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PubMed1994

In-hospital monitoring after coronary angioplasty.

At the University Hospital of Geneva there are three postcoronary angioplasty monitoring levels: (A) intensive care unit; (B) optional ECG monitoring (cardiology unit); and (C) no monitoring (other unit). To assess the adequacy of patient monitoring after coronary angioplasty, we studied the clinical outcome of 200 consecutive patients undergoing coronary angioplasty at different monitoring levels. Thirty-nine patients (20%) were in level A. Their outcome was 1 death, 1 emergency bypass operation, and 7 acute myocardial infarcts. Ninety-six patients (48%) were in level B: no major complication, no transfer of monitoring level, and mean hospital stay 2.7 +/- 1.3 days. Sixty-five patients (32%) were in level C: 1 death, 2 elective bypass operations, 6 transfers to level A, and mean hospital stay 5.9 +/- 4.6 days. Electrocardiogram monitoring of 135 patients yielded 23 significant findings (17%), 22 of which occurred in patients with complicated or failed procedure. In the 122 patients with successful coronary angioplasty without angiographic visible local complications and without clinical symptoms at the end of the procedure, no significant arrhythmia or acute myocardial infarction was documented. For this type of patient, ECG monitoring is not a prerequisite after coronary angioplasty. Surveying all patients after coronary angioplasty in the coronary care unit would not significantly reduce complications. Aftercare in a cardiology unit results in a shorter hospital stay.

Adult↗
PubMed2002

Transcranial Doppler ultrasound: a new method of monitoring hemispheric anesthetization during the intracarotid amobarbital procedure.

BACKGROUND: Electroencephalography (EEG) is traditionally used to assess the duration of hemispheric anesthetization and to monitor return of function in the anesthetized hemisphere during the intracarotid amobarbital procedure (IAP), but EEG changes are not consistently seen. The authors evaluated the role of continuous transcranial Doppler (TCD) monitoring as an alternative to EEG. METHODS: The authors performed both continuous TCD monitoring and EEG during the IAP in 10 patients with medically intractable partial epilepsy. Mean velocities were monitored continuously in both middle cerebral arteries (MCAs), and changes in MCA velocities on continuous TCD monitoring were time locked with the EEG changes. RESULTS: The average mean MCA velocities were within normal limits bilaterally (50-85 cm/s) in all patients at baseline. Mean MCA velocites increased in all patients to 95-115 cm/s at the start of the test when the patients were asked to raise their hands and start counting. After injection of sodium amobarbital, mean MCA velocities in all patients dropped dramatically on the ipsilateral side to values of 12-39 cm/s and returned to the baseline average value when the hemiparesis recovered. In 8 patients, the duration of delta activity on EEG coincided with the time interval during which the mean MCA velocities were low on TCD monitoring. In 2 patients, despite the presence of hemiparesis clinically and a drop in mean MCA velocities on the ipsilateral side on continuous TCD monitoring, EEG remained normal on the ipsilateral side. CONCLUSIONS: Continuous TCD monitoring may be a more sensitive method than EEG in determining the duration of hemispheric anesthetization during IAP. Because the items for assessment of memory are presented during the period of hemispheric anesthetization, TCD may be useful in more precisely defining the time window for memory testing.

Amobarbital↗
PubMed2000

Continuous electrocardiographic monitoring and cardiac arrest outcomes in 8,932 telemetry ward patients.

OBJECTIVE: To estimate the benefit of routine electrocardiographic (ECG) telemetry monitoring on in-hospital cardiac arrest survival. METHODS: In a tertiary care hospital, all telemetry ward admissions and cardiac arrests occurring over a five-year period were reviewed. Ward location and survival to discharge were determined for all patients outside of critical care areas. RESULTS: During the study period, 8,932 patients were admitted to the telemetry ward, and 20 suffered cardiac arrest (0.2%; 95% CI = 0.1 to 0.3). Telemetry monitors signaled the onset of cardiac arrest in only 56% (95% CI = 30 to 80) of monitored arrests. Three patients survived to discharge, and in two of these three patients the arrest onset was signaled by the monitor. This yields a monitor-signaled survival rate among telemetry ward patients of 0.02% (95% CI = 0 to 0.05). All survivors suffered significant arrhythmias prior to their cardiac arrests. CONCLUSIONS: Cardiac arrest is an uncommon event among telemetry ward patients, and monitor-signaled survivors are extremely rare. Routine telemetry offers little cardiac arrest survival benefit to most monitored patients, and a more selective policy for telemetry use might safely avoid ECG monitoring for many patients.

