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Pain management for trauma patients is a neglected aspect in the chain of emergency care in general practices, ambulance services, mobile trauma teams and in hospital emergency departments. The aim of the guideline 'Pain management for trauma patients in the chain of emergency care' is to provide pain management recommendations for trauma patients in the chain of emergency care and thereby improve the assistance that patients receive. Paracetamol is the treatment of choice, if necessary with additional use of NSAIDs or opioids; NSAIDs can be administered in the absence of contra-indications, but should be avoided in cases where the patient history is unknown; fentanyl and morphine can be given for severe pain during emergency care, esketamine can be considered in patients with severe pain and hypovolemia. The guideline contains 3 algorithms for measuring pain and for its pharmacological treatment in the chain of emergency care. Implementation of the algorithms requires an alternative working procedure; pain scores must be documented, and general practitioners and nursing staff may administer opioids intravenously.

Context: Previous studies report that pressure ulcer classification and differentiation from incontinence associated dermatitis are difficult. Incorrect classification and differentiation result in incorrect prevention and treatment. Education is important to spread evidence-based insights about this topic and to improve classification skills., Aim: To assess the effectiveness of the Pressure Ulcer Classification (PUCLAS) education tool. PUCLAS was developed by the PUCLAS Workgroup of the European Pressure Ulcer Advisory Panel., Design: Randomised controlled trial., Setting and Participants: A convenience sample of 1217 Belgian, Dutch, British and Portuguese nurses., Outcome Measure: Correct classification of pressure ulcer photographs and differentiation from photographs of incontinence-associated dermatitis., Results: Baseline, 44.5% of the photographs were classified correctly. In the post-test, the results in the intervention group were significantly higher (63.2%) compared with the control group (53.1%; p<0.001). The percentage of correct assessments of incontinence associated dermatitis (IAD) was 70.7% in the intervention group and 35.6% in the control group (p<0.001). The skill to differentiate IAD from pressure ulcers was significantly associated with the experimental intervention (OR 4.07, 95% CI 3.21 to 5.15, p<0.001)., Conclusion: The PUCLAS tool improved pressure ulcer classification and IAD differentiation significantly.

Background: Patients in hospitals and nursing homes are at risk for the development of often preventable adverse events. Guidelines for the prevention of many types of adverse events are available, however compliance with these guidelines appears to be lacking. As a result many patients do not receive appropriate care. We developed a patient safety program that allows organisations to implement multiple guidelines simultaneously and therefore facilitates guideline use to improve patient safety. This program was developed for three frequently occurring nursing care related adverse events: pressure ulcers, urinary tract infections and falls. For the implementation of this program we developed educational activities for nurses as a main implementation strategy., Objectives: The aim of this study is to describe the effect of interactive and tailored education on the knowledge levels of nurses., Design: A cluster randomised trial was conducted between September 2006 and July 2008., Settings: Ten hospital wards and ten nursing home wards participated in this study. Prior to baseline, randomisation of the wards to an intervention or control group was stratified for centre and type of ward., Participants: All nurses from participating wards., Methods: A knowledge test measured nurses' knowledge on the prevention of pressure ulcers, urinary tract infections and falls, during baseline en follow-up. The results were analysed for hospitals and nursing homes separately., Results: After correction for baseline, the mean difference between the intervention and the control group on hospital nurses' knowledge on the prevention of the three adverse events was 0.19 points on a zero to ten scale (95% CI: -0.03 to 0.42), in favour of the intervention group. There was a statistically significant effect on knowledge of pressure ulcers, with an improved mean mark of 0.45 points (95% CI: 0.10-0.81). For the other two topics there was no statistically significant effect. Nursing home nurses' knowledge did neither improve (0 points, CI: -0.35 to 0.35) overall, nor for the separate subjects., Conclusion: The educational intervention improved hospital nurses' knowledge on the prevention of pressure ulcers only. More research on long term improvement of knowledge is needed., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Background: During the last decade, the Internet has become increasingly popular and is now an important part of our daily life. When new "Web 2.0" technologies are used in health care, the terms "Health 2.0" or "Medicine 2.0" may be used., Objective: The objective was to identify unique definitions of Health 2.0/Medicine 2.0 and recurrent topics within the definitions., Methods: A systematic literature review of electronic databases (PubMed, Scopus, CINAHL) and gray literature on the Internet using the search engines Google, Bing, and Yahoo was performed to find unique definitions of Health 2.0/Medicine 2.0. We assessed all literature, extracted unique definitions, and selected recurrent topics by using the constant comparison method., Results: We found a total of 1937 articles, 533 in scientific databases and 1404 in the gray literature. We selected 46 unique definitions for further analysis and identified 7 main topics., Conclusions: Health 2.0/Medicine 2.0 are still developing areas. Many articles concerning this subject were found, primarily on the Internet. However, there is still no general consensus regarding the definition of Health 2.0/Medicine 2.0. We hope that this study will contribute to building the concept of Health 2.0/Medicine 2.0 and facilitate discussion and further research.

