Dabigatran: will it change clinical practice?

Dabigatran (Pradaxa) is a new oral anticoagulant approved in the United States for the primary prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation. It offers clinicians an alternative to warfarin (Coumadin), and it has received considerable interest because of its convenience of use, clinical efficacy, and safety profile. However, it is more expensive, and this may limit its widespread use.     

Opioid-induced constipation in intensive care patients: relief in sight?

Constipation is the most common gastrointestinal complication associated with opioid therapy in chronic pain patients, and also frequently occurs in sedated intensive care unit patients. Conventional therapy may not provide sufficient relief from constipation, which can be severe enough to limit opioid use or the dose. In a recent study on terminally ill patients suffering from laxative-resistant opioid-induced constipation, Thomas and colleagues demonstrated subcutaneous methylnaltrexone to rapidly induce defecation. This appealing result might also have favourable prospects for intensive care patients, as their outcome is often codetermined by recovery of bowel functioning.     

Endobronchial adrenaline: should it be reconsidered? Dose response and haemodynamic effect in dogs

BACKGROUND: Tracheal drug administration is a route for drug delivery during cardiopulmonary resuscitation when intravenous access is not immediately available. However, tracheal adrenaline (epinephrine) injection has been recently shown to be associated with detrimental decrease in blood pressure. This was attributed to exaggerated early beta2 mediated effects unopposed by alpha-adrenergic vasoconstriction. We hypothesized that endobronchial adrenaline administration is associated with better drug absorption, which may abolish the deleterious drop of blood pressure associated with tracheal drug administration. OBJECTIVE: To determine haemodynamic variables after endobronchial adrenaline administration in a non-arrest canine model. DESIGN: Prospective, randomized, laboratory study. METHODS: Adrenaline (0.02, 0.05, 0.1 mg/kg) diluted with normal saline was injected into the bronchial tree of five anaesthetized dogs. Injection of 10-ml saline served as control. Heart rate, blood pressure and arterial blood gases were monitored for 60 min after drug instillation. The protocol was repeated after 1 week. RESULTS: Adrenaline at a dose of 0.02 mg/kg produced only a minor initial decrease in diastolic (from 90 +/- 5 to 78 +/- 3 mmHg, P=0.05), and mean blood pressure (from 107 +/- 4 to 100 +/- 3 mmHg, P=0.05), in all dogs. This effect lasted less then 30 s following the drug administration. In contrast, higher adrenaline doses (0.05 and 0.1 mg/kg) produced an immediate increase in diastolic (from 90 +/- 5 to 120 +/- 7 mmHg; and from 90 +/- 5 to 170 +/- 6 mmHg, respectively), and mean blood pressure (from 107 +/- 4 to 155 +/- 10 mmHg; and from 107 +/- 4 to 219 +/- 6 mmHg, respectively). All adrenaline doses resulted in an immediate increase in systolic blood pressure and pulse. Endobronchial administration of saline (control) affected none of the haemodynamic variables. CONCLUSIONS: In a non-arrest model, endobronchial adrenaline administration, as opposed to the effect of tracheal adrenaline, produced only a minor decrease in diastolic and mean blood pressure. We suggest that endobronchial adrenaline administration should be investigated further in a CPR low-flow model when maintaining adequate diastolic pressure may be crucial for survival.     

Gender bias and discrimination in nursing education: can we change it?

Gender bias in nursing education impedes recruitment and retention of males into the profession. Nurse educators who are unaware of men's historical contributions to the profession may unknowingly perpetuate gender bias. The author describes how traditional stereotypes can be challenged and teaching/learning strategies can be customized to gender-driven learning styles.     

Lung cancer screening: is it time for a change in policy?

Two recent studies of computed tomography (CT) as a screening test for lung cancer have heightened debate about this topic. Although the International Early Lung Cancer Action Program investigators (N Engl J Med 2006; 355:1763-1771) concluded that annual CT screening can detect lung cancer that is curable, Bach et al (JAMA 2007; 297:953-961) concluded that it may not meaningfully reduce the risk of advanced lung cancer or death from lung cancer. We feel that questions remain about the degree of reduction in lung cancer-specific mortality, the potential morbidity caused by screening, the appropriate group to screen, and the cost-effectiveness of screening. These questions warrant further study prior to accepting CT screening as the standard of care. Hopefully, much of this knowledge will be gained when the results of ongoing controlled studies are available.     

Radiation Dose in Coronary CT Angiography: How High is it and What Can be Done to Keep it Low?

Radiation dose reduction strategies in coronary CT angiography are paramount to ensure the lowest radiation exposure. This review provides basic knowledge of radiation physics. The technical background and the clinical implementations of various radiation dose-saving strategies for coronary CT angiography are discussed.     

Is rehabilitation associated with change in functional status among nursing home residents?

Assessing functional status of residents in nursing homes is one way to evaluate the quality of care provided. The purpose of this study was to investigate whether rehabilitation interventions could lead to improved functional independence. A prospective study was carried out to examine the change in activities of daily living (ADL) of 310 residents aged 65 or above over a period of 6 months. About 41.3% (n = 128) received rehabilitation therapy. Functional improvement was observed in 30.6% of the participants. The corresponding figures for stabilization and functional decline were 45.2% and 24.2%, respectively. Using a multinomial logistic regression, we found that factors significantly associated with change in functional status included baseline ADL score, family visit, number of beds in the institution, and transfer to acute hospitals. After adjusting for these confounding variables, change in functional status of those who received rehabilitation and those who did not was not significantly different.     

