Less Time In Hospital Research Articles

Kangaroo Mother versus Traditional Care for Newborn Infants (2000 grams). A randomized Controlled Trial. † 1138

Objectives: This Open Randomized Controlled Trial compares effectiveness and safety of KMI and traditional care in LBW infants.Setting: The largest tertiary care hospital in Colombia, with neonatal intensive care and LBW infants follow-up clinic. Patients: Newborn infants (≤ 2000 g.) who survive the neonatal period and are eligible for an in-patient Minimal Care Unit (MCU). 1084 consecutive deliveries were followed and 746 were randomized (382 to KMI and 364 to control). Interventions: KMI infants were discharged as soon as they were randomized, regardless of weight or gestational age. Infants were kept 24 hr/day in an upright position, in skin-to-skin contact and firmly attached to the mother's chest until KMI wasn't tolerated anymore. Control infants were kept in incubators at the MCU until they satisfied usual discharge criteria. Both groups were followed at term and at 3, 6, 9 and 12 months of corrected age. Outcome measures: mortality, infectious episodes, length of hospital stay, growth and development, sequels and proportion of breast feed infants. Results: Baseline variables were evenly distributed, except weight at recruitment (KMI=1678, controls=1713, p=0.045). Risk of dying was lower in the KMI althought not significant (11/339-3.1%- vs. 19/324 -5.5%- RRO.57, 95%CI 0.27-1.17). There were no difference in growth or development indexes nor in length of breast feeding. KMI infants, specially those weighting under 1200 g. at birth spent less time in hospital although the difference was not significant. Number and severity of infections in survivors was similar. A larger proportion of Kangaroo infants was breast feed up to 3 months of corrected age, but the difference disappeared after that age. Conclusions: Results support earlier findings regarding mortality. Growth indexes are almost identical in the two groups, clarifying a previous finding of poor early growth in Kangaroo infants. Kangaroo care is associated with no excess risk of infection. It seems appropriate to recommend the KMI for populations and where health facilities are similar to ours.

Dose intensification in acute myloid leukaemia: greater effectiveness at lower cost. Principal report of the Medical Research Council's ATML9 study

Between 1984 and 1990, 972 patients aged 1-79 years with acute myeloid leukaemia (AML), from 85 British hospitals, were entered into the MRC's 9th AML trial. Patients were randomized between DAT 1 + 5 (daunorubicin for 1 d, with cytarabine and 6-thioguanine for 5 d) and DAT 3 + 10 (same dose drugs for 3 and 10 d respectively) as induction therapy. The 63% who achieved complete remission (CR) were randomized to receive two courses of DAT 2 + 7 alternating with two courses of either MAZE (m-AMSA, 5-azacytidine, etoposide) or COAP (cyclophosphamide, vincristine, cytarabine, prednisone). Finally, those still in CR were randomized to receive either 1 year of maintenance treatment with eight courses of cytarabine and thioguanine followed by four courses of COAP, or no further cytotoxic therapy. Resistance to induction therapy was less common with the DAT 3 + 10 regimen than with DAT 1 + 5 (13% v 23%; P = 0.0001) and hence, despite a 5% increase in the risk of induction death, the CR rate was higher (66% v 61%; P = 0.15). Moreover, CR was achieved more rapidly with DAT 3 + 10 (median 34 v 46 d; P < 0.0001) and thus patients required less time in hospital (mean 20 v 29 d) and less blood product support. 5-year relapse-free survival (28% v 23%; P = 0.05) and survival (23% v 18%; P < 0.05) were also better with DAT 3 + 10. Post-remission intensification of therapy with MAZE resulted in fewer relapses (66% v 74% at 5 years; P = 0.03) but patients allocated MAZE required considerably more supportive care and 14 (4.5%) died following 312 MAZE courses, whereas no deaths occurred following COAP. 5-year survival was not significantly higher with MAZE (37% v 31%). Finally, although 1 year of outpatient maintenance treatment appeared to delay, but not prevent, recurrence it did not improve 5-year survival which was non-significantly worse for those allocated maintenance treatment (41% v 44%). We conclude that the more intensive induction regimen, DAT 3 + 10, is not only more effective than DAT 1 + 5, even for older patients, but is also less expensive; intensive post-remission therapy with MAZE achieves better leukaemic control but at the cost of substantial toxicity; whereas low-level maintenance therapy confers no apparent advantage in survival as well as being inconvenient and costly.

