital Capacity in 1-second and an incremental shuttle walk). Economic outcome measures include assessment of direct and indirect costs. The sample size of 318 patients (106 per group) is required to detect 4 point difference in the SGRQ, power 90% employing a 2 tailed alpha = 0.05.Results:Enrollment to start April 2008 and complete December 2010. Intention to treat analyses will be used to compare group effect.Conclusion:The results will provide an evidence base regarding the community management of individuals with COPD.     

Pneumothorax in association with spontaneous ventilation general anaesthesia--an unusual cause of hypoxaemia

A 43-year-old ASA PS II male patient developed a pneumothorax while breathing pontaneously through a supraglottic airway device during a general anaesthetic. Unexplained hypoxaemia occurred after an episode of coughing. Clinical examination appeared to be normal apart from the persistent oxygen desaturation. A pneumothorax was diagnosed in the post anaesthesia care unit by chest X-ray. The pneumothorax responded to conventional management and the patient made an uneventful recovery. We recommend a high index of suspicion in any patient who coughs and later has unexplained hypoxaemia during general anaesthesia, even if a supraglottic airway device has been inserted.