Emergency nurses' knowledge and understanding of their role in recognising and responding to patients with sepsis: A qualitative study.

AIM: Sepsis is a significant and time-sensitive clinical concern for patients who present to Emergency Departments (EDs). Existing guidelines do not define nurses' roles in managing sepsis. This study explored ED nurses' experiences and perceptions around recognising and responding to patients with sepsis, and their awareness of sepsis screening and prognostic tools. The knowledge and insights gained from this study may be used to inform local and international ED policies, and enrich nursing educational packages that may be used to improve quality of patient care and patient outcomes. METHODS: Qualitative design incorporating semi-structured interviews with 14 ED nurses was undertaken. Thematic and consensus-based content analyses were used to explore transcripts. FINDINGS: Six key themes were identified; (1) contribution of the organisation, (2) appreciation of knowledge, (3) appreciation of clinical urgency, (4) appreciation of importance of staff supervision, (5) awareness of the importance of staff experience, and (6) awareness of the need to seek advice. CONCLUSION: ED nurses' identified deficits in their capacity to recognise and respond to patients with sepsis, despite their vital role within the multidisciplinary team that cares for patients with sepsis. The knowledge and insights gained from this study can be used to inform ED policies, to enrich context-specific educational packages that aim to improve quality of patient care and outcomes and identify areas for further research. Development and implementation of a nurse-inclusive sepsis pathway may address many deficits identified in this study.

Compression socks and the effects on coagulation and fibrinolytic activation during marathon running.

PURPOSE: Compression socks are frequently used in the treatment and prevention of lower-limb pathologies; however, when combined with endurance-based exercise, the impact of compression socks on haemostatic activation remains unclear. OBJECTIVES: To investigate the effect of wearing compression socks on coagulation and fibrinolysis following a marathon. METHODS: Sixty-seven participants [43 males (mean ± SD: age: 46.7 ± 10.3 year) and 24 females (age: 40.0 ± 11.0 year)] were allocated into a compression (SOCK, n = 34) or control (CONTROL, n = 33) group. Venous blood samples were obtained 24 h prior to and immediately POST-marathon, and were analyzed for thrombin-anti-thrombin complex (TAT), tissue factor (TF), tissue factor pathway inhibitor (TFPI), and D-Dimer. RESULTS: Compression significantly attenuated the post-exercise increase in D-Dimer compared to the control group [median (range) SOCK: + 9.02 (- 0.34 to 60.7) ng/mL, CONTROL: + 25.48 (0.95-73.24) ng/mL]. TF increased following the marathon run [median (range), SOCK: + 1.19 (- 7.47 to 9.11) pg/mL, CONTROL: + 3.47 (- 5.01 to 38.56) pg/mL] in all runners. No significant post-exercise changes were observed for TAT and TFPI. CONCLUSIONS: While activation of coagulation and fibrinolysis was apparent in all runners POST-marathon, wearing compression socks was shown to reduce fibrinolytic activity, as demonstrated by lower D-Dimer concentrations. Compression may reduce exercise-associated haemostatic activation when completing prolonged exercise.

Sensitivity, specificity and predictive probability values of serum agglutination test titres for the diagnosis of Salmonella Dublin culture-positive bovine abortion and stillbirth.

The objective of this study was to determine the diagnostic value of maternal serology for the diagnosis of Salmonella Dublin bovine abortion and stillbirth. A retrospective, unmatched, case-control study was carried out using twenty year's data (1989-2009) from bovine foetal submissions to an Irish government veterinary laboratory. Cases (n = 214) were defined as submissions with a S. Dublin culture-positive foetus from a S. Dublin unvaccinated dam where results of maternal S. Dublin serology were available. Controls (n = 415) were defined as submissions where an alternative diagnosis other than S. Dublin was made in a foetus from an S. Dublin unvaccinated dam where the results of maternal S. Dublin serology were available. A logistic regression model was fitted to the data: the dichotomous dependent variable was the S. Dublin foetal culture result, and the independent variables were the maternal serum agglutination test (SAT) titre results. Salmonella serology correctly classified 87% of S. Dublin culture-positive foetuses at a predicted probability threshold of 0.44 (cut-off at which sensitivity and specificity are at a maximum, J = 0.67). The sensitivity of the SAT at the same threshold was 73.8% (95% CI: 67.4%-79.5%), and the specificity was 93.2% (95% CI: 90.3%-95.4%). The positive and negative predictive values were 84.9% (95% CI: 79.3%-88.6%) and 87.3% (95% CI: 83.5%-91.3%), respectively. This study illustrates that the use of predicted probability values, rather than the traditional arbitrary breakpoints of negative, inconclusive and positive, increases the diagnostic value of the maternal SAT. Veterinary laboratory diagnosticians and veterinary practitioners can recover from the test results, information previously categorized, particularly from those results declared to be inconclusive.

