Does implementation of a paediatric asthma clinical practice guideline worksheet change clinical practice?

Background

Despite the development of evidence-based practice guidelines in many countries for asthma treatment in children, there is limited evidence that using such guidelines improves patient care.

Aims

Our aim was to evaluate whether the implementation of an evidence-based asthma clinical practice guideline (CPG) worksheet changes clinical practice.

Methods

The study was a before and after study of the implementation of a paediatric asthma CPG in a tertiary paediatric emergency department (ED). All children aged 2–16 years who had a diagnosis of asthma were included. Clinical data were obtained by retrospective chart review for time periods before (May to September 2003) and after (May to September 2005) the introduction of the CPG worksheet. Primary outcomes were: use of spacers for salbutamol instead of nebulisers, use of ipratropium and use of corticosteroids. Secondary outcomes were use of an ED action plan, ordering chest X-rays (CXR) and admission rate.

Results

Before implementation, 240 children presented with asthma and after implementation, 286 children presented. The two groups had similar ages, asthma severity, admission respiratory rate (RR) and oxygen saturation. Following implementation there was an increase in spacer use from 17 to 26% [+9%; 95% confidence interval (CI): 2–16%; p?=?0.015] and a reduction in ipratropium use from 58 to 44% (?13%; 95% CI: ?22 to ?5%; p?=?0.0029). The proportion of patients treated with corticosteroids did not change. The number of patients with an ED action plan increased. The number of CXR ordered decreased and the hospital admission rate decreased.

Conclusions

The study demonstrates that implementation of an asthma CPG worksheet in a tertiary paediatric ED resulted in modest changes in clinical practice, mainly by increasing clinician adherence to the guidelines.     

The impact of paediatric oncology education on clinical practice – A phenomenological study

PurposeOver the past 40 years, 5-year survival rates for children and young people with cancer have risen dramatically in the United Kingdom (UK), an improvement largely attributable to the increasingly effective treatments and the centralisation of care. Registered nurses in clinical roles, both within the hospital and the community setting, require on-going and relevant education and training programmes to equip them with the necessary professional and personal skills to ensure they are fit for purpose.MethodThis research study reports on Child Health Nurses (CHN's) perceptions of the impact of paediatric oncology education on their practice. Using a phenomenological approach, this study explores this phenomenon in depth, constructing meaning through the individual participants ‘lived experiences’. A purposive sample was selected to participate in semi-structured interviews within their clinical environment.ResultsFindings suggest that formal paediatric oncology nurse education is perceived to positively impact on certain aspects of the practitioners practice. All the CHN's felt empowered through their newly found knowledge, confidence and attitude and ability to apply evidence-based care. All participants perceived a need for education at all levels, most enjoyed the blended approach to the teaching, learning, and assessment, however all experienced great support from one another and the sharing of personal and professional experiences.ConclusionsFrom this study it is acknowledged that paediatric oncology education is required and is important for the delivery of quality care. However, there is a dearth of research-based literature which truly analyses the effectiveness and impact of education on paediatric oncology practice.     

How does the introduction of a pain and sedation management guideline in the paediatric intensive care impact on clinical practice? A comparison of audits pre and post guideline introduction

Despite the use of guidelines to inform practice for pain and sedation management there are few evaluations of the effect of their introduction on clinical practice. Previous evaluations of the protocols and guidelines used to manage pain and sedation in the paediatric intensive care unit (PICU) report increases in pain and sedation medication administration post guideline introduction. In most reported cases the guideline was accompanied by a treatment algorithm. To our knowledge there is no published data on the effect of introducing a guideline without a treatment algorithm on pain and analgesia administration.PurposeTo evaluate the impact the introduction of a pain and sedation guideline will have on clinical practice.MethodsA 19 bed PICU was audited for one month prior to the introduction of a guideline and one month post.FindingsThe proportion of patients receiving oral Clonidine increased (p = 0.001) and the administration of Ketamine, particularly via bolus (p = 0.003), reduced after the introduction of the guideline. The use of a validated pain tool to assess pain increased by 25% and communication of management plans increased by 25%. The documentation of the use of boluses increased by 36%.ConclusionThe introduction of a clinical practice guideline for pain and sedation management in PICU contributes to changes in medication administration, use of validated pain assessments, improved documentation of boluses and communication of management plans.     