Introduction: Predictive models, such as acute physiology and chronic health evaluation II (APACHE-II), are widely used in intensive care units (ICUs) to estimate mortality. Although the presence of delirium is associated with a higher mortality in ICU patients, delirium is not part of the APACHE-II model. The aim of the current study was to evaluate whether delirium, present within 24 hours after ICU admission, improves the predictive value of the APACHE-II score., Methods: In a prospective cohort study 2116 adult patients admitted between February 2008 and February 2009 were screened for delirium with the confusion assessment method-ICU (CAM-ICU). Exclusion criteria were sustained coma and unable to understand Dutch. Logistic regression analysis was used to estimate the predicted probabilities in the model with and without delirium. Calibration plots and the Hosmer-Lemeshow test (HL-test) were used to assess calibration. The discriminatory power of the models was analyzed by the area under the receiver operating characteristics curve (AUC) and AUCs were compared using the Z-test., Results: 1740 patients met the inclusion criteria, of which 332 (19%) were delirious at the time of ICU admission or within 24 hours after admission. Delirium was associated with in-hospital mortality in unadjusted models, odds ratio (OR): 3.22 (95% confidence interval [CI]: 2.23 - 4.66). The OR between the APACHE-II and in-hospital mortality was 1.15 (95% CI 1.12 - 1.19) per point. The predictive accuracy of the APACHE-II did not improve after adding delirium, both in the total group as well as in the subgroup without cardiac surgery patients. The AUC of the APACHE model without delirium was 0.77 (0.73 - 0.81) and 0.78 (0.74 - 0.82) when delirium was added to the model. The z-value was 0.92 indicating no improvement in discriminative power, and the HL-test and calibration plots indicated no improvement in calibration., Conclusions: Although delirium is a significant predictor of mortality in ICU patients, adding delirium as an additional variable to the APACHE-II model does not result in an improvement in its predictive estimates.

Introduction: Effects of systemic inflammation on cerebral function are not clear, as both inflammation-induced encephalopathy as well as stress-hormone mediated alertness have been described., Methods: Experimental endotoxemia (2 ng/kg Escherichia coli lipopolysaccharide [LPS]) was induced in 15 subjects, whereas 10 served as controls. Cytokines (TNF-alpha, IL-6, IL1-RA and IL-10), cortisol, brain specific proteins (BSP), electroencephalography (EEG) and cognitive function tests (CFTs) were determined., Results: Following LPS infusion, circulating pro- and anti-inflammatory cytokines, and cortisol increased (P < 0.0001). BSP changes stayed within the normal range, in which neuron specific enolase (NSE) and S100-beta changed significantly. Except in one subject with a mild encephalopathic episode, without cognitive dysfunction, endotoxemia induced no clinically relevant EEG changes. Quantitative EEG analysis showed a higher state of alertness detected by changes in the central region, and peak frequency in the occipital region. Improved CFTs during endotoxemia was found to be due to a practice effect as CFTs improved to the same extent in the reference group. Cortisol significantly correlated with a higher state of alertness detected on the EEG. Increased IL-10 and the decreased NSE both correlated with improvement of working memory and with psychomotor speed capacity. No other significant correlations between cytokines, cortisol, EEG, CFT and BSP were found., Conclusions: Short-term systemic inflammation does not provoke or explain the occurrence of septic encephalopathy, but primarily results in an inflammation-mediated increase in cortisol and alertness., Trial Registration: NCT00513110.

