The high impact actions for nursing and midwifery. 3: Staying safe, preventing falls

The National Patient Safety Agency reported 152,000 falls in England and Wales in acute hospitals in 2009, 26,000 in mental health trusts and 28,000 in community hospitals. The number of falls is due to rise in line with increasing numbers of older and frail people who have more complex health needs. Many of these falls are preventable; the challenge for the NHS is to improve patient safety while protecting independence patients' rights to make informed choices.

The high impact actions for nursing and midwifery 2: fit and well to care

Each year in the health service in England, 10.3 million working days are lost to sickness absence (Chartered Institute of Personnel and Development, 2009). This is the equivalent of 4.5% of the current workforce, or 45,000 whole time equivalent nurses. This article, the third in our series on the high impact a actions for nursing and midwifery, looks at how ward managers and team leaders can provide support and information to improve nurses' health and wellbeing.

The high impact actions for nursing and midwifery 1: keeping nourished--getting better

Approximately one in four patients in NIIS hospitals are either malnourished or at risk of malnurition and as much as 70% of malnutrition in acute hospital admission is unrecognised and unmanaged. Although most of those who are malnourished live in the community, malnutrition and dehydration are key challenges for NHS organisations. Well hydrated and nourished patients get better more quickly, have a shorter length of stay and a more positive experience of care. Ensuring patients receive all of the nutrients they need is vital to the delivery of good care. This article, the second in our series on the high impact actions for nursing and midwifery, looks at how nurses can reduce malnutrition in their patients.

How nurses can implement the high impact actions to improve quality and cost effectiveness

In November 2009 the NHS Institute for Innovation and Improvement published a list of eight high impact actions for nursing and midwifery and stated that, if implemented across the NHS, the actions could save over pounds 9 bn a year while improving the quality of care. The NHS Institute has now published a selection of case studies from different settings demonstrating successful initiatives relating to each action and a range of other supporting material. This article, the first in a Nursing Times series summarising the main information on how the high impact actions can be achieved, sets the context for the initiative. Subsequent articles will discuss the individual actions and offer practical information on implementation.

Is a Weekly Supervised Upper Limb Exercise Program of Value for Women with Early Breast Cancer?

The aim of this randomised single blinded study was to determine whether an upper limb exercise program, commencing 4-weeks after surgery for early breast cancer, prevents upper limb symptoms, such as pain, swelling, stiffness and weakness.Methods: 156 women, aged 52.5 ± 11.7 y, who had undergone either axillary node dissection (AND; n=94) or sentinel node biopsy (SNB; n=62) for unilateral breast cancer in combination with either mastectomy (n=74) or wide local excision (n=82) within the previous 4 weeks, participated. Women were randomised to either an 8-week exercise program (n=79) or to usual care (n=77); participants were stratified for type of axillary surgery (SNB or AND) and treatment site. The exercise program comprised a home program of daily passive stretching for shoulder muscles and resistance training using Thera-Band® on alternate days for muscles about the shoulder. Women also attended a weekly exercise session. Usual care included routine follow-up with their medical specialists, a breast nurse and a post-operative visit with the physiotherapist and occupational therapist who provided instructions about exercises. The primary outcome was self-reported arm and chest symptoms derived from the EORTC breast cancer specific questionnaire (BR23) which was scored out of 100 with a low score indicative of fewer symptoms. The secondary outcomes included physical measures of shoulder range of motion, strength, and swelling. Presence of lymphoedema (LE) was determined by the inter-limb impedance ratio, using bioimpedance spectroscopy.Results: After the 8-week intervention period, there was no significant difference between groups in either the self-reported or the physical measurements (Table 1).Table 1. Baseline and 8 weeks data (mean ± SD). Usual care group Exercise group  Baseline8 weeksBaseline8 weeksSelf-report symptoms (max 100)    Arm24.5 ± 14.514.6 ± 14.225.9 ± 18.512.5 ± 12.9Breast25.8 ± 16.219.2 ± 17.725.6 ± 19.217.1 ± 16.7Range of motion interlimb difference (deg)    Flexion19.8 ± 19.06.9 ± 7.023.9 ± 19.05.4 ± 7.3Abduction14.5 ± 14.04.7 ± 8.821.1 ± 18.43.8 ± 8.1Inter-limb strength difference (Newtons)    Flexion15.9 ± 21.55.6 ± 19.417.0 ± 21.84.0 ± 15.8Abduction20.0 ± 25.85.7 ± 19.725.2 ± 28.61.0 ± 19.3Swelling (n)    Prevalence of LE (by impedance)7/7714/745/789/74 Conclusion: A weekly, supervised, 8-week upper limb exercise program is not warranted for all women with early breast cancer treated with surgery to the axilla. Usual care in which women are seen post-operatively by a physiotherapist, occupational therapist, and breast nurse with ongoing monitoring by the specialists is sufficient for most women.Acknowledgement: Supported by NSW Cancer Council

