Novice nurses' first death in critical care

BACKGROUND

The curative focus of critical care and the advanced technology may overshadow the fact that critically ill patients die. Research investigating critical care nurses involvement with death has predominately focused on experienced nurses, but these findings may not be applicable to novice nurses. Increasingly, novice nurses are beginning their careers in critical care and there is minimal research describing their experiences with death.

PURPOSE

To explore the experiences of novice nurses with their first patient death in critical care.

METHOD

Approval was received by the University of Alberta Health Research Ethics Board and the health region's Nursing Division Administration to conduct a qualitative research study. Five nurses, employed in a medical-surgical intensive care unit, participated in the study. Data collection involved an unstructured interview with each participant.

FINDINGS

Analysis of the data revealed five themes: anticipating death, transition from life to death, the moment of death, being with the family, and carrying on. These findings are discussed with implications for academic and clinical settings and suggestions for future nursing research.

Hub-and-spoke model for a 5-day structured patient education programme for people with Type 1 diabetes

AIMS

Structured education programmes for people with Type 1 diabetes can deliver improved diabetes control (including reduced severe hypoglycaemia) and quality of life. They can be cost-effective but are resource intensive. We tested the ability to deliver an evidence-based 5-day programme in diabetes centres too small to deliver the courses.

METHODS

Specialist medical and nursing staff from three district general hospital diabetes services (the 'spokes') were trained in all aspects of the education programme, except those directly related to course delivery, by a larger centre (the 'hub'). The hub staff delivered the 5-day patient education courses, but all other patient education and management was managed locally. Diabetes control and quality of life were assessed at 1 year post-course.

RESULTS

In 63 patients with follow-up data, glycated haemoglobin (HbA(1c)) fell by 0.42 +/- 1.0% (P = 0.001), with a greater fall in those with high HbA(1c) at baseline, and no mean weight gain. Emergency call-out for severe hypoglycaemia fell from 10 episodes in seven patients the year before to one episode in one patient (P = 0.03). Quality-of-life measures improved, with reduced negative impact of diabetes on diabetes-related quality of life (P < 0.00004) and 'present quality of life' improving (P < 0.001).

CONCLUSIONS

The benefits of a 5-day structured education programme can be provided to patients with Type 1 diabetes attending centres without the resources to provide the teaching course itself, by a 'hub-and-spoke' methodology.

Disability in multiple sclerosis and the provision of social and medical services: findings in Wellington, New Zealand

A study of the incapacity and socioeconomic scales in 120 patients with multiple sclerosis (MS) living in Wellington, New Zealand, is described. The questionnaire has been compared by different health professionals. There was good correlation between the observations of different professionals on incapacity analysis and this may be improved by reducing the questions to six. The findings on the socioeconomic scale, however, cannot be predicted accurately from the incapacity scale. The socioeconomic survey revealed major improvement in patient support in New Zealand during the last decade. We consider that our New Zealand findings indicate the value of field officers concerned with co-ordination of services and provision of information for patients with MS. Future research should be directed towards assessment of support systems.

Detection of positive selection in the major capsid protein VP60 of the rabbit haemorrhagic disease virus (RHDV)

Mutations were analysed in the major capsid protein VP60 of the rabbit haemorrhagic disease virus (RHDV), a calicivirus responsible for high mortality rates in both wild and domestic European rabbits (Oryctolagus cuniculus). Likelihood of positive selection was estimated using the PAML software applied to 43 non-identical complete sequences of the major capsid protein. Three codons showed signs of positive selection (with posterior probabilities over 95%), one of them is located in the region containing the major antigenic determinants (region E). The presence of positively selected codons (PSCs) in other regions may suggest the existence of other antigenic regions on the major capsid protein that stimulate protective immune responses. At all the 3 PSCs, variation contributes to putative N-glycosylation sites of the protein. An N-glycosylation site is deleted in the non-pathogenic strain RCV. Some of the substitutions at PSCs may alter the polarity and the charge of the protein with possible implications in the protein structure and host interaction. The detection of PSCs should allow a better understanding of the interaction between RHDV and the rabbit immune system.

