Preventing asthma exacerbations: what are the targets?

Exacerbations of asthma are the main cause of asthma morbidity. They induce acute respiratory failure, and sometimes death. Two immunological signals acting in synergy are necessary for inducing asthma exacerbations. The first, triggered by allergens and/or unknown agents leads to the chronic Th2 inflammation characteristic of asthma. The second, caused by either viral infection, allergens, pollutants or a combination of these, results in an acute Th1 and Th2 inflammation precipitating symptoms. In both, innate and adaptive immunities are involved, providing a series of potential targets for therapy. Molecules associated to the first, chronic inflammation constitute targets for preventing therapies, when these related to the second, acute signal provide the rationale for curative treatments. Toll like receptors and bronchial epithelial cell-derived cytokines, engaged upstream of inflammation constitute interesting candidates for future treatments. The great heterogeneity of asthma has to be taken into account when considering targets for therapy to identify clusters of responders and nonresponders, and an integrative system biology approach will be necessary to go further.     

Empiric therapy for febrile neutropenia: what are the choices?

The management of febrile neutropenia has evolved gradually over the years toward a risk-adapted strategy based on validated prediction rules by risk of complications. The drug choice for empiric therapy is influenced by several factors, either related to the patient or to the institution. Microbiological distribution of offending pathogens and their pattern of susceptibility to antibiotics are continuously changing. New mechanisms of resistance in both Gram-negative and -positive bacteria have emerged. Guidelines and general statements should always be considered with the local epidemiology.     

Animal models for trauma research: what are the options?

Even if trauma patients initially avoid death after trauma (due to massive blood volume loss, primary severe brain injury), they are still at risk for multiple organ failure. Thus, it is crucial to elucidate the underlying pathophysiological mechanisms of trauma/hemorrhagic shock and the immune response involved. As of now, many hemorrhagic shock/trauma studies have used various types of animal models. Despite a large number of results from these efforts, some authors have argued that animal model results are difficult to translate directly into the clinical scenario. This review summarizes the advantages and the disadvantages of using animal models in trauma/hemorrhagic shock studies and discusses the relevance of various animal studies to the clinical scenario.     

Empiric therapy for febrile neutropenia: what are the choices?

The management of febrile neutropenia has evolved gradually over the years toward a risk-adapted strategy based on validated prediction rules by risk of complications. The drug choice for empiric therapy is influenced by several factors, either related to the patient or to the institution. Microbiological distribution of offending pathogens and their pattern of susceptibility to antibiotics are continuously changing. New mechanisms of resistance in both Gram-negative and -positive bacteria have emerged. Guidelines and general statements should always be considered with the local epidemiology.     

Guidelines for severe infections: are they useful?

PURPOSE OF REVIEW: The large variability in clinical practice plus the increasing awareness that certain processes of care are associated with improved medical outcomes has led to the development of clinical practice guidelines in serious infection. The evolution of guidelines and their impact on delivery of care in severe infection is reviewed. RECENT FINDINGS: Guidelines development has centered around community- and hospital-acquired pneumonia as well as sepsis. The Institute of Healthcare Improvement has emerged as an international leader in changing healthcare professional behavior to be consistent with clinical recommendations in infection-related morbidity. These educational programs are designed to increase awareness of guidelines recommendations and to optimize their implementation. Change bundles are selected sets of interventions or processes distilled from evidence-based practice guidelines that are likely to improve outcome. As new evidence is published, and as experts ponder how the guidelines should best be expressed in the bundles, the bundles will be adapted to optimize their utility. SUMMARY: The change bundle approach to performance improvement (guidelines-based) is the key to change in practice. The Surviving Sepsis Campaign/Institute of Healthcare Improvement sepsis change bundles are an excellent example of progress along these lines.     

Plasma transfusion for patients with severe hemorrhage: what is the evidence?

The following review will detail the current knowledge in massive hemorrhage with regard to the pathophysiology of the coagulation disturbance, the role of plasma, the role of alternatives to plasma, and the clinical value of having a massive transfusion protocol. The coagulation disturbance in trauma patients is more than just the result of consumption of clotting factors at sites of injury and dilution from the infusion of intravenous fluids and red blood cells (RBCs). Even before substantial amounts of fluid resuscitation and RBC transfusion, one-quarter of trauma patients already have abnormal coagulation variables. There is an apparent role for the activation of protein C, hypofibrinogenemia, and fibrin(gen)olysis in the coagulation disturbance after trauma and massive hemorrhage. None of these three disturbances would be completely mitigated by the use of plasma alone, suggesting that there may be an opportunity to improve care of these patients with alternative strategies, such as fibrinogen concentrates and antifibrinolytics. Despite numerous retrospective cohort studies evaluating 1:1 plasma to RBC formula-driven resuscitation, the overall clinical value of this approach is unclear. Studies have even raised concerns regarding a potential increase in morbidity associated with this approach, particularly for patients overtriaged to 1:1 where a massive transfusion is unlikely. We also do not have sufficient evidence to recommend either goal-directed therapy with thromboelastography or early use of fibrinogen replacement, with either cryoprecipitate or fibrinogen concentrates. We have high-quality data that argue against the role for recombinant Factor VIIa that should prompt removal of this strategy from existing protocols. In contrast, we have high-level evidence that all bleeding trauma patients should receive tranexamic acid as soon as possible after injury. This therapy must be included in hemorrhage protocols. If we are to improve the care of massively bleeding patients on a firm scientific ground, we will need large-scale randomized trials to delineate the role of coagulation replacement and the utility of laboratory monitoring. But even until these trials are completed, it is clear that a massive transfusion protocol is needed in all hospitals that manage bleeding patients, to ensure a prompt and coordinated response to hemorrhage.     

