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.     

Are parent‐reported repetitive and restricted behaviours associated with psychological problems in pre‐school‐aged children?

This study surveys the association of restricted and repetitive behaviours in pre-school children with their emotional and behavioural problems. Parents of 504 pre-school children selected by cluster sampling participated and filled in the questionnaires including repetitive and restricted behaviour (RRB) scale and the Strengths and Difficulties Questionnaire. The parents reported repetitive and restrictive behaviours are gender-related in pre-school-aged children. Hyperactivity and emotional problems are significantly in association with all the four types of repetitive and restrictive behaviours. Prosocial problems score is in association with 'reaction to change' subscale score. Children with higher scores of conduct problems have higher rates of 'sensorimotor stereotypies', 'reaction to change' and 'modulation insufficiency'. Pre-school children with a higher rate of RRBs are more hyperactive and have more emotional problems than those with lower rates of RRBs. Conduct problems are more common in children with 'sensorimotor stereotypies', 'reaction to change' and 'modulation insufficiency' problems. Repetitive and restricted behaviours are associated with mental health problems in pre-school-aged children.     

What is supportive when an adult next‐of‐kin is in critical care?

There is little documented knowledge about what is supportive from the perspective of relatives with a critically ill next-of-kin in the intensive care unit (ICU). The aim of the present study was to generate a theoretical understanding of what relatives experience as supportive when faced with the situation of having an adult next-of-kin admitted to critical care. The study was designed using a grounded theory methodology. Interviews were conducted with 29 adult relatives of adult ICU patients in southwest Sweden. Relatives described the need to be empowered and that support was needed to enable them to use both internal and external resources to cope with having a next-of-kin in critical care. To achieve empowerment, the relatives described the need to trust in oneself, to encounter charity and to encounter professionalism. The findings can contribute understanding and sensitivity to the situation of the relatives as well as indicating what form social support should take. It is essential that healthcare professionals understand how important it is for relatives to have control over their vulnerable situation and that they also reflect upon how they would like to be treated themselves in a similar situation. Recommendations for future practice are presented.     

What are the cut‐off levels for IL‐6 and CRP in neonatal sepsis?

Neonatal sepsis, characterized by systemic signs of infection in the first month of life, remains an important clinical syndrome. Despite advances in neonatology, it has high rates of mortality and morbidity. The combine or alone usage of interleukin‐6 (IL‐6) and C‐reactive protein (CRP) has recently been proven to be useful in the early diagnosis of sepsis in newborns. The study included 282 patients; there were 232 in Group I (170 proven and 62 clinical sepsis) and 50 in Group II (control group). The optimum cut‐off value in the diagnosis of neonatal sepsis was found to be 24.65 pg/ml for IL‐6 and 4.82 mg/l for CRP. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of this IL‐6 cut‐off for neonatal sepsis were 72, 84, 95, and 42%, respectively. Sensitivity, specificity, PPV, and NPV of the CRP cut‐off for neonatal sepsis were 67, 97, 99, and 39%, respectively. The combination of IL‐6 (>24.65 pg/ml) and CRP (>4.82 mg/l) in the diagnosis of neonatal sepsis gave sensitivity, specificity, PPV, and NPV of 53, 100, 100, and 33%, respectively. To our knowledge, this is the largest reported study seeking to determine cut‐off levels for IL‐6 and CRP in the diagnosis of neonatal sepsis. In conclusion, we think that it is useful to evaluate IL‐6 and CRP, in combination, for the early diagnosis of neonatal sepsis. J. Clin. Lab. Anal. 24:407–412, 2010. © 2010 Wiley‐Liss, Inc.     

Symptom‐based diagnosis of urinary tract infection in women: are we over‐prescribing antibiotics?

