The application of a haemorrhage assessment tool in evaluating control of bleeding in a pilot trauma haemorrhage trial

OBJECTIVES

To determine whether it was feasible to use a haemorrhage assessment tool (HAT) within a trauma trial and whether the data obtained could differentiate patients who had achieved haemostasis.

BACKGROUND

Major haemorrhage is one of the leading causes of death worldwide, affecting 40% of trauma patients. Clinical trials evaluating haemostatic interventions often use transfusion outcomes as a primary endpoint. Transfusion is highly dependent on local practice, limiting its reliability as a robust, transferable endpoint.

METHODS

A five-point HAT questionnaire was applied to participants enrolled into the EFIT-1 trial. This RCT evaluated the feasibility of administering a 6 g fibrinogen concentrate to patients with severe trauma haemorrhage.

RESULTS

Of participants, 98% completed a HAT; 75% participants had 'achieved haemostasis' at the time of tool completion, as determined by clinical acumen alone. HAT scores were able to differentiate which participants required transfusion after 3 h. Of participants, 56% were transfused red blood cells when they scored 0-2, compared to 17% with HAT scores between 3 and 5.

CONCLUSION

This study has confirmed the feasibility of using a HAT during the emergency care of patients suffering trauma haemorrhage, and future studies should be conducted to determine its value as an endpoint in haemostasis studies.

Etanercept in Alzheimer disease: A randomized, placebo-controlled, double-blind, phase 2 trial

OBJECTIVES

To determine whether the tumor necrosis factor α inhibitor etanercept is well tolerated and obtain preliminary data on its safety in Alzheimer disease dementia.

METHODS

In a double-blind study, patients with mild to moderate Alzheimer disease dementia were randomized (1:1) to subcutaneous etanercept (50 mg) once weekly or identical placebo over a 24-week period. Tolerability and safety of this medication was recorded including secondary outcomes of cognition, global function, behavior, and systemic cytokine levels at baseline, 12 weeks, 24 weeks, and following a 4-week washout period. This trial is registered with EudraCT (2009-013400-31) and ClinicalTrials.gov (NCT01068353).

RESULTS

Forty-one participants (mean age 72.4 years; 61% men) were randomized to etanercept (n = 20) or placebo (n = 21). Etanercept was well tolerated; 90% of participants (18/20) completed the study compared with 71% (15/21) in the placebo group. Although infections were more common in the etanercept group, there were no serious adverse events or new safety concerns. While there were some interesting trends that favored etanercept, there were no statistically significant changes in cognition, behavior, or global function.

CONCLUSIONS

This study showed that subcutaneous etanercept (50 mg/wk) was well tolerated in this small group of patients with Alzheimer disease dementia, but a larger more heterogeneous group needs to be tested before recommending its use for broader groups of patients.

CLASSIFICATION OF EVIDENCE

This study shows Class I evidence that weekly subcutaneous etanercept is well tolerated in Alzheimer disease dementia.

Monitoring of home safety issues in children on enteral feeds with inherited metabolic disorders

OBJECTIVE

To assess the safety aspects of carers' enteral feeding technique when home enteral tube feeding children with inherited metabolic disorders (IMD).

METHODS

40 patients (median age, 5.1 years; range, 0.3-13.6 years) with IMD requiring pump tube feeding were recruited. 12 patients had glycogen storage disease, 11 organic acidemias, 8 fatty acid oxidation disorders, 4 urea cycle disorders, and 5 had other conditions. 50% of the patients were fed by gastrostomy and 50% nasogastric tube. A questionnaire and practical assessment of feeding process was completed with carers by a dietician and nurse in the child's home. Areas investigated included carer hygiene, feed preparation, tube care, tube changing, use of feeding pumps and equipment, and storage of enteral feeding equipment.

RESULTS

The main issues identified were poor hygiene practices (78% unclean work surfaces; 25% no hand washing); inaccurate ingredient measuring (40%); irregular checking of tube position (40%); inadequate tube flushing (50%); poor knowledge of how to clear tube blockages (80%); incorrect priming of pump sets (50%); incorrect position of child for night feeding (63%); untrained secondary carers (43%); and poor knowledge of pump alarms, battery life, and charging time. Children commonly slept in parent's room as a safety precaution (58%).

