Implementation of therapeutic hypothermia guidelines for post-cardiac arrest syndrome at a glacial pace: seeking guidance from the knowledge translation literature

The 2005 International Liaison Committee on Resuscitation (ILCOR) Consensus on Science and Treatment Recommendations document represents the most extensive and rigorous systematic review of the resuscitation literature to date and included evidence-based recommendations for post-resuscitation care. A new recommendation for the induction of mild therapeutic hypothermia for comatose cardiac arrest survivors was included in this document. Accordingly, constituent national member associations of ILCOR, including the American Heart Association, incorporated the recommendation for therapeutic hypothermia into their respective guidelines. Despite these endorsements there is a concern that therapeutic hypothermia is not being used in practice. Data from a number of surveys in Europe and the United States suggest that rates of use among physicians may be as low as 30-40%. Despite the cost and effort associated with the production of these guidelines and the potential impact on patient care, current efforts in implementing the guideline have not achieved widespread success. This commentary explores the issue of underutilization of the American Heart Association guidelines for therapeutic hypothermia and looks to the knowledge translation literature to inform a new approach to implementation. We will review the underlying phenomenon of research implementation into practice, specific barriers to guideline implementation and interventions that may improve therapeutic hypothermia uptake.     

Quality improvement opportunities in blood banking and transfusion medicine

With the advent of blood banks and subsequent advances in collection and preservation of blood, the transfusion of blood allowed the performance of blood-losing surgery and the support of rigorous cancer treatments, as well as the support of patients who have hematologic illnesses. As the life-saving functions of transfusion were realized, so were the associated hazards inherent in this most widely performed type of tissue transplantation. This article reviews the quality initiatives that have been used to make blood transfusion safer and offers suggestions for further quality improvements.     

Ocular distribution, bactericidal activity and settling characteristics of TobraDex® ST ophthalmic suspension compared with TobraDex® ophthalmic suspension

Introduction

TobraDex® ophthalmic suspension (tobramycin 0.3%, dexamethasone 0.1%; Alcon Laboratories Inc, Fort Worth, Tex) is frequently used for inflammatory ocular conditions where a risk of bacterial ocular infection exists. A new formulation, TobraDex® ST ophthalmic suspension (tobramycin 0.3%, dexamethasone 0.05%, Alcon), utilises a novel suspension technology to reduce viscosity and help prevent settling in the container.

Methods

A rabbit model that closely mimics the human eye and a clinical study with cataract patients was used to compare the pharmacokinetics and tissue permeability of TobraDex ST and TobraDex. An in-vitro model was used to assess the bactericidal activity using the rabbit tear concentrations of tobramycin 10 minutes after a single topical dose.

Results

Concentrations of both tobramycin and dexamethasone were greater in the tear film and ocular tissues of rabbits treated with TobraDex ST. There was an 8.3-fold increase in tobramycin concentration in the rabbit tear film 10 minutes after dosing with TobraDex ST compared with TobraDex. Concentrations of tobramycin and dexamethasone in ocular tissues from rabbits exposed to TobraDex ST were up to 12.5-fold greater relative to TobraDex. The in-vitro bactericidal activity (>99.9% kill, 3-log reduction) of TobraDex ST toward tobramycin-resistant and methicillin-resistant Staphylococcus aureus occurred in 90 minutes. TobraDex ST killed Streptococcus pneumoniae 3-log in 5 minutes. TobraDex had no activity toward tobramycin-resistant, methicillin-resistant S. aureus and required approximately 120 minutes for 3-log reduction of S. pneumoniae. In humans, the mean ratio of dexamethasone levels in the aqueous humour at 1 hour was 1.17 in favour of TobraDex ST.

Conclusion

TobraDex ST demonstrated improved suspension formulation characteristics, enhanced pharmacokinetic distribution and improved bactericidal characteristics, and may provide a useful alternative as compared to TobraDex.     