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 811.

Post-Operative Resistance Training for Early Breast Cancer Survivors Is Not Associated with Increased Prevalence of Lymphedema

Introduction: Women treated for early breast cancer are routinely advised against lifting heavy objects on the affected side as it may precipitate lymphedema (LE). Women often therefore report that their arm feels weak. As part of a single-blinded randomised trial, we investigated whether an exercise program that included resistance training, commencing 4 weeks post-operatively, was associated with higher prevalence of LE.Methods: Women (mean age: 52.5 ± 11.7 y) who had undergone either axillary node dissection (AND; n=94) or sentinel node biopsy (SNB; n=62) in combination with mastectomy (n=74) or wide local excision (n=82) within the previous 4 weeks for unilateral early stage breast cancer were randomised to an exercise group (79) or usual care group (n=77). Women were stratified for axillary surgery (AND or SNB) and treatment site. The exercise group received a weekly supervised program that comprised resistance training and passive stretching for muscles about the shoulder. The muscles targeted for resistance training included the flexors, abductors, external rotators and horizontal flexors. Women completed two sets of 8 to 12 repetitions for each muscle group. For weekly supervised sessions, the resistance was provided by free weights; for the home program, women were provided with an appropriate grade of elastic Thera-Band®. Each week, the exercises were monitored, and progressed as required, aiming to achieve 'Hard' (15) on the 6 – 20 Borg Effort Scale. Presence of swelling was assessed by self-report, and by circumferential measurements at 10 cm-intervals, commencing at the ulnar styloid and by bioimpedance spectroscopy. Women in the usual care group received advice regarding active stretching.Results: Following an 8-week exercise program, women in the exercise group were not more likely to have LE or changes suggestive of LE. The results for women who had undergone AND are shown in Table 1; results are similar for women who underwent SNB. At baseline, more women in the exercise group had signs and symptoms indicative of LE but at 8 weeks, they had similar or fewer signs.Table 1. Prevalence of lymphoedema in women treated with AND Usual Care Exercise  Baseline (n=46)8 weeks (n=44)Baseline (n=48)8 weeks (n=46)SELF REPORTED    a) on exertion6 (13)4 (9)6 (12)4 (9)b) During ADL's2 (4)1 (2) 1 (2)c) Consistent, minor disability10 (22)3 (7)13 (26)7 (15)d) Consistent, major disability  4 (8)1 (2)ARM CIRCUMFERENCE (>2cm interlimb diff)    a) 1 measure >2 cm1 (2)5 (11)8 (16)3 (7)b) 2+ measures >2 cm2 (4)3 (7) 5 (11)BIOIMPEDANCE SPECTROSCOPY    a) Above interlimb ratio cut-off5 (11)11 (25)5 (106 (13)b) >10 % change from baseline to week 8 5 (11) 3 (7) Conclusion: An 8-week resistance training program for women at risk of LE did not result in greater numbers of women having measures associated with LE than those who did not participate in the training program. Weakness, following surgery for breast cancer, can commence early as 4 weeks post-operatively. Women will be re-assessed in 6 months to determine whether the low prevalence of LE in the exercise group is maintained.Acknowledgements: Cancer Council NSW for funding.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1057.

