Significant Changes In Management Research Articles

PWE-066 Impact of A Capsule Endoscopy Service on The Management of Iron Deficiency Anaemia

Introduction Capsule endoscopy (CE) is increasingly being used to investigate iron deficiency anaemia (IDA) when bi-directional endoscopy does not find a cause although current guidelines do not recommend routine small intestinal investigation unless symptoms or recurrent/refractory IDA. 1 The aim of this study was to review the use of CE in the investigation of IDA over a two year period in a medium sized DGH following the creation of a new CE service. Methods Electronic records of all patients undergoing CE between 1 st April 2013 and 31 st March 2015 were reviewed. Indication for CE was recorded along with the result of the investigation. Clinic letters were reviewed to assess the impact of CE on patient management. Results Over the study period 97 CE procedures were performed. Fifty (52%) procedures were performed to investigate IDA, 34 (35%) for investigation of possible or known Crohn’s disease; 4 (4%) for polyposis and 9 (9%) for other indications. Of the 50 CE procedures for IDA, 18 (36%) showed abnormalities in the small bowel; these included polyps (28%), vascular lesions (33%) and ulcers (28%). No malignancy was found over the 2 year period although one large (3 cm) polyp exhibited high grade dysplasia. Thirteen procedures (26%) showed gastroduodenal pathology but no small bowel abnormality. There was no difference between the mean ages of patients with normal compared to abnormal small bowel CE findings (56.9 years old vs 57.6 years old). In 8 of the 18 cases (44%) where small bowel abnormalities were found there was a subsequent change in patient management; this included surgery to remove polyps, endoscopic treatment of vascular lesions and medication changes. Thirty-eight patients (76%) were discharged from clinical follow up following CE with advice to continue long-term iron supplementation; this included 8 patients with abnormalities seen at CE. Conclusion Over a third of patients undergoing CE to investigate IDA were found to have small bowel pathology. However less than half of these findings resulted in significant management changes. In total CE findings altered clinical management in only 16% of patients although it did allow 76% of patients to be discharged from further clinical follow-up. Clincal factors such as age did not appear to predict the presence of small bowel pathology. As a result, the role and timing of CE in the investigation of IDA remains uncertain. Reference 1 Guidelines for the management of iron deficiency anaemia. Goddard, et al . on behalf of the British Society of Gastroenterology 2011. Disclosure of Interest None Declared

The effect of implementing a new guideline and operative pro forma on the detection and management of third- and fourth-degree perineal tears.

BackgroundObstetric anal sphincter injury (OASI) is a serious complication of vaginal births, resulting in possible long-term consequences such as incontinence and pain. Adequate detection and management of these injuries is vital in minimizing the impact they have on women.AimTo assess the rates of detection, management, and outcomes of OASI before and after the implementation of a new clinical practice guideline and operative pro forma.Materials and methodsA 12-month audit of the incidence, management, and outcomes of OASI was conducted in 2009. An operative pro forma and practice guideline were implemented in 2010 followed by a further audit undertaken between 2010 and 2012. Statistical analysis was performed to determine any significant change in practice.ResultsThe distribution of risk factors for OASI including primiparity, birthweight, and type of vaginal delivery was similar between the two audited groups. After implementation of the pro forma, the reported incidence of OASI increased from 1.62% to 3.1% (P=0.004). Significant changes in management included an increase in the use of recommended suture material (48% vs 80%, P=0.002), postoperative antibiotics (78% vs 99%, P=0.001), postoperative catheterization (52% vs 90%, P<0.001), and inpatient physiotherapy consultations (44% vs 97%, P=<0.001). An increase was seen in women attending their 6-week follow-up appointment (33% vs 54% P=0.058); however, this was just below the level of statistical significance.ConclusionThe introduction of the new pro forma and guideline resulted in an increase in the reported incidence of OASI, improved management, and follow-up of patients.

Effects of an Enhanced Recovery After Surgery programme on emergency surgical patients.

