A randomised prospective study comparing the effectiveness of esomeprazole treatment strategies in clinical practice for 6 months in the management of patients with symptoms of gastroesophageal reflux disease

One option for patients with symptoms of gastroesophageal reflux disease (GERD) is treatment with proton pump inhibitors without prior endoscopy. Continuous or on-demand maintenance therapy are options for symptom-free patients. This study assessed the efficacy of three different treatment options in GERD patients in Norway. About 395 General Practitioners enrolled 2156 patients with symptoms of GERD in an open, randomised, parallel group trial. Following a 4-week symptom control phase [esomeprazole 40 mg once daily (od)], patients received either esomeprazole 20 mg od continuously or on-demand or ranitidine 150 mg twice-daily continuously for 6 months. The percentage of patients with no heartburn at the end of the study was maintained most effectively in the esomeprazole 20 mg continuous group (72.2%) and least effectively in the ranitidine group (32.5%). Significantly, more patients were completely/very satisfied with esomeprazole continuous (82.2%) and esomeprazole on-demand (75.4%) than with ranitidine continuous (33.5%) treatment (p < 0.0001). More patients were kept in remission, symptom free and were overall more satisfied with esomeprazole treatment than ranitidine.     

A prospective randomised controlled trial of spinal manipulation and ultrasound in the treatment of chronic low back pain

Objectives

To assess the short- and long-term effectiveness of spinal manipulation therapy, and to identify the effect of manipulation on lumbar muscle endurance in patients with chronic low back pain (LBP).

Design

A randomised controlled trial comparing manipulation and exercise treatment with ultrasound and exercise treatment.

Setting

An outpatient physiotherapy department.

Participants

One hundred and twenty patients with chronic LBP were allocated at random into the manipulation/exercise group or the ultrasound/exercise group.

Interventions

Both groups were given a programme of exercises. In addition, one group received spinal manipulation therapy and the other group received therapeutic ultrasound.

Main outcome measures

Pain intensity, functional disability, lumbar movements and muscle endurance were measured shortly before treatment, at the end of the treatment programme and 6 months after randomisation using surface electromyography.

Results

Following treatment, the manipulation/exercise group showed a statistically significant improvement (P = 0.001) in pain intensity [mean 16.4 mm, 95% confidence interval (CI) 6.1-26.8], functional disability (mean 8%, 95% CI 2-13) and spinal mobility (flexion: mean 9.4 mm, 95% CI 5.5-13.4; extension: mean 3.4 mm, 95% CI 1.0-5.8). There was no significant difference (P = 0.068) between the two groups in the median frequency of surface electromyography (multifidus: mean 6.8 Hz, 95% CI 1.24-14.91; iliocostalis: mean 2.4 Hz, 95% CI 2.5-7.1), although a significant difference (P = 0.013) was found in the median frequency slope of surface electromyography in favour of spinal manipulation for multifidus alone (mean 0.3, 95% CI 0.1-0.5). A significant difference was also found between the two groups in favour of the manipulation/exercise group at 6-month follow-up.

Conclusions

Although improvements were recorded in both groups, patients receiving manipulation/exercise showed a greater improvement compared with those receiving ultrasound/exercise at both the end of the treatment period and at 6-month follow-up.     

Comparison of acute nonthrombolytic and thrombolytic treatments in ischemic stroke patients 80 years or older

Objectives

The aim of this study was to compare the clinical outcomes of acute ischemic stroke patients 80 years or older treated with intravenous recombinant tissue plasminogen activator (IV rt-PA), or endovascular intervention with or without IV rt-PA, or nonthrombolytic medical treatment.

Methods

This study was a retrospective, nonrandomized, observational study of patients, admitted within 9 hours of symptom onset, at 3 academic, university-affiliated hospitals. The main outcome measures were neurologic improvement, defined by improvement in National Institutes of Health Stroke Scale score at 7 days or discharge of 4 or more, or achieving a score of 0; symptomatic and asymptomatic intracerebral hemorrhage; favorable outcome (discharge modified Rankin score 0-2); and in-hospital mortality.

