Bedside testing for myasthenia gravis: the ice-test

A 67-year-old man presented to the acute medical take with a history of droopy eyelids and difficulty swallowing. A diagnosis of myasthenia gravis was suspected from the clinical history. The patient's symptoms were progressive, raising concerns of aspiration pneumonia or respiratory compromise if untreated. Definitive diagnosis of myasthenia gravis relies upon a combination of serological and electrophysiological investigations, the results of which are not immediately available in an acute situation. Bedside tests are therefore of practical clinical importance to enable prompt and effective initiation of treatment, particularly where critical symptoms are present. The ice-test is a straightforward and non-invasive investigation with a high sensitivity for myasthenia gravis and is a useful alternative to edrophonium testing. It is especially helpful in patients with cardiac and respiratory co-morbidities for whom acetylcholinesterase inhibitors are contraindicated. We describe a case where this simple bedside test successfully expedited the correct treatment and improved patient care.

An improved manufacturing process for Xyntha/ReFacto AF

SUMMARY

ReFacto Antihemophilic Factor is a second-generation antihaemophilia A product manufactured using a process that includes therapeutic grade human serum albumin (HSA) in the cell culture medium, but is formulated without HSA as a stabilizer. Even though this second-generation antihaemophilia product has a good safety profile, a programme was implemented to eliminate all animal- and human-derived raw materials from the production process, thus producing a third-generation product. To that end, HSA has been removed from the master and working cell banks and from the culture medium. The hybridoma-derived monoclonal antibody formerly used in the purification process has been replaced by a chemically synthesized affinity peptide, and a virus-retaining filtration step has been added to enhance the clearance of large viruses, such as retroviruses. The purification process has been validated for the removal of a panel of model viruses and provides significant clearance of all viruses tested. Host cell- and process-derived impurity removal validations also were conducted, including host cell DNA and protein, in addition to the affinity peptide. Compared with the product manufactured according to the original process, these changes had no detectable effect on the structural integrity, stability or clinical efficacy of this antihaemophilia A product. The product produced by the improved manufacturing process is named Xyntha/ReFacto AF.

Achieving evidence-based nursing practice: impact of the Caledonian Development Model

AIM

To determine the impact of the Caledonian Development Model, designed to promote evidence-based practice.

BACKGROUND

The model features practice-development activities, benchmarking, knowledge pooling and translation through membership of a community of practice and a virtual college.

METHODS

Twenty-four nurses, from 18 practice sites formed three communities of practice, each selecting evidence-based guidance to implement. A modified group supervision framework empowered nurses to champion local implementation. Outcomes were determined at 6 months.

RESULTS

Eighty per cent of the patient-related criteria and 35% of the facilities criteria were achieved. The Revised Nursing Work Index indicated these nurses experienced greater autonomy (P = 0.019) and increased organizational support (P = 0.037). Focus groups revealed a deepening organizational support for the initiative over time, illuminated work-based learning challenges and overall enthusiasm for the approach.

CONCLUSION

Implementation of the model effectively promoted evidence-based practice, most notably at the level of the individual patient.

IMPLICATIONS FOR NURSING MANAGEMENT

Time and budgetary constraints necessitate smart, value for money approaches to developing evidence-based practice and improved care standards. This work demonstrates an effective model that strikes a balance between individual and group learning, virtual and real-time activities, coupled with resource pooling across organizations and sectors.

Describing gerontological nursing: an academic exercise or prerequisite for progress?

AIMS AND OBJECTIVES

To develop a practitioner-led description of gerontological nursing and articulate the principles which underpin its practice.

BACKGROUND

As the population ages expertise in gerontological nursing will become increasingly important. However, a complete and widely accepted delineation of the rationale, philosophy, knowledge base and special skills for gerontological nursing is yet to be developed.