Aged↗
PubMedDate not supplied

MAROS: a decision support system for optimizing monitoring plans.

The Monitoring and Remediation Optimization System (MAROS), a decision-support software, was developed to assist in formulating cost-effective ground water long-term monitoring plans. MAROS optimizes an existing ground water monitoring program using both temporal and spatial data analyses to determine the general monitoring system category and the locations and frequency of sampling for future compliance monitoring at the site. The objective of the MAROS optimization is to minimize monitoring locations in the sampling network and reduce sampling frequency without significant loss of information, ensuring adequate future characterization of the contaminant plume. The interpretive trend analysis approach recommends the general monitoring system category for a site based on plume stability and site-specific hydrogeologic information. Plume stability is characterized using primary lines of evidence (i.e., Mann-Kendall analysis and linear regression analysis) based on concentration trends, and secondary lines of evidence based on modeling results and empirical data. The sampling optimization approach, consisting of a two-dimensional spatial sampling reduction method (Delaunay method) and a temporal sampling analysis method (Modified CES method), provides detailed sampling location and frequency results. The Delaunay method is designed to identify and eliminate redundant sampling locations without causing significant information loss in characterizing the plume. The Modified CES method determines the optimal sampling frequency for a sampling location based on the direction, magnitude, and uncertainty in its concentration trend. MAROS addresses a variety of ground water contaminants (fuels, solvents, and metals), allows import of various data formats, and is designed for continual modification of long-term monitoring plans as the plume or site conditions change over time.

Cost-Benefit Analysis↗
PubMed1991

Home monitoring of transcutaneous oxygen tension in the early detection of hypoxaemia in infants and young children.

Twenty three patients (age range 0.5-40 months) with recurrent cyanotic episodes underwent physiological recordings, including transcutaneous oxygen tension (TcPO2) from a monitor modified for use at home (Kontron 821S). Of 69 episodes in which the arterial oxygen saturation (SaO2, Nellcor N200) was less than or equal to 80% for greater than or equal to 20 seconds and/or central cyanosis was present, the TcPO2 monitor alarmed (less than or equal to 20 mmHg or 2.67 kPa) in every episode. The pulse oximeter identified hypoxaemia in 62 out of 69 episodes, failing in seven episodes due to signal loss from movement artefact. In only seven of 69 episodes was there an accompanying apnoeic pause (greater than or equal to 20 seconds), and heart rate fell to less than or equal to 80 beats/minute in only five of 28 episodes in which an electrocardiogram was recorded. In 32 episodes in which SaO2 fell to less than or equal to 60%, the TcPO2 monitor alarmed after a median time interval of 16 seconds (maximum time interval 30 seconds). The TcPO2 monitor was then used in an uncontrolled trial at home in 350 patients at increased risk of sudden death and/or hypoxaemia. Indications for monitoring included apparent life threatening events or cyanotic episodes (n = 163), prematurity and prematurity related disorders (n = 86), and sudden unexpected death in one or more siblings (n = 122). The TcPO2 monitor detected cyanotic episodes at home in 81 patients, 52 of whom received vigorous stimulation and/or mouth to mouth resuscitation. Twenty one of these 52 patients had further hypoxaemic episodes documented in hospital with pulse oximetry. In 30 patients, the TcPo2 monitor also identified the gradual development of hypoxaemia, as confirmed by pulse oximetry. Twenty of these needed additional inspired oxygen and six subsequently needed ventilatory support in hospital. This TcPo2 monitor is a reliable detector of both sudden and gradual onset hypoxaemia and is able to be used by parents in the home.

Child, Preschool↗
PubMed2001

Parental compliance with home cardiorespiratory monitoring.