CONCLUSIONS

Long term follow-up of children with IMD on home enteral tube feeding suggests that regular updates on knowledge and technique for carers may be necessary to reduce risk.

Long-term effects of Abeta42 immunisation in Alzheimer's disease: follow-up of a randomised, placebo-controlled phase I trial

BACKGROUND

Immunisation of patients with Alzheimer's disease with full-length amyloid-beta peptide (Abeta(42)) can clear amyloid plaques from the brain. Our aim was to assess the relation between Abeta(42) immune response, degree of plaque removal, and long-term clinical outcomes.

METHODS

In June, 2003, consent for long-term clinical follow-up, post-mortem neuropathological examination, or both, was sought from 80 patients (or their carers) who had entered a phase I randomised, placebo-controlled trial of immunisation with Abeta(42) (AN1792, Elan Pharmaceuticals) in September, 2000. The follow-up study was completed in September, 2006. Plaques were assessed in terms of the percentage area of the cortex with Abeta immunostaining (Abeta load) and in terms of characteristic histological features reflecting plaque removal. Survival of all 80 individuals until severe dementia or death was assessed with a Cox proportional hazard model.

FINDINGS

20 participants--15 in the AN1792 group, five in the placebo group--died before follow-up started. A further 22 patients--19 in the AN1792 group, three in the placebo group--died during follow-up. Nine of the deceased patients, all in the AN1792 group, had given consent for post-mortem analysis; one of these who did not die with Alzheimer's disease was excluded. In the remaining eight participants who received immunisation and who were examined neuropathologically, mean Abeta load was lower than in an unimmunised control group that was matched for age at death (2.1% [SE 0.7] in treated participants vs 5.1% [0.9] in controls; mean difference 3.0%, 95% CI 0.6-5.4; p=0.02). Although there was considerable variation in Abeta load and degree of plaque removal among immunised participants, the degree of plaque removal varied significantly with mean antibody response attained during the treatment study period (Kruskal-Wallis p=0.02). Seven of the eight immunised patients who underwent post-mortem assessment, including those with virtually complete plaque removal, had severe end stage dementia before death. In the whole cohort, there was no evidence of improved survival (hazard ratio 0.93, 95% CI 0.43-3.11; p=0.86) or of an improvement in the time to severe dementia (1.18, 0.45-3.11; p=0.73) in the AN1792 group versus the placebo group.

INTERPRETATION

Although immunisation with Abeta(42) resulted in clearance of amyloid plaques in patients with Alzheimer's disease, this clearance did not prevent progressive neurodegeneration.

Home enteral tube feeding in patients with inherited metabolic disorders: safety issues

BACKGROUND

Many children with inherited metabolic disorders (IMD), at risk of hypoglycaemia and metabolic decompensation, are dependent on long-term home overnight enteral tube feeding but its safety issues have not been evaluated.

OBJECTIVE

To identify common safety issues and carer pressures for patients with IMD on home enteral tube feeds (HETF).

METHODS

Thirty-four patients (53% male; median age 4.1, range: 1.2-15.8 years), with IMD on home continuous overnight tube feeds were recruited. They were all following specialized feeding regimens. A questionnaire, administered by face-to-face interview with carers identified family members involved in feeding, training they received; child safety issues; equipment reliability and carer night time disturbance.

RESULTS

The principal problems were: carer sleep disturbance (100%); tube entanglement (71%); untrained secondary carers (71%); faulty pumps (50%); tube blockages (45%); faulty equipment (32%); and child tampering with pumps and feeding equipment (29%).

CONCLUSIONS

Significant risks for children on HETF with IMD were identified, potentially leading to metabolic decompensation and hospitalization. The safety of feeding equipment, lack of training of extended family members and practical support for carers requires urgent attention.

Keep music live: music and the alleviation of apathy in dementia subjects

BACKGROUND

A recent Cochrane report concluded that more and better quality research is required to investigate the effectiveness of music therapy in reducing problems in behavioral, social, emotional and cognitive domains in patients with dementia. This randomized placebo-controlled trial with blinded observer rater aimed to explore whether music, live or pre-recorded, is effective in the treatment of apathy in subjects with moderate to severe dementia.