Enhanced Recovery After Surgery (ERAS) programmes have been used in elective surgery since the 1990s to optimize peri-operative care, reducing post-operative complications, length of stay and overall costs. Following the local introduction of an ERAS programme for colorectal elective patients, it was suggested an increase in the use of ERAS-type principles in emergency patients may have occurred. The aims of this study were to determine whether management changes could be demonstrated and if there was a difference in outcomes. A retrospective cohort study comparing emergency patients undergoing major abdominal surgery October 2008 to May 2010 (pre-ERAS) and January 2011 to December 2012 (post-ERAS) was performed. Details collected included admission and operative details, post-operative management and outcomes. A total of 370 patients were studied. Baseline variables were comparable. Post-ERAS, intra-operative (P < 0.001) and post-operative 48 h totals (P < 0.001) of intravenous fluids were significantly reduced. Significantly fewer patients in the post-ERAS group had a catheter (P < 0.001), drain (P = 0.001) and patient controlled analgesia (P = 0.01) for more than two days. Major complications (P = 0.002) and individual minor complications such as urinary tract infections (P = 0.02), urinary retention (P = 0.001) and chest infections (P = 0.001) were all significantly reduced in the post-ERAS period. This study demonstrates a significant change in management towards ERAS principles in emergency patients following the introduction of such a programme in elective patients. The lack of increased complications in the second period suggests the use of ERAS principles is not harmful. The wider application of ERAS principles could improve outcomes in emergency surgery and deserves further study.

Limited utility of routine early postoperative radiography after primary ACL reconstruction

BackgroundGiven the overall success of anterior cruciate ligament (ACL) reconstruction and the infrequent occurrence of complications detectable on radiographs, the clinical utility and cost-effectiveness of routine radiographs in the early postoperative setting is questionable. MethodsNine hundred thirty-three consecutive adult patients undergoing uncomplicated ACL reconstruction at a single institution were retrospectively reviewed to determine whether a postoperative knee radiograph was obtained within the first three months postoperatively. Images, reports and clinical notes were reviewed to determine if any clinical management change occurred due to x-ray findings. Radiograph charges, including imaging, technical and professional charges were calculated. ResultsFive hundred ninety-nine of 933 primary ACL reconstruction patients (64.8%) had postoperative knee radiography at an average of 6.3±3.5weeks postoperatively. A musculoskeletal radiologist read 97.7% of x-rays as normal. In the associated visit note, 70.3% of x-ray results were documented. Only 14.1% of patients with a postoperative x-ray had subsequent imaging. There were no significant management changes based on the routine postoperative radiographs using the defined criteria. A total of $336,683 ($562 per patient) was billed to patients for postoperative radiographs. ConclusionsRoutine early postoperative radiography after primary ACL reconstruction is of questionable utility. The significant per-patient expense is not balanced by the low yield of clinically meaningful data, as nearly all radiographs in the present series were normal and none resulted in significant changes in postoperative clinical management. These results suggest that routine radiographs after uncomplicated ACL reconstruction may be unnecessary although larger, multicenter studies are necessary to confirm these findings. Level of evidenceLevel IV, retrospective case series.

Livestock vs. wild ungulate management in the conservation of Mediterranean dehesas: Implications for oak regeneration

Dehesas are traditional silvo-pastoral systems with scattered oak trees that maintain considerably high biodiversity. Over the last five decades, dehesas have undergone significant management changes, causing a reduction in oak recruitment that threatens their long-term persistence. Here we examine oak regeneration in Mediterranean dehesas of Central Spain under three distinct and representative management regimes for more than 30years: (1) traditional management of extensive sheep rearing; (2) high commercially-competitive management with extensive cattle grazing, and (3) wildlife grazing, mostly by deer. We found that cattle-grazed dehesas sustained a very low density of young oaks (0.05 young plants per 4m2), one third and one fifth of that found in sheep and wildlife areas, respectively. We also found differences in young oak densities depending on plant growth stage, revealing that saplings (late-stage regeneration), but not seedlings, were more abundant under traditional sheep management. Overall, the probability of herbivory damage was higher in areas with cattle (0.85 probability) than in areas with sheep (0.68) and wildlife (0.30). Cattle areas presented, by far, the highest intensity of herbivory, with 63% of the plants showing very high browsing levels (>70% of the biomass damaged). For all management regimes, shrubs were important microhabitat (nurse plants) for seedlings but not for saplings or oak bushes. Our results suggest that conservation practices should include promotion of traditional sheep rearing, reduction of cattle stocking rates, protection of saplings and oak bushes, rotational grazing and preservation of some shrubs. We conclude that agriculture policies that favor traditional sheep rearing and sustainable wildlife populations can promote the conservation of these valuable systems.