Does intramuscular ondansetron have an effect on intramuscular ketamine-associated vomiting in children? A prospective,randomized, double blind,controlled study

ObjectiveThis study was conducted to determine the effect of intramuscular ondansetron on ketamine-associated vomiting in children undergoing procedural sedation.MethodsThis randomized, double-blind, placebo-controlled, parallel-group clinical trial was conducted at the emergency departments of two university-affiliated tertiary care hospitals. Eligible participants included all 6-month to 16-year-old children who received IM ketamine for PSA in the ED. A convenience sampling approach was used and a block randomization method was applied (blocks of four) using a computer-generated random sequence. Patients received ketamine 4 mg/kg or ketamine 4 mg/kg plus ondansetron 0.1 mg/kg intramuscularly. All findings including the occurrence of vomiting and its frequency were then recorded in the data collection sheets.ResultsOf 56 patients who received ondansetron plus ketamin, 7 (12.5%) and 1 (1.8%) experienced vomiting during recovery and before discharge and Of 65 patients in the control group, 14 (21.5%) and 6 (9.2%) experienced vomiting during recovery and before discharge, respectively. The observed differences in the rates of vomiting during recovery and at discharge were statistically significant between the two groups (P-value of 0.03 and <0.001, respectively).ConclusionIntramuscular ondansetron is effective in controlling ketamine-associated vomiting.     

Non-white noise in fMRI: Does modelling have an impact?

The sources of non-white noise in Blood Oxygenation Level Dependent (BOLD) functional magnetic resonance imaging (fMRI) are many. Familiar sources include low-frequency drift due to hardware imperfections, oscillatory noise due to respiration and cardiac pulsation and residual movement artefacts not accounted for by rigid body registration. These contributions give rise to temporal autocorrelation in the residuals of the fMRI signal and invalidate the statistical analysis as the errors are no longer independent. The low-frequency drift is often removed by high-pass filtering, and other effects are typically modelled as an autoregressive (AR) process. In this paper, we propose an alternative approach: Nuisance Variable Regression (NVR). By inclusion of confounding effects in a general linear model (GLM), we first confirm that the spatial distribution of the various fMRI noise sources is similar to what has already been described in the literature. Subsequently, we demonstrate, using diagnostic statistics, that removal of these contributions reduces first and higher order autocorrelation as well as non-normality in the residuals, thereby improving the validity of the drawn inferences. In addition, we also compare the performance of the NVR method to the whitening approach implemented in SPM2.     

Do sleep disorders have an impact on blood pressure?

In this article, the relationship, perhaps interdependence, between sleep-disordered breathing, hypertension, and obesity is discussed. There is strong evidence that sleep-disordered breathing and hypertension are related. On the one hand, the prevalence of hypertension increases with the number of apnea-hypopnea episodes per hour of sleep, whereas on the other hand, treating sleep-disordered breathing reduces hypertension. It has also been shown that this relationship between sleep-disordered breathing and hypertension is stronger in individuals with a high body mass index. Thus, it is concluded that in individuals presenting with hypertension, sleep-disordered breathing, or increased weight, the two other variables must be investigated and treated if present.     

Is self-massage an effective joint range-of-motion strategy? A pilot study

Increases in joint range of motion may be beneficial in both improving performance and reducing the risk of injury. The purpose of this study was to investigate short-term changes in passive hip flexion (HF) and extension (HE) after foam rolling (FR) and roller massage (RM) durations of 60 and 120s. Ten recreationally active men (27.6 ± 2.4 years old; 164.8 ± 6.6 cm; 62.2 ± 8.0 kg; 24.2 ± 2.1 m²/kg) were recruited for this study. Subjects performed foam rolling (FR) and roller massage (RM) on the hamstrings for 60 (FR60 and RM60) and 120 (FR120 and RM120) seconds. Significant differences between FR120 and RM60 were observed in both HF (p < 0.001) and HE (p < 0.001) suggesting an intervention (roller style) effect. Furthermore, significant differences (p < 0.001) between RM60 and RM120 suggest a dosage based response. Thus, the findings indicate that different roller type or rolling volume may affect range-of-motion.     

Does myeloma genetic have an effect on stem cell mobilization?