Comparative genomics-guided loop-mediated isothermal amplification for characterization of Pseudomonas syringae pv. phaseolicola

AIMS

To design and evaluate a loop-mediated isothermal amplification (LAMP) protocol by combining comparative genomics and bioinformatics for characterization of Pseudomonas syringae pv. phaseolicola (PSP), the causal agent of halo blight disease of bean (Phaseolus vulgaris L.).

METHODS AND RESULTS

Genomic sequences of Pseudomonas syringae pathovars, P. fluorescens and P. aeruginosa were analysed using multiple sequence alignment. A pathovar-specific region encoding pathogenicity-related secondary metabolites in the PSP genome was targeted for developing a LAMP assay. The final assay targeted a polyketide synthase gene, and readily differentiated PSP strains from other Pseudomonas syringae pathovars and other Pseudomonas species, as well as other plant pathogenic bacteria, e.g. species of Pectobacterium, Erwinia and Pantoea.

CONCLUSION

A LAMP assay has been developed for rapid and specific characterization and identification of PSP from other pathovars of P. syringae and other plant-associated bacteria.

SIGNIFICANCE AND IMPACT OF THE STUDY

This paper describes an approach combining a bioinformatic data mining strategy and comparative genomics with the LAMP technology for characterization and identification of a plant pathogenic bacterium. The LAMP assay could serve as a rapid protocol for microbial identification and detection with significant applications in agriculture and environmental sciences.

Perception and measurement of strength and range of movement in women following treatment for breast cancer

Abstract #1124

Introduction: About half the women who undergo breast cancer surgery report consequent shoulder problems. However, their perception of symptoms such as loss of movement and strength may not be reflected in physical measurements. The aim of this study was to compare the women's perception of symptoms with objective measurements of muscle strength and range of motion (ROM). Methods: One hundred thirty two women (mean age 53 years, SD 12) with early stage breast cancer participated in this study within 6 weeks of their surgery. Participants rated their perception of shoulder ROM and strength on a 5-point likert scale, with the anchors “no impairment” (0) to extreme (4). Shoulder abduction and forward flexion muscle strength were tested using a hand-held dynamometer and ROM with a digital inclinometer. Muscle weakness was defined as a deficit > 20% compared to the unaffected side in either movement. Limited ROM was categorized as > 20° deficit compared to the unaffected side. Results: Thirty two percent of women reported minor weakness, 17% reported moderated weakness, 4% reported major weakness, and no women reported extreme weakness. In addition, 36% reported a minor limited ROM, 32% reported moderate limited ROM, 11% reported major limited ROM, and no women reported extreme limited ROM. Fifty eight percent of women had > 20% muscle weakness and 15% of women had > 20° limited ROM in either shoulder flexion or abduction. There was a moderate relationship between participants' perception and objective measurements in range of motion (Spearman's rho = 0.55 and 0.57 for abduction and flexion, respectively) and a weak relationship for muscle strength (0.28 and 0.18). Interestingly, 28 women reported having no weakness on their affected side, although, strength measurements showed > 20% weakness compared to the unaffected side. Also, 20 women showed less than 20% strength difference between arms but reported having minor to major loss of muscle strength. Conclusion: The women's perception was weakly related to the objective measurements. Physical and psychological factors may contribute to the perception of symptoms. Acknowledgement: Supported by NSW Cancer Council.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1124.

Effect of airplane travel on women treated for breast cancer

Abstract #1119

Background: Many patient materials promulgate lifestyle adaptations purported to minimize risk of lymphedema. One factor often mentioned is development or exacerbation of lymphedema due to airplane travel. The aim of this study was to describe prospectively the effect of airplane travel on women treated for breast cancer, traveling to Caloundra, Qld., Australia to attend a dragon boat regatta.
 Methods: Pre and post data were obtained from 63 women traveling from Canada to Australia, and from 12 women traveling within Australia. 54% were treated for breast cancer on their dominant side, 63% underwent mastectomy with or without reconstruction, 77% underwent axillary node dissection, and 21% wore a compression sleeve during flight; 94% trained at a moderate to vigorous intensity for the regatta. Single frequency bioimpedance analysis (BIA; XCA; Impedimed Inc.®) was used to determine the inter-limb difference in upper limb extracellular fluid. BIA is highly reliable and has high sensitivity and specificity for increased extracellular fluid accumulation. Change in ratio >0.05 for women without lymphoedema is of clinical significance. Women were measured within 2 weeks of their flight to Caloundra, immediately on arrival in Caloundra, and for 46 women, within 6 weeks of return to Canada.
 Results: Airplane travel did not have a significant effect on the upper limb BIA ratio, either between the pre and post flight (t75= -0.355; p=0.72) or between the pre and follow-up measures (t44=.241; p=0.811).
 
