腹腔镜腹壁切口疝修补术的临床疗效分析

目的探讨腹腔镜腹壁切口疝修补术的临床疗效。方法选取2015年6月~2016年5月我院收治的腹壁切口疝患者89例,根据治疗方式的不同将患者分为开放组44例和腹腔镜组45例。开放组44例患者采用开放式腹壁切口疝修补术,腹腔镜组45例患者行腹腔镜腹壁切口疝修补术,并对两组患者的手术时间、术中出血量、术后疼痛评分、并发症及复发情况、住院时间进行比较。结果腹腔镜组患者的手术时间长于开放组(P0.05),而术中出血量、术后疼痛评分和住院时间均低于开放组(P0.05),并发症发生率和复发率低于开放组(P0.05)。结论腹腔镜腹壁切口疝修补术是一种安全、有效、可行的治疗手段,值得临床推广应用。     

腹腔镜腹股沟疝修补术患者术后出血及二次手术相关因素分析

目的:探讨影响腹腔镜腹股沟疝修补术患者术后出血及二次手术相关因素。方法:回顾性分析行腹腔镜腹股沟疝修补术的6632例患者的临床资料,将凝血病、抗凝治疗或抗血小板治疗的829例患者归入风险组(n=829),其他患者归为对照组(n=5803),收集并比较二组患者的手术方式、年龄、性别、美国麻醉师协会(ASA)分级、疝缺损面积(I-III级)、一期手术与二次手术等患者资料,进行一年随访;采用多变量分析影响患者继发性出血及并发症所致二次手术的相关因素。结果:风险组的术后出血发生率显著高于对照组(4.22%vs 1.26%,P0.001),所有患者术后出血发生率为1.63%。影响术后继发性出血的其它负面因素有:开放式腹股沟疝术式、年龄增加、较高ASA分级、二次手术、男性和较大的疝缺损。风险组与并发症相关的二次手术发生率显著高于对照组(2.65%vs 1.14%,P0.001),所有患者与并发症相关的二次手术发生率为1.32%。影响患者并发症所致二次手术负面因素有:双侧手术、较高ASA分级、凝血病与抗凝治疗和抗血小板治疗、高龄,保护因素包括:较小的疝缺损面积与腹腔镜手术式。结论:行腹腔镜腹股沟疝手术患者术后出血性及并发症相关的二次手术的风险小于行开放术式患者。     

Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study

Objective: To determine the long term relative survival of all patients who had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Design: Population based study. Setting: Western Australia. Subjects: All patients who had had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. Main outcome measures: Morbidity and mortality data of patients admitted and surgically treated for abdominal aortic aneurysm in Western Australia during 1985-94. Elective, ruptured, and acute non-ruptured cases were analysed separately. Independent analyses for sex and patients aged 80 years or more were also undertaken. Postoperative (>30 days) relative survival was assessed against age and sex matched controls. Results: Overall, 1475 (1257 men, 218 women) cases were identified. The crude five year survival after elective surgery, including deaths within 30 days of surgery, was 79% for both men and women. When compared with a matched population the five year relative survival after elective surgery was 94.9% (95% confidence interval 89.9% to 99.9%) for men but only 88.0% (76.3% to 99.7%) for women. The five year relative survival of those aged 80 years and over was good: 116.6% (89.1% to 144.0%) compared with 92.4% (87.7% to 97.0%) for those under 80 years of age (men and women combined). Cardiovascular disease caused 57.8% of the 341 deaths after 30 days. Conclusion: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.

Key messages

• Background mortality for conditions such as abdominal aortic aneurysm in elderly patients needs to be taken into account when assessing long term survival after surgery
• Relative survival methodology can correct for background mortality
• The five year relative survival for patients surviving beyond 30 days of elective surgery for abdominal aortic aneurysm was 95% for men and 88% for women
• For octogenarians, five year survival after elective surgery was greater than that expected of an age matched population
• Age over 80 years should not preclude consideration for elective surgery for abdominal aortic aneurysm

     