The aim of this systematic review was (a) to synthesize the evidence on the effectiveness of detection, mitigation, and actions to reduce risks in hospitals and (b) to identify and describe components of interventions responsible for effectiveness. Thirteen literature databases were explored using a structured search and data extraction strategy. All included studies dealing with incident reporting described positive effects. Evidence regarding the effectiveness and efficiency of safety analysis is scarce. No studies on mitigation were included. The collected evidence on risk reduction concerns a variety of interventions to reduce medication errors, fall incidents, diagnostic errors, and adverse events in general. Most studies reported positive effects; however, interventions were often multifaceted, and it was difficult to disentangle their impact. This made it difficult to draw generic lessons from this body of research. More rigorous evaluations are needed, in particular, of continuous learning and safety analysis techniques.

The purpose of this study was to determine the cost for prevention and treatment of pressure ulcers from a hospital perspective and to identify the least resource-intensive pressure ulcer prevention strategy. Cost analyses were examined from a hospital perspective using direct costs. The study was carried out alongside a prospective cohort study on the incidence and risk factors for pressure ulcers. Two large teaching hospitals in the Netherlands with (partly) opposing approaches in prevention, a technological versus a human approach, were analyzed. The main outcome measures were resource use, costs of preventive measures and treatment, and pressure ulcer incidence in both hospitals. Pressure ulcer prevention through a predominantly technical approach resulted in a similar incidence rate as prevention through a predominantly human approach. However, the technical approach was considerably less expensive.

Objectives: To identify the impact of pressure ulcers (PUs) and PU interventions on health-related quality of life (HRQL)., Design: Systematic review and metasynthesis of primary research reporting the impact of PU and PU interventions on HRQL according to direct patient reports. Quality assessment criteria were developed and applied. Data extraction identified findings in the form of direct quotes from patients or questionnaire items and domain results. Combined synthesis of qualitative and quantitative research was performed using content analysis to generate categories and themes from findings. Thirteen electronic databases were searched, and hand searching, cross-referencing, contact with experts, and an online search was undertaken. No language restrictions were applied., Setting: Adults with PUs in acute, community, and long-term care settings across Europe, the United States, Asia, and Australia., Participants: Thirty-one studies including 2,463 participants with PUs were included in the review. Ages ranged from 17 to 96., Results: The review included 10 qualitative and 21 quantitative studies; 293 findings, 46 categories, and 11 themes emerged. The 11 HRQL themes were physical impact, social impact, psychological effect, PU symptoms, general health, and other impacts of PUs: healthcare professional-client relationships, need for versus effect of interventions, impact on others, financial impact, perceived etiology, and need for knowledge., Conclusion: There is evidence that PUs and PU interventions have a significant impact on HRQL and cause substantial burden to patients.

Background: Patients in hospitals and nursing homes are at risk of the development of, often preventable, adverse events (AEs), which threaten patient safety. Guidelines for prevention of many types of AEs are available, however, compliance with these guidelines appears to be lacking. Besides general barriers that inhibit implementation, this non-compliance is associated with the large number of guidelines competing for attention. As implementation of a guideline is time-consuming, it is difficult for organisations to implement all available guidelines. Another problem is lack of feedback about performance using quality indicators of guideline based care and lack of a recognisable, unambiguous system for implementation. A program that allows organisations to implement multiple guidelines simultaneously may facilitate guideline use and thus improve patient safety.The aim of this study is to develop and test such an integral patient safety program that addresses several AEs simultaneously in hospitals and nursing homes. This paper reports the design of this study., Methods and Design: The patient safety program addresses three AEs: pressure ulcers, falls and urinary tract infections. It consists of bundles and outcome and process indicators based on the existing evidence based guidelines. In addition it includes a multifaceted tailored implementation strategy: education, patient involvement, and a computerized registration and feedback system. The patient safety program was tested in a cluster randomised trial on ten hospital wards and ten nursing home wards. The baseline period was three months followed by the implementation of the patient safety program for fourteen months. Subsequently the follow-up period was nine months. Primary outcome measure was the incidence of AEs on every ward. Secondary outcome measures were the utilization of preventive interventions and the knowledge of nurses regarding the three topics. Randomisation took place on ward level. The results will be analysed separately for hospitals and nursing homes., Discussion: Major challenges were the development of the patient safety program including a digital registration and feedback system and the implementation of the patient safety program., Trial Registration: Trial registration: ClinicalTrials.gov ID [NCT00365430].

