Survey of the use of rapid sequence induction in the accident and emergency department

OBJECTIVES

To determine the current position regarding the use of rapid sequence induction (RSI) by accident and emergency (A&E) medical staff and the attitudes of consultants in A&E and anaesthetics towards this.

METHODS

A questionnaire was designed that was distributed to consultant anaesthetists and A&E physicians in hospitals receiving over 50,000 new A&E patients per year.

RESULTS

A total of 140 replies were received (a response rate of 72%). The breakdown of results is shown. There was wide difference of opinion between anaesthetists and A&E consultants as to who performs RSI at present in their A&E departments, however two thirds of anaesthetists thought A&E staff with appropriate training and support should attempt RSI either routinely or in certain circumstances.

CONCLUSIONS

A&E staff in several hospitals routinely undertake RSI and the majority of A&E consultants thought that RSI would be undertaken by A&E staff if an anaesthetist were unavailable. There is disagreement regarding the length of anaesthetic training required before A&E medical staff should undertake RSI.

Effects of influenza vaccination of health-care workers on mortality of elderly people in long-term care: a randomised controlled trial

BACKGROUND

Vaccination of health-care workers has been claimed to prevent nosocomial influenza infection of elderly patients in long-term care. Data are, however, limited on this strategy. We aimed to find out whether vaccination of health-care workers lowers mortality and the frequency of virologically proven influenza in such patients.

METHODS

In a parallel-group study, health-care workers in 20 long-term elderly-care hospitals (range 44-105 patients) were randomly offered or not offered influenza vaccine (cluster randomisation, stratified for policy for vaccination of patients and hospital size). All deaths among patients were recorded over 6 months in the winter of 1996-97. We selected a random sample of 50% of patients for virological surveillance for influenza, with combined nasal and throat swabs taken every 2 weeks during the epidemic period. Swabs were tested by tissue culture and PCR for influenza viruses A and B.

FINDINGS

Influenza vaccine uptake in health-care workers was 50.9% in hospitals in which they were routinely offered vaccine, compared with 4.9% in those in which they were not. The uncorrected rate of mortality in patients was 102 (13.6%) of 749 in vaccine hospitals compared with 154 (22.4%) of 688 in no-vaccine hospitals (odds ratio 0.58 [95% CI 0.40-0.84], p=0.014). The two groups did not differ for proportions of patients positive for influenza infection (5.4% and 6.7%, respectively); at necropsy, PCR was positive in none of 17 patients from vaccine hospitals and six (20%) of 30 from no-vaccine hospitals (p=0.055).

INTERPRETATION

Vaccination of health-care workers was associated with a substantial decrease in mortality among patients. However, virological surveillance showed no associated decrease in non-fatal influenza infection in patients.

Zidovudine (AZT) versus AZT plus didanosine (ddI) versus AZT plus zalcitabine (ddC) in HIV infected adults

BACKGROUND

Zidovudine (AZT) monotherapy was the first antiretroviral drug to be tested widely. The next two drugs to be developed were didanosine (ddI) and zalcitabine (ddC).

OBJECTIVES

To assess the effects of zidovudine (AZT), zidovudine plus didanosine (ddI) and zidovudine plus zalcitabine (ddC) on HIV disease progression and survival.

SEARCH STRATEGY

Investigators and pharmaceutical companies were contacted, and MEDLINE searches were supplemented by searching conference abstracts.

SELECTION CRITERIA

Randomised controlled trials comparing any two of AZT plus ddI, AZT plus ddC or AZT alone in participants with or without AIDS which collected information on deaths and new AIDS events.

DATA COLLECTION AND ANALYSIS

Individual patient data with, wherever possible, follow-up obtained beyond that previously published were obtained and checked for internal consistency and consistency with any published reports; any apparent discrepancies were resolved with the trialists. Time to death and to disease progression (defined as a new AIDS-defining event or prior death) were analysed on an intention to treat basis, stratified to avoid direct comparisons between participants in different trials.