BackgroundAutologous stem cell transplantation (ASCT) after induction treatment is the standard of care. Our understanding of myeloma genetics has been very limited and its effect to stem cell mobilization is not widely investigated. We aimed to investigate the effect of genetic abnormalities on stem cell mobilization in myeloma.MethodsThe data of 150 MM patients who underwent stem cell mobilization at our center between 2009–2020 were included and analyzed retrospectively. Pre-treatment bone marrow cytogenetics and fluorescence in situ hybridization tests were performed for each patient.ResultsGroups were divided into two as patients with normal cytogenetic and abnormal cytogenetic. No difference observed between groups regarding age, gender and ECOG (p = 0.4; p = 0.2; p = 0.3). Groups were similar concerning myeloma characteristics, received treatment and treatment response. Median CD34+ cells/kg harvested was 444(2−11.29) in normal cytogenetic group whereas it was 4,8(2.4−8.6) in abnormal cytogenetic group(p = 0.2). Optimal CD34+ cells level achievement was 73 (67 %) in normal cytogenetic group while it was 25(71.4 %) in abnormal cytogenetic group(p = 0.6). Neutrophil and platelet engraftment durations were similar among cytogenetic groups (p = 0.7; p = 0.9). R-ISS based groups were also did not differ regarding harvested CD34+ cells and achievement optimal CD34 level (p = 0.79, p = 0.74). Engraftment durations for neutrophil and platelet were comparable between R-ISS based groups (p = 0.59, p = 0.65)ConclusionsHere we were not able to find any impact of genetic abnormalities on stem cell mobilization in myeloma patients. Expanded studies can aid to identify the effect of particular genetic anomalies on the stem cell mobilization.     

Does electrical stimulation reduce spasticity after stroke? A randomized controlled study

OBJECTIVE: To investigate the therapeutic effect of electrical stimulation on plantarflexor spasticity in stroke patients. DESIGN: A randomized controlled clinical trial study. SETTING: Rehabilitation clinic of Semnan University of Medical Sciences. SUBJECTS: Forty stroke patients (aged from 42 to 65 years) with ankle plantarflexor spasticity. INTERVENTION: Fifteen minutes of inhibitory Bobath techniques were applied to one experimental group and a combination of 9 minutes of electrical stimulation on the dorsiflexor muscles and inhibitory Bobath techniques was applied to another group for 20 sessions daily. MAIN MEASURES: Passive ankle joint dorsiflexion range of motion, dorsiflexion strength test, plantarflexor muscle tone by Modified Ashworth Scale and soleus muscle H-reflex. RESULTS: The mean change of passive ankle joint dorsiflexion in the combination therapy group was 11.4 (SD 4.79) degrees versus 6.1 (SD 3.09) degrees, which was significantly higher (P = 0.001). The mean change of plantarflexor muscle tonicity measured by the Modified Ashworth Scale in the combination therapy group was -1.6 (SD 0.5) versus -1.1 (SD 0.31) in the Bobath group (P = 0.001). Dorsiflexor muscle strength was also increased significantly (P = 0.04) in the combination therapy group (0.7 +/- 0.37) compared with the Bobath group (0.4 +/- 0.23). However, no significant change in the amplitude of H-reflex was found between combination therapy (-0.41 +/- 0.29) and Bobath (-0.3 +/- 0.28) groups. CONCLUSION: Therapy combining Bobath inhibitory technique and electrical stimulation may help to reduce spasticity effectively in stroke patients.     

Does an aerobic endurance programme have an influence on information processing in migraineurs?

Background

Migraine is a disorder of central information processing which is characterized by a reduced habituation of event-related potentials. There might be positive effects of aerobic exercise on brain function and pain. The aim of this study was to investigate the influence of exercise on information processing and clinical course of migraine.

Methods

33 patients completed a ten-week aerobic exercise programme. To examine the influence of the treatment on information processing and attention, Trail Making Test (TMT) A and B, d2-Letter Cancellation Test (LCT) and recordings of the Contingent Negative Variation (CNV) were performed before and after the training.

Results

Patients showed a significant reduction of the migraine attack frequency, the iCNV-amplitude and the processing time for TMT-A and TMT-B after treatment. Moreover, there was a significant increase of the habituation and positive changes in parameters of attention (d2-LCT) after the training.

Conclusions

This study demonstrates that aerobic exercise programme influences central information processing and leads to clinical effects on the migraine symptomatology. The results can be interpreted in terms of an improvement of a dysfunctional information processing and a stimulus selection under aerobic exercise.