14 492 calls were received during the specified times in the trial year (7308 in the control arm and 7184 in the intervention arm) concerning 10 134 patients (10.4% of the registered population). There were no substantial differences in the age and sex of patients in the intervention and control groups, though male patients were underrepresented overall. Reasons for calling the service were consistent with previous studies. Nurses managed 49.8% of calls during intervention periods without referral to a general practitioner. A 69% reduction in telephone advice from a general practitioner, together with a 38% reduction in patient attendance at primary care centres and a 23% reduction in home visits was observed during intervention periods. Statistical equivalence was observed in the number of deaths within seven days, in the number of emergency hospital admissions, and in the number of attendances at accident and emergency departments. Conclusions Nurse telephone consultation produced substantial changes in call management, reducing overall workload of general practitioners by 50% while allowing callers faster access to health information and advice. It was not associated with an increase in the number of adverse events. This model of out of hours primary care is safe and effective.
Increased risk of PD peritonitis and reduced PD survival is reported in this cohort of 17 heart and heart--lung recipients with ESRD. Nevertheless, for patients with severely impaired cardiac function, PD may still offer therapeutic advantage.
We recently published the results of a randomised controlled trial of a nurse telephone consultation service in primary care out of hours. 1 The new service, operating at evenings and weekends, significantly reduced general practitioners' workload and was at least as safe as the existing out of hours service. Contacts diminish sharply after about 10 pm, 2 and, anecdotally, a higher proportion of night calls necessitate consultation with a general practitioner. We report here a parallel trial aimed at establishing whether nurse telephone consultation was equally effective in managing workload at night. Subjects, methods, and resultsThis study was an adjunct to a randomised controlled trial in a 55 member general practice cooperative serving 97 000 patients in Wiltshire. The design has been described. 1 The night nurse telephone consultation service ran over two two-week periods (15-28 October 1997 and 12-25 November 1997) from 11.15 pm until 8 am. Outcome measures were as used in the main trial with one addition: the number of patients attending daytime surgery within three days of a call.1 One of us (FT) visited each surgery to extract details of attendances from patient records.In the main study 49.8% of calls were handled by the nurse alone. Specifying = 0.1 (0.05 in a one sided calculation) and = 0.2, we calculated that the night nurse service would need to receive 78 calls to establish equivalence with this figure, with equivalence limits being 40% and 60%.3 A one sided calculation was used as we were interested to establish only whether the night nurse intervention produced worse results (lower numbers of calls handled without referral to a doctor) than the evening and weekend service. For other within-trial outcomes, results are presented as relative risks with 95% confidence intervals, calculated with EpiInfo. This trial was not powered to show within-trial equivalence in numbers of adverse events.During the study 210 callers made 223 calls, 123 in the control group and 100 in the nurse telephone consultation (intervention) group. Follow up was 94% complete: 12 sets of patient records (6%) could not be found, seven in the control group and five in the intervention group. The median age (range) of patients was 34.0 ( 0.01-97.2) years in the control group and 32.5 (0.49-97.0) years in the intervention group. Fifty three patients (43%) in the control group and 44 (44%) in the intervention group were male.The table shows details of call management and outcome. Altogether 59% of calls (95% confidence interval 48.7% to 68.7%) were handled by the nurse alone. As we were interested only in whether the nurse service handled fewer calls at night, this can be interpreted as showing equivalence with the proportion observed in the main trial. The proportions of calls in which callers received advice from a general practitioner and calls ending in a home visit showed clear reductions, with 95% confidence intervals not embracing 1. A lower proportion of calls resulted in a daytime surgery attendance in the intervention ...
Twenty-two patients with heart, lung or heart and lung transplants maintained on cyclosporin for periods ranging from 3 months to 10 years developed renal insufficiency which was investigated by renal biopsy. The histopathological changes were: (i) severe vascular and glomerular damage due to thrombotic microangiopathy (TM); (ii) a form of focal segmental glomerulosclerosis (FSGS); (iii) glomerular ischaemia. Rather than being separate entities, these changes appeared to represent a spectrum of pathology, some biopsies showing all three forms of glomerular injury. In all cases the glomerular changes were accompanied by arteriolar and arterial pathology, and we identified novel ultrastructural changes in the arteriolar endothelial basal lamina. Tubular atrophy was a consistent feature, the severity of which reflected the severity of the glomerular sclerosis, and which appeared to be a consequence of glomerular loss. Our findings are consistent with the nephrotoxic effects of cyclosporin being mediated chiefly via damage to preglomerular vessels and glomerular capillary endothelium. From an analysis of the clinical aspects of these cases, the effects of cyclosporin appear to be to some extent idiosyncratic, and therefore not entirely preventable, but strict monitoring of blood cyclosporin levels is essential to minimize the risk of permanent renal damage. Monitoring urinary protein in addition to plasma creatinine may detect the onset of FSGS, as proteinuria precedes creatinine elevation.
