Evaluation of a nurse-led glaucoma assessment clinic for non-complex patients.

AIMS AND OBJECTIVES: The purpose of this study was to assess the safety, feasibility and effectiveness of a nurse-led glaucoma assessment clinic service. BACKGROUND: Glaucoma is a group of serious, irreversible optic neuropathies that progressively damage the optic nerve resulting in blindness. Over 64.3 million people globally are affected by glaucoma with numbers projected to increase to 111.8 million by 2040. Glaucoma is a major public health concern that requires the development of innovative models of care to meet current and future health care demands. METHODS/DESIGN: A mixed method design was used to evaluate the assessment of non-complex glaucoma patients attending a new nurse-led clinic. Under an ophthalmologist's supervision, the glaucoma nurse completed 100 hof clinical training and assessment to ensure they were competent in completing and interpreting the required glaucoma assessment protocols. Interrater reliability between the glaucoma nurse and ophthalmology doctor was undertaken. Glaucoma patient waitlist appointment data were also compared before and after the introduction of the nurse-led clinics. This study adhered to the SQUIRE checklist for the reporting of excellence with quality improvement projects. PATIENT CONTRIBUTION: Patients contributed to the evaluation of this new nurse-led service by providing follow-up feedback on their experience. RESULTS: Agreement between clinicians for appropriate follow-up appointment times was high with 93% (n = 315) agreement achieved. Furthermore in 297 (87.5%) cases, both clinicians agreed on the patient being referred to the doctor for follow-up review. Glaucoma consultations were shown to increase from 3,115 appointments in 2019/20 to 3,504 appointments in 2020/21 after the introduction of the nurse-led clinic. The nurse-led clinics accounted for 14.5% (n = 512) of clinic appointments. CONCLUSIONS: The introduction of the nurse-led glaucoma assessment clinic service allowed patients to be reviewed safely, efficiently and satisfactorily. This new service subsequently allowed for more complex glaucoma patients to be seen by the ophthalmologists. RELEVANCE TO CLINICAL PRACTICE: Findings revealed that suitably trained glaucoma nurses are able to clinically assess and safely monitor stable non-complex glaucoma patients. Highlights the need for appropriate investment in clinical training and supervision to ensure that glaucoma assessment nurses are adequately prepared to undertake this new practice role.

Evaluation of an immersive simulation programme for mental health clinicians to address aggression, violence, and clinical deterioration.

This study investigated the effectiveness of high-fidelity immersive simulation education to support inter-professional hospital clinical staff in recognizing and responding to aggression, violence, and clinical deterioration of patients admitted with mental health issues. Increased incidents of aggression and violence have been reported in many clinical hospital settings, especially in mental health wards. Patients experiencing severe psychological distress/agitation can result in the escalation of physiological symptoms such as chest pain, difficulty breathing, traumatic injury, etc. Mental health staff do receive aggression prevention training and medical emergency team training. However, there is added complexity when dealing with a mental health patient who is exhibiting aggressive, violent behaviour while also experiencing a medical or psychological emergency. Therefore, mental health staff needed a combined training programme that enhanced their delivery of recovery focussed care, de-escalation, and medical emergency crisis resource management skills. This study used a prospective quasi experimental research design with repeated measures. Hospital clinical staff were immersed in two mental health emergency response and clinical deterioration scenarios and debriefing sessions. Self-efficacy was evaluated using a 10-item validated tool which addressed non-technical skills of Leadership, Management, Communication, and Teamwork. The sample consisted of 122 clinical staff, with the majority from mental health wards (52%; n = 63) who were nurses (68%; n = 83). Mean self-efficacy scores increased significantly across the three time points (F = 11.555; df = 2; P = 0.000). Post hoc pairwise comparisons showed that self-efficacy scores increased between pretest (mean 62.9; n = 122) and posttest 1 (mean 83.2; n = 122) and follow up, 3 months later (posttest 2; mean 81.9; n = 24). Between pre- and posttest 1, significant improvements in self-efficacy were observed for both the Leadership/Management domain (t = 8.2; df 119; P < 0.000; 95% CI 13.3-21.7) and the Communication/Teamwork domain (t = 8.0; df 119; P < 0.000; 95% CI 11.1-18.4). Immersive simulation with high fidelity education was found to be effective in improving hospital nursing and medical staffs' confidence, when responding to incidents of aggression/violence and clinical deterioration of a mental health patient.

Manipulating water for amphibian conservation.