AIMS: To evaluate parental compliance with home cardiorespiratory monitoring of premature infants with apnoea, siblings of infants who died of sudden infant death syndrome (SIDS), and infants with an apparent life threatening event (ALTE), during the first month of use. METHODS: A retrospective review of the first month's recordings was conducted on 39 premature infants with apnoea, 13 siblings of SIDS, and 16 infants with ALTE. All infants were singletons. Recommendations during the study period (1992-1994) were for daily use for 23 hours per day. Measurements were average daily hours of use and consistency of use (daily or variable). Gestational age, maternal age, and socioeconomic status as measured by receipt of public assistance were also recorded. RESULTS: Siblings of SIDS were monitored for fewer hours than were premature or ALTE infants. Only 54% of sibings of SIDS were monitored daily, compared to 87% of premature infants and 93% of ALTEs. Within each diagnostic category socioeconomic status did not affect average hours of monitoring. Consistency of use was more evident in those with private insurance, although the trend did not reach significance. CONCLUSIONS: Parents of infants with apnoea of prematurity or ALTE are highly compliant with cardiorespiratory monitoring recommendations in the first month of monitor usage. Siblings of SIDS are monitored for fewer hours and are less likely to be monitored on a daily basis.

Analysis of Variance↗
PubMed2006

Immune monitoring of T-cell responses in cancer vaccine development.

Monitoring cellular immune responses is one prerequisite for rational development of cancer vaccines. The primary objective of immune monitoring is to determine the efficacy of a vaccine to induce or augment a specific T-cell response. Further questions relate to the prevalence and functional relevance of spontaneous tumor-directed immune responses, the functional characteristics of T-cell responses, and, finally and most importantly, the relationship between immune monitoring assay results and clinical end points. The issue of T-cell monitoring has become more complex as different types and generations of assays have been adopted during the past decade and both standardization and validation of assays have often been insufficient. Because the development of assays parallel the clinical development of cancer vaccines, technical advances have been achieved simultaneously with broadening understanding of cancer immunity. Suitable animal models for immune monitoring are, however, lacking, because preclinical vaccine development in rodents does not allow serial immune monitoring of the peripheral blood, as is commonly used in patients. The current situation is characterized by a lack of universal standards for T-cell assessment, uncertainty about the association between immune monitoring assay results and clinical antitumor end points, and lack of knowledge regarding the contribution of different aspects of T-cell function to clinical efficacy. It is acknowledged that T-cell monitoring will have to be validated in large trials with clinically effective vaccines, but this necessity should not discourage the current application of novel assays within clinical trials of all stages.

Animals↗
PubMed1994

Long-term video-EEG monitoring revisited. The value of interictal and ictal video-EEG recording, a follow-up study.

Between October 1990 and November 1992, 100 patients were monitored at the University of Gent Epilepsy Monitoring Unit. Sixty-three patients were referred for refractory epilepsy, 38 of whom were entered in the epilepsy surgery protocol. Thirty-seven patients were evaluated for the diagnosis of attacks of uncertain origin. Average duration of monitoring was 3.5 days (2-15 days). Prolonged interictal EEG was recorded in all patients. Ictal EEG was obtained in 63 patients; the average number of recorded episodes was 3 (1-15). Pre-monitoring tentative seizure diagnosis was available in 81 patients, 59 of whom had clinical attacks. Premonitoring diagnosis was confirmed in 31 patients and revised in 28 patients. As a result of the monitoring session, anticonvulsant medication was started in 10 patients, changed in 47, stopped in 5 and left unchanged in 23 patients. Twelve patients underwent surgery. Average follow-up after monitoring was 17 months (4-30 months). Four patients were lost to follow-up; 2 patients died of an underlying disease. In the nonsurgical group (85 patients), 60 patients became seizure-free or experienced significant reduction in seizure frequency. Outcome was unrelated to the availability of ictal recording. While prolonged interictal EEG monitoring is mandatory in the successful management of patients with refractory epilepsy, ictal video-EEG monitoring is very helpful but not indispensable, except in patients enrolled for epilepsy surgery or suspected of having pseudoseizures.

Adolescent↗
PubMed2005

Self-monitoring of blood glucose as part of a multi-component therapy among non-insulin requiring type 2 diabetes patients: a meta-analysis (1966-2004).