Randomised trial of filgrastim-mobilised peripheral blood progenitor cell transplantation versus autologous bone-marrow transplantation in lymphoma patients

SummaryBackground A randomised trial comparing filgrastim-mobilised peripheral blood progenitor cell (PBPC) transplants with autologous bone marrow transplantation (ABMT) for haematopoietic stem cell support has not been done. We compared the effects of filgrastim-mobilised PBPC or autologous bone marrow reinfused to lymphoma patients after high-dose chemotherapy in a prospective randomised multicentre trial.Methods The trial was done at six centres in three European countries. After high-dose chemotherapy (carmustine, etoposide, cytarabine, and melphalan [BEAM protocol]) 58 patients with advanced Hodgkin's disease or high-grade non-Hodgkin lymphoma received either filgrastim-mobilised PBPC (n=27) or bone marrow (n=31) for haemopoietic reconstitution.Findings The median number of days with platelet transfusions after grafting was 6 in the PBPC transplantation group and 10 in the ABMT group (estimate of treatment difference 5 days, 95% Cl 3-7 days). Time to platelet recovery above 20×109/L was 16 days in the PBPC transplantation group and 23 days in the ABMT group (p=0·02). Time to neutrophil recovery above 0·5×109/L was also reduced in the PBPC transplantation group (11 vs 14 days, p=0·005). Patients randomised to PBPC transplantation needed fewer red blood cell transfusions (two vs three, p=0·002) and spent less time in hospital (17 vs 23 days, p=0·002). Early post-transplant morbidity and mortality as well as overall survival (median follow-up 311 days) were similar in both groups. There was no notable toxicity ascribed to filgrastim administration or the leucapheresis procedures.Interpretation In patients with lymphoma treated with high-dose chemotherapy, reinfusing filgrastim-mobilised PBPC instead of autologous bone marrow significantly reduced the number of platelet transfusions, the time to platelet and neutrophil recovery, and led to earlier discharge from hospital.

Vaginal delivery after Caesarean section: factors influencing success rates.

In a retrospective review of 333 pregnancies in women who had 1 previous Caesarean section, 244 (73.3%) underwent a trial of scar, and 89 (26.7%) had an elective Caesarean section. In the trial of scar group 197 (80.7%) had a vaginal delivery and 47 (19.3%) required an emergency Caesarean section. The success of the trial was favourably influenced by a nonrecurring indication for the original Caesarean section, a previous vaginal delivery, and a smaller baby. Maternal morbidity was greater in the groups requiring a Caesarean section, whether elective or emergency. Those patients delivered vaginally spent significantly less time in hospital. In 2 of the 244 patients (0.8%) who underwent a trial of scar the previous lower segment scar was found at Caesarean section to have dehisced or ruptured.

Do Acute Stroke Units Improve Care?

Background and Purpose: Stroke rehabilitation units have been shown to improve mortality and reduce morbidity and hospital length of stay as compared with conventional medical ward care. In contrast, the effectiveness of acute stroke units (ASUs), which only provide early in-patient care, is unknown. We have compared ASU care with that administered on a general medical or geriatric ward. Methods: Historical comparison of 116 consecutive patients admitted to a new ASU during the 6-month period from February to July 1994 with 128 consecutive patients admitted to general medical or geriatric wards during the previous 6-month period (August 1993 to January 1994). Results: Admission baseline characteristics were similar between the two groups. As compared with conventional general ward care, patients admitted to the ASU had a shorter stay in casualty, 6 h (4–6) versus 7 h (4–11; 2p = 0.03); reduced length of stay in hospital, 20 days (10–55) versus 31 days (13–80; 2p = 0.09); increased carotid Doppler investigation, 40/94 versus 25/101 (2p = 0.013); increased prescription of secondary prevention measures, aspirin 49/94 versus 33/101 (2p = 0.009) or treatment of hypertension 19/50 versus 5/47 (2p = 0.004); improved outcome, home: institution: death, 69:11:18 versus 63:13:32 (2p = 0.049). Conclusion: ASUs appear to contribute to improved care (investigations, secondary prevention) and outcome following stroke whilst patients spend less time in hospital.

Laparoscopic minilaparotomy hysterectomy.

A laparoscopic minilaparotomy hysterectomy technique is described. An abdominal elevator allowed the use of an open 2 cm port in the lower abdomen to introduce the finger and instruments used for laparotomy. The technique was developed in 3 patients with moderate to severe endometriosis. The second and third operations were quicker than could be expected by laparovaginal surgery. The use of laparotomy instruments and techniques make the technique easier to learn, cheaper than techniques using disposable products and has the potential to be faster and possibly safer than current techniques. It retains the advantage of laparoscopy surgery, reduced postoperative pain, small incisions and early discharge from hospital.