Evaluation and management of joint pain

The purpose of this article was to provide a review for orthopaedic nurses and nurse practitioners who evaluate, manage, and care for patients with joint pain. Joint pain is a common complaint evaluated by primary care providers. The causation of joint pain is complicated to identify because of an extensive range of differential diagnosis. The history and physical examination are crucial components in evaluating and managing joint pain. The primary care provider uses clinical factors such as patient demographics, presence of inflammation, acute/chronic duration, extra-articular manifestations, pattern of joint involvement, and disease chronology. Many rheumatologic laboratory tests are nonspecific, but aspiration of the joint with synovial fluid analysis may provide diagnostic clues, especially to differentiate infection versus inflammation. Primary care providers utilize both pharmacologic and nonpharmacologic regimens to manage acute and chronic joint pain.     

Brain dopamine response in human opioid addiction

BACKGROUND: Drugs of dependence cause dopamine release in the rat striatum. Human neuroimaging studies have shown an increase in dopamine in the equivalent region in response to stimulants and other drugs. AIMS: We tested whether opioids provoke dopamine release and its relationship to the subjective experience. METHOD: In two combined studies 14 heroin addicts on methadone maintenance treatment underwent two positron emission tomography brain scans of the dopamine system using [(11)C]-raclopride following an injection of placebo and either 50 mg intravenous diamorphine or 10 mg subcutaneous hydromorphone in a double-blind, random order design. RESULTS: Both opioids produced marked subjective and physiological effects, but no measurable change in [(11)C]-raclopride binding. CONCLUSIONS: The absence of a dopamine response to opioid agonists contrasts with that found with stimulant drugs and suggests dopamine may not play the same role in addiction to opioids. This questions the role of dopamine in the subjective experience of heroin in opioid addicts.     

Use of the venous flap for salvage of difficult ring avulsion injuries

Ring avulsion can lead to soft tissue compromise resulting in eventual digit failure or restriction of motion. The authors present use of the venous flow through flap for simultaneous soft tissue and digital vessel reconstruction in severe ring avulsion injury. A retrospective review of ring avulsion injuries treated with transplantation of an arterialized (A-V-A) venous flap between 1999 and 2006 was conducted. Indications included digits which were debrided and required soft tissue and digital artery reconstruction. Eight venous flaps were transplanted for 3 Urbaniak class II and 5 Urbaniak class III ring avulsions. Average size of the venous flap was 6 cm(2). All flaps and digits survived without partial necrosis. The soft tissue envelope was supple in all cases. Total active motion (TAM) ranged from 160 to 210 degrees. The arterialized venous flow-through flap is a reliable solution for the complex ring avulsion injury which requires simultaneous soft tissue and digital vessel reconstruction.     

Lithium toxicity from an internet dietary supplement

Introduction

The widespread availability of medications and herbal products on the Internet has increased the potential for poisonings. We are reporting a case of mild, acute lithium toxicity occurring after the intentional misuse of a lithium-containing “dietary supplement” (Find Serenity Now®) obtained over the Internet.

Case Report

An 18-year-old woman presented to our emergency department (ED) after ingesting 18 tablets of Find Serenity Now®; each tablet contained, according to the listing, 120 mg of lithium orotate [3.83 mg of elemental lithium per 100 mg of (organic) lithium orotate compared to 18.8 mg of elemental lithium per 100 mg of (inorganic) lithium carbonate]. The patient complained of nausea and reported one episode of emesis. Her examination revealed normal vital signs. The only finding was a mild tremor without rigidity. Almost 90 minutes after the ingestion, her serum lithium level was 0.31 mEq/L, a urine drug screen was negative, and an electrocardiogram (ECG) showed a normal sinus rhythm. The patient received intravenous fluids and an anti-emetic; one hour later, her repeat serum lithium level was 0.40 mEq/L. After 3 hours of observation, nausea and tremor were resolved, and she was subsequently transferred to a psychiatric hospital for further care. Prior human and animal data have shown similar pharmacokinetics and shared clinical effects of these lithium salts.

Discussion

Over-the-Internet dietary supplements may contain ingredients capable of causing toxicity in overdose. Chronic lithium toxicity from ingestion of this product is also of theoretical concern.