What is the cause of the opthalmoplegia in this young child? What treatment is necessary?

Not all orbital fractures are associated with clinical signs of swelling, ecchymosis, and subconjunctival hemorrhage. The “white‐eyed” blowout fracture is more commonly seen in children and is associated with entrapment of the extraocular muscles. Early surgical intervention is indicated and it must have been in the differential diagnosis of the head injury patient with opthalmoplegia.     

Comparison of lifestyle and health among Danish nurses and the Danish female population: is it possible to generalize findings from nurses to the general female population?

AIMS: To generalize findings from a nursing population to the general female population, the aim of this study was to compare lifestyle and health among Danish female nurses with that among Danish women. Furthermore, the aim was to compare lifestyle and health among Danish female nurses with women belonging to the same socio-economic group as nurses. METHODS: Danish females above the age of 44 in 1999 (n = 22,715) were compared with a group of women from the Danish Health and Morbidity Survey conducted in 2000 (n = 4,445). Age standardized risk ratios (SRR) with 95% confidence intervals were calculated to compare the two groups. RESULTS: Nurses smoke less (SRR 0.74, CI: 0.70-0.78) and are more physically active (SRR 2.53, CI: 2.31-2.77) when compared with the general female population. A higher percentage of nurses consume five drinks or more on a weekday compared with the general female population (SRR 2.68, CI: 2.25-3.19). When comparing nurses with women belonging to the same socio-economic group, these differences are also found to be statistically significant, but no differences are found according to overweight/obesity, self-reported health and limitations in daily activities when nurses are compared with women belonging to the same socio-economic group. CONCLUSIONS: In general, Danish nurses have a healthier lifestyle than other Danish women. In future studies, differences and similarities in lifestyle and health between nurses and other women should be considered when generalizing findings from Danish nurses to the Danish female population.     

What is the proper workup of a patient with hypertension?

Because hypertension is common and many tests are available, an uncritical approach to laboratory and radiologic evaluation leads to unnecessary expenses. However, in most patients, accurate blood pressure measurement, a focused history and physical examination, and a handful of basic tests are enough. In this review we address the key questions in the evaluation of the patient with an elevated pressure reading, ie, does the patient have sustained high blood pressure? And if so, is the hypertension primary or secondary, are other cardiovascular risk factors present, and is there evidence of target organ damage?     

What is the effect of preoperative information on patient satisfaction?

The aim of this literature review is to examine the relationship between the provision of written information given to patients' preoperatively and their postoperative recovery following elective surgery. It is not currently apparent which is the most effective method of delivering preoperative information, or at what stage of the preoperative phase is the optimum time to deliver such important information. The purpose of this review is to briefly outline the affiliation between anxiety experienced by surgical patients and the information received preoperatively and to examine the relationship between the provision of written information given to patients preoperatively and their postoperative recovery following elective surgery. Research findings are contradictory with respect to the effect of preoperative information on postoperative pain and patient satisfaction. However, research does indicate that the provision of good-quality preoperative information facilitates patients' active involvement in their care, and therefore may contribute to an overall increase in satisfaction. There remains a need for rigorous research that identifies the optimum timing and method of delivering preoperative information to maximize their positive effects on patients undergoing elective surgery.     

What factors predict full or partial return to work among sickness absentees with spinal pain participating in rehabilitation?

Purpose.?To identify the factors that predict full or partial return to work among long-term (≥90 days) sickness absentees due to spinal pain who begin a multidisciplinary rehabilitation programme.

Method.?In a prospective cohort study, 312 patients with neck, thoracic and/or lumbar pain, aged 20–64, participated in a 4-week multidisciplinary rehabilitation programme in Sweden. Questionnaire data at inclusion were used. Factors included in logistic regressions were as follows: age, gender, type of work, pain location, pain intensity (visual analogue scale), activity limitations [Disability Rating Index (DRI)], health-related quality of life (SF-36), pain-related fear of movement (Tampa Scale of Kinesiophobia), motivation (Self Motivation Inventory), sickness absence at baseline and number of sick-leave days during the previous 2 years. Outcome factor was increased versus not increased working time at follow-up 6 months later.

Results.?Most patients (68%) reported two or three pain locations. At baseline, 56% were full-time sickness absent and 23% at follow-up; 61% had increased their working time. Predictors for increased working time were age below 40 years, low activity limitation (DRI < 50), low SF-36 bodily pain (>30) and high SF-36 social functioning (>60). Number of sick-leave days during the previous 2 years (md 360; range 90–730) had no influence.

Conclusions.?Even patients with long previous sick leave can increase working time after a multidisciplinary rehabilitation programme, especially if they are younger, have lower levels of activity limitations and pain and better social functioning. To include information on part-time work is useful when evaluating work ability following rehabilitation programmes.     

What do newly-qualified nurses expect from preceptorship? Exploring the perspective of the preceptee

Preceptorship plays an important role in ensuring the smooth transition from student to registered nurse (UKCC 1993). To date, there has been little evidence to demonstrate the extent to which preceptorship has been introduced, and scant research into newly-qualified nurses' expectations and experiences of preceptorship. A longitudinal, questionnaire survey is exploring the expectations of preceptorship, from the perspective of newly qualified nurses, as part of a Department of Health funded study into the careers of people qualifying from nursing diploma courses. The paper demonstrates how pilot work with a cohort of newly qualified nurses, combined with literature on preceptorship, enabled the identification of key aspects of preceptorship. Findings are presented on the expectations of adult branch nurses at the point of qualification. There was an overwhelming demand for preceptorship, and the majority of respondents anticipated that all identified aspects of preceptorship would be important in their first job. Aspects identified as particularly important were 'constructive feedback on my clinical skills' and 'teaching new clinical skills'. Future questionnaires will reveal the extent to which these expectations are met.     