The Role of FDG-PET in the Diagnosis and Staging of Ocular Adnexal Lymphoproliferative Disease

Purpose: To further evaluate fluorine 18 fluoro-deoxyglucose positron emission tomography (FDG PET) in the staging of ocular adnexal lymphoproliferative disease (OALD).Methods: Retrospective and prospective case series with review of clinical and imaging records including computed tomography (CT), FDG PET (±PET/CT) and/or magnetic resonance imaging (MRI).Results: Thirty-four patients had FDG PET and CT scans at initial staging. Eleven were retrospectively reviewed and 23 were prospectively enrolled. Of 34 patients, 17 (50%) had primary disease, 17 (50%) had secondary and of these, 13 patients (38%) had OALD as their initial manifestation. Sixteen patients had active systemic disease in conjunction with their orbital disease. Systemic disease was demonstrated by FDG PET (± CT) in 15 of 16 (94%) patients and 11 of 16 (69%) patients with CT. FDG PET found orbital disease in 27 of 34 patients (79%) versus 33 of 34 patients with orbital CT (97%). Four of 16 patients in which FDG-PET detected systemic disease where CT did not were upstaged and their management changed significantly in 5 cases.Conclusions: This study reaffirms FDG PET as an important part of initial staging. Our study suggests FDG PET detects systemic disease more reliably than CT alone and results in significant changes in management. Our findings suggest FDG PET detection for local OALD is less sensitive than CT. MRI is helpful in augmenting other imaging modalities in further identifying disease. Given the prevalence of simultaneous systemic presentations of OALD, FDG PET in this regard is especially important and highlights the need for coordinated multidisciplinary care.

Blood and blood components preparation, storage and supply during the Great Patriotic War

During the Great Patriotic War, work of health workers not only in frontline medical institutions of different levels, but also directly on the battlefield was invaluable. Sanitary losses, especially among combat medics taking the wounded from the battlefield, were the most crucial. During the war, military hospitals were established throughout the territory of the USSR where over 22 million of wounded were treated. 85% of them returned to the Army. The role of blood transfusion stations staff who supplied front and rear medical facilities by blood and its components is invaluable. The objective of the article - to illustrate the role and importance of medical service and its part - medical institutions dealing with blood and blood components collection, storage, processing and supply to military units, hospital, performing transfusions for the wounded. Archival materials and statistical data gained from various publications, wartime and postwar, were used. The gained data confirm the invaluable role of these services in providing medical aid to the wounded and the sick during the Great Patriotic War, as well as describe reorganization and flexible tactics of the blood service staff in accordance with the Great Patriotic War periods in supplying medical service with blood and its components. Blood service staff training and management measures allowed to uninterrupted supply front and rear medical institutions with blood. Blood service in different periods of the Great Patriotic War had undergone significant management changes in the section of the donation, processing and supply of medical facilities with blood, enabling to attract huge crowds of people in the USSR to donate blood, to ensure an uninterrupted, adequate supply of troops with blood.

Should we call the neurologist? The value and cost of a growing neurology consultation service.

St Vincent's University Hospital has an established neurology consultation service. Referral volumes have been growing. The Department regularly reviews its service to monitor changes and seek improvements. We sought to determine the impact of the growing service on patient care, on the department itself in delivering the service, and on inpatient admission trends. We reviewed the electronic referral forms of all consults seen over a 9-week period in 2014 (n=213). We recorded the source of each consult, demographic information, clinical presentation, time from referral to consult, and outcome. We compared the consult list to inpatient admissions list to determine the proportion admitted from consults. We compared our results to previous reviews by this and other neurology departments in Ireland. Three quarters of neurology consults relate to acute admissions. Patients are all seen within one working day of referral. A significant change in management (83.6%) resulted from the majority of consults. Consultants see an average of 4.8 (range 0-10) consults per day, needing up to 7.5h per day to deliver the service. One-third of the department's inpatients come from consults. The service significantly benefits patient care. The increasing number of consults will require increased resources and/or service reorganisation to maintain the current level of service.

