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The Cochrane Database of Systematic... Jan 2015Central venous catheters can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein),... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Central venous catheters can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein), upper chest (subclavian vein) or groin (femoral vein). Whilst this is beneficial overall, inserting the catheter risks arterial puncture and other complications and should be performed in as few attempts as possible.In the past, anatomical 'landmarks' on the body surface were used to find the correct place to insert these catheters, but ultrasound imaging is now available. A Doppler mode is sometimes used to supplement plain 'two-dimensional' ultrasound.
OBJECTIVES
The primary objective of this review was to evaluate the effectiveness and safety of two-dimensional ultrasound (US)- or Doppler ultrasound (USD)-guided puncture techniques for subclavian vein, axillary vein and femoral vein puncture during central venous catheter insertion in adults and children. We assessed whether there was a difference in complication rates between traditional landmark-guided and any ultrasound-guided central vein puncture.When possible, we also assessed the following secondary objectives: whether a possible difference could be verified with use of the US technique versus the USD technique; whether there was a difference between using ultrasound throughout the puncture ('direct') and using it only to identify and mark the vein before starting the puncture procedure ('indirect'); and whether these possible differences might be evident in different groups of patients or with different levels of experience among those inserting the catheters.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to 15 January 2013), EMBASE (1966 to 15 January 2013), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 15 January 2013), reference lists of articles, 'grey literature' and dissertations. An additional handsearch focused on intensive care and anaesthesia journals and abstracts and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting companies and experts in the field, and we searched trial registers. We reran the search in August 2014. We will deal with any studies of interest when we update the review.
SELECTION CRITERIA
Randomized and quasi-randomized controlled trials comparing two-dimensional ultrasound or Doppler ultrasound versus an anatomical 'landmark' technique during insertion of subclavian or femoral venous catheters in both adults and children.
DATA COLLECTION AND ANALYSIS
Three review authors independently extracted data on methodological quality, participants, interventions and outcomes of interest using a standardized form. We performed a priori subgroup analyses.
MAIN RESULTS
Altogether 13 studies enrolling 2341 participants (and involving 2360 procedures) fulfilled the inclusion criteria. The quality of evidence was very low (subclavian vein N = 3) or low (subclavian vein N = 4, femoral vein N = 2) for most outcomes, moderate for one outcome (femoral vein) and high at best for two outcomes (subclavian vein N = 1, femoral vein N = 1). Most of the trials had unclear risk of bias across the six domains, and heterogeneity among the studies was significant.For the subclavian vein (nine studies, 2030 participants, 2049 procedures), two-dimensional ultrasound reduced the risk of inadvertent arterial puncture (three trials, 498 participants, risk ratio (RR) 0.21, 95% confidence interval (CI) 0.06 to 0.82; P value 0.02, I² = 0%) and haematoma formation (three trials, 498 participants, RR 0.26, 95% CI 0.09 to 0.76; P value 0.01, I² = 0%). No evidence was found of a difference in total or other complications (together, US, USD), overall (together, US, USD), number of attempts until success (US) or first-time (US) success rates or time taken to insert the catheter (US).For the femoral vein, fewer data were available for analysis (four studies, 311 participants, 311 procedures). No evidence was found of a difference in inadvertent arterial puncture or other complications. However, success on the first attempt was more likely with ultrasound (three trials, 224 participants, RR 1.73, 95% CI 1.34 to 2.22; P value < 0.0001, I² = 31%), and a small increase in the overall success rate was noted (RR 1.11, 95% CI 1.00 to 1.23; P value 0.06, I² = 50%). No data on mortality or participant-reported outcomes were provided.
AUTHORS' CONCLUSIONS
On the basis of available data, we conclude that two-dimensional ultrasound offers small gains in safety and quality when compared with an anatomical landmark technique for subclavian (arterial puncture, haematoma formation) or femoral vein (success on the first attempt) cannulation for central vein catheterization. Data on insertion by inexperienced or experienced users, or on patients at high risk for complications, are lacking. The results for Doppler ultrasound techniques versus anatomical landmark techniques are uncertain.