OBJECTIVE: To determine if therapeutic management programs that include self-monitoring of blood glucose result in greater HbA1c reduction in non-insulin-requiring type 2 diabetes patients compared to programs without blood glucose self-monitoring. RESEARCH DESIGN AND METHODS: Electronic databases including MEDLINE (1966-2004), Cochrane Database of Systematic Reviews, EMBASE (1950-2004), Centre for Reviews and Dissemination (CRD) and the Online Index Journals of the American Diabetes Association (ADA 1978-2004) were searched. Personal collections of investigators were also explored. Randomized controlled trials comparing HbA1c reduction in therapies with and without blood glucose self-monitoring among adult, non-insulin-treated type 2 diabetes patients were selected. Studies on patients who are pregnant, taking insulin, troglitazone or experimental drugs were excluded. Out of 14 potentially useful randomized controlled trials on self-monitoring of blood glucose in non-insulin treated type 2 diabetes patients, eight studies with a total of 1307 subjects were included in the analysis. Two independent reviewers assessed the quality of studies. MAIN OUTCOME MEASURE: The effect of SMBG was assessed by means of meta-analysis of the difference in HbA1c reduction between self-monitoring and non-self-monitoring groups. RESULTS: Antidiabetic therapies that included blood glucose self-monitoring as part of a multi-component management strategy produced a mean additional HbA(1c) reduction of -0.39% (95%CI: -0.54%, -0.23%) under the fixed effects model and -0.42% (95%CI: -0.63%, -0.21%) under the random effects model, when compared to therapies that did not. Heterogeneity among studies was not statistically significant. CONCLUSION: Multi-component diabetes management programs with self-monitoring of blood glucose result in better glycemic control among non-insulin-using type 2 diabetes patients.

Aged↗
PubMed2006

Resource consumption and management associated with monitoring of warfarin treatment in primary health care in Sweden.

BACKGROUND: Warfarin is used for the prevention and treatment of various thromboembolic complications. It is an efficacious anticoagulant, but it has a narrow therapeutic range, and regular monitoring is required to ensure therapeutic efficacy and at the same time avoid life-threatening adverse events. The objective was to assess management and resource consumption associated with patient monitoring episodes during warfarin treatment in primary health care in Sweden. METHODS: Delphi technique was used to systematically explore attitudes, demands and priorities, and to collect informed judgements related to monitoring of warfarin treatment. Two separate Delphi-panels were performed in three and two rounds, respectively, one concerning tests taken in primary health care centres, involving 34 GPs and 10 registered nurses, and one concerning tests taken in patients' homes, involving 49 district nurses. RESULTS: In the primary health care panel 10 of the 34 GPs regularly collaborated with a registered nurse. Average time for one monitoring episode was estimated to 10.1 minutes for a GP and 21.4 minutes for a nurse, when a nurse assisted a doctor. The average time for monitoring was 17.6 minutes for a GP when not assisted by a nurse. Considering all the monitoring episodes, 11.6% of patient blood samples were taken in the individual patient's home. Average time for such a monitoring episode was estimated to 88.2 minutes. Of all the visits, 8.2% were performed in vain and took on average 44.6 minutes. In both studies, approximately 20 different elements of work concerning management of patients during warfarin treatment were identified. CONCLUSION: Monitoring of patients during treatment with warfarin in primary health care in Sweden involves many elements of work, and demands large resources, especially when tests are taken in the patient's home.

Anticoagulants↗
PubMed2006

Data and safety monitoring in social behavioral intervention trials: the REACH II experience.

