[Pharmaceutical residues in aquatic compartments : Status quo and perspectives]

Meanwhile, more than 600 different pharmaceuticals have been detected in surface water, with diclofenac, ethinylestradiol and cotrimoxazole as the frequently dominating substances. The highest concentrations of parent compounds, metabolites and transformation products were measured particularly in urban wastewater discharges, in liquid manure from animal husbandries and aquaculture facilities; however, the levels of certain psychopharmaceuticals and estrogen effective substances in surface water have been associated with behavioral changes and reproduction toxicity in fish species. As a consequence, in the near future measures must be implemented that noticeably reduce the discharge of pharmaceuticals into the environment. With respect to drinking water, the currently detected concentrations of active agents have so far not been found to reach toxicologically relevant concentrations for human beings. In contrast, swimming and bathing in receiving waters can be critical.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial

BACKGROUND

The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported.

OBJECTIVE

To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia.

DESIGN

Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505).

SETTING

46 U.S. and Canadian hospitals.

PARTICIPANTS

Patients aged 50 years or older undergoing hip fracture surgery.

INTERVENTION

Spinal or general anesthesia.

MEASUREMENTS

Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care.

RESULTS

A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups.

LIMITATION

Missing outcome data and multiple outcomes assessed.

CONCLUSION

Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia.

PRIMARY FUNDING SOURCE

Patient-Centered Outcomes Research Institute.

Guidelines for day-case surgery 2019: Guidelines from the Association of Anaesthetists and the British Association of Day Surgery

Guidelines are presented for the organisational and clinical management of anaesthesia for day-case surgery in adults and children. The advice presented is based on previously published recommendations, clinical studies and expert opinion.

Peri-operative management of the surgical patient with diabetes 2015: Association of Anaesthetists of Great Britain and Ireland

Diabetes affects 10-15% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough pre-operative assessment and optimisation of their diabetes (as defined by a HbA1c < 69 mmol.mol(-1) ); deciding if the patient can be managed by simple manipulation of pre-existing treatment during a short starvation period (maximum of one missed meal) rather than use of a variable-rate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurate and well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guideline is to provide detailed guidance on the peri-operative management of the surgical patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.

A guide to critiquing a research paper on clinical supervision: enhancing skills for practice

This paper aims to do two things: First, we want to show the reader how to critique a published research paper. The second aim is to take the reader through the various stages of critiquing using a guide. In the paper, we explain at each stage the research terms that can deter the novice critic from reading and understanding the findings in research. From this we hope the reader will have developed an ability to do their own critiquing, so that they are better informed about the quality of research that influences nursing practice. In this paper we have taken a previously published paper on the effectiveness of clinical supervision and undertaken a systematic critique of the merits of this quantitative research using a recognized critiquing framework compiled by Coughlan et al. (2007). Our purpose was twofold: First, we wanted to demonstrate the various stages of critiquing a paper in order that the reader might make an informed judgment of the quality and relevance of the research. The reader/critic is then able to decide whether to use this research in their own practice. Second, we wanted to assist the reader to develop their own critical, analytical skills through methodically appraising the merits of published research. Nursing as an evidence-based profession requires nurses at both pre- and post-registration level to be able to understand, synthesize and critique research, this being a fundamental part of many nursing curricula. These have become core skills to acquire because implementing up-to-date evidence is the cornerstone of contemporary nursing practice. We have provided in this paper a template for critiquing, which is based on our combined experiences as academics specifically in teaching at the bachelor, master's and doctoral levels.

NHS Diabetes guideline for the perioperative management of the adult patient with diabetes

These Joint British Diabetes Societies guidelines, commissioned by NHS Diabetes, for the perioperative management of the adult patient undergoing surgery are available in full in the Supporting Information. This document goes through the seven stages of the patient journey when having surgery. These are: primary care referral; surgical outpatients; preoperative assessment; hospital admission; surgery; post-operative care; discharge. Each stage is given its own considerations, outlining the roles and responsibilities of each group of healthcare professionals. The evidence base for the recommendations made at each stage, discussion of controversial areas and references are provided in the report. This document has two key recommendations. Firstly, that the management of the elective adult surgery patients should be with modification to their usual diabetes treatment if the fasting is minimized because the routine use of a variable rate intravenous insulin infusion is not recommended. Secondly, that poor preoperative glycaemic control leads to post-outcomes and thus, where appropriate, needs to be addressed prior to referral for surgery.

Vaccination of poultry workers: delivery and uptake of seasonal influenza immunization

Avian influenza is a highly infectious disease in poultry and although the risk of human infection is low, concerns exist that it could evolve into a new human strain of pandemic potential if reassortment with a human influenza virus occurs. In January 2007, the UK government introduced a programme to vaccinate poultry workers to reduce the potential of such an event. This study evaluates the delivery, uptake and costs of the programme in three counties of England. A questionnaire survey was completed by consultants in public health in all the Primary Care Trusts in Norfolk, Suffolk and Cambridgeshire in May 2007. The delivery of the programme varied between Primary Care Trusts, including being delivered in some cases by clinics in primary care, by general practitioners and occupational health services in others. The uptake of vaccination was low ranging from 7% to 29% at a cost of £29 to £132 per person vaccinated. Vaccination of poultry workers as a public health measure to prevent an influenza pandemic is likely to be ineffective with the level of coverage found in this evaluation in our region.

