Assessing patient category/dependence systems for determining the nurse/patient ratio in ICU and HDU: a review of approaches

BACKGROUND: A huge range of patient classification systems/tools are used in critical care units to inform workforce planning, however, they are not always applied appropriately. Many of these systems/tools were not originally developed for the purposes of workforce planning and so their use in determining the nurse:patient ratio required in critical care settings raises a number of issues for the organisation and management of these services. AIM: The aim of this paper is to review the three main assessment systems that are commonly used in critical care settings in the UK and evaluate their effectiveness in accurately determining nurse : patient ratios. If the application of these systems/tools is to enhance care, a thorough understanding of their origins and purpose is necessary. If this is lacking, then decisions relating to workload planning, particularly when calculating nurse : patient ratios, may be flawed. CONCLUSIONS: Patient dependency/classification systems and patient dependency scoring systems for severity of illness are robust measures for predicting morbidity and mortality. However, they are not accurate if used to calculate nurse : patient ratios because they are not designed to measure nursing input. Nursing intensity measures provide a useful framework for calculating the cost of providing a nursing service in critical care and can serve as a measure of nursing input, albeit a fairly basic one. However, many components of the nursing role are not "accounted" for in these measures. IMPLICATIONS: The implications of these findings for the organization and management of critical care services are discussed. Careful consideration of these areas is vital if a cost efficient and cost-effective critical care service is to be delivered.     

Herbal weight-loss supplement misadventures per a regional poison center

BACKGROUND: Many herbal supplements used for weight loss contain stimulants. The poison control center has noted an increase in reports of adverse events with intentional and unintentional ingestion of herbal weight-loss supplements. OBJECTIVE: To identify characteristics of the callers (eg, demographic properties, underlying type of ingestion) and, from this information, determine populations at increased risk for adverse events secondary to intentional and unintentional herbal weight-loss supplement ingestion. METHODS: Demographic information such as patient weight, age, gender, and medical history was recorded from ingestions reported to the Central Ohio Poison Control Center (COPC) in 2000. Ingredients, concurrent medications, ingestion and treatment site, clinical presentation, and therapies received were documented. Type of ingestion, acuity, clinical presentation, and treatment site were used to identify patients at increased risk of adverse events secondary to herbal supplement ingestion. RESULTS: Eighty calls were recorded in 2000 (49 females involved). Underlying reasons for ingestion differed between males and females (p = 0.025). Twenty-five percent of the intentional ingestions and 51% of the unintentional ingestions occurred in males. Reported symptoms differed with the underlying reason for ingestion (p < or = 0.001) and were more common in intentional ingestions (80%). Symptoms were reported more often with unknown or higher-than-recommended doses (78%); however, 70% (n = 10) of subjects ingesting the recommended dose reported at least one symptom (p = 0.15). CONCLUSIONS: Intentional and unintentional ingestions of herbal supplements for weight loss vary with age and gender. The significant presence of symptoms in nonabusers requires more study to assess overall safety and potential toxicity of agents such as Stacker 2. Patients who abuse or misuse herbal weight-loss supplements are generally women, who may seek medical treatment more often.     

Osteoporosis: point-of-care testing

OBJECTIVE: To review the literature concerning the utility of point-of-care (POC) testing devices for the diagnosis and management of osteoporosis. DATA SOURCES: Articles were identified from a MEDLINE search (1993-June 2003). Additional references were obtained from cross-referencing the bibliographies of selected articles. STUDY SELECTION AND DATA EXTRACTION: After evaluation of clinical trials and select review articles, articles comparing peripheral dual-energy absorptiometry (pDXA) or quantitative ultrasound (QUS) with central DXA (cDXA) measurements were emphasized in this analysis. DATA SYNTHESIS: Sensitivity for detecting osteoporosis by QUS or pDXA varies widely (range 35-75%). Using adjusted T-score cutoffs increases sensitivity to 85-95%, at the price of reducing device specificity to 23-49%. Many states require a radiology technician to perform pDXA tests. CONCLUSIONS: POC testing with peripheral devices should only be considered in areas with limited access to cDXA or for women who initially refuse cDXA testing. T scores of-1.0 or less with POC testing typically require further evaluation via cDXA. Many states require pDXAs to be performed by certified radiology technologists, making QUS use more feasible for pharmacists. POC testing should not be used for assessing response to osteoporosis therapy.     