Results

A total of 44 patients received IV rt-PA, 46 received endovascular intervention with or without IV rt-PA, and 66 received nonthrombolytic medical treatment. IV rt-PA-treated patients had a significantly clinically higher chance of favorable outcome (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.8-17.5), when compared with nonthrombolytic medical treatment. A significantly higher rate of neurologic improvement was observed among the IV rt-PA (7.2; 95% CI, 2.7-19.5) and endovascularly treated patients (5.8; 95% CI, 2-16.8) when compared with nonthrombolytic medical treatment.

Conclusions

A prominently higher rate of neurologic improvement and favorable clinical outcome was observed among acute ischemic stroke patients 80 years or older treated with IV rt-PA or endovascular intervention when compared with nonthrombolytic medical treatment, supporting the use of acute thrombolytic therapies in this patient population when contraindications are not present.     

Quality of life in patients with functional dyspepsia: Short- and long-term effect of Helicobacter pylori eradication with pantoprazole, amoxicillin, and clarithromycin or cisapride therapy: A prospective, parallel-group study

Background:

Quality of life (QOL) is impaired in functional dyspepsia (FD). Little is known about the effects of different therapies on the QOL profile in patients with this condition.

Objectives:

The aims of this study were to measure baseline QOL in patients with FD and to assess changes in QOL over time associated with Helicobacter pylori eradication and prokinetic treatment. The primary and secondary end points were the improvement in QOL 6 weeks and 1 year after successful eradication of the infection or prokinetic therapy.

Methods:

This 1-year, single-center, prospective, open-label, controlled, parallel-group trial was conducted at the Department of Gastroenterology, Ferencvdros Health Centre, Budapest, Hungary. The Functional Digestive Disorder Quality of Life (FDDQoL) Questionnaire (MAPI Research Institute, Lyon, France) was translated and validated previously in Hungarian. Male and female subjects aged 20 to 60 years were enrolled and classified as H pylori positive (HP+), H pylori negative (HP-) with FD, or healthy (control group). The HP+ patients received pantoprazole 40 mg BID + amoxicillin 1000 mg BID + clarithromycin 500 mg BID for 7 days, followed by on-demand ranitidine (150-300 mg/d) for 1 year. The HP- patients received the prokinetic cisapride 10 mg TID for 1 month, followed by on-demand cisapride (10-20 mg/d) for 1 year. The FDDQoL questionnaire was completed by all 3 groups on enrollment, at 6 weeks, and 1 year.

Results:

A total of 101 HP+ patients, 98 HP- patients, and 123 healthy controls were included in the study (185 women, 137 men; mean age, 39.0 ears). The mean (SD) baseline QOL scores were significantly lower in the HP+ group (53.3 [9.6]; 95% CI, 54.4-58.2) and the HP- groups (50.0 [9.8]; 95% CI, 58.0-62.0) compared with that in healthy controls (76.2 [8.7]; 95% CI, 74.6-77.8) (both, P < 0.001). Analysis of the short-term domain scores found that the HP+ group had significantly decreased scores in 6 of 8 domains: daily activities (P = 0.005), anxiety level (P = 0.02), diet (P = 0.008), sleep (P < 0.001), discomfort (P = 0.004), and disease control (P = 0.02); the HP- group had significantly decreased scores in 5 of 8 domains: daily activities (P < 0.001), diet (P = 0.004), sleep (P = 0.005), discomfort (P < 0.001), and disease control (P = 0.02). Eradication of the infection was successful in 77/101 (76.2%) of the patients on intent-to-treat analysis and 77/94 (81.9%) on per-protocol analysis. Eradication was associated with an increase in mean (SD) QOL score to 70.8 (10.7) at 6 weeks (95% CI, 63.3-73.2; P < 0.001 vs baseline) and to 75.3 (9.3) at 1 year (95% CI, 73.2-77.5; P= 0.05 vs 6 weeks). In the HP- group, the QOL score increased to 73.3 (9.7) (95% CI, 71.3-75.4; P < 0.001 vs baseline) at 6 weeks of cisapride treatment and to 76.5 (8.5) at 1 year (95% CI, 74.5-78.4; P = 0.06 vs 6 weeks). Most of the impaired domain scores improved significantly after both treatments. The short-term effect size was 1.48 in HP+ and 1.35 in HP− patients. Adverse events (AEs) occurred in 22 (21.8%) patients in the HP+ group (nausea, 8 [7.9%] patients; diarrhea, 5 [5.0%]; loss of appetite, 5 [5.0%]; stomatitis, 5 [5.0%]; abdominal pain, 4 [4.0%]; bloating, 4 [4.0%]; headache, 4 [4.0%]; vomiting, 4 [4.0%]; constipation, 3 [3.0%]; and vaginitis, 3 [3.0%]). In HP− cases, AEs occurred in 9 (9.2%) patients (abdominal cramps, 7 [7.1%]; diarrhea, 4 [4.1%]; and nausea, 3 [3.1%]).

