Death of a Simulated Patient: An Innovative Approach to Teaching Dosage Calculations

ABSTRACT

Dosage calculation errors impact patient safety. A creative teaching strategy for undergraduate nursing students in the nursing skills laboratory incorporated a simulated patient who had died. The patient received three incorrect medication dosages. The objective of the learning activity was for students to calculate the medication dosages and determine which error most likely resulted in the patient's death. Students were highly engaged in this activity. Faculty observed student learning in the cognitive and affective domains. This innovative teaching strategy encouraged students to evaluate dosage calculations in a safe learning environment.

Developing Faith Community Emergency Response Teams Through Simulation

ABSTRACT

The development of a volunteer emergency response team is an effective method to mitigate the negative impacts and improve outcomes of health emergencies in faith communities and is supported by faith community nursing scope and standards of professional practice. Conducting simulated emergency drills with a core team of volunteers within one parish supported the confidence and comfort levels of the multidisciplinary group of volunteers, led by a nurse. Simulation and debriefing increased team members' preparedness for physical and mental health emergencies.

Evaluation of Piperacillin-Tazobactam Testing against Enterobacterales by the Phoenix, MicroScan, and Vitek2 Tests Using Updated Clinical and Laboratory Standards Institute Breakpoints

In 2022, the Clinical and Laboratory Standards Institute (CLSI) updated piperacillin-tazobactam (TZP) breakpoints for Enterobacterales, based on substantial data suggesting that historical breakpoints did not predict treatment outcomes for TZP. The U.S. Food and Drug Administration (FDA) has not yet adopted these breakpoints, meaning commercial manufacturers of antimicrobial susceptibility testing devices cannot obtain FDA clearance for the revised breakpoints. We evaluated the Phoenix (BD, Sparks, MD), MicroScan (Beckman Coulter, Sacramento, CA), and Vitek2 (bioMérieux, Durham, NC) TZP MICs compared to reference broth microdilution for a collection of 284 Enterobacterales isolates. Phoenix (n = 167 isolates) demonstrated 84.4% categorical agreement (CA), with 4.2% very major errors (VMEs) and 1.8% major errors (MEs) by CLSI breakpoints. In contrast, CA was 85.0% with 4.3% VMEs and 0.8% MEs for the Phoenix with FDA breakpoints. MicroScan (n = 55 isolates) demonstrated 80.0% CA, 36.4% VMEs, and 4.8% MEs by CLSI breakpoints and 81.8% CA, 44.4% VMEs, and 0.0% MEs by FDA breakpoints. Vitek2 (n = 62 isolates) demonstrated 95.2% CA, 6.3% VMEs, and 0.0% MEs by CLSI and 96.8% CA, 0.0% VMEs, and 2.2% MEs by FDA breakpoints. Overall, the performance of the test systems was not substantially different using CLSI breakpoints off-label than using on-label FDA breakpoints. However, limitations were noted with higher-than-desired VME rates (all three systems) and lower-than-desired CA (MicroScan and Phoenix). Laboratories should consider adoption of the revised CLSI breakpoints with automated test systems but be aware that some performance challenges exist for testing TZP on automated systems, regardless of breakpoints applied.

217 THE USE OF SIILO MESSAGING APP BETWEEN HOSPITAL-BASED FRAILTY INTERVENTION THERAPY TEAM AND COMMUNITY-BASED EMERGENCY DEPARTMENT IN THE HOME TEAM

Background

Effective communication is an important component of any healthcare system. There is frequent communication of patient care and information between the EDITH (Emergency Department In The Home) and the FIT (Frailty Intervention Therapy) teams, which are based across two sites. Traditionally handovers between therapists were completed via email/ fax. Siilo is a secure medical messaging app designed to facilitate instant communication of patient information between healthcare professionals in a confidential manner.

Methods

A 3-month pilot of the Siilo app was commenced in August 2021 to improve the flow of information between teams, facilitate timely decision making and improve patient care. A questionnaire to rate speed, efficiency, accuracy, accessibility and confidentiality on a 4point scale was completed by all therapy staff members. Qualitative questions regarding positive and negative aspects, and future suggestions were included.

Results

Pre-pilot the median time from EDITH assessment to receipt of handover was 20 hours. During the pilot, median time to handover was 1 hour. Speed, efficiency and accessibility of communication between teams received a median rating of 2 (“average”) pre-pilot, increasing to 4 (“excellent”) during the pilot. Accuracy and confidentiality received a median rating of 3 (“good”) pre-pilot, improving to a median rating of 4 (“excellent”). 100% of respondents reported Siilo had a positive impact on decision making and on patient care.Qualitative themes included; earlier acute care discharge planning; ease of use and reduction in paperwork. Suggestions to further improve communication between the services were made and will be explored at a later date.

Conclusion

A significant reduction in time from assessment to handover improved the flow of communication between the teams, reduced duplication of assessments and improved patient care for older patients. Confidentiality and accuracy were maintained over this period. The use of the app will be continued and suggestions to further improve the integration between the services will be implemented.

215 WHAT VALUE DOES OCCUPATIONAL THERAPY ADD TO THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE?

Background

The EDITH team has provided an alternative care pathway for older adults with emergency care that takes place in the persons’ home. The EDITH service provides both medical and Occupational Therapy assessment and intervention in the home environment with onward referrals to appropriate agencies as indicated, thus negating the need for an emergency department presentation.

Methods

To assess consistency in OT practice and assessment, an audit was completed of OT logbooks and electronic patient data. Paper count method was used. Data gathered with regards to OT process and assessment.

Results

100% of patients had at least 1 type of OT assessment (e.g functional, home environment, falls prevention, cognitive etc), 80% had at least 2 and 43% had 3 or more types of OT assessments. 100% of patients had Clinical Frailty Scores completed, 100% had their living situation and level of care supports assessed and documented. 43% of patients received onwards referrals to community supports, day hospital, voluntary supports etc.

