Pain after barium enema: effect of CO2 and air on double-contrast study

One hundred fifty-one consecutive patients scheduled for double-contrast barium enema studies were assigned randomly to insufflation with either air or carbon dioxide (CO2) in a double-blind, prospective trial. Within 24 hours after the enema study, the patients were contacted by telephone by an interviewer, who completed a standard questionnaire. Radiographs from the enema studies were assessed for quality by two radiologists. Pain experienced after the procedure was graded from 0 (none) to 4 (severe). Clinically relevant (grades 2-4) pain was experienced by 30% of patients after insufflation with room air, compared with 11% of patients in whom CO2 was used for insufflation (P = .005). The mean pain score for CO2 was 0.4, and for room air, 1.2 (P less than .005). Although five patients experienced grade 4 pain after insufflation with air, no patient reported severe pain after CO2 insufflation. Post-evacuation films confirmed there was significantly less residual gas in the CO2 group. The quality of radiographs was equal in the two groups. CO2 has advantages for use in the double-contrast barium enema examination.     

Three patients with structurally abnormal X chromosomes, each with Xq13 breakpoints and a history of idiopathic acquired sideroblastic anemia

Structural abnormalities of the X chromosome are rarely found in neoplastic disorders. We describe three patients with a history of idiopathic acquired sideroblastic anemia (IASA); each one had an abnormal clone of cells in the bone marrow, characterized by a structurally abnormal X chromosome. In two of these patients, the predominant karyotype was 47,X,2idic(X)(q13); in the other patient, it was 46,X,t(X;11)(q13;p15). Inasmuch as all three of these cases involved chromosome band Xq13, as did two previously published cases, we suggest that band Xq13 may be more prone to structural rearrangement than other X chromosome bands in hematologic disorders. The common Xq13 chromosome breakpoint and clinical presentation (IASA) among these three patients and the occurrence of an X-linked type of sideroblastic anemia may suggest that an association exists between X chromosome abnormalities and IASA. Perhaps alteration of a gene or chromosome structure in or near band Xq13 predisposes to development of IASA. The fact that two of these patients had preleukemia and the third had overt acute leukemia may imply that patients with IASA and X chromosome abnormalities have a poor prognosis. Cases of IASA without associated X chromosome abnormalities are known; thus, if an association between IASA and an abnormal X chromosome does exist, most likely it involves only some patients with IASA.     

Refining the focus of construction injury surveillance

We conducted two studies of construction injury occurring at Denver International Airport (DL4), whose construction required 31 million work hours. Initially we conducted a retrospective cohort study that allowed estimation of injury and workers' compensation (WC) payment rates for strata such as size of employer and type of work; risk factors were also estimated. The second study examined written injury reports for 4,000 injuries at DIA. We modified Haddon's matrix to classify factors contributing to injury. We identified 108 factors within 4 broad categories: human, object, environment and organization. This approach provided information on rates at which each factor contributed to injury and the WC payment rates for each factor. A study shortcoming was that injury reports varied in completeness and quality. In a third ongoing study, to compensate for the shortcomings of injury reports, particularly to improve consistency and completeness of data, we designed a worker questionnaire completed immediately after injury, which included questions specific to hazards associated with each type of injury. Upon completion, the interviewer (a safety professional) uses the modified Haddon's matrix to note contributors to the injury and explain briefly the reasons for each notation. This requires the interviewer to consider a full set of possible factors and determine whether they contributed to injury. This process elicits richer data and places specific factors within the four higher-level categories. This process confer advantages on both contractors and researchers. Contractors can become immediately aware of contributing factors and ameliorate them quickly. The data can also be used in post hoc analysis of injury etiology. Moreover, the data are sufficiently flexible and complete that they can be coded into schemes describing sequences of events leading to injury, as well as those simply identifying factors contributing to injury. Haddon's matrix is invaluable in such analysis because it leads to a fuller understanding of the origins of the most proximate contributors to injury than would otherwise occur. Particularly for contractors and owners with significant safety infrastructures, this approach may be attractive, because it allows for more complete and quicker correction of specific hazards and, with systematic evaluation, recognition of more general safety concerns present on many construction sites.     

What is important in evaluating health care quality? An international comparison of user views

Background  

Quality of care from the perspective of users is increasingly used in evaluating health care performance. Going beyond satisfaction studies, quality of care from the users' perspective is conceptualised in two dimensions: the importance users attach to aspects of care and their actual experience with these aspects. It is well established that health care systems differ in performance. The question in this article is whether there are also differences in what people in different health care systems view as important aspects of health care quality. The aim is to describe and explain international differences in the importance that health care users attach to different aspects of health care.