Continuous Vital Signs Monitoring with a Wireless Device on a General Ward: A Survey to Explore Nurses' Experiences in a Post-Implementation Period.

BACKGROUND: Nurse engagement, perceived need and usefulness affect healthcare technology use, acceptance and improvements in quality, safety and accessibility of healthcare. Nurses' opinions regarding continuous monitoring appear to be positive. However, facilitators and barriers were little studied. This study explored nurses' post-implementation experiences of the facilitators and barriers to continuously monitoring patients' vital signs using a wireless device on general hospital wards. METHODS: This study employed a cross-sectional survey. Vocational and registered nurses from three general wards in a Dutch tertiary university hospital participated in a survey comprising open and closed questions. The data were analysed using thematic analysis and descriptive statistics. RESULTS: Fifty-eight nurses (51.3%) completed the survey. Barriers and facilitators were identified under four key themes: (1) timely signalling and early action, (2) time savings and time consumption, (3) patient comfort and satisfaction and (4) preconditions. CONCLUSIONS: According to nurses, early detection and intervention for deteriorating patients facilitate the use and acceptance of continuously monitoring vital signs. Barriers primarily concern difficulties connecting patients correctly to the devices and system.

'No more heroes': The ILC Oxford Statement on fundamental care in times of crises.

AIM: To outline the International Learning Collaborative (ILC) Oxford Statement, explicating our commitment to ensuring health and care systems are equipped to meet patients' fundamental care needs during times of unprecedented crisis. DESIGN/METHOD: Discussion paper. The content was developed via a co-design process with participants during the ILC's international conference. KEY ARGUMENTS: We, the ILC, outline what we do and do not want to see within our health and care systems when faced with the challenges of caring for patients during global pandemics and other crises. Specifically, we want fundamental care delivery to be seen as the minimum standard rather than the exception across our health and care systems. We want nursing leaders to call out and stand up for the importance of building fundamental care into systems, processes and funding priorities. We do not want to see the voices of nursing leaders quashed or minimized in favour of other agendas. In turn, what we want to see is greater recognition of fundamental care work and greater respect for the people who do it. We expect nurses to have a 'seat at the table' where the key health and care decisions that impact patients and staff are made. CONCLUSION: To achieve our goals we must (1) ensure that fundamental care is embedded in all health and care systems, at all levels; (2) build on and strengthen the leadership skills of the nursing workforce by clearly advocating for person-centred fundamental care; (3) co-design systems that care for and support our staff's well-being and which foster collective resilience rather than overly rely on individual resilience; (4) improve the science and methodologies around reporting and measuring fundamental care to show the positive impact of this care delivery and (5) leverage the COVID pandemic crisis as an opportunity for transformational change in fundamental care delivery.

EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee.

OBJECTIVES: The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of variation in diagnostic and therapeutic performance across disciplines, have found consensus in starting task forces aiming at achieving diagnostic and therapeutic uniformity, and have identified medical conditions with which representatives of both organisations will frequently be confronted in common clinical practice. The aim of the present work was to establish recommendations for the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee. METHODS: The EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations were followed. RESULTS: In all, 11 rheumatologists from 11 countries and 12 orthopaedic surgeons from 7 countries met twice under the leadership of 2 conveners, a clinical epidemiologist and a research fellow. After carefully defining the content and procedures of the task force, research questions were developed, a comprehensive literature search was performed and the results were presented to the entire committee. Subsequently, a set of 10 recommendations was formulated based on evidence from the literature if available, and after discussion and consensus building. CONCLUSIONS: This is the first combined interdisciplinary project of rheumatologists and orthopaedic surgeons, successfully aiming at achieving consensus in the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

Arteriovenous fistulae as an alternative to central venous catheters for delivery of long-term home parenteral nutrition.

BACKGROUND & AIMS: The success of home parenteral nutrition (HPN) programs is compromised by complications of central venous catheters (CVCs), such as occlusions and bloodstream infections. We performed a retrospective analysis of complication rates of arteriovenous fistulae versus CVCs in patients on long-term HPN. METHODS: Data were collected from 127 consecutive patients who received HPN between January 2000 and October 2006, comprising 344 access years of CVCs and 194 access years of arteriovenous fistulae. We evaluated access-related bloodstream infection and occlusion incidence rates (number of complications per access year) using Poisson-normal regression analysis. Complication incidence rate ratios were calculated by dividing complication incidence rates of CVCs by those of arteriovenous fistulae, adjusting for HPN frequency, medication use, infusion fluid composition, and underlying diseases. RESULTS: Bloodstream infection incidence rates were 0.03/year for arteriovenous fistulae, 1.37/year for long-term CVCs (Port-a-Caths and tunneled catheters), and 3.12/year for short-term CVCs (nontunneled catheters). Occlusion incidence rates were 0.60/year for arteriovenous fistulae, 0.35/year for long-term CVCs, and 0.93/year for shortterm CVCs. Adjusted incidence rate ratios of long-term CVCs over arteriovenous fistulae were 47 (95% confidence interval, 19-117) for bloodstream infections and 0.53 (95% confidence interval, 0.31-0.89) for occlusions. CONCLUSIONS: The occlusion incidence rate was higher for arteriovenous fistulae than for certain types of CVCs. The incidence rate of the most serious access-related complication (bloodstream infections) was much lower for arteriovenous fistulae than for all types of CVCs. Thus, arteriovenous fistulae are safe and valuable alternatives to CVCs for patients requiring long-term HPN.

