Biological tissue adhesive for multiple use in the accident and emergency department

OBJECTIVE

To assess the strength of the glue and microbial contamination over 28 days from opening a vial of tissue adhesive in the accident and emergency setting, and to quantify cost savings of repeated use of the vials.

METHOD

(1) Strips of reinforced nylon and a specially constructed piece of apparatus designed to measure the force at which the glue gave way were used to measure the strength of the tissue adhesive at various times after the glue was opened to assess if the glue strength deteriorated over time. (2) Microbial contamination of the glue was assessed.

RESULTS

There was no deterioration in the glue strength over time. There was no evidence of microbial contamination of the glue.

CONCLUSION

Cyanoacrylate tissue adhesive can safely be reused for a period of 28 days after opening with no risk of degradation of glue strength or contamination with micro-organisms. In our department this represents a potential saving of ł5400 per year.

Treatment outcome for a maltreated population: benefits, procedural decisions, and challenges

OBJECTIVE

To review the benefits, challenges, and procedural decisions to consider when implementing and managing a treatment outcome program for a maltreated population.

METHOD

We reviewed the reasons to implement a treatment outcome program, decisions regarding procedures, and challenges likely to be encountered based on literature in the field and the authors' 6 years of experience in developing and maintaining an outcome program at a center specializing in the treatment of maltreated children.

RESULTS

The development of an outcome programs requires careful measurement selection, early and ongoing staff-involvement, support from higher management, a well-developed data base and client tracking system, a coordinator and support staff, clinical utility, planning for fiscal impact, and flexibility to contend with challenges.

CONCLUSIONS

Based on our experience, the plethora of clinically rich and administratively useful information derived from an outcome program far outweighs the challenges and costs of establishing and maintaining an outcome program.

The weaning continuum use of Acute Physiology and Chronic Health Evaluation III, Burns Wean Assessment Program, Therapeutic Intervention Scoring System, and Wean Index scores to establish stages of weaning

OBJECTIVE

To determine whether four stages of weaning (acute, prewean, wean, and outcome) could be identified by using clinical instruments designed to quantify severity of illness, patient stability, or weaning readiness. The instruments used were the Acute Physiology and Chronic Health Evaluation (APACHE III), the Therapeutic Intervention Scoring System (TISS), the Burns Wean Assessment Program (BWAP), and the Wean Index (WI). The stages were adapted from those proposed by the American Association of Critical Care Nurses Third National Study Group's Weaning Continuum Model.

DESIGN

Prospective, convenience cohort. This study was part of a larger study designed to test an outcomes managed approach to weaning by using an outcomes manager and a clinical pathway.

SETTING

University medical intensive care unit.

PATIENTS

Adult patients requiring mechanical ventilation >3 days admitted to the medical intensive care unit between November 1994 and May 1995.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Scores for the APACHE III, TISS, BWAP, and WI were collected on 97 patients every other day until they weaned, were transferred, or died. Outcomes described for each stage of weaning were dated on the clinical pathway when achieved. Comments about patient stability and ventilator progress also were recorded along with a subjective determination of the stage of weaning. We used decision rules to identify time intervals for each stage of weaning and outcomes attained by stage. Finally, APACHE III, TISS, BWAP, and WI scores were placed in each stage by date for analysis. The APACHE III, TISS, and BWAP scores were able to differentiate the acute, prewean, and wean stages but not the outcome stage.

CONCLUSIONS

By identifying distinct scores for each stage, we may be able to better explore appropriate interventions for the stages as well as predict weaning outcomes. Indices that include physiologic and respiratory factors can differentiate weaning stages, but respiratory factors alone cannot.

