Monitoring vital signs using early warning scoring systems: a review of the literature

AIM

To evaluate the need for, and the development and utility of, pen-and-paper (Modified) Early Warning Scoring (MEWS/EWS) systems for adult inpatients outside critical care and emergency departments, by reviewing published literature.

BACKGROUND

Serious adverse events can be prevented by recognizing and responding to early signs of clinical and physiological deterioration.

EVALUATION

Of 534 papers reporting MEWS/EWS systems for adult inpatients identified, 14 contained useable data on development and utility of MEWS/EWS systems. Systems without aggregate weighted scores were excluded.

KEY ISSUES

MEWS/EWS systems facilitate recognition of abnormal physiological parameters in deteriorating patients, but have limitations. There is no single validated scoring tool across diagnoses. Evidence of prospective validation of MEWS/EWS systems is limited; neither is implementation based on clinical trials. There is no evidence that implementation of Westernized MEWS/EWS systems is appropriate in resource-poor locations.

CONCLUSIONS

Better monitoring implies better care, but there is a paucity of data on the validation, implementation, evaluation and clinical testing of vital signs' monitoring systems in general wards.

IMPLICATIONS FOR NURSING MANAGEMENT

Recording vital signs is not enough. Patient safety continues to depend on nurses' clinical judgment of deterioration. Resources are needed to validate and evaluate MEWS/EWS systems in context.

Multiple sclerosis prevalence in Ireland: relationship to vitamin D status and HLA genotype

BACKGROUND

The relationship between prevalence of multiple sclerosis (MS) and latitude may be due to both genetic and environmental factors. The hypothesis that, in Ireland, MS prevalence is increasing and that north-south differences relate to variation in serum 25-hydroxyvitamin D (25(OH)D) levels was tested in this study.

PATIENTS AND METHODS

Patients and matched control subjects were identified in counties Donegal, Wexford and South Dublin through multiple sources. Prevalence was determined. Blood samples were taken for serum 25(OH)D and serum intact parathyroid hormone measurement, and DNA was extracted.

RESULTS

Prevalence in 2007 was significantly greater in Donegal (northwest) (290.3/105, 95% CI 262.3 to 321.7) compared with 2001 (184.6/105; 162 to 209.5). In Wexford (southeast), there was a non-significant increase in prevalence in 2007 compared with 2001. Prevalence was significantly higher in Donegal than in Wexford (144.8/105; 126.7 to 167.8, p<0.0001) and South Dublin (127.8/105; 111.3 to 148.2, p<0.0001). Overall, mean 25(OH)D levels were low and did not differ between patients (38.6 nmol/l) and controls (36.4 nmol/l) However, significantly more patients than controls had 25(OH)D levels <25 nmol/l (deficiency) (p=0.004). Levels of 25(OH)D (mean 50.74 nmol/l) were significantly higher in South Dublin (area with lowest prevalence) (p<0.0001) than in Donegal or Wexford. HLA DRB1*15 occurred most frequently in Donegal (greatest MS prevalence) and least frequently in South Dublin.

CONCLUSION

Vitamin D deficiency is common in Ireland. Latitudinal variation in MS probably relates to an interaction between genetic factors and environment (25(OH)D levels), and MS risk may be modified by vitamin D in genetically susceptible individuals.

Clinical skills required of ophthalmic nurse practitioners in tertiary level public hospitals in the Western Cape Province

BACKGROUND

South Africa has a 32-year history of training ophthalmic nurse practitioners (ONPs). The role and required skills and competencies of ONPs are not well documented in the international literature and are also absent from South African publications, including South African Nursing Council publications.

AIM

This study aims to inform curriculum development and human resource planning by reporting on the clinical skills expected of ONPs by members of multidisciplinary ophthalmology teams.

METHOD

A limited survey was undertaken in the ophthalmology wards and outpatient departments of three tertiary level hospitals in the Western Cape Province. A researcher-designed structured self-completion questionnaire was distributed to 30 ophthalmology practitioners: doctors, nurses and technicians. Respondents were asked to indicate the expected clinical skills of ONPs.

FINDINGS

All questionnaires were completed. All respondents favoured ONPs taking histories and performing emergency eye irrigations. There was less support for more complex procedures, such as B-scans. One-third of respondents did not expect ONPs to have skills in eight key areas, including examination of the anterior chamber angle for glaucoma. No statistically significant differences were found between responses of doctors and nurses, with one exception: more nurses (15/18) than doctors (4/10) had confidence in the ONP undertaking basic eye examinations for ocular motility (Fisher's exact test, P = 0.035).

