Selenate bioreduction in a large in situ field trial.

Removing selenium (Se) from mine effluent is a common challenge. A long-term, in situ experiment was conducted to bioremediate large volumes (up to 7500 mc d-1) of Se(VI)-contaminated water (mean 87 µg L-1) by injecting the water into a saturated waste rock fill (SRF) at a coal mining operation in Elk Valley, British Columbia, Canada. To stimulate/maintain biofilm growth in the SRF, labile organic carbon (methanol) and nutrients were added to the water prior to its injection. A conservative tracer (Br-) was also added to track the migration of injected water across the SRF, identify wells with minimal dilution and used to quantify the extent of bioreduction. The evolution of the Se species through the SRF was monitored in time and space for 201 d. Selenium concentrations of <3.8 µg L-1 were attained in monitoring wells located 38 m from the injection wells after 114 to 141 d of operation. Concentrations of Se species in water samples from complementary long-term (351-498 d) column experiments using influent Se(VI) concentrations of 1.0 mg L-1 were consistent with the results of the in situ experiment. Solid samples collected at the completion of the column experiments confirmed the presence of indigenous Se-reducing bacteria and that the sequestered Se was present as insoluble Se(0), likely in Se-S ring compounds. Based on the success of this ongoing bioremediation experiment, this technology is being applied at other mine sites.

Nontechnical skills and decision making in operative vaginal delivery.

Nontechnical skills are defined as social, cognitive and personal resource skills that are necessary to conduct any technical skill safely. Whilst the skills are categorised into three domains: social, cognitive and personal resources, these are dependent on each other and the development and effectiveness of one relies on the other two. Effective nontechnical skills are essential in the safe care of patients in any setting, and their importance can be clearly demonstrated in the safe development of skills in many areas of medicine and surgery. Increasingly the importance of these skills is being recognised in outcomes for patients and staff, and training courses and assessment tools are being developed and used in obstetrics. Understanding of the role of nontechnical skills in labour and especially in operative vaginal births should be embedded across the specialty. Further research is needed in validation of assessment tools for these skills when used in obstetrics.

Role of Systematic Lymphadenectomy to Tailor Adjuvant Therapy in Early Endometrial Cancer.

OBJECTIVE: The long-standing protocol at our center for apparent stage I and II endometrial cancers comprises hysterectomy and bilateral salpingo-oophorectomy without lymphadenectomy. Adjuvant treatment is based in line with Postoperative Radiation Therapy in Endometrial Carcinoma 1 protocol. Our aim was to quantify the number of patients who would avoid external beam radiation therapy (EBRT) in our institution if we adopted a protocol of lymphadenectomy to tailor adjuvant EBRT and its impact on cost and quality of life. DESIGN: Retrospective case-cohort study. SETTING: Gynecological oncology center. METHODS: All endometrial cancers treated from 2007 to 2012 were included. The European Organization for Research and Treatment of Cancer (EORTC) quality of life (QLQ-30) and endometrial cancer specific (EN-24) questionnaires were used to measure the quality of life. The NHS tariff for EBRT, VBT and lymphadenectomy were obtained from our Trust's contract with the local commissioning groups. MAIN OUTCOME MEASURES: Quality of life and cost. RESULTS: Systematic pelvic lymphadenectomy in early endometrial cancers of all grades would avoid EBRT in 23.3% of patients, and if performed for grade 2 and 3 cancers, 39.5% of patients would avoid EBRT. The global health scores were significantly lower, and pain scores were considerably higher in patients who received EBRT. Performing systematic lymphadenectomy and tailored adjuvant therapy in grade 2 and 3 endometrial cancers would save £134,691 and for all grades save £37,161 for every 100 patients treated with early endometrial cancer. CONCLUSION: Systematic lymphadenectomy with tailored adjuvant therapy may offer better QoL with reduced cost to NHS without a reduction in overall survival.

CA-MRSA Decolonization Strategies: Do They Reduce Recurrence Rate?

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus commonly presents as a skin and soft tissue infection. Recurrence of the infection is common even after incision and drainage of the affected area. OBJECTIVE: This Evidence-Based Report Card reviews whether decolonization strategies will reduce the rate of methicillin-resistant Staphylococcus aureus skin and soft tissue infection (MRSA-SSTI) recurrence or colonization in patients with a history of MRSA-SSTI. METHODS: A systematic review of the literature was conducted from 1987 to the present day. The studies that were evaluated included individuals with recurrent skin and soft tissue infections that used decolonization procedures to decrease recurrence. The literature search generated 754 articles. Of these, 288 articles were eliminated due to duplication. Of the 466 remaining citations, 372 were not relevant. Of the remaining 94 full-text articles, 12 met the inclusion criteria. These studies were then reviewed and findings synthesized. FINDINGS: Four studies found topical decolonization procedures were effective in reducing colonization rates. Of the studies that used combination decolonization therapy, 3 of 4 studies showed a decrease in colonization rate. Despite successful decolonization, the rate of SSTI recurrence did not decrease. Two studies that showed a decrease in SSTI recurrence utilized different study parameters. In one study, the decolonization regimen was completed monthly over 1 year. The other study treated family members in addition to the affected individual. Currently, there is insufficient evidence to support the routine use of topical or systemic decolonization regimens to decrease recurrent SSTIs in individuals with a history of MRSA-SSTI. CONCLUSION: The focus of decolonization should be focused on the prevention and spread of infection. Hygiene education should be provided to patients, household members, and close contacts to reduce infection rates.