Ventilating patients with acute severe asthma: what do we really know?

The goal of mechanical ventilation for patients with acute severe asthma is to ensure adequate oxygenation, ventilation, and gas exchange while simultaneously preventing hyperinflation, auto-positive end expiratory pressure, and subsequent barotrauma. Though existing evidence on the topic is relatively scarce, the application of current knowledge may guide our practice and prevent iatrogenic complications. To that end, this article describes selected ventilatory management strategies for the patient with acute severe asthma, such as the limitation of tidal volume size and respiratory rate, selection of specific inspiratory and expiratory ratios, the use of positive end expiratory pressure, and the application of helium-oxygen mixtures.     

Complementary therapies: what are the ethics challenges for Kansas nurses?

Nurses have an important role in CT/IM now and in the future. Their influence is great because they serve as the frontline in health care and are often the source of patient information. Since the trend of integrating CT/IM modalities into patient self-care appears to be here to stay, nurses need to understand what they are, how they are used, and what the contraindications might be. In addition, each nurse must decide his or her position on these modalities. This decision should be an educated decision that is in keeping with nursing philosophy and practice. There are several take away points about CT/IM from this article; it should be remembered that: 1. CT/IM is here to stay and can be a part of nursing practice now and in the future. 2. Patients use a variety of CT/IM modalities to augment treatment or to work toward quality of life. 3. It is important for nurses to be lifelong learners where CT/IM is concerned so that they can be a better advocate for patient's information and safety needs. 4. Opportunities exist for nurses to expand their practices to include CT/IM modalities. 5. Ethics-based nursing practice supports the need to maintain currency about CT/IM practices.     

Drug combinations for HIV: what’s new?

Since the advent of combined antiretroviral therapy there have been reductions in mortality and morbidity from HIV, transforming the disease into a chronic medical condition where newly diagnosed individuals can expect to live a near-normal life expectancy. When choosing therapy, probably the most important consideration is the risk of developing drug-related toxicity both in the short and long term, and new strategies to permit individualization of therapy will play a vital role in reducing this risk. The management of comorbidities including cardiovascular, renal, hepatic, bone and CNS disease, coinfections and malignancy are important considerations when choosing combined antiretroviral therapy, as is the cost of therapy. In individuals failing therapy, treatment switches will be guided by the presence of present and previously detected resistance mutations. This article will focus on the evidence for current therapies and strategies in ART-naive individuals and the potential for use of novel agents in the future.     

Evidence for teaching: what are faculty using?

The benefit of engaging in evidence-based teaching practice (EBTP) is to identify and implement best practices in nursing education. Unfortunately, nursing education has made little forward movement in identifying the evidence upon which faculty base their teaching practices. A national online survey of 295 nurse educators from 86 programs revealed the evidence they use in their teaching practices as well as the facilitators and barriers to EBTP. The majority of participants indicated they used quantitative and qualitative research (94 percent) but also considered written course evaluations, conference information, class feedback, and student comments as evidence. Participants identified personal beliefs as the most frequent facilitator to EBTP with 25 percent indicating their institution as a barrier. As EBTP offers a guide to establishing best practices in nursing education, building a science of nursing education is the responsibility of all nurse educators.     

CAM evaluation: what are the research questions?

Much effort is being directed towards the evaluation of CAM therapies. Yet evaluation is often encouraged before truly considering the research questions which need to be asked. Research questions like 'Does this CAM therapy work?' must be clearly distinguished from 'Does this particular CAM treatment work?' and the latter question needs to be replaced by even more specific ones like 'Does it work when administered by therapist X?' and 'Is therapist X effective?'. Suggestions for the study of the therapeutic process and the evaluation of therapist effectiveness are presented.     

Spirituality in nursing: what are the issues?

This article describes the author's attempt to highlight the problem areas associated with providing spiritual care for patients. The focus of this work is to discuss the following areas of interest: What is spirituality? The issue of spirituality in nursing. The impact of spirituality for the patient. The relevance or irrelevance of religion. The concept of serenity as a goal for nursing practice. The author provides examples, specifically regarding older people, explaining why spiritual care of patients is decidedly problematic in the British healthcare system and provides suggestions as to how to reintegrate this essential part of caregiving back into daily practice.     

Inpatient psychosomatic rehabilitation for Turkish migrants: what can be realized, what are the effects?

A sample of 184 Turkish migrants who had been treated in a department for psychosomatic rehabilitation, were included in a study using retrospective analysis of their clinical documents. Somatoform disorders and depressions predominated among the main diagnoses but somatic diseases and risk factors were frequent as well. Because of insufficient outpatient treatment, diagnostic procedures concerning somatic state often became necessary during the rehabilitation measure, uncovering previously unknown somatic diseases in 16% of the patients. The main focus of the psychotherapy offered to the migrants had been slightly more on unburdening from suffering, also it included more psycho-educational elements, but apart from this the quality and quantity of treatment hardly differed from a sample of German patients. Hence, though based on higher efforts and costs, the psychosomatic rehabilitation offered to the Turkish migrants had been implemented according to current standards. An important effect of inpatient rehabilitation seems to have been the working out of an overall therapeutic concept comprising all psychic and somatic problems. The very poor results in social-medical respects found in the study have with increasing experience been considerably improved in the meantime.