Tight glycemic control: what do we really know,and what should we expect?

Tight glycemic control has engendered large numbers of investigations, with conflicting results. The world has largely embraced intensive insulin as a practice, but applies this therapy with great variability in the manner of glucose control and measurement. The present commentary reviews what we actually know with certainty from this vast sea of literature, and what we can expect looking forward.     

Suicide among Asian Americans: what do we know? What do we need to know?

The current review begins with an acknowledgment of the diversity within the Asian American population as well as the scarcity of information on suicide among this particular racial/ethnic minority group. In analyzing what is known and what still needs to be learned about suicide among Asian Americans, the current article provides a critical review of significant factors such as age, gender, religious and spirituality issues, acculturation, social support, familial dynamics, social integration as well as gay/lesbian/bisexual orientations. In examining these factors, recommendations related to interventions and the existing research gaps are also discussed.     

What do we know about perioperative hypersensitivity reactions and what can we do to improve perioperative safety?

Hypersensitivity reactions are an important aspect of perioperative care and are a crucial interdisciplinary issue in anaesthesiological practice, as well as allergological and laboratory diagnostics. This phenomenon was observed as early as the 1980s and 1990s in Western European countries, and knowledge on this subject has grown significantly over time. Although hypersensitivity reactions are not frequent events (the incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency − 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations), their courses are unfortunately serious and life-threatening. It should also be noted that there is no information regarding the occurrence of perioperative hypersensitivity reactions in many countries. Hence, global assessment of the problem is underestimated. The primary source of actual knowledge comes from epidemiological studies, which indicate an increasing frequency of hypersensitivity reaction occurrence and changes in aetiological factors. The first report from France (1984 to 1989) described two main causes – neuromuscular blocking agents and hypnotic agents. The following years confirmed an increase in perioperative hypersensitivity reactions associated with latex and antibiotics. The most recent data from the National Audit Project 6 indicated increased participation of antibiotics, chlorhexidine, and contrast agents. The results of epidemiological analyses are the basis of medical management guidelines and practice modification. Thanks to the activity of many organisations monitoring the intensity and nature of perioperative hypersensitivity reactions, guidelines for diagnostics and management have been developed. This article presents the results of numerous studies, including the first and the most recent, from various geographical regions. The clinical significance, pathogenesis mechanisms are also discussed. This publication also presents important directions for further scientific and epidemiological research on perioperative hypersensitivity reactions.

Key messages

• The incidence of perioperative hypersensitivity reactions ranges from 1:386 to 1:13 000 procedures, with higher frequency – 1 per 6500 general anaesthesias with neuromuscular blocking agents administrations.
• Reactions may occur during the first episode of anaesthesia, most frequently in the induction of general anaesthesia, and much less frequently during postoperative follow-up.
• The first reports of perioperative hypersensitivity reaction come from the 1990s, and knowledge on this subject has grown significantly over time.
• In many countries, multidisciplinary teams and organisations have been established to identify, monitor the occurrence of this phenomenon, and have set the directions of medical activities and have changed the rules and recommendations.
• There is no information about the occurrence of perioperative hypersensitivity reactions in many countries, and global assessment of the problem is underestimated. Additionally, there is a great need to develop a system to monitor their occurrence in other countries.
• The long-term epidemiologic studies have demonstrated variability in pharmacologic triggers. However, the main pharmacological substances (antibiotics, muscle relaxants, disinfectans, contrast agents) are related to aspects of patient safety during anaesthesia.

     

Advanced cardiac life support instruction: do we know tomorrow what we know today?

This study compared two instructional and evaluation methods for teaching advanced cardiac life support (ACLS) to health care professionals who were taking the ACLS course for the first time. Outcomes of the instruction were measured on completion of the course and at 3 months and 6 months postinstruction to identify differences in participants' knowledge retention, skills competency, and self-efficacy in performing ACLS. In addition, satisfaction with the teaching method was evaluated. The two methods of teaching and evaluating competencies for ACLS were (1) traditional classroom instruction plus practice and evaluation with monitors (low-fidelity simulation); and (2) classroom instruction plus practice with high-fidelity patient simulators. Participants in the study were 148 health care professionals or health care students who were novices in ACLS preparation. Participants were recruited from a large Midwest school of nursing and school of medicine, a Midwest physicians' assistant program, and a not-for-profit hospital. The findings showed no significant differences in ACLS knowledge, skills, self-efficacy, or learner satisfaction immediately after instruction or at 3 to 9 months posttraining. Retention of ACLS knowledge and skills competency over time was low in both groups; recommendations and interventions are discussed based on the study results.     