Outcome of low back pain in general practice: a prospective study

Objectives: To investigate the claim that 90% of episodes of low back pain that present to general practice have resolved within one month. Design: Prospective study of all adults consulting in general practice because of low back pain over 12 months with follow up at 1 week, 3 months, and 12 months after consultation. Setting: Two general practices in south Manchester. Subjects: 490 subjects (203 men, 287 women) aged 18-75 years. Main outcome measures: Proportion of patients who have ceased to consult with low back pain after 3 months; proportion of patients who are free of pain and back related disability at 3 and 12 months. Results: Annual cumulative consultation rate among adults in the practices was 6.4%. Of the 463 patients who consulted with a new episode of low back pain, 275 (59%) had only a single consultation, and 150 (32%) had repeat consultations confined to the 3 months after initial consultation. However, of those interviewed at 3 and 12 months follow up, only 39/188 (21%) and 42/170 (25%) respectively had completely recovered in terms of pain and disability. Conclusions: The results are consistent with the interpretation that 90% of patients with low back pain in primary care will have stopped consulting with symptoms within three months. However most will still be experiencing low back pain and related disability one year after consultation.

Key messages

• It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month
• In a large population based study we examined the outcome of episodes of low back pain in general practice with respect to both consultation behaviour and self reported pain and disability
• While 90% of subjects consulting general practice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability
• Only 25% of the patients who consulted about low back pain had fully recovered 12 months later
• Since most consulters continue to have long term low back pain and disability, effective early treatment could reduce the burden of these symptoms and their social, economic, and medical impact

     

腹腔镜下腹壁疝修补术的治疗现状与进展

腹壁疝是普外科最常见的疾病之一,主要包括腹股沟疝、切口疝、造口旁疝等,手术是其唯一的治愈方法。腹腔镜腹壁疝修 补术是在无张力疝修补术的基础上发展起来的一种微创技术,主要包括腹腔镜下腹壁疝修补术(LIHR),如经腹腔镜腹膜前补片修 补术(TAPP)和完全腹膜外补片修补术(TEP),腹腔镜下切口疝修补术及腹腔镜下造口旁疝修补术。其术后常见并发症与传统疝修 补术相同,但发生率显著低于传统的开腹疝修补术。与传统疝修补术相比,腹腔镜腹壁疝修补术具有术后疼痛轻、并发症少、疤痕 小、复发率低等优势,因此临床应用前景广阔。本文主要就腹腔镜下腹壁疝修补术的治疗现状与进展进行了综述。     

Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial

ObjectiveTo evaluate the influence of preoperative abstinence on postoperative outcome in alcohol misusers with no symptoms who were drinking the equivalent of at least 60 g ethanol/day. DesignRandomised controlled trial.SettingCopenhagen, Denmark.Subjects42 alcoholic patients without liver disease admitted for elective colorectal surgery.InterventionsWithdrawal from alcohol consumption for 1 month before operation (disulfiram controlled) compared with continuous drinking.ResultsThe intervention group developed significantly fewer postoperative complications than the continuous drinkers (31% v 74%, P=0.02). Delayed type hypersensitivity responses were better in the intervention group before (37 mm² v 12 mm², P=0.04), but not after surgery (3 mm² v 3 mm²). Development of postoperative myocardial ischaemia (23% v 85%) and arrhythmias (33% v 86%) on the second postoperative day as well as nightly hypoxaemic episodes (4 v 18 on the second postoperative night) occurred significantly less often in the intervention group. Surgical stress responses were lower in the intervention group (P⩽0.05).ConclusionsOne month of preoperative abstinence reduces postoperative morbidity in alcohol abusers. The mechanism is probably reduced preclinical organ dysfunction and reduction of the exaggerated response to surgical stress.

Key messages

• Recent data have shown alcohol misusers to have a threefold increase in postoperative morbidity
• In misusers recovery from organ dysfunction induced by alcohol is seen after abstinence
• Abstinence from alcohol for 1 month before surgery reduces postoperative morbidity after colorectal surgery
• Mechanisms may involve reduced responses to surgical stress and improved cardiac and immune dysfunction
• Withdrawal from alcohol before an operation is recommended in alcohol abusers

     

A Novel and Effective Balanced Intravenous-Inhalant Anaesthetic Protocol in Swine by Using Unrestricted Drugs