Conclusion:

In this study in patients with FD and healthy controls, eradication of H pylori infection in infected patients and cisapride treatment in uninfected patients reversed low QOL scores during the 1-year follow-up period.     

A prospective study of the incidence of falls in patients with advanced cancer

Context

The association between aging and falls risk, and the morbidity and mortality resulting from falls in older persons, is well documented. Results from a small number of studies of patients with cancer in inpatient settings suggest that patients with advanced cancer may be at high risk of falling. We present preliminary results pertaining to the incidence of falls in patients with advanced cancer from an ongoing study of risk factors for falls.

Objectives

To measure incidence of falls in patients with advanced cancer receiving palliative care, and to test the hypothesis that patients aged ≥65 years are at greater risk of falling than those aged <65 years.

Methods

Ambulant patients with cancer admitted to palliative care services were recruited. Demographic details were ascertained by patient interview and routine record review. Participants were followed-up by weekly telephone calls for up to six months.

Results

Follow-up has been completed for 119 patients; mean age was 66.91 (±12.86) years and 53.8% were male. Sixty-two participants (52.1%) fell during follow-up. The median time to fall for participants aged <65 and ≥65 years was 85 days (95% confidence interval [CI] 51.54-118.46) and 80 days (95% CI 44.07-115.93), respectively (χ² = 0.034, P = 0.85). The incidence density of falls was 2770 per 1000 person-years.

Conclusion

One in two patients with advanced cancer fell during follow-up of up to six months, regardless of age. There is a need to investigate the sequelae of falls in patients with cancer, to ascertain the risk factors, and in particular, the modifiable risk factors in this population.     

The impact of prehospital activation of the cardiac catheterization team on time to treatment for patients presenting with ST-segment-elevation myocardial infarction

Objective

We sought to evaluate the accuracy of emergency medical services (EMS) activation of the cardiac catheterization laboratory (CCL) for patients with ST-elevation myocardial infarction (STEMI) and its impact on treatment intervals from dispatch to reperfusion.

Methods

We conducted a before-and-after cohort study of patients presenting via EMS with prehospital electrocardiogram findings consistent with STEMI. Before August 20, 2007, percutaneous coronary intervention was initiated after patient arrival. Afterward, EMS providers could activate the CCL if the prehospital electrocardiogram automated interpretation indicated STEMI. All interval times from EMS dispatch to percutaneous coronary intervention were measured via synchronized timepieces.

Results

A total of 53 patients, 14 before and 39 after prehospital activation, were included. Emergency medical services CCL activation was 79.6% sensitive (95% confidence interval [CI], 65.2%-89.3%) and 99.7% specific (95% CI, 99.1%-99.9%). Mean door-to-hospital electrocardiogram and mean CCL-to-reperfusion times were unaffected by the intervention. Prehospital activation of the CCL significantly improved mean door-to-balloon (D2B) time by 18.2 minutes (95% CI, 7.69-28.71 minutes; P = .0029) and door-to-CCL by 14.8 minutes (95% CI, 6.20-23.39 minutes; P = .0024). Improvements in D2B were independent of presentation during peak hours (F ratio = 17.02, P < .0001). There were significant time savings reflected in all EMS intervals: 20.7 minutes (95% CI, 9.1-32.3 minutes; P = .0015) in mean dispatch-to-reperfusion time, 22.2 minutes (95% CI, 11.45-32.95 minutes; P = .0003) in mean first medical contact-to-reperfusion time, and 20 minutes (95% CI, 10.95-29.05 minutes; P = .0001) in recognition-to-reperfusion time.