Topics: Adult; Anatomic Landmarks; Catheterization, Central Venous; Child; Critical Illness; Femoral Vein; Humans; Punctures; Randomized Controlled Trials as Topic; Subclavian Vein; Ultrasonography, Interventional
PubMed: 25575245
DOI: 10.1002/14651858.CD011447 -
The Cochrane Database of Systematic... Jan 2015Central venous catheters (CVCs) can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Central venous catheters (CVCs) can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein), upper chest (subclavian vein) or groin (femoral vein). Whilst this is beneficial overall, inserting the catheter risks arterial puncture and other complications and should be performed with as few attempts as possible. Traditionally, anatomical 'landmarks' on the body surface were used to find the correct place in which to insert catheters, but ultrasound imaging is now available. A Doppler mode is sometimes used to supplement plain 'two-dimensional' ultrasound.
OBJECTIVES
The primary objective of this review was to evaluate the effectiveness and safety of two-dimensional (imaging ultrasound (US) or ultrasound Doppler (USD)) guided puncture techniques for insertion of central venous catheters via the internal jugular vein in adults and children. We assessed whether there was a difference in complication rates between traditional landmark-guided and any ultrasound-guided central vein puncture.Our secondary objectives were to assess whether the effect differs between US and USD; whether the effect differs between ultrasound used throughout the puncture ('direct') and ultrasound used only to identify and mark the vein before the start of the puncture procedure (indirect'); and whether the effect differs between different groups of patients or between different levels of experience among those inserting the catheters.
SEARCH METHODS
We searched the Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to 15 January 2013), EMBASE (1966 to 15 January 2013), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 15 January 2013 ), reference lists of articles, 'grey literature' and dissertations. An additional handsearch focused on intensive care and anaesthesia journals and abstracts and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting companies and experts in the field, and we searched trial registers. We reran the search in August 2014. We will deal with identified studies of interest when we update the review.
SELECTION CRITERIA
We included randomized and quasi-randomized controlled trials comparing two-dimensional ultrasound or Doppler ultrasound with an anatomical 'landmark' technique during insertion of internal jugular venous catheters in both adults and children.
DATA COLLECTION AND ANALYSIS
Three review authors independently extracted data on methodological quality, participants, interventions and outcomes of interest using a standardized form. A priori, we aimed to perform subgroup analyses, when possible, for adults and children, and for experienced operators and inexperienced operators.
MAIN RESULTS
Of 735 identified citations, 35 studies enrolling 5108 participants fulfilled the inclusion criteria. The quality of evidence was very low for most of the outcomes and was moderate at best for four of the outcomes. Most trials had an unclear risk of bias across the six domains, and heterogeneity among the studies was significant.Use of two-dimensional ultrasound reduced the rate of total complications overall by 71% (14 trials, 2406 participants, risk ratio (RR) 0.29, 95% confidence interval (CI) 0.17 to 0.52; P value < 0.0001, I² = 57%), and the number of participants with an inadvertent arterial puncture by 72% (22 trials, 4388 participants, RR 0.28, 95% CI 0.18 to 0.44; P value < 0.00001, I² = 35%). Overall success rates were modestly increased in all groups combined at 12% (23 trials, 4340 participants, RR 1.12, 95% CI 1.08 to 1.17; P value < 0.00001, I² = 85%), and similar benefit was noted across all subgroups. The number of attempts needed for successful cannulation was decreased overall (16 trials, 3302 participants, mean difference (MD) -1.19 attempts, 95% CI -1.45 to -0.92; P value < 0.00001, I² = 96%) and in all subgroups. Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I² = 82%) and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I² = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.Use of Doppler ultrasound increased the chance of success at the first attempt by 58% (four trials, 199 participants, RR 1.58, 95% CI 1.02 to 2.43; P value 0.04, I² = 57%). No evidence showed a difference for the total numbers of perioperative and postoperative complications/adverse events (three trials, 93 participants, RR 0.52, 95% CI 0.16 to 1.71; P value 0.28), the overall success rate (seven trials, 289 participants, RR 1.09, 95% CI 0.95 to 1.25; P value 0.20), the total number of attempts until success (two trials, 69 participants, MD -0.63, 95% CI -1.92 to 0.66; P value 0.34), the overall number of participants with an arterial puncture (six trials, 213 participants, RR 0.61, 95% CI 0.21 to 1.73; P value 0.35) and time to successful cannulation (five trials, 214 participants, each using a different definition for this outcome; MD 62.04 seconds, 95% CI -13.47 to 137.55; P value 0.11) when Doppler ultrasound was used. It was not possible to perform analyses for the other outcomes because they were reported in only one trial.
