Cultural considerations at end of life in a geriatric inpatient rehabilitation setting

Aim

To explore the impact of cultural factors on the provision of end-of-life care in a geriatric inpatient rehabilitation setting.

End-of-life care for older people in subacute care: A retrospective clinical audit

Background

With an ageing population and chronic illness the leading cause of death, challenges exist in meeting the healthcare needs of older people. For older people, care may be provided in subacute care services where, although the focus is on rehabilitation and optimisation of functioning, many older people will die.

Attitudes of midwives and maternal child health nurses towards suicide: A cross‐sectional study

Perinatal women are at risk of depression and/or suicidality. Suicide is the highest cause of indirect maternal deaths in the perinatal period. Midwives and maternal child health nurses (MCHN), as key clinicians, need to be able to detect these mental health issues. Little is known about these clinicians' attitudes to suicide. In this paper, we report on the results of a cross‐sectional study of midwives' and MCHN attitudes to suicide. A convenience sample of midwives (n = 95) and MCHN (n = 86) from south–eastern Victoria, Australia, was recruited into the study. Participants completed the Attitudes to Suicide Prevention Scale. The results showed that MCHN have more positive attitudes towards suicide prevention than midwives, and younger participants have more positive attitudes to suicide prevention compared to older participants. Midwives and MCHN could benefit from continuing professional education to build their knowledge and skills in assessing suicide risk for childbearing women and their families, increasing positive attitudes, improving detection, and mental health referrals.     

Neuropsychological outcomes of traumatic brain injury and substance abuse in a New Zealand prison population

Fifty subjects with a history of traumatic brain injury TBI and or substance use, completed neuro psychological measures of short and long term verbal and visual memory, information processing, motor speed and co ordination, executive functioning, and malingering. All subjects performed below norms on tests of verbal memory and verbal abstract thinking, but overall no differences were found due to either severity of TBI or level of substance use. Maori subjects obtained the lowest scores on tests of verbal ability, but also reported higher rates of TBI and substance use, which is presumed to account for this result. In conclusion, prison populations seem to have disproportionately high rates of TBI, recurrent TBI, and substance use, compared to the general population. Further, there are a group of individuals who have experienced both TBI and substance abuse, with associated impairments in verbal memory and learning, abstract thinking, and who report problems with general memory and socialization. These difficulties may affect functioning both in prison and following release.     

Relation between viral fitness and immune escape within the hepatitis C virus protease

BACKGROUND: The hepatitis C virus (HCV) mutates within human leucocyte antigen (HLA) class I restricted immunodominant epitopes of the non-structural (NS) 3/4A protease to escape cytotoxic T lymphocyte (CTL) recognition and promote viral persistence. However, variability is not unlimited, and sometimes almost absent, and factors that restrict viral variability have not been defined experimentally. AIMS: We wished to explore whether the variability of the immunodominant CTL epitope at residues 1073-1081 of the NS3 protease was limited by viral fitness. PATIENTS: Venous blood was obtained from six patients (four HLA-A2+) with chronic HCV infection and from one HLA-A2+ patient with acute HCV infection. METHODS: NS3/4A genes were amplified from serum, cloned in a eukaryotic expression plasmid, sequenced, and expressed. CTL recognition of naturally occurring and artificially introduced escape mutations in HLA-A2-restricted NS3 epitopes were determined using CTLs from human blood and genetically immunised HLA-A2-transgenic mice. HCV replicons were used to test the effect of escape mutations on HCV protease activity and RNA replication. RESULTS: Sequence analysis of NS3/4A confirmed low genetic variability. The major viral species had functional proteases with 1073-1081 epitopes that were generally recognised by cross reactive human and murine HLA-A2 restricted CTLs. Introduction of mutations at five positions of the 1073-1081 epitope prevented CTL recognition but three of these reduced protease activity and RNA replication. CONCLUSIONS: Viral fitness can indeed limit the variability of HCV within immunological epitopes. This helps to explain why certain immunological escape variants never appear as a major viral species in infected humans.     

Assessing the impact of inadequate hydration on isotope-GFR measurement

Guidelines state that patients undergoing isotope glomerular filtration rate (GFR) tests should maintain adequate hydration, but pragmatically these tests can coincide with procedures requiring the patient not to eat or drink (‘nil-by-mouth’) for up to 12?hours beforehand. This study investigated the impact of a 12-hour nil-by-mouth regime on GFR measurement. Twelve healthy volunteers were recruited from our institution. Exclusion criteria included diabetes mellitus, being under 18?years of age and pregnancy. Isotope GFR measurements were carried out on these volunteers twice. One of the tests adhered strictly to the British Nuclear Medicine Society (BNMS) guidelines for GFR measurement and the other test was carried out after the volunteers had refrained from eating or drinking anything for 12?hours. The order of these tests was randomly assigned. The results show that after a nil-by-mouth regime, participants’ average absolute GFR fell from 108?ml/min to 97?ml/min (p?<?.01), while normalised GFR fell from 97?ml/min/1.73 m² to 88?ml/min/1.73m² (p?<?.01). Serum creatinine rose from 68?mmol/L to 73?mmol/L (p?<?.05). There were no changes in blood pressure, serum hydration markers or bio-impedance measured fluid status. Urine analysis showed statistically significant increases in urea, creatinine and osmolality levels after the nil-by-mouth regime. The results highlight the importance of following current guidelines recommending fluid intake during the procedure. Practitioners should consider what other outpatient appointments are being scheduled concurrently with a GFR test.     

Onsite training of doctors,midwives and nurses in obstetric emergencies,Zimbabwe

ProblemIn Zimbabwe, many health facilities are not able to manage serious obstetric complications. Staff most commonly identified inadequate training as the greatest barrier to preventing avoidable maternal deaths.ApproachWe established an onsite obstetric emergencies training programme for maternity staff in the Mpilo Central Hospital. We trained 12 local staff to become trainers and provided them with the equipment and resources needed for the course. The trainers held one-day courses for 299 staff at the hospital.

Local setting

Maternal mortality in Zimbabwe has increased from 555 to 960 per 100 000 pregnant women from 2006 to 2011 and 47% of the deaths are believed to be avoidable. Most obstetric emergencies trainings are held off-site, away from the clinical area, for a limited number of staff.

Relevant changes

Following an in-hospital train-the-trainers course, 90% (138/153) of maternity staff were trained locally within the first year, with 299 hospital staff trained to date. Local system changes included: the introduction of a labour ward board, emergency boxes, colour-coded early warning observation charts and a maternity dashboard. In this hospital, these changes have been associated with a 34% reduction in hospital maternal mortality from 67 maternal deaths per 9078 births (0.74%) in 2011 compared with 48 maternal deaths per 9884 births (0.49%) in 2014.

Lessons learnt

Introducing obstetric emergencies training and tools was feasible onsite, improved clinical practice, was sustained by local staff and associated with improved clinical outcomes. Further work to study the implementation and effect of this intervention at scale is required.