Monitoring universal precautions: a new assessment tool.

OBJECTIVES: Two pilot studies were conducted to produce efficacy data on an observational tool designed to assess the use of Universal Precautions (UP) in patient care settings. The instrument addresses barrier precautions, hand-washing, handling of sharps, and avoidance of unprotected mouth to mouth resuscitation. DESIGN: The Universal Precautions Assessment Tool was submitted to a panel of 3 experts to establish consensual validity. It was pilot tested by 2 simultaneous observers to establish interrater reliability. SETTING: Pilot Study I was conducted in 3 different units within a 100-bed U.S. Army hospital. Pilot Study II was conducted in the emergency department of a large university-based hospital. PARTICIPANTS: Subjects observed were registered nurses providing acute patient care. RESULTS: Two simultaneous raters calculated UP compliance rates of 76.4% and 78.6%, respectively, for 9 nurses in Pilot Study I, and 62% and 65%, respectively, for 5 nurses in Pilot Study II. The intraclass correlation coefficient for the raters' scores in Pilot Study I was 0.992 with a 95% confidence interval (0.979, 0.997). Consensual validity was established. CONCLUSIONS: The instrument has acceptable interrater reliability under the conditions used. Limitations to use include the possibility of a Hawthorne effect and the fact that assessing proper implementation of UP occasionally relies on a "judgment call" by the observer. With test conditions adjusted to minimize these limitations and with proper consideration of sample size, the tool can be used by researchers and by monitors of hospital quality control to measure UP compliance of caregivers individually or collectively.     

The heart and doping

Doping is becoming an everyday problem in sports medicine. Its main feature is its universality: it concerns all sports, even the most unexpected, from cycling to billiards; all countries are affected with certain continental preferences with regards to the substances used; it is seen in all levels of competition, both in amateurs and professionals. Doping is observed early on, even in childhood. Many substances are used and they are increasingly available: all bodily functions are targeted: cerebral, metabolic, cardiovascular, respiratory, haematological and, in the near future, genetic. Detection of doping is difficult and unpredictable in a legislative environment which is gradually improving. The different modes of action of the doping substances often target the cardiovascular system, especially with regards to their potential complications: hypertension, arrhythmias, thrombosis, coronary artery and peripheral artery diseases and also cardiomyopathies. Every cardiologist should therefore be aware of the problem, even outside the context of sport, as it may impact on daily cardiological practice.     

Progress in clinical neurosciences: Canadian guidelines for the development of antidementia therapies: a conceptual summary

The magnitude of the problems faced by an aging Canadian society has been clearly identified. Perhaps the single most important problem is the increasing incidence of dementia. Alzheimer's disease (AD) accounts for 50-60% of the dementias in later life within a spectrum of other contributing dementias. Regulatory approval has been given to Acetylcholinesterase inhibitors for the symptomatic treatment of mild to moderate AD, and conditional approval to memantine for the symptoms of moderate to severe AD. There has been no regulatory approval for the treatment of the degenerative dementias beyond AD. The very rapid progress in the past decade in biotechnology and in the molecular biology of the dementias is supporting a new generation of innovative treatment strategies that will more directly target the underlying disease pathogenic mechanisms. Such treatments will foreseeably include immunotherapies, anti-aggregants that may prevent misfolding and deposition of proteins, and neuroregenerative interventions. These Guidelines follow the 2nd Canadian Conference on the Development of Antidementia Therapies, held in 2004, which covered a range of design, methodological and ethical issues facing clinical researchers and regulatory authorities. They are intended to provide a common point of reference and guidance in Canada for therapeutic development of the dementias.     

