Enhancing the management of deteriorating patients with Australian on line e‐simulation software: Acceptability,transferability, and impact in Hong Kong

International concerns relating to healthcare professionals’ failure to rescue deteriorating patients exist. Web‐based training programs have been developed and evaluated in Western settings but further testing is required before application in non‐Western countries, as traditional modalities of learning may differ between cultures. We trialed an Australian English language online simulation program for the management of deteriorating patients, Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST²ACTWeb), to test cultural acceptability, transferability, and educational impact. The study was designed as a quasi‐experimental evaluation of the FIRST²ACTWeb program with final year nursing students from a Bachelor of Nursing program at the University of Hong Kong. Participants completed pre‐course and post‐course tests, three interactive scenarios, and program evaluations. The program was positively evaluated, with significant improvements in knowledge, skills, self‐rating of performance, confidence, and competence. Outcomes were comparable to earlier evaluations with Australian students, demonstrating that an interactive simulation‐based program of patient deterioration management has cultural and language acceptability and transferability across communities with significant educational impact.     

Early Diagnostic Efficiency of Cardiac Troponin I and Troponin T for Acute Myocardial Infarction

Objective : To compare the early diagnostic efficiency of the cardiac troponin I (cTn-I) level with that of the cardiac troponin T (cTn-T) level, as well as the creatine kinase (CK), CK-MB, and myoglobin levels, for acute myocardial infarction (AMI) in patients without an initially diagnostic ECG presenting to the ED within 24 hours of the onset of their symptoms. Methods : A prospective, observational, cohort study was performed involving chest pain patients admitted to a large urban community hospital. Participants were consecutive consenting ED chest pain patients ≥30 years of age. Exclusions included duration of symptoms >24 hours, inability to complete data collection, receipt of CPR, and ST-segment elevation on the initial ECG. Measurements included levels of cTn-I, cTn-T, CK, CK-MB, and myoglobin at the time of presentation and 1, 2, 6, and 12–24 hours after presentation as well as presenting ECG and clinical follow-up. Confirmation of the diagnosis of AMI was based on World Health Organization criteria. Results : Of the 177 patients included in the study, 27 (15%) were diagnosed as having AMIs. The sensitivities of all 5 biochemical markers for AMI were poor at the time of ED presentation (3.7–33.3%) but rose significantly over the study period. The sensitivity of cTn-T was significantly better than that of cTn-I over the initial 2 hours, but both markers' sensitivities were low (<60%) during this time frame. The cTn-I was significantly more specific for AMI than was the cTn-T, but not significantly better than CK-MB or myoglobin. Likelihood ratio analysis showed that the biochemical markers with the highest positive likelihood ratios for AMI during the first 2 hours following ED presentation were myoglobin and CK-MB. From 6 through 24 hours, the positive likelihood ratios for cTn-I, CK-MB, and myoglobin were superior to those of CK and cTn-T. Conclusions : cTn-I, CK-MB, and myoglobin are significantly more specific for AMI than are CK and cTn-T. Myoglobin is the biochemical marker having the highest combination of sensitivity, specificity, and negative predictive value for AMI within 2 hours of ED presentation. Neither cTn-I nor cTn-T offers significant advantages over myoglobin and CK-MB in the early (≤2 hours) initial screening for AMI. The cardiac troponins are of benefit in identifying AMI ≤6 hours after presentation.     

Surveying patients about their experience with a urinary catheter

About 15–20% of hospital inpatients are catheterized, and it has been estimated that in an average sized hospital 10–15 patients will die each year from catheter‐related sepsis. Reducing catheterization rates or indwell times has been shown to reduce associated sepsis. This study examined patient experience of catheterization; the rationale for the study was to broaden understanding of catheter impact as part of a wider quality improvement agenda. Fifty patients completed a detailed catheter‐experience patient questionnaire. The patients were all inpatients from 17 wards across a range of specialties. Data were sought on demographics, catheter status, experience and their knowledge of and involvement in the catheter care. Fifty percent gender split. Median catheter time was 5 d (range 2 h to long term). Median age 72 years (range 22–92). Thirty‐four percent (n = 17) of patients did not have the process and options discussed before catheterization. Eighteen percent did not know why they were catheterized. Patients experienced leaking (32%), ‘pain’ (26%), inconvenience (26%), embarrassment (24%), blocking (24%) with 8% finding their catheters ‘restrictive’. Fourteen percent felt they could have coped without the catheter. Urinary catheters have a profound and often negative effect on the inpatient experience. This information can help support and empower colleagues to push for less urinary catheter use in the non‐urological inpatient population and start to better understand the patient experience.     

Novel pathogenic LRRK2 p.Asn1437His substitution in familial Parkinson's disease

Genealogical investigation of a large Norwegian family (F04) with autosomal dominant parkinsonism has identified 18 affected family members over four generations. Genetic studies have revealed a novel pathogenic LRRK2 mutation c.4309 A>C (p.Asn1437His) that co‐segregates with disease manifestation (LOD = 3.15, θ = 0). Affected carriers have an early age at onset (48 ± 7.7 SD years) and are clinically asymmetric and levodopa responsive. The variant was absent in 623 Norwegian control subjects. Further screening of patients from the same population identified one additional affected carrier (1 of 692) with familial parkinsonism who shares the same haplotype. The mutation is located within the Roc domain of the protein and enhances GTP‐binding and kinase activity, further implicating these activities as the mechanisms that underlie LRRK2‐linked parkinsonism. © 2010 Movement Disorder Society     

Use of complementary and alternative therapies in outpatients with Parkinson's disease in Argentina

We interviewed 300 patients (54.7% male; mean age was 65.8 ± 9.5) attending the Movement Disorders Clinic at the Buenos Aires University Hospital to determine the prevalence of CATs use and their association with demographic, social, or disease‐specific characteristics among patients with Parkinson's disease (PD) in Buenos Aires, Argentina. We found that 25.7% of the PD patients interviewed (77/300) stated they had used CATs to improve their PD symptoms whereas 38.0% (114/300) had used some CATs without any relation to PD, at least once in life. At the moment of the interview, CATs prevalence use was 50.6% in the former group and 25.0% in the latter. The use of CATs was much more frequent among women and more common in the 50‐ to 69‐year age group. Friends and neighbors of the patients had most frequently recommended these therapies. No major association was observed between CATs use and the duration of the disease, side of initial involvement, PD phenotype, or the Hoehn and Yahr staging. Acupuncture, homeopathy, yoga, and therapeutic massage were the most widely used therapies. After the initiation of conventional treatment the use of massage, yoga, and acupuncture in patients using CATs to improve PD significantly increased. Neurologists should be aware and inquire about the use of CATs to rule out potentially harmful effects. © 2010 Movement Disorder Society     

External Iliac Artery Injury Complicating Prosthetic Hip Resection for Infection

Vascular injury is a rare but devastating complication of total hip arthroplasty. We present 2 cases of external iliac artery injury that complicated the removal of a chronically infected total hip arthroplasty where the acetabular component had migrated medial to Kohler's line. In both cases, hemostasis and reperfusion were achieved with the assistance of a vascular surgeon. This report describes the diagnosis, treatment, and associated risk factors for this rare complication. The combination of deep infection and medial migration of the acetabular component represents a high-risk situation for vascular injury. We advocate preoperative consultation with a vascular surgeon in this setting.