Educating parents on gastrostomy devices: necessary components to achieve success.

Often parents leave the hospital without the education needed to care for their child's gastrostomy device. Lack of nurse knowledge and the use of various types of devices contribute to their confusion and inability to adequately educate parents. An enhanced methodology and process to standardize gastrostomy education were designed and implemented. Data results confirmed an improvement in the knowledge and competency of both staff nurses and parents. Empowering staff nurses with knowledge and the necessary resources and tools to confidently educate parents, along with a standardized process, has improved overall outcomes.

Long-term follow-up of hepatitis C infection in a large cohort of patients with inherited bleeding disorders.

BACKGROUND & AIMS: Patients with inherited bleeding disorders are an interesting group to study the long-term course of chronic hepatitis C virus (HCV) infection, because of their uniform mode of infection and reliable follow-up. Our aim was to assess the long-term occurrence of adverse liver-related events in these patients. METHODS: The occurrence and determinants of end-stage liver disease (ESLD) were assessed using retrospective data of 863 HCV infected patients with inherited bleeding disorders from the Netherlands and the UK. RESULTS: Median follow-up since HCV infection was 31 years, while 30% of patients had >35 follow-up years. Nineteen percent of patients spontaneously cleared the virus and 81% developed chronic HCV infection. Of the 700 patients with chronic HCV, 90 (13%) developed ESLD. Hepatocellular carcinoma (HCC) was diagnosed in 3% of patients with chronic HCV, 41% of which occurred in the last six years. Determinants of ESLD development were age at infection (hazard ratio (HR) 1.09 per year increase), HIV co-infection (HR 10.85), history of alcohol abuse (HR 4.34) and successful antiviral treatment (HR 0.14). Of the 487 patients who were still alive at the end of follow-up, 49% did not undergo optimal conventional antiviral treatment. CONCLUSIONS: After over 30 years of HCV infection, ESLD occurred in a significant proportion of patients with inherited bleeding disorders. HCC appears to be an increasing problem. There is a significant potential for both conventional and new antiviral treatment regimens to try and limit ESLD occurrence in the future.

Methods of bowel management in critical care: a randomized controlled trial.

PURPOSE: The purpose of this study was to compare 3 methods of bowel management to control fecal incontinence in adult critical care patients and their effect on incontinence-associated dermatitis, pressure ulcer prevalence, and clinician satisfaction. SUBJECTS AND SETTING: Fifty-nine adult patients in critical care with liquid fecal incontinence were recruited from 6 critical care units in a large Midwest healthcare system. METHODS: Subjects were randomly assigned to 1 of 3 groups: bowel management system catheter, rectal/nasopharyngeal trumpet, or usual care. Subjects were assessed daily for incontinence-associated dermatitis, pressure ulcer prevalence, and other clinical data. Direct care nurse satisfaction with each method was evaluated by self-administered survey. RESULTS: Incontinence-associated dermatitis severity and pressure ulcer prevalence did not differ across groups at baseline. Over time, the change in incontinence-associated dermatitis severity score was significantly different across groups (P < .001). There were no significant differences in proportion of patients experiencing pressure ulcers during the study among groups. Clinicians reported significantly greater satisfaction with the bowel management system (P = .007) and rectal trumpet (P = .001) as compared to usual care. In addition, economic and safety benefits were identified with use of internal fecal devices. Specifically, an economic savings of $3100 to $3400 per 29 days of care was identified. Subjects experienced no adverse side effects when internal devices were used. CONCLUSION: Results of this randomized controlled trial provide new information for the care of patients with fecal incontinence in the critical care setting. Incontinence-associated dermatitis severity scores differed across groups over time, pressure ulcer prevalence did not differ across groups over time, use of an internal device or bowel management system improved clinician satisfaction, and the use of internal fecal methods was more cost-effective than usual care.

Conservative versus arthroscopic management for medial coronoid process disease in dogs: a prospective gait evaluation.