AUTHORS' CONCLUSIONS
Based on available data, we conclude that two-dimensional ultrasound offers gains in safety and quality when compared with an anatomical landmark technique. Because of missing data, we did not compare effects with experienced versus inexperienced operators for all outcomes (arterial puncture, haematoma formation, other complications, success with attempt number one), and so the relative utility of ultrasound in these groups remains unclear and no data are available on use of this technique in patients at high risk of complications. The results for Doppler ultrasound techniques versus anatomical landmark techniques are also uncertain.
Topics: Adult; Anatomic Landmarks; Catheterization, Central Venous; Child; Humans; Jugular Veins; Punctures; Randomized Controlled Trials as Topic; Ultrasonography, Interventional
PubMed: 25575244
DOI: 10.1002/14651858.CD006962.pub2 -
Journal of Vascular Surgery. Venous and... Jul 2020Whereas the internal jugular vein is the most common site of thrombosis in patients with deep venous thrombosis (DVT) of the upper extremity, the association between...
OBJECTIVE
Whereas the internal jugular vein is the most common site of thrombosis in patients with deep venous thrombosis (DVT) of the upper extremity, the association between internal jugular vein thrombus and pulmonary embolism (PE) has not been clearly characterized. The objective of this paper was to determine the risk of embolization of an isolated internal jugular vein thrombus causing a clinically overt PE, with the secondary objective of assessing the value of therapeutic anticoagulation in patients with isolated internal jugular vein thrombosis (IJVT) in improving clinical outcomes.
METHODS
The National Center for Biotechnology Information, Cochrane Library, Web of Science, and Cumulative Index to Nursing and Allied Health Literature were searched for articles. The relevant articles included were selected according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they specifically examined incidence of IJVT and incidence of PE and were excluded if they did not report on these rates specifically or failed to specify the exact site of upper extremity DVT.
RESULTS
Of the 274 articles screened, 25 were selected for full review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses inclusion criteria. Seven of those provided adequate data and were included in the review. There were only two studies demonstrating IJVT before PE that could probably establish causality, but this might be confounded by the presence of concomitant upper extremity DVT in one of the cases and radiologic findings compatible with resolving PE in another that might have preceded the presence of internal jugular vein thrombus. In the patients who were found to have PE in the setting of IJVT, the overall observed mortality attributed to PE was low. In specific studies, the use of anticoagulation did not reduce the mortality in those with isolated IJVT or affect the rate of thrombus resolution while carrying the risk of bleeding complications in these patients, who often have severe comorbidities.
CONCLUSIONS
Despite the proximity of the jugular vein to the right side of the heart and the pulmonary vasculature, there is little proof of propagation of the thrombus to cause a clinically overt PE. Whereas current practice is to treat the patients with IJVT in the same way as patients with lower extremity DVTs are treated, the lack of any survival benefit in those with isolated IJVT and the risk of bleeding complications warrant further studies to characterize the need of medical management in this population of patients.
