The vastus medialis oblique:vastus lateralis electromyographic intensity ratio does not differ by gender in young participants without knee pathology

Objectives

To investigate whether there was a gender difference in the intensity of electromyographic (EMG) activity in vastus medialis oblique (VMO) relative to vastus lateralis (VL).

Design

A cross-sectional observational study measuring EMG activity during stepping down from a step and during straight leg raise exercises.

Setting

University campus laboratory.

Participants

Two groups of healthy participants were tested, one female (mean age 23.5 years, n = 15) and one male (mean age 23.5 years, n = 15).

Main outcome measures

Surface EMG activity (sampling rate 1000 Hz) was recorded from VMO and VL of the dominant limb during five repetitions of a step down activity and five repetitions of a straight leg raise exercise. The average intensity of the rectified and smoothed EMG activity from each activity was normalised to that elicited in a maximal quadriceps setting exercise. The ratio of normalised VMO:VL EMG intensity levels was calculated.

Results

The median difference in the VMO:VL ratio between the groups was 0.11 [approximate 95% confidence interval (CI) −0.62 to 1.00] during step down and −0.07 (approximate 95% CI −0.26 to 0.20) during straight leg raise. Using Mann Whitney U-tests, these differences were not statistically significant (P = 0.648 and 0.619, respectively).

Conclusions

This study found no gender difference in the VMO:VL EMG intensity ratio in asymptomatic participants. This suggests that the difference in incidence of patellofemoral pain syndrome between genders is not influenced by quadriceps intensity ratios, when participants are asymptomatic.     

Therapeutic hypothermia after cardiac arrest: A retrospective comparison of surface and endovascular cooling techniques

Objectives

Therapeutic hypothermia (32-34 °C) is recommended for comatose survivors of cardiac arrest; however, the optimal technique for cooling is unknown. We aimed to compare therapeutic hypothermia using either surface or endovascular techniques in terms of efficacy, complications and outcome.

Design

Retrospective cohort study.

Setting

Thirty-bed teaching hospital intensive care unit (ICU).

Patients

All patients (n = 83) undergoing therapeutic hypothermia following cardiac arrest over a 2.5-year period. The mean age was 61 ± 16 years; 88% of arrests occurred out of hospital, and 64% were ventricular fibrillation/tachycardia.

Interventions

Therapeutic hypothermia was initiated in the ICU using iced Hartmann's solution, followed by either surface (n = 41) or endovascular (n = 42) cooling; choice of technique was based upon endovascular device availability. The target temperature was 32-34 °C for 12-24 h, followed by rewarming at a rate of 0.25 °C h⁻¹.

Measurements and main results

Endovascular cooling provided a longer time within the target temperature range (p = 0.02), less temperature fluctuation (p = 0.003), better control during rewarming (0.04), and a lower 48-h temperature load (p = 0.008). Endovascular cooling also produced less cooling-associated complications in terms of both overcooling (p = 0.05) and failure to reach the target temperature (p = 0.04). After adjustment for known confounders, there were no differences in outcome between the groups in terms of ICU or hospital mortality, ventilator free days and neurological outcome.

Conclusion

Endovascular cooling provides better temperature management than surface cooling, as well as a more favorable complication profile. The equivalence in outcome suggested by this small study requires confirmation in a randomized trial.     

Rescuer fatigue and cardiopulmonary resuscitation positions: A randomized controlled crossover trial

Background

During cardiopulmonary resuscitation (CPR), it is recommended to alternate rescuers every 2 min when two or more rescuers are available, regardless of the rescuer's position. It is unclear, however, whether rescuer fatigue depends on the rescuer's position.

Purpose

To compare rescuer fatigue by doing CPR in different positions.

Methods

This randomized controlled crossover trial studied 24 experienced health-care providers from a teaching hospital in southern Taiwan. Each participant performed CPR for 10 min on days 1, 8, and 15 of the study in three different positions: kneeling, standing on a taboret, and standing on the floor. Effective compression was recorded using the Laerdal Resusci-Anne Skillreporter manikin. The range of motion (ROM) of the elbows and lower back were detected using a flexible goniometer, and the severity of back pain was scored using the Brief Pain Inventory short-form.