Measurement of DNA damage by the comet assay in rat embryos grown in media containing high concentrations of vitamin K(1)

It has been suggested that vitamin K(1) (phylloquinone) can cause genetic damage in rapidly dividing cells and that this should be considered in the risk/benefit analysis of the prophylactic use of vitamin K(1) in the newborn. Usual intramuscular administration of 1mg of vitamin K(1) to the newborn gives peak plasma levels of 1-2 microg/ml (approximately 2-4 microM). To investigate the possible harmful effects of high concentrations of vitamin K(1), rat embryos undergoing rapid cell division in the organogenic period were cultured for 46 hours in rat sera containing either 1, 10 or 100 microg of added vitamin K(1) per ml (2, 22 or 222 microM). At the end of the culture period the embryos were dissociated and the cells examined for evidence of DNA damage using the alkaline version of the comet assay. Control embryos were cultured in sera without added vitamin K(1) and positive controls were control embryos exposed to hydrogen peroxide at the end of the culture period. The results did not show any evidence of DNA damage in the vitamin K(1) exposed embryos. The positive controls showed a significant increase in tail length, moment and inertia. In conclusion, under the experimental conditions used, high concentrations of vitamin K(1) did not induce primary DNA damage in cells from rat embryos grown in vitro.

Newfoundland angers its MDs by seeking medical help from armed forces

When the Newfoundland government announced in June that it would use military doctors as a stopgap measure to solve physician shortages in rural parts of the province, local doctors weren't impressed. "They thought it was a joke," said Dr. Alan McComiskey. They have since learned that it wasn't.

Rural medicine: what role should nurse practitioners play?

Rural physicians and other professionals attending a recent conference in St. John's reached consensus on a number of issues surrounding the role of nurse practitioners. The issue is important for rural doctors, since some people think NPs can help solve the physician shortage in rural areas.

Pupillary dilatation and driving in diabetic patients

Diabetic patients routinely have their pupils dilated for fundoscopy as part of the annual review. To assess the ability of diabetic patients to drive after pupillary dilatation we studied 61 diabetic patients (18 IDDM, 43 NIDDM), mean age 54.98 years, before and 1 h after pupillary dilatation with 1% tropicamide. Binocular visual acuity (BVA) and contrast sensitivity were checked without glare, with glare, and with glare and sunglasses. Glare was introduced using a 60 W bulb in all 61 patients and with a 500 W bulb in 37 of these patients. Prior to dilatation all 61 patients had a BVA of 6/9 or better. A significant reduction in BVA was found post-dilatation (p = 0.005) and 4 out of the 61 patients (6.56%) had a post-dilatation BVA of less than 6/9. The 60 W glare source caused a significant reduction in BVA pre-dilatation (p < 0.05), but not the 500 W glare. With glare, post-dilatation BVA reduced further, resulting in 6 and 7 patients having a BVA of less than 6/9 with the 60 W and 500 W glare source, respectively. The addition of sunglasses with glare did not improve the BVA. No patient with a BVA of 6/5 pre-dilatation reduced to less than 6/9 post-dilatation. No significant change in contrast sensitivity was found in any of the test conditions. We conclude that patients who meet the visual legal requirements to drive (BVA < or = 6/9) prior to dilatation may not fulfil them post-dilatation. This has important clinical implications and the time course of the phenomenon requires exploration. Meanwhile, patients need to be warned not to drive after pupillary dilatation when they attend for annual fundoscopic examination, certainly for at least two hours.

Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation

BACKGROUND: Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation. OBJECTIVE: To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation. METHODS: A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used. RESULTS: Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group. CONCLUSION: Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.

Design, testing, and results of an outcomes-managed approach to patients requiring prolonged mechanical ventilation

BACKGROUND

Outcomes management that uses critical pathways may decrease costs while improving outcomes for patients who require prolonged mechanical ventilation.

OBJECTIVE

To study the efficacy of an outcomes-managed approach to weaning patients from prolonged (more than 3 days) mechanical ventilation.

METHODS

A method of multidisciplinary care delivery was designed that included an outcomes manager, a care pathway for patients receiving mechanical ventilation, and weaning protocols. Data collection consisted of three parts: a retrospective review of 124 patients who required prolonged ventilation during a 1-year period before implementation of the care model, a 6-month prospective study in which 91 patients were alternately assigned by month to an outcomes-managed approach or a non-outcomes-managed approach, and a 6-month prospective study of 90 patients in which an outcomes-managed approach without alternate-month assignment was used.