Impact of opening a new emergency department on healthcare service and patient outcomes: analyses based on linking ambulance, emergency and hospital databases.

BACKGROUND: Emergency department (ED) crowding caused by access block is an increasing public health issue and has been associated with impaired healthcare delivery, negative patient outcomes and increased staff workload. AIM: To investigate the impact of opening a new ED on patient and healthcare service outcomes. METHODS: A 24-month time series analysis was employed using deterministically linked data from the ambulance service and three ED and hospital admission databases in Queensland, Australia. RESULTS: Total volume of ED presentations increased 18%, while local population growth increased by 3%. Healthcare service and patient outcomes at the two pre-existing hospitals did not improve. These outcomes included ambulance offload time: (Hospital A PRE: 10 min, POST: 10 min, P < 0.001; Hospital B PRE: 10 min, POST: 15 min, P < 0.001); ED length of stay: (Hospital A PRE: 242 min, POST: 246 min, P < 0.001; Hospital B PRE: 182 min, POST: 210 min, P < 0.001); and access block: (Hospital A PRE: 41%, POST: 46%, P < 0.001; Hospital B PRE: 23%, POST: 40%, P < 0.001). Time series modelling indicated that the effect was worst at the hospital furthest away from the new ED. CONCLUSIONS: An additional ED within the region saw an increase in the total volume of presentations at a rate far greater than local population growth, suggesting it either provided an unmet need or a shifting of activity from one sector to another. Future studies should examine patient decision making regarding reasons for presenting to a new or pre-existing ED. There is an inherent need to take a 'whole of health service area' approach to solve crowding issues.

The haemodynamic response to pre-hospital RSI in injured patients.

BACKGROUND: Laryngoscopy and tracheal intubation provoke a marked sympathetic response, potentially harmful in patients with cerebral or cardiovascular pathology or haemorrhage. Standard pre-hospital rapid sequence induction of anaesthesia (RSI) does not incorporate agents that attenuate this response. It is not known if a clinically significant response occurs following pre-hospital RSI or what proportion of injured patients requiring the intervention are potentially at risk in this setting. METHODS: We performed a retrospective analysis of 115 consecutive pre-hospital RSI's performed on trauma patients in a physician-led Helicopter Emergency Medical Service. Primary outcome was the acute haemodynamic response to the procedure. A clinically significant response was defined as a greater than 20% change from baseline recordings during laryngoscopy and intubation. RESULTS: Laryngoscopy and intubation provoked a hypertensive response in 79% of cases. Almost one-in-ten patients experienced a greater than 100% increase in mean arterial pressure (MAP) and/or systolic blood pressure (SBP). The mean (95% CI) increase in SBP was 41(31-51) mmHg and MAP was 30(23-37) mmHg. Conditions leaving the patient vulnerable to secondary injury from a hypertensive response were common. CONCLUSIONS: Laryngoscopy and tracheal intubation, following a standard pre-hospital RSI, commonly induced a clinically significant hypertensive response in the trauma patients studied. We believe that, although this technique is effective in securing the pre-hospital trauma airway, it is poor at attenuating adverse physiological effects that may be detrimental in this patient group.

Emergency intubation: a prospective multicentre descriptive audit in an Australian helicopter emergency medical service.

OBJECTIVE: To describe the safety profile of emergency airway management when performed by a prehospital team consisting of a doctor and a paramedic. Success rates, the incidence of difficult airways and the ability of prehospital doctors to determine a difficult airway are reported. METHODS: A prospective audit and descriptive study of three Australian helicopter emergency medical service (HEMS) bases, over a 9-month period. Doctors completed questionnaires regarding the number of endotracheal intubation (ETI) attempts on patients transported intubated and ventilated, Cormack and Lehane view of the cords during laryngoscopy and the anticipated and actual ease of ETI. RESULTS: A total of 114 (11.4%) patients transported by the HEMS was intubated and ventilated. Study questionnaires were completed on 89 of the 114 cases (78.1%), of which 32 (36%) were trauma related. HEMS were involved with 43 (48.3%) of the 89 intubations and performed 12.4% (n = 11) out of hospital. The HEMS ETI success rate was 97.6%. No surgical airways were performed. The actual incidence of difficult airways was higher (n = 4, 9.3%) than the anticipated incidence (n = 1, 2.3%). Six patients (14.0%) were successfully intubated by the doctor after the paramedic failed. CONCLUSIONS: Well-trained doctor paramedic teams, utilising standardised operating procedures, can safely perform rapid sequence induction and ETI in the prehospital and emergency environment. However, prehospital doctors are not always able to anticipate a difficult airway. The complication rate was similar to that in hospital emergency departments and to that of other physician-led HEMS.