Conclusion

The OTs complete a thorough and multifactorial assessment of the older adult within the context of their home environment. This holistic assessment approach adds significant value to the overall EDITH assessment and service. It also ensures appropriate and relevant onwards referrals are completed. It is imperative to ensure value for money with regards to health care services. In line with the HSE “Value Improvement Programme” it is timely to review OT services and ensure they are delivering consistent, high quality and high value services for our stakeholders.

239 PATIENT PERCEPTIONS OF THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE

Background

The EDITH service provides an alternative to Emergency Department (ED) attendance for the older adult by providing emergency care in the person home. It is imperative to explore how this service is received by the key stakeholders in order to ensure it is meeting the needs of older adults and to improve and diversify same.

Methods

A patient feedback survey was circulated to patients and family members who received the EDITH service. A postal option and a QR code leading to an online option were utilised. 50 surveys were randomly selected for inclusion. Quantitative data was analysed via paper count method and thematic analysis was completed for the qualitative data.

Results

74% rated the service as “excellent”, 22% “very good” and 4% “good”. Alternative options to the service were identified as “going to ED” 22% , “going to GP” 22%, “waited until they would get better” 4%, “waited until they got worse” 2%, “would do nothing” 6%. 80% rated the combined expertise of a doctor and OT as “extremely important”, 94% rated the home visit aspect as “extremely important” and 90% rated ED avoidance as “extremely important”. Key themes that emerged regarding what the service does well included “personalised care”, “ED avoidance”, “compassion” and “timeliness of service”. Areas for improvement included “improving communication loop to both patients and/or community services! and “ability to directly access the service”. 95% of respondents advised they would or have already recommended the service to others. Of note, a key theme in the comments section was the need for a similar service in other hospitals.

Conclusion

The EDITH service appears to be meeting stake-holders expectations, areas for improvement have been identified and are currently being addressed. It is imperative to obtain the perception of the service user and to tailor interventions accordingly, this feedback is invaluable in order to meet future service needs.

228 LONG TERM OUTCOMES FOR FALLS PATIENTS WHO WERE TREATED BY THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE

Background

The EDITH service provides an alternative to an ED attendance for the older adult. Medical treatment and Occupational Therapy (OT) assessment take place within the patient’s home. Patients who experience an explained fall are routinely treated by the EDITH service, these patients receive OT falls prevention and home environment assessment as standard. It is imperative to assess the long-term outcomes for these patients in order to inform future service provision.

Methods

A total of 40 patients, who were referred following an explained fall to the EDITH service and remained at home following assessment, were selected for audit. These patients were seen over a 2-month period in 2021. Data were gathered with regards to ED presentations via healthcare records and mortality rates were captured via RIP.ie

Results

At 3 months, 4 patients had re-presented to ED with a fall and 3 required admission. At 6 months, 6 patients re-presented to ED with a fall with 5 requiring admission. At 9 months, 4 patients re-presented to ED with a fall and 3 required admission. 100% of patients had an OT home environment assessment and received advice regarding falls prevention. The average age of patient was 84 years. At 1 year, the mortality rate for this patient group was 10%.

Conclusion

Patients with explained falls that were treated by the EDITH service appear to have a reasonably low ED re-attendance rate at 3, 6 and 9 months for explained falls. This may be as a result of the tailored falls prevention education/home environment assessment that took place within the patient’s home by the OT. However further audit and a larger population group would be required to suggest a definite correlation between same.

Increased levels of a pro-inflammatory IgG receptor in the midbrain of people with schizophrenia

BACKGROUND

There is growing evidence that neuroinflammation may contribute to schizophrenia neuropathology. Elevated pro-inflammatory cytokines are evident in the midbrain from schizophrenia subjects, findings that are driven by a subgroup of patients, characterised as a "high inflammation" biotype. Cytokines trigger the release of antibodies, of which immunoglobulin G (IgG) is the most common. The level and function of IgG is regulated by its transporter (FcGRT) and by pro-inflammatory IgG receptors (including FcGR3A) in balance with the anti-inflammatory IgG receptor FcGR2B. Testing whether abnormalities in IgG activity contribute to the neuroinflammatory abnormalities schizophrenia patients, particularly those with elevated cytokines, may help identify novel treatment targets.

METHODS

Post-mortem midbrain tissue from healthy controls and schizophrenia cases (n = 58 total) was used to determine the localisation and abundance of IgG and IgG transporters and receptors in the midbrain of healthy controls and schizophrenia patients. Protein levels of IgG and FcGRT were quantified using western blot, and gene transcript levels of FcGRT, FcGR3A and FcGR2B were assessed using qPCR. The distribution of IgG in the midbrain was assessed using immunohistochemistry and immunofluorescence. Results were compared between diagnostic (schizophrenia vs control) and inflammatory (high vs low inflammation) groups.

RESULTS

We found that IgG and FcGRT protein abundance (relative to β-actin) was unchanged in people with schizophrenia compared with controls irrespective of inflammatory subtype. In contrast, FcGRT and FcGR3A mRNA levels were elevated in the midbrain from "high inflammation" schizophrenia cases (FcGRT; p = 0.02, FcGR3A; p < 0.0001) in comparison to low-inflammation patients and healthy controls, while FcGR2B mRNA levels were unchanged. IgG immunoreactivity was evident in the midbrain, and approximately 24% of all individuals (control subjects and schizophrenia cases) showed diffusion of IgG from blood vessels into the brain. However, the intensity and distribution of IgG was comparable across schizophrenia cases and control subjects.