Supporting mentors as assessors of clinical practice

This article presents a brief history of national and regional changes in pre-registration nurse education together with an overview of how these were adopted in Wales. The development and functions of the practice facilitator role are described and the results of a small-scale audit are discussed. The audit sought to elicit if the training and support given to mentors via the practice facilitators were effective and how this strengthened the credibility of the assessment process of students in practice.

Calf venous compliance in multiple system atrophy

In multiple system atrophy (MSA), increased venous compliance with excessive venous pooling is assumed to be a major contributor to orthostatic hypotension (OH); however, venous compliance has never been assessed in MSA patients. We evaluated the severity and distribution of adrenergic, cardiovagal, and sudomotor failure in 11 patients with probable MSA, 14 age- and sex-matched control subjects, and 8 patients with Parkinson's disease (PD) but not OH. Calf venous compliance, venous filling, and capillary filtration were measured using calf plethysmography. The response to the directly acting α-adrenergic stimulation (10 mg midodrine) on calf venous compliance was additionally evaluated. Contrary to our hypothesis, pressure-volume curves in the legs of MSA patients were flatter than in PD patients ( P < 0.05) or controls ( P < 0.001); this indicated reduced calf venous compliance in MSA. The MSA group had reduced venous filling compared with control ( P < 0.001) or PD subjects ( P < 0.001) but had a normal capillary filtration rate ( P = 0.73). Direct α-adrenergic stimulation resulted in a slight but significant reduction of calf venous compliance in controls ( P = 0.001) and PD subjects ( P < 0.001) but not in the MSA group. The compliance change in MSA significantly regressed with autonomic failure (composite autonomic severity scale, r2 = 0.56) but not with parkinsonism (Unified MSA Rating Scale, r2 = 0.12). Our data indicate that MSA patients with chronic OH have reduced, rather than increased, venous compliance in the lower leg. We postulate that chronic venous distension that is associated with OH results in structural remodeling of veins, leading to reduced compliance, a change which may protect patients against orthostatic stress.

Systemic antimicrobial prophylaxis for percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomies (PEG) maintain nutrition in the short or long term. A PEG is a feeding tube, placed surgically through the anterior abdominal wall, which delivers a liquid diet, or medication, via a clean or sterile delivery system. Those undergoing PEG placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression and underlying disease processes such as malignancy and diabetes mellitus. The increasing incidence of methicillin-resistant Staphylococcus aureus (MRSA) contributes both an additional risk to the placement procedure, and also to the debate surrounding antibiotic prophylaxis for PEG placement. The aim of surgical antimicrobial prophylaxis is to establish a bactericidal concentration of an antimicrobial drug in the patients serum and tissues, via a brief course of an appropriate agent, by the time of PEG placement.

OBJECTIVES

The review seeks to establish whether prophylactic use of systemic antimicrobials reduces the risk of peristomal infection in people undergoing placement of percutaneous endoscopic gastrostomies.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (July 2006); The Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2); handsearched wound care journals relevant conference proceedings, and bibliographies of relevant publications identified by these strategies for further studies; and contacted manufacturers and distributors of PEG products.

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the use of prophylactic antimicrobials for PEG placement, with no restrictions for language, date or publication status.

DATA COLLECTION AND ANALYSIS

Both authors performed data extraction and assessment of study quality. Meta-analysis was performed where appropriate.

MAIN RESULTS

We identified 10 eligible RCTs evaluating prophylactic antimicrobials in 1100 patients. All trials reported peristomal infection as an outcome, and a pooled analysis resulted in a statistically significant reduction in the incidence of peristomal infection with prophylactic antibiotics (pooled OR 0.31, 95% CI 0.22 to 0.44).

AUTHORS' CONCLUSIONS

Administration of systemic prophylactic antibiotics for PEG placement reduces peristomal infection.

Osmosensitive mechanisms contribute to the water drinking-induced pressor response in humans

BACKGROUND

Water drinking elicits a sympathetically mediated pressor response in multiple-system atrophy patients through an unknown mechanism. We reasoned that gastrointestinal distention, hyposomotic stimulation, or both contribute to the water-induced pressor response.

METHODS

We compared the response to normal saline and water on blood pressure in 10 patients with probable multiple-system atrophy. Patients featured moderate to severe autonomic dysfunction. EKG and finger arterial blood pressure were recorded continuously, and 500 mL normal saline and distilled water were each given in a single-blinded fashion. Fluids were applied through a previously inserted nasogastric tube within a 5-minute period.

RESULTS

Blood pressure began to increase within 10 minutes after water administration and reached a maximum after 20 minutes. Blood pressure did not change after saline administration. The blood pressure change after 20 minutes was 8 +/- 9/2 +/- 5 mmHg with water and -1 +/- 11/-1 +/- 7 mmHg with normal saline administration (p = 0.02 between interventions). Heart rate did not change with either intervention.