Nowadays, because of increasing employment of swine for experimental studies and medical training, it is hopeful to investigate novel and effective anaesthetic protocols for preserving the animal welfare in medical investigation and concurrently improving the quality of research. Therefore, the aim of this study was to investigate a novel and effective anaesthetic protocol in swine undergoing major surgery, by translating know-how of combined anaesthesia from human protocols. Seven landrace swine were anaesthetized for three hours by a combined trial anaesthetic protocol (sedation: medetomidine, acepromazine, atropine and tramadol; induction: propofol, medetomidine and acepromazine; anaesthesia: isofluorane, propofol, medetomidine and acepromazine) and both clinical and haemodynamic parameters were compared with those of five swine anaesthetized with a control protocol (sedation: diazepam, ketamine and atropina; induction: diazepam and ketamine; anaesthesia: isofluorane). Both cardiac frequency (CF) and mean blood pressure (MBP) were significantly (P<0.05) more stable in trial protocol (CF: 78.3 ± 4.6-81.1 ± 5, MBP: 63.9 ± 10.7-96.4 ± 13.0) compared to control protocol (CF: 93.7 ± 5.5-102.5 ± 8.5, MBP: 71.0 ± 6.6-108.7 ± 7.2). The body temperature remained stable in trial protocol (°C: 36.9 ± 0.7-37.2 ± 0.3) compared to control anaesthesia (°C: 36.4 ± 0.3-37.3 ± 0.2, P<0.05). Haematosis improved undergoing combined anaesthesia (+2%, P<0.05) whereas did not change in control animals. There were no differences in respiratory rate between trial and control protocols. This study demonstrates that the proposed balanced intravenous-inhalant protocol permits to carry out a very effective, stable and safe anaesthesia in swine undergoing deep anaesthesia.     

Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial

ObjectiveTo assess the effect of a 40 mg methylprednisolone injection proximal to the carpal tunnel in patients with the carpal tunnel syndrome.DesignRandomised double blind placebo controlled trial. SettingOutpatient neurology clinic in a district general hospital.ParticipantsPatients with symptoms of the carpal tunnel syndrome for more than 3 months, confirmed by electrophysiological tests and aged over 18 years.InterventionInjection with 10 mg lignocaine (lidocaine) or 10 mg lignocaine and 40 mg methylprednisolone. Non-responders who had received lignocaine received 40 mg methylprednisolone and 10 mg lignocaine and were followed in an open study.ResultsAt 1 month 6 (20%) of 30 patients in the control group had improved compared with 23 (77%) of 30 patients the intervention group (difference 57% (95% confidence interval 36% to 77%)). After 1 year, 2 of 6 improved patients in the control group did not need a second treatment, compared with 15 of 23 improved patients in the intervention group (difference 43% (23% to 63%). Of the 28 non-responders in the control group, 24 (86%) improved after methylprednisolone. Of these 24 patients, 12 needed surgical treatment within one year.ConclusionA single injection with steroids close to the carpal tunnel may result in long term improvement and should be considered before surgical decompression.

Key messages

• Corticosteroid injections into the carpal tunnel may damage the nerve, and any treatment benefits may be of short duration
• A single injection with steroids proximal to the carpal tunnel improves 77% of patients with the carpal tunnel syndrome at one month after treatment
• This single injection is still effective at one year in half of the patients
• Injections proximal to the carpal tunnel have no side effects and are easier to carry out than injections into the carpal tunnel

     

Nicotine nasal spray with nicotine patch for smoking cessation: randomised trial with six year follow up

ObjectiveTo evaluate the efficacy of using a nicotine patch for 5 months with a nicotine nasal spray for 1 year.DesignPlacebo controlled, double blind trial.SettingReykjavik health centre.Subjects237 smokers aged 22-66 years living in or around Reykjavik.InterventionsNicotine patch for 5 months with nicotine nasal spray for 1 year (n=118) or nicotine patch with placebo spray (n=119). Treatment with patches included 15 mg of nicotine for 3 months, 10 mg for the fourth month, and 5 mg for the fifth month, whereas nicotine in the nasal spray was available for up to 1 year. Both groups received supportive treatment.ResultsThe log rank test for 6 years (χ²=8.5, P=0.004) shows a significant association between abstinence from smoking and type of treatment. Sustained abstinence rates for the patch and nasal spray group and patch only group were 51% v 35% after 6 weeks (P=0.011 (χ²), 95% confidence interval 1.17% to 3.32%), 37% v 25% after 3 months (P=0.045, 1.01% to 3.08%), 31% v 16% after 6 months (P=0.005, 1.27% to 4.50%), 27% v 11% after 12 months (P=0.001, 1.50% to 6.14%), and 16% v 9% after 6 years (P=0.077, 0.93% to 4.72%).ConclusionsShort and long term abstinence rates show that the combination of using a nicotine patch for 5 months with a nicotine nasal spray for 1 year is a more effective method of stopping smoking than using a patch only. The low percentage of participants using the nasal spray at 1 year, and the few relapses during the second year, suggest that it is not cost effective to use a nasal spray for longer than 7 months after stopping a patch.

