Protamine—the need to determine the dose

A simple method of protamine titration using the Hemochron system was compared with an empirical dose protocol for reversal of heparinisation following cardiopulmonary bypass in 40 patients undergoing elective myocardial revascularisation. Protamine titration revealed a wide range for protamine requirement and resulted in a significant reduction in protamine dose compared with the empirical dose protocol (p less than 0.01). Heparin reversal was assessed as adequate in all patients. The titration technique was easy and straightforward to use in the operating theatre.     

Intravenous calcitriol versus paricalcitol in haemodialysis patients with severe secondary hyperparathyroidism

Aim:   Secondary hyperparathyroidism (SHPT) is common among haemodialysis patients. Intensive treatment with calcitriol is often complicated by hypercalcaemia, hyperphosphataemia and elevated calcium phosphorus (Ca X PO₄) product. Paricalcitol is a vitamin D analogue developed to overcome some of the limitations of calcitriol therapy. The study objectives were to compare the response of intact parathyroid hormone (iPTH) and the incidence of hypercalcaemia, hyperphosphataemia and elevated Ca X PO₄ product in patients with severe SHPT treated with either i.v. calcitriol or i.v. paricalcitol.
Methods:   This was a single centre randomized open label study. Patients with serum intact iPTH of 50 pmol/L or more were randomized to receive either i.v. calcitriol (0.01 ug/kg) or i.v. paricalcitol (0.04 ug/kg) during every haemodialysis treatment. Serum iPTH, calcium, phosphorus and alkaline phosphatase were measured at the beginning of the study and every 3 weeks for 12 weeks.
Results:   Twenty-five patients were enrolled into the study – 12 were randomized into the calcitriol group and 13 into the paricalcitol group. There were no differences in the baseline study parameters between both groups. Serum iPTH levels were significantly reduced ( P  = 0.003) only in the paricalcitol group but not in the calcitriol group ( P  = 0.101). On the other hand, serum calcium levels were significantly increased only in the calcitriol group ( P  = 0.004 vs P  = 0.242). Serum phosphorus, alkaline phosphatase and Ca X PO₄ product were not different.
Conclusion:   Intravenous paricalcitol may be superior to i.v. calcitriol for the treatment of severe SHPT in our chronic haemodialysis population. A larger randomized controlled trial is indicated to confirm these initial findings.     

A Comparative Study on the Immediate Effects of Hand Orthoses on Reducation of Hypertonus

This paper compares the immediate effects of dorsal, volar and no splints in reducing hypertonicity in the wrist flexors of spastic hemiplegic subjects. The measures include: (i) passive range of motion; (ii) angle of point of stretch reflex; (iii) resistance to passive wrist extension; and (iv) force of spontaneous wrist flexion. Results of this study indicate a significant reduction in hypertonicity following both dorsal and volar splint application on the passive range of motion and resistance to passive extension measures (P < .05), and a significant reduction in hypertonicity as measured by spontaneous flexion following two hours of dorsal splint wearing (P < .05). No significant reductions in hypertonicity were noted on the angle of point of stretch reflex measure, and on the force of spontaneous flexion measure. Possible explanations for results and suggestions for further resarch are discussed.     

Epidemiological Survey of Coeliac Disease and Inflammatory Bowel Disease in First-Degree Relatives of Coeliac Patients

One hundred and sixty-two of 182 patients with coeliac diseaseprovided satisfactory details of family size and the prevalenceof coeliac disease and inflammatory bowel disease among theirfirst-degree relatives. Patients ranged in age from 11 monthsto 79 years with a mean age of 41 (± 23) years. Twentypatients had at least one first-degree relative with coeliacdisease: a total of 25 of 861 relatives were affected (prevalence=2904/100,000)compared with an expected 0.9 cases (prevalence=100/100,000;p <0.001). Six relatives had inflammatory bowel disease (prevalence=697/100,000)compared with an expected 1.3 cases (prevalence=150/100,000;p <0.001). Five of these had ulcerative colitis, and onehad Crohn's disease. The relative risk of ulcerative colitisis, therefore, five times greater for first-degree relativesof people with coeliac disease than for the general population(95 per cent confidence interval, 4.7–7.2). There is clearassociation between coeliac disease and ulcerative colitis,which may point to factors involved in the aetiology of colitis.     