MAIN RESULTS

Six trials were included in the meta-analysis. During a median follow-up of 29 months, 2904 individuals progressed, of whom 1850 died. The addition of ddI to AZT delayed both progression (RR 0.74; 95% CI 0.67 to 0.82, P<0.0001) and death (RR 0.72; 95% CI 0.64 to 0.82, P<0.0001). Likewise, the addition of ddC to AZT also delayed progression (RR 0. 86; 95% CI 0.78 to 0.94, P=0.001) and death (RR 0.87; 95% CI 0.77 to 0.98, P=0.02). After 3 years the estimated percentages alive and without a new AIDS event were 53% for AZT+ddI, 49% for AZT+ddC and 44% for AZT alone; the percentages alive were 68%, 63% and 59% respectively. Five of the six trials involved randomised comparisons of AZT+ddI versus AZT+ddC: in these, the AZT+ddI regimen had greater effects on disease progression (P=0.004) and death (P=0.009).

REVIEWER'S CONCLUSIONS

The use of ddI and, to a lesser extent, ddC delayed both HIV disease progression and death, at least when added to AZT.

Anticholinesterases in the treatment of Alzheimer's dementia--the first year's experience in Argyll & Clyde

The local experience of the introduction of a new anticholinesterase treatment for Alzheimer's dementia is described, including the use of a protocol to introduce the use of these drugs. The results in the first 233 patients seen are reported. The protocol seemed to anticipate SMAC. guidelines and to be easy to operate; the drug appeared to have clear clinical effect.

Assaults on staff by psychiatric patients in community residences

The study examined assaultive behavior directed toward staff of community-based residential facilities by patients who had been discharged to these facilities from Massachusetts state psychiatric hospitals in the early 1990s. Observed rates of assault declined by 61 percent over a six-and-a-half-year period. Early in the study period, male patients were more likely than female patients to be assaultive, but men and women had similar rates of assaultiveness later in the study period, after they had been in residential placements for several years. The most common diagnosis among assaultive patients was schizophrenia.

Immediate versus deferred zidovudine (AZT) in asymptomatic or mildly symptomatic HIV infected adults

BACKGROUND

Zidovudine (AZT) monotherapy was the first antiretroviral drug to be tested widely. Subsequent trials in asymptomatic or early symptomatic HIV infection indicated short-term delays in disease progression with AZT, but not improved survival.

OBJECTIVES

To assess the effects of immediate versus deferred zidovudine (AZT) on HIV disease progression and survival.

SEARCH STRATEGY

Investigators and pharmaceutical companies were contacted, and MEDLINE searches were supplemented by searching conference abstracts.

SELECTION CRITERIA

Randomised controlled trials comparing immediate versus deferred AZT in participants without AIDS which prospectively collected deaths and new AIDS events.

DATA COLLECTION AND ANALYSIS

Individual patient data with, wherever possible, follow-up obtained beyond that previously published was obtained and checked for internal consistency and consistency with any published reports; any apparent discrepancies were resolved with the trialists. Time to death and to disease progression (defined as a new AIDS-defining event or prior death) were analysed on an intention to treat basis, stratified to avoid direct comparisons between participants in different trials.

MAIN RESULTS

Nine trials were included in the meta-analysis. During a median follow-up of 50 months, 1908 individuals developed disease progression, of whom 1351 died. In the deferred group, 61% started antiretroviral therapy (median time to therapy 28 months, which was AZT monotherapy in 94%). During the first year of follow-up immediate AZT halved the rate of disease progression (P<0.0001), increasing the probability of AIDS-free survival at one year from 96% to 98%, but this early benefit did not persist: after 6 years AIDS-free survival was 54% in both groups, and at no time was there any difference in overall survival, which at 6 years was 64% with immediate and 65% with deferred AZT (rate ratio [RR] 1.04, 95% confidence interval [CI] 0. 94 to 1.15).

REVIEWER'S CONCLUSIONS

Although immediate use of AZT halved disease progression during the first year, this effect was not sustained, and there was no improvement in survival in the short or long term.

