Multidisciplinary staff perceived barriers and enablers to early mobilization of patients with burns in the ICU.

BACKGROUND: Complex challenges face clinicians managing critically ill patients with burns, particularly in the context of enhancing outcomes after a stay in ICU. Compounding this, a dearth of research explores the specific and modifiable factors that impact early mobilization in the ICU environment. AIM: To explore the barriers and enablers of early functional mobilization for patients with burns in the ICU from a multidisciplinary perspective. DESIGN: A qualitative phenomenological study. METHODS: Semi-structured interviews supplemented by online questionnaires conducted with 12 multidisciplinary clinicians (four doctors, three nurses and five physical therapists) who previously managed burn patients at a quaternary level ICU. Data were thematically analysed. RESULTS: Four main themes: patient, ICU clinicians, the workplace and the physical therapist were identified as impacting on early mobilization. Subthemes identified barriers or enablers to mobilization but all were strongly influenced by overarching theme of the clinician's "emotional filter." Barriers included high levels of pain, heavy sedation and low levels of clinician exposure to treating patients with burns. Enablers included higher levels of clinician's experience and knowledge about burn management and benefits of early mobilization; increased coordinated staff resources when undertaking mobilization; and, open communication and positive culture towards early mobilization across the multidisciplinary team. CONCLUSION: Patient, clinician and workplace barriers and enablers were identified to influencing the likelihood of achieving early mobilization of patients with burns in the ICU. Emotional support for staff through multidisciplinary collaboration and development of structured burns training program were key recommendations to address barriers and strengthen enablers to early mobilization of patients with burns in the ICU.

Fatal Leptospirosis and Escherichia coli co-infection in a post-partum woman.

The occurrence of Leptospirosis and Escherichia coli coinfection in the post-partum period is a novel case. This report illustrated a previously well woman from a suburban area presented with acute neurological deterioration following a two days history of fever during her puerperal period. Early interventions with fluids, broad spectrum antibiotics and intensive supportive care were given. Despite that, she deteriorated rapidly and developed pulmonary hemorrhage, disseminated intravascular coagulopathy, and multi-organ failure. She succumbed within 12 hours of admission. The knowledge about such fatal co-infections should be disseminated to medical practitioners encountering Leptospirosis infection and general public.

Percutaneous endoscopic gastrostomy in patients with ventriculoperitoneal shunt.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) placement in patients with ventriculo-peritoneal shunt (VPS) may be associated with complications. This study reports our experience of PEG in patients with VPS. MATERIALS AND METHODS: Consecutive patients undergoing PEG insertion in a gastroenterology unit over 18 month's period were retrospectively analyzed. All patients were evaluated by an attending gastroenterologist for fitness for procedure. Instructions were given for routine antibiotic prophylaxes before the procedure and continued for 48 hours. Patients were followed for immediate complications in particular, wound infection, signs of meningitis, deterioration in neurological state and shunt malfunction. Post discharge, patients were given routine follow-up for review. RESULTS: Of 86 patients who had PEG inserted during the study period, 14 had VPS including 2 of which had VPS after PEG. The main common indications for VPS were intracerebral bleed and head trauma and for PEG were requirement of long term enteral feeding. Twelve patients had PEG at a mean interval of 61 days (range 1-187 days) after VPS. Of these, eight received prophylactic antibiotic or were on antibiotic for other indications before PEG. Two patients developed mild PEG site infections within a week of insertions, including one patient who was not given antibiotic prophylaxis, both treated successfully with antibiotics. The latter patient developed worsening hydrocephalus secondary to VPS blockage. At a mean follow-up period was 140 days (range 20-570 days), there were no death or further complications encountered. CONCLUSIONS: Although safe in the majority of patients with VPS, PEG infection can lead to intracranial complications. We recommend antibiotic prophylaxis for VPS patients before PEG.

Generating matter inhomogeneities in general relativity.