RESULTS

Outcomes management had no significant effect on total duration of mechanical ventilation or length of stay in the hospital, days of mechanical ventilation without tracheostomy, days of mechanical ventilation with tracheostomy, or outcome (weaned, withdrawal from mechanical ventilation, death, or transfer without weaning). However, duration of mechanical ventilation was 1.3 days shorter, length of stay in the hospital was 2.1 days shorter, and the cost per case was $ 3341 less for patients in the outcomes-managed group than for patients in the non-outcomes-managed group.

CONCLUSION

Outcomes-managed care did not have a significant effect on duration of ventilation, length of stay in the hospital, or outcome in patients receiving long-term mechanical ventilation.

The 97th Annual Meeting of the American Society for Microbiology

The Annual Meeting of the American Society for Microbiology took place in Miami Beach, Florida, from May 4-8, 1997. Over 9000 scientists attended this meeting, which covers all major aspects of prokaryotic research (basic, applied, medical, and diagnostic). Genomics discussions were a major part of the meeting agenda, with scientists detailing both basic and applied research effort using genomics and bioinformatics. New ideas for potential novel antimicrobials have also surfaced as the tools to pursue Drug Discovery have fallen into place and pharmaceutical companies have ;rediscovered' anti-infectives.

Knowledge and attitude assessment of Quebec daycare workers and parents regarding HIV/AIDS and hepatitis B

ISSUES

Cases of discrimination occur in Quebec daycares towards HIV-positive children as well as HIV-negative children born to seropositive parents.

OBJECTIVES

Offer three-hour information sessions on bloodborne diseases, specifically HIV and hepatitis B, universal precautions, as well as legal, ethical and psychosocial aspects of HIV/AIDS to: 1) ensure that daycare workers have basic medical information on transmission of HIV and other bloodborne infections, 2) review basic hygiene including universal precautions, 3) link daycares to HIV/AIDS resources in their communities, and 4) facilitate the development of pro-active daycare policies for the integration of HIV-positive children.

RESULTS

In total, 108 information sessions were given, in which 349 daycares participated. Results show an important difference in terms of knowledge and attitudes of the participants. Of the daycares which participated in the information sessions, 37% have developed their own pro-active policy.

Audit of a rural hospital's coronary care unit: comparison of two predictive instruments of acute myocardial infarction mortality

The purpose of the study was to compare observed mortality of a rural hospital coronary care unit with mortality rates estimated by two predictive instruments of mortality. The mortality rates of 86 consecutive patients with confirmed acute myocardial infarction were compared with those predicted by the presence or absence of eight risk factors for mortality identified by the Thrombolysis in Myocardial Infarction (TIMI) trial, and mortality predicted by a logistic regression equation LRE). Seventeen patients (20 per cent) died within 6 weeks of admission; the number of TIMI risk factors present predicted a mortality of 9.8 per cent, and the instrument of Selker's predicted a mortality of 25.9 per cent. Patients with 3 TIMI risk factors had a significantly higher mortality than predicted (46.2 versus 13.0 per cent, p < 0.01). There were no significant differences between the receiver operating characteristic (ROC) curve of either instrument. The predictions of Selker's instrument, however, showed no significant difference from observed mortality, even when the patients were grouped into quintiles, and the predicted mortality rates were corrected for any presumed benefit from thrombolysis. The predictive instrument of Selker more consistently estimates observed mortality than the presence of risk factors identified by the TIMI trial.

