Assessing the adequacy of sedation. Why and how.
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Procedural Sedation↗
Biomedical subjects
J Ball
Publications and source records attributed to J Ball.
How useful is the bispectral index in the management of ICU patients?
If you want to objectively quantify the level of sedation the intuitive solution must be to monitor the brain directly. However, due to the complexity of this organ, and our limited understanding of consciousness, this remains a daunting challenge. For many years, researchers have investigated the electrical activity of the brain and its relationship with conscious level. Over the last few years, a derived variable from the EEG, the Bispectral Index (BIS), has been developed, which appears to correlate quite well with the level of pharmacological sedation.
Critical Care↗
The 21st International Symposium on Intensive Care and Emergency Medicine, Brussels, Belgium, 20-23 March 2001.
The 21st International Symposium on Intensive Care and Emergency Medicine was dominated by the results of recent clinical trials in sepsis and acute respiratory distress syndrome (ARDS). The promise of extracorporeal liver replacement therapy and noninvasive ventilation were other areas of interest. Ethical issues also received attention. Overall, the 'state of the art' lectures, pro/con debates, seminars and tutorials were of a high standard. The meeting was marked by a sense of renewed enthusiasm that positive progress is occurring in intensive care medicine.
Critical Care↗
Tracking the response of Xid B cells in vivo: TI-2 antigen induces migration and proliferation but Btk is essential for terminal differentiation.
X-linked immunodeficient (Xid) mice carry a Bruton's tyrosine kinase (Btk) mutation and exhibit a selective failure to produce antibodies against bacterial capsular polysaccharides. Studies in vitro point to a fundamental survival defect of Xid B cells after receptor cross-linking by thymus-independent type-2 (TI-2) antigen because B cells undergo apoptosis without proliferating. We describe results from a novel model, which we have used to investigate the impact of the Xid mutation on migration, proliferation and differentiation of B cells after polysaccharide immunization in vivo. Immunoglobulin knock-in mice, in which a large proportion of B cells express transgene-encoded receptors specific for (4-hydroxy-3-nitrophenyl)-acetyl (NP), were crossed with CBA/N mice. The male progeny contain NP-specific Xid B cells, while the female progeny contain NP-specific B cells with normal Btk. After immunization with the TI-2 antigen NP-Ficoll, NP-specific Xid B cells migrate to the T zones and proliferate. Despite transient up-regulation of blimp-1 and survival beyond the time when terminal differentiation is normally underway, Btk-defective B cells fail to differentiate to plasmablasts or germinal center cells. CD40 ligation partially restores their ability to form plasma cells in response to TI-2 antigen.
Agammaglobulinaemia Tyrosine Kinase↗
Current advances in Parkinson's disease.
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Antidepressive Agents↗
Ability of hospitals to care for pediatric emergency patients.
CONTEXT: The needs of children in emergency situations differ from those of adults and require special attention, yet there has been no study of the ability of U.S. hospitals to care for emergently or critically ill children. OBJECTIVE: To estimate the distribution of pediatric services available at U.S. hospitals with emergency departments (EDs). DESIGN: Self-report survey of 101 hospital EDs. PARTICIPANTS: Stratified probability sample of all U.S. hospitals operating EDs. RESULTS: The majority of hospitals that usually admit pediatric patients do not have separate pediatric facilities. Hospitals without a pediatric department, ward, or trauma service usually transfer critically injured pediatric trauma patients; however, nearly 10% of hospitals without pediatric intensive care facilities admit critically injured children to their own facilities. Likewise, 7% of hospitals routinely admit pediatric patients known to require intensive care to their adult intensive care units rather than transferring the patient to a facility with pediatric intensive care facilities. Few hospitals have protocols for obtaining pediatric consultation on pediatric emergencies. Appropriately sized equipment for successful care of infants and children in an emergency situation was more likely to be missing than adult-sized equipment, and significant numbers of hospitals did not have adequate equipment to care for newborn emergencies. CONCLUSION: Emergent and critical care of infants and children may not be well integrated and regionalized within our health care system, suggesting that there is room for improvement in the quality of care for children encountering emergent illness and trauma.