OBJECTIVE: To investigate, using objective gait analysis, the long-term outcome of dogs with medial coronoid process disease (MCPD) treated with conservative management (CM) versus arthroscopic treatment (AT). STUDY DESIGN: Prospective clinical trial. ANIMALS: Dogs (n = 20) with unilaterally confirmed MCPD. METHODS: Eleven dogs were treated arthroscopically with removal of coronoid fragments and burring of any associated chondromalacic cartridge and 9 dogs were managed conservatively. All dogs were administered a 6-week course of oral tepoxalin on enrollment. Inverse dynamics gait analysis was performed at initial presentation and at 4, 8, 26, and 52 weeks. The gait variables analyzed were elbow moment (EM), elbow power (EP), total support moment (TSM), and total support moment ratio (TSMR) as a measure of forelimb asymmetry. RESULTS: Affected peak EM increased from 0.58 to 0.76 Nm/kg in the AT dogs, and from 0.66 to 0.81 Nm/kg in the CM dogs and there was no significant difference between groups. Affected peak EP increased marginally in the AT dogs, but was unchanged in the CM dogs and there was no significant difference between groups. TSM increased from 1.49 to 1.92 Nm/kg in the AT dogs and from 1.52 to 2.06 Nm/kg in the CM dogs and there was no significant difference between groups. TSMR was statistically different between treatment groups at 1 (P = .003) and 2 months (P = .048) with the AT group more asymmetric and hence more lame. TSMR at 12 months was 0.83 (AT) and 0.86 (CM) implying a failure of return to soundness by either group. CONCLUSIONS: AT dogs had increased mechanical asymmetry at 4 and 8 weeks compared to the CM group revealing surgery worsened limb function. There was no significant difference in mechanical symmetry between groups at 26 and 52 weeks.

Implementation of the victoria bowel performance scale.

CONTEXT: There is a lack of evidence to guide constipation management in patients receiving palliative care. Data collection requires the systematic use of validated assessment tools. OBJECTIVES: The objective of this study was to assess the usefulness of the Victoria Bowel Performance Scale (BPS) as an audit tool. METHODS: Charts were reviewed before and after the implementation of a program to monitor constipation through repeated use of the Victoria Bowel Scale. The program was initiated at three oncology pain and symptom management clinics, four palliative care units, and four residential hospices. An additional "control" palliative care unit introduced new nursing assessment tools without the new scale. RESULTS: The Victoria BPS was recorded at 86% of 192 postimplementation outpatient clinic visits and was easy to use in this setting. Documentation of bowel performance at comparable visits improved from 44% to 66% (P<0.001), and the frequency of changes to laxatives increased from 14% to 39% of visits (P<0.001). The scale was completed on 21%-55% of inpatient days, and variations in the proportion of recordings being rated as satisfactory between -1 and +1 (possible range from -4 to +4) revealed important deficiencies in bowel care, which led to change in management. CONCLUSION: The Victoria BPS was found to be an acceptable and a useful bowel function assessment tool, uniquely incorporating the patient's usual bowel function. Modifications to the scale have been made to improve clarity and allow for the expected drop in bowel activity seen in end-of-life care. Considerable educational effort and appropriate organization of the charts are required for optimal implementation. The proportion of revised BPS scores ranging from -1 to +1 is proposed as an indicator of satisfactory bowel management for clinical, audit, and research purposes.

Preventing skin breakdown in the immobile child in the home care setting.

The potential for skin breakdown presents significant challenges to the healthcare providers of physically compromised children. Pressure ulcers (PUs) can lead to grave and costly problems in the care of immobile children, contributing to hospital admissions solely for the treatment of skin breakdown and related complications; infection, septicemia, and potential death. Skin breakdown and the development of PUs in children is often overlooked as pediatric healthcare providers do not fully understand or realize the risks. Although there is little written related to skin breakdown and the risk of PU development in children, it is important for nurses who work with children to be fully aware of the factors that place a child at increased risk.

Symmetry of hind limb mechanics in orthopedically normal trotting Labrador Retrievers.

OBJECTIVE: To evaluate symmetry of the hind limbs in orthopedically normal trotting dogs. Animals-19 orthopedically normal Labrador Retrievers with no history of lameness. PROCEDURES: Retroreflective markers were applied to the hind limb joints, and a 4-camera kinematic system captured positional data at 200 Hz in tandem with force platform data collection while the dogs trotted. Morphometric data were combined with kinematic and force data in an inverse dynamics method to calculate net joint moments and powers at the joints as well as total support moment for each limb. Dogs were identified as right or left dominant when their total support moment was > 10% asymmetric between sides. RESULTS: 10 of the 19 dogs were mechanically dominant in the right hind limb as determined by their total support moments. One dog was left dominant, and the remaining 8 were symmetric. Right-dominant dogs had larger net joint moments at the right hip, tarsal, and metatarsophalangeal joints and a smaller moment at the right stifle joint, compared with values for the left hind limb. The 1 left-dominant dog had the exact opposite findings. Hip and stifle joint moments and powers varied between limbs of the right-dominant and left-dominant groups in the timing of their transition from negative to positive, and power amplitudes varied at the hip, tarsal, and metatarsophalangeal joints but not the stifle joint. CONCLUSIONS AND CLINICAL RELEVANCE: Sound trotting dogs can have asymmetries in limb and joint mechanics. These natural mechanical asymmetries should be taken into account when considering models to evaluate stresses at joints and when considering surgery for cruciate ligament rupture.

Healing during existential moments: the "art" of nursing presence.

This article addresses nursing presence, a phenomenon essential to holistic nursing care. The concept is introduced and explained, supporting background information is reviewed, barriers are identified, and successful applications are illustrated in different clinical settings. Avowing that metaphysical knowledge is the underpinning to the art of nursing presence, a Transformative Nursing Presence Model is offered as a distinctive framework for nurses and organizations interested in fostering enhanced nursing presence.