Amphibian populations globally are in decline. One great threat is the abstraction of water resources that alter surface-water hydrology. Conservation actions aimed at restoring or manipulating surface water are employed as a management tool, but empirical evidence on the effectiveness of these approaches is scarce. In this systematic review, we summarized the global experience of manipulating water for amphibian conservation. We explored examples of manipulating water to conserve amphibian species and communities. Approaches varied in their frequency of implementation and in their success. Extending hydroperiod to match larval requirements showed encouraging results, as did off-season drying to control predators. Spraying water into the environment showed several potential applications, but successes were limited. Despite some promising interventions, we identified few (n = 17) empirically supported examples of successful water manipulation to benefit amphibians. It is unclear whether this stems from publication bias or if it is an artifact of language selection. However, manipulating water shows some potential in amphibian conservation, particularly at sites with a proximal water source and in regions where aridity is increasing due to climate change. Regardless of the scale of the intervention or its perceived probability of success, high-quality reporting of empirical results will further understanding of how water manipulations can benefit threatened amphibian populations.

Manipulación del Agua para la Conservación de Anfibios Resumen Las poblaciones mundiales de anfibios están en declinación. Una gran amenaza es la extracción de los recursos hídricos que alteran la hidrología superficial. Las acciones de conservación enfocadas en la restauración o manipulación del agua superficial se emplean como herramientas de manejo, pero la evidencia empírica de la efectividad de estas estrategias es escasa. En esta revisión sistemática resumimos la experiencia mundial de la manipulación del agua para la conservación de anfibios. Exploramos ejemplos de la manipulación del agua para conservar especies y comunidades de anfibios. Las estrategias variaron en la frecuencia de implementación y en el éxito que tuvieron. La extensión del periodo hídrico para que cumpla con los requerimientos de las larvas mostró resultados alentadores, así como lo hizo la sequía atemporal para controlar a los depredadores. La aspersión de agua en el ambiente mostró varias aplicaciones potenciales, pero el éxito fue limitado. A pesar de algunas intervenciones prometedoras, identificamos pocos (n = 17) ejemplos con respaldo empírico de la manipulación exitosa del agua para el beneficio de los anfibios. Todavía no está claro si esto proviene de un sesgo en las publicaciones o si es un artificio de la selección del lenguaje. Sin embargo, la manipulación del agua muestra cierto potencial en la conservación de los anfibios, particularmente en sitios próximos a una fuente de agua y en regiones en donde la aridez está incrementando debido al cambio climático. Sin importar la escala de la intervención o la probabilidad de éxito percibida, la comunicación de alta calidad de los resultados empíricos hará crecer el entendimiento de cómo la manipulación del agua puede beneficiar a las poblaciones amenazadas de anfibios.

Anetoderma in a Patient with Newly Diagnosed Hodgkin's Lymphoma.

A previously healthy 28-year-old woman was admitted to the hospital with respiratory failure and was found to have significant lymphadenopathy on her CT scan. A lymph node biopsy was performed; the pathology was consistent with a diagnosis of Hodgkin's lymphoma and the patient was noted to have multiple, wrinkled, nonscaly, oval-shaped papules that were easily compressible (Figure 1) and were present on the upper and lower extremities, abdomen, chest, and back. The lesions were entirely asymptomatic and had first developed 1 year prior to presentation. Since their initial development, the wrinkled papules had continued to crop up. Some of the lesions began as brownish-red papules and subsequently turned skin-colored.Punch biopsies of the lesional and unaffected skin were performed. A Verhoeff-Van Gieson (VVG) stain showed loss of dermal elastic tissue in the lesional skin, compared to that of the unaffected skin. The clinical and histologic examinations were consistent with the diagnosis of anetoderma.

Searching for a toxic key to unlock the mystery of anemonefish and anemone symbiosis.

Twenty-six species of anemonefish of the genera Amphiprion and monospecific Premnas, use only 10 species of anemones as hosts in the wild (Families: Actiniidae, Stichodactylidae and Thalassianthidae). Of these 10 anemone species some are used by multiple species of anemonefish while others have only a single anemonefish symbiont. Past studies have explored the different patterns of usage between anemonefish species and anemone species; however the evolution of this relationship remains unknown and has been little studied over the past decade. Here we reopen the case, comparing the toxicity of crude venoms obtained from anemones that host anemonefish as a way to investigate why some anemone species are used as a host more than others. Specifically, for each anemone species we investigated acute toxicity using Artemia francisca (LC50), haemolytic toxicity using ovine erythrocytes (EC50) and neurotoxicity using shore crabs (Ozius truncatus). We found that haemolytic and neurotoxic activity varied among host anemone species. Generally anemone species that displayed greater haemolytic activity also displayed high neurotoxic activity and tend to be more toxic on average as indicated by acute lethality analysis. An overall venom toxicity ranking for each anemone species was compared with the number of anemonefish species that are known to associate with each anemone species in the wild. Interestingly, anemones with intermediate toxicity had the highest number of anemonefish associates, whereas anemones with either very low or very high toxicity had the fewest anemonefish associates. These data demonstrate that variation in toxicity among host anemone species may be important in the establishment and maintenance of anemonefish anemone symbiosis.