Introduction: In critically ill patients, delirium is a serious and frequent disorder that is associated with a prolonged intensive care and hospital stay and an increased morbidity and mortality. Without the use of a delirium screening instrument, delirium is often missed by ICU nurses and physicians. The effects of implementation of a screening method on haloperidol use is not known. The purpose of this study was to evaluate the implementation of the confusion assessment method-ICU (CAM-ICU) and the effect of its use on frequency and duration of haloperidol use., Methods: We used a tailored implementation strategy focused on potential barriers. We measured CAM-ICU compliance, interrater reliability, and delirium knowledge, and compared the haloperidol use, as a proxy for delirium incidence, before and after the implementation of the CAM-ICU., Results: Compliance and delirium knowledge increased from 77% to 92% and from 6.2 to 7.4, respectively (both, P < 0.0001). The interrater reliability increased from 0.78 to 0.89. More patients were treated with haloperidol (9.9% to 14.8%, P < 0.001), however with a lower dose (18 to 6 mg, P = 0.01) and for a shorter time period (5 [IQR:2-9] to 3 [IQR:1-5] days, P = 0.02)., Conclusions: With a tailored implementation strategy, a delirium assessment tool was successfully introduced in the ICU with the main goals achieved within four months. Early detection of delirium in critically ill patients increases the number of patients that receive treatment with haloperidol, however with a lower dose and for a shorter time period.

Purpose: Evidence is not always used in practice, and many examples of problematic implementation of research into practice exist. The aim of this paper is to provide an introduction and overview of current developments in implementation science and to apply these to nursing., Methods: We discuss a framework for implementation, describe common implementation determinants, and provide a rationale for choosing implementation strategies using the available evidence from nursing research and general health services research., Findings: Common determinants for implementation relate to knowledge, cognitions, attitudes, routines, social influence, organization, and resources. Determinants are often specific for innovation, context, and target groups. Strategies focused on individual professionals and voluntary approaches currently dominate implementation research. Strategies such as reminders, decision support, use of information and communication technology (ICT), rewards, and combined strategies are often effective in encouraging implementation of evidence and innovations. Linking determinants to theory-based strategies, however, can facilitate optimal implementation plans., Conclusions: An analytical, deliberate process of clarifying implementation determinants and choosing strategies is needed to improve situations where suboptimal care exists. Use of theory and evidence from implementation science can facilitate evidence-based implementation. More research, especially in the area of nursing, is needed. This research should be focused on the effectiveness of innovative strategies directed to patients, individual professionals, teams, healthcare organizations, and finances., Clinical Relevance: Implementation of evidence-based interventions is crucial to professional nursing and the quality and safety of patient care.

Background: Sheath removal after PCI by registered nurses can improve patients' comfort and shorten immobilisation time. As sheath removal is not without risk, it is important to assure the quality of performance., Aims: The aim was (a) to check if nurses' performance in 1999 and 2005 was in accordance with the protocol for arterial sheath removal and (b) to compare both measurements to explore differences in performance over time., Methods: We trained registered nurses in sheath removal and observed them during sheath removal in elective uncomplicated PCI-patients. We developed and used a checklist, including 10 elements and 65 items., Results: Both in 1999 (n=43 observations with 13 nurses) and 2005 (n=42 observations with 16 nurses) the norm of more than 90% for the total score was not achieved: we found 82% and 80%, respectively. Four elements scored more than 90%, and three elements scored less than 80% at both points in time. The results on the other three elements differed significantly over time., Conclusion: Registered nurses achieved the norm for good performance (80-89%) of removing arterial sheaths according to protocol after a training programme and this is stable in time. Since the norm for excellent performance (> or =90%) was not achieved, current performance could be improved, e.g. by yearly repetition of training and observation of skills. More research is needed, and could focus on the validation of the instrument. Also multi-centre studies with this checklist could test the association between the quality of arterial femoral sheath removal and the occurrence of vascular complications.

