Assessing clinical handover between paramedics and the trauma team

Introduction

The aim of effective clinical handover is seamless transfer of information between care providers. Handover between paramedics and the trauma team provides challenges in ensuring that information loss does not occur. Handover is often time-pressured and paramedics’ clinical notes are often delayed in reaching the trauma team. Documentation by trauma team members must be accurate. This study evaluated information loss and discordance as patients were transferred from the scene of an incident to the Trauma Centre.

Methods

Twenty-five trauma patients presenting by ambulance to a tertiary Emergency and Trauma Centre were randomly selected. Audiotaped (pre-hospital) and videotaped (in-hospital) handover was compared with written documentation.

Results

In the pre-hospital setting 171/228 (75%) of data items handed over by paramedics to the trauma team were documented and in the in-hospital handover 335/498 (67%) of information was documented. Information least likely to be documented by trauma team members (1) in the pre-hospital setting related to treatment provided and (2) in the in-hospital setting related to signs and symptoms. While 79% of information was subsequently documented by paramedics, 9% (n = 59) of information was not documented either by trauma team members or paramedics and constitutes information loss. Information handed over was not congruent with documentation on seven occasions. Discrepancies included a patient's allergy status and sites of injury (n = 2). Demographic details were most likely to be documented but not handed over by paramedics.

Conclusion

By documenting where deficits in handover occur we can identify points of vulnerability and strategies to capture this information.     

Outcome of Patients with a Positive Sentinel Lymph Node who do not Undergo Completion Lymphadenectomy

Background  

Completion lymph node dissection (CLND), although considered a standard approach for patients with melanoma and a positive sentinel lymph node (SLN), is not performed in as many as 50% of indicated cases. This study evaluates the outcome of patients who had a positive SLN but did not undergo CLND at Memorial Sloan-Kettering Cancer Center.     

An ex vivo biomechanical evaluation of a hydroxyapatite cement for use with kyphoplasty.

BACKGROUND AND PURPOSE: Previous ex vivo biomechanical studies have shown that kyphoplasty with polymethylmethacrylate cement increases vertebral body (VB) strength and restores VB stiffness and height after compression fracture. The purpose of the current study was to determine if a hydroxyapatite cement used as a void filler during kyphoplasty provides mechanical stabilization similar to that of a polymethylmethacrylate cement. METHODS: Simulated compression fractures were experimentally created in 33 osteoporotic VBs harvested from female cadaver spines. VBs were assigned to one of three groups: 1) kyphoplasty with a custom mixture of Simplex P; 2) kyphoplasty with BoneSource; and 3) no treatment. The kyphoplasty treatment consisted of inserting a balloon-like device into the VB via both pedicles, inflating the tamp, and filling the created void with Simplex P bone cement or BoneSource. VBs in the no-treatment group received no interventions. Pre- and posttreatment heights were measured, and the repaired VBs were recompressed to determine posttreatment strength and stiffness values. RESULTS: Kyphoplasty with altered Simplex P restored strength, whereas kyphoplasty with BoneSource and the no-treatment protocol both resulted in significantly weaker VBs relative to initial strength. All treatments resulted in significantly less stiff VBs relative to their initial condition. All VBs lost significant height after initial compression, but a significant amount of lost height was restored by kyphoplasty with either cement. CONCLUSION: Kyphoplasty with either cement significantly restored VB height. Kyphoplasty with altered Simplex P resulted in stronger repairs than did no treatment or kyphoplasty with BoneSource.     

Issues and challenges in staging of pressure ulcers.