Topics: Anticoagulants; Hemorrhage; Humans; Incidence; Jugular Veins; Pulmonary Embolism; Risk Assessment; Risk Factors; Treatment Outcome; Venous Thrombosis
PubMed: 32321692
DOI: 10.1016/j.jvsv.2020.03.003 -
World Journal of Clinical Cases Jul 2021Portal vein thrombosis (PVT) was previously a contraindication for trans-jugular intrahepatic portosystemic shunt (TIPS).
BACKGROUND
Portal vein thrombosis (PVT) was previously a contraindication for trans-jugular intrahepatic portosystemic shunt (TIPS).
AIM
To perform a systematic review and meta-analysis of the current available studies investigating outcomes of TIPS for cirrhotic patient with PVT.
METHODS
Multiple databases were systematically searched to identify studies investigating the outcomes of TIPS for cirrhotic patients with PVT. The quality of studies was assessed by Cochrane Collaboration method and Methodological Index for Non-Randomized Studies. The demographic data, outcomes, combined treatment, and anticoagulation strategy were extracted.
RESULTS
Twelve studies were identified with 460 patients enrolled in the analysis. The technical success rate was 98.9% in patients without portal vein cavernous transformation and 92.3% in patients with portal vein cavernous transformation. One-year portal vein recanalization rate was 77.7%, and TIPS patency rate was 84.2%. The cumulative encephalopathy rate was 16.4%. One-year overall survival was 87.4%.
CONCLUSION
TIPS is indicated for portal hypertension related complications and the restoration of pre-transplantation portal vein patency in cirrhotic patients with PVT. Cavernous transformation is an indicator for technical failure. Post-TIPS anticoagulation seems not mandatory. Simultaneous TIPS and percutaneous mechanical thrombectomy device could achieve accelerated portal vein recanalization and decreased thrombolysis-associated complications, but further investigation is still needed.
PubMed: 34307565
DOI: 10.12998/wjcc.v9.i19.5179 -
Diagnostics (Basel, Switzerland) Dec 2021This systematic review and meta-analysis aimed to investigate the ultrasonographic variation of the diameter of the inferior vena cava (IVC), internal jugular vein...
Diagnostic Accuracy of Ultrasonographic Respiratory Variation in the Inferior Vena Cava, Subclavian Vein, Internal Jugular Vein, and Femoral Vein Diameter to Predict Fluid Responsiveness: A Systematic Review and Meta-Analysis.
This systematic review and meta-analysis aimed to investigate the ultrasonographic variation of the diameter of the inferior vena cava (IVC), internal jugular vein (IJV), subclavian vein (SCV), and femoral vein (FV) to predict fluid responsiveness in critically ill patients. Relevant articles were obtained by searching PubMed, EMBASE, and Cochrane databases (articles up to 21 October 2021). The number of true positives, false positives, false negatives, and true negatives for the index test to predict fluid responsiveness was collected. We used a hierarchical summary receiver operating characteristics model and bivariate model for meta-analysis. Finally, 30 studies comprising 1719 patients were included in this review. The ultrasonographic variation of the IVC showed a pooled sensitivity and specificity of 0.75 and 0.83, respectively. The area under the receiver operating characteristics curve was 0.86. In the subgroup analysis, there was no difference between patients on mechanical ventilation and those breathing spontaneously. In terms of the IJV, SCV, and FV, meta-analysis was not conducted due to the limited number of studies. The ultrasonographic measurement of the variation in diameter of the IVC has a favorable diagnostic accuracy for predicting fluid responsiveness in critically ill patients. However, there was insufficient evidence in terms of the IJV, SCV, and FV.
PubMed: 35054215
DOI: 10.3390/diagnostics12010049 -
Surgical Neurology International 2019Internal jugular phlebectasia (IJP), the abnormal dilatation of internal jugular vein, is generally considered a benign anomaly. However, because IJP is uncommon, little... (Review)
Review
BACKGROUND
Internal jugular phlebectasia (IJP), the abnormal dilatation of internal jugular vein, is generally considered a benign anomaly. However, because IJP is uncommon, little is known about its natural history, and currently, no consensus on the best treatment modality is available.