Results

Rescuers maintained adequate effective compressions for 2 min while kneeling and standing on a taboret, but only for 1 min while standing on the floor. The ROM for elbows and lower back during CPR while kneeling were significantly lower than for standing on the floor. Moreover, the total pain (p < 0.001) and social interference (p = 0.004) scores 24 h after CPR were significantly lower for the kneeling position.

Conclusions

CPR is best performed in a kneeling position. In order to minimize rescuer fatigue, we recommend alternating rescuers every 2 min while kneeling or standing on a taboret, and every 1 min while standing on the floor.     

S-100B is superior to NSE, BDNF and GFAP in predicting outcome of resuscitation from cardiac arrest with hypothermia treatment

Objective

To conduct a pilot study to evaluate the blood levels of brain derived neurotrophic factor (BDNF), glial fibrillary acidic protein (GFAP), neuron specific enolase (NSE) and S-100B as prognostic markers for neurological outcome 6 months after hypothermia treatment following resuscitation from cardiac arrest.

Design

Prospective observational study.

Setting

One intensive care unit at Uppsala University Hospital.

Patients

Thirty-one unconscious patients resuscitated after cardiac arrest.

Interventions

None.

Measurements and main results

Unconscious patients after cardiac arrest with restoration of spontaneous circulation (ROSC) were treated with mild hypothermia to 32-34 °C for 26 h. Time from cardiac arrest to target temperature was measured. Blood samples were collected at intervals of 1-108 h after ROSC. Neurological outcome was assessed with Glasgow-Pittsburgh cerebral performance category (CPC) scale at discharge from intensive care and again 6 months later, when 15/31 patients were alive, of whom 14 had a good outcome (CPC 1-2). Among the predictive biomarkers, S-100B at 24 h after ROSC was the best, predicting poor outcome (CPC 3-5) with a sensitivity of 87% and a specificity of 100%. NSE at 96 h after ROSC predicted poor outcome, with sensitivity of 57% and specificity of 93%. BDNF and GFAP levels did not predict outcome. The time from cardiac arrest to target temperature was shorter for those with poor outcome.

Conclusions

The blood concentration of S-100B at 24 h after ROSC is highly predictive of outcome in patients treated with mild hypothermia after cardiac arrest.     

Effort-reward imbalance is associated with the frequency of sickness absence among female hospital nurses: A cross-sectional study

Background

Most research on sickness absence among nurses has focused on long-term work disability. Absence from work due to short-term sickness, however, is more common and frequent short absences result in understaffing and increased workload of nursing teams.

Objectives

To investigate health and work factors in relation to the frequency of short-term sickness absence among nurses.

Design

A cross-sectional study linking self-reported health and work factors to the frequency of registered sickness absence episodes in the preceding 3 years.

Settings

A regional hospital in the Dutch province Friesland employing 1153 persons.

Participants

459 female nurses working at least 3 years in the clinical wards (n = 337) or the outpatient clinic (n = 122) of the hospital.

Methods

Perceived general health, mental health, demand/control (DC) ratio, workplace social support, effort/reward (ER) ratio, and over-commitment (i.e. the inability to withdraw from work obligations) were assessed by a self-administered questionnaire. The associations between the questionnaire results and the registered number of sickness absence episodes were analysed by negative binomial regression analysis, distinguishing between short (1-7 days) and long (>7 days) sickness absence episodes and controlling for age, hours worked, and duration of employment.

Results

328 (71%) female nurses completed their questionnaires and of these 291 were eligible for analysis. High frequent absentees perceived poorer health, had lower over-commitment scores, and reported higher ER-ratios than low frequent absentees. Esteem rewards were related to sickness absence whereas monetary rewards were not. Feeling respect from the supervisor was associated with fewer short sickness absence episodes and respect from co-workers was associated with fewer long sickness absence episodes.

