Comparison Between Incremental and Single-Dose Allergen Administration in Bronchial Provocation Tests

To study the effect of different schedules of allergen administration on the early (EAR) and late allergic reaction (LAR), 15 asthmatic patients with dual response after allergen challenge were submitted to two consecutive bronchoprovocation tests (BPT). BPT₁ was carried out with semilogarithmic increase of allergen doses until a FEV₁ drop of 20% was recorded. BPT₂ was performed 2 weeks later using the highest allergen dose that had elicited the dual reaction in BPT₁. Both EAR and LAR were very similar for a given patient. As the allergen dose used in BPT₂ is smaller than the cumulative allergen dose administered in BPT₁, this protocol takes into account a possible influence on BPT₂ of bronchial hyperreactivity induced by BPT₁ performed 2 weeks before.     

Long-term evaluation of usefulness of skin and incremental challenge tests in patients with history of adverse reaction to local anesthetics

A variety of adverse reactions to local anesthetics has been described, some of which are thought to be allergic. Different protocols of prick and intradermal skin tests as well as subcutaneous challenge tests are used to select a local anesthetic which can safely be used. Their long-term effectiveness has not yet been assessed. Twenty-eight patients with a history of adverse reaction to local anesthetics were evaluated over a 3-year period. Loss of consciousness occurred in eight patients, skin reaction in nine, and vagal symptoms in eight. Various reactions were recorded in the remaining three patients. Rapid spontaneous recovery was the rule, suggesting that immediate allergic reaction and, in particular, anaphylactic reaction were unlikely. Investigation allowed the selection of a tolerated anesthetic in all cases. Reexposure occurred in 19 patients 16–50 months after evaluation and 6.8 ± 5.5 years after the first reaction. No patient presented a second reaction. In conclusion, adverse reactions to local anesthetics seem to be, in most cases, not allergic in nature. Evaluation protocols are effective in selecting an agent susceptible to tolerance, but are time consuming. However, they probably contribute to an important reassurance effect that is likely to increase tolerance to subsequent local anesthetic administration. Simplification of the protocols and better patient selection are proposed.     

Impact of medical practice guidelines on the assessment of patients with acute coronary syndrome without persistent ST segment elevation.

OBJECTIVE: To assess the impact of introducing clinical practice guidelines on acute coronary syndrome without persistent ST segment elevation (ACS) on patient initial assessment. DESIGN: Prospective before-after evaluation over a 3-month period. SETTING: The emergency ward of a tertiary teaching hospital. PATIENTS: All consecutive patients with ACS evaluated in the emergency ward over the two 3-month periods. INTERVENTION: Implementation of the practice guidelines, and the addition of a cardiology consultant to the emergency team. MAIN OUTCOME MEASURES: Diagnosis, electrocardiogram interpretation, and risk stratification after the initial evaluation. RESULTS: The clinical characteristics of the 328 and 364 patients evaluated in the emergency ward for suspicion of ACS before and after guideline implementation were similar. Significantly more patients were classified as suffering from atypical chest pain (39.6% versus 47.0%; P = 0.006) after guideline implementation. Guidelines availability was associated with significantly more formal diagnoses (79.9% versus 92.9%; P < 0.0001) and risk stratification (53.7% versus 65.4%, P < 0.0001) at the end of initial assessment. CONCLUSION: Guidelines implementation, along with availability of a cardiology consultant in the emergency room had a positive impact on initial assessment of patients evaluated for suspicion of ACS. It led to increased confidence in diagnosis and stratification by risk, which are the first steps in initiating effective treatment for this common condition.     

Using case management in a universal health coverage system to improve quality of life of frequent Emergency Department users: a randomized controlled trial

Purpose

Frequent Emergency Department users are likely to experience poor quality of life (QOL). Case management interventions are efficient in responding to the complex needs of this population, but their effects on QOL have not been tested yet. Therefore, the aim of our study was to examine to what extent a case management intervention improved frequent Emergency Department users’ QOL in a universal health coverage system.

Methods

Data were part of a randomized controlled trial designed to improve frequent Emergency Department users’ QOL at the Lausanne University Hospital, Switzerland. A total of 250 frequent Emergency Department users (≥?5 attendances during the previous 12 months) were randomly assigned to the control (n?=?125) or the intervention group (n?=?125). The latter benefited from case management intervention. QOL was evaluated using the WHOQOL-BREF at baseline, two, five and a half, nine, and twelve months later. It included four dimensions: physical health, psychological health, social relationship, and environment. Linear mixed-effects models were used to analyze the change in the patients’ QOL over time.

Results

Patients’ QOL improved significantly (p?<?0.001) in both groups for all dimensions after two months. However, environment QOL dimension improved significantly more in the intervention group after 12 months.

