Multispecialty tracheostomy experience

INTRODUCTION

Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK.

METHODS

A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously.

RESULTS

A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days.

CONCLUSIONS

This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.

La Crosse Virus Vectors Are Host-Seeking and Ovipositing After 1700 H in Eastern Tennessee

La Crosse virus (LACV) is transmitted via the bites of infected Aedes mosquitoes (Ae. triseriatus, Ae. albopictus, and Ae. japonicus) and causes La Crosse encephalitis, which is the most commonly diagnosed arbovirus in eastern Tennessee children. This study identified host-seeking and oviposition activity of LACV vectors over a diel period, as it relates to traditional working hours. Nineteen sites in Knox County, TN, were monitored with host-seeking (Centers for Disease Control and Prevention [CDC] miniature light traps) and oviposition traps (CDC gravid traps) during 2 diel periods (0900-1700 h and 1700-900 h). We collected 2,444 adult mosquitoes, comprising 19 different species of which 1,337 (54.7%) were LACV vectors: Ae. albopictus (1,207 specimens), Ae. triseriatus (85 specimens), and Ae. japonicus (45 specimens). These species were active throughout the sampling period, but significantly more were collected from 1700-0900 h. The CDC gravid trap was the most effective method for monitoring Ae. japonicus; there were no trap effects or trap × time interactive effects for Ae. albopictus or Ae. triseriatus. Overall, significantly more LACV vectors were collected from 1700-0900 h compared to 0900-1700 h. Information gathered in this study improves vector surveillance, helps communities control mosquito populations, and minimizes nontarget effects.

Impact analysis in virtual outreach information services (VIVOS project)

The aim of the VIVOS project was to develop and evaluate methodologies, that is, sets of methods, for determining the value and impact of ‘virtual outreach’ information services, in the health sector. Five different projects were recruited initially, with another two added later. Around 150 interviews were conducted, with additional postal questionnaire surveys. Preliminary findings are discussed in relation to policy initiatives for clinical governance and improved patient information. Conclusions suggest that design of information service support is necessary.

Evaluating Surveillance Methods for Arboviral Vectors of La Crosse Virus and West Nile Virus of Southern Appalachia

To monitor mosquito-borne diseases, public health departments conduct mosquito and pathogen surveillance. Our objective was to evaluate mosquito monitoring methods for collecting La Crosse virus (LACV) and West Nile virus (WNV) vectors (Aedes and Culex mosquitoes, respectively) in southern Appalachia. Centers for Disease Control and Prevention (CDC) light traps baited with carbon dioxide (CO(2)), CDC light traps baited with CO(2) and BG lure, BG-Sentinel traps baited with CO(2), gravid traps baited with oak (Quercus)-water infusion, and resting traps were compared in eastern Tennessee in 2013. Traps operated at 8 different urban sites throughout Knox County were randomly assigned to and rotated among 6 plots within each site. Results were specific for each vector; the BG-Sentinel trap was the best method for Aedes triseriatus, the CDC trap baited with CO(2) and BG lure was the best method for Ae. albopictus, and the gravid trap was the best method for Ae. japonicus. Culex erraticus collections varied by week and trapping method, indicating no single method was best, but the questing traps collected more mosquitoes. There was no significant trapping difference for Cx. pipiens complex in this region using the methods tested. The results suggest using a combination of trapping methods when sampling for LACV and/or WNV mosquito vectors in southern Appalachia. Effective trapping methods are necessary to enable accurate surveillance, improve control methods, enhance understanding of dispersal, and use for early detection of vectors and pathogens.

Platelet and coagulation activation markers in myeloproliferative diseases: relationships with JAK2 V6I7 F status, clonality, and antiphospholipid antibodies

BACKGROUND AND OBJECTIVES

Patients with myeloproliferative disease (MPD) have an increased risk of thrombosis. We studied markers of platelet and coagulation activation in a large cohort of patients with MPD (n = 118) and related this to Janus Kinase 2 (JAK2) V617 F mutation status, a marker of clonality, and the presence of antiphospholipid antibodies (APA), all of which have been associated with thrombosis in MPD.