Individual Psychotherapy and Persons With Serious Mental Illness: The Clients' Perspective

The perspectives of persons with serious mental illness about their experiences with individual psychotherapy were obtained from a stratified random sample of 12 psychosocial rehabilitation centers from all centers in Maryland. Response and completion rates, test-retest reliability, and generalization data were positive. Eight areas were explored: (1) Utilization and duration: of the 212 respondents, 90 percent had been in therapy for a median of 12 months (mean = 3 years); only a third expected to end their therapy within 5 years. (2) Therapeutic effectiveness: most of the respondents (72%) reported that individual psychotherapy had brought positive changes to their lives, 14 percent reported negative changes, and 14 percent reported that therapy had had no effect. (3) Preferred interventions and parameters: sixteen percent felt that medication was most useful, 25 percent felt that talking therapy was most useful, and 60 percent endorsed a combination of the two. With respect to diagnosis and psychotherapy, 84 percent of respondents with schizophrenia preferred brief, less frequent sessions of reality-oriented therapy over longer, more frequent sessions of insight therapy. Respondents with bipolar and major depression were equally split between the two. (4) Therapeutic issues: human concerns were more frequently rated as important and were rated higher in importance than illness-specific symptoms. (5) Clients' view of illness: Only 8 percent thought their illness was a brain disease, a third thought it was a psychological problem, and a quarter thought it was a combination of both; a third answered, open quote I don't know closed quote. Almost half did not know what their therapists thought. (6) Therapeutic relationship: Friendliness was the quality most desired in a therapist. (7) Confidentiality: Most felt that therapists generally kept the clients' confidences. (8) Empowerment: Persons who felt empowered in therapy spent less time in hospitals, expected a shorter stay in therapy, and knew more about their problems. Suggestions are made about a more client-responsive model of individual psychotherapy for persons with serious mental illness.

Depot Antipsychotics in the Prophylaxis of Bipolar Affective Disorder

The efficacy of depot antipsychotic drugs in the prophylaxis of bipolar affective disorder was investigated. Life charts were constructed for 18 outpatients with bipolar disorder receiving prophylactic treatment with depot medication. The durations of affective episodes were compared during periods on or off medication. The subjects suffered fewer relapses and spent significantly less time in hospital (P = 0.001) for treatment of manic, depressive and mixed affective illness during treatment with depot antipsychotics. Depot antipsychotic medication may be a useful prophylactic treatment for certain patients with bipolar affective disorder.

Placebo-controlled phase III trial of lenograstim in bone-marrow transplantation

Haemopoietic growth factors are accepted as accelerating haemopoietic recovery after bone-marrow grafting, yet no large randomised trials have been published that convincingly show benefit. Lenograstim (glycosylated recombinant human granulocyte colony-stimulating factor) was given to 315 patients after bone-marrow transplantation in a prospective randomised placebo-controlled multicentre trial. 1 day after bone-marrow infusion, 163 patients received lenograstim 5 μg/kg per day by 30-min infusion, and 152 patients received placebo daily for 28 days or until neutrophil recovery. 137 patients had lymphoma, 35 myeloma, 85 acute lymphoblastic leukaemia, and 58 a solid tumour. Patients were stratified by age and by type of bone-marrow transplantation (BMT). Neutrophil recovery to above 10 9/L for 3 consecutive days was seen earlier in lenograstim-treated patients (16 vs 27 days, p<0·001). Time to neutrophil recovery above 0·5 × 10 9/L was reduced (14 vs 20 days, p< 0·001). The difference was significant both in autograft (20 vs 14 days, p<0·001) and allograft (20 vs 14 days, p<0·01) patients, in children (20 vs 13 days, p<0·001), and adults. Lenograstim-treated patients had fewer days of infection, and of antibiotic administration, and also spent less time in hospital. However, clinical and microbiological sepsis was similar in both groups. There was no significant toxicity ascribed to lenograstim. Survival was the same at days 100 and 365. In patients undergoing autologous or allogeneic BMT for neoplastic disease, lenograstim significantly reduced duration of neutropenia and led to earlier hospital discharge.

The role of the clinical nurse co-ordinator in the provision of cost-effective orthopaedic services for elderly people.

