1068 QIP ASSESSING ROUTINE RECORDING OF OVERNIGHT VITAL SIGNS (OVS) AND OVERNIGHT MEDICATIONS ADMINISTRATIONS (OMARS) IN ELDERLY CARE

Introduction

Poor sleep is experienced by up to half of hospital inpatients1, associated with poor cognition, weak immunity, hypertension and increased mortality2. Recent studies recommend fewer sleep interruptions through targeted reductions in routine recording of overnight vital signs (OVS) and overnight medication administrations (OMARS) 3. The following standards were agreed at New Cross Hospital for audit (expected compliance 90%); 1. Routine OVS for stable patients shouldn’t be done overnight (2,200 pm to 0600 am). 2. Routine OMARS shouldn’t be undertaken overnight. These were derived after scrutinizing following; NICE CG1034 and QS635, NSF (Department of health)-4.256, RCP Acute care toolkit 37, CG508.

Method

Retrospective data recorded over 10 days in May and August 2021 from electronic records which included 61 elderly patients in 1st and 53 in 2nd audit cycle. Exclusion was Early Warning Score ≥ 3. We also ran night shift surveys to observe staff perceptions, completed online.

Results

OVS recording showed poor compliance of 0% and 3.77%. OMARS were done in less than half of patients but improved in subsequent audit cycle to about in 1/3rd of patients (77.35% compliance). No patient became unwell or required escalation of care. The estimated time spent on these interventions was 2.5 hours/week or 30 days in 1 calendar year. Almost all survey participants agreed to stop OVS while 66.6% of them agreed to stop OMARS in both cycles. 39.39% in 1st cycle believed that this strategy can cause harm and this misperception was reduced to 22.22% in subsequent cycle.

Conclusion

Our QIP advocates for rationalizing interventions and ensuring we only complete interventions where clinically relevant9. It showed improvement in reducing OMARS but success in stopping OVS couldn’t be fully translated in true spirits, possibly due to common misperceptions which will be further addressed in subsequent audit cycles.

Molecular epidemiology of hepatitis B virus genotypes in blood donors in Islamabad, Pakistan

BACKGROUND:

Hepatitis B virus (HBV) is a major causative agent of early, severe and prolonged liver infection that subsequently leads to cirrhosis of liver and hepatocellular carcinoma. The aim of this study was to evaluate the molecular epidemiology of hepatitis B virus (HBV) genotypes and comparison of serological assay performance versus polymerase chain reaction (PCR) in HBV screening.

METHODS:

Blood samples of 8517 healthy blood donors were collected during the period of January to June 2017 from Blood Bank of Shaheed Zulfiqar Ali Bhutto Medical University, Islamabad. Samples were screened for HBsAg assay using technique of chemiluminescence immunoassay. PCR of positive samples was carried out using already reported genotype-specific primers by Naito et al. (2001). The results were confirmed by visualizing genotype bands.

RESULTS:

The study confirmed the presence of HBV in 2.5% of blood donors, and PCR confirmed the presence of HBV-DNA in 92 samples. The genotyping was done by PCR using type-specific primer sequences. PCR was dogged to check six genotypes, i.e., A, B, C, D, E, and F. The results of this study show high levels of Genotype D is this region, i.e., 52.17% with less dominating Genotype C, which is 16.30% with decreasing ratio of Genotype E (14.13%), Genotype A and B (9.78%), and mixed D + E (2.17%). The presence of coinfection is found at lowest rate. Due to the high percentage of HBV/D, it is concluded that D genotype is common in our population.

CONCLUSION:

The most prevalent HBV genotype in ICT region was genotype D, which is responsible for liver cirrhosis and hepatocellular carcinoma. Efficacy of drugs varies with variation in genotypes of hepatitis B virus and also with geographical distribution.

Role of fine-needle aspiration cytology in evaluating mediastinal masses

Background:

Fine-needle aspiration cytology is an important and useful investigation and is considered next to imaging in the diagnosis of mediastinal lesions. We carried out this study in the Department of TB and respiratory diseases JNMC Aligarh from March 2000 to March 2002 with the following aims.

Objectives:

To make etiological diagnosis of mediastinal lesions, determine the pathological type of the tumor in cases of malignancy and evaluate the role of fine-needle aspiration cytology in staging of bronchogenic carcinoma.

Materials and Methods:

A total of 56 patients were included in this study who had mediastinal mass with or without lung lesions on chest X-ray or computed tomography scan. Of these patients, 36 had mediastinal mass only and 20 had mediastinal mass with parenchymal lesion.

Results:

In the present study, of 56 patients, 36 had mediastinal masses and 20 had pulmonary mass.

Conclusion:

Percutaneous fine-needle aspiration is an easy and reliable method for reaching a quick tissue diagnosis in pulmonary and mediastinal masses.

Patients' attitudes towards trainee surgeons performing cataract surgery at a teaching hospital

AIM

To evaluate patients' preferences of surgeon to perform their cataract surgery if given a choice between consultant and trainee.