METHODS

D-dimer, thrombin-antithrombin complexes (TAT), prothrombin fragments 1 + 2 (F(1+2)), soluble E-selectin (sE-selectin), and soluble P-selectin (sP-selectin) levels were compared between patients and hypertensive controls (n = 127). Assays for lupus anticoagulant (LA), anticardiolipin antibodies (ACA), antibeta2 glycoprotein 1 antibodies (anti-beta(2)GP1), and antiprothrombin antibodies (alpha-Pro) were also performed. The JAK2 V617F mutation status was determined in the cohort using amplification refractory mutation system (ARMS) polymerase chain reaction. Disease clonality was determined in 54 patients using the HUMARA assay.

RESULTS

sP-selectin was significantly increased in patients with MPD (P

CONCLUSIONS

The JAK2 V617F mutation is associated with platelet activation, as measured by elevated sP-selectin levels, in MPD. In contrast to previous reports, we found no excess of APA in patients with MPD.

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Antibodies, Antiphospholipid/chemistry
• Blood Coagulation
• Blood Platelets/cytology
• Blood Platelets/metabolism
• Cohort Studies
• Female
• Humans
• Janus Kinase 2/genetics
• Male
• Middle Aged
• Myeloproliferative Disorders/genetics
• Myeloproliferative Disorders/metabolism
• Thrombosis/genetics

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Nursing record systems: effects on nursing practice and health care outcomes

BACKGROUND

A nursing record system is the record of care planned and/or given to individual patients/clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice.

OBJECTIVES

To assess the effects of nursing record systems on nursing practice and patient outcomes.

SEARCH STRATEGY

We searched The Cochrane Library, the EPOC trial register (October 2002), MEDLINE, Cinahl, Sigle, and databases of the Royal College of Nursing, King's Fund, the NHS Centre for Reviews and Dissemination, and the Institute of Electrical Engineers up to August 1999; and OCLC First Search, Department of Health database, NHS Register of Computer Applications and the Health Visitors' Association database up to the end of 1995. We hand searched the Journal of Nursing Administration (1971-1999), Computers in Nursing (1984-1999), Information Technology in Nursing (1989-1999) and reference lists of articles. We also hand searched the major health informatics conference proceedings. We contacted experts in the field of nursing informatics, suppliers of nursing computer systems, and relevant Internet groups. To update the review the Medline, Cinahl, British Nursing Index, Aslib Index to Theses databases were all searched from 1998 to 2002. The Journal of Nursing Administration, Computers in Nursing, Information Technology in Nursing were all hand searched up to 2002. The searches of the other databases and grey literature included in the original review, were not updated (except for Health Care Computing Conference and Med Info) as the original searches produced little relevant material.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series comparing one kind of nursing record system with another, in hospital, community or primary care settings. The participants were qualified nurses, students or health care assistants working under the direction of a qualified nurse and patients receiving care recorded and/or planned using nursing record systems.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Eight trials involving 1497 people were included. In three studies of client held records, there were no overall positive or negative effects, although some administrative benefits through fewer missing notes were suggested. A paediatric pain management sheet study showed a positive effect on the children's pain intensity. A computerised nursing care planning study showed a negative effect on documented nursing care planning, although two other computerised nursing information studies showed an increase in recording but no change in patient outcomes. Care planning took longer with these computerised systems, but the numbers of patients and nurses included in these studies was small. A controlled before-and-after study of two paper nursing record systems showed improvement in meeting documentation standards.

REVIEWER'S CONCLUSIONS

No evidence was found of effects on practice attributable to changes in record systems. Although there is a paucity of studies of sufficient methodological rigour to yield reliable results in this area, it is clear from the literature that it is possible to set up randomised trials or other quasi-experimental designs needed to produce evidence for practice. The research undertaken so far may have suffered both from methodological problems and faulty hypotheses. Qualitative nursing research to explore the relationship between practice and information use, could be used as a precursor to the design and testing of nursing information systems.

Telemedicine versus face to face patient care: effects on professional practice and health care outcomes

BACKGROUND

Telemedicine is the use of telecommunications technology for medical diagnosis and patient care. From its beginnings telemedicine has been used in a variety of health care fields, although widespread interest among healthcare providers has only now become apparent with the development of more sophisticated technology.