Short communication: In vitro antimicrobial susceptibility of Prototheca wickerhamii and Prototheca zopfii isolated from bovine mastitis

Bovine mastitis caused by Prototheca spp. can assume high significance because of economic losses and the potential risk to public health. Studies on the susceptibility of Prototheca spp. to antimicrobials have demonstrated its high level of resistance. We report the susceptibility of bovine isolates of Prototheca wickerhamii and Prototheca zopfii to amphotericin B and nystatin, 2 antifungal agents commonly used in the control of protothecosis, and discuss the results. After subculture, minimum inhibitory concentrations of both antifungal drugs were determined using macrodilution and agar diffusion methods. The inoculum concentration was standardized by determination of colony-forming units per milliliter. Nystatin showed more efficacy than amphotericin B in inhibiting P. wickerhamii growth. In contrast, growth inhibition of P. zopfii was similar for both antifungal agents. This study demonstrates different in vitro susceptibility patterns of P. wickerhamii and P. zopfii, reinforcing the necessity for more investigation into drugs that can be used with clinical efficacy.

Genetic characterization of the chemokine receptor CXCR4 gene in lagomorphs: comparison between the families Ochotonidae and Leporidae

Chemokines receptors are transmembrane proteins that bind chemokines. Chemokines and their receptors are known to play a crucial role in the immune system and in pathogen entry. There is evidence that myxoma virus, the causative agent of myxomatosis, can use the chemokine receptor CXCR4 to infect cells. This virus causes a benign disease in its natural host, Sylvilagus, but in the European rabbit (Oryctolagus cuniculus) it causes a highly fatal and infectious disease known as myxomatosis. We have characterized the chemokine receptor CXCR4 gene in five genera of the order Lagomorpha, Ochotona (Ochotonidae), and Oryctolagus, Lepus, Bunolagus and Sylvilagus (Leporidae). In lagomorphs, the CXCR4 is highly conserved, with most of the protein diversity found at surface regions. Five amino acid replacements were observed, two in the intracellular loops, one in the transmembrane domain and two in the extracellular loops. Oryctolagus features unique amino acid changes at the intracellular domains, putting this genus apart of all other lagomorphs. Furthermore, in the 37 European rabbits analysed, which included healthy rabbits and rabbits with clinical symptoms of myxomatosis, 14 nucleotide substitutions were obtained but no amino acid differences were observed.

Rapid differentiation between fluconazole-sensitive and -resistant species of Candida directly from positive blood-culture bottles by real-time PCR

In view of both the delay in obtaining identification by conventional methods following blood-culture positivity in patients with candidaemia and the close relationship between species and fluconazole (FLC) susceptibility, early speciation of positive blood cultures has the potential to influence therapeutic decisions. The aim was to develop a rapid test to differentiate FLC-resistant from FLC-sensitive Candida species. Three TaqMan-based real-time PCR assays were developed to identify up to six Candida species directly from BacT/Alert blood-culture bottles that showed yeast cells on Gram staining at the time of initial positivity. Target sequences in the rRNA gene complex were amplified, using a consensus two-step PCR protocol, to identify Candida albicans, Candida parapsilosis, Candida tropicalis, Candida dubliniensis, Candida glabrata and Candida krusei; these are the most commonly encountered Candida species in blood cultures. The first four of these (the characteristically FLC-sensitive group) were identified in a single reaction tube using one fluorescent TaqMan probe targeting 18S rRNA sequences conserved in the four species. The FLC-resistant species C. krusei and C. glabrata were detected in two further reactions, each with species-specific probes. This method was validated with clinical specimens (blood cultures) positive for yeast (n=33 sets) and the results were 100 % concordant with those of phenotypic identification carried out concomitantly. The reported assay significantly reduces the time required to identify the presence of C. glabrata and C. krusei in comparison with a conventional phenotypic method, from ∼72 to <3 h, and consequently allows optimization of the antifungal regimen at an earlier stage.

Biological and molecular variability among geographically diverse isolates of sweet potato virus 2

Sweet potato virus 2 (SPV2) is a tentative member of the genus Potyvirus, family Potyviridae. In addition to the type isolate of SPV2 recently characterised in greater detail, twelve additional isolates of this virus were obtained from sweet potato clones originating from China, Portugal, South Africa and Zambia. Sequences of the coat protein (CP) gene and 3' non-translated region (NTR) were determined. Comparisons of the CP gene sequences of these isolates revealed nucleotide and amino acid sequence identities ranging from 81 to 99% and from 86 to 99%, respectively. Phylogenetic analysis of sequences distinguished several groups, which partially correlated with the geographic origin of the isolates, and indicated that some isolates from South Africa and a Zambian isolate are most distinct both in CP and 3'NTR sequences. Host range studies of a selected number of isolates revealed some differences in test plant reactions, which appeared to correlate to some extent with the geographic origin and molecular distinctness of the SPV2 isolates. The results strongly suggest the occurrence of biologically and genetically diverse strains of SPV2.