CONCLUSION

These findings suggest that an increase in the pro-inflammatory Fcγ receptor FcGR3A, rather than an overall increase in IgG levels, contribute to midbrain neuroinflammation in schizophrenia patients. However, more precise information about IgG-Fcγ receptor interactions is needed to determine their potential role in schizophrenia neuropathology.

215 WHAT IMPACT CAN ‘EMERGENCY DEPARTMENT IN THE HOME’ (EDITH) HAVE ON THE OLDER ADULT POPULATION PRESENTING WITH FALLS?

Background

EDITH is a frailty response service providing medical and occupational therapy input to older adults living within the catchment area of a level 4 acute hospital. EDITH aims to reduce avoidable Emergency Department (ED) attendances and utilise alternative care pathways. Falls are common among older people and are often associated with poorer outcomes. Traditionally, older patients who have had a fall and contact emergency services for assistance are transferred to the ED and this can be associated with elevated risks. Additionally, older patients who have had a fall and are discharged on scene by the emergency services are at greater risk of recurring falls in the absence of immediate onward referral to community falls prevention services (Nowak and Hubbard 2009).

Methods

Paper count method data collection was completed. Inclusion criteria included referrals from the National Ambulance Service within the last 6 months.

Results

75 patients met the inclusion criteria; 34 males, 41 females with an average age of 82. 11 patients were conveyed to hospital, giving a conveyance rate of 14.6%, the average conveyance rate for the EDITH service is 7.2%. 3 patients were conveyed to ED, while 8 patients were conveyed to the Medical Assessment Unit (MAU) in the local level 3 hospital. This resulted in 72% of patients that required hospital conveyance being streamed to the MAU; traditionally 100% of these patients would have presented to ED. Overall, 85.4% of patients seen remained at home.

Conclusion

EDITH are providing targeted medical and occupational therapy assessment(s) for older adults in their homes with successful outcomes. Implementation of alternative care pathways, reduction in avoidable ED attendances and prolonged independence in the home for this patient profile are some of the favourable findings.

Reference

1. Nowak A, Hubbard RE. (2009) Falls and frailty: lessons from complex systems. Journal of the Royal Society of Medicine. 102(3):98–102.

106 EDITH (EMERGENCY DEPARTMENT IN THE HOME): AN 18 MONTH AUDIT OF A NOVEL SERVICE

Background

The EDITH team has provided an alternative care pathway for older adults in need of emergency services. The traditional model, which involved the transport of an older adult to an emergency department has been replaced with emergency care that takes place in the persons’ home. The EDITH service provides both medical and Occupational Therapy assessment and intervention in the home environment with onward referrals to appropriate agencies as indicated, thus negating the need for an emergency department presentation.

Methods

Data from electronic patient records and OT logbooks were audited from the period 22/02/20 to 09/08/21. Data was gathered regarding attendances, outcomes and conveyance rates.

Results

Since its’ inception the EDITH service has treated 3,137 patients. Following treatment, 2,909 patients remained at home while 228 patients were transferred to hospital. This gives a conveyance rate of 7.2%. Three hundred and thirty six patients were referred to primary care or day hospital services. The average age of patients is 82 years and the average Manchester Triage category is priority 4. The EDITH service has saved the hospital 7.9 years of bed days (2,909 bed days) as these patients have not presented to the emergency department.

Conclusion

There is a growing body of evidence highlighting the detrimental impact a hospitalisation can have on an older adult (Mudge et al., 2019). There is a clear need for health care services to diversify in order to meet the needs of this ageing population. The EDITH service is leading this change in Irish healthcare by providing specialised emergency care and OT intervention for the older adult in their own homes.

Reference

1. Mudge et al. (2019). Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care. Journal of the American Geriatrics Society. 67(2).

107 EMERGENCY DEPARTMENT IN THE HOME, WHO IS THE EDITH PATIENT?

Background

The EDITH team has provided an alternative care pathway for older adults in need of emergency services. This vulnerable patient population receive emergency medical and occupational therapy treatment and intervention in their home environment. The typical patient profile is assumed to be ‘frail older adults’, but this needs to be more specifically defined within the clinical practice in EDITH.

Methods

A total of 230 electronic patient records were selected at random. Data was audited and analysed with regard to clinical descriptors for this patient population.

Results

Of the 230 patients treated, 26 were referred to hospital or rehabilitation facilities. This is a conveyance rate of 11% which is above the average rate of 7.2% for this service.

The Rockwood Clinical Frailty Scale (CFS): 22% had a CFS of 5 (mildly frail), 37% had a CFS of 6 (moderately frail), 22% had a CFS of 7 (severely frail), 3% had a CFS of 8 (very severely frail).

Living Status: 26% living alone, 48% living with family, 4% sheltered living accommodation and 22% in nursing homes.

Formal Supports: 37% have no formal supports, 18% have &lt;10 hours per week, 19% have between 11–21 hours, 4% have 24-hour care and 22% reside in nursing homes.

Presenting complaint: 41% medically unwell, 23% fall, 14% functional decline, 9% pain, 5% infection, 5% orthopaedic and 2% confusion.

Ages range from 61 years to 100 years with an average age of 82 years.

Conclusion

It is imperative to identify the type of patient that uses this service, in order to plan for future service needs and ensure their current clinical care needs are being met. Of note, a significant proportion of patients are living alone, have high CFS scores and have no formal supports in situ.

80 Improving Documentation of DNAR Decisions on the Acute Medical Take

Introduction

The BMA, Resuscitation Council and Royal College of Nursing have set out clear guidelines on documentation of Resuscitation discussions and decisions.1 On the acute medical take documentation of these discussions and decisions can be unclear despite use of an electronic patient record (EPR). The aim of this audit was to improve documentation of Do Not Attempt Resuscitation (DNAR) decisions in EPR.