Conclusions

Environment QOL dimension was the most responsive dimension for short-term interventions. This may have been due to case management’s assistance in obtaining income entitlements, health insurance coverage, stable housing, or finding general health care practitioners. Case management in general should be developed to enhance frequent users’ QOL.Trial registration: http://www.clinicaltrials.gov, Unique identifier: NCT01934322

     

Impact of a computerized information system on quality of nutritional support in the ICU

OBJECTIVE: In intensive care units (ICUs), patient outcome depends on quality of nutritional support. We investigated the effect of computerized information systems (CISs) on quality of nutritional support by comparing two ICUs with or without CIS and burned patients before and after CIS implementation. METHODS: Part 1 was a 2-wk prospective survey in two units of a surgical ICU: unit A (11 beds) without CIS and unit B (four beds) with CIS. Part 2 consisted of two 18-mo periods in burn patients before and after CIS implementation. Nurses and doctors belonged to the same team; procedures were identical. A computer page was configured to retrieve data related to nutritional support. RESULTS: A total of 1313 ICU days were analyzed in 109 patients. Patients' characteristics were similar in parts 1 and 2. In part 1, nutritional support was required 38% of days. Nutritional route was similar but data were more frequently missing in unit A. Energy delivery was higher with CIS but below target values in both units (31+/-11% of target in unit A, 77+/-4% in unit B). Computations were incomplete and time consuming for unit A versus B (11+/-2 versus 2+/-1 min/patient, P<0.0001). In part 2, in the 54 burn patients, use of postpyloric feeding tubes and energy delivery increased with CIS, resulting in less weight loss. CONCLUSION: Computerized information systems favored standardization of nutritional care and monitoring, thus decreasing time required for writing and computations. Follow-up was improved and nutrient delivery was closer to target values, thus increasing quality of care. In burn patients, the better data visibility was associated with a significant improvement in nutrient delivery.     

Impact of an intervention to control risk associated with patient transfer

QUESTION UNDER STUDY: Hospitals transferring patients retain responsibility until admission to the new health care facility. We define safe transfer conditions, based on appropriate risk assessment, and evaluate the impact of this strategy as implemented at our institution. METHODS: An algorithm defining transfer categories according to destination, equipment monitoring, and medication was developed and tested prospectively over 6 months. Conformity with algorithm criteria was assessed for every transfer and transfer category. After introduction of a transfer coordination centre with transfer nurses, the algorithm was implemented and the same survey was carried out over 1 year. RESULTS: Over the whole study period, the number of transfers increased by 40%, chiefly by ambulance from the emergency department to other hospitals and private clinics. Transfers to rehabilitation centres and nursing homes were reassigned to conventional vehicles. The percentage of patients requiring equipment during transfer, such as an intravenous line, decreased from 34% to 15%, while oxygen or i.v. drug requirement remained stable. The percentage of transfers considered below theoretical safety decreased from 6% to 4%, while 20% of transfers were considered safer than necessary. A substantial number of planned transfers could be "downgraded" by mutual agreement to a lower degree of supervision, and the system was stable on a short-term basis. CONCLUSION: A coordinated transfer system based on an algorithm determining transfer categories, developed on the basis of simple but valid medical and nursing criteria, reduced unnecessary ambulance transfers and treatment during transfer, and increased adequate supervision.     

Quality of life on chronic dialysis: comparison between haemodialysis and peritoneal dialysis.

BACKGROUND: Quality of life (QOL) assessment in patients on chronic haemodialysis (HD) or peritoneal dialysis (PD) has only rarely been carried out with the generic Euroqol-5D questionnaire. METHODS: All chronic HD and PD patients in the 19 centres of western Switzerland were requested to fill in the validated Euroqol-5D generic QOL questionnaire, assessing health status in five dimensions and on a visual analogue scale, allowing computation of a predicted QOL value, to be compared with the value measured on the visual analogue scale. RESULTS: Of the 558 questionnaires distributed to chronic HD patients, 455 were returned (response rate 82%). Fifty of 64 PD patients (78%) returned the questionnaire. The two groups were similar in age, gender and duration of dialysis treatment. Mean QOL was rated at 60+/-18% for HD and 61+/-19% for PD, for a mean predicted QOL value of 62+/-30 and 58+/-32% respectively. Results of the five dimensions were similar in both groups, except for a greater restriction in usual activities for PD patients (P = 0.007). The highest scores were recorded for self-care, with 71% HD and 74% PD patients reporting no limitation, and the lowest scores for usual activities, with 14% HD and 23% PD patients reporting severe limitation. Experiencing pain/discomfort (for HD and PD) or anxiety/depression (for PD) had the highest impact on QOL. CONCLUSIONS: QOL was equally diminished in HD and PD patients. The questionnaire was well accepted and performed well. Improvement could be achievable in both groups if pain/discomfort and anxiety/depression could be more effectively treated.