Conclusions

Emergency medical service providers can appropriately activate the CCL for patients with STEMI before emergency department arrival, significantly reducing mean D2B time. Significant reduction is demonstrated throughout EMS intervals.     

Home-based deep breathing for depression in patients with coronary heart disease: A randomised controlled trial

Objectives

The primary aim of this study was to examine the effect of a home-based deep-breathing training programme on depressive symptoms as compared with a control condition (i.e., weekly telephone support) in patients with coronary heart disease (CHD).

Design

This efficacy trial used a randomised controlled, parallel group design.

Participants and methods

A total of 62 CHD patients with a Beck Depression Inventory-II (BDI-II) >10 were randomised to receive either home-based deep-breathing training (experimental group, n = 28) or weekly telephone support (control group, n = 34). Both participants and data assessors were blinded to the study hypothesis. The primary outcome measure was the change in the self-reported depressive symptom severity, measured by the BDI-II. The secondary outcome was the change in the Patient Health Questionnaure-9 (PHQ-9)-assessed depressive symptom severity. Depressive symptoms were assessed at baseline and post-test in both groups. For the experimental group, depressive symptoms were also assessed at the end of the first 2 weeks of training.

Results

The post-test BDI-II and PHQ-9 were significantly lower in the experimental group than in the control group (p < 0.001 and p < 0.001, respectively). The decreases in BDI-II, from baseline, at post-test were significantly greater in the experimental group as compared with the control group (95% confidence interval (CI): −12.554 to −5.408, p < 0.001). Similarly, the pre-test-to-post-test change in PHQ-9 scores was significantly greater in the experimental group as compared with the control group (95% CI: −5.59 to −0.092, p = 0.007). Examining the changes in BDI-II and PHQ-9 within the experimental group by the repeated-measures analysis of variance (ANOVA) revealed that both measures of depressive symptoms decreased significantly over time (both p < 0.001). The percentage of participants with a BDI-II ≥17 decreased over time from 28.6% at baseline, and 17.9% during treatment, to 10.7% post-test.

Conclusions

Home-based deep-breathing training is effective in reducing depressive symptoms as compared with telephone support in patients with CHD.     

Outcome of asymptomatic electric shock victims requesting an emergency ambulance

Objective

To determine whether patients suffering from electric shock without significant symptoms at the point of an emergency call could be appropriately assigned a nonemergency ambulance response using the Medical Priority Dispatch System (MPDS).

Methods

Welsh Ambulance Service dispatch records were searched to identify patients allocated the MPDS code of 15C01 (electric shock without priority symptoms) over a 30-month period. Ambulance and hospital records were also reviewed.

Results

Records were unavailable for seven of the 52 patients identified (13%). Nine refused transport (17%, 95% CI 8.2% to 30.3%), and 36 were taken to emergency departments (69%, 95% CI 55% to 81%). Of the 52 patients, 23 were discharged shortly after arrival (44%, 95% CI 31% to 59%), 11 receiving no treatment (21%, 95% CI 11% to 35%). Thirteen patients were admitted as inpatients or were transferred to another hospital (25% of the total sample, 95% CI 14% to 39%). Fourteen had burns (27% of the total sample, 95% CI 16% to 41%). Five of these were admitted or transferred to another hospital, five were discharged after treatment, and two left without treatment (one self-discharged). Records were unavailable for two burns patients.

Conclusions

The findings of this study do not justify allocating a low-priority response to victims of electric shock without significant symptoms at the point of the emergency call, since 25% require hospital admission. Further research is required to determine whether the addition of questions to the MPDS about burns and pregnancy might allow safe allocation of a nonemergency response to other asymptomatic electric shock patients.     

Effect of delay in presentation on rate of perforation in children with appendicitis

Introduction

Appendicitis is the most common emergency operation in children. The rate of perforation may be related to duration from symptom onset to treatment. A recent adult study suggests that the perforation risk is minimal in the first 36 hours and remains at 5% thereafter. We studied a pediatric population to assess symptom duration as a risk factor for perforation.

Methods

We prospectively studied all children older than 3 years who underwent an appendectomy over a 22-month period.