OBJECTIVES

To assess the effects of telemedicine as an alternative to face-to-face patient care.

SEARCH STRATEGY

We searched the Effective Practice and Organisation of Care Group's specialised register, The Cochrane Library, MEDLINE (1966-August 1999), EMBASE (to 1996), Cinahl (to August 1999), Inspec (to August 1996), Healthstar (1983-1996), OCLC, Sigle (to 1999), Assia, SCI (1981-1997), SSCI (1981-1997), DHSS-Data. We hand searched the Journal of Telemedicine and Telecare (1995-1999), Telemedicine Journal (1995-1999) and reference lists of articles. We also hand searched conference proceedings and contacted experts in countries identified as having an interest in telemedicine.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series comparing telemedicine with face-to-face patient care. The participants were qualified health professionals and patients receiving care through telemedicine.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Seven trials involving more than 800 people were included. One trial was concerned with telemedicine in the emergency department, one with video-consultations between primary health care and the hospital outpatients department, and the remainder were concerned with the provision of home care or patient self-monitoring of chronic disease. The studies appeared to be well conducted, although patient numbers were small in all but one. Although none of the studies showed any detrimental effects from the interventions, neither did they show unequivocal benefits and the findings did not constitute evidence of the safety of telemedicine. None of the studies included formal economic analysis. All the technological aspects of the interventions appear to have been reliable, and to have been well accepted by patients.

REVIEWER'S CONCLUSIONS

Establishing systems for patient care using telecommunications technologies is feasible, but there is little evidence of clinical benefits. The studies provided variable and inconclusive results for other outcomes such as psychological measures, and no analysable data about the cost effectiveness of telemedicine systems. The review demonstrates the need for further research and the fact that it is feasible to carry out randomised trials of telemedicine applications. Policy makers should be cautious about recommending increased use and investment in unevaluated technologies.

A vision-based three-dimensional capture system for maxillofacial assessment and surgical planning

We describe a vision-based three-dimensional facial data capture system designed for the planning of maxillofacial operations. We describe the system requirements and outline the methods used to develop a complete three-dimensional facial capture system. Our approach is based upon imaging the face using two stereo-pair sets of cameras. Scale-space-based stereo-matching is then used to recover correspondences between each of the captured stereo-pairs. Photogrammetric routines based on adjustment of bundles are used off-line to calibrate the system by imaging a single object that references all cameras to the same co-ordinate frame. This calibration scheme allows us to convert stereo correspondences to world points for each pair of cameras without the need for any subsequent fusion of data. Initial results show that we are able to capture key facial landmarks to within 0.5 mm.

Three-dimensional modeling for modern diagnosis and planning in maxillofacial surgery

The existing methods of recording the face in three dimensions are reviewed, and a new method for three-dimensional facial modeling is introduced. The technique utilizes two stereo pairs of videocameras, a stereo pair at each side of the patient's face. The system allows rapid capture of the face in three dimensions and precise measurement of anatomic landmarks. The system can be used to capture the facial image and a cephalogram almost simultaneously, allowing more accurate superimposition of soft and hard tissues. This precision will facilitate development of the surgical treatment plan. A computer program in the early stages of development will use the data generated by this biostereometric measurement system to predict soft tissue changes following orthognathic surgery.

A three-dimensional imaging system for archiving dental study casts: a preliminary report

Dental study casts form an essential part of patient records for both diagnostic and medicolegal purposes. Storage of study casts poses major problems because of inconvenience and cost of mass storage. Various methods for recording and storage of study casts are discussed. A new biostereometric technique for digitally recording and storing dental casts, and using the recent advances in stereophotogrammetry, is presented. Archiving dental casts in a digital format would reduce problems of mass storage and provide new benefits such as duplication of casts and use in clinical and research studies.

EVINCE: The value of information in developing nursing knowledge and competence

The aims of the EVINCE research project included examination of the impact of information on the clinical knowledge and practice of nurses, midwives and health visitors. EVINCE (Establishing the Value of Information to Nursing Continuing Education) was funded by the British Library R&D Department for 1 year, from 1 November 1995 to 31 October 1996. The methods employed (based on those used in the Value project) included a critical incident type study to establish patterns of information need and use among a random sample of nursing professionals. The nature of the impact of information obtained on present and future competencies was assessed from a survey of the searches and requests presented to library and information services. Nurses, midwives and health visitors did value the information (96% of respondents agreed that there was, or would be an effect on future practice through enhanced competence in one or more areas). The impact findings can be used to guide a more precise assessment of information needs.

