David Cook

Medical problems of adults who were sexually abused in childhood

The aim of the study was to see whether adults who had been sexually abused in childhood were vulnerable to physical symptoms and therefore investigation and intervention. The case histories of seven patients who were aged 22-39, were under the care of three consultant psychiatrists, had experienced childhood sexual abuse, and had a history of medical or surgical intervention were surveyed. The patients had had a mean of 18 contacts with non-psychiatric consultant teams and a mean of eight operations, with a high rate (66-70%) of normal findings. They had experienced many somatic symptoms, which led to investigations and interventions in the specialties of gynaecology, obstetrics, gastroenterology, urology, rheumatology, haematology, orthopaedics, neurology, and neuropsychiatry. The history of childhood sexual abuse was recognised only in the later stages of this medical and surgical intervention. The possibility of childhood sexual abuse should be considered earlier in such cases to prevent further unnecessary intervention.

Statin therapy is associated with fewer deaths in patients with bacteraemia

ObjectiveBeneficial effects with statin use are increasingly reported in a variety of patient groups. There is in vitro and clinical evidence for its antiinflammatory and immunomodulatory therapeutic roles. We aimed to assess the association between statin administration and mortality in bacteraemic patients.DesignA retrospective cohort analysis.SettingA 300-bed acute general hospital.Patients and participantsAll patients (n=438) requiring hospital care for an episode of bacteraemia during the years 2000–2003 were included. Statin use, patient outcome, and clinical and laboratory variables were collected.InterventionsNone.Measurements and resultsThere was a significant reduction in all-cause hospital mortality (10.6%xa0vs.xa023.1%, p=0.022) and death attributable to bacteraemia (6.1%xa0vs.xa018.3%, p=0.014) in patients who were receiving statin therapy at the time of bacteraemia (n=66). The reduction in all-cause hospital mortality (1.8%xa0vs.xa023.1%, p=0.0002) and death attributable to bacteraemia (1.8%xa0vs.xa018.3%, p=0.0018) was more pronounced in the patients who continued to receive statin therapy after the diagnosis of bacteraemia (n=56). The apparent mortality benefit persisted after controlling for differences between the groups. Statin use prior to admission was associated with a reduced adjusted hospital mortality rate (odds ratioxa00.39; CIxa095% 0.17, 0.91; p=0.029), and continuing statin use after bacteraemia increased this effect (odds ratioxa00.06; CIxa095% 0.01, 0.44; p=0.0056).ConclusionThis retrospective study demonstrates a significant survival benefit associated with continuing statin therapy in bacteraemic patients. The potential for statins as an adjuvant therapy in sepsis warrants further investigation.

A systematic review comparing the relative effectiveness of antimicrobial-coated catheters in intensive care units

BACKGROUNDnBloodstream infection related to a central venous catheter is a substantial clinical and economic problem. To develop policy for managing the risks of these infections, all available evidence for prevention strategies should be synthesized and understood.nnnMETHODSnWe evaluate evidence (1985-2006) for short-term antimicrobial-coated central venous catheters in lowering rates of catheter-related bloodstream infection (CRBSI) in the adult intensive care unit. Evidence was appraised for inclusion against predefined criteria. Data extraction was by 2 independent reviewers. Thirty-four studies were included in the review. Antiseptic, antibiotic, and heparin-coated catheters were compared with uncoated catheters and one another. Metaanalysis was used to generate summary relative risks for CRBSI and catheter colonization by antimicrobial coating.nnnRESULTSnExternally impregnated chlorhexidine/silver sulfadiazine catheters reduce risk of CRBSI relative to uncoated catheters (RR, 0.66; 95% CI: 0.47-0.93). Minocycline and rifampicin-coated catheters are significantly more effective relative to CHG/SSD catheters (RR, 0.12; 95% CI: 0.02-0.67). The new generation chlorhexidine/silver sulfadiazine catheters and silver, platinum, and carbon-coated catheters showed nonsignificant reductions in risk of CRBSI compared with uncoated catheters.nnnCONCLUSIONnTwo decades of evidence describe the effectiveness of antimicrobial catheters in preventing CRBSI and provide useful information about which catheters are most effective. Questions surrounding their routine use will require supplementation of this trial evidence with information from more diverse sources.

Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis

AIMnThis paper is a report of a systematic review and meta-analysis of strategies, other than antimicrobial coated catheters, hypothesized to reduce risk of catheter-related bloodstream infections and catheter colonization in the intensive care unit setting.nnnBACKGROUNDnCatheter-related bloodstream infections occur at a rate of 5 per 1000 catheter days in the intensive care unit setting and cause substantial mortality and excess cost. Reducing risk of catheter-related bloodstream infections among intensive care unit patients will save costs, reduce length of stay, and improve outcomes.nnnMETHODSnA systematic review of studies published between January 1985 and February 2007 was carried out using the keywords catheterization - central venous with combinations of infection*, prevention* and bloodstream*. All included studies were screened by two reviewers, a validated data extraction instrument was used and data collection was completed by two blinded independent reviewers. Risk ratios for catheter-related bloodstream infections and catheter colonization were estimated with 95% confidence intervals for each study. Results from studies of similar interventions were pooled using meta-analyses.nnnRESULTSnTwenty-three studies were included in the review. The strategies that reduced catheter colonization included insertion of central venous catheters in the subclavian vein rather than other sites, use of alternate skin disinfection solutions before catheter insertion and use of Vitacuff in combination with polymyxin, neomycin and bacitracin ointment. Strategies to reduce catheter-related bloodstream infection included staff education multifaceted infection control programmes and performance feedback.nnnCONCLUSIONnA range of interventions may reduce risks of catheter-related bloodstream infection, in addition to antimicrobial catheters.

Cost-Effectiveness of a Central Venous Catheter Care Bundle

Background A bundled approach to central venous catheter care is currently being promoted as an effective way of preventing catheter-related bloodstream infection (CR-BSI). Consumables used in the bundled approach are relatively inexpensive which may lead to the conclusion that the bundle is cost-effective. However, this fails to consider the nontrivial costs of the monitoring and education activities required to implement the bundle, or that alternative strategies are available to prevent CR-BSI. We evaluated the cost-effectiveness of a bundle to prevent CR-BSI in Australian intensive care patients. Methods and Findings A Markov decision model was used to evaluate the cost-effectiveness of the bundle relative to remaining with current practice (a non-bundled approach to catheter care and uncoated catheters), or use of antimicrobial catheters. We assumed the bundle reduced relative risk of CR-BSI to 0.34. Given uncertainty about the cost of the bundle, threshold analyses were used to determine the maximum cost at which the bundle remained cost-effective relative to the other approaches to infection control. Sensitivity analyses explored how this threshold alters under different assumptions about the economic value placed on bed-days and health benefits gained by preventing infection. If clinicians are prepared to use antimicrobial catheters, the bundle is cost-effective if national 18-month implementation costs are below

Cost effectiveness of antimicrobial catheters in the intensive care unit : Addressing uncertainty in the decision

1.1 million. If antimicrobial catheters are not an option the bundle must cost less than

Process monitoring in intensive care with the use of cumulative expected minus observed mortality and risk-adjusted P charts.

4.3 million. If decision makers are only interested in obtaining cash-savings for the unit, and place no economic value on either the bed-days or the health benefits gained through preventing infection, these cost thresholds are reduced by two-thirds. Conclusions A catheter care bundle has the potential to be cost-effective in the Australian intensive care setting. Rather than anticipating cash-savings from this intervention, decision makers must be prepared to invest resources in infection control to see efficiency improvements.

Hemolytic uremic syndrome following taipan envenomation with response to plasmapheresis

IntroductionSome types of antimicrobial-coated central venous catheters (A-CVC) have been shown to be cost effective in preventing catheter-related bloodstream infection (CR-BSI). However, not all types have been evaluated, and there are concerns over the quality and usefulness of these earlier studies. There is uncertainty amongst clinicians over which, if any, A-CVCs to use. We re-evaluated the cost effectiveness of all commercially available A-CVCs for prevention of CR-BSI in adult intensive care unit (ICU) patients.MethodsWe used a Markov decision model to compare the cost effectiveness of A-CVCs relative to uncoated catheters. Four catheter types were evaluated: minocycline and rifampicin (MR)-coated catheters, silver, platinum and carbon (SPC)-impregnated catheters, and two chlorhexidine and silver sulfadiazine-coated catheters; one coated on the external surface (CH/SSD (ext)) and the other coated on both surfaces (CH/SSD (int/ext)). The incremental cost per quality-adjusted life year gained and the expected net monetary benefits were estimated for each. Uncertainty arising from data estimates, data quality and heterogeneity was explored in sensitivity analyses.ResultsThe baseline analysis, with no consideration of uncertainty, indicated all four types of A-CVC were cost-saving relative to uncoated catheters. MR-coated catheters prevented 15 infections per 1,000 catheters and generated the greatest health benefits, 1.6 quality-adjusted life years, and cost savings (AUD

Management of central venous catheters in adult intensive care units in Australia: policies and practices

130,289). After considering uncertainty in the current evidence, the MR-coated catheters returned the highest incremental monetary net benefits of AUD

Controversies in treatment: Should a sexual offender be allowed castration?

948 per catheter; however there was a 62% probability of error in this conclusion. Although the MR-coated catheters had the highest monetary net benefits across multiple scenarios, the decision was always associated with high uncertainty.ConclusionsCurrent evidence suggests that the cost effectiveness of using A-CVCs within the ICU is highly uncertain. Policies to prevent CR-BSI amongst ICU patients should consider the cost effectiveness of competing interventions in the light of this uncertainty. Decision makers would do well to consider the current gaps in knowledge and the complexity of producing good quality evidence in this area.