Adult↗
Are teamwork and professional autonomy compatible, and do they result in improved hospital care?
A postal questionnaire survey of 10 022 staff nurses in 32 hospitals in England was undertaken to explore the relationship between interdisciplinary teamwork and nurse autonomy on patient and nurse outcomes and nurse assessed quality of care. The key variables of nursing autonomy, control over resources, relationship with doctors, emotional exhaustion, and decision making were found to correlate with one another as well as having a relationship with nurse assessed quality of care and nurse satisfaction. Nursing autonomy was positively correlated with better perceptions of the quality of care delivered and higher levels of job satisfaction. Analysis of team working by job characteristics showed a small but significant difference in the level of teamwork between full time and part time nurses. No significant differences were found by type of contract (permanent v short term), speciality of ward/unit, shift length, or job title. Nurses with higher teamwork scores were significantly more likely to be satisfied with their jobs, planned to stay in them, and had lower burnout scores. Higher teamwork scores were associated with higher levels of nurse assessed quality of care, perceived quality improvement over the last year, and confidence that patients could manage their care when discharged. Nurses with higher teamwork scores also exhibited higher levels of autonomy and were more involved in decision making. A strong association was found between teamwork and autonomy; this interaction suggests synergy rather than conflict. Organisations should therefore be encouraged to promote nurse autonomy without fearing that it might undermine teamwork.
Cooperative Behavior↗
If changing skill mix is the answer, what is the question?
Changing skill mix is often identified as a potential solution to health services staffing and resourcing problems, or is related to health sector reform. This paper discusses what is meant by skill mix, provides a typology of the different approaches to assessing skill mix and examines, by means of case studies, the contextual, political, social and economic factors that play a part in determining skill mix. These factors are examined in relation to three factors: the reasons (or drivers) for examining skill mix; the impact of contextual constraints; and the effect of varying spans of managerial control. Case studies conducted in Costa Rica, Finland, Mexico, the UK and the USA are used to explore the reality of assessing skill in different contexts and health care settings. We argue that, although skill mix may be a universal challenge, it is not a challenge that all managers or health professionals can meet in the same way, or with the same resources. Context can have a significant effect on the ability of health service managers to assess and change skill mix. The key determinant is the extent to which these factors are in the locus of control of management nationally, regionally, or locally, within different countries. We emphasise the need to evaluate the problem and examine the context, before deciding if a change in skill mix is the answer. The local managerial span of control and degree of organisational flexibility will be major factors in determining the likely impact of any attempts to change skill mix. Before embarking on a skill mix review, any organisation should ask itself the question: 'If changing skill mix is the answer, what is the question?'
Cost Control↗
An audit of oral care practice and staff knowledge in hospital palliative care.
Mouth care is considered one of the most basic of nursing activities, and palliative care patients are especially vulnerable to oral problems (Macmillan Practice Development Unit, 1995). This article describes a project on developing oral care practice and staff knowledge, by nursing staff and Macmillan nurses at a hospital in central England. A baseline audit (audit I) was carried out to examine all aspects of current oral care practice and nursing knowledge, including assessment, implementation, prescribing and evaluation of care. Oral care guidelines and a programme of ward-based teaching were then introduced. Several months later a follow-up audit (audit II) was conducted. Results showed an improvement in all aspects of oral care and staff knowledge. Additional benefits of this process included improved professional relationships and the promotion of further audits in hospital palliative care. Recommendations include the need for further nursing research into oral care to build the evidence base further. Additionally, it is suggested that nurses must recognize their important and central role in improving this aspect of palliative care. Education and training is pivotal to this process.
Humans↗
Reporting drug abuse in the emergency department.
