Beyond the debriefing debate: what should we be doing?

It is clear that it is very difficult to treat trauma-related stress after the fact. EMS and fire personnel must develop personal stress management strategies and have a personal-support system in place. Most stresses in EMS are the day-to-day hassles of the job. Occasionally, some of us will be involved in a disaster operation. As with the day-to-day stressors, the best way to manage disasters is through planning and preparation. As Lauren Simon Ostrow wrote, "In the end, EMS may want to re-examine the all-American notion that we should always feel good, that stress is bad and that we have to take corrective action to resolve every negative reaction to stress, even if it is normal."     

Endpoints of resuscitation: what should we be monitoring?

Major resuscitation goals in the management of shock include restoration of adequate tissue perfusion and oxygen balance and normalization of cellular metabolism. Identification of the most appropriate endpoints of resuscitation is difficult and often debated in the literature. Traditional endpoints, such as heart rate, blood pressure, mental status, and urine output are useful in the initial identification of inadequate perfusion, but are limited in their ability to identify ongoing, compensated shock. Many clinicians continue to use these parameters as indicators that systemic oxygenation imbalances have resolved, even though they have been found to be poor indicators of ongoing tissue hypoxia. Additional resuscitation endpoints that more closely evaluate the adequacy of perfusion and oxygenation at the tissue level should also be used when managing the critically ill. Selected endpoints should include a variety of global and regional indicators to guide and evaluate the effectiveness of treatment.     

Non-invasive brain stimulation for the lower limb after stroke: what do we know so far and what should we be doing next?

Background: Non-invasive brain stimulation (NIBS) is promising as an adjuvant to rehabilitation of motor function after stroke. Despite numerous studies and reviews for the upper limb, NIBS targeting the lower limb and gait recovery after stroke is a newly emerging field of research. Purpose: To summarize findings from studies using NIBS to target the lower limb in stroke survivors. Methods: This narrative review describes studies of repetitive transcranial magnetic stimulation, paired associative stimulation and transcranial direct current stimulation with survivors of stroke. Results: NIBS appears capable of inducing changes in cortical excitability and lower limb function, but stimulation parameters and study designs vary considerably making it difficult to determine effectiveness. Conclusions: Future research should systematically assess differences in response with different stimulation parameters, test measures for determining who would be most likely to benefit and assess effectiveness with large samples before NIBS can be considered for use in clinical practice.

• Implications for Rehabilitation

• Stroke is a leading cause of disability, often resulting in dependency in activities of daily living and reduced quality of life.

• Non-invasive brain stimulation has received considerable interest as a potential adjuvant to rehabilitation after stroke and this review summarizes studies targeting the lower limb and gait recovery.

• Non-invasive brain stimulation can be used to modulate excitability of lower limb muscle representations and can lead to improvements in motor performance in stroke survivors.

• Non-invasive brain stimulation for gait recovery needs further investigation before translation to clinical practice is possible.

     

The smacking controversy: what advice should we be giving parents?

Background. Even among countries that have ratified the United Nations Convention on the Rights of the Child there is much disagreement about corporal punishment of children. Last year the Scottish Executive proposed a new law banning the smacking of children under the age of three, becoming the tenth European nation to do so. The proposal, currently abandoned whilst ostensibly still under debate, has raised a wave of controversy in child protection circles. In the nearest neighbouring country, England, a similar proposal was robustly rejected. Purpose of the paper. Given an increasing family and community focus in nursing, the implications of the debate for the profession cannot be ignored. What should we be telling ‘ordinary’ families about smacking? Thus this paper presents a positional statement on the smacking controversy and outlines some pointers for practice. Discussion. While for many the legislation proposed does not go far enough, others decry it as a breach of parental rights and, thus, the issue has become hugely controversial. Media opinion and various opposing campaigns dominate both public and professional spheres. Rights, responsibilities, examples from other countries, culture and gender are all used as fodder in the debate. Extreme examples are cited by both sides and used as grist for what are at times tenuous arguments. As there is even a division within child protection arenas, practising professionals may struggle to find a way through the maze of seemingly contradictory findings from research, policy and opinion. Conclusions. A wide range of literature suggests that both public and professional opinion is divided on the use of smacking as a form of discipline of young children. Opinion is also divided on the ability of legislation to bring about change in social attitudes and behaviour. Health care professionals need to be in a position to recommend best practice and to do so consistently.     

Grade inflation: should we be concerned?

Grade inflation is defined as an increase in grade point average without an associated increase in overall student ability. The literature supports the idea that grade inflation is rampant throughout higher education. Shoemaker and DeVos described the scope of the problem in higher education in general and note the lack of existing empirical information in nursing education. Given the perceived problem in faculties of nursing, the widespread nature of the issue of grade inflation across universities and colleges, and the lack of empirical data, understanding the nature of grade inflation is important. This article will discuss a study designed to investigate the extent to which grade inflation is an issue within a western Canadian faculty of nursing. Recommendations related to grade inflation are discussed.     

Health care surveillance: what should be included?

