Innovation in learning – An inter-professional approach to improving communication

Inter-professional education (IPE) is recognised as a major way of introducing students in the health professions to the importance of teamwork and communication in the delivery of excellent healthcare. This pilot project evaluated mixed versus single discipline group tutorials of nursing and medical students as a way to promote IPE and understanding of communication. Four tutorial sessions were video-recorded and analysed using a video analysis coding grid. Additional data were drawn from student evaluations and assessment of group participation and were subjected to quantitative and qualitative analysis. The case study as portrayed in the DVD was thought to provide an effective learning tool by both sets of students. Medical students rated the need for mixed group tutorials significantly lower than the nursing students who thought the tutorial activity helped with an appreciation of the importance of communication to effective teamwork. However, medical students in the single discipline group did not understand the nursing role. The resources fostered reflection on student’s own professional role as well as others; however, the importance of communication within the nursing role needs to be recognised by nursing students and curriculum designers.     

Colorectal Cancer – An Update for Primary Care Nurse Practitioners

The picture of colorectal cancer (CRC) is changing. Our understanding of factors that drive the growth of CRC, the image of a CRC patient, and our approach to treating CRC is all evolving. This article will bring the picture into clearer focus. We will start with an update of the pathogenesis of CRC, review screening methods, look at a meta-analysis of risk factors, then follow with new information about the concern of younger patients developing CRC. We finish with a look at a new treatment option. With this more focused view, nurse practitioners can screen more effectively for colorectal cancer.     

Examination of musculoskeletal chest pain – An inter-observer reliability study

Chest pain may be caused by joint and muscle dysfunction of the neck and thorax (termed musculoskeletal chest pain). The objectives of this study were (1) to determine inter-observer reliability of the diagnosis ‘musculoskeletal chest pain’ in patients with acute chest pain of non-cardiac origin using a standardized examination protocol, (2) to determine inter-observer reliability of single components of the protocol, and (3) to determine the effect of observer experience. Eighty patients were recruited from an emergency cardiology department. Patients were eligible if an obvious cardiac or non-cardiac diagnosis could not be established at the cardiology department. Four observers (two chiropractors and two chiropractic students) performed general health and manual examination of the spine and chest wall. Percentage agreement, Cohen's Kappa and ICC were calculated for observer pairs (chiropractors and students) and all. Musculoskeletal chest pain was diagnosed in 45 percent of patients. Inter-observer kappa values were substantial for the chiropractors and overall (0.73 and 0.62, respectively), and moderate for the students (0.47). For single items of the protocol, the overall kappa ranged from 0.01 to 0.59. Provided adequate training of observers, the examination protocol can be used in carefully selected patients in clinical settings and should be included in pre- and post-graduate clinical training.     

The human vasodilator axon reflex – An exclusively peripheral phenomenon?

The effect of regional anesthesia of the brachial plexus on the size and intensity of the histamine-induced axon reflex flare (neurogenic inflammation) of the forearm and the upper arm was compared to that of the contralateral arm as control in humans. No changes in the axon reflex could be assessed. Thus the lateral spread of the axon reflex flare must be transmitted by peripheral nerve branches not affected by the anesthesia in the axilla. This excludes the existence of physiologically relevant amounts of proximal branchpoints, DRG neurons with multiple peripheral axons or spinal interneurons transmitting action potentials between peripheral C-afferents involved in the axon reflex flare. Mechanoinsensitive C-fibres are known to be activated by histamine and to be responsible for the neuropeptide release in the skin inducing the axon reflex flare. Reports on those proximal connections can therefore obviously not extend to mechanoinsensitive C-fibres and do not explain the origin of neurogenic inflammation in humans without prior sensitization.     

Fixed-angle plate osteosynthesis of the patella – An alternative to tension wiring?

Background

The goal of this study is carry out a biomechanical evaluation of the stability of a bilateral, polyaxial, fixed-angle 2.7 mm plate system specifically designed for use on the patella. The results of this approach are then compared to the two currently most commonly used surgical techniques for patella fractures: modified anterior tension wiring with K-wires and cannulated lag screws with anterior tension wiring.

Methods

A transient biomechanical analysis determining material failure points of all osteosyntheses were conducted on 21 identical left polyurethane foam patellae, which were osteotomized horizontally. Evaluated were load (N), displacement (mm) and run-time (s) as well as elastic modulus (MPa), tensile strength (MPa) and strain at failure (%).

Findings

With a maximum load capacity of 2396 (SD 492) N, the fixed-angle plate proved to be significantly stronger than the cannulated lag screws with anterior tension wiring (1015 (SD 246) N) and the modified anterior tension wiring (625 (SD 84.9) N). The fixed-angle plate displayed significantly greater stiffness and lower fracture gap dehiscence than the other osteosyntheses. Additionally, osteosynthesis deformation was found to be lower for the fixed-angle plate.

