Families' experiences of the Low Arousal Approach: a qualitative study.

Background: Parents and carers supporting a family member presenting with behaviors of concern experience heightened stress. The Low Arousal Approach is a crisis management strategy which recognizes that stress, or physiological arousal, can be expressed through behaviors of concern. This approach aims to equip parents and carers to manage behaviors in a person-centered and non-confrontational way. There is a paucity of published research exploring the experiences of families applying this approach. Methods: Seventeen parents who had received training in the Low Arousal Approach were interviewed to gain their perspectives on supporting their family members using this approach. Results: Thematic analysis revealed themes relating to parental stress, which was related to external pressures, isolation, family stress, and challenges in their caring role. They described encountering negative narratives relating to self-criticism and negative judgments from others. Training in the Low Arousal Approach was related to being empowered through access to evidence, increased confidence, and increased ability to advocate for their family member's needs. Low Arousal was described as a "lifestyle" that enabled increased coping for the family unit as a whole. Discussion/conclusion: Findings indicate that it is vitally important to recognize the views of parents and carers, and these are equally as important as the views of professionals. We must understand parents' and carers' needs in order to provide adequate support.

Anticipation or avoidance: internal medicine resident experiences performing invasive bedside procedures.

Background: Internal Medicine (IM) residents are required to perform bedside procedures for diagnostic and therapeutic purposes. Residents' experiences with procedures vary widely, for unclear reasons. Objective: To explore IM residents' experiences with performing bedside procedures and to identify barriers and facilitators to obtaining sufficient experience. Methods: Using an inductive, thematic approach, we conducted five individual semi-structured interviews and one focus group with seven IM residents (12 residents in total) during the 2017-2018 academic year at a Canadian tertiary care centre. We used iterative, open-ended questions to elicit residents' experiences, and barriers and facilitators, to performing bedside procedures. Transcripts were analyzed for themes using Braun and Clarke's method. Results: We identified four themes 1) Patient-specific factors such as body habitus and procedure urgency; 2) Systems factors such as time constraints and accessibility of materials; 3) Faculty factors including availability to supervise, comfort level, and referral preferences, and 4) Resident-specific factors including preparation, prior experiences, and confidence. Some residents expressed procedure-related anxiety and avoidance. Conclusion: Educational interventions aimed to improve procedural efficiency and ensure availability of supervisors may help facilitate residents to perform procedures, yet may not address procedure-related anxiety. Further study is required to understand better how procedure-averse residents can gain confidence to seek out procedures.

Contexte: Les résidents en médecine interne (MI) sont amenés à effectuer des procédures au chevet du patient à des fins diagnostiques et thérapeutiques. Les expériences des résidents en lien avec ces procédures varient considérablement, et ce sans raison évidente. Objectif: Explorer les expériences des résidents en MI lors des procédures effectuées au chevet du patient et identifier les facteurs qui entravent ou, au contraire, facilitent l'acquisition d'une expérience suffisante. Méthodes: En utilisant une approche inductive et thématique, nous avons mené cinq entrevues individuelles semi-structurées et un groupe de discussion avec sept résidents de MI (12 résidents au total) dans un centre de soins tertiaires canadien au cours de l'année universitaire 2017-2018. Nous avons utilisé des questions ouvertes itératives pour recueillir les expériences des résidents lors des procédures faites au chevet du patient, ainsi qu'identifier les obstacles et les facilitateurs de ces interventions. Les transcriptions d'entrevues ont été analysées pour identifier les thèmes émergents selon la méthode de Braun et Clarke. Résultats: Nous avons relevé quatre thèmes : 1) les facteurs spécifiques aux patients comme la morphologie du patient et l'urgence de la procédure; 2) les facteurs systémiques comme les contraintes de temps et l'accessibilité du matériel; 3) les facteurs liés corps professoral, notamment leur disponibilité pour superviser, leur niveau de confort et leur propension à orienter certaines procédures vers d'autres collègues; et 4) les facteurs spécifiques aux résidents, à savoir la préparation, les expériences antérieures et la confiance. Certains résidents ont exprimé vivre de l'anxiété face aux procédures et de l'évitement. Conclusion: Les initiatives éducatives visant à améliorer l'efficacité des procédures et à assurer la disponibilité de superviseurs peuvent faciliter leur réalisation par les résidents, mais elles peuvent ne pas atténuer l'anxiété reliée aux procédures. Des études supplémentaires sont nécessaires pour mieux comprendre comment accroître la confiance des résidents qui sont réticents face aux procédures au chevet du patient.

Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study.