Results

Of 202 patients undergoing appendectomies, 197 had appendicitis. Median age was significantly lower in the perforated group, but temperature and leukocytosis were not. As expected, length of hospital stay was longer in the perforated group (4-13 vs 2-6 days). The incidence of perforation was 10% if symptoms were present for less than 18 hours. This incidence rose in a linear fashion to 44% by 36 hours. Prehospital delays were greater in patients with perforated appendicitis. However, in-hospital delay (from presentation to surgery) was less than 5 hours in the perforated group and 9 hours in the nonperforated group.

Discussion

Appendiceal perforation in children is more common than in adults and correlates directly with duration of symptoms before surgery. Perforation is more common in younger children. Unlike in adults, the risk of perforation within 24 hours of onset is substantial (7.7%), and it increases in a linear fashion with duration of symptoms. In our experience, however, perforation correlates more with prehospital delay than with in-hospital delay.     

Fatigue in patients with chronic heart failure — A burden associated with emotional and symptom distress

Background

The relationship between experience of fatigue and emotional and symptom distress in chronic heart failure (CHF) needs to be thoroughly explored, because fatigue has major impact on daily activities in life.

Aims

The purpose was to examine the association between fatigue, as a multidimensional experience and anxiety, depression and symptom distress, and to explore the relationships between individual symptoms and the dimensions of fatigue in patients with CHF.

Methods

A consecutive sample of 112 patients with exacerbation of symptoms of CHF answered the Multidimensional Fatigue Inventory (MFI-20), the Hospital Depression and Anxiety (HAD) Scale and the Symptom Distress Scale (SDS).

Results

Anxiety was associated with mental fatigue, whereas depression was associated with reduction of activity, low motivation and decreased functioning. Physical fatigue was affected by symptom distress, with women reporting more distress than men. With exception of breathlessness, poor agreement was found between fatigue and the most intensive reported symptoms.

Conclusions

The relationship between emotional distress and the experience of fatigue in patients with CHF may have a devastating affect on the patient's ability to cope and manage daily activities, including self-care and adherence to recommended treatment.     

Resuscitation with balanced electrolyte solution prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis

Objective

The objective of the study was to determine if balanced electrolyte solution (BES) prevents hyperchloremic metabolic acidosis in patients with diabetic ketoacidosis (DKA).

Methods

This is a prospective, randomized, double-blind study. A convenience sample of DKA patients aged 18 to 65 years with serum bicarbonate less than or equal to 15 and anion gap greater than or equal to 16 was enrolled at “Louisiana State University Health Sciences Center-Shreveport" an capitalize Emergency Department over a 24-month period (2006-2008). Patients were randomized to standardized resuscitation with normal saline (NS) or BES (Plasma-Lyte A pH 7.4; Baxter International, Deerfield, IL). Every 2 hours, serum chloride and bicarbonate were measured until the patient's anion gap decreased to 12. An intention-to-treat analysis was performed on patients who met inclusion criteria and received at least 4 hours of study fluid. Chloride and bicarbonate measurements from the BES and NS groups were compared using unpaired and paired Student t tests.

Results

Of 52 patients enrolled, 45 (22 in BES group and 23 in NS group) met inclusion criteria and received 4 hours of fluid. The mean postresuscitation chloride was 111 mmol/L (95% confidence interval [CI] = 110-112) in the NS group and 105 mmol/L (95% CI = 103-108) in the BES group (P ≤ .001). The mean postresuscitation bicarbonate was 17 mmol/L (95% CI = 15-18) in the NS group and 20 mmol/L (95% CI = 18-21) in the BES group (P = .020).

Conclusions

Resuscitation of DKA patients with BES results in lower serum chloride and higher bicarbonate levels than patients receiving NS, consistent with prevention of hyperchloremic metabolic acidosis.     

Diagnostic Value of History Taking and Physical Examination to Assess Effusion of the Knee in Traumatic Knee Patients in General Practice

Kastelein M, Luijsterburg PA, Wagemakers HP, Bansraj SC, Berger MY, Koes BW, Bierma-Zeinstra SM. Diagnostic value of history taking and physical examination to assess effusion of the knee in traumatic knee patients in general practice.

Objective

To assess the diagnostic value of history taking and physical examination for knee joint effusion in patients with a knee injury who consult their general practitioner (GP). In addition, to determine the association between effusion seen on magnetic resonance imaging (MRI) and internal derangement of the knee.