Reduced bile flow associated with parenteral nutrition is independent of oxidant load and parenteral multivitamins

BACKGROUND: Reduction in bile flow is a characteristic of cholestasis related to parenteral nutrition. Light exposure of parenteral multivitamin preparations is the major source of peroxides contaminating parenteral nutrition solutions. They may contribute to local oxidative stress. Oxidants are reported to affect transport mechanisms across the hepatocyte membrane into bile. The authors hypothesize that an oxidant-antioxidant imbalance is involved in parenteral nutrition related cholestasis. The aim of this study was to investigate the roles of multivitamin preparations and peroxides on bile flow in newborn guinea pigs receiving parenteral nutrition. METHODS: Three-day-old guinea pigs were fed enterally or parenterally with solutions containing 8% dextrose/0.45% NaCl +/- multivitamin preparation +/- amino acids +/- lipids. The influence of the oxidant-antioxidant balance on bile flow was evaluated using 500 microM hydrogen peroxide and 1% and 3% multivitamin preparations +/- Na metabisulfite. Four days later, animals were anesthetized and bile flow was recorded over 2 hours. Glutathione determinations were performed on bile and liver samples. The percentage of oxidized glutathione, reflecting the redox status, was used as a marker of oxidative stress. Data were compared by analysis of variance with P < 0.05. RESULTS: Bile flow decreased first on initiating dextrose + NaCl infusion (a 25% decrease) and subsequently by adding amino acids (a further 30% decrease). Although antioxidant vitamins and peroxides modified the hepatic redox status, they did not influence bile flow. CONCLUSION: Although the composition of parenteral nutrition affects bile flow and the hepatic redox status, the oxidant-antioxidant imbalance in infused solutions is not the causal event in the installation of cholestasis.     

Coaching in Northern Canadian Communities: Reflections of Elite Coaches

This study addressed geographical uniqueness in relation to elite coaching. The study explores the complexities associated to coaching in northern Canadian communities, and how unique geographical surroundings can affect coaching success. The views of fourteen National and International elite coaches from different northern Canadian communities are included within the study. The respondents were from 9 different sport backgrounds and averaged 17.1 years of coaching experience (range: 8-30 years). Data were gathered using a structured open-ended questionnaire, a focus group, and a follow-up in-depth semi-structured interview. Content was analyzed to uncover emergent themes. Based on the respondents’ views, there is indication that despite numerous adversities, rural coaches experience advantages that are unavailable in larger urban centers. Precisely, there is evidence that northern Canadian coaches acquire unique skills while responding to the demands placed on them within their unique communities. Generalizations in regards to coaching development strategies across physical locations are questioned following the findings of the current study.

Key Points

• The study explores the complexities associated with coaching in northern Canadian communities and how unique geographical surroundings can affect coaching success.
• From the respondents’ views, there is indication that northern Canadian elite coaches are subject to numerous adversities.
• Despite numerous adversities, northern Canadian elite coaches experience advantages that are unavailable in larger urban centers.
• Including context specificity within the elite coaching literature could help to better understand this profession.

Key words: Coaching, contextual factors, geography, adversities, advantages     

Cervical ripening with transcervical foley catheter and the risk of uterine rupture

OBJECTIVE: To estimate whether the rate of uterine rupture in patients with a previous cesarean delivery is related to labor induction and/or cervical ripening using transcervical Foley catheter. METHODS: Charts of all patients who had a trial of labor after a previous cesarean delivery in our institution between 1988 and 2002 were reviewed. The rates of successful vaginal birth after cesarean delivery and uterine rupture in patients with spontaneous labor (control group) were compared with those of patients who underwent a labor induction by means of amniotomy with or without oxytocin and patients who underwent a labor induction/cervical ripening using a transcervical Foley catheter. Logistic regression analysis was performed to adjust for confounding variables. RESULTS: Of 2479 patients, 1807 had a spontaneous labor, 417 had labor induced by amniotomy with or without oxytocin, and 255 had labor induced by using transcervical Foley catheter. The rate of successful vaginal birth after cesarean delivery was significantly different among the groups (78.0% versus 77.9% versus 55.7%, P <.001), but not the rate of uterine rupture (1.1% versus 1.2% versus 1.6%, P =.81). After adjusting for confounding variables, the odds ratio (OR) for successful vaginal birth after cesarean delivery was 0.68 (95% confidence interval [CI] 0.41, 1.15), and the OR for uterine rupture was 0.47 (95% CI 0.06, 3.59) in patients who underwent an induction of labor using a transcervical Foley catheter when compared with patients with spontaneous labor. CONCLUSION: Labor induction using a transcervical Foley catheter was not associated with an increased risk of uterine rupture.     