BACKGROUND: Psychosocial and behavioral interventions trials targeting a broad range of complex social and behavioral problems such as smoking, obesity and family caregiving have proliferated in the past 30 years. At the same time the use of Data and Safety Monitoring Boards (DSMBs) to monitor the progress and quality of intervention trials and the safety of study participants has increased substantially. Most of the existing literature and guidelines for safety monitoring and reporting of adverse events focuses on medical interventions. Consequently, there is little guidance for investigators conducting social and behavior trials. PURPOSE: This paper summarizes how issues associated with safety monitoring and adverse event reporting were handled in the Resources for Enhancing Alzheimer's Caregiver Health (REACH II) program, a multi-site randomized clinical trial, funded by the National Institutes on Aging (NIA) and the National Institutes of Nursing Research (NINR), that tested the efficacy of a multicomponent social/behavioral intervention for caregivers of persons with Alzheimer's disease. METHODS: A task force was formed to define adverse events for the trial and protocols for reporting and resolving events that occurred. The task force conducted a review of existing polices and protocols for data and safety monitoring and adverse event reporting and identified potential risks particular to the study population. An informal survey regarding data and safety monitoring procedures with investigators on psychosocial intervention trials was also conducted. RESULTS: Two categories of events were defined for both caregivers and patients; adverse events and safety alerts. A distinction was also made between events detected at baseline assessment and those detected post-randomization. Standardized protocols were also developed for the reporting and resolution of events that occurred and training of study personnel. Results from the informal survey indicated wide variability in practices for data safety and monitoring across psychosocial intervention trials. CONCLUSIONS: Overall, the REACH II experience demonstrates that existing guidelines regarding safety monitoring and adverse event reporting pose unique challenges for social/behavioral intervention trials. Challenges encountered in the REACH II program included defining and classifying adverse events, defining "resolution" of adverse events and attributing causes for events that occurred. These challenges are highlighted and recommendations for addressing them in future studies are discussed.

Alzheimer Disease↗
PubMed2006

An Institutional Review Board dilemma: responsible for safety monitoring but not in control.

Clinical trials have become a major research tool to evaluate new medical interventions. Most trials require some level of data monitoring for quality control and many trials require special monitoring for participant safety. For national multicenter trials, independent data monitoring committees have become the standard for monitoring for evidence of participant benefit or harm in trials with irreversible outcomes such as death or serious morbidity. The Institutional Review Board (IRB) is held responsible for monitoring local trials. Often local institutions do not have an infrastructure in place to meet this responsibility, and therefore local IRBs cannot fulfill this obligation. In addition, IRBs are currently inundated with individual safety reports from local and multi-institutional trials which may appear to provide some level of safety monitoring, but in fact gives a false sense of security. We propose the establishment of institutional data monitoring committees and appropriate informatics infrastructure to monitor local trials.

Clinical Trials Data Monitoring Committees↗
PubMed2006

Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial.

Vocal cord injuries (VCI) and postoperative hoarseness (PH) are common complications after general anesthesia. Poor muscle relaxation at the moment of tracheal intubation may result in VCI. There is a large interindividual variation in neuromuscular depression after administration of neuromuscular blocking drugs. Therefore, the optimal individual timing of tracheal intubation based on neuromuscular monitoring (monitoring) may decrease VCI. In this prospective trial, 60 patients were randomized into 2 groups: Monitoring group: tracheal intubation at maximum block based on monitoring after atracurium 0.5 mg/kg and 2-min group: tracheal intubation 2 min after injection of atracurium 0.5 mg/kg. Intubating conditions were evaluated with the Copenhagen score. VCI were examined by stroboscopy before and 24 and 72 h after surgery. PH was assessed at 24, 48, and 72 h after surgery by a standardized interview. Excellent intubating conditions were significantly increased in the monitoring group compared with the 2-min group: 8 versus 2 patients, respectively (P = 0.036). The incidence of PH between the study groups was comparable: 7 (monitoring) versus 8 patients (2-min) (P = 0.860). Similar findings were observed for VCI: 9 versus 5 patients; respectively (P = 0.268); type of VCI: thickening of the vocal cords: 8 (monitoring) versus 5 (2-min) patients (P = 0.423), hematomas: 2 patients in each group (not significant). The present study demonstrated that neuromuscular monitoring improved endotracheal intubating conditions. However, tracheal intubation at maximum intensity of neuromuscular block was not associated with a decrease in vocal cord injuries.

Adult↗
PubMed2003

Laboratory calibration and validation of the Biotrainer and Actitrac activity monitors.