Key messages

• Combined methods of nicotine replacement therapy have a potential advantage over one method because of high levels of substitution
• Nicotine patches release nicotine slowly, but nicotine nasal spray delivers nicotine more rapidly, enabling the smoker to respond quickly to any smoking urges
• Treatment with a patch and nicotine nasal spray was significantly more effective than patch and placebo from day 15 after stopping smoking
• Using a patch for 5 months with a nicotine nasal spray for 1 year provides a more effective means of stopping smoking than using a patch only
• It is not cost effective to use a nicotine nasal spray for longer than 7 months after stopping a patch

     

腹股沟疝腹腔镜下修补术与无张力修补术应用于老年患者的综合疗效研究

目的:腹股沟疝是外科中最常见的疾病之一,手术治疗是腹股沟疝的惟一可靠方法。腹腔镜下腹股沟疝修补术,尤其是完全腹膜外腹腔镜(Totally Extra-preperioneal Prosthetic,TEP)疝修补术,已经成为腹股沟疝治疗的"金标准"。然而,针对65岁以上老年人群,心血管基础疾病较多,全麻风险大,TEP术式疗效是否优于无张力疝修补术还未有报道,本研究拟探讨针对老年人腹股沟疝修补的最佳手术方式。方法:排除两种修补术明确的禁忌症患者,对研究入组的92例≥65岁腹股沟疝老年患者,根据手术方式(TEP术或无张力疝修补术)进行分组,术后分别统计:(1)围手术期评价指标(手术时间、术中出血量、手术并发症、疼痛等级、离床活动时间、住院时间及住院总费用);(2)远期随访指标(术后2年内的慢性疼痛和复发情况)。综合评估腹腔镜下修补术与无张力修补术应用于老年腹股沟疝气治疗的综合疗效。结果:TEP术相比于无张力疝术只显示出在平均减少20 m L出血量及缓解术后24小时1个AVS疼痛数量级的优势(P0.01);在术后下床活动时间、手术时间、术后96小时疼痛指数、围手术期并发症、住院天数、慢性疼痛指数及远期疗效等主要评价指标中均与无张力修补术相当(P0.05);但却大大增加了手术费用(P0.01)。结论:针对≥65岁腹股沟疝老年患者,尤其是基础疾病多,对医疗费用敏感的人群,开展无张力修补术仍不失为目前最佳选择。     

Cold related mortalities and protection against cold in Yakutsk,eastern Siberia: observation and interview study

Objective To assess how effectively measures adopted in extreme cold in Yakutsk control winter mortality.Design Interviews to assess outdoor clothing and measure indoor temperatures; regressions of these and of delayed cause-specific mortalities on temperature.Setting Yakutsk, east Siberia, Russia.Subjects: All people aged 50-59 and 65-74 years living within 400 km of Yakutsk during 1989-95 and sample of 1002 men and women who agreed to be interviewed.Main outcome measures Daily mortality from all causes and from ischaemic heart, cerebrovascular, and respiratory disease.Results Mean temperature for October-March 1989-95 was −26.6°C. At 10.2°C people wore 3.30 (95% confidence interval 3.08 to 3.53) layers of clothing outdoors, increasing to 4.39 (4.13 to 4.66; P<0.0001) layers at −20°C. Thick coats, often of fur, replaced anoraks as temperature fell to −48.2°C. 82% of people went out each day when temperatures were 10.2°C to −20°C, but below −20°C the proportion fell steadily to 44% (35% to 53%) at −48.2°C (P<0.001), and overall shivering outdoors did not increase. Living room temperature was 17.9 (17.2 to 18.5)°C at 10.2°C outdoors, 19.6 (18.8 to 20.4)°C at −20°C, and 19.1 (18.6 to 19.6)°C at −48.2°C. Mortality from all causes and from ischaemic heart and respiratory disease was unaffected by the fall in temperature. Mortality from respiratory disease (daily deaths per million) rose from 4.7 (4.3 to 5.1) to 5.1 (4.4 to 5.7) (P=0.03), but this was offset by a fall in deaths from injury.Conclusions People in Yakutsk wore very warm clothing, and in extremely cold weather stayed indoors in warm housing, preventing the increases in mortality seen in winter in milder regions of the world. Only respiratory mortality rose, perhaps because of breathing cold air.