 Overall, the BIA post ratio increased from the pre measure by ≤0.02 in 48 women; 0.02 to <0.05 in 12 women; 0.05 to <0.10 in 10 women; and >0.10 in 5 women (Fig 1). In Figure 1, symbols in grey-shaded area represents women who did not have lymphedema prior to flight but presented with it post flight and the dashed lines indicate previously established cut-offs for criteria for detection of lymphedema. Dotted line on each graph is the line of agreement. The 6 symbols in the grey shaded area (Fig 1) represent women from the international group; their change in BIA ranged from 0.05 to 0.28. Follow-up measures were available on 5 of these women, and indicated that 4 were below the cut-offs for lymphedema. All 6 women had undergone mastectomy and axillary clearance of their lymph nodes and for 5, surgery was on their dominant side. Only 3 of the women wore a compressive sleeve on the plane.
 Discussion: For the majority of women who undertake moderate to vigorous upper limb exercise, airplane travel did not have a significant impact on extracellular fluid ratio. Acknowledgment: Impedimed for funding and equipment.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1119.

Poor adoption of ley-pastures in south-west Queensland: biophysical, economic and social constraints

The present review identifies various constraints relating to poor adoption of ley-pastures in south-west Queensland, and suggests changes in research, development and extension efforts for improved adoption. The constraints include biophysical, economic and social constraints. In terms of biophysical constraints, first, shallower soil profiles with subsoil constraints (salt and sodicity), unpredictable rainfall, drier conditions with higher soil temperature and evaporative demand in summer, and frost and subzero temperature in winter, frequently result in a failure of established, or establishing, pastures. Second, there are limited options for legumes in a ley-pasture, with the legumes currently being mostly winter-active legumes such as lucerne and medics. Winter-active legumes are ineffective in improving soil conditions in a region with summer-dominant rainfall. Third, most grain growers are reluctant to include grasses in their ley-pasture mix, which can be uneconomical for various reasons, including nitrogen immobilisation, carryover of cereal diseases and depressed yields of the following cereal crops. Fourth, a severe depletion of soil water following perennial ley-pastures (grass + legumes or lucerne) can reduce the yields of subsequent crops for several seasons, and the practice of longer fallows to increase soil water storage may be uneconomical and damaging to the environment. Economic assessments of integrating medium- to long-term ley-pastures into cropping regions are generally less attractive because of reduced capital flow, increased capital investment, economic loss associated with establishment and termination phases of ley-pastures, and lost opportunities for cropping in a favourable season. Income from livestock on ley-pastures and soil productivity gains to subsequent crops in rotation may not be comparable to cropping when grain prices are high. However, the economic benefits of ley-pastures may be underestimated, because of unaccounted environmental benefits such as enhanced water use, and reduced soil erosion from summer-dominant rainfall, and therefore, this requires further investigation. In terms of social constraints, the risk of poor and unreliable establishment and persistence, uncertainties in economic and environmental benefits, the complicated process of changing from crop to ley-pastures and vice versa, and the additional labour and management requirements of livestock, present growers socially unattractive and complex decision-making processes for considering adoption of an existing medium- to long-term ley-pasture technology. It is essential that research, development and extension efforts should consider that new ley-pasture options, such as incorporation of a short-term summer forage legume, need to be less risky in establishment, productive in a region with prevailing biophysical constraints, economically viable, less complex and highly flexible in the change-over processes, and socially attractive to growers for adoption in south-west Queensland.

Impact of an early weighing policy on neonatal hypernatraemic dehydration and breast feeding

AIMS

To ascertain the effect of a policy of early weighing on the detection and severity of neonatal hypernatraemic dehydration (NHD) and on breastfeeding rates in the short and medium term.