METHODS

As one cycle of a larger action research project informed by realistic evaluation, a representative sample of 30 Scottish nurses worked together as a Community of Practice to develop a description of gerontological nursing that would have utility in their practice and in the development of best practice care guidance. Data collection involved group interviews and records of on-line discussions. Data were analysed using content analysis. The emerging description was verified through external consultation with other nursing colleagues and older people.

RESULTS

Nursing older people within Scotland was perceived as low status and participants reported that a positive reframing of gerontological nursing was needed. A description and underlying principles were developed by nurses and used as a lens to shape best practice statements. The description embraces a person-centred and enabling approach to evidenced-based gerontological nursing.

CONCLUSIONS

Gerontological practice requires an accessible consensus view and description to support its development. Practising nurses developed such a view and its utility has been seen in the development of best practice statements. Relevance to clinical practice. The description and principles of gerontological nursing can be used to guide nursing practice, practice development and research.

Transmissible spongiform encephalopathy agent clearance by the immunoaffinity and anion-exchange chromatography steps of the ReFacto manufacturing process

ReFacto (moroctocog alfa), a recombinant factor VIII approved for the treatment of haemophilia A, is produced by a mammalian cell-culture process that includes therapeutic-grade human serum albumin (HSA) in the cell-culture medium. While to date there have been no cases of transmissible spongiform encephalopathy (TSE) resulting from the clinical use of HSA, Wyeth conducted a study to demonstrate that the ReFacto manufacturing process has significant capacity to remove a TSE agent if it were present as a contaminant in the HSA. The immunoaffinity (8A4 Sepharose) and anion-exchange (Q Sepharose) chromatography steps were evaluated for the clearance of the hamster TSE agent, strain 263K. This Good Laboratory Practice study was performed using appropriately qualified, laboratory-scale chromatography systems. Filtered brain homogenate from TSE-infected hamsters was added to loads of both chromatographic columns, and the concentration of TSE agent in the loads and product pools were determined using a validated western blot quantitation method. Replicate chromatography runs were consistent, as demonstrated by the < or =0.7 log(10) difference observed in TSE agent reduction between each pair of runs. The immunoaffinity and anion-exchanges steps demonstrated 3.8 log reduction and >5.2 log reduction respectively. These data provide a high degree of assurance that in the unlikely event of a TSE contamination of the HSA used in the ReFacto cell-culture process, the purification steps have the potential to remove the infectious agent to extremely low levels, thereby significantly reducing the risk to patients receiving ReFacto.

Helping or hindering: the role of nurse managers in the transfer of practice development learning

AIM

This paper reports selected findings from a recent PhD study exploring how graduates from a BSc Specialist Nursing programme, with an NMC-approved Specialist Practitioner Qualification, engage in practice development during their subsequent careers.

BACKGROUND

The UKCC (1998) defines specialist practice as requiring higher levels of judgement, discretion and decision-making, with leadership in clinical practice development forming a core dimension of this level of practice. However, there is little evidence in the published literature that describes or evaluates the practice development role of graduate specialist practitioners.

METHODS

This study applied a modified Glaserian approach to grounded theory methods. A preliminary descriptive survey questionnaire was posted to all graduates from the programme, response rate of 45% (n=102). From these respondents, theoretical sampling decisions directed the selection of 20 participants for interview, permitting data saturation.

RESULTS

The grounded theory generated by this study discovered a basic social process labelled 'making a difference', whereby graduate specialist practitioners are increasingly able to impact in developing patient care at a strategic level by coming to own the identity of an expert practitioner (Currie, 2006). Contextual factors strongly influence the practitioner journey, with organizational position and other people presenting enabling or blocking conditions.

IMPLICATIONS FOR NURSING MANAGEMENT

The line manager plays a crucial role in helping or hindering graduate specialist practitioners to transfer their learning to the clinical setting and become active in practice development. Recommendations to enhance managerial support for the practice development role of graduate specialist practitioners are proposed. ADDING TO CURRENT KNOWLEDGE: This work adds to currently limited knowledge of the graduate specialist practitioners' role in the leadership of clinical practice development. In addition, the findings emphasize the potential influence of the workplace environment by analyzing organizational factors in the specific context of the graduate specialist practitioner attempting to develop practice.