Key messages

• Death rates from ischaemic heart, cerebrovascular, and respiratory disease and all causes have been shown to increase as air temperature falls
• In Yakutsk, Russia, mortality from cerebrovascular and ischaemic heart disease and all causes among people aged 50-59 and 65-74 was unchanged as temperature fell to −48.2°C
• Mortality from respiratory disease increased as temperatures fell below −20°C but this was more than offset by a decrease in deaths from accidents
• Exceptionally warm clothing, with reduction of outdoor excursions at temperatures below −20°C, prevented overall outdoor cold stress

     

Cumulative risk adjusted mortality chart for detecting changes in death rate: observational study of heart surgery

Objective: To detect changes in mortality after surgery, with allowance being made for variations in case mix. Design: Observational study of postoperative mortality from January 1992 to August 1995. Setting: Regional cardiothoracic unit. Subjects: 3983 patients aged 16 and over who had open heart operations. Main outcome measures: Preoperative risk factors and postoperative mortality in hospital within 30 days were recorded for all surgical heart operations. Mortality was adjusted for case mix using a preoperative estimate of risk based on additive Parsonnet factors. The number of operations required for statistical power to detect a doubling of mortality was examined, and control limits at a nominal significance level of P=0.01 for detection of an adverse trend were determined. Results: Total mortality of 7.0% was 26% below the Parsonnet predictor (P<0.0001). There was a highly significant variation in annual case mix (Parsonnet scores 8.7-10.6, P<0.0001). There was no significant variation in mortality after adjustment for case mix (odds ratio 1-1.5, P=0.18) with monitoring by calendar year. With continuous monitoring, however, nominal 99% control limits based on 16 expected deaths were crossed on two occasions. Conclusions: Hospital league tables for mortality from heart surgery will be of limited value because year to year differences in death rate can be large (odds ratio 1.5) even when the underlying risk or case mix does not change. Statistical quality control of a single series with adjustment for case mix is the only way to take into account recent performance when informing a patient of the risk of surgery at a particular hospital. If there is an increase in the number of deaths the chances of the next patient surviving surgery can be calculated from the last 16 deaths.

Key messages

• Changes in the patient population affect a hospital’s annual death rate
• Year to year differences in death rate can be large even when there is no change in the underlying risk or case mix
• It takes surprisingly many operations before an increase in death rate can be distinguished from random fluctuation
• A formal inquiry should take place in a hospital if the death rate rises above control limits
• The chances of the next patient surviving surgery should be calculated using the surgeon’s most recent results

     

Human albumin administration in critically ill patients: systematic review of randomised controlled trials

Objective: To quantify effect on mortality of administering human albumin or plasma protein fraction during management of critically ill patients. Design: Systematic review of randomised controlled trials comparing administration of albumin or plasma protein fraction with no administration or with administration of crystalloid solution in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia. Subjects: 30 randomised controlled trials including 1419 randomised patients. Main outcome measure: Mortality from all causes at end of follow up for each trial. Results: For each patient category the risk of death in the albumin treated group was higher than in the comparison group. For hypovolaemia the relative risk of death after albumin administration was 1.46 (95% confidence interval 0.97 to 2.22), for burns the relative risk was 2.40 (1.11 to 5.19), and for hypoalbuminaemia it was 1.69 (1.07 to 2.67). Pooled relative risk of death with albumin administration was 1.68 (1.26 to 2.23). Pooled difference in the risk of death with albumin was 6% (95% confidence interval 3% to 9%) with a fixed effects model. These data suggest that for every 17 critically ill patients treated with albumin there is one additional death. Conclusions: There is no evidence that albumin administration reduces mortality in critically ill patients with hypovolaemia, burns, or hypoalbuminaemia and a strong suggestion that it may increase mortality. These data suggest that use of human albumin in critically ill patients should be urgently reviewed and that it should not be used outside the context of rigorously conducted, randomised controlled trials.

