Electroencephalogram for prognosis after cardiac arrest

Background

In assessing neurologic prognosis after cardiac arrest (CA), electroencephalogram (EEG) reactivity has not been specifically included with EEG classifications. Most studies have divided recordings into benign and malignant; however, some patterns within these groups may have greater prognostic significance than such broad classifications. We sought to explore reactivity, with broad classifications and subclassifications for their prognostic significance.

Methods

All consecutive adults in coma who had an EEG recording performed at least 1 day after CA or during normothermia after a 24-hour mild hypothermia protocol. Outcomes were dichotomous: recovery of awareness or no recovery of awareness during hospitalization.

Results

Twenty-nine patients met the inclusion criteria. Of the 18 patients with no reactivity, only 1 recovered awareness; of the 11 patients who demonstrated reactivity, 10 recovered awareness (sensitivity of 90% [95% confidence interval, or CI, 0.57-1] and specificity of 94% [95% CI, 0.7-1]). Of those with benign patterns, 7 recovered awareness and 1 did not; however, those patients demonstrating malignant patterns, 4 recovered and 17 did not (sensitivity of 94% [95% CI, 0.7-1] and a specificity of 63% [95% CI, 0.32-0.88]). None of the 15 patients with suppression or generalized spikes recovered consciousness, and none of these patients demonstrated reactivity.

Conclusions

Electroencephalogram reactivity after CA is a relatively favorable EEG feature; generalized suppression or generalized epileptiform activity, without reactivity, is associated with lack of recovery of awareness.     

A randomized controlled trial to assess the impact of an Admission Service on patient and staff satisfaction

Norton‐Westwood D, Robertson‐Malt S, Anderson R. International Journal of Nursing Practice 2010; 16 : 461–471
A randomized controlled trial to assess the impact of an Admission Service on patient and staff satisfaction This study aims to assess the benefits of an Admission Service (AS) wherein the nurse, when fluent in the language spoken by the patient (Arabic), improves the accuracy and efficiency of acquiring key assessment data needed to guide nursing care. Patients' satisfaction with their hospital experience begins formulating from their time of admission. Dissatisfaction is frequently reported in areas requiring careful, skilled communication such as obtaining emotional support and family participation and education. Over a 3‐month study recruitment, 314 patients were randomly assigned to be admitted either through the AS (n = 150) or to the unit via the standard admission process (n = 164). The AS improved the efficiency of admission time by > 150%. The nurse's assessment of their quality of admission was also improved: 76 vs. 26 nurses rated their quality of admission as ‘very good’ when assisted by the AS compared with standard admission to the unit.     

The effect of within-session instruction on lumbopelvic motion during a lower limb movement in people with and people without low back pain

The purpose of the current study was to examine how effectively people with and people without low back pain (LBP) modify lumbopelvic motion during a limb movement test. Nineteen subjects with LBP and 20 subjects without LBP participated. Kinematic data were collected while subjects performed active hip lateral rotation (HLR) in prone. Subjects completed trials (1) using their natural method (Natural condition) of performing HLR, and (2) following standardized instructions to modify lumbopelvic motion while performing HLR (Modified condition). Variables of interest included (1) the amount of HLR completed prior to the start of lumbopelvic motion, and (2) the maximum amount of lumbopelvic motion demonstrated during HLR. Compared to the Natural Condition, all subjects improved their performance during the Modified condition by (1) completing a greater amount of HLR prior to the start of lumbopelvic motion, and (2) demonstrating less lumbopelvic motion (P < 0.01 for all comparisons). There was a tendency for people without LBP to demonstrate a greater difference in maximal lumbopelvic rotation between the Natural and Modified conditions (P = 0.07). In conclusion, people are able to modify lumbopelvic motion following instruction. Further study is needed to determine if people without LBP improve lumbopelvic motion following instruction to a greater extent than people with LBP.     

The impact of the use of the isolated echogenic intracardiac focus as a screen for Down syndrome in women under the age of 35 years.

OBJECTIVE: The purpose of this study was to determine the public health impact of the routine offering of amniocentesis to women under the age of 35 years who have an isolated fetal echogenic intracardiac focus on second trimester ultrasound scan. STUDY DESIGN: A decision analytic model was designed that compared the accepted standard of second trimester triple marker screen for Down syndrome to a policy in which amniocentesis with an isolated echogenic intracardiac focus on ultrasound in addition to the triple marker screen is offered to all women in the United States who are <35 years of age. A sensitivity of 20%, an echogenic intracardiac focus screen positive rate of 5%, and a risk of Down syndrome of 1:1000 were assumed. A sensitivity analysis was performed that varied the screen positive rate, the sensitivity of echogenic intracardiac focus for Down syndrome, and the prescreen risk for Down syndrome in the population. RESULTS: With the baseline sensitivities, rates, and risks, the use of isolated echogenic intracardiac focus as a screen would result in an additional 118,146 amniocenteses performed annually to diagnose 244 fetuses with Down syndrome. These amniocenteses would result in 582 additional miscarriages. It would be necessary to perform 485 amniocenteses that would result in 2.4 procedure-related losses for each additional Down syndrome fetus that was identified. CONCLUSION: Although the echogenic intracardiac focus appears to be associated with a small increased risk of Down syndrome, its use as a screening tool in low-risk populations would lead to a large number of amniocenteses and miscarriages to identify a small number of Down syndrome fetuses.     

An assessment of clinical guidelines for the management of acute pancreatitis.