CONCLUSION

Ingestion of water elicits a greater pressor response than the ingestion of normal saline. Thus, gastric distention is probably not the crucial mechanisms for the water-induced pressor response. Instead, the response may be mediated through osmosensitive afferent structures in the gastrointestinal tract, portal vein, and liver.

Preoperative skin antiseptics for preventing surgical wound infections after clean surgery

BACKGROUND

Approximately 15% of elective surgery patients and 30% of patients receiving contaminated or dirty surgery are estimated to develop post-operative wound infections. The costs of surgical wound infection can be considerable in financial as well as social terms. Preoperative skin antisepsis is performed to reduce the risk of post-operative wound infections by removing soil and transient organisms from the skin. Antiseptics are thought to be both toxic to bacteria and aid their mechanical removal. The effectiveness of preoperative skin preparation is thought to be dependent on both the antiseptic used and the method of application, however it is unclear whether preoperative skin antisepsis actually reduces post-operative wound infection and if so which antiseptic is most effective.

OBJECTIVES

To determine whether preoperative skin antisepsis reduces post-operative surgical wound infection.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Trials Register and the Cochrane Central Register of Controlled Trials in April 2004. In addition we handsearched journals, conference proceedings and bibliographies.

SELECTION CRITERIA

Randomised controlled trials evaluating the use of preoperative skin antiseptics applied immediately prior to incision in clean surgery. There were no restrictions based on language, date or publication status.

DATA COLLECTION AND ANALYSIS

Three reviewers independently undertook data extraction and assessment of study quality. Pooling was inappropriate and trials are discussed in a narrative review.

MAIN RESULTS

We identified six eligible RCTs evaluating preoperative antiseptics. There was significant heterogeneity in the comparisons and the results could not be pooled. In one study, infection rates were significantly lower when skin was prepared using chlorhexidine compared with iodine. There was no evidence of a benefit in four trials associated with the use of iodophor impregnated drapes.

REVIEWERS' CONCLUSIONS

There is insufficient research examining the effects of preoperative skin antiseptics to allow conclusions to be drawn regarding their effects on post-operative surgical wound infections. Further research is needed.

A randomized trial of botulinum toxin A for treatment of drooling

The authors compared the efficacy of three different doses (18.75, 37.5, and 75 MU per parotid gland) of botulinum toxin A (BTX-A; Dysport, Ipsen Pharma, Germany) injections vs vehicle in patients with sialorrhea (n = 32) using a single-center, prospective, double-blind, placebo-controlled dose-finding study. The primary endpoint was achieved with 75 MU BTX-A without treatment-related adverse events, suggesting BTX-A is a safe and effective treatment for patients with sialorrhea.

Disposable surgical face masks for preventing surgical wound infection in clean surgery

BACKGROUND

Surgical face masks were originally developed to contain and filter droplets of microorganisms expelled from the mouth and nasopharynx of healthcare workers during surgery, thereby providing protection for the patient. However there are several ways in which surgical face masks could potentially contribute to contamination of the surgical wound.

OBJECTIVES

To identify and review all randomised controlled trials evaluating disposable surgical face masks worn by the surgical team during clean surgery to prevent post-operative surgical wound infection.

SEARCH STRATEGY

All relevant publications about disposable surgical face masks were sought through the Specialised Trials Register of the Cochrane Wounds Group (March 2001). Manufacturers and distributors of disposable surgical masks as well as professional organisations including the National Association of Theatre Nurses and the American Operating Room Nurses Association were contacted for details of unpublished and ongoing studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled trials comparing the use of disposable surgical masks with the use of no mask were included.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by AL and PE.

MAIN RESULTS

Two randomised controlled trials were included involving a total of 1453 patients. In a small trial there was a trend towards masks being associated with fewer infections, whereas in a large trial there was no difference in infection rates between the masked and unmasked group. Neither trial accounted for cluster randomisation in the analysis.

REVIEWER'S CONCLUSIONS

From the limited results it is unclear whether wearing surgical face masks results in any harm or benefit to the patient undergoing clean surgery.

Theatre nursing in Finland

As part of the Socrates exchange system three students from the School of Care Sciences, University of Glamorgan visited Finland for a 15-week placement. They were based in two areas Hameenlinna and Kuopio. As part of the exchange I visited the students, did some teaching and observed some of the clinical areas.

An enquiry into a combined approach for nursing ethics

A definitive theory for ethical decision making in nursing is still only conjecture. The literature confirms that there have been numerous examinations of ethical decision making in nursing, with most proposing either the justice or the care orientation, or a combination of both. In the absence of a definitive theory, this exploratory work sets out, via grounded theory, to shed some light on the methods used every day by nurses to make ethical decisions in the clinical area. The data show that some factors, such as doctors, colleagues and the organization, profoundly influence ethical decision making. The informants used both care and justice to formulate decisions, which is known as the combined approach. As a result of these findings, this article concludes with tentative suggestions and recommendations for practice.