Water Level Declines in the High Plains Aquifer: Predevelopment to Resource Senescence

A large imbalance between recharge and water withdrawal has caused vital regions of the High Plains Aquifer (HPA) to experience significant declines in storage. A new predevelopment map coupled with a synthesis of annual water levels demonstrates that aquifer storage has declined by approximately 410 km(3) since the 1930s, a 15% larger decline than previous estimates. If current rates of decline continue, much of the Southern High Plains and parts of the Central High Plains will have insufficient water for irrigation within the next 20 to 30 years, whereas most of the Northern High Plains will experience little change in storage. In the western parts of the Central and northern part of the Southern High Plains, saturated thickness has locally declined by more than 50%, and is currently declining at rates of 10% to 20% of initial thickness per decade. The most agriculturally productive portions of the High Plains will not support irrigated production within a matter of decades without significant changes in management.

Pediatric Blunt Solid Organ Injury: Beyond the APSA Guidelines

The APSA guidelines were published in 2000 making nonoperative management of pediatric blunt liver and spleen injury standard for most injured children. A review of recent literature supports significant changes in management of children with liver, spleen, as well as kidney injury. Of the >300 articles on pediatric abdominal injury since the publication of the APSA guidelines, no randomized controlled trials have been conducted. Six prospective studies, however, have been completed, and several large database studies add significant insights into our understanding of pediatric spleen, liver, and kidney injury. Significant decreases in use of resources can be safely applied to children with hemodynamic stability at presentation. Recent studies suggest management based on physiologic criteria rather than injury grade may result in improved resource utilization through shortened hospitalization, abbreviated periods of bedrest, decreased use of intensive care units, earlier return to school, fewer tests, and a lower transfusion threshold. New algorithms are now available to assist in management.

The role of magnetic resonance imaging in management of patients with nonlobar hypertensive intracerebral hemorrhage.

Despite the increased use and availability of magnetic resonance imaging (MRI), its role in hypertensive intracerebral hemorrhage (ICH) remains uncertain. In this retrospective study, we assessed the utility of MRI in diagnosis and management of patients with hypertensive ICH. We retrospectively reviewed the charts of patients with ICH presenting to our hospital over an 18-month period. We included patients who presented with hypertensive ICH in typical locations and excluded lobar hemorrhages. We further isolated cases that had undergone MRI. Collected data included mean age, gender, location of hematoma, neuroradiologist's interpretative report of the MRI, and management steps taken in response to the results of the MRI. Logistic regression was used to determine whether the overall yield of MRI in these patients was significant. We found 222 patients with ICH in our database. Forty-eight patients met our inclusion criteria, of which 24 had brain MRI done as a part of their hospital workup. Brain MRI obtained in 2 (8%) of the 24 patients revealed abnormalities that led to a change in management. The diagnostic yield of MRI and the management decisions that followed were both insignificant. The diagnostic yield of brain MRI in patients with nonlobar hypertensive ICH is low and does not result in significant changes in management.

Impact of Transesophageal Echocardiography on Management in Patients With Suspected Cardioembolic Stroke

Transesophageal echocardiography (TEE) is frequently performed in patients with acute ischemic cerebrovascular events to exclude a cardioembolic source. We aimed to determine the clinical impact of TEE on management. This is a retrospective single-center study of 1,458 consecutive patients hospitalized with acute ischemic stroke or transient ischemic attack who underwent TEE for evaluation of a suspected cardioembolic cause. Significant TEE findings were determined for each patient as recorded on the TEE report. The medical record was reviewed for baseline, clinical, and demographic variables and to determine whether significant management changes occurred as a result of the TEE findings. Potential significant changes in management included initiation of anticoagulation, placement of a patent foramen ovale (PFO) closure device, initiation of antibiotic therapy for endocarditis, surgical PFO closure, other cardiac surgery, and coil embolization of a pulmonary arteriovenous malformation. A significant change in management occurred in 243 patients (16.7%); 173 (71%) underwent treatment for PFO with a percutaneous PFO closure device (n= 100), initiation of chronic systemic anticoagulation (n= 68), or surgical PFO closure (n= 5). Additional findings leading to achange in management included endocarditis (n= 20), aortic arch atheroma (n=14), intracardiac thrombus (n= 13), pulmonary arteriovenous malformation (n= 2), aortic valve fibroelastoma (n= 2), other valve masses (n= 4), and miscellaneous causes (n= 15). In conclusion, in patients with suspected cardioembolic stroke, TEE findings led to a change in management in 16.7% of patients. Of these, most (71%) were directed at prevention of subsequent paradoxical emboli in patients with PFO.