Design

Prospective, observational cohort study.

Setting

Primary care.

Participants

Patients (N=134) aged 18 to 65 years with a traumatic knee injury who consulted their GP.

Interventions

Not applicable.

Main Outcome Measures

Patients filled out a questionnaire, underwent a standardized physical examination and underwent an MRI scan to assess the presence of effusion. Multivariate logistic regression analysis was used to determine the diagnostic value of history taking and physical examination (P<0.10) as assessed by sensitivity, specificity, predictive values, and likelihood ratios. The relationship between effusion and internal derangement of the knee was assessed with a chi-square test.

Results

Of the 134 participating patients, 42 had knee joint effusion seen on MRI. Multivariate analysis showed an association with knee joint effusion for the symptom “self-noticed swelling” (history taking) and for the “ballottement test” (physical examination). The likelihood ratio positive (LR+) was 1.5 for self-noticed swelling and 1.6 for the ballottement test. These 2 combined improved the diagnostic value to an LR+ of 3.6. Effusion showed a positive association with internal derangement of the knee (chi-square 9.5); 31 of the 42 patients with knee joint effusion had internal derangement of the knee.

Conclusions

In patients with traumatic knee injury, knee joint effusion is frequently seen on MRI. The combination of self-noticed swelling and the ballottement test was of diagnostic value. Knee joint effusion was associated with internal derangement of the knee.     

Mental health and exposure to patient distress among families of nursing home residents with advanced dementia

Context

The effect of suffering among patients with advanced dementia on their family members’ mental health has not been investigated.

Objectives

To describe family members’ exposure to distressing symptoms among nursing home (NH) residents with advanced dementia and associations between such exposure and family members’ mental health.

Methods

Data were obtained from an 18-month prospective cohort study of NH residents with advanced dementia and their family member health care proxies (HCPs). Exposure to resident symptoms and associated fear and helplessness was measured quarterly using the Stressful Caregiving Adult Reactions to Experiences of Dying (SCARED) scale (range 0-120). HCP mental health was assessed quarterly using the Composite International Diagnostic Interview Short Form (CIDI-SF) (depression), K6 (psychological distress, range 0-24), and SF-12^® mental health subscale.

Results

Seven hundred seventy-nine SCARED scale assessments were completed by 225 HCPs. The most frequent distressing symptoms were the following: feeling the resident had had enough (33.2%), choking (21.1%), and pain (18.9%). The symptoms eliciting the greatest fear were thinking the resident was dead and seeing them choke. A sense of helplessness was highest when the resident was observed to be in pain or choking. Family members with SCARED scores >0 were more likely to meet criteria for depression on the CIDI-SF (adjusted odds ratio [AOR] 2.59, 95% confidence interval [CI] 1.14, 5.85), have a K6 score >0 (AOR 2.31, 95% CI 1.55, 3.43), and have lower SF-12 scores (adjusted parameter estimate −1.51, 95% CI −2.56, −0.47).

Conclusion

Family member exposure to distressing symptoms experienced by their loved ones with advanced dementia is not uncommon and is associated with worse mental health.     

The effect of the SAFE or SORRY? programme on patient safety knowledge of nurses in hospitals and nursing homes: A cluster randomised trial

Background

Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy.

Objectives

The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses.

Design

A cluster randomised trial was conducted between September 2006 and July 2008.

Settings

Ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward.

Participants

All nurses from participating wards.

Methods

A knowledge test measured nurses’ knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately.

Results

After correction for baseline, the mean difference between the intervention and the control group on hospital nurses’ knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: −0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10-0.81). For the other two topics there was no statistically significant effect. Nursing home nurses’ knowledge did neither improve (0 points, CI: −0.35 to 0.35) overall, nor for the separate subjects.

Conclusion

The educational intervention improved hospital nurses’ knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is needed.

Trial registration

ClinicalTrials.gov ID [NCT00365430].     

Choline for diagnosis and prognostication of acute coronary syndromes in the Emergency Department

Objectives

Choline has been identified as a promising marker of coronary inflammation, plaque destabilisation and ischaemia. We sought to evaluate plasma choline levels for rapid confirmation or exclusion of acute myocardial infarction (AMI) in the Emergency Department (ED) and for predicting major adverse cardiac events (MACE).