OBJECTIVE: Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS: A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS: Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION: This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.

Guideline No. 414: management of pregnancy of unknown location and tubal and nontubal ectopic pregnancies

To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. All patients of reproductive age. The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage,methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows.

Directive clinique no 414 : Prise en charge des grossesses de localisation indéterminée et des grossesses ectopiques tubaires et non tubaires.

OBJECTIF: Fournir un algorithme fondé sur des données probantes pour orienter le diagnostic et la prise en charge de la grossesse de localisation indéterminée et de la grossesse ectopique tubaire ou non tubaire. POPULATION CIBLE: Toutes les patientes en âge de procréer. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive a pour objectif de bénéficier aux patientes ayant obtenu un résultat positif pour la sous-unité bêta de la gonadotrophine chorionique et de fournir aux médecins un algorithme normalisé pour l'expectative et le traitement pharmacologique ou chirurgical en cas de grossesse de localisation indéterminée et de grossesse ectopique tubaire ou non tubaire. DONNéES PROBANTES: Les termes de recherche suivants ont été entrés dans les bases de données PubMed-Medline et Cochrane en 2018 : cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography et prenatal. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Obstétriciens-gynécologues, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies.

OBJECTIVE: To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION: All patients of reproductive age. BENEFITS, HARMS, AND COSTS: The implementation of this guideline aims to benefit patients with positive ß-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE: The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE: Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Exploring the services and management available to women experiencing complications in early pregnancy: a survey of Ontario, Canada hospitals.

This investigation surveyed the gynaecologic services and management available to women experiencing early pregnancy complications in the province of Ontario, Canada. The Chiefs of Gynaecology/Obstetrics of 61 Ontario hospitals were invited to complete a 55-item, online questionnaire using modified Dillman methodology. Forty-three hospital site respondents completed the survey (a response rate of 70.5%). It was reported that 18 (41.9%) hospitals had access to an early pregnancy assessment unit (EPAU), and 12 (66.7%) EPAUs had ≤2 days between the referral and the first appointment. Of the 25 (58.1%) hospital respondents without an EPAU, 14 (56.0%) reported previous consideration of creating an EPAU. At these hospitals, patients with early pregnancy complications have access to care through the ED (n = 22, 88.0%), obstetricians/gynaecologists (n = 22, 88.0%), person on-call (n = 16, 64.0%), family physicians (n = 11, 44.0%) or midwives (n = 9, 36.0%). This investigation found great heterogeneity in the care accessible to women experiencing early pregnancy complications in hospitals in Ontario, Canada.Impact statementWhat is already known on this subject? Early pregnancy assessment units (EPAUs) are the standard for evaluating and caring for complications of early pregnancy. It has been well documented that EPAUs result in positive health service outcomes such as more cost-effective care, more timely management, and improved quality of care and patient satisfaction.What do the results of this study add? This investigation found that the province of Ontario, Canada has begun to adopt the EPAU model; however, a great heterogeneity exists in the care accessible to women experiencing early pregnancy complications throughout the province. Nonetheless, where EPAUs are available, they provide a structured referral system for women experiencing complications of early pregnancy that require gynaecologic assessment, such as ectopic pregnancy, providing close follow-up and predictable pathways of care for this patient population.What are the implications of these findings for clinical practice and/or further research? This study highlights the need for hospitals in the province of Ontario to improve their current service delivery models for women experiencing early pregnancy complications. Further research should be undertaken to determine whether the positive health service outcomes of EPAUs are also relevant in the Canadian healthcare system.

Life on Call: Perspectives of Junior and Senior Internal Medicine Residents.

PURPOSE: Models of daytime and nighttime on-call responsibilities for residents vary across internal medicine training programs, but there are few data regarding residents' perceptions of their on-call experiences. The authors sought to understand what residents perceive as the benefits and detriments of 24-hour, in-house call, a perspective instrumental to informing change. METHOD: The authors conducted in-depth individual interviews and focus groups between December 2018 and March 2019 with 17 internal medicine residents from postgraduate years 1, 2, and 3 at the University of Toronto about their on-call experiences. Using constructivist grounded theory, the authors developed a framework to understand the residents' perceived benefits and drawbacks of 24-hour in-house call. RESULTS: Residents' experiences on call were grouped into 7 themes regarding negative and positive aspects of call. Participants reported multidimensional fatigue related to call, including decision fatigue, emotional fragility and lability, and loss of empathy, and also reported that call adversely affected their personal lives. Residents expressed conflicting opinions as to whether prolonged duty hours affected patient outcomes. In contrast, residents also expressed benefits to call, including that overnight call led to increased autonomy and decision-making skills and provided preparation for future careers as independent internists. They described developing camaraderie and a sense of belonging to a team with coresidents overnight. Lastly, residents described occupying different roles during regular duty hours and while on call-daytime roles revolved around follow-up of previously admitted patients and administrative tasks, while overnight duties centered on initial workup and medical stabilization of referred patients. CONCLUSIONS: Understanding the nuanced phenomenon of being on call from the perspective of those who live through it is a critical step in creating evidence-based educational policies. New call models should emphasize resident autonomy and decision making and should include a consideration of residents' perceived differences between daytime and on-call roles.

