Addressing overtreatment in patients with refractory epilepsy at a tertiary referral centre in Brazil

Background. Patients with refractory epilepsy often have impaired quality of life (QOL) as a consequence of seizures and adverse effects of antiepileptic drugs. We assessed the impact of adverse effects on QOL and the utility of a structured instrument to help the physician manage adverse effects in patients with refractory epilepsy. Methods. Clinical characteristics, drug treatment and adverse effects were evaluated in 102 patients with refractory epilepsy at a single tertiary referral centre. The Adverse Events Profile (AEP) and Quality of Life in Epilepsy-31 (QOLIE-31) questionnaires were completed at baseline and after six months. At baseline, patients with a high burden of adverse effects (AEP scores >= 45) were randomized to an intervention or control group. AEP scores in the intervention group were available to the physician as an instrument to help to reduce adverse effects. Results. Ninety-five patients (93.1%) were on polytherapy. Sixty-six completed the questionnaires and, of these, 43 (65.1%) had a high AE burden and were randomized to the intervention and control group. QOLIE-31 scores were inversely correlated with AEP scores at both visits. Among randomized patients, AEP scores tended to decrease between the baseline and the final visit without significant differences between groups (intervention group: 54.1 +/- 6.1 vs 51.1 +/- 9.1; control group: 55.8 +/- 5.8 vs 50.5 +/- 12.2). QOLIE-31 scores did not change substantially between visits (intervention group: 45.9 +/- 17.4 vs 48.4 +/- 14; control group: 47.5 +/- 15.7 vs 45.2 +/- 18.9). Conclusion. A significant proportion of patients had a high toxicity burden which had an impact on their QOL. Reduction of over-treatment is a difficult challenge which cannot be addressed solely by providing a structured assessment of adverse effects, but requires a more comprehensive approach aimed at optimizing the many components of the management strategy.

Impact of implementing an exclusively dedicated respiratory isolation room in a Brazilian tertiary emergency department

Background Occupational risk due to airborne disease challenges healthcare institutions. Environmental measures are effective but their cost-effectiveness is still debatable and most of the capacity planning is based on occupational rates. Better indices to plan and evaluate capacity are needed. Goal To evaluate the impact of installing an exclusively dedicated respiratory isolation room (EDRIR) in a tertiary emergency department (ED) determined by a time-to-reach-facility method. Methods A group of patients in need of respiratory isolation were first identified-group I (2004; 29 patients; 44.1 +/- 3.4 years) and the occupational rate and time intervals (arrival to diagnosis, diagnosis to respiratory isolation indication and indication to effective isolation) were determined and it was estimated that adding an EDRIR would have a significant impact over the time to isolation. After implementing the EDRIR, a second group of patients was gathered in the same period of the year-group II (2007; 50 patients; 43.4 +/- 1.8 years) and demographic and functional parameters were recorded to evaluate time to isolation. Cox proportional hazard models adjusted for age, gender and inhospital respiratory isolation room availability were obtained. Results Implementing an EDRIR decreased the time from arrival to indication of respiratory isolation (27.5 +/- 9.3 X 3.7 +/- 2.0; p = 0.0180) and from indication to effective respiratory isolation (13.3 +/- 3.0 X 2.94 +/- 1.06; p = 0.003) but not the respiratory isolation duration and total hospital stay. The impact on crude isolation rates was very significant (8.9 X 75.4/100.000 patients; p < 0.001). The HR for effective respiratory isolation was 26.8 (95% CI 7.42 to 96.9) p < 0.001 greater for 2007. Conclusion Implementing an EDRIR in a tertiary ED significantly reduced the time to respiratory isolation.

Drug use evaluation of ipratropium bromide at two tertiary referral hospitals in Brisbane.

Objective: To assess the appropriateness of ipratropium bromide prescribing in two tertiary referral hospitals. Method: Criteria for optimal use were developed based on current literature and modified after consultation with respiratory physicians and clinical pharmacists. A prospective review of prescribing was performed over a 2-month period to assess conformity to these criteria. Results: Information was collected from 84 patients; 5% were receiving inhalers and 96% nebuliser therapy (one patient used both). 77% of patients (n = 65) had a principal diagnosis of chronic obstructive pulmonary disease, 14% (n = 12) asthma and 8% (n = 7) had neither diagnosis. 75% of patients were using ipratropium outside the guidelines. The major areas where the guidelines were not met were a lack of therapeutic justification, use of inappropriate doses, and use of an inappropriate delivery device. Feedback and educational interventions were designed and delivered based on the data obtained. Conclusions: There was widespread use of ipratropium outside the developed guidelines. Interventions in specific areas could lead to significant improvements in the use of this high cost drug

Auditing complications of laparoscopy in a major tertiary hospital in Australia

Objective To review complications in both diagnostic and operative laparoscopic procedures at a university-affiliated major teaching hospital and to assess possible risk factors for complications. Design and setting A retrospective review of all laparoscopic procedures at the Royal Women's Hospital Brisbane, Australia, from 1990 to 1997 inclusive. A non-medical or nursing independent assessor reviewed charts. Data were collected on a standard form. Incomplete charts were excluded from analysis. Results There was a total of 1505 procedures. Analysis was based on 1435 complete data records. The overall complication rate was 2.86% with infection (1.3%) being the most common. The rate of gastrointestinal injury was 0.14%. Compared with women who had diagnostic laparoscopies, a higher rate of complication was found in women who had undergone operative laparoscopic procedures. However, this difference did not reach statistical significance. The complication rate was unrelated to seniority of the surgeon. Conclusion Complications can occur in any laparoscopic procedure. Regular reviews, especially in teaching hospitals, will provide feedback to clinicians to improve quality of care.