Background: Current clinical guidelines for the management of symptoms suggesting urinary tract infection recommend empiric antibiotic therapy. Objective: To determine the diagnostic accuracy of urinary tract symptoms for early identification of urinary tract infection (UTI) in sexually active women when culture results are not available. Method: This was a cross‐sectional observational study conducted in a tertiary care hospital between July 2009 and May 2011. Subjects comprised 312 women ≥ 18 year of age who reported to the physician with symptoms suggestive of UTI. A predesigned questionnaire was filled and urine was analysed by microscopic examination and culture. Diagnostic values were calculated against gold standard urine culture results (> 10² CFU/ml) and 95% CIs and likelihood ratios are reported. Results: A total of 312 women were enrolled, as culture was contaminated in 36 only 276 women were included in final analysis. Prevalence of UTI was 46.01% amongst symptomatic women. Urgency (p = 0.001), burning sensation during micturition (p = 0.035), dysuria (p = 0.004), frequency of sexual intercourse > 5 per month (p = 0.010) and pyuria (p = 0.000) were significantly associated with culture positivity. Absence of pyuria emerged as best predictor for ruling out UTI even if the woman had symptoms (sensitivity 93.70%, NPV 91.84%, AUC 77.07%, LR? 0.1). The combination of urgency, burning during micturition and pyuria was the best predictor of UTI in our study (sensitivity 85.83%, PPV 71.71%, AUC 78.48%, LR+ 2.97) Conclusion: Symptoms alone have low accuracy when assessed against the reference standard for diagnosing UTI. Empiric treatment of UTI based on symptoms may expose large number of patients to unnecessary antibiotics. Wet mount microscopy for presence of pyuria as a ‘near patient test’ before starting antibiotics seems a rational approach for management of UTI in symptomatic women.     

What counts as evidence in evidence‐based practice?

BACKGROUND: Considerable financial and philosophical effort has been expended on the evidence-based practice agenda. Whilst few would disagree with the notion of delivering care based on information about what works, there remain significant challenges about what evidence is, and thus how practitioners use it in decision-making in the reality of clinical practice. AIM: This paper continues the debate about the nature of evidence and argues for the use of a broader evidence base in the implementation of patient-centred care. DISCUSSION: Against a background of financial constraints, risk reduction, increased managerialism research evidence, and more specifically research about effectiveness, have assumed pre-eminence. However, the practice of effective nursing, which is mediated through the contact and relationship between individual practitioner and patient, can only be achieved by using several sources of evidence. This paper outlines the potential contribution of four types of evidence in the delivery of care, namely research, clinical experience, patient experience and information from the local context. Fundamentally, drawing on these four sources of evidence will require the bringing together of two approaches to care: the external, scientific and the internal, intuitive. CONCLUSION: Having described the characteristics of a broader evidence base for practice, the challenge remains to ensure that each is as robust as possible, and that they are melded coherently and sensibly in the real time of practice. Some of the ideas presented in this paper challenge more traditional approaches to evidence-based practice. The delivery of effective, evidence-based patient-centred care will only be realized when a broader definition of what counts as evidence is embraced.     

Nursing migration: global treasure hunt or disaster‐in‐the‐making?

International nurse migration--moving from one country to another in the search of employment--is the focus of this article. The majority of member states of the World Health Organization report a shortage, maldistribution and misutilisation of nurses. International recruitment has been seen as a solution. The negative effects of international migration on the 'supplier' countries may be recognised today but are not effectively addressed. Nurse migration is motivated by the search for professional development, better quality of life and personal safety. Pay and learning opportunities continue to be the most frequently reported incentives for nurse migration, especially by nurses from less-developed countries. Career opportunities were considered key incentives for nurses emigrating from high-income countries. Language was reported to be a significant barrier. The positive global economic/social/professional development resulting from international migration needs to be weighed against a substantial 'brain and skills drain' experienced by supplier countries. The vulnerable status of migrant nurses is also of concern in certain cases. The focus on short-term solutions as opposed to resolving the problem of a worldwide shortage of nurses causes great concern. Recent initiatives attempt to curb or channel international recruitment. The delicate balance between recognising the right of individual nurses to migrate and a collective concern for the health of a nation's population must be achieved.     

