Long term transtracheal oxygen delivery through microcatheter in patients with hypoxaemia due to chronic obstructive airways disease.

Transtracheal administration of oxygen is a new technique for long term treatment. Twenty patients with hypoxaemia due to chronic obstructive airways disease were studied while receiving oxygen through a microcatheter inserted percutaneously into the trachea. By bypassing most of the dead space and avoiding oxygen wastage at the face this method of delivery reduced oxygen requirements by roughly half compared with delivery through nasal cannulas, thus reducing costs and facilitating portable treatment. Twelve of these patients continued to use the system for up to 13 months in preference to using nasal cannulas. Two important complications were a staphylococcal infection and a fractured catheter. Transtracheal oxygen reduced breathlessness and helped patients with routine daily activities. Transtracheal administration of oxygen is a practical method of treatment which may have an important role in rehabilitating patients with chronic lung disease.     

How patients use domiciliary oxygen.

Forty-five patients in Southampton who received domiciliary oxygen were visited at home to find out how they used and coped with their oxygen. Generally, the organisation and administration of supplies presented no problems, nearly all the apparatus complied with the drug tariff, and most patients coped well with the equipment. Only two patients were taking oxygen for prescribed periods; the others were taking it when necessary for symptomatic relief. No patient received oxygen for over five hours daily. Most patients thought that they were helped by oxygen, but only four said that it allowed them to increase their level of activity, and the overall benefit seemed slight. This was partly because oxygen was usually limited to one room, so patients used oxygen after rather than during exercise. The amount of oxygen consumed differed widely, ranging from three and a half cylinders a week in three patients to less than one cylinder in six months in 17 patients. The average yearly cost of oxygen per patient ranged from 500 pounds in patients consuming one cylinder or more per week, to 15 pounds in those consuming less than one cylinder in six months. The main cost of domiciliary oxygen is determined by the number of cylinder refills, so patients who use it infrequently are a relatively small drain on resources.     

β Blockade after myocardial infarction: systematic review and meta regression analysis

ObjectivesTo assess the effectiveness of β blockers in short term treatment for acute myocardial infarction and in longer term secondary prevention; to examine predictive factors that may influence outcome and therefore choice of drug; and to examine the clinical importance of the results in the light of current treatment.DesignSystematic review of randomised controlled trials.SettingRandomised controlled trials.SubjectsPatients with acute or past myocardial infarction.Interventionβ Blockers compared with control.Mainoutcome measures All cause mortality and non-fatal reinfarction.ResultsOverall, 5477 of 54 234 patients (10.1%) randomised to β blockers or control died. We identified a 23% reduction in the odds of death in long term trials (95% confidence interval 15% to 31%), but only a 4% reduction in the odds of death in short term trials (−8% to 15%). Meta regression in long term trials did not identify a significant reduction in effectiveness in drugs with cardioselectivity but did identify a near significant trend towards decreased benefit in drugs with intrinsic sympathomimetic activity. Most evidence is available for propranolol, timolol, and metoprolol. In long term trials, the number needed to treat for 2 years to avoid a death is 42, which compares favourably with other treatments for patients with acute or past myocardial infarction.Conclusionsβ Blockers are effective in long term secondary prevention after myocardial infarction, but they are underused in such cases and lead to avoidable mortality and morbidity.

Key messages

• The first randomised trials of β blockade in secondary prevention after myocardial infarction were published in the 1960s
• β blockers were once heralded as a major advance, but their use for secondary prevention has declined in recent years
• Firm evidence shows that long term β blockade remains an effective and well tolerated treatment that reduces mortality and morbidity in unselected patients after myocardial infarction
• The benefits from β blockade compare favourably with other drug treatments for this patient group
• Most evidence is for propranolol, timolol, and metoprolol, whereas atenolol, which is commonly used, is inadequately evaluated for long term use

     

75 deaths in asthmatics prescribed home nebulisers.

