Pressure‐aided transfusion of platelets: does it affect the platelets?

BACKGROUND: In massively bleeding patients, pressure infusers are used for transfusion of red blood cells and plasma but not for platelets (PLTs) due to an assumed negative effect on the PLTs. This study examined whether pressure‐aided in vitro transfusion affected the number, activation state, and/or function of the PLTs as measured by flow cytometry and thrombelastography (TEG). STUDY DESIGN AND METHODS: PLT concentrates stored for 1 (n = 8) or 8 (n = 7) days were transfused in vitro by means of a pressure inducer (300 mmHg). Samples before and after transfusion were measured for PLT concentration and expression of CD62P, CD63, and PAC‐1. These activation markers were measured by flow cytometry on resting PLTs as well as PLTs stimulated with thrombin receptor–activating peptide. Clot generation and strength was examined by TEG by measuring the angle (degree) and maximum amplitude (mm), values that are highly dependent on the PLT function. RESULTS: PLT concentrations were unchanged after pressure‐aided transfusion reflecting no destruction. With respect to activation state and in vitro functional capacity either no or only minor differences (<7%) were detected. CONCLUSION: In this study, use of a pressure inducer decreased the transfusion time of in vitro PLT transfusion by approximately 50%. No or only minor and inconsistent changes of the PLT number and function were observed. Consequently, this study indicates that pressure infusers could be used for transfusion of PLTs if clinically indicated, that is, in massively bleeding patients. However, in vivo studies to assess the safety and utility of pressure‐aided PLT transfusion are warranted.     

Congenital diaphragmatic hernia without herniation of the liver: does the lung‐to‐head ratio predict survival?

The purpose of the present study was to determine the ability of lung-to-head ratio to predict survival and need for extracorporeal membrane oxygenation support in fetuses with left congenital diaphragmatic hernia without herniation of the liver into the chest. The perinatal records of 20 fetuses with isolated left congenital diaphragmatic hernia without herniation of the left lobe of the liver into the chest were reviewed. Fetuses were stratified into two groups depending on lung-to-head ratio: those with a ratio of less than 1.4 (historically a poor prognosis group) and those with a ratio of greater than 1.4. The outcome of both groups was compared with chi-square analysis. Eight of 11 fetuses with a lung-to-head ratio greater than 1.4 survived, whereas 8 of 9 fetuses with a ratio of less than 1.4 survived. No differences were noted in the need for extracorporeal membrane oxygenation support or survival between the two groups. Fetuses with a prenatally diagnosed left congenital diaphragmatic hernia without herniation of liver into the chest have a favorable prognosis even in the presence of a low lung-to-head ratio.     

Patient‐controlled analgesia: what information does the patient want?

AIMS OF THE STUDY: To formulate and evaluate an information leaflet for patients using patient-controlled analgesia (PCA), incorporating information thought to be important by patients. RATIONALE: The benefit of current information leaflets, written by professionals, has not been studied and their value to patients is unknown. BACKGROUND: Previous studies have shown that information leaflets were poorly designed and written in language too difficult for patients to understand. RESEARCH METHODS: Seven focus groups were conducted to establish what information patients wanted to know about PCA. This information was incorporated into a new information leaflet. One hundred patients were randomized to receive either the new leaflet or the old leaflet in current use. A questionnaire was used to establish whether the new leaflet was more clear and informative than the old one. RESULTS: Patients wanted to know that the drug used in PCA was morphine. They wanted more information about side-effects, needed to be reassured that it was safe, and that they could not overdose or become addicted. They wanted detailed instructions and diagrams about the technique. The questionnaire study established that the new leaflet was clearer and more informative. CONCLUSION: Patients' contribution led to major change, producing a leaflet which was clearer, more attractive, more informative and which proved more satisfactory to patients.     

Application of the ambulatory care groups in the primary care of a European national health care system: does it work?