CONCLUSION

In the study settings, ONPs are not using their specialist skills to the full. Not all practitioners were receptive to ONPs using the skills that they had acquired during their postgraduate diploma, threatening the educational effectiveness of this initiative.

Clinical applications of intravenous immunoglobulins (IVIg)--beyond immunodeficiencies and neurology

The clinical use of intravenous immunoglobulin (IVIg) has expanded beyond its traditional place in the treatment of patients with primary immunodeficiencies. Due to its multiple anti-inflammatory and immunomodulatory properties, IVIg is used successfully in a wide range of autoimmune and inflammatory conditions. Recognized autoimmune indications include idiopathic thrombocytopenic purpura (ITP), Kawasaki disease, Guillain-Barré syndrome and other autoimmune neuropathies, myasthenia gravis, dermatomyositis and several rare diseases. Several other indications are currently under investigation and require additional studies to establish firmly the benefit of IVIg treatment. Increasing attention is being turned to the use of IVIg in combination with other agents, such as immunosuppressive agents or monoclonal antibodies. For example, recent studies suggest that combination therapy with IVIg and rituximab (an anti-CD20 monoclonal antibody) may be effective for treatment of autoimmune mucocutaneous blistering diseases (AMBDs), with sustained clinical remission. The combination of IVIg and rituximab has also been used in the setting of organ transplantation. Firstly, IVIg +/- rituximab has been administered to highly human leucocyte antigen (HLA)-sensitized patients to reduce anti-HLA antibody levels, thereby allowing transplantation in these patients. Secondly, IVIg in combination with rituximab is effective in the treatment of antibody-mediated rejection following transplantation. Treatment with polyclonal IVIg is a promising adjunctive therapy for severe sepsis and septic shock, but its use remains controversial and further study is needed before it can be recommended routinely. This review covers new developments in these fields and highlights the broad range of potential therapeutic areas in which IVIg may have a clinical impact.

A randomised controlled trial to evaluate both the role and optimal fractionation of radiotherapy in the conservative management of early breast cancer

Abstract #5125

Background: Postoperative radiotherapy is routinely used in early breast cancer using 50Gy in 25 daily fractions (Long). Both the role of radiotherapy and shorter regimens require validation.&#x2028; Methods: Patients with clinical stage 1 and 2 disease were randomised to receive immediate postoperative (RT) or delayed salvage treatment (No RT). Patients receiving RT were further randomised to Long or Short (40Gy in 15 daily fractions) regimens. The primary outcome measure was time to first relapse. Reported results are at median follow up of 16.9 years (IQR 15.4 - 18.8).&#x2028; Results: 707 women were recruited between 1985 and 1992: median age 59 years (range 28-80), 72% post menopausal, median tumour size 2.0cms (range 0.12-8.0). 271 patients have relapsed: 110 RT, 161 No RT. Site of first relapse was reported as 158 (64%) locoregional and 87 (36%) distant. Immediate RT significantly reduced the risk of relapse by 42% (HR=0.58 (95%CI: 0.45, 0.73), chi2LR=20.40, p&lt;0.001) consistent across all prognostic subgroups. Immediate RT reduced the risk of locoregional relapse by 65% (HR=0.35 (95%CI: 0.25, 0.47), (chi2LR=40.47, p&lt;0.001). No difference in relapse site, or frequency was seen between the 2 fractions. No differences were seen in overall or breast cancer specific survival.&#x2028; Discussion: With a median follow-up of 17 years, this study confirms the benefit for patients with early breast cancer receiving radiotherapy. We conclude that a radiotherapy schedule of 40 Gy in 15 daily fractions is a safe, efficient and effective regime at least as good as the international conventional regime of 50 Gy in 25 daily fractions.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5125.