The filter system for tertiary treatment of sewage effluent by land application - its performance in a subtropical environment

FILTER is an innovative, CSIRO developed system for treating effluent using high rate land application and subsequent effluent recapture via a closely spaced, subsurface drainage network. We report on the summer performance of a FILTER system established in a subtropical environment on a relatively impermeable swelling clay soil underlain by a deep regional water table. Using secondary treated sewage effluent, the FILTER system produced effluent of tertiary nutrient standards (less than or equal to5 mg/L TN; less than or equal to1 mg/L TP), with salinity levels suitable for subsequent irrigation reuse (EC less than or equal to2.5 dS/m). Removal of faecal coliforms was considerably less effective. The hydraulic loading rate achieved was about two and a half times larger than conventional irrigation demand, but this was associated with high deep percolation losses (e 3 mm/day). Comparisons are made with the original FILTER system developed and tested by Jayawardane et al. in temperate Australia. Suggestions are made for modifications to, and further testing of FILTER in a subtropical environment.

Metabolic activation of heterocyclic amines and other procarcinogens in Salmonella typhimurium umu tester strains expressing human cytochrome P4501A1, 1A2, 1B1, 2C9, 2D6, 2E1, and 3A4 and human NADPH-P450 reductase and bacterial O-acetyltransferase

We investigated roles of different forms of cytochrome P450 (P450 or CYP) in the metabolic activation of heterocyclic amines (HCAs) and other procarcinogens to genotoxic metabolite(s) in the newly developed umu tester strains Salmonella typhimurium (S. typhimurium) OY1002/1A1, OY1002/1A2, OY1002/1B1, OY1002/2C9, OY1002/2D6, OY1002/2E1 and OY 1002/3A4. which express respective human P450 enzymes and NADPH-cytochrome P350 reductase (reductase) and bacterial O-acetyltransferase (O-AT). These strains were established by introducing two plasmids into S. typhimurium TA 1535, one carrying both P450 and the reductase cDNA in a bicistronic construct under control of an IPTG-inducible double me promoter and the other, pOA 102, carrying O-AT and umuClacZ fusion genes. Expression levels of CYP were found to range between 35 to 550 nmol/l cell culture in the strains tested. O-AT activities in different strains ranged from 52 to 135 nmol isoniazid acetylated/min/mg protein. All HCAs tested, and 2-aminoanthracene and 2-aminofluorene exhibited high genotoxicity in the OY1002/1A2 strain, and genotoxicity of 2-amino-3-methylimidazo [4,5-f]quinoline was detected in both the OY1002/1A1 and OY1002/1A2 strains. 1-Amino-1,4-dimethyl-5H-pyrido[4.3-b]-indole and 3-amino-1-methyl-5H-pyrido[4,3-b]-indole were activated in the OY1002/1A1, OY1002/1B1, OY1002/1A2, and OY1002/3A4 strains. Aflatoxin B-1 exhibited genotoxicity in the OY1002/1A2, OY1002/1A1, and OY1002/3A4 strains. beta -Naphthylamine and benzo[a]pyrene did not exhibit genotoxicity in any of the strains. These results suggest that CYP1A2 is the major cytochrom P450 enzyme involved in bioactivation of HCAs. (C) 2001 Elsevier Science B.V. All rights reserved.

From molecular complexes to zwitterions and final products. Reactions between C3O2 and amines

The formation of molecular complexes (prereactive intermediates) between C3O2 and amines (ammonia, dimethylamine, trimethylamine, and 4-(dimethylamino)pyridine) as well as the subsequent transformation of the complexes into C3O2-amine zwitterions in cryogenic matrixes (ca. 40 K) has been observed. In the case of dimethylamine, the formation of tetramethylmalonamide has also been documented. Calculations using density functional theory (B3LYP/6-31G(2d, p)) are used to assign all above species and are in excellent agreement with the IR spectra.

High prevalence, persistent hazardous drinking among new zealand tertiary students

Aims: To determine the prevalence of hazardous drinking and alcohol-related negative consequences in New Zealand tertiary students, and to identify predictors of hazardous drinking across a 6-month period. Methods: A total of 1480 tertiary students living in halls of residence was surveyed at the start of the academic year, and a subsample of 967 students was followed up 6 months later. Questionnaire items included quantity and frequency of drinking, alcohol-related problems, use of other substances, and the Alcohol Use Disorders Identification Test (AUDIT). Drinking at follow-up was modelled using demographic characteristics, mental well-being, other substance use, alcohol-related problems, and hall drinking norms, measured at baseline. Results: Among drinkers, mean (+/- SD) weekly consumption was 243 +/- 241 and 135 +/- 157 g of ethanol for males and females respectively. The majority of male (60.0%) and female (58.2%) drinkers typically consumed more than national safe drinking guidelines. Mean (+/- SD) AUDIT scores were 10.9 +/- 7.6 for males and 7.6 +/- 5.9 for females. After controlling for AUDIT scores at baseline, increased AUDIT scores at follow-up were higher with lower age, Maori ethnicity, smoking, cannabis use, high levels of alcohol-related negative consequences, and higher levels of drinking in the student's hall of residence. Conclusions: Hazardous drinking is widespread and persistent among students living in the halls of residence. There is a need for university alcohol policies and intervention approaches among New Zealand tertiary students.