Community-based injury prevention interventions

Community-based interventions offer a promising solution for reducing child and adolescent unintentional injuries. By focusing on altering behavior, promoting environmental change within the community, or passing and enforcing legislation, these interventions seek to change social norms about acceptable safety behaviors. This article systematically reviews 32 studies that evaluated the impact of community-based injury prevention efforts on childhood injuries, safety behaviors, and the adoption of safety devices. Interventions targeted schools, municipalities, and cities. Most relied on an educational approach, sometimes in combination with legislation or subsidies, to reduce the cost of safety devices such as bicycle helmets. Results indicate that community-based approaches are effective at increasing some safety practices, such as bicycle helmet use and car seat use among children. The evidence is less compelling that such interventions increase child pedestrian safety, increase adolescent vehicle safety by reducing drinking and driving behaviors, or reduce rates of several categories of childhood injuries. Strong evidence supporting the effectiveness of community-based interventions is lacking, in part because few studies used randomized controlled designs or examined injury rates among children and youths as outcome measures. Nonetheless, this review identifies common elements of successful community-based approaches that should be replicated in future studies. First, the use of multiple strategies grounded in a theory of behavior change is critical. Second, to maximize success, interventions should be integrated into the community and approaches should be tailored to meet unique community needs. Third, community stakeholders should be included in the development of community-based strategies. This community involvement and ownership of the intervention increases the likelihood of modeling and peer pressure, leading to widespread adoption of a safety behavior. Finally, when possible, a randomized controlled design should be used to maximize the trustworthiness of reported findings and aid decisions about where to invest resources in community-based approaches to injury prevention.

Neurological features of cerebral malaria in Nigerian children

Cerebral malaria is one of the commonest causes of an acute neurological syndrome in malaria-endemic areas. However, there are few detailed reports of findings on clinical neurological examination of the condition. The neurological features of cerebral malaria in 103 children aged 5 years or less were studied in Ibadan, Nigeria, an area of high malaria transmission. The correlation of these features with prognosis was also studied. Convulsions occurred in 87% of subjects and were in most cases of a generalized tonic-clinic nature. Abnormalities of posture were observed in 41%, abnormal tone in 70% and abnormal deep tendon reflexes in 74%. Absent corneal reflexes were found in about 14%. The time interval between the last seizure episode and presentation in hospital, abnormal posture (decerebrate or decorticate), absence of corneal reflex and depth and duration of coma were indicators of poor prognosis. In this study, cerebral malaria presented with non-specific features of diffuse, symmetrical, upper motor neurone dysfunction, and some specific neurological features were associated with poor prognosis. It is important that cerebral malaria be considered in any child with features of acute encephalopathy in a malaria-endemic area. Careful clinical examination of such children is essential as neurological features of the condition may provide a clue to prognosis.

Ageing in Europe--challenges and consequences

This article outlines the five key social and economic policy challenges presented by the ageing population of the European Union (EU). These challenges are the maintenance of economic security in old age, preserving intergenerational solidarity, combating the social exclusion created by age discrimination, providing long-term care in the context of changes in family and residence patterns, and enabling older people to participate in society as full citizens. The nature of each of these challenges is discussed and priorities pinpointed. The discussion of policy challenges is preceded by an outline of the demographic context of the EU: the combination of declining fertility and increasing longevity. This also includes a discussion of the links between demography and policy. The conclusion of the article considers the current threat to the European model of social policy and suggests ways in which the gerontological community might contribute to its defence.

Combating age discrimination at the workplace

The article consists of four main parts. To begin, it examines the changing context within which organizations are operating their human resource policies and practices, especially the aging of the work force and changing public policies, and summarizes the main forms of age discrimination. Secondly it outlines the "Age Barriers" project and how good practice was defined. The third and main part of the article uses the results of the project to distil some key lessons for labor market participation about the factors which lead organizations to try to counteract age discrimination and the essential ingredients of successful policies. The fourth part emphasizes the importance of moving beyond specific and sometimes tokenistic examples of good practice towards an integrated age management strategy which focuses on the prevention of workforce aging. The conclusion will highlight some key action points for all participants in the labor market. The focus of the article is on policies and human resource practices (the demand side of the labor market), not the abilities of older workers. Discrimination can operate independently of work ability.

Intra-abdominal bleeding caused by spontaneous rupture of an accessory spleen: the CT findings

Accessory spleens are common. Their clinical importance lies in the need to include their removal when performing a splenectomy for primary haematological disorders, or as the source of 'preservable' splenic tissue in cases of ruptured primary spleen. Rupture of a normal spleen almost always occurs because of trauma, spontaneous rupture is rare. In pathological spleens, however, 'spontaneous' rupture is more widely reported, although it is argued that minor trauma is often still responsible in these cases. We report a case of spontaneous isolated rupture of a histologically normal accessory spleen and show the CT findings.

