What is the impact of PRIME on real‐life diabetic nephropathy?

Type 2 diabetes is increasing globally and is a major cause of conditions such as cardiovascular disease, retinopathy and nephropathy. The Diabetes Control and Complications Trial and the UK Prospective Diabetes Study demonstrated that the progression of renal disease could be slowed by tight glycaemic control and treating any associated hypertension with angiotensin-converting enzyme inhibition. Recent clinical trials have supported the use of angiotensin II receptor antagonists in the treatment of diabetic nephropathy, resulting in the approval of new therapeutic indications in the United States and Europe. The objective of this review is to demonstrate how results from the Program for Irbesartan Mortality and morbidity Evaluation studies apply to clinical practice, and to show how the benefits of irbesartan therapy can be realised at any stage of renal disease in patients with diabetes.     

The impact of critical care outreach: is there one?

An evaluation of critical care outreach services was published in the previous issue of Critical Care that fails to demonstrate any important outcome benefit associated with these services. It is now time to ask some difficult questions about the future of outreach, including whether the lack of evidence should lead to disinvest-ment in such services.     

The design of venous thromboembolism prophylaxis trials: is enoxaparin more effective than fondaparinux?

The aim of thromboprophylaxis is to minimise the incidence of clinically relevant venous thromboembolism (VTE) but in many trials designed to determine the efficacy of thromboprophylactic agents, asymptomatic VTE is included in the primary endpoint. Since asymptomatic events occur much more frequently than symptomatic events, they dominate the results. Data from trials comparing the thromboprophylactic efficacy of enoxaparin and fondaparinux in orthopaedic surgical patients are used to demonstrate that asymptomatic and symptomatic endpoints may yield different conclusions. There was no difference between these agents in the incidence of symptomatic VTE. Efficacy and safety results of thromboprophylactic studies are affected by other aspects of trial design such as the dose of each agent and the timing of treatment initiation and endpoint assessment. Such factors should be considered when designing clinical trials and evaluating their results.     

Prophylaxis with low‐dose low‐molecular‐weight heparin during pregnancy and postpartum: is it effective?

Summary. Background: The optimal approach for venous thrombosis (VTE) prophylaxis during pregnancy and postpartum in women with an increased risk of VTE is not established. Objectives: To evaluate the effectiveness, represented as the incidence of pregnancy‐related VTE, and safety, represented as incidence of postpartum hemorrhage (PPH), of a protocol recommending prophylaxis with low‐dose low‐molecular‐weight heparin (LMWH) in women at intermediate to high risk of VTE. Patients/methods: In this retrospective cohort study, we analyzed 34 women (44 pregnancies) with intermediate risk of VTE who received low‐dose LMWH for 6 weeks postpartum and 57 women (82 pregnancies) with high risk of VTE who received low‐dose LMWH during pregnancy and for 6 weeks postpartum. Pregnancy‐related VTE was defined as VTE during pregnancy or ≤ 3 months postpartum. PPH was defined as blood loss > 500 mL and severe PPH as blood loss > 1000 mL. Results: The incidence of pregnancy‐related VTE was 5.5% (95% CI, 2.4–12.3) despite prophylaxis with low‐dose LMWH. All events occurred in women at high risk, with a postpartum incidence of 7.0% (95% CI, 2.9–16.7) and antepartum incidence of 1.8% (95% CI, 0.4–9.2). The risk of PPH was 21.6% (95% CI, 14.3–31.3) and severe PPH 9.1% (95% CI, 4.7–16.9), which was not different in women who started LMWH postpartum and those who used LMWH during pregnancy. Conclusions: Although prophylaxis with low‐dose LMWH during pregnancy and postpartum proved to be safe, the risk of pregnancy‐related VTE is considerable in women with a high risk of VTE. VTE prophylaxis with low‐dose LMWH may not be sufficiently effective in these women.     

The impact of debriefing modalities on nurse practitioner students’ knowledge and leadership skills in managing fatal dysrhythmias: A pilot study

Acute care nurse practitioners (ACNPs) require special training and educational preparation to meet their role expectations. Using high fidelity simulation with debriefing modalities is considered one of the innovative learning strategies in graduate nursing. No studies have investigated debriefing modalities in nurse practitioner programs specially ACNPs leadership skills. The purpose of this study was to examine the difference in students' knowledge, code team leader skills and self-efficacy using two debriefing modalities. A two group, pretest-posttest quasi-experimental design was used. Students were divided into video-assisted debriefing group vs. verbal debriefing following a simulation scenario of managing emergency codes. There were no significant differences between the two groups in knowledge acquisition/retention, leadership skills, and self-efficacy, but there was a significant difference in self-efficacy in both groups between two-time points. There was a general improvement in teams' performance. Students preferred verbal debriefing over video-assisted debriefing. The debriefing session plays an important role in graduate nursing education. Acute care nurse practitioners are lacking a formal leadership training to meet their advanced role. Nurse Educators, and simulation/debriefing leaders may benefit from our study results to develop a structured, formal curriculum and educational instruction focusing on acute care nurse practitioners’ role change especially leading a resuscitation team.     

The role and preparation of first‐line nurse managers in Australia: where are we going and how do we get there?