Methods

We listed patients admitted on the medical take over 1-week, looking at resuscitation status and the documentation of the DNAR decision. We then implemented a change to the format of the EPR treatment escalation plan (TEP) form. Prior to the change the DNAR form was behind the TEP form which had to be clicked on separately and was not mandatory to complete. After the intervention the DNAR decision was placed in a box on the front page of the TEP form to ensure that it was clear and accessible.

Results

Pre-intervention we reviewed 114 patients notes of which 94 were DNAR. Of these 94 only 17 (18%) had correctly documented DNAR decisions in EPR. Following the intervention we again looked at all admissions to the medical take over a 1-week period, out of 151 patients 75 were DNAR and of these 75 patients 29 had correctly documented DNAR forms. This shows an increase in the percentage of the DNAR decisions filled in from 18% to 39%.

Conclusion

The results show that although there has been an improvement in the number of DNAR decisions being documented there are still a large percentage of patients who do not have this correctly documented. We are designing further interventions to ensure that the DNAR documentation is marked as a mandatory part of the TEP form as well as educating around the importance of this documentation.

High Preservation Potential of Paleogeographic Range Size Distributions in Deep Time

AbstractReconstructing geographic range sizes from fossil data is a crucial tool in paleoecology, elucidating macroecological and macroevolutionary processes. Studies examining links between range size and extinction risk may also offer a predictive tool for identifying species most vulnerable in the "sixth mass extinction." However, the extent to which paleogeographic ranges can be recorded reliably in the fossil record is unknown. We perform simulation-based extinction experiments to examine (1) the fidelity of paleogeographic range size preservation in deep time, (2) the relative performance of different methods for reconstructing range size, and (3) the reliability of detecting patterns of extinction "selectivity" on range size. Our results suggest both that relative paleogeographic range size can be consistently reconstructed and that selectivity patterns on range size can be preserved under many extinction intensities, even when sedimentary rocks are scarce. By identifying patterns of selectivity across Earth's history, paleontologists can thus augment neontological work that aims to predict and prevent extinctions of living species. Last, we find that introducing "false extinctions" in the fossil record can produce spurious range-selectivity signals. Errors in the temporal ranges of species may pose a larger barrier to reconstructing range size-extinction risk signals than the spatial distribution of fossiliferous sediments.

Literature review and case series of haemorrhagic cholecystitis

A diagnosis of haemorrhagic cholecystitis is difficult to make as it is rare and mimics other common disorders. We present three patients who presented with haemorrhagic cholecystitis, two of whom were on anti-coagulation at presentation. All 3 patients were treated conservatively, 2 with percutaneous cholecystostomy drainage and 1 patient with intravenous antibiotics. There are few guidelines on the management of such a condition.

Root morphology and seed and leaf ionomic traits in a Brassica napus L. diversity panel show wide phenotypic variation and are characteristic of crop habit

BACKGROUND

Mineral nutrient uptake and utilisation by plants are controlled by many traits relating to root morphology, ion transport, sequestration and translocation. The aims of this study were to determine the phenotypic diversity in root morphology and leaf and seed mineral composition of a polyploid crop species, Brassica napus L., and how these traits relate to crop habit. Traits were quantified in a diversity panel of up to 387 genotypes: 163 winter, 127 spring, and seven semiwinter oilseed rape (OSR) habits, 35 swede, 15 winter fodder, and 40 exotic/unspecified habits. Root traits of 14 d old seedlings were measured in a 'pouch and wick' system (n = ~24 replicates per genotype). The mineral composition of 3-6 rosette-stage leaves, and mature seeds, was determined on compost-grown plants from a designed experiment (n = 5) by inductively coupled plasma-mass spectrometry (ICP-MS).

RESULTS

Seed size explained a large proportion of the variation in root length. Winter OSR and fodder habits had longer primary and lateral roots than spring OSR habits, with generally lower mineral concentrations. A comparison of the ratios of elements in leaf and seed parts revealed differences in translocation processes between crop habits, including those likely to be associated with crop-selection for OSR seeds with lower sulphur-containing glucosinolates. Combining root, leaf and seed traits in a discriminant analysis provided the most accurate characterisation of crop habit, illustrating the interdependence of plant tissues.

CONCLUSIONS

High-throughput morphological and composition phenotyping reveals complex interrelationships between mineral acquisition and accumulation linked to genetic control within and between crop types (habits) in B. napus. Despite its recent genetic ancestry (<10 ky), root morphology, and leaf and seed composition traits could potentially be used in crop improvement, if suitable markers can be identified and if these correspond with suitable agronomy and quality traits.

Technical tip: cold saline infiltration instead of local anaesthetic in endovenous laser treatment

Endovenous laser treatment (EVLT) is a novel technique that is fast gaining acceptance as an alternative to open surgery for the treatment of long saphenous vein incompetence. In our experience, the use of cold saline infiltration (CSI) prior to laser occlusion is a safe alternative to local anaesthetic infiltration (LAI), avoiding the risks associated with local anaesthetic toxicity. CSI does not affect the immediate outcome of EVLT and allows the use of LAI to be reserved for additional open phlebectomies if required.