Hydroxychloroquine cardiotoxicity in systemic lupus erythematosus: a report of 2 cases and review of the literature

BACKGROUND: Hydroxychloroquine (HCQ) is extensively used in the long-term treatment of systemic lupus erythematosus (SLE). Although considered by clinicians to be relatively safe, serious side effects have been documented in the literature. Retinotoxicity has received the most attention, whereas neuromyotoxicity and cardiotoxicity have been described in isolated case reports. We present 2 cases of potential cardiotoxicity occurring in patients with SLE while receiving long-term HCQ therapy. OBJECTIVE: To review the incidence, presentation, and mechanism of serious antimalarial toxicity, and to discuss the impact of HCQ on cardiac health in SLE. METHODS: The authors reviewed the English-language literature from 1948 to December 2002 using Medline databases. RESULTS: In addition to our patients, there are 2 published cases of biopsy-proven HCQ cardiotoxicity in the English-language literature. Both occurred in patients with SLE. The literature indicates that antimalarial cardiotoxicity may be of particular importance in patients with SLE given their already increased cardiac risk due to primary heart disease and accelerated atherosclerosis. Endomyocardial biopsy reveals a constellation of findings including vacuolar myopathy, myeloid bodies, and curvilinear bodies. CONCLUSIONS: As HCQ use among SLE patients increases, clinicians should be alert to the possibility of antimalarial cardiotoxicity. The potential severity and reversibility of this complication underscore the importance of timely diagnosis. The cases presented here, one with biopsy and one without, illustrate the utility of endomyocardial biopsy in HCQ-treated SLE patients with cardiac complaints to ensure accurate diagnosis and appropriate management.     

Imaging drug delivery and drug responses in the lung

Conventional two-dimensional and three-dimensional single photon emission computed tomography and positron emission tomography imaging tools and specific inhaled radiotracers allow accurate and reliable measurements of drug delivery to the lung. Pharmacokinetics and patterns of drug distribution can be monitored over time. In addition, physiologic measurements of ventilation, perfusion, mucociliary clearance, inflammation, and respiratory absorption can be determined using imaging; the results correlate with "black-box" outcomes (for example, spirometry, airway responsiveness, and inflammatory markers in sputum, and bronchoalveolar lavage fluid), providing an indication of the disease state in situ and the effectiveness of therapeutic and other interventions on these critical lung functions. Imaging is widely used in drug discovery. Screening of new drugs using animal models and specifically molecular imaging before human studies is an approach used extensively by the pharmaceutical industry. Topical drug delivery to the lung remains the route of choice for administering respiratory therapies; recently, inhaled therapies have been formulated to gain access to the systemic circulation via the distal lung. Imaging provides a means of validating drug delivery to the site of action in the lung and of measuring the resulting pharmacokinetics of these therapies. No other tool or test provides this type of visual detail supported by numerical information related to a specific drug molecule.     

Predictors of bacterial vaginosis in adolescent women who douche

OBJECTIVE: Risk factors for bacterial vaginosis (BV) include douching and sexual activity, although the exact cause of BV is unknown. GOAL: The goal of this study was to determine the relative significance of douching as a risk factor for BV. STUDY DESIGN: Two hundred fifty adolescent women who regularly douched were enrolled into a randomized douching intervention trial. Behavioral questionnaires and testing for sexually transmitted diseases and BV were performed. Associations between baseline characteristics and behaviors were compared for teens who were BV-positive and BV-negative at baseline. RESULTS: Positive correlates of BV included multiple partners, recent sexual intercourse, douching after menses, recent douching, and gonorrhea. Of these, douching after menses showed the strongest association (odds ratio, 5.11; 95% confidence interval, 1.99-13.15) in a multivariate analysis. CONCLUSIONS: Douching after menses was strongly correlated with BV; however, difficulty remains in trying to evaluate douching and sexual behavior independently.     

Panic attacks and psychoticism

OBJECTIVE: The authors sought to determine the association between panic attacks and psychoticism among young adults in the community. METHOD: Data were drawn from a 21-year longitudinal birth cohort study (N=1,265). Negative binomial regression models were used to determine the association between panic attacks in adolescence (age 15-21) and psychoticism during young adulthood. RESULTS: Having a panic attack in the preceding 3 years was associated with elevated rates of psychoticism at ages 18 (rate ratio=2.81, 95% CI=1.92-4.13) and 21 (rate ratio=3.01, 95% CI=2.10-4.33). These associations were adjusted for differences in previous psychoticism, comorbid anxiety, depression, and substance use disorders and a range of other potential confounding factors by using a generalized estimating equation model. This analysis showed that after adjustment for confounding factors, having a panic attack was still associated with an increased rate of psychoticism (rate ratio=1.51, 95% CI=1.14-2.02). CONCLUSIONS: Panic attacks during adolescence are associated with significantly increased levels of psychoticism among young adults in the community compared with young persons with no history of panic attacks. Much of the relationship between panic attacks and psychoticism appears to be explained by common risk factors and psychiatric comorbidity, yet these data provide evidence of an independent association between panic attacks in adolescence and psychoticism during young adulthood in the community. Replication of these findings is needed, as are future studies that further investigate the mechanism of this association.