Bacterial diversity associated with ornithogenic soil of the Ross Sea region, AntarcticaThis article is one of a selection of papers in the Special Issue on Polar and Alpine Microbiology

In the Ross Sea region of Antarctica, ornithogenic soils form on land under Adélie Penguin rookeries. Compared with mineral soils of the Ross Sea region, ornithogenic soils are generally high in microbial biomass, organic carbon, and total nitrogen and phosphorus, with high electrical conductivity and large variations in pH. The objective of this study was to assess the bacterial composition of ornithogenic soils from Cape Hallett and Cape Bird in the Ross Sea region using culture-independent methods. Soil clone libraries were constructed and those clones that occurred ≥3 times were sequenced. The bacterial diversity of the soils was dependent on the presence of penguins. Firmicutes most closely related to the endospore-formers (e.g., Oceanobacillus profundus and Clostridium acidurici ) and (or) Gammaproteobacteria belonging to the genus Psychrobacter dominated soils currently occupied with penguins. In contrast, Gammaproteobacteria, closely related to cultured members of the genera Rhodanobacter , Psychrobacter , Dokdonella , and Lysobacter , dominated the soils previously colonized by penguins. Results of this study indicate that despite relatively high nutrient levels and microbial biomass, bacterial communities of ornithogenic soils were not more diverse than those of mineral soils of the Ross Sea region of Antarctica.

Intravenous immunoglobulin treatment for acute fulminant inflammatory cardiomyopathy: series of six patients and review of literature

BACKGROUND

Although an autoimmune mechanism has been postulated for myocarditis and acute-onset inflammatory dilated cardiomyopathy (DCM), immunomodulatory treatment strategies are still under investigation.

METHODS AND RESULTS

The clinical data of six patients with acute inflammatory DCM referred for evaluation for possible heart transplantation were reviewed. All patients were admitted with acute congestive heart failure and severely impaired left ventricular (LV) function and were treated with high-dose (2 g/kg) intravenous immunoglobulin (IVIG). The diagnosis of acute inflammatory DCM was based on recent onset of congestive heart failure (New York Heart Association functional class III or IV) with severely depressed LV ejection fraction ([LVEF] 30% or lower) occurring shortly after viral-like illness. All patients had inflammation on endomyocardial biopsy or elevated cardiac enzymes, as well as a normal coronary angiogram. All patients were in New York Heart Association class I or II at the time of hospital discharge. The mean LVEF improved from 21.7+/-7.5% at baseline to 50.3+/-8.6% at discharge (P=0.005). Four patients had complete recovery (LVEF 50% or higher) and two patients had partial LV recovery. Patients were followed for a median 13.2 months (range two to 24 months) and had a mean LVEF of 53+/-6% (P not significant versus LVEF at discharge).

CONCLUSIONS

Therapy with intravenous high-dose IVIG may be a potentially useful treatment in selected patients if given early in the course of acute fulminant inflammatory DCM. A randomized, prospective trial is warranted to prove the real benefit of IVIG in this patient population.

Outcome of management strategies for BK virus replication in pediatric renal transplant recipients

Management of BKV infection is not well defined. Eighteen pediatric renal transplant patients with BKV-PCR (+) were divided into three groups; Group 1: Viruria only (6), Group 2: Viremia with stable GFR (4), Group 3: Viremia with >25% decline in GFR and BKVAN on biopsy (8). With initial BKV-PCR(+), Group 1 received no treatment; Group 2 had MMF reduced 30%; Group 3: 6/8 had CNI discontinuation, 2/8 had reduced MMF and cidofovir. BKV, GFR and histology were compared pre- and post-treatment. In Group 1 viruria decreased in all patients; GFR remained stable. Group 2 showed reduced viremia with no GFR change. Group 3 showed reduced viremia in 8/8 patients. Patients with >50% decline in GFR from baseline (6/8) showed worse histology: 2/6 lost grafts despite no BKV on follow-up biopsy. Our results show that with viruria alone no treatment is necessary; with viremia and stable GFR, reduced immunosuppression decreases viremia and maintains GFR. With viremia and reduced GFR, immunosuppression reduction with or without cidofovir decreases viremia and stabilizes GFR in most patients. Greater than 50% reduction in GFR at BKVAN diagnosis correlates with risk for graft loss. Serial monitoring of BKV viremia with early intervention may prevent BKVAN graft loss in children.

Review article: anatomic double bundle anterior cruciate ligament reconstruction

The anterior cruciate ligament (ACL) consists of 2 bundles: a slightly larger anteromedial bundle and a posterolateral bundle, named according to their relative tibial insertion sites. Both bundles are crucial to knee stability. Although it is more technically demanding, a double bundle ACL reconstruction restores the knee biomechanics better and provides more rotational stability than a single bundle ACL reconstruction. Intermediate and long-term clinical investigation including the measurement of rotational laxity and the evaluation of osteoarthritic change is needed to confirm biomechanical and short-term clinical outcomes.