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Emergency Medical Services↗
Measurement of tensor polarization in elastic electron-deuteron scattering at large momentum transfer
Tensor polarization observables ( t(20), t(21), and t(22)) have been measured in elastic electron-deuteron scattering for six values of momentum transfer between 0.66 and 1.7 (GeV/c)(2). The experiment was performed at the Jefferson Laboratory in Hall C using the electron High Momentum Spectrometer, a specially designed deuteron magnetic channel and the recoil deuteron polarimeter POLDER. The new data determine to much larger Q2 the deuteron charge form factors G(C) and G(Q). They are in good agreement with relativistic calculations and disagree with perturbative QCD predictions.
Journal Article↗
Germinal centers without T cells.
Germinal centers are critical for affinity maturation of antibody (Ab) responses. This process allows the production of high-efficiency neutralizing Ab that protects against virus infection and bacterial exotoxins. In germinal centers, responding B cells selectively mutate the genes that encode their receptors for antigen. This process can change Ab affinity and specificity. The mutated cells that produce high-affinity Ab are selected to become Ab-forming or memory B cells, whereas cells that have lost affinity or acquired autoreactivity are eliminated. Normally, T cells are critical for germinal center formation and subsequent B cell selection. Both processes involve engagement of CD40 on B cells by T cells. This report describes how high-affinity B cells can be induced to form large germinal centers in response to (4-hydroxy-3-nitrophenyl) acetyl (NP)-Ficoll in the absence of T cells or signaling through CD40 or CD28. This requires extensive cross-linking of the B cell receptors, and a frequency of antigen-specific B cells of at least 1 in 1,000. These germinal centers abort dramatically at the time when mutated high-affinity B cells are normally selected by T cells. Thus, there is a fail-safe mechanism against autoreactivity, even in the event of thymus-independent germinal center formation.
Animals↗
Efficacy of unilateral versus bilateral temporal artery biopsies for the diagnosis of giant cell arteritis.
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Biopsy↗
Survey of nationally registered emergency medical services providers: pediatric education.
STUDY OBJECTIVE: To survey emergency medical services (EMS) providers on a national level to determine and describe their perspective regarding their initial and continuing education (CE) needs in pediatrics. METHODS: A 10-question survey was developed, pilot-tested, and sent to EMS providers as a part of their National Registry of Emergency Medical Technicians reregistration materials. RESULTS: Surveys were completed by 18,218 EMS providers, a response rate of 67%. During a typical month, 60% of emergency medical technician-paramedics (EMT-Ps), 84% of EMT-intermediates (EMT-Is), and 87% of basic EMTs (EMT-Bs) care for 0 to 3 pediatric patients. CE was identified by all provider levels as the main source of their pediatric knowledge and skills. A state or national mandate for required CE in pediatrics was supported by 76% of surveyed providers. More than 70% of all providers responded they were comfortable to some degree with their own ability and their EMS system's ability when confronted with a critical pediatric call. Cost, availability, and travel distance were identified by all levels as the primary barriers to obtaining pediatric CE. All levels identified infants as the age of greatest concern if the provider was called to manage a critical case. CONCLUSION: Surveyed practicing nationally registered EMS providers have infrequent contact with pediatric patients and have acquired most of their pediatric knowledge and skills from CE. In general, these providers are comfortable with their personal and their system's ability to care for children, but clearly support the need for required pediatric CE and identify the birth to 3-year age range as the priority for an educational focus. Cost, travel distance, and availability of pediatric CE are barriers that should be considered if pediatric CE is to be required of EMS providers.
Attitude of Health Personnel↗
Effectiveness of the National Death Index for establishing the vital status of older women in the Australian Longitudinal Study on Women's Health.