Structures of the dehydrogenation products of methane activation by 5d transition metal cations

The activation of methane by gas-phase transition metal cations (M(+)) has been studied extensively, both experimentally and using density functional theory (DFT). Methane is exothermically dehydrogenated by several 5d metal ions to form [M,C,2H](+) and H2. However, the structure of the dehydrogenation product has not been established unambiguously. Two types of structures have been considered: a carbene structure where an intact CH2 fragment is bound to the metal (M(+)-CH2) and a carbyne (hydrido-methylidyne) structure with both a CH and a hydrogen bound to the metal separately (H-M(+)-CH). For metal ions with empty d-orbitals, an agostic interaction can occur that could influence the competition between carbene and carbyne structures. In this work, the gas phase [M,C,2H](+) (M = Ta, W, Ir, Pt) products are investigated by infrared multiple-photon dissociation (IR-MPD) spectroscopy using the Free-Electron Laser for IntraCavity Experiments (FELICE). Metal cations are formed in a laser ablation source and react with methane pulsed into a reaction channel downstream. IR-MPD spectra of the [M,C,2H](+) species are measured in the 300-3500 cm(-1) spectral range by monitoring the loss of H (2H in the case of [Ir,C,2H](+)). For each system, the experimental spectrum closely resembles the calculated spectrum of the lowest energy structure calculated using DFT: for Pt, a classic C(2v) carbene structure; for Ta and W, carbene structures that are distorted by agostic interactions; and a carbyne structure for the Ir complex. The Ir carbyne structure was not considered previously. To obtain this agreement, the calculated harmonic frequencies are scaled with a scaling factor of 0.939, which is fairly low and can be attributed to the strong redshift induced by the IR multiple-photon excitation process of these small molecules. These four-atomic species are among the smallest systems studied by IR-FEL based IR-MPD spectroscopy, and their spectra demonstrate the power of IR spectroscopy in resolving long-standing chemical questions.

Developing a user-generated measure of continuity of care: brief report

OBJECTIVE

This paper describes a measure of continuity of care, establishes its reliability and tests it in a field trial sample for evidence of its validity. In contrast to others, this measure has been generated from the perspectives of service users. As continuity of care is a concern particularly for those with severe mental illness, we have confined our work to this population group.

METHOD

Service users in focus groups and expert panels generated the measure. The researchers were themselves service users. Test-retest reliability was assessed with an independent sample. The measure was administered to a final independent field trial sample to determine their experiences of continuity of care and for further psychometric testing.

RESULTS

The measure generated by service users has satisfactory psychometric properties. Service users in the field trial sample were more satisfied when continuity, as assessed by this measure, was in place.

CONCLUSION

It is possible and valid to construct outcome measures in mental health entirely from the user perspective. This has not been done before.

Differences in time to detection and recovery of Mycobacterium spp. between the MGIT 960 and the BacT/ALERT MB automated culture systems

Mycobacterium sp. recovery and time to detection were compared in the MGIT 960 and BacT/ALERT MB automated broth culture systems. The MGIT 960 demonstrated shorter time to detection (13.5 versus 25.2 days) and greater sensitivity (100% versus 66.6%) for recovery of the Mycobacterium tuberculosis complex than the BacT/ALERT MB system.

Rapid, standardized method for determination of Mycobacterium tuberculosis drug susceptibility by use of mycolic acid analysis

Multidrug-resistant (MDR) Mycobacterium tuberculosis and extrensively drug-resistant (XDR) M. tuberculosis are emerging public health threats whose threats are compounded by the fact that current techniques for testing the susceptibility of M. tuberculosis require several days to weeks to complete. We investigated the use of high-performance liquid chromatography (HPLC)-based quantitation of mycolic acids as a means of rapidly determining drug resistance and susceptibility in M. tuberculosis. Standard susceptibility testing and determination of the MICs of drug-susceptible (n = 26) and drug-resistant M. tuberculosis strains, including MDR M. tuberculosis strains (n = 34), were performed by using the Bactec radiometric growth system as the reference method. The HPLC-based susceptibilities of the current first-line drugs, isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA), were determined. The vials were incubated for 72 h, and aliquots were removed for HPLC analysis by using the Sherlock mycobacterial identification system. HPLC quantitation of total mycolic acid peaks (TMAPs) was performed with treated and untreated cultures. At 72 h, the levels of agreement of the HPLC method with the reference method were 99.5% for INH, EMB, and PZA and 98.7% for RIF. The inter- and intra-assay reproducibilities varied by drug, with an average precision of 13.4%. In summary, quantitation of TMAPs is a rapid, sensitive, and accurate method for antibiotic susceptibility testing of all first-line drugs currently used against M. tuberculosis and offers the potential of providing susceptibility testing results within hours, rather than days or weeks, for clinical M. tuberculosis isolates.

Mycobacterium arupense sp. nov., a non-chromogenic bacterium isolated from clinical specimens

SeveralMycobacterium-like organisms related to theMycobacterium terraecomplex have been isolated from clinical samples. In the clinical microbiology laboratory, partial 16S rRNA gene sequencing (approximately the first 500 bp) rather than full 16S rRNA gene sequencing is often used to identifyMycobacteriumspecies. Partial 16S rRNA gene sequence analysis revealed 100 % similarity between 65 clinical isolates andMycobacteriumsp. MCRO 6 (GenBank accession no. X93032). Even after sequencing the nearly full-length 16S rRNA gene, closest similarity was only 99.6 % toMycobacterium nonchromogenicumATCC 19530T. Sequencing of the nearly full-length 16S rRNA gene, the 16S–23S internal transcribed spacer region and thehsp65gene did not reveal genotypic identity with the type strains ofM. nonchromogenicum,M. terraeorMycobacterium triviale. Although sequence analysis suggested that these clinical isolates represented a novel species, mycolic acid analysis by HPLC failed to distinguish them fromM. nonchromogenicum. Therefore, phenotypic analysis including growth characterization, antibiotic susceptibility testing and biochemical testing was performed. These strains from clinical samples should be recognized as representing a novel species of the genusMycobacterium, for which the nameMycobacterium arupensesp. nov. is proposed. The type strain is AR30097T(=ATCC BAA-1242T=DSM 44942T).

Methods for reducing bacterial contamination in the BacT/Alert mycobacterial culture detection system

Two methods were compared for decreasing bacterial contamination in the BacT/Alert mycobacterial culture detection system. Two concentrations, 0.5 ml (standard amount) and 1.0 ml, of mycobacterial antibiotic supplement were evaluated. Contamination rates were 14% and 6% for the standard and the doubled concentrations, respectively. This difference was statistically significant (P < 0.005).