Wound assessment is a key element of effective wound care, and assessment of pressure ulcers includes accurate determination of wound stage. Although the original staging system established by Shea was based on his understanding of the pathology involved in pressure ulcer development, subsequent staging systems (and the one currently in use) were intended simply to establish the level of tissue damage. Recently, clinicians have drawn attention to numerous limitations associated with the current staging system, including the inability to differentiate between an inflammatory response involving intact skin and a deep tissue injury (deep bruising) underneath intact skin. This is a clinically significant difference because clinicians have noted that most inflammatory responses resolve with intervention, whereas most areas of deep tissue injury progress to full-thickness ulcers even when appropriate intervention is provided. A second area of controversy involves partial-thickness (Stage 2) lesions; because many of these lesions are caused by maceration and/or friction (as opposed to pressure) clinicians are frequently unclear regarding which of these lesions should be staged. In response to these concerns, the National Pressure Ulcer Advisory Panel convened a consensus forum and published white papers to clearly outline the issues; they solicited clinician feedback on the white papers and the Wound, Ostomy, Continence Nurses Society provided a written response. This article summarizes the key points of the white papers, WOCN Society response, and consensus forum discussion.     

Tomographic assessment of therapeutic response to uveitic macular oedema

PURPOSE: To evaluate the therapeutic effects on the different morphological patterns of uveitic macular oedema and central macular thickness using optical coherence tomography (OCT). METHODS: Retrospective observational case series. Fifty consecutive patients with a clinical diagnosis of new or recurrent macular oedema due to uveitis were examined with serial OCTs for 1 year. The correlation between different patterns of macular oedema (diffuse macular oedema, inner cystoid oedema, outer cystoid oedema, oedema involving both inner and outer layers of retina and serous retinal detachment) and change in logMAR visual acuity and the recorded variables including age, gender, systemic disease associated with uveitis, location and duration of uveitis, and duration of macular oedema were examined. Response to treatment was measured as change in logMAR visual acuity and evolution of patterns of macular oedema. RESULTS: Diffuse macular oedema, external cystoid and serous retinal detachment responded well to treatment. Cysts in the inner retinal layers were more resistant to treatment. The cysts in the outer layers disappeared faster than cysts in the inner layers in patients with cysts in both layers at baseline. Multivariate analysis showed that cystoid macular oedema (all types) (P = 0.03) and inner cystoid oedema (P = 0.031) were the variables significantly associated with final visual acuity. CONCLUSION: Assessment of patterns of uveitic macular oedema by OCT gives useful information on the prognosis. Inner retinal cystoid oedema is more resistant to treatment than any other patterns of oedema.     

Activation of SRC kinases signals induction of posterior capsule opacification

PURPOSE: Posterior capsule opacification (PCO) is a complication of cataract surgery resulting from the proliferation, migration, and epithelial-to-mesenchymal transition (EMT) of lens epithelial cells that remain associated with the lens capsule. These changes cause a loss of vision. The authors developed a chick embryo lens capsular bag model to study mechanisms involved in the onset of PCO. Because Src family kinases (SFKs) signal cell proliferation, migration, and EMT, the authors examined whether the inhibition of SFKs can prevent PCO. METHODS: After mock cataract surgery, chick lens capsular bags were pinned to a culture dish and grown in the presence or absence of the SFK inhibitor PP1. Cell movement was followed by photomicroscopy. Progression of proliferation and EMT in the PCO cultures was determined by Western blot analysis and immunofluorescence staining. RESULTS: As occurs in PCO, lens cells in this model proliferated, migrated across the posterior capsule, and expressed EMT markers, alpha-smooth muscle actin (alpha-SMA), and fibronectin (FN). Lens cells treated with PP1 maintained an epithelial phenotype, accumulated cadherin junctions, and did not migrate to the posterior capsule, increase proliferation, or express EMT markers. Therefore, exposure to PP1 prevented PCO. Short-term inhibition of SFKs was sufficient to prevent EMT, but longer inhibition was necessary to prevent lens cell migration. CONCLUSIONS: Progression of PCO involved early activation of SFKs. Lens cell migration preceded EMT, and each of these two events required activation of an SFK signaling pathway. Suppression of SFK activation blocked PCO, suggesting SFKs as a therapeutic target for the prevention of PCO.     