Key messages

• Human albumin solution has been used in the treatment of critically ill patients for over 50 years
• Currently, the licensed indications for use of albumin are emergency treatment of shock, acute management of burns, and clinical situations associated with hypoproteinaemia
• Our systematic review of randomised controlled trials showed that, for each of these patient categories, the risk of death in the albumin treated group was higher than in the comparison group
• The pooled relative risk of death with albumin was 1.68 (95% confidence interval 1.26 to 2.23) and the pooled difference in the risk of death was 6% (3% to 9%) or six additional deaths for every 100 patients treated
• We consider that use of human albumin solution in critically ill patients should be urgently reviewed

     

Randomised trial of impact of model of integrated care and case management for older people living in the community

Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.

Key messages

• Responsibility for management of care of elderly people living in the community is poorly defined
• Integration of medical and social services together with care management programmes would improve such care in the community
• In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

     

Cost effectiveness analysis of antenatal HIV screening in United Kingdom

ObjectiveTo assess the cost effectiveness of universal antenatal HIV screening compared with selective screening in the United Kingdom.DesignIncremental cost effectiveness analysis relating additional costs of screening to life years gained. Maternal and paediatric costs and life years were combined.SettingUnited Kingdom.ResultsOn base case assumptions, a new diagnosis of a pregnant woman with HIV results in a gain of 6.392 life years and additional expenditure of £14 833. If decision makers are prepared to pay up to £10 000 for an additional life year, this would imply a net benefit of £49 090 (range £12 300-£59 000), which would be available to detect each additional infected woman in an antenatal screening programme. In London, universal antenatal screening would be cost effective compared with a selective screening under any reasonable assumptions about screening costs. Outside London, universal screening with uptake above 90% would be cost effective with a £0.60 HIV antibody test cost and up to 3.5 minutes for pretest discussion. Cost effectiveness of universal testing is lower if selective testing can achieve high uptake among those at higher risk. A universal strategy with only 50% uptake may not be less cost effective in low prevalence districts and may cost more and be less effective than a well run selective strategy.ConclusionsUniversal screening with pretest discussion should be adopted throughout the United Kingdom as part of routine antenatal care as long as test costs can be kept low and uptake high.

Key messages

• In 1997 only 13% of undiagnosed HIV infection in pregnant women was picked up on antenatal testing, resulting in many preventable paediatric infections
• Assuming NHS willingness to pay £10 000 per life year gained, universal testing would be much more cost effective than selective testing throughout London on any reasonable assumptions on costs, prevalence, and uptake of testing
• Outside London, universal testing would also be cost effective, even allowing 2-4 minutes for pretest discussion, provided that test costs were no more than £0.60 and uptake exceeded 90%
• Low cost tests could be achieved by pooling antenatal sera or centralisation of testing
• Universal testing with uptake of 50% may be less cost effective than a well run selective programme

     

Cost effectiveness of community leg ulcer clinics: randomised controlled trial

Objectives: To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses. Design: Randomised controlled trial with 1 year of follow up. Setting: Eight community based research clinics in four trusts in Trent. Subjects: 233 patients with venous leg ulcers allocated at random to intervention (120) or control (113) group. Interventions: Weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district nursing service (control group). Main outcome measures: Time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored. Results: The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2.03). No significant differences were found between the groups in health status. Mean total NHS costs were £878.06 per year for the clinic group and £859.34 for the control (P=0.89). Conclusions: Community based leg ulcer clinics with trained nurses using four layer bandaging is more effective than traditional home based treatment. This benefit is achieved at a small additional cost and could be delivered at reduced cost if certain service configurations were used.