Conclusions

Effort-reward imbalance was associated with frequent short sickness absence episodes among nurses. Work efforts and rewards ought to be potentially considered when managing nurses who are frequently absent from work as these factors can be dealt with by managers.     

Electromyography of the Upper Limbs During Computer Work: A Comparison of 2 Wrist Orthoses in Healthy Adults

Ferrigno IS, Cliquet Jr, A, Magna LA, Zoppi Filho A. Electromyography of the upper limbs during computer work: a comparison of 2 wrist orthoses in healthy adults.

Objective

To examine the effect of wrist orthoses on the electromyography activities of the extensor carpi ulnaris, flexor digitorum superficialis, and fibers of the upper trapezius muscles during computer work.

Design

A randomized, 3×2 factorial design: orthoses (no orthosis, wearing a custom-made orthosis, wearing a commercial orthosis) and tasks (typing, using the mouse).

Setting

Laboratory for biomechanics and rehabilitation.

Participants

Healthy university students (N=23), ranging from 18 to 26 years of age.

Intervention

Study volunteers performed standardized tasks such as typing and using the mouse while wearing 1 of 2 types of wrist orthoses or no orthosis.

Main Outcome Measures

We used surface electromyography and considered 100% maximum voluntary contraction to represent the amplitude of electromyographic activity.

Results

We observed a significant increase in the electromyographic activity of the trapezius (P<.05) with the use of orthoses. No significant difference was observed in the activities of the flexor digitorum superficialis or extensor carpi ulnaris in participants who typed with or without orthoses (P>.05). However, when the participants used the mouse, the extensor muscle presented an increase in activity with both orthoses, and the same pattern was observed in the flexor muscle when the volunteers used the custom-made orthosis.

Conclusions

Wrist orthoses affected the muscle activities in the upper limbs of healthy adults who were using a computer. Electromyographic activity increased in the trapezius when the subjects used either type of orthosis, and the same pattern was observed in the extensor carpi ulnaris when the subjects used the mouse. The flexor digitorum superficialis presented an increase in activity only when the subjects worked with the mouse and used a custom-made splint.     

Comparison of procalcitonin measurement by a semi-quantitative method and an ultra-sensitive quantitative method in a pediatric emergency department

Objective

To compare procalcitonin measurements between semi-quantitative and quantitative assays.

Method

Procalcitonin was measured with the PCT-Q® and the Kryptor® assays in a pediatric emergency department.

Results

Among the 359 pairs of results, 103 had discordant results. The linear weighted kappa was 0.44 (95% CI 0.36, 0.51). The concordant/discordant results distribution varied depending on the laboratory technician (p = 0.018).

Conclusion

Agreement between procalcitonin measured semi-quantitatively and quantitatively was moderate. This is probably due to a subjective interpretation of the assay result.     

Measurement of soft tissue temperature and impedance following the application of transdermal direct current

Objective

To measure temperature and impedance changes at various depths in human tissue in vivo, after the application of transdermal direct current (TDC).

Design

Prospective experimental single cohort study.

Setting

Genesis Surgery Center.

Participants

Eight patients who underwent a lumbar rhizotomy for chronic low back pain consented to an additional procedure involving TDC with saline solution. Two TDC electrodes (active, 55 mm; dispersive, 62 mm) were placed 51-56 cm apart, and a current amplitude of 4.0 mA was delivered for an average of 18.4 minutes.

Main outcome measures

Temperature and impedance readings recorded by the RFG-3CF Lesion Generator probe, from depths of 5 cm to the skin surface were obtained before TDC, and just before TDC was terminated. Data were analyzed using non-parametric statistics.

Results

A statistically significant decrease in impedance (mean 48 Ω, 95% confidence interval: 26-70) was detected, but there was no interaction of impedance change with tissue depth. Overall, tissue temperature decreased by 2 °C (95% confidence interval: 1.9-2.8) from baseline to the second measurement and the change was greatest within 1 cm of the surface.