In this Letter we discuss a natural general relativistic mechanism that causes inhomogeneities and hence generates matter perturbations in the early Universe. We concentrate on spikes, both incomplete spikes and recurring spikes, that naturally occur in the initial oscillatory regime of general cosmological models. In particular, we explicitly show that spikes occurring in a class of G2 models lead to inhomogeneities that, due to gravitational instability, leave small residual imprints on matter in the form of matter perturbations. The residual matter overdensities from recurring spikes are not local but form on surfaces. We discuss the potential physical consequences of the residual matter imprints and their possible effect on the subsequent formation of large-scale structure.

Subacute cardiac toxicity following autologous haematopoietic stem cell transplantation in patients with normal cardiac function.

OBJECTIVE: To investigate subacute cardiac toxicity in patients with normal baseline cardiac function following autologous haematopoietic stem cell transplantation. DESIGN: Prospective observational study. PATIENT AND METHODS: Thirty-two consecutive patients (mean (SD) age 60 (11) years) with normal left ventricular ejection fraction (LVEF >or=50%) undergoing autologous haematopoietic stem cell transplantation were studied. Transthoracic echocardiography (including colour tissue Doppler imaging-derived myocardial velocities, strain and strain rates), troponin-T and B-type natriuretic peptide (BNP) and clinical details were recorded at baseline, after conditioning chemotherapy and serially over 6 weeks from the day of transplantation. RESULTS: The mean (SD) LVEF at baseline was 62 (6)% and decreased to 55 (16)%, 6 weeks after transplantation (p = 0.007). Cardiac toxicity (>or=10% absolute decline of LVEF to an LVEF

Allopurinol safely and effectively optimizes tioguanine metabolites in inflammatory bowel disease patients not responding to azathioprine and mercaptopurine.

BACKGROUND: Many non-responders to azathioprine or mercaptopurine (6-mercaptopurine) have high normal thiopurine methyltransferase activity and preferentially metabolize mercaptopurine to produce 6-methylmercaptopurine instead of the active 6-tioguanine (6-tioguanine) metabolites. AIM: To describe the use of allopurinol in mercaptopurine/azathioprine non-responders to deliberately shunt metabolism of mercaptopurine towards 6-tioguanine. METHODS: Fifteen thiopurine non-responders whose metabolites demonstrated preferential metabolism towards 6-methylmercaptopurine are described. Subjects were commenced on allopurinol 100 mg po daily and mercaptopurine/azathioprine was reduced to 25-50% of the original dose. Patients were followed clinically and with serial 6-tioguanine and 6-methylmercaptopurine metabolite measurements. RESULTS: After initiating allopurinol, 6-tioguanine levels increased from a mean of 185.73 +/- 17.7 to 385.4 +/- 41.5 pmol/8 x 10(8) red blood cells (P < 0.001), while 6-methylmercaptopurine decreased from a mean of 10 380 +/- 1245 to 1732 +/- 502 pmol/8 x 10(8) RBCs (P < 0.001). Allopurinol led to a decrease in white blood cell from a mean of 8.28 +/- 0.95 to 6.1 +/- 0.82 x 10(8)/L (P = 0.01). CONCLUSIONS: The addition of allopurinol to thiopurine non-responders with preferential shunting to 6-methylmercaptopurine metabolites appears to be an effective means to shift metabolism towards 6-tioguanine.

Infectiousness of HBsAg carriers in Malaysia.

HBV-DNA were analysed in 330 HBsAg-positive carriers in Malaysia by dot-blot hybridization and polymerase chain reaction. Seventy-three (22.12%) were positive for the virus. Of these, 65 (89%) were males and 8 (11%) were females. Statistically, there was no significant difference (P = 0.13). No significant decline in HBV-DNA with age in the Malay and Chinese males was observed (P = 0.2). Prevalence of HBV-DNA was higher in the Chinese carriers than in the Malay carriers for most age groups in both sexes. Sixty-one HBV-DNA-positive carriers were also positive for HBeAg. However, three individuals were positive only for anti-HBe, one was positive for both HBeAg and anti-HBe, and eight were negative for both HBeAg and anti-HBe. Fifty-seven were positive for HBeAg but negative for HBV-DNA. No relation was observed between raised alanine aminotransaminase and aspartate aminotransaminase levels and the presence of HBV-DNA (P = 0.4).