Preparing for Post-Registration Education and Practice (PREP): the support role of the library

A survey of 5% of trained nursing staff in the Plymouth area provided indications of the impact of changes in post-registration education and practice on the library service of the Tor & South West College of Health in Plymouth. The survey comprised, first, a structured interview to obtain details of professional development plans and preferences, number of courses attended recently, learning styles, use made of ward/unit resources (particularly journals) and optimum periods for library opening. The second part of the survey was a vignette information problem. The responses (written by the participants) provided an indication of information-seeking skills and perceptions of various information sources, both formal (publications) and informal (colleagues and organizations). Analysis indicated that the most popular method of learning was attending a study day, and the most popular combination of learning styles was study day combined with further reading. Reading or journals was selective. Most staff would have to rely on a library for journal literature, particularly the new journals. One third of the sample appeared lacking in information-seeking skills. One third appeared confident in information-seeking skills, and this group was associated with the use of more than two sources of information and use of a library. No single library in Plymouth would be adequate for the sources of information required, indicating the need for better networking and/or integration.

The value of information supplied to clinicians by health libraries: devising an outcomes-based assessment of the contribution of libraries to clinical decision-making

The Value project, a study funded by the British Library Research and Development Department and a group of postgraduate medical deans, has examined the effectiveness of NHS library and information services. Clinicians at 11 hospital library sites were asked to describe the purposes for which they needed information, the steps they took to obtain it, and to assess the value of the information obtained from interlibrary loan requests, database searches and end-user searches. A sample of non-library users and of users of the BMA Dial-Up MEDLINE service were also asked similar questions. Results show that information did, or would in the future, assist in personal clinical decision-making and which kinds of decisions were most supported. Information new to clinicians was often provided. Follow-up interviews provided illustrations of the ways in which developments aimed at more cost-effective patient care were supported by information obtained from the library. Results are being used to guide the production of a quality assurance toolkit to help libraries audit their services and improve the delivery of information to clinicians.

Thymidine uptake by chicken kidney cells parasitized by Eimeria tenella: evidence for a diffusable mediating substance

The pattern of DNA synthesis in chicken kidney (CK) cells parasitized by Eimeria tenella was altered; a 2-fold increase in the uptake of [3-H]-thymidine occurred in these cells compared with that shown by the controls. This difference was significantly different at 16 h post-inoculation (p.i.) and reached a peak at 20 h p.i. Non-parasitized cells in co-culture with parasitized cells showed a level of incorporation intermediate between that of the parasitized and non-parasitized monocultures. It was shown that this stimulation was due to a factor released into the medium by the parasite or the parasitized cell. A possible course of events leading to induced and prolonged DNA synthesis by the host cell and the significance of this change in the life-cycle of the parasite is discussed.

Morphological and adhesive changes to cultured chick kidney cells following parasitization with Eimeria tenella (Protozoa: Coccidia)

Cultured adult chick kidney (CK) cells inoculated with sporozoites of Eimeria tenella showed progressive alterations in their morphological and adhesive characteristics. Scanning electron microscopy (SEM) showed that during a 3-day period following the inoculation of parasites there was a gradual loss of contact between the cells. Initially, the cells remained connected by long cytoplasmic bridges but with the breakdown of these, the cells began to round up, losing complete contact with each other and remaining attached to the substratum by means of retraction fibres. By 3 days many cells had completely detached. The factors inducing these alterations were transmissable via the medium as the alterations were mimicked by non-parasitized cells in co-culture with parasitized cells. Studies with the reflection interference microscope (RIM) showed that the changes were accompanied by an increase in the cell-substrate separation distance and the loss of focal contacts. These changes were not effected by substances transmissable via the medium. Parasitized cells showed enhanced agglutination with Concanavalin A (Con A) which could be eliminated by pre-fixation. The possibility that changes to the host cell indicate a rearrangement of cytoskeletal apparatus is discussed.