METHODS
The purpose of this article is to conduct a systematic review of available literature on recently reported IJP cases to understand the main characteristics of IJP and its most frequent therapeutic approaches. Following the preferred reporting items for systematic reviews and meta-analyses guidelines, literature search for IJP cases was conducted in the COCHRANE, PUBMED, EBSCOHOST, SCOPUS, OVID, and SCIELO databases.
RESULTS
A total of 97 original articles were found, with a total of 247 IJP cases reported including both pediatric and adult patients.
CONCLUSIONS
To the best of our knowledge, this study is the largest systematic review analyzing all the reported cases of IJP. IJP is considered by most authors as a benign abnormality that predominantly affects the right jugular vein. It is most commonly diagnosed in children. At present, conservative treatment is preferred for pediatric but not for adult patients. Multicenter randomized prospective studies are required to further understand this rare anomaly.
PubMed: 31528444
DOI: 10.25259/SNI-217-2019 -
Journal of Personalized Medicine Apr 2022Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion... (Review)
Review
Autologous fillet flaps are a common reconstructive option for large defects after forequarter amputation (FQA) due to advanced local malignancy or trauma. The inclusion of osseous structures into these has several advantages. This article therefore systematically reviews reconstructive options after FQA, using osteomusculocutaneous fillet flaps, with emphasis on personalized surgical technique and outcome. Additionally, we report on a case with an alternative surgical technique, which included targeted muscle reinnervation (TMR) of the flap. Our literature search was conducted in the PubMed and Cochrane databases. Studies that were identified were thoroughly scrutinized with regard to relevance, resulting in the inclusion of four studies (10 cases). FQA was predominantly a consequence of local malignancy. For vascular supply, the brachial artery was predominantly anastomosed to the subclavian artery and the brachial or cephalic vein to the subclavian or external jugular vein. Furthermore, we report on a case of a large osteosarcoma of the humerus. Extended FQA required the use of the forearm for defect coverage and shoulder contour reconstruction. Moreover, we performed TMR. Follow-up showed a satisfactory result and no phantom limb pain. In case of the need for free flap reconstruction after FQA, this review demonstrates the safety and advantage of osteomusculocutaneous fillet flaps. If the inclusion of the elbow joint into the flap is not possible, we recommend the use of the forearm, as described. Additionally, we advocate for the additional implementation of TMR, as it can be performed quickly and is likely to reduce phantom limb and neuroma pain.
PubMed: 35455676
DOI: 10.3390/jpm12040560 -
JA Clinical Reports Sep 2022Thyrocervical trunk rupture is an unusual, but critical, complication associated with central venous catheter (CVC) placement. The management of this complication has...
BACKGROUND
Thyrocervical trunk rupture is an unusual, but critical, complication associated with central venous catheter (CVC) placement. The management of this complication has not been fully determined because it is rare.
CASE PRESENTATION
A 53-year-old Japanese woman with anorexia nervosa developed refractory ventricular fibrillation. After returning spontaneous circulation, a CVC was successfully placed at the initial attempt in the right internal jugular vein using real-time ultrasound guidance. Immediately after CVC placement, she developed enlarging swelling around the neck. Contrast-enhanced computed tomography showed massive contrast media extravasation around the neck and mediastinum. Brachiocephalic artery angiography showed a "blush" appearance of the ruptured right thyrocervical trunk. After selective arterial embolization with 33% N-butyl-2-cyanoacrylate, the extravasation completely disappeared and hemostasis was achieved.
CONCLUSION
Our findings suggest that severe vascular complications arising from CVC placement can occur in patients with a fragile physiological state. Endovascular embolization is an effective treatment for such complications.