Neurodevelopmental and neurobehavioral sequelae of selected substances of abuse and psychiatric medications in utero

Alcohol exposure in utero affects growth and morphology, and produces FAS, adverse cognitive outcomes, and poorer linguistic abilities and deficits in attention and memory. Maternal smoking, which is widespread in pregnancy, has been associated with physical, cognitive, and behavioral effects in offspring. The effects of fetal exposure to cocaine are more controversial, but increasing evidence identifies a pattern of decreased neonatal head circumference, decreased adaptability to stress, including a disruption in the habituation response in infants, and impaired attention. The literature on the effects of in utero exposure to marijuana is thus far inconclusive, but there is compelling evidence for its producing decreased birth weight and length and deleterious cognitive and attentional effects in some preschool and early school-age samples. Of the widely prescribed medications used in psychiatric practice, evidence for the deleterious effects of lithium and the anticonvulsants carbamazepine and depakote is well-established and compelling. More prospective studies are required before the safety of the atypical antipsychotics and the newer antidepressants is established. Difficulties of standardizing amount, timing, and patterns of use, as well as the confounding effect of the risk factors, must be carefully considered when interpreting the results of outcome studies, especially those regarding substances of abuse.

Low rates of hospitalization for asthma among Aboriginal children compared to non-Aboriginal children of the top end of the northern territory

OBJECTIVE

To determine the hospitalization rates from asthma for Aboriginal and Torres Strait Islander (ATSI) and non-Aboriginal (non-ATSI) children in the 'top end' of the Northern Territory and to determine the proportion of hospitalizations due to asthma.

METHODOLOGY

A retrospective review was undertaken of separation data from the Royal Darwin Hospital for the period July 1991 to June 1997. All children aged 1-9 years residing in the Darwin urban or rural district were included, with asthma identified by the International Classification of Diseases Version 9 codes 493.0-493.9.

RESULTS

The overall average annual hospitalization rate per 1000 population with a principal diagnosis of asthma for ATSI children from rural areas (ATSI-rural) was 2.6, 4.7 for ATSI children from urban areas (ATSI-urban) and 5.5 for non-ATSI children. These hospitalization rates were significantly different between ATSI and non-ATSI children (rate ratio 0.72, 95% CI 0.59-0.86). On stratification for residence, the rates were significantly different between ATSI-rural and non-ATSI children (rate ratio 0.61, 95% CI 0. 47-0.80) but not different between rural and urban dwelling ATSI children (rate ratio 0.76, 95% CI 0.54-1.07) or between ATSI-urban children and non-ATSI children (rate ratio 0.81, 95% CI 0.63-1.03). Asthma was diagnosed in 6.5% of ATSI admissions (4.0% for ATSI-rural and 13.8% for ATSI-urban) and 12.7% of non-ATSI admissions.

CONCLUSION

The hospitalization rate for ATSI children with asthma was significantly lower than for non-ATSI children. Asthma plays a far less significant role in the spectrum of disease affecting hospitalized ATSI children compared to non-ATSI children. There are significant differences in disease frequency between urban and rural resident ATSI children but less marked differences between urban resident ATSI children and non-ATSI children. Further study is required if the underlying causes behind these differences are to be determined.

Nurses' perception and experiences of advocacy

This small qualitative research study, undertaken for a Bachelor (Honours) Course, was aimed at discovering nurses' perceptions and experiences of advocacy, through focused, in-depth interviews. Thematic analysis identified seven major themes: advocacy as a moral obligation, knowing the patient, triggers to becoming an advocate, considering the consequences, the difficulties of advocating, becoming an effective advocate and outcomes of advocacy. When further examined, these themes suggested that advocacy is a process rather than an event. The themes are supported from the data and the steps in the process are outlined and offered as a tentative model of nursing advocacy. This study increases understanding of advocacy from a nursing perspective and may help minimise the difficulties of enacting an advocacy role.

Measuring progress towards a primary care-led NHS

BACKGROUND

The push towards a 'primary care-led' National Health Service (NHS) has far-reaching implications for the future structure of the NHS. The policy involves both a growing emphasis on the role of primary care practitioners in the commissioning of health services, and a change from hospital to primary and community settings for a range of services and procedures. Although the terminology has changed, this emphasis remains in the recent Scottish Health Service White Paper and its English counterpart.

AIM

To consider three questions in relation to this policy goal. First, does the evidence base support the changes? Secondly, what is the scale of the changes that have occurred? Thirdly, what are the barriers to the development of a primary care-led NHS?