The effect of the implementation of institutional checklist on expert opinion of oxytocin use in labor.

PURPOSE: Oxytocin is a commonly used drug in the labor and delivery unit. There are wide variations in oxytocin use between countries and medical centers, which may reflect the lack of structured guidelines. The aim of our study was to evaluate the need of oxytocin checklist in labor and delivery unit, while assessing the management of oxytocin with and without such a checklist. METHODS: This study was conducted in a single, university-affiliated medical center in two phases: before and after the implementation of an oxytocin checklist in the labor and delivery unit (2016-2017). Six experts reviewed cardiotocographs of deliveries performed in an urgent Cesarean delivery due to non-reassuring fetal heart rate, after completing at least 4 h of oxytocin infusion for induction or augmentation of labor. The experts included three obstetricians, a midwife, and two obstetrical expert nurses, who were tasked to conclude whether oxytocin was managed properly or not. Each case was reviewed by two reviewers separately. A total of 100 cases were reviewed; 50 before the oxytocin checklist implementation, and 50 after that implementation. RESULTS: We did not find a difference in the reviewers' assessment of oxytocin management before and after the institutional implementation of the checklist. Additionally, there were significant inconsistencies and inter-observer variations in their assessment before and after the checklist implementation. CONCLUSION: The implementation of an institutional oxytocin checklist did not affect expert assessment of the use of oxytocin in labor.

Clinical holding: ethical guidance for children's nurses working in the UK.

This article explores ethical decision-making surrounding clinical holding of children and young people in healthcare environments with the aim of enhancing autonomy and engagement on their behalf. A considerable body of evidence, published over the last 20 years, suggests that this complex and challenging area of practice is not always well managed, with mixed messages about the nature of consent, choice and negotiated practice countered by best interests decisions taking precedence ahead of the child's wishes. An ethical framework is proposed comprising four levels of value-based interventions and how they may be applied in clinical practice, allowing for increased engagement, empowerment and support on behalf of children and young people in relation to clinical holding decisions.

Efficacy, effectiveness, and safety of herpes zoster vaccines in adults aged 50 and older: systematic review and network meta-analysis.

OBJECTIVE: To compare the efficacy, effectiveness, and safety of the herpes zoster live attenuated vaccine with the herpes zoster adjuvant recombinant subunit vaccine or placebo for adults aged 50 and older. DESIGN: Systematic review with bayesian meta-analysis and network meta-analysis. DATA SOURCES: Medline, Embase, and Cochrane Library (inception to January 2017), grey literature, and reference lists of included studies. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Experimental, quasi-experimental, and observational studies that compared the live attenuated vaccine with the adjuvant recombinant subunit vaccine, placebo, or no vaccine in adults aged 50 and older. Relevant outcomes were incidence of herpes zoster (primary outcome), herpes zoster ophthalmicus, post-herpetic neuralgia, quality of life, adverse events, and death. RESULTS: 27 studies (22 randomised controlled trials) including 2 044 504 patients, along with 18 companion reports, were included after screening 2037 titles and abstracts, followed by 175 full text articles. Network meta-analysis of five randomised controlled trials found no statistically significant differences between the live attenuated vaccine and placebo for incidence of laboratory confirmed herpes zoster. The adjuvant recombinant subunit vaccine, however, was statistically superior to both the live attenuated vaccine (vaccine efficacy 85%, 95% credible interval 31% to 98%) and placebo (94%, 79% to 98%). Network meta-analysis of 11 randomised controlled trials showed the adjuvant recombinant subunit vaccine to be associated with statistically more adverse events at injection sites than the live attenuated vaccine (relative risk 1.79, 95% credible interval 1.05 to 2.34; risk difference 30%, 95% credible interval 2% to 51%) and placebo (5.63, 3.57 to 7.29 and 53%, 30% to 73%, respectively). Network meta-analysis of nine randomised controlled trials showed the adjuvant recombinant subunit vaccine to be associated with statistically more systemic adverse events than placebo (2.28, 1.45 to 3.65 and 20%, 6% to 40%, respectively). CONCLUSIONS: Using the adjuvant recombinant subunit vaccine might prevent more cases of herpes zoster than using the live attenuated vaccine, but the adjuvant recombinant subunit vaccine also carries a greater risk of adverse events at injection sites. PROTOCOL REGISTRATION: Prospero CRD42017056389.