BACKGROUND: Ambulatory Care Groups (ACGs), a US case-mix system that uses the patient as the unit of analysis, is particularly appropriate for health care systems in which physicians serve a defined list of patients. OBJECTIVE: To determine the extent to which the categorization of patients according to ACGs would account for the utilization of primary care services in a national health care system within the European Union. METHODS: Of all subjects continuously assigned to 9 physicians from public primary health care centers in Bizkaia, Basque Country (Spain) over a 12-month period, those visited at least once (n = 9,093) were included. According to the subject's age, sex, and ICD-9-CM diagnoses assigned during a year of patient-provider encounters, patients were classified by means of the ACGs system. RESULTS: Multiple linear regression analyses indicated that age and sex did not explain more than 7.1% of the variance in annual visits made by adults and 25.7% by children to primary care physicians. However, the r2 adjusted to the ACGs model was 50% and 48%, respectively, and even higher, that is 58% and 64% for another component of the system, the Ambulatory Diagnostic Groups (ADGs). CONCLUSIONS: Those results support the inadequacy of using the patient's age and sex alone to estimate physicians' workload in the primary health setting and the need to consider morbidity categories. The ACGs case-mix system is a useful tool for incorporating patients' morbidity in the explanation of the use of primary health care services in a European national health system.     

Meta‐analysis: the glass eye of evidence‐based practice?

Meta-analysis was developed as a technique for combining the results of many different quantitative studies: it is often used to produce quantitative estimates of causal relations and/or association between variables. Meta-analysis is sometimes regarded as a central component of evidence-based practice. We draw attention to an incompatibility in the epistemology and methods of reasoning in quantitative meta-analysis and the epistemology and reasoning implicit in expert practice. We argue that this may be because the common perception of meta-analysis appeals to truth as correspondence; we suggest that rejecting the naive realism that underpins truth as correspondence allows meta-analysis to be understood in terms of truth as coherence. We can then develop an account of meta-analysis that does not depend upon reduction to a mathematical procedure but is an attempt to maximise coherence in beliefs about what works that is consistent with clinical reasoning in expert practice.     

Review of small rural health services in Victoria: how does the nursing‐medical division of labour affect access to emergency care?

Aims. This paper is based on a review of the Australian and International literature relating to the nursing‐medical division of labour. It also explores how the division of labour affects patient access to emergency care in small rural health services in Victoria, Australia. Background. The paper describes the future Australian health workforce and the implications for rural Victoria. The concept of division of labour and how it relates to nursing and medicine is critically reviewed. Two forms of division of labour emerge – traditional and negotiated division of labour. Key themes are drawn from the literature that describes the impact of a traditional form of division of labour in a rural context. Methods. This paper is based on a review of the Australian and international literature, including grey literature, on the subject of rural emergency services, professional boundaries and roles, division of labour, professional relationships and power and the Australian health workforce. Results. In Australia, the contracting workforce means that traditional divisions of labour between health professionals cannot be sustained without reducing access to emergency care in rural Victoria. A traditional division of labour results in rural health services that are vulnerable to slight shifts in the medical workforce, unsafe services and recruitment and retention problems. A negotiated form of division of labour provides a practical alternative. Conclusion. A division of labour that is negotiated between doctors and nurses and supported by a legal and clinical governance framework, is needed to support rural emergency services. The published evidence suggests that this situation currently does not exist in Victoria. Strategies are offered for creating and supporting a negotiated division of labour. Relevance to clinical practice. This paper offers some strategies for establishing a negotiated division of labour between doctors and nurses in rural emergency care.     

Pacemaker‐mediated tachycardia in a dual‐lead CRT‐D: What is the mechanism?

A 73‐year‐old gentleman with dilated cardiomyopathy, left bundle branch block and a left ventricular (LV) ejection fraction of 20% was implanted with two LV leads in a tri‐ventricular cardiac resynchronisation therapy defibrillator (CRT‐D) trial. As a part of the trial he was programmed with fusion‐based CRT therapy with dual LV lead only pacing. The patient presented to local heart failure service 12 years after implant, after a positive response to CRT therapy, with increase in fatigue, shortness of breath and bilateral pitting oedema. The patient sent a remote monitoring transmission that suggested loss of capture on one of the LV leads. This coupled with atrial ectopics was producing a high burden of pacemaker‐mediated tachycardia (PMT) that was not seen when both LV leads had been capturing. What is the mechanism for this? Dual LV‐lead tri‐ventricular leads have been shown to have variable improvements in CRT response but with an increased complexity of implant procedure. This is the first case report of PMT‐induced heart failure exacerbation in a tri‐ventricular device following loss of LV capture of one lead.     