Background: Pressure ulcers frequently occur in hospitalised patients. The prevalence of pressure ulcers grade 2 or worse varies from 3% to 12% in hospitalised patients. Incidence figures are not frequently reported. While incidence and prevalence are both measures of disease frequency, they provide different perspectives on pressure ulcers., Objectives: To describe the incidence rate and prevalence of pressure ulcers in hospitalised patients., Design: Prospective inception cohort study., Setting: Two large hospitals, one general (530-beds) and one teaching (1042-beds), in The Netherlands., Participants: A non-selected, though not strictly random, sample of 1536 patients was eligible for inclusion in the study. One thousand four hundred and thirty one patients (93.2%) consented to participate. Eventually, 1229 patients (80%) had a complete follow-up. The sample consisted of patients admitted to the surgical, internal, neurological and geriatric wards for more than 5 days between January 1999 and June 2000., Methods: Follow-up once a week until pressure ulcer occurrence, discharge or length of stay over 12 weeks., Main Outcome Measures: Occurrence of a pressure ulcer grade 2 or worse during admission to hospital, according to the classification of the European Pressure Ulcer Advisory Panel., Results: One hundred and thirty four patients developed 172 pressure ulcers during follow-up. The overall weekly incidence rate was 0.06 per week (95% confidence interval 0.05-0.07 per week). Highest rates were observed for surgical patients and lowest for geriatric and neurologic patients (0.08 and 0.02, respectively). The week specific prevalence varied between 12.8% and 20.3%., Conclusions: Among patients hospitalised for more than 5 days overall one may expect 6% per week to develop pressure ulcers. It would appear that any preventive measures can only be effective if taken timely. Accordingly, preventive measures should be considered early, because pressure ulcers were observed already within the first week of admission.

Objective: Firstly, this paper aims to systematically review the mitochondrial disease literature to identify studies assessing the needs and problems in the daily life of children with a mitochondrial disease and of their parents and family. The second aim is to provide more insight into the need for information by the parents of these children during the diagnostic process while in hospital., Design: A systematic review and a pilot study, using a qualitative (focus group interviews; n = 7) and a quantitative (questionnaire; n = 37) design., Results: Mothers reported great socioeconomic and psychoaffective strain and showed psychopathological symptoms in the two studies published with respect to this topic. The pilot study showed that parents considered an honest and interested attitude of the person who is giving the information as most important. Furthermore they wanted oral and written information and a central point where they could go with their questions at any time they felt the need. The need for information increased during the four phases of the diagnostic process and was highest in the fourth phase., Conclusions: The few studies found in the review, combined with expectations that having a mitochondrial disease must have a great impact on these children and their parents and family, call for more research in their needs and problems. Furthermore, there are gaps in the current information provision to parents of these children. A better understanding of the needs and problems of these children and their family is essential for effective care planning and might result in an improved quality of life.