Demographics of cattle positive for Mycobacterium avium subspecies paratuberculosis by faecal culture, from submissions to the Cork Regional Veterinary Laboratory.

The demography of bovine infections caused by Mycobacterium avium subspecies paratuberculosis (MAP) in Ireland is poorly defined. The objective of this study was to describe the demographics of cattle positive to MAP on faecal culture, based on submissions to the Cork Regional Veterinary Laboratory (Cork RVL) from 1994 to 2006. The study focused on all available faecal samples from adult cattle with non-responsive chronic diarrhoea that were submitted by private veterinary practitioners to Cork RVL for MAP culture. For each MAP-positive by faecal culture animal, data were collated from Cork RVL and Cattle Movement Monitoring Scheme (CMMS) records. Johne's disease (JD) was confirmed in 110 animals from 86 herds by the Cork RVL between 1994 and 2006, with a rate of positive cases between 15% and 18% over last four years of the study. Two breeds (Holstein/Friesian or Limousin) made up 78% of submissions. Movements were assessed for the 57 study animals with available movement information, 90% died within one year of the test and 26% tested positive in the herd they were born into. The study provides preliminary information about movement trends and demographics of animals with MAP positive submissions. Although the study area is restricted, it includes the most intensive (and economically-important) dairy region in Ireland. The demographics of JD infection from the study area are in agreement with international reports. Further work is required to determine demographic trends, incidence and prevalence of JD throughout Ireland. It is hoped this work may contribute to the development of a surveillance strategy for MAP by regional veterinary laboratories.

Antibody response after varicella vaccination in children treated with budesonide inhalation suspension or non-steroidal conventional asthma therapy.

We evaluated if budesonide inhalation suspension (BIS) reduces the immunogenicity of the varicella vaccine in paediatric patients with asthma. This open-label, parallel-group, cohort study included varicella-naïve (disease and vaccine) children aged 12 months to 8 years with asthma requiring therapy. Patients who received > or = 4 weeks of asthma treatment with BIS 0.25-1 mg daily or non-steroidal conventional asthma therapy (NSCAT) daily or as needed and met eligibility requirements received the varicella vaccine (Varivax) and continued the same asthma treatment for > or = 8 weeks postvaccination. Varicella-zoster virus (VZV) antibody levels were assessed before and 6 weeks after vaccination using a glycoprotein enzyme-linked immunosorbent assay (gpELISA). Adverse events (AEs) were assessed throughout the study. Antibody levels were analysed in 243 of 274 patients who were vaccinated and received treatment. After immunisation, the percentage of patients in each group achieving a 'protective' level of VZV antibody (> or = 5 gpELISA units/ml) was similar: 85% (129/151) in the BIS group and 90% (83/92) in the NSCAT group (relative risk = 0.95; 95% confidence interval 0.86-1.04). Eight patients in each group reported AEs related to varicella vaccination (primarily pyrexia, agitation and injection-site reactions). There were no cases of severe varicella in either group; one case of mild varicella-like rash was reported in a 12-month-old child in the NSCAT group 11 days after vaccination. VZV antibody responses and tolerability to the live varicella vaccine in paediatric asthma patients treated with BIS vs. NSCAT were comparable, demonstrating that young children with asthma receiving nebulised BIS can be immunised effectively with Varivax.

Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma.