METHODS

A policy of weighing infants at 72-96 h was introduced from 1 July 2004. Two time periods were studied: pre-policy and post-policy (18 months each). Babies <28 days of age referred to hospital from the community who, on investigation, had plasma sodium concentrations of >145 mmol/l were identified. Age, plasma sodium concentration, percentage loss of body weight at presentation, breastfeeding rates at discharge and at 8 weeks, and complications due to hypernatraemia or its management were compared between the two groups.

RESULTS

60 cases of NHD were identified: 23 before and 37 after introduction of the policy. After the policy, there was earlier recognition of NHD (median 3 vs 6 days), lower percentage weight loss (11% vs 15%), smaller increase in sodium (147 vs 150 mmol/l), and higher breastfeeding rate at discharge (73% vs 22%) and 8 weeks (57% vs 22%). All the differences were significant (p<0.01). There was one death in the pre-policy group, and none in the post-policy group.

CONCLUSIONS

Weighing babies early coupled with appropriate lactation support resulted in the early recognition of NHD, with less dehydration, less severe hypernatraemia, and higher breastfeeding rates in the short and medium term.

Osteoporotic vertebral fractures redux

Osteoporosis remains an important cause of morbidity and mortality especially in the elderly. This fact is largely due to fractures of the proximal femur and spine. As recently recognized, vertebral fractures are as much a threat to health and longevity as fractures of the proximal femur. In recent decades, the development of tools to evaluate fracture risk as well as medications to treat osteoporosis has altered the management of people who are at fracture risk. At the same time identification and management procedures concerning spinal fracturing are not very clear. Besides there is not even clear consensus about what exactly constitutes a vertebral fracture, particularly those of minor degree. While height loss is a simple and valuable tool to detect vertebral fractures, it is neither sensitive nor specific enough to replace radiographs. Some 65% of fractures cause no symptoms. Often vertebral fractures are misdiagnosed, especially if they have occurred silently and if the opportunity for diagnosis arises fortuitously. It is to the patient's benefit that radiologists report and physicians identify vertebral fractures evident on a chest or other radiograph, no matter how incidental to the immediate clinical indication for the examination. Technological evolution now allows dual-energy x-ray absorptiometry machines to be used to take spine images while doing a densitometry. The images are adequate, even if not of high radiographic quality, and, more important, the patient undergoes a smaller radiation dose than with conventional spinal radiographs. Such technology may promote fracture recognition. The recognition of vertebral fractures, as well as the prevention and treatment of further fractures, will likely do much to reduce both the burden of osteoporosis-related morbidity and mortality, as well as fracture-related costs to healthcare systems.

Bisphosphonate therapy for children and adolescents with secondary osteoporosis

BACKGROUND

Children with chronic illnesses are at increased risk for reductions in bone strength and subsequent fractures (osteoporosis), either due to the impact of the underlying condition on skeletal development or due to the osteotoxic effect of medications (e.g., glucocorticoids) used to treat the chronic illness. Bisphosphonates are being administered with increasing frequency to children with secondary osteoporosis; however, the efficacy and harm of these agents remains unclear.

OBJECTIVES

To examine the efficacy and harm of bisphosphonate therapy in the treatment and prevention of secondary osteoporosis in children and adolescents.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (Issue 4, 2006), MEDLINE, EMBASE, CINAHL and ISI Web of Science (inception-December 2006). Further literature was identified through expert contact, key author searches, scanning reference lists of included studies, and contacting bisphosphonate manufacturers.

SELECTION CRITERIA

Randomized, quasi-randomized, controlled clinical trials, cohort, and case controls of bisphosphonate(s) in children 0-18 years of age with at least one low-trauma fracture event or reductions in bone mineral density in the context of secondary osteoporosis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed quality. Case series were used for supplemental harms-related data.