Conclusion

The data suggest that transdermal delivery of medications to deep tissues of the lumbar region may not be enhanced by use of direct current as applied clinically.     

Quality of closed chest compression on a manikin in ambulance vehicles and flying helicopters with a real time automated feedback

Context

Automated verbal and visual feedback improves quality of resuscitation in out-of-hospital cardiac arrest and was proven to increase short-term survival. Quality of resuscitation may be hampered in more difficult situations like emergency transportation. Currently there is no evidence if feedback devices can improve resuscitation quality during different modes of transportation.

Objective

To assess the effect of real time automated feedback on the quality of resuscitation in an emergency transportation setting.

Design

Randomised cross-over trial.

Setting

Medical University of Vienna, Vienna Municipal Ambulance Service and Helicopter Emergency Medical Service Unit (Christophorus Flugrettungsverein) in September 2007.

Participants

European Resuscitation Council (ERC) certified health care professionals performing CPR in a flying helicopter and in a moving ambulance vehicle on a manikin with human-like chest properties.

Interventions

CPR sessions, with real time automated feedback as the intervention and standard CPR without feedback as control.

Main outcome measures

Quality of chest compression during resuscitation.

Results

Feedback resulted in less deviation from ideal compression rate 100 min⁻¹ (9 ± 9 min⁻¹, p < 0.0001) with this effect becoming steadily larger over time. Applied work was less in the feedback group compared to controls (373 ± 448 cm × compression; p < 0.001). Feedback did not influence ideal compression depth significantly. There was some indication of a learning effect of the feedback device.

Conclusions

Real time automated feedback improves certain aspects of CPR quality in flying helicopters and moving ambulance vehicles. The effect of feedback guidance was most pronounced for chest compression rate.     

Differential features of burden between spouse and adult-child caregivers of patients with Alzheimer's disease: An exploratory comparative design

Background

Research into burden among spouse and adult-child caregivers of patients with Alzheimer's disease has generated contradictory results as regards the group which suffers the greatest burden and the factors underlying any differences.

Objectives

The aim of the present study was to identify and compare the factors associated with caregiver burden among spouse and adult-child caregivers.

Design

Cross-sectional analytic study.

Settings

All clinical subjects had been referred on an out-patient basis to the Memory and Dementia Assessment Unit of the Santa Caterina Hospital in Girona (Spain).

Participants

Data were collected from 251 patients and their caregivers, 112 with spouse and 139 with adult-child caregivers.

Methods

The association between caregiver burden and the socio-demographic and clinical variables of both patients and caregivers was analysed, the results being compared for spouse vs. adult-child caregivers. Burden was analysed using a multivariate linear regression including all the variables for the two groups of caregivers.

Results

The results show greater burden among adult-child caregivers (p < .05), who experience more feelings of guilt (p < .001). In both groups the behavioural and psychological symptoms of patients were correlated with burden (p < .001). Living with the patient has a notable influence on burden among adult children (p < .001). Husbands, wives, daughters and sons, in this order, showed increasing levels of burden (p < .05) and progressively worse mental health (p < .01). However, the correlations between burden and mental health were strongest in daughters (p < .001).

Conclusion

The differences in burden between spouse and adult-child caregivers were not associated with age, physical health or clinical factors of the patients. Overall burden was greater among adult-child caregivers, especially those who lived with the patient and who had other family duties. Feelings of guilt were associated with not living with the patient, and there was a strong correlation between burden and mental health. These results support the hypothesis that spouses regard caregiving as part of their marital duties, whereas for adult children such tasks imply an important change in their lifestyle.     

A pilot study of mechanical chest compressions with the LUCAS™ device in cardiopulmonary resuscitation

Aim

The LUCAS™ device has been shown to improve organ perfusion during cardiac arrest in experimental studies. In this pilot study the aim was to compare short-term survival between cardiopulmonary resuscitation (CPR) performed with mechanical chest compressions using the LUCAS™ device and CPR performed with manual chest compressions. The intention was to use the results for power calculation in a larger randomised multicentre trial.