Secondary intervention following endovascular repair of abdominal aortic aneurysm: A single centre experience

AIMS

We aim from a review of our early and late experience of secondary intervention for technical failures, to examine and describe the impact of endovascular and open interventions.

METHODS

108 Abdominal Aortic Aneurysms (AAAs) repaired endoluminally between 1995-2001 were analysed. In our early experience, during 1995/96 home made pre-expanded polytetrafluoroethylene grafts fixed with Palmaz stents were used (n = 26). In our later experience, 1997/2001 Talent (n = 70) or Zenith endografts (n = 12) were used. All cases underwent spiral CT at 5 days and 6 monthly intervals post-op. Angiography was performed when further intervention was intended. All technical failures requiring intervention or not were studied.

RESULTS

There were 28 (26%) technical failures identified of which 14 of 26 (54%) occurred in our early experience, and 14 of 86 (16%) occurred in our later experience (p < 0.05). Eleven in all required open conversion at the time of endovascular repair. Our study cohort were the remaining 17 cases requiring secondary intervention, seven were from our early experience and 10 from our later experience. There were 12 endoleaks, including two as a result of graft migration, two graft occlusions, two graft distortions and one graft infection. Overall 10 (66%) technical failures were treated by endoluminal repair and seven (34%) by open methods. However, in our later experience significantly more endoluminal techniques (80%) were used (p < 0.05).

CONCLUSIONS

Technical failure rates were significantly higher in our earlier experience. Open repair, which was a feature of our early experience, has been avoided over the final 3 years. Instead, endoluminal techniques were used without further morbidity or mortality. Aneurysm rupture has not so far been experienced in this experience.

Psychosocial correlates of sun-protective practices of preschool staff toward their students

The skin cancer rate in the US has been increasing faster than that for other cancers. Most skin cancers are related to sun exposure and the majority of exposure occurs before adulthood. Thus, children are an important target group to study and preschools can be useful avenues for delivering sun-protection messages. The current study examines the behaviors of preschool staff in protecting students from sun exposure and investigates factors related to sun-protective practice. Preschool staff (n = 245) were surveyed about their sun-protective practices toward students as the cross-sectional baseline measurement for a larger project. The primary aim of this study was to investigate correlates of staff's sun-protective behavior toward students. A theoretical model of psychosocial constructs that combined components of the Theory of Planned Behavior and Social Cognitive Theory was evaluated using structural equation modeling. Self-efficacy and perceived norms were the strongest correlates of behavior. A hypothesized link between expectancy and behavior was not supported. The roles of self-efficacy and perceived norms in the preschool context are discussed as they relate to staffs behavior.

Tracing migrant farmworkers in Starr County, Texas

BACKGROUND

In response to The National Cancer Institute (NCI) concerns about the ability to conduct studies among migrant farmworkers, this study evaluated the feasibility of identifying migrant farmworkers in their home state and tracing them over an extended period of time.

METHODS

In 1995, a group of 196 persons who had classified themselves as "migrant farmworkers" in two earlier chronic disease studies was identified. The primary objective of the current study was to determine the proportion of these farmworkers who could be located in 1995-1996.

RESULTS

Of these farmworkers, 163 were located and were living (83.2%), 15 had died (7.6%), and 18 (9.2%) were lost to follow-up.

CONCLUSIONS

The excellent follow-up rate was due in part to the high participation rates among persons contacted for information, stability of the farmworkers' permanent homes, predictable timing of migration, and a longstanding health research program with established community contacts.

Prenatal exposure to pesticides: a feasibility study among migrant and seasonal farmworkers

BACKGROUND

Migrant and seasonal farmworkers have a high potential for pesticide exposures, yet are rarely included in epidemiologic studies. This study examined the feasibility of assessing prenatal exposures to pesticides and other compounds in pregnant Hispanic farmworkers.

METHODS

Nine women completed a survey about work experiences during pregnancy. Maternal urine, cord blood, and placenta samples were obtained at delivery for analysis of 51 analytes, including 6 phenoxy acid or triazine herbicides, 21 organochlorine insecticides, 10 PCBs, and 14 volatile organic compounds.

RESULTS

Seven of 51 analytes were found in the biological samples. DDE, DDT, dichlorbenzene, toluene, trimethylbenzene, and endosulfan sulfate were detected in cord blood samples, and 2,4-D in urine from one or more women.

CONCLUSIONS

We documented the feasibility of following farmworkers to assess in utero exposure to pesticides and other contaminants, and demonstrated exposure to these compounds. Difficulties in measuring pesticides with short half lives were noted.

Development of a life events/icon calendar questionnaire to ascertain occupational histories and other characteristics of migrant farmworkers

BACKGROUND

Specialized methods are necessary to collect data from migrant farmworkers for epidemiologic research.

METHODS

We developed a questionnaire that collected lifetime occupational histories and other lifestyle risk factors via a life events/icon calendar, and administered the questionnaire to a convenience sample of 162 migrant farmworkers in nine areas of the U.S.

RESULTS

The average duration of the interviews was about 1 h 30 min, with an average of 45 min for the work history section. The occupational histories covered a median of 27.6 years per person for men and 20.8 years per person for women. The median number of years spent in farm jobs was 11.3 for men and 5.8 for women. The median number of farm jobs (crop/task combination) per person was 59 among men and 27 among women. Many farmworkers performed the same crop/task combinations at multiple times throughout their lives, yielding a median of 13 unique farm jobs and 8 unique crops among men and 7 jobs and 5 crops among women.