Organizational restructuring is impacting heavily on the first-line nurse managers' role. Given their critical role, it is important that the best and most talented are attracted to and prepared to be first-line managers. The authors provide an overview of the role of first-line nurse managers in Australia, proposing that nurse administrators take a more active role than has traditionally been the case in ensuring staff are appropriately educated and selected for management positions.     

Drug‐induced vasculitis: Thiazide or the COVID‐19 vaccine,which one is guilty? A case report and literature review

A middle‐aged woman with a history of COVID‐19 vaccine administration and valve replacement surgery was admitted with bilateral palpable purpuric lesions in the lower extremities and headache. Based on the initial diagnosis of vasculitis, corticosteroid therapy was initiated, which led to the resolution of skin lesions.     

The attitudes and attributions of student nurses: do they alter according to a person’s diagnosis or sexuality and what is the effect of nurse training?

The threat of an AIDS (acquired immune deficiency syndrome) epidemic in the early 1980s saw the emergence of strong negative attitudes from both the public and health care professionals alike. Certain 'high risk' groups in society, who were considered as susceptible to the disease, homosexuals and intravenous drug users in particular, became the victims of prejudice and discrimination. More recent research has indicated a possible shift to a more positive orientation, although the findings are far from conclusive. In this current study, the Prejudicial Evaluation and Social Interaction Scale (PESIS) was administered to four separate cohorts of student nurses approximately a year apart in training (n = 192). Each cohort was divided into four groups, each one completing the PESIS after reading a version of a vignette that described either a person with AIDS or leukaemia, and who was either homosexual or heterosexual. The design therefore allowed for within-group and between-group comparisons. Overall the results showed that the student nurses held positive attitudes although they reported a significantly greater prejudice towards AIDS. No significant differences were found for sexual orientation. Additionally significantly greater levels of blame and responsibility were associated with the person with AIDS, but again there was no effect for sexual orientation. The findings suggest that a slightly more negative attitude continues to be associated with a diagnosis of AIDS but no longer with homosexuality. No effect across cohorts was noted either, student nurses being as positive at the beginning of training as at the end. Some of the limitations of PESIS and the difficulties of attitude assessment in general are discussed and future areas of research are identified.     

Effects of dopamine,norepinephrine, and epinephrine on the splanchnic circulation in septic shock: which is best?

OBJECTIVE: To assess the effects of different doses of dopamine, norepinephrine, and epinephrine on the splanchnic circulation in patients with septic shock. DESIGN: Prospective, randomized, open-label study. SETTING: A 31-bed, medicosurgical intensive care unit of a university hospital. PATIENTS: Convenience sample of 20 patients with septic shock, separated into two groups according to whether (moderate shock group, n = 10) or not (severe shock, n = 10) dopamine alone was able maintain mean arterial pressure >65 mm Hg. INTERVENTIONS: Dopamine was progressively withdrawn and replaced successively by norepinephrine and then epinephrine (the order of the two agents was randomly determined) to maintain mean arterial pressure constant (moderate shock) or to increase mean arterial pressure above 65 mm Hg (severe shock). MEASUREMENTS AND MAIN RESULTS: Systemic circulation (pulmonary artery catheter) and splanchnic circulation (indocyanine green dilution and hepatic vein catheter) and gastric mucosal Pco(2) (gas tonometry) were measured during dopamine (moderate shock only), norepinephrine, and epinephrine administration (both groups). Data were analyzed with nonparametric tests and are presented as median [percentiles 25-75]. In moderate shock, cardiac index was similar to dopamine and norepinephrine (3.1 [2.7-3.8] vs. 2.9 [2.7-4.1] L/min.m2, p = nonsignificant) but greater with epinephrine (4.1 [3.5-4.4] p <.01 vs. dopamine and norepinephrine). Splanchnic blood flow was similar with the three agents (732 [413-1483] vs. 746 [470-1401] vs. 653 [476-1832] mL/min.m, p = nonsignificant). The gradient between mixed-venous and hepatic venous oxygen saturations was lower with dopamine than with norepinephrine and epinephrine, but the Pco(2) gap was similar with the three agents. In severe shock, cardiac index was higher, but splanchnic blood flow was lower, with epinephrine than with norepinephrine (4.6 [3.7-5.3] vs. 3.4 [3.0-4.1] L/min.m2, p <.01 and 860 [684-1334] vs. 977 [806-1802] mL/min.m2, p <.05, respectively). Epinephrine increased the mixed-venous and hepatic venous oxygen saturation gradient but did not alter Pco(2) gap. CONCLUSIONS: Dopamine and norepinephrine have similar hemodynamic effects, but epinephrine can impair splanchnic circulation in severe septic shock.     

How effective is a short‐term educational and support intervention for families of an adolescent with type 1 diabetes?

Purpose. To study adaptation and coping strategies of parents who had adolescents with diabetes and the effect of a short‐term educational and support intervention. Design and Method. A quasi‐experimental design was used in the study on 23 families of adolescents with diabetes. Results. A significant difference was found between parents' coping patterns before the intervention. Fathers were, however, found to rate their coping patterns significantly more helpful after the intervention than before. The mothers demonstrated, nevertheless, a significantly greater use of all the coping patterns. Practice Implications. Educational and support intervention is helpful for parents of adolescents with diabetes.