PURPOSE: The Biotrainer and Actitrac activity monitors (IM Systems) offer potential research advantages over existing accelerometry-based activity monitors, but they have not been tested under controlled conditions. The purpose of this study was to develop and test laboratory-based prediction equations for both monitors to estimate energy expenditure (EE) for walking/running movements. METHODS: Participants in the study wore a Biotrainer and Actitrac monitor on both hips and completed three paced bouts on the treadmill (3, 4, and 6 mph for 6 min each). Metabolic data collected using an indirect calorimetry system were used as the criterion measure. Multiple regression techniques were performed to develop prediction equations, and these equations were then applied to data from a separate sample for cross-validation purposes. Reliability was also examined. RESULTS: The correlations between the raw counts from each monitor and the measured metabolic variables ranged from r = 0.74-0.88 for the Biotrainer and from r = 0.81-0.91 for the Actitrac. The equations predicting EE (kcal x min-1) from counts yielded strong validation results for both the Biotrainer (R2 = 0.88, SEE = 1.47) and the Actitrac (R2 = 0.91, SEE = 1.24). When used on the cross-validation sample, the correlations between measured and predicted EE were r = 0.93 (Biotrainer) and r = 0.94 (Actitrac). Intraclass reliability coefficients computed between the left and right monitors ranged from 0.60 to 0.71 (Biotrainer) and 0.80 to 0.87 (Actitrac). When the equation developed from one side was applied to data from the monitor on the other side, there were no significant differences in predicted and measured EE for most comparisons. CONCLUSION: The results support the validity of Biotrainer and Actitrac monitors for estimating energy expenditure under controlled conditions.

Adult↗
PubMed2005

Cardiac event recording yields more diagnoses than 24-hour Holter monitoring in patients with palpitations.

Palpitation is a common symptom that sometimes results from a substantial cardiac arrhythmia. We compared the diagnostic yield of trans-telephonic event monitors with those of Holter monitoring in patients with intermittent palpitations. In all, 310 patients were randomly assigned to receive an event recorder or 24-hour Holter monitoring. Event recorders were used for seven days or until two recordings were obtained while symptoms occurred. The main end-point was an electrocardiogram (ECG) recorded during symptoms. The patients with palpitation recorded the one-lead ECG trace and sent it to a telemedicine call centre, where a nurse responded. There were 119 symptomatic patients in the event recorder group and 74 in the Holter group. The total costs were 6019 for event recording and 9605 for Holter monitoring. The average costs were 51 per symptomatic patient detected by event recorder monitoring and 130 per symptomatic patient detected by Holter monitoring. More patients therefore received a clear diagnosis, and more quickly, when using event recording than with Holter monitoring. For this reason, event recorders are preferable to Holter monitors for patients with palpitations.

Arrhythmias, Cardiac↗
PubMed1996

Ambulatory blood pressure monitoring in evaluating the prevalence of hypertension in adults in Ohasama, a rural Japanese community.

We estimated the prevalence of hypertension and evaluated the degree of blood pressure control on the basis of ambulatory blood pressure monitoring in patients receiving antihypertensive medication. A total of 969 adults (mean age +/- SD, 59.3 +/- 12.1 years old range: 20-79 yr) among 1,575 eligible persons (65.1%) recruited from a total adult population of 2,789 people living in a rural region of northern Japan underwent measurement of initial screening blood pressure; ambulatory blood pressure was measured subsequently. A total of 285 subjects (66.5 +/- 9.2 years old) were taking antihypertensive medication (treated group), while 684 (56.3 +/- 12.0 years old) were not (untreated group). The WHO criteria were used to categorize screening blood pressure. Ambulatory blood pressure levels were classified as follows: hypertension, systolic blood pressure > or = 144 mmHg and/or diastolic blood pressure > or = 85 mmHg; and normotension, systolic blood pressure < or = 133 and diastolic blood pressure < or = 78 mmHg. Of the 285 treated subjects, 49 (17.2%) were classified as hypertensive by screening measurements, while 36 (12.6%) were classified as such by ambulatory blood pressure monitoring. Only 12 (24.5%) of the former 49 subjects were also classified as hypertensive, while 20 (40.8%) were classified as normotensive by ambulatory blood pressure monitoring. Of the 684 untreated subjects, 34 (5.0%) were hypertensive by screening measurements and 43 (6.3%) were hypertensive by ambulatory blood pressure monitoring. Only 14 (41.2%) of the former 34 subjects were classified as hypertensive by ambulatory blood pressure monitoring. Of the 34 untreated subjects classified as hypertensive by screening measurements, ambulatory blood pressure monitoring showed 12 (35.3%) to be normotensive, suggesting that they were cases of "white coat" hypertension. The study first confirmed, based on community-derived data, that there are large discrepancies between screening (casual) blood pressure measurements and ambulatory blood pressure monitoring with respect to the recognition of hypertension and normotension. The determination of blood pressure levels by ambulatory blood pressure monitoring may result in a different prognosis of hypertension from that made on the basis of screening blood pressure measurements. The prognostic value of ambulatory blood pressure has to be further investigated.