SGK1 activity in Na+ absorbing airway epithelial cells monitored by assaying NDRG1-Thr346/356/366 phosphorylation.

Studies of HeLa cells and serum- and glucocorticoid-regulated kinase 1 (SGK1) knockout mice identified threonine residues in the n-myc downstream-regulated gene 1 protein (NDRG1-Thr(346/356/366)) that are phosphorylated by SGK1 but not by related kinases (Murray et al., Biochem J 385:1-12, 2005). We have, therefore, monitored the phosphorylation of NDRG1-Thr(346/356/366) in order to explore the changes in SGK1 activity associated with the induction and regulation of the glucocorticoid-dependent Na(+) conductance (G (Na)) in human airway epithelial cells. Transient expression of active (SGK1-S422D) and inactive (SGK1-K127A) SGK1 mutants confirmed that activating SGK1 stimulates NDRG1-Thr(346/356/366) phosphorylation. Although G (Na) is negligible in hormone-deprived cells, these cells displayed basal SGK1 activity that was sensitive to LY294002, an inhibitor of 3-phosphatidylinositol phosphate kinase (PI3K). Dexamethasone (0.2 muM) acutely activated SGK1 and the peak of this response (2-3 h) coincided with the induction of G (Na), and both responses were PI3K-dependent. While these data suggest that SGK1 might mediate the rise in G (Na), transient expression of the inactive SGK1-K127A mutant did not affect the hormonal induction of G (Na) but did suppress the activation of SGK1. Dexamethasone-treated cells grown on permeable supports formed confluent epithelial sheets that generated short circuit current due to electrogenic Na(+) absorption. Forskolin and insulin both stimulated this current and the response to insulin, but not forskolin, was LY294002-sensitive and associated with the activation of SGK1. While these data suggest that SGK1 is involved in the control of G (Na), its role may be minor, which could explain why sgk1 knockout has different effects upon different tissues.

Ergonomics oriented to processes becomes a tool for continuous improvement.

A holistic view is essential for quality initiatives such as Total Quality Management (TQM), Standard No. ISO 9001:1994 (International Organization for Standardization [ISO], 1994), Concurrent Engineering, Business Reengineering, and Business Process Improvement. The challenge is knowing how to transition from this theoretical concept to implementation. The relationship between quality interest and an ergonomics program will be the focus of this discussion. An ergonomics oriented improvement program includes (a) ergonomics or fitting the job to the person; (b) integration of operations management, safety engineering, medical management, and employees as co-owners of the process; (c) the emphasis of ergonomic precepts in the engineering of new processes and improvement of current processes; and (d) the emphasis of employees taking responsibility for their own well being and the improvement of their work environment. The parallel between the continuous improvement process delineated by the quality-system requirements in Standard No. ISO 9001:1994 (ISO, 1994) and the improvement contributions of ergonomics are very revealing (Getty, Abbott, & Getty, 1995). It is the contention of this approach that if the precepts of ergonomics were applied to the work environment, it would support the objective of world class quality and productivity, resulting in improved global competitiveness of businesses.

Two cases with interstitial deletions of chromosome 2 and sex reversal in one.

We present two children with de novo interstitial deletions of the long arm of chromosome 2 (karyotypes 46,XY, del(2)(q31.1q31.3) and 46,XY, del(2)(q24.3q31.3), respectively). The first child had severe learning difficulties, growth retardation, unilateral ptosis, small palpebral fissures, a cleft uvula, and bilateral cutaneous syndactyly of the second and third toes. Despite her male karyotype, she had female external genitalia with hypoplasia of the clitoris and labia minora. This is the first reported case of feminization of the external genitalia in a genotypic male with an interstitial deletion of chromosome 2q31 and adds to the growing amount of evidence for a gene involved in sex determination in this chromosome region. The second child had severe mental and growth retardation, ptosis, down-slanting palpebral fissures, low-set ears, micrognathia, finger camptodactyly, and brachysyndactyly of the second to fifth toes. The clinical manifestations associated with deletions of 2q31 to 2q33 are similar to those found with proximal deletions at 2q24 to 2q31 and of band 2q24, suggesting that the phenotype may result from haploinsufficiency for one or more genes located at 2q31. Microsatellite marker studies showed that both children had paternally derived deletions that included the HOXD gene cluster and the EVX2, DLX1, and DLX2 genes known to be important in limb development.