The circumstances surrounding the deaths of 75 asthmatic patients who had been prescribed a domiciliary nebuliser driven by an air compressor pump for administration of high dose beta sympathomimetic drugs were investigated as part of the New Zealand national asthma mortality study. Death was judged unavoidable in 19 patients who seemed to have precipitous attacks despite apparently good long term management. Delays in seeking medical help because of overreliance on beta agonist delivered by nebuliser were evident in 12 cases and possible in a further 11, but these represented only 8% of the 271 verified deaths from asthma in New Zealanders aged under 70 during the period. Evidence for direct toxicity of high dose beta agonist was not found. Nevertheless, the absence of serum potassium and theophylline concentrations and of electrocardiographic monitoring in the period immediately preceding death precluded firm conclusions whether arrhythmias might have occurred due to these factors rather than to hypoxia alone. In most patients prescribed domiciliary nebulisers death was associated with deficiencies in long term and short term care similar to those seen in patients without nebulisers. Discretion in prescribing home nebulisers, greater use of other appropriate drugs, including adequate corticosteroids, and careful supervision and instruction of patients taking beta agonist by nebuliser should help to reduce the mortality from asthma.     

Effect of continuous ambulatory peritoneal dialysis on a British renal unit.

Experience in the use of continuous ambulatory peritoneal dialysis (CAPD) for the treatment of end stage renal failure in Nottingham was reviewed. During six years 150 patients aged from 11 to 73 received this type of treatment. At three years patient actuarial survival was 69% and CAPD technique survival was 41%. Although CAPD was satisfactory as a first treatment for many patients, its long term use was possible in only a few. Actuarial survival of patients who changed to haemodialysis was 64% at one year after the change, suggesting that unsuccessful CAPD increased the risk of death. Hospital haemodialysis was the only suitable form of treatment for most patients in whom CAPD had been abandoned. British renal units have adopted CAPD to a much greater extent than those in Europe, but care in the selection of patients is necessary to reduce mortality, and many patients may eventually need hospital haemodialysis. Greater numbers of hospital haemodialysis places will probably have to be made available to meet this extra demand.     

Ontwikkeling van algoritmes voor oordeelkundig gebruik van psychofarmaca bij ouderen met verhoogd valrisico

Psychotropic drugs (hypno-sedatives, antidepressants and antipsychotics) are commonly used in the older population. On the long term, psychotropic drug use in older persons is associated with several negative functional outcomes such as an increased risk of falls. Gradual withdrawal of psychotropic drugs in older persons is feasible and leads to a significant reduction of falls. Both withdrawal of psychotropic drugs as well as the initiation of appropriate treatment with psychotropic drugs requires knowledge, consultation and cooperation between disciplines and a mentality change among healthcare professionals. In order to inform and support healthcare professionals, the Centre of Expertise for Fall and Fracture Prevention Flanders developed three clinical practice algorithms for the appropriate use of psychotropic drugs in older persons with high risk of falls and a fact sheet with background information.     

New Method for Oxygen Therapy in the Home using an Oxygen Concentrator

Patients with pulmonary hypertension due to chronic bronchitis may improve during long-term treatment with oxygen. The methods of administration which are currently available are expensive and present practical difficulties. The Rimer-Birlec domiciliary oxygen concentrator produces an oxygen concentration of 92% at a flow of 21./min. It has been used successfully in a patient''s home but further use will require an increase in mechanical reliability and a decrease in noise. In view of its convenience and the economic advantages the oxygen concentrator is an important advance in treatment with oxygen and could prove to be the method of choice in the home.     

Prehospital analgesia with nitrous oxide/oxygen.

A pilot study of prehospital analgesia with 50% nitrous oxide and 50% oxygen was undertaken in patients experiencing severe pain from various sources. Under the supervision of an ambulance attendant N2O/O2 was administered through a face mask held by the patient and connected to a portable regulator/tank unit. Two types of units were evaluated -- Entonox (with premixed N2O and O2) and Nitronox (with separate cylinders of N2O and O2, the gases being mixed at the time of administration). Of the 72 patients 69 obtained worthwhile analgesia (marked or partial relief of pain) during treatment in the field or in the ambulance. There were no serious side effects, and those that did occur reflected N2O''s expected action (e.g., giddiness). N2O/O2 is thus considered a safe and effective analgesic, suitable for use by ambulance personnel.     