The early diagnosis of acute myocardial infarction. Comparison of a simple algorithm with a computer program for electrocardiogram interpretation

The sensitivity and specificity of electrocardiographic (ECG) interpretation by a simple algorithm was compared with a computer read ECG machine. Clinical data and ECG findings on 264 consecutive patients admitted to a coronary care unit with suspected acute myocardial infarction were prospectively entered into an algorithm with 13 end-points. These end-points were compared with the interpretations of a computer read ECG machine (Marquette MAC PC). 86 patients (32.5%) had confirmed acute infarction. 85% of those with infarction had some form of ST elevation on their initial ECG. Patients with ST elevation presented earlier (4.9 +/- 4.9 versus 8.0 +/- 9.7 hours after symptom onset, p < 0.001), and were older (66.5 +/- 11.0 versus 62.0 +/- 12.5 years, p < 0.01) than those without infarction. According to the algorithm 94.2% of patients with infarction had some form of ECG abnormality, compared with 55.6% of those without infarction (p < 0.001). The area under the receiver operating characteristic (ROC) curve of the algorithm was 92.3% of the area of the graph. This was more (p < 0.01) than the area under the ROC curve of the interpretations of the computer read ECG machine (83.9%). Marked ST elevation with reciprocal changes was the most specific indicators of infarction (Likelihood ratio 51.7). The algorithm, therefore, was comparatively sensitive and specific in the early diagnosis of acute infarction.

Management of tracheal and bronchial stenoses with the Gianturco stent

Thirty-six cancer patients with symptomatic tracheobronchial stenoses received Gianturco tracheobronchial stents over a 9-year period. Symptoms improved in 28 patients (78%). The overall median survival was 1 month 3 weeks (range, 4 days to 35 months). The median survival for patients who showed improvement after receiving stents was 3 months compared with 1 week for those who did not respond. Complications were minimal. The Gianturco stent may palliate symptoms of tracheobronchial compression in selected cancer patients.

Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites

BACKGROUND: Nursing textbooks and tradition suggest that the high-Fowler's position is best to optimize diaphragmatic excursion and effective breathing pattern. The optimal position for intubated patients with obesity, ascites or abdominal distention has yet to be determined but is important because weaning trial outcomes may reflect the effect of position rather than weaning trial tolerance. OBJECTIVE: To determine the body position that optimizes breathing pattern (tidal volume and respiratory rate) in spontaneously breathing, intubated patients with a large abdomen. METHODS: Nineteen intubated patients with abdominal distention, ascites or obesity who were on continuous positive airway pressure or the pressure support ventilation mode were studied in the 0 degrees, 45 degrees, 90 degrees and reverse Trendelenburg's at 45 degrees positions for 5 minutes prior to data collection. RESULTS: The RT at 45 degrees position resulted in a significantly larger tidal volume and lower respiratory rate than the 90 degrees position in intubated, spontaneously breathing patients with a large abdomen. The 45 degrees position resulted in a significantly lower respiratory rate than at 90 degrees; however, no difference in tidal volume was demonstrated. DISCUSSION: A high respiratory rate and low tidal volume potentiates atelectasis and ultimately failure to wean. It is important that the effect of positioning on breathing pattern in intubated patients be determined so that care planning results in optimal outcomes. CONCLUSIONS: The results of this study have implications for the selection of chair and bed positioning during weaning trials.

Effect of body position on spontaneous respiratory rate and tidal volume in patients with obesity, abdominal distension and ascites

BACKGROUND

Nursing textbooks and tradition suggest that the high-Fowler's position is best to optimize diaphragmatic excursion and effective breathing pattern. The optimal position for intubated patients with obesity, ascites or abdominal distention has yet to be determined but is important because weaning trial outcomes may reflect the effect of position rather than weaning trial tolerance.

OBJECTIVE

To determine the body position that optimizes breathing pattern (tidal volume and respiratory rate) in spontaneously breathing, intubated patients with a large abdomen.

METHODS

Nineteen intubated patients with abdominal distention, ascites or obesity who were on continuous positive airway pressure or the pressure support ventilation mode were studied in the 0 degrees, 45 degrees, 90 degrees and reverse Trendelenburg's at 45 degrees positions for 5 minutes prior to data collection.