Minimally invasive cardiopulmonary bypass: does it really change the outcome?

Introduction  

Many innovative cardiopulmonary bypass (CPB) systems have recently been proposed by the industry. With few differences, they all share a philosophy based on priming volume reduction, closed circuit with separation of the surgical field suction, centrifugal pump, and biocompatible circuit and oxygenator. These minimally invasive CPB (MICPB) systems are intended to limit the deleterious effects of a conventional CPB. However, no evidence exists with respect to their effectiveness in improving the postoperative outcome in a large population of patients. This study aimed to verify the clinical impact of an MICPB in a large population of patients undergoing coronary artery revascularization.     

What is action research and can it promote change in primary care?

Improving the quality of health care is an international priority. However, research has shown that methods of altering clinician's behaviour or implementing organizational change are often ineffective. Action research has been used successfully to facilitate change and improve service provision in industry, education and more recently in health care. In this paper, action research methodology and why it should be successful in promoting change are outlined. Recently published studies using action research in the primary health care team setting in the UK are discussed. They demonstrate that action research improves clinical care, teamwork, communication and administration. It also encourages practice teams to audit their work and identify their educational needs. The main problems encountered were the amount of time and effort required to maintain collaboration with participants, staff turnover and completing the research process in a short time scale. Action research should be a useful means of improving quality in health care and could be used more widely. In the UK, government strategy has called for individual- and team-based development plans based on individual learning needs. Action research could be a useful method of transforming these from theory to practice.     

The value of continence training: does it change clinical practice?

It is estimated that one in six people over 40 are incontinent 'several times a month' and that most of them will not have sought help (Perry et al, 2000). Containment of the problem is no longer the first-line treatment and patients should be given access to an assessment, with a management plan addressing the cause of incontinence. It is thought that around 70% of the estimated population with continence problems in the UK would show a good response to treatment (Royal College of Physicians (RCP), 1995). However, it is recognized that healthcare professionals need knowledge and training to deliver care (Brittain et al, 2001). Previous studies have shown continence education, for both professionals and users, to be cost-effective because investment in techniques to promote continence can reduce dependence on incontinence containment products (Bradley and Morgan, 1998; Williams et al, 1999). This study was based on the belief that there is an educational gap between what is taught and what is practised (Macleod, 1998; Severinsson, 1998). The study drew on an opportunistic sample of students attending continence-training courses. They were asked to complete pre- and post-course questionnaires. Using a follow-up research design, three periods of data were collected. Data were analysed using Microsoft Excel and the Statistical Package for Social Science (SPSS). The results conclude that there was a statistically significant change in the quantitative measure - the test result - but qualified nurses were experiencing some difficulty relating the theory to clinical practice.     

PAC in FACTT: Time to PAC it in?

Citation

Wheeler AP, Bernard GR, Thompson BT, Schoenfeld D, Wiedemann HP, deBoisblanc B, Connors AF, Jr., Hite RD, Harabin AL. Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med 2006;354:2213–2224 [1].

Background

The balance between the benefits and the risks of pulmonary artery catheters (PACs) has not been established.

Methods

Objective

To assess the safety and efficacy of PAC-guided vs. central venous catheter-guided management in reducing mortality and morbidity in patients with established acute lung injury (ALI).

Design

Randomized, controlled, non-blinded trial.

Setting

36 centers in the United States and 2 in Canada.

Subjects

1000 patients with established acute lung injury of less than 48 hours duration. Subjects were excluded if they already had a PAC in place or had chronic conditions that could independently influence survival, impair weaning, or compromise compliance with the protocol, such as dialysis dependence, severe lung or neuromuscular disease, or terminal illness.

Intervention

Subjects were randomized to hemodynamic management guided by a PAC or a CVC using an explicit management protocol.

Outcomes

Hospital mortality during the first 60 days before discharge home was the primary outcome. Secondary outcomes included ventilator-free days, intensive care unit-free days, organ failure-free days, and adverse events.

Results

The groups had similar baseline characteristics. The rates of death during the first 60 days before discharge home were similar in the PAC and CVC groups (27.4 percent and 26.3 percent, respectively; P = 0.69; absolute difference, 1.1 percent; 95 percent confidence interval, -4.4 to 6.6 percent), as were the mean (+/-SE) numbers of both ventilator-free days (13.2 +/- 0.5 and 13.5 +/- 0.5; P = 0.58) and days not spent in the intensive care unit (12.0 +/- 0.4 and 12.5 +/- 0.5; P = 0.40) to day 28. PAC-guided therapy did not improve these measures for subgroup of patients in shock at the time of enrollment. There were no significant differences between groups in lung or kidney function, rates of hypotension, ventilator settings, or use of dialysis or vasopressors. Approximately 90 percent of protocol instructions were followed in both groups, with a 1 percent rate of crossover from CVC- to PAC-guided therapy. Fluid balance was similar in the two groups, as was the proportion of instructions given for fluid and diuretics. Dobutamine use was uncommon. The PAC group had approximately twice as many catheter-related complications (predominantly arrhythmias), though rates per catheter insertion were similar between groups.

Conclusion

PAC-guided therapy did not improve survival or organ function but was associated with more complications than CVC-guided therapy. These results, when considered with those of previous studies, suggest that the PAC should not be routinely used for the management of acute lung injury. (ClinicalTrials.gov number, {"type":"clinical-trial","attrs":{"text":"NCT00281268","term_id":"NCT00281268"}}NCT00281268.).