A longitudinal study of the prevalence and super-shedding of Escherichia coli O157 in dairy heifers

The fecal shedding and super-shedding of the human pathogen Escherichia coli O157 by cattle has been the focus of many previous studies with varied results observed. The heterogeneity of shedding is becoming more accepted, both in the numbers of animals shedding and the levels at which animals shed. To clarify patterns in shedding and super-shedding we undertook a longitudinal study to investigate shedding within a cohort of replacement dairy heifers. The cohort of 52 heifers was sampled 18 times at approximately weekly intervals with no significant changes in management during the sampling period. An overall prevalence of 44.3% (412/930 samples) was detected with prevalence ranging from 9.6 to 94.3% at individual sampling points. Each of the 52 heifers yielded at least one sample which was detected positive for E. coli O157. Super-shedding was detected at a sample level of 3.6% (32/893) and ranged between 0 and 9.6% at each sampling point. Of the 52 heifers, 24 (46.2%) were detected to be super-shedding at some point during the study, 19 of which were detected as super-shedding at only one point. From our findings we conclude that super-shedding is not associated with a small subset of animals that shed at high levels continually as had been proposed by earlier studies. We propose that the term ‘super-shedding event’ as opposed to ‘super-shedding animal’ better describes the nature of shedding.

Incorporating a Radiologist in a Radiation Oncology Department: A New Model of Care?

AimsIncreasingly complex imaging techniques, such as computed tomography, magnetic resonance imaging and positron emission tomography/computed tomography scans are being used by radiation oncologists to improve the accuracy of their radiotherapy planning contours, despite limited formal training in diagnostic imaging. This study aimed to assess whether the availability of an ‘in-house’ radiologist would be beneficial in enhancing the interpretation of oncological imaging and accuracy of contouring. Materials and methodsA radiology/oncology fellow was based in the oncology department, providing radiological advice on diagnostic and planning images, for two sessions per week over a 9 month period. Oncology staff were able to book a time slot with the radiologist on a MOSAIQ cancer database and record the reason for the consultation and its outcome. The radiologist also reviewed the accuracy of the patient's contours for the weekly quality assurance audit meetings. ResultsThe radiologist reviewed 56 scans during the 49 consultation sessions. Advice over diagnostic images and target volume delineation were the main reasons for the consultations, which resulted in a change of practice in 45% of cases, ranging from changing target volumes (25%) to carrying out further imaging (20%). For the quality assurance audit meetings, the radiologist's review of 99 patients' planning contours resulted in a significant change in management in 6% of cases. ConclusionsThis is the first study to attempt to formally quantify the clinical benefit of having a dedicated ‘in-house’ radiologist within a radiation oncology department, clearly showing the valuable impact of such a role.