METHODS

A questionnaire based patient satisfaction survey was conducted in a large University Teaching Hospital in the UK. One hundred and eighty patients undergoing first eye cataract surgery between January and March 2006 were asked a number of set questions on their preferences regarding the surgeon performing the operation. Primary outcome measure was the patient's preference for who would perform their cataract surgery (consultant or trainee).

RESULTS

Overall, 126 (70%) accepted that trainee surgeons should operate as part of their training. Only 102 (81%) of these (57% of the total) would be happy to be operated on themselves by a supervised surgical trainee. Ninety-eight (78%) patients objected to being operated on by a trainee if they were to be unsupervised. One hundred and forty-two (79%) patients stated they would choose to wait longer for their surgery if it meant that a consultant would perform their operation. This preference was held significantly more strongly among patients who had been listed for surgery from a consultant's clinic rather than from the pooled 'cataract clinic' (P=0.048). One hundred and forty-four (80%) patients thought they should be told the name and designation of the surgeon who was to perform their operation.

CONCLUSIONS

Patients undergoing their first cataract procedure appear to have a preference for their named consultant to perform their surgery. If 'patient choice' extends to the choice of operating surgeon, then there are clear implications for the training of future UK ophthalmologists.

The −174G/C interleukin-6 promoter polymorphism influences the development of macular oedema following uncomplicated phacoemulsification surgery

AIM

To determine whether the functional -174 G/C interleukin-6 gene polymorphism is a risk factor for the development of cystoid macular oedema (CMO) following routine uncomplicated phacoemulsification surgery in patients with no established risk factors.

METHODS

A total of 40 patients who underwent routine phacoemulsification surgery as part of a randomised controlled trial comparing the use of postoperative steroid drops against a single sub-tenon injection of triamcinolone were genotyped for the IL-6 -174G/C polymorphism. All patients underwent fluorescein angiography at 30 days and anterior chamber flare measurements pre-operatively and at day 1, 7, and 30.

RESULTS

Angiographic CMO developed in 14 patients of the 40 studied. 9 out of the 14 patients carried the GG genotype (Fisher's exact test P=0.05, Hazard ratio for GG genotype; 4.05 (1.02-16.00)). There was no difference in flare measurements between the GG and Non-GG (GC/CC) group. The two groups were otherwise well matched in terms of age, sex, phacoemulsification energy used intraoperatively, and proportion of patients receiving postoperative triamcinolone or steroid drops.

CONCLUSION

The -174G/C interleukin-6 promoter gene variant appears to modulate the response to phacoemulsification surgery and to influence the development of postoperative CMO. These data suggest a genetic predisposition to this complication.

Expression of the plasminogen activator system in the human vascular wall

In this paper we describe the expression of the tissue plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), plasminogen activator inhibitor-1 (PAI-1) and the uPA receptor (uPAR), in normal and atheromatous human vascular tissue obtained at coronary and peripheral vascular surgery. tPA, uPA, PAI-1 and uPAR antigens were localised by immunohistochemistry. Vessel homogenates were used to quantitate tPA, uPA and PAI-1 antigens as well as uPA and PAI-1 activities using immunoassay and immunoactivity assays, respectively. Quantitative reverse transcription polymerase chain reaction assays (PAI-1 and uPA) were developed and used to quantify PAI-1 and uPA mRNA. In-situ hybridisation (tPA, uPA and PAI-1) was used to localise mRNA. In normal saphenous vein or internal mammary artery, expression of tPA, uPA and PAI expression is associated with endothelium and with intimal or medial smooth muscle cells, but expression is at a low level. uPAR protein was seen on the endothelium of normal saphenous vein or internal mammary artery but absent on the smooth muscle cells. In complex atheroma tPA, uPA, PAI and uPAR proteins were associated with the endothelium, groups of smooth muscle cells (in the intima and around vascular channels, but not with the media), infiltrating mononuclear cells, and also with acellular areas. PAI-1, tPA and uPA mRNA were demonstrated in atheroma in endothelial cells and smooth muscle cells, as well as in areas rich in macrophages. In stenosing saphenous vein grafts there was strikingly increased tPA and uPA (but not PAI-1) expression in neointimal smooth muscle cells and migrating SMC at the intima/media border. A major difference between complex atheroma and either normal vessel or saphenous vein grafts was greatly increased expression of PAI-1 mRNA associated with smooth muscle cells (SMC) in the former. In spite of the greatly increased PAI-1 mRNA expression in atheromatous lesions, the immunoactivity assay showed PAI-1 activity to be low compared to normal internal mammary artery. Our findings would be compatible with previous reports implicating the plasminogen activator/inhibitor system in the initiation and control of matrix remodelling during normal and pathological vessel growth and repair, but also emphasize the complexity of this process in human vessels.