METHOD

Programme budgets were compiled to assess changes over time in the balance of NHS resource allocation with respect to primary and secondary care. Total NHS revenue expenditure for the 15 Scottish health boards was grouped into four blocks or 'programmes': primary care, secondary care, community services, and a residual. The study period was 1991/2 to 1995/6. Expenditure data were supplied by the Scottish Office.

RESULTS

Ambiguity of definitions and the absence of good data cause methodological difficulties in evaluating the scale and the appropriateness of the shift. The data that are available suggest that, at the aggregate level, there have been changes over time in the balance of resource allocation between care settings: relative investment into primary care has increased. It would appear that this investment is relatively small and from growth money rather than a 'shift' from secondary care. In addition, the impact of GP-led commissioning is variable but limited.

CONCLUSION

General practitioners' (GPs') attitudes to the policy suggest that progress towards a primary care-led NHS will continue to be patchy. The limited shift to date, alongside evidence of ambivalent attitudes to the shift on the part of GPs, suggest that this is a policy objective that may not be achieved.

Racial differences in bone mineral density and bone loss among end-stage renal disease patients

Although black patients without end-stage renal disease (ESRD) have a greater bone mineral density (BMD) than whites, the impact of race on BMD among patients with ESRD who are likely to have varying degrees of renal osteodystrophy is not known. We undertook a cohort study of 106 hemodialysis patients comparing BMD and bone loss between black and white patients with ESRD to determine if black patients have a greater BMD and less bone loss than white patients with ESRD. BMD was determined by dual-energy radiograph absorptiometry (DEXA). Osteopenia was defined as greater than 1 standard deviation (SD) less than the mean of peak bone mass (T score <-1), and osteoporosis was defined as greater than 2.5 SDs less than the mean of peak bone mass (T score <-2.5). The association between BMD and race was estimated using linear regression. The risk for osteopenia among black compared with white patients was calculated using logistic regression. Black patients were similar to white patients with respect to all characteristics noted, except black patients were less likely to be men (69.7% v 49. 4%) and tended to have greater intact parathyroid hormone (PTH) values (mean, 403.2 +/- 384.5 pg/mL v 161.4 +/- 129.0 pg/mL). Compared with whites, the BMD of blacks was a mean of 1.15 (95% confidence interval [CI], 0.54 to 1.78) SDs greater at the femoral neck after adjusting for age, PTH level, and sex. The percentage of bone loss per year was similar between blacks and whites. The risk for osteopenia among blacks was significantly less than that among whites (odds ratio = 0.15; 95% CI, 0.04 to 0.59) after adjusting for age, sex, and PTH level. Black patients with ESRD have a greater BMD and are at decreased risk for osteopenia compared with whites, independent of renal osteodystrophy. When considering bone disease among patients with ESRD, physicians should also consider osteoporosis and the impact of race on BMD.

Implementation of a national guideline on prophylaxis of venous thromboembolism: a survey of acute services in Scotland. Thromboembolism Prevention Evaluation Study Group

BACKGROUND

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are major complications for hospital patients in developed countries. In 1995, the Scottish Intercollegiate Guidelines Network (SIGN) published an evidence-based guideline to encourage the appropriate use of prophylaxis for DVT among hospitalised patients at risk. The guideline was widely distributed within the NHS in Scotland; however, it is not clear what actions trusts have taken to implement it.

OBJECTIVE

To investigate the type and extent of DVT guideline implementation activities in acute trusts in Scotland.

METHOD

A semi-structured telephone interview with senior clinical audit staff in those trusts with acute services in Scotland.

RESULTS

Twenty-nine of the 30 trusts approached participated in the survey (97%). A range of responses to the guideline were reported, including development of local protocols (n = 20), audit of DVT prophylaxis (n = 19), patient specific reminders (n = 13) and provision of a specialist DVT adviser (n = 3). Overall, 25 of the trusts had undertaken guideline development and dissemination activities, and 17 were involved in more active guideline implementation strategies.

CONCLUSIONS

The majority of acute trusts in Scotland have responded to the SIGN guideline, usually through the development of local protocols. Strategies to implement the guideline or local protocol are less common. Further guidance is needed on this in the next edition of the guideline.

Dissatisfaction is high--but we're listening

Results of the membership services survey conducted at the 19th conference of the HIMAA, Brisbane, October 1998