Resuscitation of the pregnant patient: What is the effect of patient positioning on inferior vena cava diameter?

Study objective

Patients in the third trimester of pregnancy presenting to the emergency department (ED) with hypotension are routinely placed in the left lateral tilt (LLT) position to relieve inferior vena cava (IVC) compression from the gravid uterus thereby increasing venous return. However, the relationship between patient position and proximal intrahepatic IVC filling has never assessed directly. This study set out to determine the effect of LLT position on intrahepatic IVC diameter in third trimester patients under real-time visualization with ultrasound.

Methods

This prospective observational study on the labor and delivery floor of a large urban academic teaching hospital enrolled patients between 30 and 42 weeks estimated gestational age from August 2011 to March 2012. Patients were placed in three different positions: supine, LLT, and right lateral tilt (RLT). After the patient was in each position for at least 3 min, IVC ultrasound using the intercostal window was performed by one of three study sonologists. Maternal and fetal hemodynamics were also monitored and recorded in each position.

Results

A total of 26 patients were enrolled with one excluded from data analysis due to inability to obtain IVC measurements. The median IVC maximum diameter was 1.26 cm (95% confidence interval [CI] 1.13–1.55) in LLT compared to 1.13 cm (95% CI 0.89–1.41) in supine, p = 0.01. When comparing each individual patient's LLT to supine measurement, LLT lead to an increase in maximum IVC diameter in 76% (19/25) of patients with the average LLT measurement 29% (95% confidence interval 10–48%) larger. Six patients had the largest maximum IVC measurement in the supine position. No patients experienced any hemodynamic instability or distress during the study.

Conclusion

IVC ultrasound is feasible in late pregnancy and demonstrates an increase in diameter with LLT positioning. However, a quarter of patients had a decrease in IVC diameter with tilting and, instead, had the largest IVC diameter in the supine position suggesting that uterine compression of the IVC may not occur universally. IVC assessment at the bedside may be a useful adjunct in determining optimal positioning for resuscitation of third trimester patients.     

What is the role of direct renin inhibitors in the treatment of the hypertensive diabetic patient?

The renin-angiotensin system (RAS) is the most important mechanism leading to cardiovascular and renal damage in diabetic patients. Studies conducted until now have unequivocally demonstrated that antihypertensive treatment with RAS blockers (angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers) improve the prognosis of patients with diabetes, by reducing rates of cardiovascular events and preventing or delaying the progression of diabetic nephropathy. However, despite the benefits of such treatment, cardio-renal events are still very frequent in diabetics. Several strategies for reducing this cardiovascular and renal risk have been proposed, but among them, a more complete blockade of the RAS seems the most attractive. Direct renin inhibitors are RAS blockers with some particularities, such as their ability to reduce plasma renin activity or the possibility to modulate tissue and intracellular RAS, which could represent a theoretical advantage when treating diabetic patients. In experimental and clinical studies conducted until now, aliskiren is able to reduce blood pressure in diabetics, alone or in combination with ACE inhibitors or angiotensin-receptor blockers. Moreover, aliskiren reduces markers of cardiac and renal disease, such as left ventricular hypertrophy or post-infarction ventricular remodeling, as well as proteinuria in diabetics already treated with other RAS blockers. The translation of these promising results to the clinical arena is currently being investigated in the Aliskiren Trial in Type 2 Diabetes Using Cardio-Renal Endpoints (ALTITUDE), where more than 8600 diabetic patients with chronic kidney disease and at high-risk of cardio-renal events are treated with aliskiren or placebo added to the current treatment consisting of another RAS blocker. If positive, aliskiren will be the treatment of choice in the prevention of cardiorenal disease in diabetics.     

What research is needed to show the effectiveness of homeopathy?

Using the similia principle, the classical homeopath tries to find a substance that fits the patients complaints as closely as possible. Unusual symptoms that do not fit the symptom complexes recognised by conventional medicine may be considered even more important than the regular symptoms. This is why homeopathy is a highly individualised treatment, resulting in different treatments for patients who would receive an identical treatment in conventional medicine.     

Are nurses’ assessments of their workload affected by non‐patient factors? An analysis of the RAFAELA system

Aims To identify (1) the contribution of non‐patient factors to patient classification systems and (2) the explanatory power of nursing care intensity and non‐patient factors to Professional Assessment of Optimal Nursing Care Intensity Level workload. Background In the Rainio, Fagerström and Rauhala (RAFAELA) patient classification system, nursing care intensity per nurse is measured daily by the Oulu Patient Classification/Qualisan instrument. The optimal nursing care intensity is determined using Professional Assessment of Optimal Nursing Care Intensity Level instrument. However, nurses’ workload may be affected by factors other than nursing care intensity. Therefore, RAFAELA contains 12 non‐patient questions. Methods A retrospective study of all 22 somatic wards of a secondary healthcare hospital in Finland. Results Non‐patient questions were answered in 26% of 4870 questionnaires. They added to workload in 62%. Eight questions were grouped into four factors: administration; staff resources and mental stress; co‐operation within and between units. The explanatory value between Oulu Patient Classification/Qualisan and Professional Assessment of Optimal Nursing Care Intensity Level had a median of 0.45. Including the non‐patient questions raised it to 0.55. Conclusions Non‐patient factors affect the nurses’ assessments of their workload, but less than nursing care intensity. They contribute valuable information on the functioning and problems of wards.