Early re-presentation to hospital after discharge from an acute medical unit: perspectives of older patients, their family caregivers and health professionals.

AIMS AND OBJECTIVES: To explore the perceptions of older patients who re-presented to hospital within 28 days of discharge from an acute medical unit (AMU), their family caregivers and appropriately experienced health professionals. BACKGROUND: Hospitals are increasingly using AMUs to provide rapid assessment and treatment for medical patients. Evidence of efficacy is building, however in-depth exploration of the experiences of older patients who re-present to hospital soon after discharge from an AMU, and those who care for them, appears to be lacking. DESIGN: A qualitative, descriptive design was used. METHODS: In 2007, our team purposively sampled older patients who re-presented to hospital within 28 days of discharge from an AMU (n = 12), family caregivers (n = 15), and health professionals (n = 35). Data were collected using semi-structured interviews and subjected to thematic content analysis. RESULTS: Four themes emerged: the health trajectory, communication challenges, discharge readiness and the decision to return. Re-presentation to hospital was seen as part of a declining health trajectory. The AMU was viewed as treating acute illness well, however patients and family caregivers left hospital with limited understanding of underlying health problems and, therefore, ill-prepared for future health crises. CONCLUSION: There are clear benefits for older patients from AMUs, which expedite treatment for acute health crises. However, AMU discharge planning needs to consider patients' overall health status and likely future needs to optimise outcomes. Such a requirement is problematic in the context of acute time pressures. RELEVANCE TO CLINICAL PRACTICE: To ensure prompt and expert attention to key aspects of discharge planning for older people leaving AMUs, there is a role for in-depth clinical expertise in the care of older people facing deteriorating life-limiting conditions. Therefore, a leadership role for nurses with geriatric and palliative care expertise, alongside medical and allied health professionals, merits attention in this context.

Pediatric proteomics: an introduction.

The overall goal of this series is to detail the paradigm shift that proteomics will bring to the practice of pediatric medicine and research. Proteomics is the global study of proteins in a biological system, tissue or bodily fluid. This first review will provide a brief overview of proteomics and describe its niche in the other "omics" of system biology. The underlying technology and methodology will be outlined as well as the obstacles that must be surmounted before pediatric proteomics is optimally useful for clinicians. The potential of proteomics in the area of personalized pediatric medicine will also be discussed since this is of particular clinical relevance. The second article in this series will focus on the application of proteomics to neonatology with particular emphasis on diseases where oxidative stress plays a key pathophysiological role.

Bowel problems, self-care practices, and information needs of colorectal cancer survivors at 6 to 24 months after sphincter-saving surgery.

The aim of this study was to describe bowel problems, self-care practices, and information needs of patients who have recovered from the acute effects of sphincter-saving surgery for colorectal cancer. A retrospective, descriptive survey was conducted using a structured telephone interview and mailed questionnaires. The sample consisted of 101 patients who had undergone sphincter-saving surgery for colorectal cancer in the last 6 to 24 months. Most participants (71.3%) reported a change in bowel habits after surgery. The 6 most frequently reported gastrointestinal problems were incomplete evacuation (75.2%), excessive flatus (75.2%), urgency (73.3%), straining (61.4%), perianal soreness or itching (49.5%), and bloating (43.6%). Incontinence of feces (varying from smears to complete bowel action) was reported by 37.6% of participants. The most frequently reported information needs were related to diet (50.5%) and managing conditions such as diarrhea (31.7%), bloating/wind/gas (28.7%), pain (21.8%), and incomplete emptying of the bowel (18.8%). Patients who had recovered from the acute effects of sphincter-saving surgery for colorectal cancer reported a wide range of bowel problems and ongoing concerns about managing symptoms. Findings from this study provide valuable information to guide the development of educational resources to prevent or better manage bowel problems after surgery.

Exploring critical thinking in critical care nursing education: a pilot study.