MAIN RESULTS

Six RCTs, two CCTs, and one prospective cohort (n=281 children) were included and classified into osteoporosis due to: 1) neuromuscular conditions (one RCT) and 2) chronic illness (five RCTs, two CCTs, one cohort). Bisphosphonates examined were oral alendronate, clodronate, and intravenous (IV) pamidronate. Study quality varied. Harms data from 23 case series (n=241 children) were used. Heterogeneity precluded statistically combining the results. Percent change or Z-score change in lumbar spine areal BMD from baseline were consistently reported. Two studies carried out between-group analyses; one showed no significant difference (using oral alendronate in anorexia nervosa) while the other demonstrated a treatment effect on lumbar spine with IV pamidronate in burn patients. Frequently reported harms included the acute phase reaction, followed by gastrointestinal complaints, and bone/muscle pain.

AUTHORS' CONCLUSIONS

The results justify further evaluation of bisphosphonates among children with secondary osteoporosis. However, the evidence does not support bisphosphonates as standard therapy. Short-term (3 years or less) bisphosphonate use appears to be well-tolerated. An accepted criterion for osteoporosis in children, a standardized approach to BMD reporting, and examining functional bone health outcomes (e.g., fracture rates) will allow for appropriate comparisons across studies.

Prediction of fat-free body mass from bioelectrical impedance among 9- to 11-year-old Swedish children

AIM

Predictive equations for estimating body composition from bioelectrical impedance analysis (BIA) among Scandinavian children are lacking. In the present study, equations for estimation of fat-free body mass (FFM) and lean tissue mass (LTM) were developed and cross-validated from BIA using dual-energy X-ray absorptiometry (DXA) as the reference measurement of body composition.

METHODS

The study population consisted of 49 girls and 52 boys aged 9-11 years from Malmö, Sweden. Bioelectrical impedance was measured between hand and foot at 50 kHz. Predictive equations were developed by multiple linear regression and cross-validated against DXA measurements of body composition.

RESULTS

FFM was predicted from BIA and anthropometric variables with an adjusted R(2)= 0.95 and root mean square error (RMSE) = 0.84 kg, and LTM was predicted with an adjusted R(2)= 0.95 and RMSE = 0.87 kg. Cross-validation revealed a mean RMSE = 0.95 kg FFM and a mean RMSE = 0.96 kg LTM. Prediction of body composition from equations developed in previous literature was mixed when applied to the present cohort of children.

CONCLUSIONS

FFM and LTM are predicted with sufficient accuracy at the population level. We recommend that the predictive equations developed in the present study are used in prepubescent European children aged 9-11 years only in order to minimize confounding of results because of possible differences in population samples.

Relationships between bereavement and cognitive functioning in older adults

BACKGROUND

Bereavement is often associated with increased levels of depression, anxiety, and stress. The question of whether grief is associated with cognitive deficits in older adults remains largely unanswered. Although Xavier and coworkers (see text) found preliminary evidence that grief, in the absence of depression, impacted on memory in a sample of the oldest-old in Brazil, the impact of bereavement on cognitive functioning, independent of the effects of mood, has not been adequately examined.

OBJECTIVE

To replicate and expand on the work of Xavier and colleagues to examine whether there is an association between bereavement due to spousal loss and performance in a range of cognitive functioning domains in older adults, independent of the effects of depression, stress, and anxiety.

METHODS

Samples of bereaved (n = 25) and non-bereaved (n = 25) participants, who were aged between 65 and 80 years and who were matched for age, gender, education, premorbid intellectual functioning, and general cognitive ability, were compared on a battery of tests designed to assess attention, verbal fluency, memory, and visuospatial ability. Depression, anxiety, and stress were also assessed, as were the presence of complicated grief and the adequacy of social support in the bereaved group. Cognitive tests that differed between the groups and correlated with depression, stress, or anxiety were analyzed using hierarchical multiple regression.

RESULTS

The bereaved groups were more depressed, anxious, and stressed, and performed more poorly on tests assessing attention, information-processing speed, and verbal fluency. With the exception of the attentional switching task, the cognitive measures on which the groups differed were correlated with mood. When mood was controlled statistically, the group differences in these cognitive tests disappeared. Twenty-eight percent of the bereaved group met the criteria for a diagnosis of complicated grief. This subgroup was younger than the other bereaved participants and had higher levels of stress.

CONCLUSION

The evidence suggests that grief associated with death of a spouse has limited associations with cognition beyond those that would be expected to occur as a result of depression, anxiety, and stress.