CONCLUSIONS

The project demonstrated that it is feasible to collect detailed work histories and other risk factor data from farmworkers, documented the complexity of work histories encountered among farmworkers, and yielded recommendations for refining a questionnaire that will facilitate future epidemiologic research on farmworkers.

Recent dental attendance and levels of untreated caries in a sample of 11-12 year old children in Northern Ireland

The object of the present study was to determine the relationship between dental attendance and the levels of untreated caries in a sample of 11-12 year old pupils attending first form of second level schools in the South Belfast area of Northern Ireland. A sample of 199 first form pupils attending second level schools in the area was obtained. The diagnosis of caries depended mainly on visual evidence following removal of debris and moisture. Blunted probes were used to confirm or reject doubtful lesions and no radiographs were taken. Details of parental employment status were obtained by a questionnaire to the parents. The data were entered on to an N.C.S.S. data analysis system for stepwise regression and analysis of variance. Overall there was a significant difference in the untreated caries status of those with different attendance patterns, the major difference being that a much higher proportion of those who had not attended within the previous 12 months had active caries. Almost half of the children had attended in the previous six months and only 16 (8 per cent) had not attended in the previous 12 months. Independent analysis indicated that parental employment status was significantly related to the level of untreated caries (p > or = 0.05). Independent variables entered in the stepwise regression were attendance, employment status and DMFT. The strongest predictors of untreated caries were previous caries experience and period since dental attendance, while employment status was a significant but weaker factor in the analysis. These findings may be relevant when planning the frequency of school dental screenings and managing the frequency of dental recalls and examinations.

Bupropion SR as an aid to smoking cessation in smokers treated previously with bupropion: a randomized placebo-controlled study

BACKGROUND

Many persons who attempt to quit smoking have made previous unsuccessful attempts to quit with pharmacologic aids. An understanding of the impact of these previous attempts to quit is vital for selecting medications that may be more successful in a future attempt to quit. In particular, the effect of repeated use of bupropion SR (Zyban; INN, amfebutamone) on abstinence rates has not been studied previously.

METHODS

This was a multicenter, randomized, double-blind, placebo-controlled study in 450 smokers who had previously used bupropion in a smoking cessation attempt. The study consisted of a screening phase, a 12-week treatment phase, and a follow-up at month 6. Participants made regular clinic visits throughout the treatment phase during which they received brief counseling sessions to encourage abstinence from smoking. The primary end point was continuous abstinence from smoking from weeks 4 through 7. Secondary efficacy end points were examined throughout the treatment phase and at follow-up after 6 months.

RESULTS

In participants receiving bupropion SR, 27% (61 of 226) remained abstinent throughout the period from weeks 4 through 7 compared with 5% (11 of 224) of participants receiving placebo (P <.001). Significantly (P <.001) more participants who received bupropion SR during the treatment phase remained continuously abstinent from the start of week 4 through month 6 (27 of 226; 12%) compared with participants who received placebo (5 of 224; 2%). Eleven participants receiving placebo (5%) and 19 participants receiving bupropion SR (8%) stopped taking the study medication because of an adverse event.

CONCLUSIONS

Bupropion SR is an effective medication for retreatment of smokers who have used bupropion SR previously.

Effect of abciximab on cardiac enzyme elevation after transluminal extraction atherectomy (TEC) in high-risk saphenous vein graft lesions: comparison with a historical control group

Saphenous vein graft (SVG) intervention has been associated with an increased incidence of distal embolization. Long lesions and lesions associated with thrombus are particularly at increased risk. This study was performed to determine whether abciximab may decrease this risk in high risk SVG angioplasty. From June 1994 to June 1998, 84 patients with at least one high risk factor, i.e., lesion length >20 mm or angiographic evidence of thrombus, underwent Transluminal extraction atherectomy (TEC) procedure followed by balloon dilatation or stenting. Of these 84 patients, 37 who had procedure after September 1995 underwent TEC with abciximab (Abciximab Group) and 47 who had their procedure before that date had TEC without abciximab thereby serving as historic control (Non-Abciximab Group). All patients had normal pre-procedure CK and CK-MB. Total creatine kinase (CK) and CK-MB were measured every 8 hr post-procedure for 24 hr. Baseline demographics, angiographic characteristics, incidence of LV dysfunction and triple vessel disease were similar between the two groups. Graft age was similar between two groups (122 +/- 70 vs. 117 +/- 54 months). Graft diameter, pre and post-procedure percent stenoses were not different between the two groups. Stents were used in 65% in the Abciximab group and 45% in Non-Abciximab group (P = 0. 14). There was no in-hospital repeat PTCA, urgent bypass surgery, or cardiac death. There was no difference between the two groups in regards to the incidence of any elevation of total CK (27% vs. 21. 3%) or CK-MB (54% vs. 51%). When used in conjunction with TEC in treating high risk vein graft lesions, abciximab did not reduce post procedure CK-MB elevation in this patient population.

Multiplex Reverse Transcriptase PCR Assay for Simultaneous Detection of Three Fish Viruses

A multiplex reverse transcriptase (RT)-PCR assay was developed for the simultaneous detection of three different fish viruses: infectious pancreatic necrosis virus (IPNV), infectious hematopoietic necrosis virus (IHNV), and viral hemorrhagic septicemia virus (VHSV). The sensitivity levels of the multiplex RT-PCR assay were 100, 1, and 32 50% tissue culture infective doses/ml for IPNV, IHNV, and VHSV, respectively.