Methods

In a prospective pilot study, from February 1, 2005, to April 1, 2007, 149 patients with out-of hospital cardiac arrest in two Swedish cities were randomised to mechanical chest compressions or standard CPR with manual chest compressions.

Results

After exclusion, the LUCAS and the manual groups contained 75 and 73 patients, respectively. In the LUCAS and manual groups, spontaneous circulation with a palpable pulse returned in 30 and 23 patients (p = 0.30), spontaneous circulation with blood pressure above 80/50 mmHg remained for at least 5 min in 23 and 19 patients (p = 0.59), the number of patients hospitalised alive >4 h were 18 and 15 (p = 0.69), and the number discharged, alive 6 and 7 (p = 0.78), respectively.

Conclusions

In this pilot study of out-of-hospital cardiac arrest patients we found no difference in early survival between CPR performed with mechanical chest compression with the LUCAS™ device and CPR with manual chest compressions. Data have been used for power calculation in a forthcoming multicentre trial.     

Use of cyst fluid CEA, CA19-9, and amylase for evaluation of pancreatic lesions

Objectives

The study goals were development of reference intervals and an interpretive algorithm for pancreatic cyst fluid tumor markers.

Design and methods

442 pancreatic cyst fluids were tested for CEA, CA19-9, and amylase.

Results

CEA > 30 ng/mL discriminates mucinous from non-mucinous cysts. After CEA analysis, amylase and CA19-9 segregate non-mucinous and mucinous subtypes, respectively.

Conclusions

Pancreatic cyst fluid tumor markers supplement other diagnostic measures. This study provides estimated reference intervals and an algorithm for interpretation.     

Correspondence of diagnosis to initial treatment for neck pain

Objectives

A patient care model has been proposed linking patient assessment to diagnosis to treatment to outcomes. Validation of this method is required. McKenzie developed the mechanical diagnosis and therapy (MDT) process to diagnose neck pain and direct its treatment. No study known to the authors has determined the link between MDT diagnosis and treatment for neck pain. The objective of the current study was to determine inter-rater agreement on the link between MDT diagnosis and treatment for neck pain.

Setting

Outpatient physical therapy clinics.

Participants

Fifty-four clinician raters, 20 patients with neck pain.

Design

Clinicians, MDT-trained for neck pain, viewed videotaped examinations of adult patients with neck pain and rated diagnosis and initial treatment.

Main outcomes measures

Inter-rater agreement on the MDT diagnosis-treatment link and derangement-directional preference link.

Results

Inter-rater agreement on the diagnosis-treatment link of derangement-directional preference and not derangement-no directional preference of treatment was with moderate clinical and statistical significance (κ = 0.46, 95% confidence interval 0.45-0.47; P < 0.001; 86% agreement). There was moderate agreement on derangement-directional preference for the ‘derangement-extension’ link (κ = 0.40, 95% confidence interval 0.38-0.41; P < 0.001) and ‘derangement-lateral’ link (κ = 0.45, 95% confidence interval 0.44-0.46; P < 0.001), but with poor agreement for the ‘derangement-flexion’ link (κ = 0.04, 95% confidence interval 0.02-0.05; P < 0.001).

Conclusions

Clinicians trained in MDT for neck pain link diagnosis to initial treatment of patients with neck pain with moderate reliability, specifically using extension or laterally directed preference for treatment. The current study contributes towards validation of the diagnosis-treatment link of the MDT patient care model for neck pain.     

Pulmonary rehabilitation for chronic obstructive pulmonary disease: a pilot study evaluating a once-weekly versus twice-weekly supervised programme

Objectives

To compare the effectiveness of a once-weekly supervised pulmonary rehabilitation programme with a standard twice-weekly format.

Design

Randomised trial of equivalency.

Setting

Pulmonary rehabilitation service of a primary care trust delivered at two physiotherapy outpatient departments.

Participants

Thirty patients with chronic obstructive pulmonary disease.