OBJECTIVE: To assess the effectiveness of the National Death Index (NDI) in identifying participants in the oldest cohort of the Australian Longitudinal Study on Women's Health (ALSWH) who had died between 1996 and 1998. METHODS: Identifying information for each woman was matched with the NDI using a probabilistic algorithm and clerical review. Differences in full name, date of birth, State of residence and date of last contact were used to assess the probability of a true match. RESULTS: NDI identified 410 matches of death records for 409 women; 386 were categorised as true matches and 23 were doubtful matches. Responses to the follow-up survey confirmed that for six of the doubtful matches the women had died, 16 were alive and the vital status of one woman remained unconfirmed at 30 June 1998. Twelve deaths, known to have occurred before July 1998, were not identified through NDI. The sensitivity of the NDI for identifying known deaths was 95%. Detailed identifying information, particularly the middle name, was important for accurate identification of the vital status. CONCLUSIONS: Using surname, all given names, gender, date of birth, State of residence and age at last contact as matching variables, the NDI was an effective tool for identifying women who had died. IMPLICATIONS: Routinely collected mortality data in the NDI are useful for the practice of epidemiology.
Aged↗
Women drivers' behaviour, socio-demographic characteristics and accidents.
The purpose of this study was to examine factors which affect driving behaviour and accident rates in women in Australia. Two groups of women (aged 18-23 and 45-50 years) participating in the Australian Longitudinal Study on Women's Health, completed a mailed questionnaire on driver behaviour and road accidents. Self reported accident rates in the last 3 years were 1.87 per 100,000 km for the young drivers (n = 1199) and 0.59 per 100,000 km for the mid-age drivers (n = 1564); most accidents involved damage only, not injury. Mean scores for lapses obtained using the Driver Behaviour Questionnaire, were similar in the two age groups and similar to those found in other studies. In contrast, scores for errors and violations for the young women were higher than for the mid-age group and previous reports using the same instruments. Riskier driving behaviour among young women was associated with stress and habitual alcohol consumption. In the mid-age group, poorer driver behaviour scores were related to higher levels of education, feeling rushed, higher habitual alcohol consumption and lower life satisfaction scores. Accident rates in both groups were significantly related to lapses. Women born in non-English speaking countries had significantly higher risk of accidents compared to Australian-born women: relative risk = 3.40, 95% confidence interval (1.93, 5.98) for the young drivers; relative risk = 1.77, 95% confidence interval (1.11, 2.83) for mid-age drivers. These findings support the need for road safety campaigns targeted at young women to reduce dangerous driving practices, such as speeding, 'tail gating' and overtaking on the inside. There is also a need for further research to understand how lifestyle characteristics are associated with higher risk of accidents and to explore factors which might account for the higher risk for women drivers who were born overseas.
Accidents, Traffic↗
Comparison of the upper gastrointestinal safety of Arthrotec 75 and nabumetone in osteoarthritis patients at high risk for developing nonsteroidal anti-inflammatory drug-induced gastrointestinal ulcers.
A 6-week, multicenter, double-masked, placebo-controlled, parallel-group study compared the upper gastrointestinal (UGI) safety of Arthrotec 75 (diclofenac sodium 75 mg-misoprostol 200 microg; G.D. Searle & Co., Skokie, Illinois) administered twice daily with that of nabumetone 1500 mg administered once daily in 1203 patients with symptomatic osteoarthritis (OA) of the hip or knee. All patients had a documented clinical history of endoscopically confirmed gastric, pyloric-channel, or duodenal ulcer or > or = 10 erosions in the stomach or duodenum. UGI endoscopy was performed at baseline and again at week 6 or early withdrawal. Treatment with Arthrotec 75 resulted in a significantly lower combined incidence of endoscopically confirmed gastric and duodenal ulcers compared with nabumetone (4% vs 11%), and its rate of endoscopically confirmed ulceration was equivalent to that of placebo. The incidence of gastric ulcers alone was also significantly lower with Arthrotec 75 than with nabumetone (1% vs 9%). The incidence of duodenal ulcer with Arthrotec 75 was not significantly different from that with nabumetone (4% vs 3%). Types of adverse events were similar for all treatment groups, with GI adverse events predominating. Arthrotec 75 was well tolerated by the majority of patients. The results of this study demonstrate that Arthrotec 75 has a superior UGI safety profile, causing significantly fewer UGI ulcers, in comparison with nabumetone in patients with symptomatic OA and a documented history of ulcers or > or = 10 erosions.
Adult↗