Key messages

• Leg ulcer clinics based in the community using four layer compression bandaging can be more clinically effective than usual care provided by the district nursing service
• Community based leg ulcer clinics could be provided more cost effectively than usual home based care for venous leg ulcers
• Recurrence of venous leg ulcers is an important variable that should be measured in future trials of venous leg ulcer care
• It is difficult to measure improvements in health related quality of life among people with venous leg ulcers

     

Diagnosis of Creutzfeldt-Jakob disease by measurement of S100 protein in serum: prospective case-control study

Objective: To analyse serum concentrations of brain specific S100 protein in patients with Creutzfeldt-Jakob disease and in controls. Design: Prospective case-control study. Setting: National Creutzfeldt-Jakob disease surveillance unit. Subjects: 224 patients referred to the surveillance unit with suspected Creutzfeldt-Jakob disease and 35 control patients without dementia. Main outcome measure: Serum concentration of S100 protein in patients with Creutzfeldt-Jakob disease, in patients with other diseases causing dementia, and in the control group. Results: Of the 224 patients with suspected Creutzfeldt-Jakob disease, 65 were classed as definitely having the disease after neuropathological verification, an additional 6 were classed as definitely having the disease as a result of a genetic mutation, 43 as probably having the disease, 36 as possibly having the disease, and 74 patients were classed as having other disease. In the 108 patients classed as definitely or probably having Creutzfeldt-Jakob disease the median serum concentration of S100 was 395 pg/ml (SD 387 pg/ml). This was significantly higher than concentrations found in the 74 patients classed as having other diseases (median 109 pg/ml; SD 177 pg/ml; P=0.0001). At a cut off point of 213 pg/ml sensitivity for the diagnosis of the disease was 77.8% (95% confidence interval 68.8% to 85.2%) and specificity was 81.1% (70.3% to 89.3%). There was a significant difference in survival at different concentrations of S100 in Kaplan-Meier curves (P=0.023). Conclusion: Measurement of serum concentrations of S100 is a valuable tool which can be used more easily than tests on cerebrospinal fluid in the differential diagnosis of Creutzfeldt-Jakob disease. More studies are needed to determine whether serial testing of serum S100 improves diagnostic accuracy.

Key messages

• Creutzfeldt-Jakob disease is a rare, fatal neurodegenerative disease. Diagnosis is made clinically and neuropathologically
• There is no serum test which allows the diagnosis to be made while the patient is alive
• In this study raised serum concentrations of S100 protein were found in patients with Creutzfeldt-Jakob disease
• Serum concentrations of S100 could be used with a sensitivity of 77.8% and a specificity of 81.1% to confirm Creutzfeldt-Jakob disease in the differential diagnosis of diseases that cause dementia
• Serial measurement of S100 concentrations will enhance diagnostic accuracy

     

Randomised,double blind placebo controlled trial of pentoxifylline in the treatment of venous leg ulcers

ObjectiveTo determine whether pentoxifylline 400 mg (Trental 400) taken orally three times daily, in addition to ambulatory compression bandages and dressings, improves the healing rate of pure venous ulcers.DesignRandomised, double blind placebo controlled trial, parallel group study of factorial design, permitting the simultaneous evaluation of alternative pharmaceutical, bandaging, and dressings materials.SettingLeg ulcer clinics of a teaching and a district general hospital in southern Scotland.Participants200 patients with confirmed venous ulcers and in whom other major causal factors were excluded.InterventionsPentoxifylline 400 mg three times daily or placebo.ResultsComplete healing occurred in 65 of the 101 (64%) patients receiving pentoxifylline and 52 of the 99 (53%) patients receiving placebo.ConclusionsThe difference in the healing rates between patients taking pentoxifylline and those taking placebo did not reach statistical significance.

Key messages

• Leg ulcers cost the NHS around £400 million per annum
• 50%-75% of venous leg ulcers can be succesfully treated with dressings and compression bandages but take many months to heal
• A drug that reduced the healing time of venous ulcers would be useful, although no agent has been proved to be effective to date
• Trials with pentoxifylline, a vasoactive drug used in the treatment of peripheral vascular diseases, as an adjunct to the treatment of venous ulcers have been inconclusive
• At the 5% level, pentoxifylline had a non-significant effect on healing rates of pure venous ulcers