Outcome measures

Primary outcomes were the Incremental Shuttle Walking Test (ISWT), Endurance Shuttle Walking Test (ESWT) and St George's Respiratory Questionnaire (SGRQ), assessed at baseline and at completion of the supervised programme. Secondary outcomes were home-exercise activity, attendance levels and patient satisfaction with the programme.

Interventions

The once-weekly group (n = 15) received one supervised rehabilitation session per week, and the twice-weekly group (n = 15) received two sessions per week, both for 8 weeks, together with a home-exercise plan.

Results

After pulmonary rehabilitation, the groups showed similar improvements in exercise tolerance (median values: ISWT once-weekly 60 metres, twice-weekly 50 metres; ESWT once-weekly 226 seconds, twice-weekly 109 seconds). However, for health-related quality-of-life, the once-weekly group's score did not change (SGRQ 0), whereas an improvement was seen for the twice-weekly group (SGRQ 3.7). The number of home-exercise sessions and attendance levels were similar between the groups. Patient satisfaction with both formats was high and almost identical between the groups.

Conclusions

This pilot provides data to inform a larger study and shows that the methodology is feasible. The findings suggest that once-weekly supervision may be capable of producing equivalent improvements in exercise tolerance as a twice-weekly programme, but the health-related quality-of-life outcome appeared to be poorer for once-weekly supervision.     

Student nurses’ de-escalation of patient aggression: A pretest-posttest intervention study

Background

Experts recommend staff training to prevent and manage aggressive situations involving patients or their relatives. However, in many countries this subject is not covered in pre-registration nursing education. In addition, the evidence regarding its impact on practical placements remains weak.

Objective

This study examines the influence of an aggression management training programme for nursing students on their performance in de-escalating aggressive patients.

Design

Pretest-posttest within-and-between-groups design.

Setting

A School of Nursing in Germany.

Participants

Convenience sample out of six classes of nursing students at differing educational levels (10th to 28th month of nursing education, n = 78, mean age = 22).

Methods

In a cross-sectional and longitudinal two groups before and after design nursing students encountered two scenarios (A or B) with simulation patients. After completing the training, each student was confronted with the unknown other scenario. De-escalation experts from three German-speaking countries evaluated 156 video scenes using the De-escalating Aggressive Behaviour Scale (DABS), not knowing whether the videos had been recorded before or after the training. Mean values and statistical significance tests were computed to compare the results.

Results

The performance levels of students who had been trained rose significantly from 2.74 to 3.65 as measured by the DABS on a 5-point Likert scale (Wilcoxon test p < .001). The trained students managed scenario A significantly better than the untrained students (untrained 2.50, trained 3.70; Mann-Whitney-U-test p < .001,). Similar results were found for scenario B (untrained 3.01, trained 3.61; Mann-Whitney-U-test p < .001). No significant differences were found in the pretest results irrespective the students’ age or duration of previous nursing education.

Conclusions

Aggression management training is able to improve nursing students’ performance in de-escalating aggressive behaviour. A maturation-effect on the de-escalating performance due to general nursing education or age is unlikely.     

Increased EMG response following electromyographic biofeedback treatment of rectus femoris muscle after spinal cord injury

Objective

To study increases in electromyographic (EMG) response from the right and left rectus femoris muscles of individuals with long-term cervical spinal cord injuries after EMG biofeedback treatment.

Design

Repeated measure trials compared EMG responses before and after biofeedback treatment in patients with spinal cord injuries.

Main outcome measures

The Neuroeducator was used to analyse and provide feedback of the EMG signal and to measure EMG response.

Setting

Department of Traumatic Orthopaedics, School of Medicine, University of São Paulo, Brazil.

Participants

Twenty subjects (three men and 17 women), between 21 and 49 years of age, with incomplete spinal cord injury at level C6 or higher (range C2 to C6). Of these subjects, 10 received their spinal cord injuries from motor vehicle accidents, one from a gunshot, five from diving, three from falls and one from spinal disc herniation.