Mechanism of anti-inflammatory activity of umbelliferone 6-carboxylic acid isolated from Angelica decursiva

Aims of the study

We recently reported the potential antioxidant and anti-inflammatory activities of umbelliferone 6-carboxylic acid (UMC) isolated from the whole plants of Angelica decursiva. In this study, we elucidated the anti-inflammatory mechanisms of UMC in vitro and in vivo.

Methods

The inhibitory effects of UMC on the production of nitric oxide (NO), prostaglandin E₂ (PGE₂), and tumor necrosis factor-α (TNF-α), the expression of nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2), the activation of nuclear factor kappa B (NF-κB) were evaluated using lipopolysaccharide (LPS)-stimulated RAW 264.7 cells. The reactive oxygen species (ROS) generation inhibitory activity of UMC was evaluated using t-butyl hydroperoxide (t-BHP)-induced RAW 264.7 cells. Furthermore, the in vivo anti-inflammatory activity of UMC was evaluated using carrageenan induced mouse paw edema model.

Results

UMC dose-dependently inhibited NO and PGE₂ production by down-regulating iNOS and COX-2 protein expression in LPS-stimulated RAW 264.7 macrophages. UMC also suppressed the production of the proinflammatory cytokine TNF-α in LPS stimulated RAW 264.7 cells in a concentration dependent manner. In addition, UMC dose-dependently prevented LPS-induced nuclear translocation of NF-κB in RAW 264.7 macrophages. Furthermore, UMC exhibited the inhibitory activity against t-BHP-induced ROS generation in RAW 264.7 cells with an IC₅₀ value of 705.1 μg/ml. Moreover, UMC inhibited λ-carrageenan induced mouse paw edema by 70.40 and 60.20% at doses of 50 and 25 mg/kg body weight, respectively.

Conclusion

The combined results of this study indicate that UMC is an important anti-inflammatory constituent of A. decursiva and its anti-inflammatory effect was due to its ability to inhibit the production of inflammatory mediators via inhibition of NF-κB activation pathway.     

Long-term use of cochlear implant systems in paediatric recipients and factors contributing to non-use

The aim of the present paper was to assess children's long-term use of their cochlear implant systems and to explore factors influencing the extent of daily use. The parents of 138 deaf children who had been implanted for seven years completed an annual questionnaire about the extent of their child's use of their implant system. The results revealed that seven years after implantation 115 children (83%) were wearing their implants full-time, 16 (12%) most of the time, three (2%) some of the time and four (3%) were non-users. The children were categorised into those who were full-time users (group F) and those who were not full-time users (group N). The mean age at implantation in group F was 4.4 years with a median of four whereas in group N the mean age at implantation was 5.8 years with a median of 5.5 years. This difference was highly statistically significant. There were no children who were total non-users implanted below the age of five. The predominant mode of communication was oral in group F and signed communication in group N and the difference was also statistically significant. In group F, 90 (78%) were in mainstream education, either mainstream school or a resource base in a mainstream school, whereas the respective percentage in group N was 57 per cent and this difference was statistically significant. Further investigation of those in group N shows a fluctuating pattern of use over the years prior to becoming complete non-users seven years after implantation. The four children who were complete non-users at seven years after implantation were all implanted at five and had other difficulties with all having complex family issues, three having significant other learning difficulties and one experiencing pain on stimulation. None had experienced device failure. In conclusion, this study of 138 children showed very high levels of full-time use seven years after implantation. Factors linked with full-time use seven years after implantation were early implantation, oral mode of communication and mainstream educational placement. Additional difficulties were not significant. Psycho-social issues such as family and educational support appeared to be important in facilitating continued use of the implant system. Non-use may occur after several years of use and in this group non-use followed a fluctuating pattern of use over time. The regular monitoring of device use may enable cochlear implant teams to be alert to potential non-users and to provide appropriate and timely support to the child, family and educational service.