BACKGROUND: Recent guidelines have been issued for the management of acute pancreatitis. The aim of this study was to audit the management of acute pancreatitis in one district general hospital, to determine the problems and benefits associated with the implementation of such guidelines. METHODS: Data were collected over the period 1991-1995 for all patients diagnosed as having acute pancreatitis who were admitted to one district general hospital. Data regarding severity grading, determination of aetiology and treatment of mild and severe pancreatitis were analysed in conjunction with the recommendations issued by the British Society of Gastroenterology Working Party on the management of acute pancreatitis in 1995. RESULTS: A total of 210 patients were admitted on 263 occasions; 16% of cases were severe but severity prediction was inaccurate. 56.1% had gallstone pancreatitis and 20.9% had idiopathic pancreatitis. Definitive treatment of gallstones was within the recommended time limit in only 70.1%. 27 patients experienced recurrent attacks of pancreatitis before definitive treatment of their gallstones, due either to inadequate investigation for gallstones after suboptimal ultrasound examination (n = 12) or to inappropriate delay before definitive treatment of gallstones (n = 15). Recommendations for the management of severe cases with early ITU/HDU admissions and CT scanning were not followed. 28 day mortality was 6.3%, median age of those dying was 80.5 years. CONCLUSIONS: Acceptable mortality can be achieved for acute pancreatitis despite failure to implement BSG guidelines for the management of severe acute pancreatitis. Inadequate investigation and treatment of gallstone disease leads to an unacceptable incidence of recurrent acute pancreatitis.     

Methodology of biofeedback for adults with fecal incontinence: a program of care.

In a previous article we described a nursing assessment for adults with fecal incontinence. This article outlines in detail the program of care, tailored to an individual's assessed needs, that is available in the nurse-led biofeedback service for fecal incontinence at St Mark's Hospital in England. A recent evaluation of this program found that two thirds of patients reported improved fecal continence after receiving care from this service.     

A comparison of oral fluid collection devices for use in the surveillance of virus diseases in children

Three oral fluid collection devices (OraSure, Omni-SAL and Oracol) were compared in terms of the quality of oral fluid collected by each device for antibody testing and their acceptability to participants. Participants (143 children aged 3.5-5 y from North Hertfordshire, UK, who had recently received DTaP and MMR vaccination) were randomised to use one of the three types of collection device. Oral fluid was collected by a parent who completed a short questionaire recording information on ease of use and willingness to use the device again. A matching serum sample was collected by a nurse. Oral fluid samples were screened for total IgG and IgM by ELISA and for rubella specific IgG and parvovirus specific IgG by radioimmunoassay. Serum samples were screened for rubella specific IgG and parvovirus B19 specific IgG by ELISA. 87.4% (125) of participants provided a matching oral fluid and serum sample. Of these, 100% (125) and 10.4% (13) had serum IgG specific for rubella and parvovirus B19, respectively. The Oracol device provided oral fluid samples with the highest geometric mean titres of total IgG and IgM and with rubella specific IgG results which correlated most closely with those of matching sera. A higher proportion of parents found the Oracol and OraSure devices easier to use than the Omni-SAL (P<0.001) and the proportion who would not take another test was higher for the Omni-SAL than for the Oracol or Orasure. Oral fluid samples collected by each of the devices gave qualitative results acceptable for surveillance and epidemiological studies of rubella and parvovirus B19. The highest quality oral fluid sample for antibody testing in terms of total IgG and IgM concentration and rubella specific IgG concentration was collected by the Oracol. The acceptability to participants of both the Oracol and OraSure was high. As the cheapest device available, the Oracol is the preferred oral fluid collection device for studies involving children in the UK.     

Modulation of glycosaminoglycan levels in tree shrew sclera during lens-induced myopia development and recovery

PURPOSE: In juvenile tree shrews, positioning a negative-power lens in front of an eye produces a hyperopic shift in refractive state and causes a compensatory increase in axial length over several days so that the eye is myopic when the lens is removed. During negative lens compensation, the scleral extracellular matrix is remodeled. A biomechanical property of the sclera, creep rate, increases; during recovery from induced myopia, the creep rate decreases below normal levels. Changes in glycosaminoglycan (GAG) levels, including those of hyaluronan, may participate in these changes in creep rate and, in turn, participate in controlling the axial length and refractive state. This study investigated the unsulfated and sulfated GAG composition of the sclera during compensation for a -5 diopter (D) lens and during recovery. METHODS: Capillary electrophoresis was used to assess the relative levels (ng/mg dry scleral weight) of unsulfated GAGs (hyaluronan [HA] and chondroitin [C0S]), sulfated GAGs (chondroitin-4-sulfate [C4S], chondroitin-6-sulfate [C6S], and dermatan sulfate [DS]) in the sclera of groups of tree shrews (n = 5 per group) that wore a monocular -5 D lens for 1, 2, 4, or 11 days or had 11 days of -5 D lens wear followed by 1, 2, or 4 days of recovery from lens wear. The fellow eye served as an untreated control. Groups of normal and plano lens-treated animals provided age-matched values. RESULTS: Expressed as a fraction of dry weight, levels of HA were lower after 1, 4, and 11 days of -5 D lens wear. Levels of C0S, C6S, and C4S were significantly lower after 4 and 11 days of lens wear. After 1 and 2 days of recovery, GAG levels in the treated eyes were not significantly different from those in control eyes. After 4 recovery days, HA levels were lower, but the levels of all other GAGs were not different in the recovering and control eyes. Some binocular changes also occurred. CONCLUSIONS: The rapid differential decrease in HA levels during negative lens compensation and the absence of any difference after just 1 day of recovery suggest that HA levels may play a previously unrecognized early role in regulating the biomechanical property (creep rate) of the sclera. The reduced levels of the other GAGs, which occur when creep rate is at its peak elevation, and their rapid return to normal after 1 day of recovery suggest that they may also participate in regulating this biomechanical property of the sclera.