Search

A retrospective study to investigate the prevalence and severity of impairment of the lung diffusing capacity for carbon monoxide (Dco) in patients with lung carcinoma was done using a case-control [...]

Objective:Hospital restructuring often results in fewer inpatient beds, increased ambulatory services, and closures of hospitals or emergency departments (EDs). The authors sought to determine the impact of systematic hospital restructuring on ED overcrowding. Methods:Time series analyses of average monthly overcrowding for EDs in Toronto, Ontario, Canada, from 1991 and 2000 (n ? 20 hospitals, 120 months) were conducted. Autoregression models evaluated the rate of increase of overcrowding before and during systematic restructuring. A secondary analysis included total ED visits, patient age, and sex distribution as covariates. Seasonality was assessed by means of spectral analysis. Results:Severe and moderate overcrowding averaged 3% and 14% of the time each month, respectively, over the whole period. Before restructuring (n ? 74 months), severe and moderate overcrowding averaged 0.5% and 9% per month, respectively; during restructuring (n ? 46 months), the monthly averages were 6% and 23%, respectively. Neither severe nor moderate overcrowding was increasing before restructuring. During restructuring, however, both increased significantly (severe 0.2% per month [p < 0.0001]; moderate 0.5% per month [p < 0.0001]). Similar results were found after controlling for ED utilization. Female gender independently predicted increased overcrowding; older age predicted reduced moderate overcrowding; number of total visits was not a predictor. Spectral analysis revealed significant seasonality in overcrowding. Conclusions:Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics. Restructuring should proceed slowly to allow time for monitoring of its effects and modification of the process, because the impact of incremental reductions in hospital resources may be magnified as maximum operating capacity is approached.

Many clinical trials of uncommon diseases are underpowered because of the difficulty of recruiting adequate numbers of subjects. We propose a clinical trial design with improved statistical power compared to the traditional randomized trial for use in clinical trials of rare diseases. The three-stage clinical trial design consists of an initial randomized placebo-controlled stage, a randomized withdrawal stage for subjects who responded, and a third randomized stage for placebo non-responders who subsequently respond to treatment. Test level and power were assessed by computer-intensive exact calculations. The three-stage clinical trial design was found to be consistently superior to the traditional randomized trial design in all cases examined, with sample sizes typically reduced by 20 per cent to 30 per cent while maintaining comparable power. When a treatment clearly superior to placebo was considered, our design reached a power of 75 per cent with a sample of 21 patients compared with the 52 needed to attain this power when only a randomized controlled trial was used. In situations where patient numbers are limited, a three-stage clinical trial design may be a more powerful design than the traditional randomized trial for detecting clinical benefits. Copyright © 2001 John Wiley & Sons, Ltd.

Background: Despite universal coverage under a provincial health plan, the residents of Ontario, Canada, still bear some costs for outpatient care, particularly for prescription drugs.Objective: To determine the financial and nonmonetary costs borne by patients presenting at a dermatology clinic in an academic centre, and to assess the extent to which these costs were problematic.Methods: Consecutive new patients in a 6-week period completed a self-administered questionnaire.Results: Eighty-six of 140 questionnaires (61%) were returned for analysis. The mean total cost to patients was C$28.92 (range $0 to $177.00). Medications were the largest expense (mean $35.66 for those receiving medication). Despite relatively prompt referrals (mean 12.4 days) and short in-office waiting time (mean 26.5 minutes), there was a trend for subjects to rate time costs as more problematic than monetary costs.Conclusion: Patients attending a dermatology clinic bear variable monetary and nonmonetary costs. For some patients these costs may have the potential to impair access to care.

When predictive covariates for a dichotomous outcome dependent variable are undetectable or unmeasurable for some subjects, a fact in itself that may be of considerable prognostic importance, traditionally such subjects' data are dropped from multiple logistic regression analyses. An alternative analytical algorithm is offered here for such situations. First, a series of multiple logistic regressions are applied to the complete data where covariates are initially coded as dichotomous, e.g., detectable or nondetectable. Then, a second series of logistic regressions are fitted for those subjects for whom a covariate is detectable and measurable with the fully resolved measure as the covariate. Ultimately, all individual model-specific predicted probabilities of the outcome for a subject are combined into a single probability through the proposed “Composite Probability Modelling of Increased Resolution” (CPMIR). When such an analysis was applied to discriminate 133 patients with acoustic tumours from a sample of 133 patients with cochlear disease, using a latency measure of the auditory brainstem response evoked potential as the predictive covariate, CPMIR yielded a superior model chi square to any component model, used the full cohort of patients, and produced the largest area under the ROC curve. This algorithm is offered as a general statistical modelling device.

Various factors may influence bioavailability and blood concentrations of cyclosporine, a problem that may be compounded by diseases such as cystic fibrosis in which impaired absorption through the gastrointestinal tract is common. Neoral, a microemulsion formulation of cyclosporine, has improved bioavailability and more stable blood concentrations than earlier formulations. We conducted a prospective, open, crossover study to examine whether these findings held true in 12 clinically stable patients with cystic fibrosis who had undergone lung transplantation at least 6 months earlier. In the first arm, patients continued their usual dosage of cyclosporine twice/day. In the second arm they received Neoral for at least 1 week before having blood studies. For each arm whole blood trough concentrations were drawn for 7–10 successive days, together with a pharmacokinetic study with concentrations drawn at times zero, 1, 2, 3, 4, 6, 12, and 24 hours. Variance was assessed from morning concentrations. Area under the curve from zero to 12 hours (AUC12), maximum concentration (Cmax), and time to Cmax(Tmax) were calculated for each arm. Eleven subjects completed the protocol. The daily variance for Neoral was significantly less than for cyclosporine (p=0.04). The AUC12for Neoral and cyclosporine were 4164 ± 1467 and 5318 ± 1670 μg·L/hour (p=0.09), respectively. Respective Cmaxwere 613 ± 242 and 931 ± 458 μg/L (p=0.08) and relative Cmaxand AUC12were 1.91 and 1.47 (p<0.05). Thus Neoral had a superior pharmacokinetic profile and less day‐to‐day variability in patients with cystic fibrosis who had undergone lung transplantation.

The aim of this study is to evaluate the effect of an external nasal dilator in patients with nasal obstruction secondary to mucosal congestion (n = 33) or to septal deviation in the nasal valve area (n = 28). A group of subjects with healthy nasal cavities was tested also (n = 51). Acoustic rhinometric and rhinomanometric nasal measurements were performed with and without the dilator and before and after topical decongestion of the nasal mucosa. A visual analog scale was employed to evaluate the subjective sensation of nasal obstruction. Objective measurements showed that the external dilator increased the minimum cross‐sectional area and decreased the nasal resistance significantly in all three groups (P< 0.01). The effect was more impressive in patients with septal deviation (P< 0.001). Subjective assessments reflected patency in all subjects except those in the mucosal swelling group (P= 0.06). From this study the authors conclude that the external nasal dilator offers an effective, nonsurgical therapeutic approach in the management of septal deviation that obstructs the nasal valve area. Although patients with nasal obstruction secondary to mucosal congestion showed objective improvement with the nasal dilator, these changes were not accompanied by a sensation of enhanced patency.