Methods

We prospectively recruited 361 patients who presented to the ED with suspected cardiac chest pain within the previous 24 h. Blood was drawn at the time of presentation for plasma choline levels. All patients underwent troponin T testing ≥ 12 h after symptom onset and were followed up for the occurrence of MACE within 6 months. Whole blood choline (WBCho) levels were also measured in a convenience sample of 39 patients.

Results

Plasma choline levels did not help to predict a diagnosis of AMI (odds ratio (OR) 1.00 (95% confidence intervals (CI) 0.91-1.10, p = 0.98). For a diagnosis of AMI the area under the receiver operating characteristic (ROC) curve was 0.48. Plasma choline was not predictive of the combined endpoint of MACE (OR 1.03, 95% CI 0.95-1.12, p = 0.45) but predicted AMI within 6 months (OR 1.31, 95% CI 1.09-1.56, p = 0.003). WBCho levels were significantly different to plasma levels and were predictive of MACE.

Conclusions

Plasma choline, measured at the time of ED presentation, is not a diagnostic marker of AMI but predicts AMI within 6 months. While plasma choline failed to predict MACE, WBCho was predictive and warrants further evaluation.     

Antiemetic treatment in the emergency department: Patient opinions and expectations

Objective

To determine patient expectations of antiemetic treatment in the ED.

Methods

Survey of adult ED patients with nausea. Primary outcome: expectation of antiemetic treatment as symptoms being ‘totally gone’, ‘a lot less’, ‘a little less’ and ‘the same’. Secondary outcomes: comparison between expectations and symptom change when expectations were met; general views on indications for treatment, treatment satisfaction and reasons for additional medication use.

Results

Of 176 surveyed, treatment expectation was recorded by 165 (94%). These were: ‘totally gone’, ‘a lot less’ or ‘a little less’ for 60 (36%), 84 (51%) and 21 (13%), respectively. This pre‐treatment nomination, was matched or exceeded by the reported level of symptom reduction at 30 min, for 43/87 (49%, 95% CI: 39–60) whose expectations were met, and 6/33 (18%, 95% CI: 7–35) whose were not. The majority (117/176, 66%) believed treatment should be reserved for moderate or severe nausea; 158/176 (90%) would accept treatment if offered; 130/165 (79%) expected a treatment effect by 30 min. Treatment satisfaction findings were similar to expectations being met. Further drug treatment at 30 min was desired by 29/120 (24%) who received an antiemetic drug. Most were improved, but believed additional drugs might help more. Of the 91 not wanting more treatment, most were improved and thought no more drugs were necessary.

Conclusion

Most patients expected antiemetic treatment to make symptoms at least ‘a lot less’. Most also believe treatment should be reserved for moderate or severe nausea, and should take effect by 30 min.     

Patterns of change in symptom clusters with HIV disease progression

Context

With better antiretroviral treatments (ARTs), persons living with HIV (PLWH) are living longer, healthier lives. Therefore, they also experience more medical comorbidities that come with normal aging, as well as side effects of multiple treatments and long-term sequelae of HIV. It can be hard to know whether symptoms reported by PLWH are related to comorbidities or are signs of HIV disease progression and possible treatment failure.

Objectives

The current study was designed to disentangle these issues by examining within-person symptom changes in data collected from a cohort of PLWH before the advent of highly efficacious ART.

Methods

This study was a secondary analysis of symptom reports in longitudinal data collected from 246 PLWH in 1992-1994. Multilevel modeling was used to test for changes over time in HIV-related symptom clusters. Analyses also tested the effects of person-level demographic covariates and co-occurring mental health symptoms on HIV symptoms and examined the magnitude of within-person versus between-person variations in reported symptom severity.

Results

Two of six HIV-related symptom clusters, malaise/fatigue and nausea/vomiting, increased over time in the context of HIV disease progression, but the other four did not. Changes were independent of baseline disease severity or psychological covariates. There was substantial within-person variability in absolute symptom severity.

Conclusion

Relatively small but consistent changes in symptoms related to nausea or fatigue may suggest HIV disease progression, but changes in other HIV symptom clusters may instead be related to comorbidities or normal aging. Further research is recommended on symptom progression in PLWH.