Is licofelone,a dual inhibitor of cyclo‐oxygenase and 5‐lipoxygenase,a promising alternative in anti‐inflammatory therapy?

As prostaglandins and leukotrienes are critical in inflammation, dual cyclo-oxygenase and 5-lipoxygenase enzymes inhibitors, especially licofelone, are being developed by pharmaceutical companies. Experimental data indicate that licofelone shares the antipyretic, analgesic, anti-inflammatory and anti-platelet activities of conventional nonsteroidal anti-inflammatory drugs (NSAIDs), and exhibits anti-allergic properties. Although licofelone may lead to similar adverse effects on the kidney than available NSAIDs, it appeared to induce less gastrointestinal damaging effects than nonselective NSAIDs in animals. Unfortunately, preliminary clinical studies provided less impressive data with respect to efficacy. Finally, the experimental promise of licofelone as a safe and potent anti-inflammatory and analgesic agent remains to be proved in humans.     

Medical hegemony in decision‐making – a barrier to interdisciplinary working in intensive care?

BACKGROUND: Health care policy in the United Kingdom identifies the need for health professionals to find new ways of working to deliver patient-focussed and economic care. Much debate has followed on the nature of working relationships within the health care team. AIM: This paper reports on an ethnographic study that examined the nursing role in clinical decision-making in intensive care units. This was chosen as a case for analysis due to the close doctor-nurse relationships that are essential in this acute and complex care setting. METHODS: Data were collected during two-stages of fieldwork using participant observation, in-depth ethnographic interviews and documentation across three clinical sites. FINDINGS: The findings revealed the different types of knowledge used for, divergence of roles involved in and degree of authority in clinical decision-making. Furthermore, conflict arose between doctors and nurses due to these differences and in particular because medicine dominated the decision-making process. CONCLUSIONS: The nursing role, whilst pivotal to implementing clinical decisions, remained unacknowledged and devalued. Medical hegemony continues to render nurses unable to influence substantially the decision-making process. This has fundamental ramifications for the quality of team decision-making and the effectiveness of new ways of inter-professional working in intensive care.     

Cell‐assisted lipotransfer: Friend or foe in fat grafting? Systematic review and meta‐analysis

Autologous fat grafting is a common procedure for soft‐tissue reconstruction but is associated with a graft resorption rate ranging from 20% to 80%. To improve the fat graft survival rate, a new technique, called cell‐assisted lipotransfer (CAL), was developed. With CAL, fat is injected along with adipose‐derived stromal cells that are assumed to improve fat survival rate. We conducted an evidence‐based meta‐analysis to evaluate the efficacy and safety of CAL as compared with conventional autologous fat grafting (non‐CAL). The databases MEDLINE (via PubMed), Cochrane Library, EBSCO, Web of Science, and EMBASE were searched for reports of clinical trials, case series, and cohorts available from 2008 to 2016. We conducted a meta‐analysis of the efficacy of CAL with data analysis concerning fat survival rate. The incidence of complications and the need for multiple procedures were evaluated to determine the safety of CAL. We identified 25 studies (696 patients) that were included in the systematic review; 16 studies were included in the meta‐analysis to evaluate the efficacy of CAL. The fat survival rate was significantly higher with CAL than non‐CAL (64% vs. 44%, p < .0001) independent of injection site (breast and face). This benefit of CAL was significant for only injection volumes <100 ml (p = .03). The two groups did not differ in frequency of multiple procedures after fat grafting, but the incidence of complications was greater with CAL than non‐CAL (8.4% vs. 1.5%, p = .0019). The CAL method is associated with better fat survival rate than with conventional fat grafting but only for small volumes of fat grafting (<100 ml). Nonetheless, the new technique is associated with more complications and did not reduce the number of surgical procedures needed after the first fat grafting. More prospective studies are required to draw clinical conclusions and to demonstrate the real benefit of CAL as compared with common autologous fat grafting.