METHODS

Thirty-two subjects meeting ICD-10 diagnostic criteria for moderate to severe dementia and fulfilling diagnostic criteria for apathy were exposed to live interactive music, passive pre-recorded music or silence for 30 minutes. Each subject was randomized to 30-minute music or silent periods and was video recorded and the muted recording analyzed every 3 minutes using dementia care mapping to assess the quality of engagement to the blinded music intervention.

RESULTS

Compared to low baseline levels of positive engagement (12.5%) in the silent placebo period, the majority of subjects (69%), regardless of dementia severity, showed a significant and positive engagement to live music. Engagement to pre-recorded music was non-significant, with just 25% of all subjects showing positive engagement. No subjects showed any evidence of experiencing a state of ill-being during either the live or pre-recorded music sessions.

CONCLUSIONS

During the intervention, live interactive music has immediate and positive engagement effects in dementia subjects with apathy, regardless of the severity of their dementia. Pre-recorded music is non-harmful but less clearly beneficial.

The effect of link nurses on hospital readmission rates

This study investigates whether visits to a patient early post-discharge by a member of the ward team (locality link nurse) reduces psychiatric hospital readmission rates for older people and improves the physical and psychological state of the patient. This is a summary of the paper the full version can be accessed at nursingtimes.net.

Diagnostic criteria for irritable bowel syndrome: utility and applicability in clinical practice

BACKGROUND/AIMS

Symptom-based criteria have been introduced to aid the diagnosis of irritable bowel syndrome (IBS). Although they have been widely adopted and have proved useful for research purposes by ensuring homogeneity of study populations, there is little information about their utility in routine clinical practice. It was the aim of this study to assess the applicability of the Manning, Rome I and Rome II criteria in the clinical setting and to ascertain how often hospital specialists and general practitioners (GPs) use them.

METHODS

Hundred secondary-care IBS patients were assessed for their conformity to these criteria. Forty-eight hospital specialists and 68 GPs were asked about their knowledge and utilization of these criteria.

RESULTS

Seventy-three percent of IBS patients met Rome II diagnostic criteria with 82 and 94% meeting Rome I and Manning, respectively. Approximately 80% of GPs had no knowledge of any of the specific criteria, and only 4% had ever used them. The majority of specialists had knowledge of the criteria, with 70% having used them.

CONCLUSION

The Rome II criteria are remarkably insensitive and if rigidly applied in the clinical situation would lead to much diagnostic uncertainty. The current lack of interest in them, especially amongst GPs, is unlikely to change unless they can be considerably improved.

Lavender oil as a treatment for agitated behaviour in severe dementia: a placebo controlled study

OBJECTIVE

To determine whether aromatherapy with lavender oil is effective in the treatment of agitated behaviour in patients with severe dementia.

DESIGN

A placebo controlled trial with blinded observer rater.

SETTING

A long-stay psychogeriatric ward.

PATIENTS

Fifteen patients meeting ICD-10 diagnostic criteria for severe dementia and suffering from agitated behaviour defined as a minimum score of three points on the Pittsburgh Agitation Scale (PAS).

INTERVENTION

A 2% lavender oil aromatherapy stream was administered on the ward for a two hour period alternated with placebo (water) every other day for a total of ten treatment sessions.

ASSESSMENTS

For each subject 10 total PAS scores were obtained. Five during treatment and five during placebo periods.

RESULTS

Nine patients (60%) showed an improvement, five (33%) showed no change and one patient (7%) showed a worsening of agitated behaviour during aromatherapy compared with placebo. A comparison of the group median PAS scores during aromatherapy showed a significant improvement in agitated behaviour during aromatherapy compared with placebo (median PAS scores 3 c.f. 4; Wilcoxon Signed-Ranks test p = 0.016 (one-tailed)).

CONCLUSIONS

Lavender oil administered in an aroma stream shows modest efficacy in the treatment of agitated behaviour in patients with severe dementia.

Clinical supervision: making it happen

When owned and governed by those who implement it, clinical supervision can become a living, breathing part of professional working life, and not just another ritual. A multidisciplinary team from Southampton explains.

Dementia in acute units: communication

This is the second article in our series which looks in detail at one of the most pressing nursing problems of the age--coping with the behaviours of people with dementia in acute care units. The authors analyse the misunderstandings and misperceptions which conspire to build barriers to communication between nurses and people with dementia, and offer some practical advice on how to overcome them.