BACKGROUND: Critical care nurses process vast amounts of information and require well developed critical-thinking skills to make clinical decisions. METHOD: Using a pretest posttest design, the critical-thinking skills of 31 postgraduate nurses were evaluated using the California Critical Thinking Skills Test (CCTST). RESULTS: For the total group, mean critical-thinking scores improved slightly over time. The CCTST revealed a mean pretest score of 18.5 and a mean posttest score of 19.7, both of which were higher than the established norms for the test. Overall, no significant difference was observed between pretest and posttest. However, statistical significance was observed posttest for nurses whose critical-thinking scores improved (p < .000). CONCLUSION: Despite the small sample, the majority of the postgraduate nurses improved their critical-thinking skills during the course of their study.

Patients' self-report of procedural pain in the intensive care unit.

AIM: To determine which routine nursing procedures performed on conscious intensive care unit (ICU) patients were painful and which routine procedures were not painful. BACKGROUND: Current empirical evidence supports that routine procedures are often not viewed in the context of causing pain to the critically ill patient. Given the complexity of illness and the need to prioritize care in ICU patients, clinicians may not consider routine procedures as causing pain. With patients in intensive care undergoing frequent routine procedures, greater understanding of which procedures inflict pain is warranted to improve patient care and inform and shape nursing practice. DESIGN: A prospective, descriptive study using a convenience sample of ICU patients was used. METHODS: Sixty-one patients were asked to rate pain intensity experienced prior to and during a routine nursing procedure using a verbal numeric rating scale. The procedures observed were turning, tracheal suctioning, line removal, deep breathing and coughing exercises, simple dressings and drain removal. RESULTS: Results showed that certain routine procedures cause pain with significant differences observed between pre- and postprocedure pain scores for drain removal (p = 0.042), deep breathing and coughing exercises (p = 0.003), suctioning (p = 0.025), positional change (p = 0.000) and line removal (p = 0.010). A higher proportion of morphine was administered to those patients undergoing drain removal (50%), deep breathing and coughing exercises (38.5%) and turns (32.6%) but results show that <50% of patients actually received analgesia. Heart rate, systolic and diastolic blood pressure all increased slightly postprocedure but were not found to be statistically significant. CONCLUSION: Haemodynamic measures are not suitable indicators for the presence of pain. Nurses need to recognise that certain routine procedures can cause pain and should therefore plan patient care with this in mind. RELEVANCE TO CLINICAL PRACTICE: Nurses need to recognise of the fact that routine procedures can cause pain and to use analgesia appropriately to minimize this pain. Practice guidelines should recommend that pain relieving measures be considered as part of routine procedural instructions. Analgesic prescription and administration could be improved for this patient group.

Getting on with life: accepting the permanency of an implantable cardioverter defibrillator.

Increasing numbers of people with cardiovascular disease are requiring the insertion of Implantable Cardioverter Defibrillators (ICDs). Although these devices are an effective life-saving treatment, psychological distress sometimes accompanies their insertion. A qualitative approach was used to explore the experiences, concerns and needs of recipients of the device in Western Australia. Twenty-two tape-recorded interviews were carried out and transcribed verbatim. This paper focuses on the physical and psychological adjustments following the insertion of the device. A central theme of 'getting on with it' used to cope with the permanency of the device was identified. This was an approach to life in which the presence of the device was accepted and then put aside while life was continued and optimized. This study provides directions for the identification of persons who might be experiencing difficulties adjusting, or who are taking extended amounts of time to accept the permanency of the device.

Use of a Behavioural Pain Scale to assess pain in ventilated, unconscious and/or sedated patients.

UNLABELLED: Current empirical evidence supports claims that pain in sedated, unconscious Intensive Care Unit (ICU) patients is underrated and under-treated. Given the severity of ICU patients' illness pain management, whilst important, may not be considered a priority and therefore can be easily overlooked. The aim of this study was to validate the Behavioural Pain Scale (BPS) for the assessment of pain in critically ill patients by evaluating facial expressions, upper limb movements and compliance with mechanical ventilation. METHODS: A prospective, descriptive repeated measures study design was used to assess the validity and reliability of the BPS for assessing pain in critically ill patients undergoing routine painful (repositioning) and non-painful (eye care) procedures. RESULTS: An average of 73% of BPS scores increased (indicating pain) after patients were repositioned, as opposed to 14% after eye care. This increase was statistically significant for repositioning (p < 0.003) but not for eye care (p > 0.3). The odds of an increase in BPS between pre- and post-procedure assessments was more than 25 times higher for repositioning compared with eye care (p < 0.0001), after controlling for analgesics and sedatives. CONCLUSION: The BPS was found to be a valid and reliable tool in the assessment of pain in the unconscious sedated patient. Results also highlighted that traditional pain indicators, such as fluctuations in haemodynamic parameters, are not always an accurate measure for the assessment of pain in unconscious patients and as such more objective pain assessment measures are essential. Finally, further validation of the BPS and identification of other painful routine procedures is needed to enhance pain management delivery for unconscious patients.