Interpretation

A bilateral fixed-angle plate was the most rigid and stable osteosynthesis for horizontal patella fractures with the least amount of fracture gap dehiscence. Further biomechanical trials performed under cycling loading with fresh cadaver specimen should be done to figure out if a fixed-angle plate may be an alternative in the surgical treatment of patella fractures.     

A colloid cyst of the third ventricle – the cause of episodic headache and sudden unexpected death in an adolescent girl

An 18-year-old girl was found dead in her bed. The autopsy revealed a colloid cyst of the third ventricle. The cyst obstructed the flow of cerebrospinal fluid, leading to prominent internal hydrocephalus with consecutive brain edema and compression of the caudal medulla at the foramen magnum. The girl's only previous complaints were episodic headaches for the previous 2-3 years. Computed tomography and magnetic resonance imaging were not performed prior to her death. This case report highlights the importance of early diagnosis of colloid cyst of the third ventricle and the need to perform computed tomography and magnetic resonance imaging in patients with episodic headaches even when they show no neurologic deficit. Although it is a very rare disorder, it should be included in the differential diagnosis of headaches in children and young adults, and also in the differential diagnosis of conditions causing increased intracranial pressure, in view of the life-saving management required to prevent a fatal outcome.     

An Analysis of Bone Donor Deferral Rates in Scotland – a 6-Year Study

Background

The Scottish National Blood Transfusion Service (SNBTS) is the main provider of tissues in Scotland. Tissue collection programmes were established in the mid-1990s, and the range of tissues collected has increased progressively over the years.

Mathods

Whilst the majority of tissues are obtained from cadaveric donations, bone is collected only from living donors who are usually patients undergoing primary hip replacement surgery (surgical donors). The bone is collected in an operating theatre, and, once stored, no further processing takes place prior to issue. Bone that fails for any reason (quality, microbiology or virological nonnegative result) is discarded.

Results

The deferral rate amongst live surgical bone donors in Scotland is around 65%, and it has been slowly and progressively rising from around 55% over the past few years. This needed investigated, particularly because comparisons with blood donors show that the deferral rate amongst bone donors is more than double that of first-time blood donors (29.7%). Our processes and systems are standardised, and our cohort of bone bank nurses have all been similarly trained and competency assessed. Moreover our data collection was done in a uniform fashion. It was therefore possible to conduct a 6-year audit on bone donor deferrals. It was found that a history of transfusion (16%), history of malignancy (18%) and bone quality (26%) were the main reasons for bone donor deferrals, accounting for 60% of all deferrals.

Conclusions

When these are taken into account, the residual deferral rates become very similar numerically to blood donors. It is important to note however that there are significant differences between the blood and bone donor cohorts. This study also highlighted some of deferral reasons. Particularly malignancy is a cause of significant numbers of deferrals, and the evidence of transmissibility of malignancy through bone donation is not strong. More robust risk assessments should be undertaken prior to implementing deferral conditions.Key Words: Living bone donors, Deferral rates, Tissue donation, Femoral head     

Nurses’ provision of spiritual care in the Emergency Setting – An Irish Perspective

BackgroundThe researcher’s interest in spiritual care arose during clinical experience in an emergency department. Over a 10-year period, I have observed, that in midst of a busy and increasingly overcrowded setting, nurses find time to provide spiritual care. Although this dimension of nursing practice is not explicitly labelled as spiritual care, it is apparent that interventions such as active listening, touch and ultimately connecting with the patient has, on most occasions, positive effects on the patient’s spiritual dimension. Subsequently, this has provided the momentum to carry out a study on how nurses provide spiritual care, in an emergency setting. The findings revealed that participants regarded spiritual care to be an integral component of their role. In addition, participants reported that they derived positive personal outcomes from providing this aspect of nursing care. Nevertheless, although most participants would argue that spiritual care is central to nursing practice, concerns were expressed with regard to its provision, in the emergency setting.     

Clinical-sonographic diagnostics and laser therapy treatment options in lymphatic vascular malformations – An experience-based report

Lymphatic vascular malformations occur with a large variety of different characteristics. Color-coded duplex sonography is the most effective preoperative and intra-operative diagnosis method. According to different manifestations, suitable laser procedures can be performed with minor side effects and a noticeable stabilization of the clinical situation after only a few interventions. We report on our experience in diagnostics and the laser therapy of lymphatic vascular malformations which are based on the treatment of 168 patients over the last 8 years.     

Septic arthritis of the wrist and the hand: – An Emergency department case study

Joint pain is a common presentation in the Emergency department. There are countless potential causes for pain and swelling in a joint. Septic arthritis is a true joint emergency as it can lead to rapid, irreversible destruction of the joint. If not diagnosed early this infection can lead to considerable functional deficit. Our case is unique in that our patient presented to the Emergency department requesting referral to the fracture clinic for continued management of a suspected scaphoid bone fracture but was found to have Neisseria gonorrhoea causing septic arthritis of the joint. This case highlights the importance of accurate history taking, clinical examination and assessment of the patients presenting with joint pain.     