Adult↗
PubMed2005

Fifteen years of experience in cholinesterase monitoring of insecticide applicators.

INTRODUCTION: Measuring cholinesterase(ChE) enzyme levels in red blood cells (RBC) and plasma has become a useful tool in the early detection of organophosphate and carbamate poisoning in insecticide handlers. Since 1974 the State of California has required testing of pesticide applicators to prevent disease. This study is a review of the testing experience of two physicians and using one laboratory so that a comparison can be made to previous studies by the author and others. METHODS: The files of 366 workers who were referred by their employers for ChE activity monitoring were abstracted for patient data, employer identification, and testing data. Results were entered into the EPIINFO program for analysis. RESULTS: A total of 366 workers from 45 companies were tested over a 15-year period between 1989 and 2004. Most were applicators. There were 690 attempts to establish baselines, of which 545 (79%) were successful. There were 519 monitoring tests on 228 workers, resulting in the removal from exposure of 18 employees, most in 1996. Self-reported exposure history and symptoms resulted in only 3 responses (.6%). The costs were significant ($47,160 total and $36 per test), especially when considering the failure of 145 (21%) employees to establish baselines. There was monthly and yearly variation in plasma and RBC baselines, monthly variance in plasma monitoring tests, and no monthly variance in RBC monitoring. The use of a third baseline test when the first two varied by 15% avoided two false positives. The mean time for recovery from ChE depression was 5.38 weeks. DISCUSSION: The California ChE monitoring program remains a valuable tool. There was significant monthly and yearly variation in values for both baseline and monitoring plasma and RBC values, with the exception of RBC monthly variance. Self-reported symptoms were not found to be a valuable tool in measuring exposure. Rates of recovery from ChE depression were highly variable. The warning feature of the program was very effective. The costs of monitoring were substantial, but possibly not as great as a single workers' compensation case. CONCLUSIONS: The California ChE monitoring program serves as a useful and cost-effective means of preventing organophosphate and carbamate overexposure. Elimination of the third baseline test requirement should be considered.

Agriculture↗
PubMed2005

Anticoagulation monitoring part 1: warfarin and parenteral direct thrombin inhibitors.

OBJECTIVE: To review the availability, mechanisms, limitations, and clinical application of point-of-care (POC) devices used in the management of warfarin and parenteral direct thrombin inhibitors. DATA SOURCES: Scientific articles were identified through a MEDLINE search (1966-August 2004), manufacturer Web sites, additional references listed in articles and Web sites, and abstracts from scientific meetings. STUDY SELECTION AND DATA EXTRACTION: English-language literature from clinical trials was reviewed to evaluate the accuracy, reliability, and clinical application of POC monitoring devices. DATA SYNTHESIS: The prothrombin time expressed as the international normalized ratio (PT-INR) is a well-established test for monitoring warfarin anticoagulation. Multiple devices are available for POC testing. Because there is no universally accepted standard, the performance of each device is typically tested against a standard test performed in a reference laboratory. Performance of currently available devices, as measured by correlations to a standard reference laboratory PT-INR, may be considered very good and acceptable for use in patient care. Utilization of patient self-testing and patient self-monitoring of warfarin anticoagulation using POC devices is increasing. Parenteral direct thrombin inhibitors are typically monitored using a standard laboratory activated partial thromboplastin time. Some research has shown that POC monitoring of direct thrombin inhibitors using the ecarin clotting time is helpful for patients undergoing cardiopulmonary bypass surgery, although that test is not readily available. CONCLUSIONS: POC testing for anticoagulation therapy has been available for >20 years. Multiple POC devices are available to monitor warfarin. There is some variability in results between devices and between reagents used in the same device. Despite these limitations, POC monitoring of warfarin via the PT-INR is an integral part of clinical practice. Additional research evaluating POC monitoring of direct thrombin inhibitors is necessary.

Anticoagulants↗