Renal function and electrolyte levels in hyperthyroidism: urinary protein excretion and the plasma concentrations of urea, creatinine, uric acid, hydrogen ion and electrolytes.

In order to help clarify the effects of hyperthyroidism on renal function and electrolyte metabolism, we measured the venous plasma concentrations of urea, creatinine, urate, hydrogen ion and electrolytes, and the urinary concentrations of total protein, albumin, retinol-binding protein, N-acetyl-beta-D-glucosaminidase activity, and creatinine in patients when hyperthyroid and again after they had been euthyroid for at least 4 months. Significant (P less than 0.05) decreases in the mean plasma concentrations of urate and chloride and significant increases in creatinine, total CO2 and hydrogen ion mean concentrations were observed when the patients became euthyroid. The mean concentrations of sodium, potassium and urea did not change significantly. The values of the ratios total protein/creatinine, albumin/creatinine, N-acetylglucosaminidase/creatinine and retinol-binding protein/creatinine were all significantly (P less than 0.05) elevated in random urine specimens obtained from hyperthyroid patients as compared to the values when euthyroid. Mild proteinuria occurs in most thyrotoxic patients which does not appear to be due predominantly to either glomerular or tubular renal injury. The changes in plasma analytes that were observed may be attributed to increases in glomerular filtration rate and tissue nucleic acid turnover and a tendency to respiratory alkalosis in the hyperthyroid patients.

Hemoglobin A1 and serum fructosamine levels in hyperthyroidism.

The severity, prevalence and pathogenesis of abnormalities of carbohydrate metabolism in hyperthyroidism are incompletely defined. The extent of glycosylation of proteins provides an objective, retrospective index of glycemic control. We have measured the percent hemoglobin A1, random plasma glucose level and serum concentrations of fructosamine, total protein and albumin in hyperthyroid and euthyroid subjects attending a hospital-based thyroid clinic. A significant (p = 0.002) increase in the mean value for hemoglobin A1 and a significant (p = 0.0003) decrease in the mean values for fructosamine were found in the hyperthyroid group. The lower mean fructosamine value in the hyperthyroid group was attributed to a concomitant decline in the mean albumin concentration (p = 0.001). The mean value for glucose tended to be higher in the hyperthyroid group, but the difference did not reach significance at the 0.05 level (p = 0.09). The finding of a higher mean hemoglobin A1 concentration in hyperthyroid patients compared to euthyroid subjects is new evidence for a persistent abnormality in glycemic regulation in most thyrotoxic patients.

Subcellular distribution of hepatic bile acid-conjugating enzymes.

1. The subcellular location of enzymes conjugating bile acids with glycine or taurine was investigated by centrifugation of rat liver homogenates. 2. [14C]Cholic acid-conjugating activity was predominantly associated with the soluble-microsomal region of the gradient after centrifugation in a Ti-15 zonal rotor but the bulk of the conjugating activity sedimented with mitochondrial-lysosomal fractions in differential pelleting experiments. 3. Cholate: CoA ligase (EC 6.2.1.7) and cholyltransferase (EC 2.3.1) were not enriched in purified Golgi or plasma-membrane fractions. Cholate: CoA ligase was distributed evenly between rough- and smooth-surfaced microsomal subfractions but cholyltransferase showed a dual soluble-rough microsomal activity distribution. 4. Sedimentation of cholyltransferase in mitochondria-enriched fractions prepared by differential centrifugation appears to be an artefact of sedimentation of rough microsomal membranes in mitochondrial fractions. 5. The subcellular distribution of bile acid-conjugating enzymes is discussed with reference to hepatic processing of bile acids.