Intraosseous samples can be used for opioid measurements – An experimental study in the anaesthetized pig

Abstract

Aim. The intraosseous route provides access to the systemic circulation in an emergency situation when other forms of vascular access are unavailable and there is an urgent need for fluid or drug therapy. The intraosseous access has also been used for collecting samples for laboratory testing. A question that may arise in an unconscious or severely exhausted patient is whether this condition is caused by an unknown drug. We aimed to evaluate whether intraosseous samples could be used to measure opioids and to study the accuracy and precision of such measurements. Methods. Five healthy, anaesthetized pigs were treated with a continuous morphine infusion as part of the anaesthesia procedure. Samples for morphine testing were collected hourly for 6 h from two tibial intraosseous cannulae and a central venous catheter. Results. The differences in morphine concentrations between the two tibial intraosseous cannulae were less than 10% in 32/33 times. The values were also relatively stable over time. Conclusion. Our findings suggest that intraosseous samples can be used for the analysis of opioids if an IV route is not available.     

Hemorrhagic fever with renal syndrome in the Pomurje region of Slovenia – An 18-year survey

OBJECTIVE: To determine the etiology of hemorrhagic fever with renal syndrome (HFRS) in the north-eastern part of Slovenia (Pomurje region) together with demographic, epidemiological and clinical data on 25 patients from this region who were diagnosed and treated at the General Hospital in Murska Sobota between 1986 and 2003. METHODS: Medical records of patients with a discharge diagnosis of HFRS who were either hospitalized or referred to an infectiologist as outpatients were included in this retrospective study. Data on demographic characteristics, clinical manifestations and laboratory parameters were collected from the patients' records. In addition, all available follow-up records were examined and information on general health, blood pressure, basic blood and biochemical examination and urine analysis was collected. RESULTS: Infection with Puumala virus (PUUV) was indicated in 23 patients and Dobrava virus (DOBV) infection in two patients. The median age of patients was 39 years; 19 were male. The patients primarily had outdoor occupations. Most of the HFRS cases occurred between May and August. The most common findings were fever, vomiting, headache, myalgia, chills, cough, back and abdominal pain, and blurred vision. The most prominent laboratory abnormalities were elevated erythrocyte sedimentation rate and C-reactive protein concentration, thrombocytopenia, and leucocytosis with neutrophilia. The signs of renal dysfunction were observed in 24 of the 25 patients. Oliguric renal failure was seen in 13 of 23 (57%) PUUV-infected patients. Six of 23 (26%) patients infected with PUUV and one of two (50%) patients from the DOBV group had hypotension or developed signs of shock. Seven out of 15 (47%) patients had elevated protein concentration in cerebrospinal fluid (CSF). Sinus bradycardia was documented in 7 of 17 (41%) patients with PUUV infection. CONCLUSIONS: HFRS is endemic in the north-eastern part of Slovenia; PUUV and DOBV infections coexist, with PUUV being the main causative agent of HFRS. Demographic, clinical and laboratory findings in our patients with HFRS caused by PUUV were mostly in accordance with those published previously, but the ratio of patients with sinus bradycardia, oliguric renal failure and mildly elevated CSF protein concentration was rather high.     

Procalcitonin after cardiac arrest – An indicator of severity of illness,ischemia-reperfusion injury and outcome

Aim

To investigate serial serum concentrations of procalcitonin (PCT) and C-reactive protein (CRP) in patients treated with mild hypothermia after cardiac arrest, and to study their association to severe infections, post cardiac arrest syndrome (PCAS) and long-term outcome.

Methods

Serum samples from cardiac arrest patients treated with mild hypothermia were collected serially at admission, 2, 6, 12, 24, 36, 48 and 72 h after cardiac arrest. PCT and CRP concentrations were determined and tested for association with three definitions of infection, two surrogate markers of PCAS (circulation-SOFA and time to return of spontaneous circulation (ROSC)) and cerebral performance category (CPC) at six months.

Results

Eighty-four patients were included. PCT displayed an earlier release pattern than CRP with a significant increase within 2 h, increasing further at 6 h and onwards in patients with poor outcome. CRP increased later and continued to rise during the study period. PCT was strongly associated with circulation-SOFA and time to ROSC, and predicted a poor neurologic outcome with high accuracy (area under the receiver operating characteristic curve of 0.88, 0.86 and 0.87 at 12, 24 and 48 h respectively). No association of PCT or CRP to infection was observed.

Conclusion

Our results suggest that PCT is released early after resuscitation following cardiac arrest, is associated with markers of PCAS but not with infection, and is an accurate predictor of poor outcome. Validation of these findings in larger studies is warranted.