Tracheostomy in human immuno-deficiency virus infected children at the Red Cross War Memorial Children's Hospital, Cape Town, South Africa

Tracheostomy in adults with HIV/AIDS has been reported to be associated with both high and early mortality of 47-100%. There is minimal data regarding the role of tracheostomy in HIV infected children. We did a retrospective analysis of HIV positive children that underwent tracheostomy at our institution over a 5-year period, 2002-2006. A total of 70 tracheostomies were done during the period and 15 (21.4%) of these children were confirmed as HIV infected. The average age at presentation for HIV infected children with upper airway obstruction resulting eventually in tracheostomy was 9.4 months and 60% were under 1 year of age. Only three (20%) were on Anti-Retroviral Therapy (ART) prior to presentation. The cause of upper airway obstruction was croup in 14 (93%) of these 15 children. Following tracheostomy all were treated with ART. To date six children have been successfully decannulated (40%) and there have been three deaths (20%) which were unrelated to tracheostomy.

CONCLUSION

Tracheostomy in HIV positive children is not associated with the high mortality that has been reported in adults provided such children are started on treatment with antiretroviral therapy.

Using action research to construct national evidence-based nursing care guidance for gerontological nursing

AIM

This paper explores the development of a low-cost, involving methodology for constructing nursing-focused evidence-based national care guidance, known as Best Practice Statements, the intended users of which are gerontological nurses practising throughout Scotland.

DESIGN

The Best Practice Statement construction methodology forms one cycle in a five-year longitudinal action research study that aims to achieve evidence-based nursing, facilitate professional networking to support practice development and promote the principles and practice of gerontological nursing. Achieving these aims involved designing a virtual Practice Development College.

METHODS

A Community of Practice comprising practising gerontological nurses, expert advisors, academic teaching and research nurses collaborated in face-to-face meetings and in the virtual Practice Development College to delineate and refine the procedural model for Best Practice Statement construction. Focus groups, telephone interviews, analysis of on-line archives and documentary outputs formed the analytic dataset.

RESULTS

Qualitative analysis indicated that, from the perspective of the community of practice, the emerging methodology facilitated the melding of knowledge sources reflecting the dominant evidence hierarchy with other forms of evidence valued by gerontological nurses, in the Best Practice Statement.

RELEVANCE TO CLINICAL PRACTICE

Current methods of care guidance construction rarely address the concerns of nurses and the evidence from which guidelines are developed is narrowly defined with regard to inclusion and acceptability. In contrast this model focuses on nursing issues, embraces a wider definition of evidence and ensures that the published Best Practice Statements are credible and achievable in gerontological practice, where they are tested and refined as an inherent aspect of the development process.

Synthesis and Mesophases of Glycerate Surfactants

In the quest to rationally design novel mesophase systems the challenge remains to deconvolute the relationship between structure, composition, and function. In the current study, novel glycerol-derived surfactants with high negative interfacial areas and a preference for inverse phase behavior have been targeted and synthesized. This has been achieved by application of the rule-of-thumb afforded by the critical packing parameter (CPP), namely, that inverse phase behavior is favored by wedge-shaped molecules with relatively small head group versus chain volume. Highly splayed hydrophobes with exaggerated cross section such as oleyl (cis-octadec-9-enyl) hexahydrofarnesyl (3,7,11-trimethyl-dodecyl) and phytanyl (3,7,11,15-tetramethyl-hexadecyl) were particularly successful for this purpose across many variations of head group. The phase behavior of the binary system in water of many of these surfactants is relatively simple. Typically, cubic or inverse hexagonal phases exist at the interface with water with the inverse micellar phases present at lower hydration. The inverse liquid crystalline phases were present for a broad range of temperatures and compositions.