and found 191 acetaminophen administrations in the charts of 53 patients. For each acetaminophen administration we noted the mean arterial pressure, heart rate, and temperature for 2 h before and 3 h afterwards. We also noted the same data from a control period which was either : (i) 24 h before; (ii) 24 h after; (iii) 8 h before; or (iv) 8 h after the index acetaminophen administration and provided it coincided with the patient's stay on ICU and did not occur within 2 h of acetaminophen administration. Baseline mean arterial pressure (MAP) and heart rate were averaged over the 2 h preceding acetaminophen administration.Following acetaminophen there were significant falls in temperature, MAP, and heart rate, when compared to either baseline (Mann-Whitney) or control (Wilcoxon) values, but not during control periods ( Table 1).The absolute reduction in temperature at +1 and +2 h was correlated with age (Spearman's rank r 0.23, P = 0.0022 at +1 and r 0.27, P = 0.0004 at +2 h) as was the greatest observed absolute reduction within each patient (Spearman's rank r 0.22, P = 0.006). The lowest observed MAP ranged from 48.8 % to 113.3 % of the baseline MAP (median 89.0 %), was significantly lower in males than females, and was negatively correlated with both age (r = ±0.16, P = 0.04) and baseline MAP (r = 0.17, P = 0.02). Fluid boluses or increases in pressor agent infusion rate were noted following 26.2 % of the acetaminophen administrations whilst none were observed during control periods. There was a significant increase in mean heart rate in the 2 h preceding paracetamol compared to control periods (+1.0 beats . min ±1. h ±1 vs ±0.2 beats . min ±1. h ±1 , Mann-Whitney U = 18852, P = 0.0003).Reductions in heart rate correlated with both age (r = ±0.22, P = 0.005) and baseline heart rate (r = ±0.25, P = 0.001) but not baseline temperature.We found two previous reports of acetaminophen-induced hypotension. Brown described two patients whose hypotension was thought to be a hypersensitivity (anaphylactoid) reaction [1], whilst Boyle and colleagues reported a prospective study in 27 patients where they found a statistically significant reduction in MAP within 15 min of acetaminophen administration which persisted for 90 min [2]. Similar to this report, Boyle and colleagues recorded a lowest individual MAP that was 66 % of baseline and found that 30 % of their patients required treatment for hypotension in the form additional fluids or inotropes.Paracetamol is an analgesic and antipyretic whose actions are believed to result from the inhibition of prostaglandin synthesis in the central nervous system [3]. Hypotension is not a recognised dose-related (type A) adverse reaction to acetaminophen and is not mentioned in the product information leaflets produced by any of the UK's six manufacturers, the Association of the British Pharmaceutical Industry (ABPI) data sheets, the British National Formulary, or in information supplied by the UK's Paracetamol Information Centre. Our data suggests that further work on the relationship...
The measurement of total body water by bioelectrical impedance in a group of renal patients was evaluated against the tritium dilution method. The effect of haemodialysis and the presence of peritoneal dialysate on the impedance were also investigated. The correlation between the two methods is r = 0.90 with a residual standard deviation of 3.7. The standard deviation of the differences between the two methods against the means was 3.66 which means that total body water (TBW) estimated by the bioelectrical impedance (BEI) method may be 6.18 l (X +/- 2 SD) above or 8.38 l below the 3H2O method. The BEI method overestimated the actual weight loss after haemodialysis (3.87 +/- 1.7 l versus 2.43 +/- 1.8 l) but underestimated the volume of peritoneal dialysate in situ. The BEI method would not be appropriate for use in assessing total body water and monitoring acute volume changes in patients with renal failure who are on strict fluid restriction.
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