We do know what nurses do— now we must promulgate it

We have volumes of scientific evidence that patients get better faster when we give them the best technology, the most appropriate medical treatment plan, and the necessary supports through nursing care. Why then are nurses being targeted by restructuring? Although on paper the business algorithm may look good to organizations, we need to tell our patients and Congress that health services are in jeopardy.     

Prehospital trauma care: what do we really know?

PURPOSE OF REVIEW: The prehospital care of injured patients has been surrounded with much controversy over the years. This controversy exists regarding the specific interventions used on-scene and en-route to definitive care centers, regarding the overall approach to the care of these patients (advanced life support versus basic life support) and with regards to who should be providing this care. This section of the journal aims to review the most current literature concerning these topics as well as highlight some important and relevant literature preceding it. RECENT FINDINGS: Studies examining overall prehospital care in terms of morbidity, mortality and cost have been published over the last year and important points from these studies are highlighted in the text. Unfortunately, there have not been any recent, appropriately powered, prospective studies that help in clarifying this controversy. An international study of prehospital care has recently been completed and is summarized. Recent studies looking at specific aspects of prehospital care (endotracheal intubation, intravenous access and therapy, rural trauma) are also outlined in the text. SUMMARY: There is no convincing evidence that prehospital advanced life support in the urban setting provides any benefit to injured patients in terms of either morbidity or mortality.     

Lung-protective ventilation strategies in neonatology: what do we know--what do we need to know?

OBJECTIVE: Randomized controlled trials (RCTs) investigating various lung-protective ventilation modes or strategies in newborn infants have failed to show clear differences in mortality or bronchopulmonary dysplasia. This review tries to identify possible reasons for this observation, applying modern concepts on ventilator-induced lung injury and lung-protective ventilation. DATA SOURCE: Published RCTs and systematic reviews on mechanical ventilation in newborn infants were identified by searching PubMed and the Cochrane Library. DATA SYNTHESIS: A total of 16 RCTs and four systematic reviews comparing high-frequency ventilation with conventional mechanical ventilation (CMV) failed to show consistent differences in mortality and bronchopulmonary dysplasia. Unfortunately, clear information or data on ventilation and oxygenation targets in the search for optimal lung volumes during high-frequency ventilation or CMV is lacking in many RCTs, questioning the validity of the results and the meta-analytic subgroup analysis. Based on improvement in oxygenation, only three RCTs successfully applied the optimal lung volume strategy during high-frequency ventilation. A total of 24 RCTs and three systematic reviews comparing various CMV modes and settings and two RCTs investigating permissive hypercapnia reported no differences in mortality or bronchopulmonary dysplasia. However, the intervention arms in these RCTs did not differ in tidal volume or positive end-expiratory pressures, variables that are considered important determinants in ventilator-induced lung injury. In fact, no RCT in newborn infants has substantiated so far the experimental finding that avoiding large tidal volumes and low positive end-expiratory pressure during CMV is lung protective in newborn infants. CONCLUSION: RCTs investigating lung-protective ventilation in neonates have mainly focused on comparing high-frequency ventilation with CMV. Most of these RCTs show weaknesses in the design, which may explain the inconsistent effect of high-frequency ventilation on bronchopulmonary dysplasia. RCTs on CMV only focused on comparing various modes and settings, leaving the important question whether reducing tidal volume or increasing positive end-expiratory pressure is also lung protective in newborn infants unanswered.     

Nursing and the aging workforce: myths and reality, what do we really know?

Not unlike the general population, the population of nurses is aging. This trend is problematic for the nursing workforce in the light of a predicted shortage yet the extent of the effect of the aging population is unknown. What should individuals older than 45 years know to mitigate the effects of aging both physically and professionally? This article describes the magnitude of the aging nursing workforce issue, explores the myths and realities related to the aging process, discusses evidence-based strategies supporting healthy aging and retention of experienced nurses in one Magnet hospital, and introduces recommendations for further study.