Positions for nurses as coordinators and case managers have developed in response to demands for increased efficiency in the provision of hospital care. The Fractured Hip Management Programme in Western Sydney is one example of this development. The programme was introduced in response to mounting concern about the demands on hospital resources from elderly patients with hip fracture. A central feature of the programme is the pivotal role given to the nurse coordinator working within a multi-disciplinary team. This is not a new nursing role; rather it explicitly recognizes skills developed as part of the traditional nursing role. Evaluation of the programme found that patients received surgery sooner and spent less time in hospital, without adverse affects on outcome. The results show that recognition of the role of the nurse as patient advocate and care manager can lead to more cost-effective and higher-quality care.

IMPROVED RECOVERY AND REDUCED POSTOPERATIVE STAY AFTER THERAPEUTIC SUGGESTIONS DURING GENERAL ANAESTHESIA

The clinical value of therapeutic suggestions during general anaesthesia was assessed in a double-blind randomised placebo-controlled study. 39 unselected patients were allocated to suggestion (n =19) or control (n = 20) groups who were played either recorded therapeutic suggestions or a blank tape, respectively, during hysterectomy. The patients in the suggestion group spent significantly less time in hospital after surgery, suffered from a significantly shorter period of pyrexia, and were generally rated by nurses as having made a better than expected recovery. Patients in the suggestion group, unlike those in the control group, guessed accurately that they had been played an instruction tape.

Improved results for diabetic pregnancies after pre‐pregnancy counselling

AbstractImprovement of diabetic control in patients before pregnancy has been advocated in an attempt to reduce the risk of congenital malformations. We have shown that diabetic patients given pre‐pregnancy counselling at a separate clinic had significantly lower HbA 1C results throughout pregnancy, presented to the combined obstetric/diabetic clinic at an earlier stage of pregnancy (6.5 ± 0.6 weeks vs 12.6 ± 1.7 weeks, 2p&lt;0.01), and were more likely to go to term (39 ± 0.8 weeks vs 36.5 ± 1.0 weeks, 2p&lt;0.01) and have a vaginal delivery (SVD) than diabetic patients who did not attend the pre‐pregnancy clinic for counselling. Significantly, counselled patients spent less time in hospital for stabilization of their diabetes (3 vs 14 admissions, 2p&lt;0.02). Therefore all diabetic patients considering pregnancy should be encouraged to attend for pre‐pregnancy counselling.

Comparison of the Results of CAPD Treatment in “Experienced” versus “Inexperienced” Centres in Europe

Five per cent of almost 80,000 living patients with end stage renal failure (ESRF) in Europe were on CAPD on 31st December, 1982. The use of CAPD has grown dramatically since 1977. Centres which reported the use of CAPD to the EDTA Registry were divided into “experienced” and “inexperienced.” Patients treated in “experienced” centres had less peritonitis and spent less time in hospital because of peritonitis. Patient survival amongst those starting treatment in earlier years was worse in the “inexperienced” centres but improved so that it equalled survival in the “experienced” centres in 1982. At 12 months cumulative patient survival in patients commencing CAPD in 1982 was 87% and technique survival exceeded 95%. It appears that there is now a homogenous population of centres with approximately equal expertise.

Survival and handicap of infants with spina bifida.

A follow-up study was carried out on 213 infants born with spina bifida cystica (including encephalocele and occipital meningocele) from 1965 to 1972 to women resident in Oxfordshire and the western part of Berkshire. The 5-year survival rate was 36% (39/107) for those with open lesions, 60% (30/50) for those with closed ones, and 18% (10/56) for those with lesions which could not be classified (not known) but which were probably nearly all open. The extent of handicap among these survivors was assessed by means of criteria described by Lorber; among those with open lesions (including 'not known') 84% (41/49) were severely handicapped, 10% (4/49) were moderately handicapped, and only 6% (3/49) had no handicap; among those with closed lesions, 37% (11/30) were severely handicapped, 33% (10/30) were moderately handicapped, and the remaining 30% (9/30) were not handicapped. Closed head lesions (encephalocele or occipital meningocele) were more often associated with severe handicap (6/8; 75%) than were closed spinal lesions (5/22; 23%). The children with open lesions who survived for at least 5 years spent, on average, at least 6 months in hospital during the first 5 years of their life and had, on average, at least 6 major surgical operations. In comparison, those with closed lesions spent one-third less time in hospital, and had fewer than half as many operations. During the period of the study a selective treatment policy was adopted typical of that commonly practised now, and all the infants were born before antenatal screening had been introduced. Our results therefore may be helpful in assessing the benefits to be expected from antenatal screening for open spina bifida.