End‐of‐Dose Pain in Chronic Pain: Does it Vary with the Use of Different Long‐Acting Opioids?

A large percentage of patients with chronic pain on around‐the‐clock (ATC) opioids may experience increased pain occurring at the end of a scheduled dose, also known as end‐of‐dose pain. Despite the significant prevalence and impact of end‐of‐dose pain in patients using extended‐release (ER) opioids, there are no detailed analyses examining how the frequency of end‐of‐dose pain is linked to the formulations of long‐acting opioids. Consequently, we performed a systematic review to evaluate how many published studies on patients with chronic cancer or noncancer pain identified end‐of‐dose pain. As only a few studies mentioned end‐of‐dose pain explicitly, we used breakthrough pain (BTP) as a surrogate parameter. We determined if any opioid formulation had a greater association with the frequency of BTP, the use of rescue medication for BTP, and the frequency of end‐of‐dose pain. Of the 39 studies entered in the final analysis, 14 studies across different formulations showed that ER opioids were effective in the prevention of BTP. The opioids most frequently studied were hydromorphone (26%), followed by morphine (23%), and transdermal buprenorphine (23%). Only 5% of the studies used immediate‐release preparations. Overall, most studies showed that patients using ER preparations experienced fewer episodes of BTP compared with patients on placebo or an active comparator. This could reflect the favorable duration of action of these opioids compared with short‐acting formulations. Future studies should examine the incidence of end‐of‐dose pain and use of rescue medicine in a longitudinal manner in patients with chronic pain taking short‐ vs. long‐acting ATC opioids.     

Factor seven‐activating protease: does it do what it says on the tin?

See also Stavenuiter F, Dienava‐Verdoold I, Boon‐Spijker MG, Brinkman HJM, Meijer AB, Mertens K. Factor seven activating protease (FSAP): does it activate factor VII? This issue, pp 859–66.     

Immune remodelling of stromal cell grafts in the central nervous system: therapeutic inflammation or (harmless) side‐effect?

Over the past two decades, several cell types with fibroblast‐like morphology, including mesenchymal stem/stromal cells, but also other adult, embryonic and extra‐embryonic fibroblast‐like cells, have been brought forward in the search for cellular therapies to treat severe brain injuries and/or diseases. Although current views in regenerative medicine are highly focused on the immune modulating and regenerative properties of stromal cell transplantation in vivo, many open questions remain regarding their true mode of action. In this perspective, this study integrates insights gathered over the past 10 years to formulate a unifying model of the cellular events that accompany fibroblast‐like cell grafting in the rodent brain. Cellular interactions are discussed step‐by‐step, starting from the day of implantation up to 10 days after transplantation. During the short period that precedes stable settlement of autologous/syngeneic stromal cell grafts, there is a complex interplay between hypoxia‐mediated cell death of grafted cells, neutrophil invasion, microglia and macrophage recruitment, astrocyte activation and neo‐angiogenesis within the stromal cell graft site. Consequently, it is speculated that regenerative processes following cell therapeutic intervention in the CNS are not only modulated by soluble factors secreted by grafted stromal cells (bystander hypothesis), but also by in vivo inflammatory processes following stromal cell grafting. Copyright © 2016 John Wiley & Sons, Ltd.     

The Effectiveness of the Around‐ the‐Clock In‐Home Care System: Did It Prevent the Institutionalization of Frail Elderly?

This study compares two communities in Japan from the perspective of community health care resources and their use by the elderly during 1992-98. In one community, programs of home care services for the elderly were reorganized to provide around-the-clock in-home nursing and home help services seven days a week (ACC). Official records were the major sources of data. Evidence from the analysis indicated that ACC might contribute to less use of institutionalization as an alternative to home care, even though, in some instances, institutionalization is the only appropriate alternative.