PubMed: 36109440
DOI: 10.1186/s40981-022-00565-w -
Scandinavian Journal of Trauma,... Dec 2013Cervical immobilisation is commonly applied following trauma, particularly blunt head injury, but current methods of immobilisation are associated with significant... (Review)
Review
Cervical immobilisation is commonly applied following trauma, particularly blunt head injury, but current methods of immobilisation are associated with significant complications. Semi-rigid disposable cervical collars are known to cause pressure ulcers, and impede effective airway management. These collars may also exacerbate a head injury by increasing intracranial pressure as a result of external compression of the jugular veins. There is a clear imperative to find ways of effectively immobilising the cervical spine whilst minimising complications, and any assessment of existing or new devices should include a standardized approach to the measurement of tissue interface pressures and their effect on jugular venous drainage from the brain. This systematic review summarises the research methods and technologies that have been used to measure tissue interface pressure and assess the jugular vein in the context of cervical immobilisation devices. 27 papers were included and assessed for quality. Laboratory investigations and biomechanical studies have gradually given way to methods that more accurately reflect clinical care. There are numerous accounts of skin ulceration associated with cervical collars, but no standardised approach to measuring tissue interface pressure. It is therefore difficult to compare studies and devices, but a pressure of less than 30 mmHg appears desirable. Cervical collars have been shown to have a compressive effect on the jugular veins, but it is not yet certain that this is the cause of the increased intracranial pressure observed in association with cervical collar use. This is the first review of its type. It will help guide further research in this area of trauma care, and the development and testing of new cervical immobilisation devices.
Topics: Airway Management; Cervical Vertebrae; Humans; Immobilization; Jugular Veins; Pressure; Regional Blood Flow
PubMed: 24299024
DOI: 10.1186/1757-7241-21-81 -
BMJ (Clinical Research Ed.) Aug 2003To assess the evidence for the clinical effectiveness of ultrasound guided central venous cannulation. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To assess the evidence for the clinical effectiveness of ultrasound guided central venous cannulation.
DATA SOURCES
15 electronic bibliographic databases, covering biomedical, science, social science, health economics, and grey literature.
DESIGN
Systematic review and meta-analysis of randomised controlled trials. Populations Patients scheduled for central venous access. INTERVENTION REVIEWED: Guidance using real time two dimensional ultrasonography or Doppler needles and probes compared with the anatomical landmark method of cannulation.
DATA EXTRACTION
Risk of failed catheter placement (primary outcome), risk of complications from placement, risk of failure on first attempt at placement, number of attempts to successful catheterisation, and time (seconds) to successful catheterisation.
DATA SYNTHESIS
18 trials (1646 participants) were identified. Compared with the landmark method, real time two dimensional ultrasound guidance for cannulating the internal jugular vein in adults was associated with a significantly lower failure rate both overall (relative risk 0.14, 95% confidence interval 0.06 to 0.33) and on the first attempt (0.59, 0.39 to 0.88). Limited evidence favoured two dimensional ultrasound guidance for subclavian vein and femoral vein procedures in adults (0.14, 0.04 to 0.57 and 0.29, 0.07 to 1.21, respectively). Three studies in infants confirmed a higher success rate with two dimensional ultrasonography for internal jugular procedures (0.15, 0.03 to 0.64). Doppler guided cannulation of the internal jugular vein in adults was more successful than the landmark method (0.39, 0.17 to 0.92), but the landmark method was more successful for subclavian vein procedures (1.48, 1.03 to 2.14). No significant difference was found between these techniques for cannulation of the internal jugular vein in infants. An indirect comparison of relative risks suggested that two dimensional ultrasonography would be more successful than Doppler guidance for subclavian vein procedures in adults (0.09, 0.02 to 0.38).
CONCLUSIONS
Evidence supports the use of two dimensional ultrasonography for central venous cannulation.
Topics: Adult; Catheterization, Central Venous; Femoral Vein; Humans; Infant; Jugular Veins; Randomized Controlled Trials as Topic; Risk Factors; Subclavian Vein; Ultrasonography, Doppler; Ultrasonography, Interventional
PubMed: 12919984
DOI: 10.1136/bmj.327.7411.361