RESULTS

The RT at 45 degrees position resulted in a significantly larger tidal volume and lower respiratory rate than the 90 degrees position in intubated, spontaneously breathing patients with a large abdomen. The 45 degrees position resulted in a significantly lower respiratory rate than at 90 degrees; however, no difference in tidal volume was demonstrated.

DISCUSSION

A high respiratory rate and low tidal volume potentiates atelectasis and ultimately failure to wean. It is important that the effect of positioning on breathing pattern in intubated patients be determined so that care planning results in optimal outcomes.

CONCLUSIONS

The results of this study have implications for the selection of chair and bed positioning during weaning trials.

Risks and benefits of using Marlex mesh in chest wall reconstruction

The records of 101 patients who had undergone chest wall reconstruction both with and without stabilization of the chest wall by Marlex mesh were reviewed to see if Marlex reduced ventilator dependence and hospital stay, and to determine whether the use of Marlex was associated with any increased risk of infection. In 40 patients in whom Marlex was used, the mean number of days on postoperative ventilator support was 0.8, and mean hospital stay was 9.7 days. In 61 patients in whom Marlex was not used, the mean number of days on ventilator support was 4.9, and mean hospital stay was 17.5 days. These differences were statistically significant (p = 0.03, p = 0.006). Two patients in the Marlex-stabilized group (5%) developed wound infections, but these were preceded by ischemic necrosis of overlying flaps. None of the patients without Marlex developed wound infections. That difference was not statistically significant. We conclude that the use of Marlex in chest wall reconstruction does not significantly increase the risk of wound infection, provided that overlying tissues are properly vascularized and remain viable, and that synthetic mesh does improve chest wall stability and reduce ventilator dependence and overall hospital stay.

Intercostal nerve block, interpleural analgesia, thoracic epidural block or systemic opioid application for pain relief after thoracotomy?

The purpose of this study was to investigate the effect of different pain-relief methods (regional and systemic) following thoracotomies on the cardiovascular system, pulmonary gas exchange, various endocrine parameters and subjective perception. A further aspect was to evaluate the benefits of interpleural analgesia as a new regional technique against already established regional techniques, such as intercostal nerve block and thoracic epidural block. All postoperative pain methods led to a significant time-dependent reduction of the adrenaline concentrations in plasma while the noradrenaline concentrations did not change significantly. There were no statistical differences in catecholamine concentrations among the different study groups, although the mean concentrations of adrenaline in patients having a thoracic epidural block for pain relief were lower in comparison to the findings in other groups. The plasma concentrations of the "stress metabolites", such as glucose, free fatty acids and lactate, as well as the haemodynamic (mean arterial pressure, heart rate) and pulmonary parameters (blood gas analyses), showed no significant differences among groups. In contrast to the other pain-relieving methods, interpleural analgesia did not lead to sufficient pain relief in that 7 out of 10 patients needed supplementary systemic opioid therapy. Therefore, interpleural analgesia for pain relief following thoracotomies cannot be recommended.

Large field studies of hospital based services: lessons from occupational therapy

A study with a quasi-experimental design was developed to evaluate the effectiveness of hospital-based occupational therapy services in Nova Scotia. Seven hospitals with occupational therapy services were matched with seven hospitals without occupational therapy services. Within the two hospital groups, subjects were matched on the basis of diagnosis and disability. Outcome measures included measures of functional performance in activities of daily living, and community living skills. This paper discusses some of the strengths and weaknesses of conducting large field studies of hospital based services. It is based on our experience with an occupational therapy outcome evaluation. Some of the strengths include well developed and implemented hospital admission and discharge practices, personal contact with key hospital staff, support of the hospital occupational therapy directors and the Nova Scotia Department of Health, and professional support through national guidelines on the client-centered practice of occupational therapy. Study weaknesses can be categorized into three major areas including evaluation issues, hospital issues, and professional issues. Our experience can contribute to the scientific literature on outcome studies on occupational therapy and to the conduct of large field studies of hospital based services in general.