BACKGROUND: In acute asthma inhaled beta2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. Nebulisers require a power source and need regular maintenance, and are more expensive in the community setting. OBJECTIVES: To assess the effects of holding chambers (spacers) compared to nebulisers for the delivery of beta2-agonists for acute asthma. SEARCH STRATEGY: We last searched the Cochrane Airways Group trials register in January 2006 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2005). SELECTION CRITERIA: Randomised trials in adults and children (from two years of age) with asthma, where spacer beta2-agonist delivery was compared with wet nebulisation. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI). MAIN RESULTS: This review has been updated in January 2006 and four new trials have been added. 2066 children and 614 adults are now included in 25 trials from emergency room and community settings. In addition, six trials on in-patients with acute asthma (213 children and 28 adults) have been reviewed. Method of delivery of beta2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for spacer versus nebuliser was 0.97 (95% CI 0.63 to 1.49). The relative risk for children was 0.65 (95% CI: 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the spacer was used, with a mean difference of -0.47 hours (95% CI: -0.58 to -0.37). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for spacer in children, mean difference -7.6% baseline (95% CI: -9.9 to -5.3% baseline). AUTHORS' CONCLUSIONS: Metered-dose inhalers with spacer produced outcomes that were at least equivalent to nebuliser delivery. Spacers may have some advantages compared to nebulisers for children with acute asthma.

Holding chambers versus nebulisers for beta-agonist treatment of acute asthma.

BACKGROUND: In acute asthma inhaled beta-2-agonists are often administered to relieve bronchospasm by wet nebulisation, but some have argued that metered-dose inhalers with a holding chamber (spacer) can be equally effective. In the community setting nebulisers are more expensive, require a power source and need regular maintenance. OBJECTIVES: To assess the effects of holding chambers compared to nebulisers for the delivery of beta-2-agonists for acute asthma. SEARCH STRATEGY: We last searched the Cochrane Airways Group trials register in November 2002 and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2002). SELECTION CRITERIA: Randomised trials in adults and children (from two years of age) with asthma, where holding chamber beta-2-agonist delivery was compared with wet nebulisation. DATA COLLECTION AND ANALYSIS: Two reviewers independently applied study inclusion criteria (one reviewer for the first version of the review), extracted the data and assessed trial quality. Missing data were obtained from the authors or estimated. Results are reported with 95% confidence intervals (CI). MAIN RESULTS: This review has been updated in 2003 and has now analysed 1076 children and 444 adults included in 22 trials from emergency room and community settings. In addition, five trials on in-patients with acute asthma (184 children and 28 adults) have been added to the review. Method of delivery of beta-2-agonist did not appear to affect hospital admission rates. In adults, the relative risk of admission for holding chamber versus nebuliser was 0.88 (95% CI 0.56 to 1.38). The relative risk for children was 0.65 (95% CI 0.4 to 1.06). In children, length of stay in the emergency department was significantly shorter when the holding chamber was used, with a weighted mean difference of -0.47 hours, (95% CI -0.58 to -0.37 hours). Length of stay in the emergency department for adults was similar for the two delivery methods. Peak flow and forced expiratory volume were also similar for the two delivery methods. Pulse rate was lower for holding chamber in children, weighted mean difference -7.6% baseline (95% CI -9.9 to -5.3% baseline). REVIEWER'S CONCLUSIONS: Metered-dose inhalers with holding chamber produced outcomes that were at least equivalent to nebuliser delivery. Holding chambers may have some advantages compared to nebulisers for children with acute asthma.

The effect of feeding and management practices on calving rate in dairy herds.

The objective of this study was to examine the effects of nutrition and management practices on reproductive performance in 31 Irish dairy herds participating in the Moorepark Dairy Management Information System (DairyMIS) during the period 1991-1998. Fifty variables relating to herd reproductive indices, calving events, stocking rate, disease, concentrate feeding, fertiliser usage, milk production and economic performance were studied using factor analysis. A factor analysis, followed by varimax rotation, identified 13 factors, which accounted for 83% of the total variance of the original variables. A regression model was used to predict calving rate from the orthogonal factor scores identified by factor analysis. Calving rate was defined as the proportion of services, for which an outcome was known, which resulted in a subsequent calving. Year, farm code and factor 3 (labelled herd size) together accounted for 40% of the observed variation in calving rate. The factor scores for factor 3 (herd size) were plotted against calving rate and because the plot was not linear, it was decided that dividing the factor scores into quartiles would produce a better fitting model. The factor scores for herd size were sorted and assigned to four equal categories (n = 47 per category), from lowest to highest. The ranges in herd size according to category were as follows: category 1 (34-96), category 2 (47-103), category 3 (66-152) and category 4 (108-359). The calving rate (%), (+/-S.E.) was 67.0 +/- 2.5 for category 1, 61.8 +/- 1.8 for category 2, 56.9 +/- 1.5 for category 3 and 53.2 +/- 2.85 for category 4. Using pair-wise comparisons, calving rates differed significantly (P < 0.05) between all categories except between categories 3 and 4 (P > 0.05). Herd-level milk production was not associated with calving rate indicating that good management may overcome any adverse effects of high milk production on reproductive performance. Larger herds, in combination with other associated herd characteristics, are likely to have poorer calving rates than medium or small herds.

