Using Telehealth Rehabilitation Therapy to Treat a Finger Flexor Tendon Repair During COVID-19.

Telehealth-assisted finger rehabilitation therapy demonstrated good functional results following repair of a zone 2 flexor tendon laceration.

Anaemia and its impact on colorectal cancer patients: how can we better optimize surgical outcomes?

BACKGROUND: Anaemia is a common manifestation of colorectal cancer (CRC). However, appropriate workup prior to surgery and the effect of anaemia on outcomes have not been well defined. This study aimed to describe preoperative anaemia incidence, investigations performed, treatment and associated complications in a CRC surgical population at a single large tertiary institution in Australia. METHODS: Patients who received surgery with curative intent for CRC between 2012 and 2017 were identified from a prospectively maintained database. Demographic and clinical outcome data were analysed. RESULTS: In total, 754 patients with CRC were included. Anaemia was found in 350 (46.4%) patients, of which 124 (35.4%) were microcytic, 20 (5.7%) were macrocytic and 206 (58.9%) were normocytic. Older patients were more likely to have anaemia (mean age 70.28 years, standard deviation (SD) 12.98 versus 64.74 years, SD 11.74). Only 89 patients (25.4%) were tested for iron deficiency, and of these, 76 (85.4%) were found to be iron deficient and 42 (47.7%) had low ferritin. Preoperative anaemia was associated with a higher incidence of postoperative complications (adjusted odds ratio (OR) 1.46, 95%, CI 1.04-2.05; P = 0.03) and a longer length of stay (LOS; average 1.8 days; 95% CI 0.3-3.3 days). CONCLUSION: A significant proportion of CRC patients had anaemia and the majority were normocytic. Only a small number of anaemic patients were tested for iron deficiency. Preoperative anaemia had an adverse effect on LOS and postoperative complications. The evaluation of anaemic patients is essential in CRC patients undergoing surgery.

Emergency nurses' perceptions of their role in responding to escalations of care for clinical deterioration.

BACKGROUND: Clinical leadership is fundamental to patient safety. The Emergency Department (ED) nurse-in-charge is a key leadership role; however, few studies have explored the management of clinical deterioration from the ED nurse-in-charge perspective. The aim of this study was to explore ED nurses-in-charge' perceptions of their role in responding to episodes of escalation of care for clinical deterioration of ED patients. METHODS: A prospective exploratory descriptive design was used to address the study aims. The study was conducted in an urban ED in Melbourne, Australia. Senior emergency nurses who fulfilled the role of being in charge of the ED were invited to participate. In-depth semi-structured interviews were conducted between December 2015 and March 2016. Interview transcripts were analysed using thematic analysis. RESULTS: Two major themes, each with two subthemes were identified. The first major theme of Clinical Risk Management comprised sub-themes of Clinical Skills and Confidence. The second major theme of Resource Management comprised sub-themes of Human Resource Management and Logistical Resource Management. CONCLUSIONS: Strong collaboration, logistical and clinical risk management roles were perceived as fundamental to the nurse-in-charge's capacity to respond to escalations of care for clinical deterioration within in a complex team environment such as the ED.

Lead poisoning associated with illicit opium use.

Lead poisoning is an uncommon and challenging diagnosis to make. In 2018, The Victorian Department of Health issued a health warning following four cases of lead poisoning associated with illicit opium use in Melbourne, Australia. We present these cases to highlight clinical features and the relevant investigations leading to diagnosis. All cases occurred in recent immigrants to Australia, who had access to non-traditional sources of opioids. Health care professionals should consider lead poisoning in patients with appropriate symptoms and a history of illicit opium use.

Senior emergency nurses' responses to escalations of care for clinical deterioration.

BACKGROUND: Recognising and responding to clinical deterioration is a safety priority. The aim of this study was to determine the frequency, nature, and response of emergency department Nursing Shift Leaders to episodes of escalation of care for patient clinical deterioration. METHODS: A prospective exploratory descriptive design was used. Participants were recruited from the senior nurses at the study site that fulfilled the role of being in charge of the ED. Study data were collected between 29 October and 17 December 2015 across various shifts using an observation tool developed specifically for this study. RESULTS: This study had three major findings. First, escalation of care for clinically deteriorating patients to the Nursing Shift Leader occurs frequently. There were 37 observed escalations of care, equating to 1.02 episodes per hour. Second, Nursing Shift Leaders rely on clinical emergency nursing skills to recognise, prioritise and respond to escalation of care for clinically deteriorating patients. Finally, the Nursing Shift Leaders' role in responding to escalation of care for clinical deterioration is multifaceted. CONCLUSIONS: The Nursing Shift Leaders' role in responding to escalation of care for clinical deterioration is complex and includes navigation of a multifaceted team environment and logistical challenges unique to the time pressured, unpredictable ED milieu.

To PAPR or not to PAPR?

The present outbreak of Ebola has health care professionals seeking guidance on isolation precautions for routine care and aerosol-generating procedures (AGPs). The most recent guidelines state that during AGPs, health care professionals should wear respiratory protection at least as protective as a National Institute for Occupational Safety and Health-certified fit tested N95 filtering face piece respirator or higher; for example, a powered air-purifying respirator (PAPR). The present review discusses the advantages and disadvantages of using a PAPR versus an N95 mask, and relates the experience of the Jewish General Hospital (Montreal, Quebec) of PAPR policy implementation. Training programs on proper donning and doffing of personal protective equipment and quality control systems need to be in place. Respiratory therapists are frontline during AGPs and need to be active in the decision making of the type of equipment chosen to protect them.