Use of Point-of-Care Lactate in the Prehospital Aeromedical Environment

Lactate measurement has been used to identify critical medical illness and initiate early treatment strategies. The prehospital environment offers an opportunity for very early identification of critical illness and commencement of care. The investigators hypothesized that point-of-care lactate measurement in the prehospital aeromedical environment would: (1) identify medical patients with high mortality; (2) influence fluid, transfusion, and intubation; and (3) increase early central venous catheter (CVC) placement. Critically ill, medical, nontrauma patients who were transported from September 2007 through February 2009 by University of Massachusetts (UMass) Memorial LifeFlight, a university-based emergency medical helicopter service, were eligible for enrollment. Patients were prospectively randomized to receive a fingerstick whole-blood lactate measurement on an alternate-day schedule. Flight crews were not blinded to results. Flight crews were asked to inform the receiving attending physician of the results. The primary endpoint was the ability of a high, prehospital lactate value [> 4 millimoles per liter (mmol/L)] to identify mortality. Secondary endpoints included differences in post-transport fluid, transfusion, and intubation, and decrease in time to central venous catheter (CVC) placement. Categorical variables were compared between groups by Fisher's Exact Test, and continuous variables were compared by t-test. Patients (N = 59) were well matched for age, gender, and acuity. In the lactate cohort (n = 20), mean lactate was 7 mmol/L [Standard error of the mean, SEM = 1]. Initial analysis revealed that prehospital lactate levels of ≥ 4 mmol/L did show a trend toward higher mortality with an odds ratio of 2.1 (95% CI, 0.3-13.8). Secondary endpoints did not show a statistically significant change in management between the lactate and non lactate groups. There was a trend toward decreased time to post-transport CVC in the non lactate faction. Prehospital aeromedical point-of-care lactate measurement levels ≥ 4 mmol/L may help stratify mortality. Further investigation is needed, as this is a small, limited study. The initial analysis did not find a significant change in post-transport management.

Should centralized histopathological review in penile cancer be the global standard?

Objective To assess the role of centralized pathological review in penile cancer management. Materials and Methods Newly diagnosed squamous cell carcinomas (SCC) of the penis, including squamous cell carcinoma in situ (CIS), from biopsy specimens were referred from 15 centres to the regional supra‐network multidisciplinary team (Sn‐MDT) between 1 January 2008 and 30 March 2011. Biopsy histology reports and slides from the respective referring hospitals were reviewed by the Sn‐MDT pathologists. The biopsy specimens’ histological type, grade and stage reported by the Sn‐MDT pathologist were compared with those given in the referring hospital pathology report, as well as with definitive surgery histology. Any changes in histological diagnosis were sub‐divided into critical changes (i.e. those that could alter management) and non‐critical changes (i.e. those that would not affect management). Results A total of 155 cases of squamous cell carcinoma or CIS of the penis were referred from 15 different centres in North‐West England. After review by the Sn‐MDT, the histological diagnosis was changed in 31% of cases and this difference was statistically significant. A total of 60.4% of the changes were deemed to be critical changes that resulted in a significant change in management. When comparing the biopsy histology reported by the Sn‐MDT with the final histology from the definitive surgical specimens, a good correlation was generally found. Conclusions In the present study a significant proportion of penile cancer histology reports were revised after review by the Sn‐MDT. Many of these changes altered patient management. The present study shows that accurate pathological diagnosis plays a crucial role in determining the correct treatment and maximizing the potential for good clinical outcomes in penile cancer. In the case of histopathology, centralization has increased exposure to penile cancer and thereby increased diagnostic accuracy, and should therefore be considered the ‘gold standard’.

Responding to Higher Education Change through the Lens of Governance, Risk Management and Compliance (GRC): the Case of Autonomous Public Universities in Thailand

Due to changes in the economic, political and educational landscape in Thailand over the past 15 years, higher education institu tions are being mandated to shift from fully public, civil service entities to autonomous, quasi-public universities that require significant management changes. This research considers the likely challenges associated with future educational impacts and utilizes a case study at the College of Arts, Media and Technology, Chiang Mai University to show the current ‘as-is’ and desired ‘to-be’ management scenarios. The paper investigates potential solutions through the lens of a Governance, Risk Management and Compliance (GRC) framework to facilitate sustainability within Thailand’s affiliated universities. While the management challenges of higher education are specific to individual faculties and universities, the case study presented in this paper acts as a microcosm of Thailand’s higher education challenges. The aim of this paper is to promote discussion and consideration of the likely challenges and solutions to Thailand’s changing higher education.