Outpatient facilities now perform more than 50% of all surgical procedures--and that number continues to increase. Data on postoperative wound infections in the ambulatory surgery population "is going to be a real challenge to collect," according to William R. Jarvis, MD.     

Recent trials of antioxidant therapy: what should we be telling our patients?

The current evidence does not support the indiscriminate use of vitamins A, C, or E or beta carotene to prevent or reduce cardiovascular disease. Despite a plausible theory that antioxidants can prevent diseases caused by oxidative damage, trials thus far have not proven this. In fact, some studies found antioxidants may be harmful in some people. We review important studies of the effects of four antioxidants (vitamins A, C, and E, and beta carotene) and analyze whether the current evidence supports or confirms or rejects the presumed protective role.     

Tricuspid valve insufficiency: what should be done?

Tricuspid regurgitation is relatively common. Due to the progress made in echocardiography, its diagnosis is in general made readily and in reliable fashion. Basically one has to distinguish between functional tricuspid valve regurgitation due to volume and/or pressure overload of the right ventricle with intact valve structures versus tricuspid valve regurgitation due to pathologic valve structures. The clear identification of the regurgitation mechanism is of prime importance for the treatment. Functional tricuspid valve regurgitation can often be improved by medical treatment of heart failure, and eventually a tricuspid valve plasty can solve the problem. However, the presence of pathologic tricuspid valve structures makes in general more specific plastic surgical procedures and even prosthetic valve replacements necessary. A typical example for a structural tricuspid valve regurgitation is the case of a traumatic papillary muscle rupture. Due to the sudden onset, this pathology is not well tolerated and requires in general surgical reinsertion of the papillary muscle. In contrast, tricuspid valve regurgitation resulting from chronic pulmonary embolism with pulmonary artery hypertension, can be improved by pulmonary artery thrombendarteriectomy and even completely cured with an additional tricuspid annuloplasty. However, tricuspid regurgitations due to terminal heart failure are not be addressed with surgery directed to tricuspid valve repair or replacement. Heart transplantation, dynamic cardiomyoplasty or mechanical circulatory support should be evaluated instead.     

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.     

Hip dislocation in spina bifida: when is surgery required and what type of surgery should be performed?

Children with spina bifida develop a wide variety of congenital and acquired hip joint deformities. Among these are contractures, subluxation or dislocation. This paper will review both the overall orthopedic care of a spina bifida patient with hip problems and provide a focused review of surgery management of hip deformities. Special emphasis is placed on the indications and contraindications to surgery based on a literature review and the author's personal experience.     

Drug-eluting stents - what should be improved?

Despite the success of drug-eluting stents (DES) in reducing restenosis and the need for target vessel revascularization, several deficiencies have been unraveled since their first clinical application including the risk of stent thrombosis, undesired effects due to the stent polymer as well as the stent itself, and incomplete inhibition of restenosis (especially in complex lesions). Several novel stent systems are being investigated in order to address these issues. In second-generation DES, the rapamycin analogues zotarolimus and everolimus (and more recently biolimus) have been most extensively studied. Furthermore, special stent-coatings to actively promote endothelial healing (in order to reduce the risk of stent thrombosis) and to further reduce restenosis have been employed. To avoid undesirable effects of currently applied (durable) polymers, biocompatible and bioabsorbable polymers as well as DES delivery systems without the need for a polymer have been developed. Bioabsorbable stents, both polymeric and metallic, were developed to decrease potential late complications after stent implantation. Although most of these innovative novel principles intuitively seem appealing and demonstrate good results in initial clinical evaluations, long-term large-scale studies are necessary in order to reliably assess whether these novel systems are truly superior to first-generation DES with respect to safety and efficacy.     

Cervical cancer: what should we tell women about screening?

Cervical cancer is the second most common cancer among women worldwide, with significantly higher rates in developing areas, especially in Africa, the Caribbean, and Latin America (Parkin, Bray, Ferlay, & Pisani, 2005). In contrast, incidence and mortality rates of cervical cancer in the United States have declined significantly among women of all ethnic and racial groups; it is not among the top 10 leading causes of new cancer cases in women (American Cancer Society [ACS], 2006b; Edwards et al.,2005).     

Off-pump coronary artery bypass graft surgery: where should we stand?

Coronary artery bypass grafting (CABG) performed with cardiopulmonary bypass has become a well-established treatment modality for patients with coronary artery disease. However, there is increasing evidence that cardiopulmonary bypass may be responsible for some of the morbidity associated with CABG surgery. Thus, it has been proposed that CABG surgery would be safer if cardiopulmonary bypass could be avoided. The development of cardiac stabilization devices has allowed for the creation of safe and reproducible coronary anastomoses on the beating heart. Several large, non-randomized, retrospective case series have demonstrated that CABG surgery can be performed safely without cardiopulmonary bypass (off-pump) and have in fact suggested benefits when compared with conventional CABG. However, the randomized controlled studies published to date have, as a whole, been unable to conclusively demonstrate the advantages of off-pump surgery. Taken together, the evidence to date suggests that a large-scale, prospective, randomized trial may be required to resolve the dilemma.