Comparative analysis of cutaneous evaporative water loss in frogs demonstrates correlation with ecological habits.

Most frog species show little resistance to evaporative water loss (EWL), but some arboreal species are known to have very high resistances. We measured EWL and cutaneous resistance to evaporation (Rc) in 25 species of frogs from northern Australia, including 17 species in the family Hylidae, six species in the Myobatrachidae, and one each in the Bufonidae and the Microhylidae. These species display a variety of ecological habits, including aquatic, terrestrial, and arboreal specialisations, with the complete range of habits displayed within just the one hylid genus, Litoria. The 25 species measured in this study have resistances that range from Rc=0 to 63.1. These include low values indistinguishable from a free water surface to high values typical of "waterproof" anuran species. There was a strong correlation between ecological habit and Rc, even taking phylogenetic relationships into account; arboreal species had the highest resistance, aquatic species tended to have little or no resistance, and terrestrial species tended to have resistance between those of arboreal and aquatic frogs. For one species, Litoria rubella, we found no significant changes in EWL along a 1,500-km aridity gradient. This study represents the strongest evidence to date of a link between ecological habits and cutaneous resistance to water loss among species of frogs.

Modelling development of reptile embryos under fluctuating temperature regimes.

An increase in temperature, within bounds, will accelerate development of reptile embryos, and morphogenesis can be normal over a range of temperatures despite those varying rates of development. Less well understood is the form of the relationship that best describes variation in developmental rate with temperature. In this article, we apply a linear degree.hour model, an empirical curvilinear model, a biophysical model, and a polynomial model to data on rates of embryonic development and temperature in the pig-nosed turtle Carettochelys insculpta from northern Australia. The curvilinear models, which have been applied with success to development of insects, describe the embryonic development of turtles well. When fluctuating temperatures extend beyond the constant temperatures that support successful incubation, the curvilinear models continue to perform well, whereas the linear model predictions fail. Sensitivity analysis indicates that under some circumstances, incubation duration may be increased by diel temperature fluctuations, independent of an influence of mean temperature. In other circumstances, incubation duration may be decreased, and in still other circumstances, diel temperature fluctuations will have no impact on incubation duration. This adds an additional dimension to our understanding of how thermal regimes can be selected or manipulated by reptiles to optimise incubation duration and the timing of offspring emergence.

Reasons for attending and not attending a support group for recipients of implantable cardioverter defibrillators and their carers.

There is evidence to suggest that people who have an implantable cardioverter defibrillator and their caregivers experience psychological distress. This qualitative descriptive study explored the experiences, concerns and needs of recipients of implantable cardioverter defibrillators and their caregivers who attended or did not attend a support group organized by a public hospital located in Perth, Western Australia, Australia. Eleven recipients of implantable cardioverter defibrillators and their caregivers participated in this study. Among those who attended the support group, four major themes were identified: providing information, connecting with others, helping others and attendance. Explanations for non-attendance included difficulties attending because of the location, not wanting to be reminded about the implantable cardioverter defibrillator, and a perception, among younger recipients, that the support group was comprised of mainly older recipients with whom they had little in common.

Comparison of a urine chemistry analyser and microscopy, culture and sensitivity results to detect the presence of urinary tract infections in an elective orthopaedic population.

Currently elective orthopaedic patients require a microscopy and culture of urine (MSU) to be performed on admission. Between 70-80% of urine cultures are found to be negative for infection, making this practice costly and time consuming. The purpose of this study was to compare the accuracy of a dip stick urine chemistry analyser (Clinitek 50 machine) with a MSU, to detect the presence of nitrites and/or leukocytes in a group of elective orthopaedic surgical patients. methodology: Using a prospective cohort study design all elective orthopaedic patients who met the study criteria were invited to participate. In total 102 patients undergoing total hip or total knee replacement surgery participated. results: Results showed that the prevalence of urinary tract infections in patients undergoing total knee or hip surgery, was 14%. High specificity and negative predictive values for the detection of bacterial growth by dip stick urine chemical analysis were found, especially when either the presence of nitrites or leukocytes was used as an indicator. conclusion: This study has provided valuable baseline data on the accuracy of using photometry techniques as a screening measure, in the detection of UTI, in a sample of orthopaedic patients. While the Clinitek 50 dip stick urine chemistry analyser did not have high sensitivity in identifying those patients with a UTI, it was specific in identifying those patients who did not have an infection. Given the enormous cost in routine screening of these patients and the impact on nursing resources, use of this analyser could have potential nursing resource and financial benefits.