Results

Significant differences were found in the EMG response of the right rectus femoris muscle between pre-initial (T1), post-initial (T2) and additional (T3) biofeedback treatment with the subjects in a sitting position [mean (standard deviation) T1: 26 μV (29); T2: 67 μV (50); T3: 77 μV (62)]. The mean differences and 95% confidence intervals for these comparisons were as follows: T1 to T2, −40.7 (−53.1 to −29.4); T2 to T3, −9.6 (−26.1 to 2.3). Similar differences were found for the left leg in a sitting position and for both legs in the sit-to-stand condition.

Conclusions

The EMG responses obtained in this study showed that treatment involving EMG biofeedback significantly increased voluntary EMG responses from right and left rectus femoris muscles in individuals with spinal cord injuries.     

The use of mouth taping in people with asthma: a pilot study examining the effects on end-tidal carbon dioxide levels

Objectives

The use of mouth taping, to encourage nose breathing, is currently being recommended by some Buteyko practitioners, but its effects on physiology are unknown. This preliminary study aimed to investigate the effects of mouth taping on end-tidal carbon dioxide (ETCO₂).

Design

Preliminary study with an experimental single group repeated measures design.

Setting

Research laboratory, university campus.

Participants

Nine university students and staff with mild stable asthma.

Interventions

Physiological data were recorded before and during two experimental breathing conditions: oral breathing and nasal breathing (encouraged by mouth taping), carried out on two separate occasions 5-14 days apart. Between visits, participants familiarised themselves with the mouth taping technique.

Outcome measures

Primary outcome was ETCO₂. Secondary outcomes were respiratory rate, pulse rate, oxygen saturation and lung function.

Results

There was an increase in ETCO₂ from baseline during both breathing conditions. The mean ETCO₂ for oral breathing was 4.4 kPa versus 4.7 kPa for nasal breathing, with mean difference of 0.3 kPa (95% confidence interval −0.2 to 0.8 kPa). It was also found that ETCO₂ increased more in ‘natural’ oral breathers than ‘natural’ nasal breathers.

Conclusions

The results of this pilot study provide data to power a larger study and suggest ETCO₂ may be increased in people with asthma during nasal breathing, particularly in those who normally primarily breathe through the mouth. The methodology was found to be acceptable to this sample of people with mild asthma.     

A randomised controlled trial of two programmes of shoulder exercise following axillary node dissection for invasive breast cancer

Objective

To compare the incidence of treatment-related complications, including lymphoedema, after two programmes of shoulder mobilisation in women with invasive breast cancer when surgical treatment included axillary lymph node dissection.

Design

Randomised controlled trial.

Setting

Two secondary care National Health Service trusts.

Participants

One hundred and sixteen women (mean age 57 years, standard deviation 13.1 years) recruited from November 2003 to March 2006 (58 intervention group, 58 control group). Seven patients (6%) did not complete the study.

Intervention

Arm exercises and shoulder movement restricted to below shoulder level for the first 7 days after surgery. Controls commenced an exercise programme that incorporated exercises above shoulder level within 48 hours.

Outcome measures

All outcomes were recorded at baseline (pre-operatively) and at 1 year. The primary outcome was incidence of lymphoedema, defined by a limb volume difference of 200 ml or more compared with the contralateral arm. This outcome was measured using volume displacement. Secondary outcome measures included volume differences between the two limbs measured by actual volume displacement difference, wound drainage volumes, range of shoulder movement (manual goniometer), grip strength (hand-held dynamometer) and health-related quality of life (Shoulder Disability Questionnaire, Functional Assessment of Cancer Therapy - Breast).