Endothelin-B receptors mediate intimal hyperplasia in an organ culture of human saphenous vein

OBJECTIVE

Although a number of pharmacologic agents have been shown to reduce intimal hyperplasia in animal models of restenosis, to date no systemic agent has conclusively been shown to be effective in humans. Recently, considerable attention has been directed towards endothelin (ET), a potent vasoconstrictor and a powerful mitogen for vascular smooth muscle cells, as a mediator of intimal hyperplasia. Endothelin-1 has been shown to be mitogenic for human saphenous vein smooth muscle cells, and expression also is elevated in human vein graft stenosis. The aim of this study was the investigation of whether ET receptor antagonists can attenuate neointima formation in a laboratory model of vein graft intimal hyperplasia and the determination of whether the effects are mediated by a specific ET receptor subtype.

METHODS

We used an organ culture of human saphenous vein, a well-validated model of vein graft intimal hyperplasia. Paired segments of human long saphenous vein were cultured with and without the following antagonists: bosentan, a nonselective ET receptor antagonist; BQ 123, a specific endothelin-A antagonist; or BQ 788, a specific endothelin-B (ETB) antagonist. After 14 days in the culture, the segments were fixed and processed and the sections were immunostained to facilitate the measurements of neointimal thickness with a computerized image analysis system.

RESULTS

The nonselective antagonist bosentan and the ETB selective antagonist BQ 788 significantly reduced neointima formation by 70% (P = .001) and 50% (P = .03), respectively, but the ETA antagonist BQ 123 had no significant effect on the reduction of neointima formation (P = 1.0).

CONCLUSION

The results of this study imply an important role for ET as a mediator of human vein graft intimal hyperplasia and imply further that a specific ETB antagonist may have a therapeutic potential for the prevention of vein graft stenosis.

Endothelin-1 is a mediator of intimal hyperplasia in organ culture of human saphenous vein

BACKGROUND

Endothelin-1 (ET-1) is a powerful vasoconstrictor and a potent mitogen for vascular smooth muscle cells. Excessive smooth muscle cell proliferation is a feature of intimal hyperplasia, the pathological lesion of vein graft stenosis. This study investigates the role of ET-1 in isolated human saphenous vein smooth muscle cells and also in an organ culture of the human saphenous vein.

METHODS

Growth-arrested human saphenous vein smooth muscle cells were stimulated with ET-1 and proliferation quantified by [3H]thymidine uptake in these cells compared with unstimulated control cells. Organ cultures of the human saphenous vein were established with endothelium intact, with endothelium denuded, and with endothelium denuded and the culture medium supplemented with ET-1.

RESULTS

ET-1 stimulated DNA synthesis in isolated smooth muscle cells in a dose-dependent manner with half-maximal stimulation at 1 nmol/l. Addition of ET-1 to denuded vein caused a significant increase in median (range) neointimal thickness, from 4 (0-19) to 20 (4-30) microns (P < 0.05). In veins cultured with ET-1 a parallel increase in median (range) neointimal proliferation index, from 21 (0-31) to 33 (23-46) per cent (P < 0.05), was also observed.

CONCLUSION

These results demonstrate that ET-1 is a mediator of intimal hyperplasia in human saphenous vein in vitro. Endothelin receptor antagonists may therefore be of therapeutic value in the modulation of vein graft intimal hyperplasia.

Stimulation of two vascular smooth muscle-derived cell lines by angiotensin II: differential second messenger responses leading to mitogenesis

1. We show here that angiotensin II (AII) and endothelin-1 (ET-1) stimulate [3H]-thymidine incorporation in a smooth muscle cell line derived from aortae of spontaneously hypertensive rats (SHR), but not in cells derived from normotensive controls (WKY). We have used the differential response of the two cell lines to investigate the relationship between second messenger systems and the mitogenic response. 2. AII produced an increase in accumulation of inositol 1,4,5-triphosphate which was greater in the SHR-derived cell line than in the WKY cells. 3. AII gave an increase in cytosolic Ca2+ in each of the cell lines, with both a larger peak (15-30 s) and plateau response (2 min) in the SHR cells. ET-1 gave an enhanced response in the SHR-derived cells with respect to the peak but not the plateau of cytosolic Ca2+. 4. Phospholipase D activity was studied by monitoring the formation of [3P]-phosphatidylbutanol in 32Pi prelabelled cells. AII stimulation gave a larger phospholipase D response in the SHR-derived cells, while ET-1 gave a larger response in WKY-derived cells. 5. Stimulation of SHR-derived cells with 100 nM AII for 1 h, followed by 19 h in the absence of agonist, stimulated [3H]-thymidine incorporation over the next 4 h. When the 1 h stimulation with AII was in the presence of increasing concentrations of butanol, which diverts the product of the phospholipase D pathway, there was a loss of stimulated [3H]-thymidine incorporation which was significant at 10 mM butanol and at 30-50 mM reached a maximum loss of 40%. 6. Contrasting with this there was no apparent loss of ET-l-stimulated thymidine incorporation when butanol was present at concentrations up to 40 mM.7. These results suggest that phospholipase D is one of several pathways in the mitogenic response of SHR-derived vascular smooth muscle cells to All.