Developing a website to demonstrate clinical holding techniques.

Healthcare staff routinely use clinical holding to help infants, children or young people stay still when treatment is being administered, to prevent children or young people from interfering with the treatment, or when invasive examinations are being carried out. However, healthcare staff rarely have any formal discussion with children and young people, or their parents, on the techniques used for clinical holding. Visual tools are important when talking to children or young people about their healthcare, and a website with images of clinical holds would allow staff to discuss relevant holds with their patients. In this article, we describe a collaboration between Birmingham City University and Birmingham Children's Hospital to develop a website that presents 3D images of clinical holds, outlining how we introduced it to staff in the clinical areas that would benefit from it and how we have been evaluating its effectiveness. We hope this website will formalise the professional discussion of clinical hold techniques. This will allow information on the appropriate holds for different situations to be documented, which will enhance best practice. In addition, the website should provide information needed to allow children, young people and their parents to give true, informed consent for any procedures they need.

Cysts of the canal of Nuck: A rare sonographic diagnosis.

The canal of Nuck is a remnant of a peritoneal evagination associated with the round ligament in women. Rarely, the canal of Nuck can remain patent allowing for development of cysts. These cysts are difficult to diagnose due to their rare incidence and because they are often mistaken for other causes of inguinal pain in women. This case series of three women presenting with groin or labial masses highlights the role of sonography as the primary imaging modality in the diagnosis of canal of Nuck cysts. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:175-178, 2017.

Clinical holding with children who display behaviours that challenge.

Nurses hold children to administer treatment, prevent treatment interference and undertake clinical assessments, which can sometimes be invasive, as part of their regular duties. Clinical holding ensures this treatment or assessment is carried out safely, however, it has been reported that there is little training available in this area. This article explores the prevalent clinical holding techniques used by nursing staff when caring for children with behaviours that challenge. As an initial insight into what the researchers hope will become a more in-depth 2-year study, this investigation looks to explore current practice when holding children and the factors influencing this. It is hoped that this will inform the development of a training package offered to nurses when caring for these children. Thirteen semi-structured interviews took place with a small group of nurses, which were given thematic analysis. The overarching themes influencing holding practice were the nursing role itself along with intrinsic and external factors.

Pasteurella multocida non-native joint infection after a dog lick: A case report describing a complicated two-stage revision and a comprehensive review of the literature.

Prosthetic joint infections (PJIs) are commonly caused by pathogens such as Staphylococcus aureus and coagulase-negative staphylococci; however, other microbial etiologies and specific risk factors are increasingly recognized. Pasteurella multocida is a Gram-negative coccobacillus that is part of the normal oral flora in many animals, and is particularly common in dogs and cats. PJIs caused by P multocida have been reported only rarely in the literature and typically occur in the context of an animal bite or scratch. The present article describes a P multocida joint infection that occurred after a dog lick and complicated a two-stage revision arthroplasty. A comprehensive review of the literature regarding P multocida PJIs follows.

Les infections sur prothèse articulaire (IPA) sont souvent causées par des pathogènes comme le Staphylococcus aureus et les staphylocoques à coagulase négative. Cependant, on constate de plus en plus d'autres étiologies microbiennes et de facteurs de risque particuliers. Le Pasteurella multocida, un coccobacille à Gram négatif qui fait partie de la flore orale normale de nombreux animaux, est particulièrement courant chez les chiens et les chats. Peu d'IPA causées par le P multocida sont signalées dans les publications scientifiques, mais elles se produisent surtout après une morsure ou une griffure d'animal. Le présent article décrit une infection à P multocida qui s'est manifestée après que l'articulation a été léchée par un chien et une arthroplastie de révision compliquée en deux étapes. Une analyse bibliographique approfondie de l'IPA à P multocida suit.

Holding children and young people: identifying a theory-practice gap.