Results

All statistical tests were two-sided. Data were analysed using intention-to-treat principles. The incidence of lymphoedema (200 ml or more) increased significantly in women who had undertaken a programme of early full shoulder mobilisation. Twenty-two women (19%) developed lymphoedema (200 ml or more) in their first postoperative year. There were significantly more women with lymphoedema in the early full shoulder mobilisation group (n = 16) compared with the delayed full shoulder mobilisation group (n = 6). The relative risk of developing lymphoedema after early mobilisation was 2.7 (95% confidence interval 1.1 to 6.3; P = 0.031). Limb volume differences were significantly higher in the early mobilisation group. This was apparent in differences in limb volume displacement (P = 0.004) and percentage difference between the two limbs (P = 0.007). There were no statistically significant differences in shoulder movement, grip strength or self-evaluated outcomes between the two groups at 1 year.

Conclusion

A programme of exercise that delays full shoulder mobilisation for 1 week is recommended after axillary node dissection for invasive breast cancer.     

A narrative review of interventions to support family carers who provide physical care to family members with cancer

Objectives

Most reports of cancer caregivers’ needs focus on information and psychosocial needs. Less is known about practical knowledge and support carers need to provide physical care in the home. This review aimed to identity and critique studies of the development and/or evaluation of interventions to enable family carers to provide physical/practical care to a family member with cancer.

Design

Narrative review.

Data sources

Studies which included adult carers who provided care to a family member with cancer (any stage). Search sources included Psych Info., Cochrane Central Register of Controlled Trials, Embase Ovid, Embase, Ovid Medline, CINAHL, other databases, systematic and other reviews.

Review methods

All types of study designs were included. Initially, multiple and broadly defined search strategies and terms were used to capture the range of potential studies; later more refined procedures were applied.

Results

In total, 19 studies were included in the review. Interventions focused on skills development (n = 1), managing symptoms (n = 9), problem solving (n = 5) and learning (n = 4). Few studies were identified with well-defined and evaluated interventions to assist carers to provide physical care for their family member with cancer.

Conclusions

Future research is needed to develop well-defined interventions on practical skills and evaluate the outcomes for patients and caregivers.     

Safety and immunogenicity of hepatitis B vaccine administered into ventrogluteal vs. anterolateral thigh sites in infants: A randomised controlled trial

Background

Lowered immune response to hepatitis B vaccines has been found in individuals vaccinated into dorsogluteal site compared to vastus lateralis thigh muscle.

Objective

The aim of this study was to compare the immunogenicity and reactogenicity of a hepatitis B vaccine in infants vaccinated into ventrogluteal or anterolateral thigh sites.

Design

Randomised controlled trial.

Setting and participants

The recruitment of study participants was carried out from February to November 2007 in the five maternity hospitals located in the eastern region of Goiânia City, Central Brazil. Newborns up to 12 h old weighing at least 2.5 kg were enrolled in the study.

Methods

A total of 580 newborns were randomised to receive three hepatitis B vaccine doses into ventrogluteal (n = 286) or anterolateral thigh (n = 294) sites. Of them, 474 (81.7%) completed the study: 224 from the ventrogluteal group (intervention group) and 250 from the anterolateral thigh group (control group). Fever and local adverse events were evaluated 48 h after each vaccine dose. Blood samples (3 mL) were collected between 45 and 60 days after the third vaccine dose, and anti-HBs antibody titres were determined by automatic analysis using the Microparticle Immunoenzymatic Test (AxSYM^® Ausab^®, Abbott, Germany).

Results

The groups did not differ by gender, weight, length of time between vaccine doses, or maternal characteristics. The proportion of infants who developed protective anti-HB titres after full vaccination into the ventrogluteal site was 97.8% (95% confidence interval [CI]: 94.8-99.3; geometric mean titre: 427.5 mIU/mL; 95% CI: 344.9-530.0), similar to that of infants vaccinated into the anterolateral thigh site (97.6%; 95% CI: 94.8-99.1; geometric mean titre: 572.0 mIU/mL; 95% CI: 471.1-694.6). No complication was found after 1503 vaccine doses, but a lower proportion of fever and local adverse events was found among the intervention group (17.9%) vs. the control group (23.7%) (p < 0.01).

Conclusion

Our results suggest that the ventrogluteal region is a suitable site for intramuscular injection in infants, particularly for the hepatitis B vaccine.