Behavioral and Psychological Care in Weight Loss Surgery: Best Practice Update

The objective of this study is to update evidence‐based best practice guidelines for psychological evaluation and treatment of weight loss surgery (WLS) patients. We performed a systematic search of English‐language literature on WLS and mental health, quality of life, and behavior modification published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence‐based models. Our literature search identified 17 articles of interest; 13 of the most relevant were reviewed in detail. From these, we developed evidence‐based best practice recommendations on the psychological assessment and treatment of WLS patients. Regular updates of evidence‐based recommendations for best practices in psychological care are required to address the impact of mental health on short‐ and long‐term outcomes after WLS. Key factors in patient safety include comprehensive preoperative evaluation, use of appropriate and reliable evaluation instruments, and the development of short‐ and long‐term treatment plans.     

Hypoxia in childhood pneumonia: better detection and more oxygen needed in developing countries.

Even though hypoxia is a major risk factor for death in children with acute respiratory infection in developing countries, oxygen is not part of first line treatment. Because oxygen is not readily available in developing countries it tends to be given to the most seriously ill children, whose outcome is poor. Oxygen might be useful if given earlier in the course of the disease. Clinical signs are not clear cut, however, though the presence of cyanosis and grunting together with a raised respiratory rate can significantly increase the detection of hypoxaemia. A simple oximeter would make detection easier, and oxygen concentrators are more cost effective than bottled oxygen. Ideally oxygen should be given to children in the early stages of clinical pneumonia to prevent deterioration.     

ANTABUS IN THE TREATMENT OF ALCOHOLISM IN A PRIVATE GENERAL HOSPITAL

In 35 consecutive cases in which patients were admitted to a private hospital for alcoholism, antabus was contraindicated for eight patients and administered to 27. Sixteen patients, followed three to nine months, cooperated fully with treatment and did not return to use of alcohol. In four cases there was at least one episode of drinking, but the patients continued to cooperate with treatment and attained partial success. In seven cases, including three in which antabus was stopped because of organic disease, treatment was unsuccessful. Insufficient insight and lack of family cooperation accounted for four failures.The presence of cardiovascular or hepatic diseases contraindicates antabus. As the test of reaction to alcohol after antabus has been given is hazardous, continuous supervision by nurse and physician throughout the test reaction is mandatory.Sustained results depend upon psychotherapy, family cooperation, careful follow-up, and control of side-reactions to the drug.Antabus as an antagonist to alcohol is not safe enough to permit general use of the drug.     

Reversal of sexual impotence in male patients with chronic obstructive pulmonary disease and hypoxemia with long term oxygen therapy

Erectile impotence is commonly encountered in male patients with respiratory failure and hypoxia. In this study, 42% of the patients experienced reversal of sexual impotence during long term oxygen therapy (LTOT). We examine the association between sexual impotence, gonadal axis hormones, hypoxia, and oxygen therapy. Nineteen sexually impotent male patients eligible for LTOT (pO₂ < 7.3 kPa during stable disease) and with sexual impotence received oxygen therapy for 1 month (n = 12) or 24 h (n = 7). pO₂, LH, FSH, testosterone, and SHBG (sex hormone binding globulin) were monitored. Five of 12 patients receiving oxygen for 1 month regained sexual potency. The responders showed a significant increase in arterial pO₂ and serum testosterone, and a decline in SHBG compared to non-responders. None of the patients receiving oxygen for 24 h experienced reversal of sexual impotence, despite a significant increase in pO₂. In these patients, serum testosterone did not increase significantly. Reversal of sexual impotence may be achieved in some patients with respiratory failure. The oxygen therapy must, however be administered for an adequate length of time.     

Prevention of recurrent acute cystitis by methenamine hippurate: double blind controlled crossover long term study.

In a randomised, double blind, long term, crossover study 1 g twice daily of methenamine hippurate was compared with placebo for its preventive effect on recurrent attacks of acute cystitis. Methenamine hippurate and placebo were interchanged every six months for two years. During one of the years patients took 250 ml extra fluid every morning and evening. Out of 21 enrolled patients, 14 completed the first year and 13 both years of treatment, which permitted the evaluation of 27 patient years. There were 52 episodes of acute cystitis caused by reinfection: 41 occurred during placebo treatment and only 11 during the methenamine hippurate regimen (p less than 0.01). Extra fluid intake did not reduce the incidence of acute cystitis, nor did it reduce the effect of methenamine hippurate. Methenamine hippurate is an effective prophylactic agent against recurrent acute cystitis and has the advantage of not inducing cross resistance to conventional antibiotics.