La présente éclosion du virus Ebola incite les professionnels de la santé à chercher des conseils sur les précautions en matière d'isolement dans les soins habituels et les interventions produisant des aérosols (IPA). D'après les lignes directrices les plus récentes, pendant les IPA, les professionnels de la santé devraient porter un dispositif de protection des voies respiratoires qui leur procurera une barrière au moins aussi efficace qu'un masque N95 ayant fait l'objet d'un essai d'ajustement certifié par le National Institute for Occupational Safety and Health, tel qu'un appareil respiratoire à adduction d'air (ARAA). La présente analyse traite des avantages et des inconvénients de l'ARAA par rapport au masque N95 et rend compte de l'expérience de l'Hôpital général juif de Montréal, au Québec, qui a adopté une politique d'utilisation de l'ARAA. Il faut adopter des programmes de formation sur la mise en place et le retrait convenables du dispositif de protection personnelle ainsi qu'un système de contrôle de la qualité. Les inhalothérapeutes sont en première ligne pendant les IPA et doivent participer à la prise de décision sur le type de matériel retenu pour les protéger.

Structure-function relationships of the antigenicity of mycolic acids in tuberculosis patients.

Cell wall mycolic acids (MA) from Mycobacterium tuberculosis (M.tb) are CD1b presented antigens that can be used to detect antibodies as surrogate markers of active TB, even in HIV coinfected patients. The use of the complex mixtures of natural MA is complicated by an apparent antibody cross-reactivity with cholesterol. Here firstly we report three recombinant monoclonal scFv antibody fragments in the chicken germ-line antibody repertoire, which demonstrate the possibilities for cross-reactivity: the first recognized both cholesterol and mycolic acids, the second mycolic acids but not cholesterol, and the third cholesterol but not mycolic acids. Secondly, MA structure is experimentally interrogated to try to understand the cross-reactivity. Unique synthetic mycolic acids representative of the three main functional classes show varying antigenicity against human TB patient sera, depending on the functional groups present and on their stereochemistry. Oxygenated (methoxy- and keto-) mycolic acid was found to be more antigenic than alpha-mycolic acids. Synthetic methoxy-mycolic acids were the most antigenic, one containing a trans-cyclopropane apparently being somewhat more antigenic than the natural mixture. Trans-cyclopropane-containing keto- and hydroxy-mycolic acids were also found to be the most antigenic among each of these classes. However, none of the individual synthetic mycolic acids significantly and reproducibly distinguished the pooled serum of TB positive patients from that of TB negative patients better than the natural mixture of MA. This argues against the potential to improve the specificity of serodiagnosis of TB with a defined single synthetic mycolic acid antigen from this set, although sensitivity may be facilitated by using a synthetic methoxy-mycolic acid.

Cholesteroid nature of free mycolic acids from M. tuberculosis.

Mycolic acids (MAs) are a major component of the cell walls of Mycobacterium tuberculosis and related organisms. These alpha-alkyl beta-hydroxy long fatty acids have been the subject of numerous studies for their immunological properties. We previously reported that an interaction between cholesterol and mycolic acids could be responsible for the low accuracy in the serodiagnosis of TB when using free mycolic acid in an ELISA assay. The aim of this work was to investigate if this interaction could be due to a similarity in the structural properties between mycolic acids and cholesterol. The investigation revealed that patient sera cross-reacted with mycolic acids and cholesterol in an ELISA experiment suggesting that both molecules may present related functionality in a similar structural orientation. This relation was further supported by the interaction of mycolic acids with Amphotericin B (AmB), a known binding agent to ergosterol and cholesterol. Using a resonant mirror biosensor, we observed that AmB recognised both cholesterol and mycolic acids. In addition, a specific attraction was observed between mycolic acid and cholesterol by the accumulation of cholesterol from liposomes in suspension onto immobilized mycolic acids containing liposomes, detected with a biosensor technique. Combined, these results suggest that mycolic acids can assume a three-dimensional conformation similar to a sterol. This requires that mycolic acid exposes its hydroxyl group and assumes rigidity in its chain structure to generate a hydrophobic surface topology matching that of cholesterol. A particular folded conformation would be required for this, of which a few different types have already been proven to exist in monolayers of mycolic acids.

A novel application of affinity biosensor technology to detect antibodies to mycolic acid in tuberculosis patients.

Tuberculosis has re-emerged as a global health problem due to co-infection with HIV and the emergence of drug-resistant strains of Mycobacterium tuberculosis. HIV co-infection introduced a 30% underestimation in TB diagnosis based on sputum analysis, calling for a reliable and fast serodiagnostic assay to assist in the management of TB in HIV-burdened populations. Serodiagnosis with mycobacterial lipid cell wall antigens gave promising results, in particular with LAM and cord factor. Free mycolic acids have also been considered because they are unique in structure to each species of Mycobacterium and can be economically extracted and purified. In a standard immunoassay such as ELISA, however, an unacceptable number of false positive and false negative test results were obtained. Here we report a much improved biosensor method to detect antibodies to mycolic acids in patient serum as surrogate markers of active tuberculosis. Mycolic acid (MA) liposomes were immobilized on a non-derivatized twin-celled biosensor cuvette and blocked with saponin. A high dilution of serum was used to calibrate the binding signal of the two cells, followed by contact with patient serum at a lesser dilution, but pre-incubated with either antigen-carrying, or empty liposomes. The serum, or the protein A purified IgG thereof, from sputum-positive tuberculosis patients could be inhibited from binding to the MA in the biosensor by prior incubation with MA-containing liposomes. The accuracy of the inhibition test was 84% if HIV-positive patients for whom a negative TB sputum analyses could not be relied upon to serve as a reference standard were excluded. If biosensor technology could be made suitable for high throughput screening, then it may provide the solution to the serodiagnosis of tuberculosis against a background of HIV.