Organ transplants: interview with Jeff Getty, on ending the exclusion of people with HIV. Interview by John S. James.

AIDS: Persons with HIV have been ineligible for organ transplants since 1985 due largely to the earlier perception that HIV patients would soon die and therefore would not benefit from a transplant. However, Jeff Getty of ACT UP/Golden State is working to overcome the automatic HIV exclusion and have HIV patients evaluated based on their medical needs. Only two transplant centers currently do liver and kidney transplants for HIV patients and very few insurance policies cover the surgery. United National Organ Sharing (UNOS) guidelines say that people with HIV should not be excluded from transplant lists; however, the 266 regional centers that perform the surgery have rules against people with HIV receiving an organ. Donor organs are not accepted from HIV-positive people or from people who are gay, regardless of their HIV status.^ieng

Policy statement on FDA reform. Food and Drug Administration.

AIDS: A policy statement on the Food and Drug Administration (FDA) is presented that is endorsed by the San Francisco AIDS Foundation, the National AIDS Treatment Advocacy Project, and ACT-UP/Golden Gate. The statement addresses improving compassionate access; accelerating approval refinements; allowing university-based, non-commercial businesses to have the option of applying either to a certified Institutional Review Board or to the FDA for an IND for Phase I studies; creating an appeals process; and distributing information about off-label drug use.^ieng

Turning the corner on wasting? A symposium on wasting disorders.

AIDS: On February 23, 1995, Serono Symposia/USA sponsored a meeting of leading endocrine researchers in the field of wasting disorders to compare notes and to advance knowledge about AIDS-related wasting. Presenter Richard Rabkin, MD, of Columbia University, reported on a study of 72 men who completed a 12-week trial of biweekly testosterone replacement therapy. Mean weight increased significantly and body composition changes were noted. Of particular interest was speaker Morris Schambelan, MD, of San Francisco General Hospital, who presented "The Use of Anabolic Agents in HIV Infection". Schambelan reported on a study of HIV-positive patients who received recombinant human growth hormone (Serostim) for wasting. The study results showed both total body weight and lean body mass gain, along with simultaneous decreases in fat levels. Patients in the study had documented nitrogen level changes and protein oxidation changes. Schambelan's use of a nitrogen-retention assay and a new body-scanning system may pave the way for future Food and Drug Administration (FDA) approval of anabolic agents for the treatment of wasting. Carl Grunfeld, MD, ruled out some of the previously theorized causes of wasting. Finally, Gilla Kaplan, MD, reported on preliminary results from the thalidomide study at Rockefeller University, which show that thalidomide helps patients with HIV and tuberculosis by reducing weight loss.^ieng

Variations in the pattern of muscle innervation by the L5 and S1 nerve roots.

Evidence based on electrical studies is presented for the standard and anomalous patterns of innervation of muscles supplied by the fifth lumbar and first sacral nerve roots. Although considerable controversy still exists, previous work in this field suggests that the L5 nerve root supplies tibialis anterior, extensor hallucis longus, extensor digitorum brevis, and the lateral head of gastrocnemius, while the S1 nerve root innervates the medial head of gastrocnemius, soleus, and abductor hallucis. In order to confirm the reliability of this data, the L5 and S1 nerve roots of 50 patients were electrically stimulated during surgery, and distally evoked responses in the relevant muscles were recorded, using surface electrodes. The results confirm the essential reliability of the proposed table of segmental innervation and also demonstrate that most muscles have a dual innervation, with one nerve root being dominant. However, eight patients (16%) exhibited a marked departure from the normal pattern. For example, it is clear that on occasion the extensor digitorum brevis and the lateral head of gastrocnemius can be supplied by S1 and the soleus and medial head of gastrocnemius can be supplied by L5. In a prospective study of 100 patients presenting with clinical evidence of lumbosacral nerve root entrapment, the level of nerve root involvement, as predicted by electromyography, was compared with the operative findings. Correct preoperative nerve root localization was achieved in 84%.(ABSTRACT TRUNCATED AT 250 WORDS)

Cauda equina syndrome complicating ankylosing spondylitis: use of electromyography and computerised tomography in diagnosis.

A case of the cauda equina syndrome complicating ankylosing spondylitis (AS) is described. An unusual feature of this case was the relapsing and remitting nature of the condition, but there is sufficient evidence to explain the clinical picture on the basis of a recurrent intraspinal inflammatory process. The clinical and radiological features are similar to those of a further 28 reported in the literature. An electromyogram (EMG) proved important in defining the extent of neurological involvement. Computerised tomography (CT) showed marked laminar erosion and no bony exit foramen encroachment. We believe that the clinical diagnosis of this condition can be adequately confirmed with plain radiology, EMG, and CT scan.