Trial of labor in patients with a previous cesarean section: does maternal age influence the outcome?

OBJECTIVE: This study was undertaken to evaluate the effect of maternal age on the rate of vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior cesarean delivery. STUDY DESIGN: A cohort study of all women with a live singleton fetus undergoing a TOL after a previous low-transverse cesarean delivery was performed between 1988 and 2002 in a tertiary care center. Patients were divided into 3 groups according to maternal age: less than 30 years old, 30 to 34 years old, and 35 years or older. Women with no prior vaginal delivery and with at least 1 prior vaginal delivery were analyzed separately. The rate of vaginal delivery and the rate of symptomatic uterine rupture were calculated. Multivariate logistic regression analyses were performed to adjust for potential confounding variables. RESULTS: Of the 2493 patients who met the study criteria, there were 1750 women without a prior vaginal delivery (659, 721, and 370, respectively) and 743 women with a prior vaginal delivery (199, 327, and 217, respectively). The rate of uterine rupture was comparable between the groups (2.0%, 1.1%, 1.4%, P=.404 and 0%, 0.3%, 0.9%, P=.312). Successful vaginal delivery was inversely related to maternal age (71.9%, 70.7%, 65.1%, P=.063, and 91.5%, 91.1%, 82.9%, P=.005). After adjusting for confounding variables, maternal age equal to or greater than 35 years old was associated with a lower rate of successful vaginal delivery in patients without prior vaginal delivery (odds ratio [OR] 0.73, 95% CI: 0.56-0.94), and in patients with a prior vaginal delivery (OR: 0.47, 95% CI: 0.29-0.74). CONCLUSION: Patients who are 35 years or older are more prone to have a failed TOL after a prior cesarean delivery.     

Brain areas engaged during visual judgments by involuntary access to novel semantic information

Theories of visual recognition place different emphasis on the role of non-stimulus factors. Previously, we showed that arbitrary semantic associations influenced visual recognition of novel objects. Here, the neural substrate of this effect was investigated. During a visual task, novel objects associated with arbitrary semantic features produced more activation in frontal and parietal cortex than objects associated with names. Because the task required no semantic retrieval, access to semantics appears to be involuntary. The brain regions involved have been implicated in semantic processing, thus recently acquired semantics activate a similar network to semantics learned over a lifetime.     

Cardiac disease in children with primary glomerular disorders—role of focal segmental glomerulosclerosis

Anecdotal reports suggest a higher frequency of serious cardiac complications, particularly cardiomyopathy and congestive heart failure (CHF), in children with focal segmental glomerulosclerosis (FSGS). We report the occurrence of cardiac disease in children with FSGS compared with other glomerular causes of primary nephrotic syndrome (NS). A chart review was performed on all patients evaluated at the Schneider Childrens Hospital between 1985 and 2003 with a diagnosis of membranoproliferative glomerulonephritis (MPGN), membranous nephropathy (MN), focal global glomerulosclerosis (FGGS), and FSGS. Clinical and demographic data were compiled, specifically whether or not the patient had clinically evident cardiac disease. The blood pressure (BP) and hematocrit in patients with FSGS and chronic renal failure (CRF) (glomerular filtration rate <30 ml/min per 1.73 m²) in the 3 months prior to the development of cardiac complications were compared with the values in FSGS patients with CRF but no cardiac complications, and in patients with the other causes of primary NS in whom CRF developed. There were 48 patients with FSGS, 22 with MPGN, 19 with MN, and 4 with FGGS. Cardiac disease occurred in 6 children (mean age 11 years), all with FSGS. Four of these patients were black and 5 were female. CHF occurred in all patients, cardiomyopathy in 4, and left ventricular hypertrophy in 5 patients. There was no significant difference in the BP and the hematocrit levels between the 6 patients with both FSGS and cardiac disease, 3 patients with FSGS and CRF but no cardiac disease, and the 5 patients with the other glomerulopathies in whom CRF occurred (P>0.1). Our findings suggest that there is a clinical association between FSGS and cardiac disease in pediatric patients. We speculate that the immune mechanism responsible for the development of FSGS may also affect the heart.