Parkinson's disease: improved function with GM1 ganglioside treatment in a randomized placebo-controlled study.

BACKGROUND/OBJECTIVE: Studies in animal models of Parkinson's disease (PD) suggest that GM1 ganglioside treatment can restore neurologic and dopaminergic function. In view of positive preclinical findings and the results of a previous open-label study demonstrating efficacy of GM1 in PD patients, this study compared effects of GM1 ganglioside and placebo on motor functions in PD patients. METHODS: Forty-five patients with mild to moderate PD were studied. The primary efficacy measure was change in the Unified Parkinson's Disease Rating Scale (UPDRS) motor score. After three independent baseline assessments, patients received IV infusion of the test drug (1,000 mg GM1 or placebo) and then self-administered either GM1 or placebo twice daily (200 mg/day, subcutaneously) for 16 weeks. Patients were examined during monthly follow-up visits. RESULTS: There was a significant difference between groups in UPDRS motor scores at 16 weeks (p=0.0001). The activities of daily living portion of the UPDRS (off-period assessment) also showed a significant effect in favor of the GM1-treated patients (p=0.04). GM1-treated patients also had significantly greater mean improvements than placebo-treated patients in performance of timed motor tests including tests of arm, hand, and foot movements, and walking. GM1 was well tolerated and no serious adverse events were reported. CONCLUSIONS: This study demonstrates that GM1 ganglioside treatment enhances neurologic function significantly in PD patients. Further study is warranted to evaluate long-term effects of GM1 in PD patients and to elucidate further the mechanisms underlying patient improvements.

GM1 ganglioside treatment of Parkinson's disease: an open pilot study of safety and efficacy.

We performed an open-label study testing the effects of GM1 ganglioside on 10 Parkinson's disease (PD) patients. Patients received 1,000 mg of GM1 by IV infusion after the last of three baseline functional assessments. Patients then self-administered GM1 at a dose of 200 mg/d, by subcutaneous injection, for 18 weeks. Under these conditions, GM1 ganglioside proved to be safe and well tolerated. There were no serious adverse events and none of the patients developed elevated anti-GM1 antibody titers. Improvements on at least some functional measures were present in most patients, beginning after 4 to 8 weeks of GM1 treatment. When functional improvements occurred, they lasted for the duration of the study. These results suggest that GM1 ganglioside is well tolerated and may be a useful adjunct to the treatment of PD, and that a double-blind, placebo-controlled study is now warranted.

Psychoeducational multiple family groups: four-year relapse outcome in schizophrenia.

Earlier studies of family psychoeducation and clinical reports on multiple family groups (MFGs) have reported substantial reductions in relapse rates for patients with schizophrenia. These groups offer an expanded social network and thereby may confer a margin of protection against relapse. However, to date, there has not been an empirical trial of this modality. The advent of family psychoeducational and behavioral management strategies provided the basis for an experimental, three-way comparison of psychoeducational MFGs to psychoeducation in a single-family format and to MFGs without psychoeducation, using symptomatic relapse as the outcome criterion. After 4 years, the psychoeducational MFGs were significantly more effective in extending remission than the single-family format, while the MFGs without psychoeducation approximated outcome in the psychoeducational MFGs. The respective relapse rates at 4 years were 50%, 78%, and 57%; MFGs averaged 12.5% and 14% per year. These results point toward an enhanced and independent, long-term therapeutic effect for multiple family groups, when combined with antipsychotic medication and psychoeducation, with especially promising cost-effectiveness.

Within-session changes in sensory gating assessed by P50 evoked potentials in normal subjects.

1. The authors studied within-session changes in P50 suppression occurring in a group of 28 normal subjects. 2. A conditioning-testing paradigm was used with 120 pairs of 110 Db peak intensity clicks. Clicks were of 0.04 msec duration, 500 msec separation and delivered through headphones at 10 second intervals. 3. Mean P50 suppression ranged from 60.5% during the first 30 click pairs to -19.1% during the last 30 pairs, with an overall mean suppression of 25.4%. 4. The authors concluded that P50 suppression is a dynamic process in normal subjects, and that further work is necessary to elucidate the factors affecting P50 suppression.