Capacity to consent in dementia and the additional costs of implementing the Bournewood Judgement in geriatric psychiatry

Traditionally, patients with dementia, who do not dissent, have been informally admitted to psychiatric wards in the UK. The recent Court of Appeal judgement (Bournewood Judgement) suggested that patients lacking the capacity to consent to inpatient psychiatric care should be admitted under the Mental Health Act irrespective of absence of dissent. On appeal, this judgement was overturned by the House of Lords.The marginal and new additional costs of implementing the Bournewood Judgement in clinical practice were estimated to illustrate the resource implications of legislative changes in the wider context of capacity to consent in dementia.They were estimated for one geriatric psychiatry unit and national costs were also estimated by extrapolation. The additional annual cost of implementing the Bournewood Judgement in our unit with a catchment area of 23,000 elderly was estimated in the range of 6,670 to 13,340.The extrapolated national costs using two techniques were in the range of 8,695,000 to 17,416,000 and 2,555,000 to 5,110,000, respectively. The potential implications of the additional costs due to legislative changes on the already precarious geriatric psychiatry services is discussed in the context of capacity to consent in dementia.     

Sexual Risk Cognitions Questionnaire: A reliability and validity study

The Sexual Risk Cognitions Questionnaire was designed to assess the type and frequency of cognitions associated with unsafe sex. It consists of 22 core items (SRCQ-22) with six subsections. Each subsection consists of 8-12 items designed for specific subgroups defined by gender, sexual orientation and HIV serostatus. Data on reliability and validity are presented based on a sample of 344 respondents in London. Reliability for all sections of the questionnaire was high but sample numbers were relatively small for some subsections. Validity for the SRCQ-22 was assessed in terms of its relationship with self-reported sexual behaviour among men who have sex with men who made up the largest proportion (70%) of the sample. The results indicate that the SRCQ-22 is a reliable measure for assessing cognitions related to HIV risk sexual behaviour in this population and supports the view that they are important determinants of safe and unsafe behaviour.     

Combined surgery and radiation therapy for squamous cell carcinoma of the hypopharynx

Squamous cell carcinoma of the hypopharynx remains a highly lethal disease. This article documents our experience with 132 patients undergoing surgical management of squamous cell carcinoma of the hypopharynx, of whom 80% received postoperative radiation therapy. Local-regional control was obtained in 61% of the patients. Five-year overall and disease-free survival rates were 30% and 41%, respectively. Prognosis was better in patients with limited disease: local disease permitting larynx-sparing surgery, N0/N1 clinical neck, and stage I/II/III disease. Cancer of the hypopharynx remains an aggressive entity associated with poor prognosis. Novel strategies stressing improved local-regional control with prevention of distant metastasis are warranted. (Otolaryngol Head Neck Surg 1997; 116: 637-41.)     

Cost Analysis of Catheter Ablation for Paroxysmal Atrial Fibrillation

WEERASOORIYA, R., et al. : Cost Analysis of Catheter Ablation for Paroxysmal Atrial Fibrillation . RF ablation for paroxysmal atrial fibrillation (PAF) is a curative treatment, which when successful, eliminates the need to take antiarrhythmic drugs, be anticoagulated, and have recurrent physician visits or hospital admissions. The authors performed a retrospective cost comparison of RF ablation versus drug therapy for PAF. The study population consisted of 118 consecutive patients with symptomatic, drug refractory PAF who underwent   1.52 ± 0.71   RF ablation procedures (range 1–4) for PAF. During a follow-up of 32 ± 15 weeks, 85 (72%) patients remained free of clinical recurrence in absence of antiarrhythmic drugs. The cost of RF ablation was calculated in the year 2001 euros on the basis of resource use. The mean cost of pharmacologic treatment prior to ablation was 1,590 euros/patient per year. The initial cost of RF ablation for PAF was 4,715 euros, then 445 euros/year. After 5 years, the cost of RF ablation was below that of ongoing medical management, and continued to diverge thereafter. RF catheter ablation may be a cost-effective alternative to long-term drug therapy in patients with symptomatic, drug refractory PAF. (PACE 2003; 26[Pt. II]:292–294)