The relationship of serum androgens and ovulatory status to blood pressure in reproductive-age women

The objective of this cross-sectional study was to determine the relationship between hyperandrogenemia and blood pressure in women with menstrual irregularities seen at an endocrinology clinic. Women with serum testosterone levels (T) > or = 30 ng/dL were more likely to have general obesity (odds ratio [OR] = 6.8, 95% confidence intervals [CI] = 2.2-27.2) and central obesity (OR = 14.5, 95% CI = 6.1-38.7) than euandrogenemic women. Hyperandrogenemic women (HA) had an OR of 2.4 (95% CI = 1.0-6.2) for elevated SBP and an OR of 2.7 (95% CI = 0.8-8.8) for elevated DBP, independent of age and ovulatory status. Obese HA had an OR of 4.7 (95% CI = 2.3-10.4) for elevated SBP and an OR of 2.9 (95% CI = 1.9-9.9) for elevated DBP. In conclusion, T is associated with an increased risk for obesity and central adiposity. T predicts BP elevation independent of age and ovulatory status. There was a synergistic relationship between obesity and androgens in their affect on BP.

Evaluation of extent of shortening versus velocity of shortening at the endocardium and midwall in hypertensive heart disease

To assess the incremental value of velocity of shortening velocity parameters compared with simpler, more widely used, extent of shortening parameters in compensated left ventricular hypertrophy, we studied 52 patients with left ventricular hypertrophy and 63 age-matched controls. Velocity parameters did not provide incremental information beyond that obtained by extent of shortening parameters.

Creating and implementing guidelines on caring for difficult patients: a research utilization project

Difficult patients challenge the resourcefulness of nurses. Considering the results of a focus group study, guidelines are designed for the care of difficult patients. Four case studies present the use of the guidelines, including interventions and outcomes.

Reproductive and developmental effects of occupational pesticide exposure: the epidemiologic evidence

There is increasing evidence for reproductive and developmental effects of both maternal and paternal pesticide exposures. Here is a summary of the epidemiologic data, culled from studies in humans, with significant attention to Agent Orange.

Managing the teenager with epilepsy: paediatric to adult care

Epilepsy starting in childhood frequently persists through adolescence and into adult life, and an onset in adolescence itself is common. The management of the teenager with epilepsy is important but often inadequate. In 1991, a specific clinic for teenagers with epilepsy was established in Liverpool to address the unique needs and concerns of this age group and, importantly, to facilitate a smooth hand-over of specialist epilepsy care from paediatric to adult services. An additional and crucial benefit of this clinic has been to provide a further, and hopefully final, screen to confirm (or refute) the diagnosis of epilepsy, to corroborate, or correctly identify, the specific epilepsy syndrome and to ensure that the most appropriate antiepileptic drug (AED) is being prescribed and when, if possible, the drug can be withdrawn. Of 120 consecutive patients referred to the teenager clinic, 12 (10%) did not have epilepsy, and 26 (22%) were being treated with an inappropriate AED. The main issues and concerns voiced by the teenagers included choices of further education and career, the possibility and risks of withdrawing anticonvulsants, driving regulations, the inheritance of epilepsy and pregnancy/contraception. This teenager clinic could serve as a model for both other 'epilepsy centres' and also for managing other chronic disorders with an onset in childhood.

The management of febrile seizures in the Mersey Region

The management of children with febrile seizures admitted to hospital within the Mersey region was evaluated by case note review. The patient groups were demographically similar in all the participating hospitals. Most children were admitted for less than 48 hours and nearly all received paracetamol as an antipyretic. There was a marked variation in the number of investigations performed in each hospital, with venepunctures for blood cultures and white blood cell counts ranging from 6 to 56% and from 8 to 70%, respectively. The majority of children had a urinalysis. 23 to 78% of children were prescribed antibiotics. Further studies are required on the value of hospital admission and the appropriate use of investigations and antibiotics in children with febrile seizures.

The management of epilepsy in children: the role of the clinical nurse specialist

Epilepsy in children is frequently accompanied by learning, behavioural and psychological difficulties. These difficulties may be compounded by the ignorance and stigma which exists within the community health care and education services. The management of epilepsy in children therefore extends far beyond the use of antiepileptic drugs and must address these additional problems. The establishment of a nurse specialist service in paediatric epilepsy within our hospital has provided a more satisfactory and comprehensive management of these children and, in addition, has facilitated a close liaison with schools, community health personnel and support groups; as a result this has dispelled much of the local ignorance, misunderstanding and stigma surrounding epilepsy.

Reduced left ventricular systolic pump performance and depressed myocardial contractile function in patients > 65 years of age with normal ejection fraction and a high relative wall thickness

We studied the relation between relative wall thickness, left ventricular systolic pump performance, and myocardial contractile function in 77 older patients with normal ejection fraction who were free of valvular and myocardial ischemic disease. Group 1 comprised 49 patients with relative wall thickness > or = 0.45; group 2 (n = 28) had normal relative wall thickness. Pump performance was characterized by stroke volume index, cardiac index, and stroke work; myocardial function was characterized by midwall shortening and circumferential stress versus shortening relations. Group 1 patients had lower end-diastolic volume (83 +/- 3 vs 124 +/- 5 ml, p < 0.05), cardiac index (2.6 +/- 0.2 vs 3.5 +/- 0.1 L/min/m2, p < 0.05), and stroke work/100 g left ventricular mass (43 +/- 2 vs 53 +/- 3 g-m/100 g, p < 0.005). Although there was no significant difference with regard to ejection fraction or fractional shortening at the endocardium, fractional shortening at the midwall was significantly lower in group 1 than in group 2 (16 +/- 1% vs 19 +/- 1%, p < 0.005). This lower value for midwall shortening was observed despite lower values for endsystolic stress, implying decreased myocardial contractile function. Lower stroke volume index in group 1 patients, likely due to small chamber size, was not offset by increased heart rate, resulting in a low-normal cardiac index; in 33% of group 1 patients, cardiac index was < 2.2 L/min/m2, indicating reduced pump performance. Our data indicate an abnormality in pump performance and myocardial function in patients who have high relative wall thickness and normal ejection fraction.