Blood Culture Results Do Not Affect Treatment in Complicated Cellulitis

BackgroundCellulitis, a frequently encountered complaint in the Emergency Department, is typically managed with antibiotics. There is some debate as to whether obtaining blood cultures and knowing their results would change the management of cellulitis, although most authors argue that information from blood cultures does not change the empirical management of uncomplicated cellulitis. However, for complicated cellulitis (as defined by the presence of significant comorbidity), there is considerable disagreement and lack of evidence as to the utility of blood cultures. ObjectiveOur aim was to determine the role of blood cultures in the management of complicated cellulitis. MethodsThis retrospective chart review assessed the utility of obtaining blood cultures in complicated cellulitis (as defined by active chemotherapy, dialysis, human immunodeficiency virus/acquired immune deficiency syndrome, diabetes, or organ transplantation) vs. a cohort of individuals without medical comorbidity. ResultsSix hundred and thirty-nine patients were identified, 314 of which were deemed cases and 325 controls. Within the cases, 29 of 314 returned as positive blood cultures vs. 17 of 325 positive blood culture controls within the cases (p = 0.05; odds ratio = 1.84; 95% confidence interval 0.99–3.43). A clinically significant change in management (a change in the class of antibiotic) was found in 6 of 314 cases vs. 4 of 325 controls (p = 0.578; odds ratio = 1.5525; 95% confidence interval 0.434–5.5541). ConclusionsWithin this cohort of patients with complicated cellulitis, blood cultures rarely changed management from empirical coverage.

Utility of Ambulatory Monitoring in Patients With Congenital Heart Disease

Patients with congenital heart disease (CHD) are at increased risk of cardiac arrhythmias. The utility of ambulatory (Holter) monitoring in predicting these arrhythmias remains unclear. We sought to evaluate the clinical utility and cost effectiveness of Holter monitoring in patients with CHD. A retrospective study of patients with CHD who had undergone Holter monitoring was performed. The Holter data from patients with tetralogy of Fallot (TOF), d-transposition of the great arteries (d-TGA) after an atrial switch operation, and patients with a single ventricle after Fontan palliation were reviewed. The Holter indication included evaluation of clinical symptoms or as a part of routine screening. The Holter results were deemed clinically significant if they resulted in a change in patient treatment. Sudden cardiac events included death or aborted sudden death and appropriate defibrillator therapies. A total of 589 Holter studies were performed in 189 patients (100 with TOF, 38 with d-TGA, and 51 with Fontan). The results of Holter monitoring performed for clinical symptoms had a low positive predictive value (0.08) for clinically significant changes in management. On routine monitoring, the sensitivity was low (0.40) but the negative predictive value was high (0.96) for future clinically significant arrhythmias. The frequency of clinically significant findings and associated cost-effectiveness improved with older patient age and Fontan and d-TGA CHD type. Nonsustained ventricular tachycardia was associated with sudden cardiac events in patients with TOF but not in those with d-TGA or Fontan palliation. In conclusion, Holter monitoring is generally inefficient for symptomatic evaluation; however, within specific age and CHD type subgroups, such as patients with repaired TOF >25 years old, it could be useful in clinical management and risk assessment as a part of routine care.

The Nashua agronomic, water quality, and economic dataset

This paper describes a dataset relating management to nitrogen (N) loading and crop yields from 1990 to 2003 on 36, 0.4 ha (1 ac) individually tile-drained plots on the Northeast Research and Demonstration Farm near Nashua, Iowa, United States. The field-measured data were used to calibrate the Root Zone Water Quality Model (RZWQM), and the results were summarized in a special issue of <i>Geoderma</i> (Ahuja and Hatfield 2007). With a comprehensive, long-term measured dataset and a model that simulates many of the components of the agricultural system, one can begin to understand the effects of management practices on N loading, crop yields, and net income to the farmers. Other researchers can use this dataset to assess the effects of management on similar tile-drained systems occurring some distance from Nashua, under alternative climates and soils, with other management systems, or with simulation models using different process representations. By integrating the understanding developed at Nashua with datasets from other highly monitored sites and other sources, progress can be made in addressing problems related to excessive N fluxes in the Mississippi Basin. An example 30-year RZWQM simulation of 18 management systems implies that significant management changes are needed to meet the goal of reducing N loads to the Gulf of Mexico by 45%. This paper and the associated datasets are intended to be used in conjunction with the analyses and process descriptions presented in the <i>Geoderma</i> special issue. The datasets and additional explanatory materials are available for download at http://apps.tucson.ars.ag.gov/nashua.