Holding practices are employed to help a child or young person stay still during the administration of treatments, prevent treatment interference or to undertake an examination, which can sometimes be invasive. The aim of this study was to explore assumptions and practices of holding to develop theories about teaching practices following Grounded Theory methodology for undergraduate nursing students, university lecturers and clinical mentors. The practice of therapeutic holding is often covert and not considered to be part of the treatment per se, which has led to concealment and a reticence to discuss practices openly. This study identified that there is variance in the experiences and practices. Prominent themes that emerged were a lack of clarity and lack of training. It appears that therapeutic holding practices have moved from being viewed as 'uncontested' (practice is not disputed) to 'indifferent' (where there is denial about this practice). These findings have serious implications for current practice and future training.

Interventions for post-infectious irritable bowel syndrome: a systematic review of treatment efficacy.

BACKGROUND: Post-infectious irritable bowel syndrome (PI-IBS) due to traveler's diarrhea is the second most common illness seen in post-travel clinics, yet its optimal management remains unknown. We performed a systematic review to evaluate treatment efficacy in PI-IBS. METHODS: We searched Medline, EMBASE, LILACS, CINAHL, CAB abstracts, and the Cochrane Library to February 3, 2014 for intervention studies of the pharmacologic and non-pharmacologic management of PI-IBS and examined the evidence according to a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scale. RESULTS: Of 336 records, 9 studies were included. Eight studies of pharmacologic interventions examined 5 agents (mesalazine or mesalamine, ondansetron, prednisolone, cholestyramine, and metronidazole). One study examined the non-pharmacologic intervention of different infant nutritional formulas following acute gastroenteritis. The quality of the evidence to date was low, with small sample size (fewer than 50 participants) and short duration of follow-up. Overall, the efficacy of pharmacological treatment ranged from no benefit (ondansetron and prednisolone) to moderately beneficial (cholestyramine and metronidazole). The evidence for mesalazine was equivocal: one study showed benefit, two others showed none. CONCLUSIONS: Heterogeneity in outcome measures and low strength of evidence preclude recommendations on the optimal management of PI-IBS by a specific agent. More comparative intervention research into PI-IBS treatment is needed for consistent best practice in PI-IBS management. Clinicians may elect to pursue therapeutic trials of mesalazine, cholestyramine, or metronidazole in individual patients, but should be aware that data supporting the efficacy of these agents is limited.

Holding children and young people: defining skills for good practice.

Physical holds are used to help children and young people receive clinical care in situations where their behaviour may limit the ability of nurses and allied professionals to deliver treatment effectively. This article provides an overview of a qualitative study of 11 nurses and allied professionals who were interviewed with semi-structured questions. The major findings suggest there is a lack of clear and agreed terminology and nurses and allied professionals are guessing at how to describe the practice. As a result, there was no discussion or documentation of the practices of holding (whether successful or unsuccessful) within the clinical area. For the last decade, professional opinion was that this is an 'uncontested practice'. It can therefore be questioned whether this practice has moved from being 'uncontested' to 'indifferent'. Nurses and allied professionals need to revive a common definition of 'good' around the actions of holding, which can hopefully lead to holding skills being more clearly defined and evidence-based.

Enterohemorrhagic Escherichia coli Infections and the Hemolytic-Uremic Syndrome.

Enterohemorrhagic Escherichia coli (EHEC; Shiga toxin/verotoxin-producing E. coli) can cause bloody diarrhea and the hemolytic-uremic syndrome (HUS), typically following consumption of contaminated food (including ground beef, leafy greens, and sprouts) and water. Often associated with foodborne outbreaks, EHEC possess unique virulence factors that facilitate effective colonization of the human gastrointestinal tract and subsequent release of Shiga toxin. This article reviews the epidemiology, pathogenesis, clinical presentation, treatment, and prevention of EHEC infections, focusing on E. coli O157:H7, the serotype most common in North America, and E. coli O104:H4, the serotype responsible for the EHEC outbreak in Germany in 2011.

Dysregulation of angiopoietin 1 and 2 in Escherichia coli O157:H7 infection and the hemolytic-uremic syndrome.

Escherichia coli O157:H7-associated hemolytic-uremic syndrome (HUS) is characterized by profound prothrombotic abnormalities. Endothelial dysfunction, manifested as dysregulation of angiopoietins 1 and 2 (Ang-1/2), could underlie HUS pathophysiology. We measured Ang-1/2 in 77 children with E. coli O157:H7 infection. Ang-1, Ang-2, and the Ang-2/Ang-1 ratio were significantly different in HUS vs the pre-HUS phase of illness or uncomplicated infection. Angiopoietin dysregulation preceded HUS and worsened as HUS developed. In vitro exposure of human microvascular endothelial cells to Shiga toxin recapitulated the in vivo observations. Angiopoietin regulation is profoundly affected before and during HUS, reflecting that subclinical endothelial dysfunction precedes overt microangiopathy.