Aims and Objectives: We investigated whether: (i) Early postoperative lateral position after coronary artery bypass surgery may have a negative influence on the cardiac output and (ii) Whether turning procedures cause practical problems., Background: Directly following surgery, coronary artery bypass patients are not receiving routine turning every two hours to prevent pressure ulcers, because a negative influence on hemodynamic parameters is assumed., Design: Clinical trial., Methods: Fifty-five coronary artery bypass patients were randomly assigned to four intervention regimens and underwent a two-hour period of 30 degrees lateral position. Fourteen patients in supine position served as a reference group. We hypothesized that 30 degrees lateral position does not cause a relevant change in the cardiac output., Results: Turning the patients did not have any significant influence on the cardiac index, not even in the patients in a poor hemodynamic condition. The cardiac index in 30 degrees lateral position and supine position two to eight hours postoperatively after coronary artery bypass surgery is statistically bioequivalent. No clinically relevant deviations from preset 'safe' values for mean arterial pressure, right atrial pressure, pulmonary artery wedge pressure and pulmonary arterial pressure were observed, which would require ending the lateral position. There were no practical problems hindering the turning regimen, not even in the patients with an intra-aortic balloon pump., Conclusions: Early postoperative turning of coronary artery bypass surgery patients in lateral position is an easy and feasible procedure that does not influence the cardiac index not even in patients receiving antihypertensive or inotropic/vasopressor therapy. Further research is needed to find out whether our findings are also valid in other patient groups and other position conditions., Relevance to Clinical Practice: If there are no strict contra-indications, lateral position has to be considered to prevent complications of continuous supine position within two hours after coronary artery bypass surgery patients have been admitted to the intensive care unit.

Background: Home parenteral nutrition (HPN) is offered to patients who are unable to absorb sufficient nourishment from normal oral food intake or tube feeding. Major causes include severe motility disorders and limited resorption surface in the small intestine. HPN is a lifesaving therapy but has severe consequences on daily life. The aim of this study was to make an inventory of the problems experienced by patients receiving HPN., Methods: Open interviews were held with 48 patients from the 2 major centers for HPN in the Netherlands, centered around the question: Which 3 HPN problems have the most severe impact on your daily life? Data were analyzed using content analysis., Results: The respondents mentioned 7 central problems: negative emotions, physical problems, social limitations, dependence on others, incapability, complications, and patient-care provider problems. In addition, practical problems were mentioned: sleeping problems, financial problems, and the "hospital atmosphere" at home. The latter issues formed less of a problem for the patients., Conclusion: The main underlying elements in the lives of many HPN patients appeared to be loss, longing, and grief. In contrast, a smaller proportion of the patients expressed that they had clearly adapted to life with HPN. By means of the HPN, they were still alive and enjoying all the things they could still do.

Objective: To determine the effects of a new policy on the efficiency of pressure ulcer care., Design: Series of 1-day pressure ulcer surveys before and after the implementation., Setting: A 900-bed University Medical Centre in The Netherlands., Participants: On the days of the surveys, 657 patients were included before the implementation, 735 patients at 4 months after the implementation, and 755 patients at 11 months after the implementation., Intervention: Implementation of a hospital guideline for pressure ulcer care combined with the introduction of viscoelastic foam mattresses on the efficiency of the prevention and treatment of pressure ulcers., Main Outcome Measures: Comparisons before versus after the implementation were made regarding the care behaviour of nurses and the frequency of patients with pressure ulcer., Results: Inadequate prevention decreased from 19 to 4% after 4 months and to 6% after 11 months (P < 0.001), and inadequate treatment decreased from 60 to 31% (P = 0.005). Excluding the use of mattresses as a positive indicator for care behaviour, we found no significant increase in adequate care to prevent pressure ulcers. Also, in adequate treatment activities, we found no significant difference. Overall, we found a significant decrease in hospital-acquired pressure ulcer frequency from 18 to 13% (P = 0.003) after 4 months and 11% (P < 0.001) after 11 months., Conclusion: The number of pressure ulcer patients in hospital can successfully be reduced. General measures such as the introduction of adequate mattresses and guidelines for prevention and treatment are promising tools in this respect.

Aim: This paper reports a study examining the interrater and intrarater reliability of classifying pressure ulcers according to the European Pressure Ulcer Advisory Panel classification system when using photographs of pressure ulcers and incontinence lesions., Background: Pressure ulcer classification is an essential tool for assessing ulcers and their severity and determining which preventive or therapeutic action is needed. Many classification systems are described in the literature. There are only a limited number of studies that evaluate the interrater reliability of pressure ulcer grading scales. The intrarater reliability is seldom studied., Methods: The study consisted of two phases. In the first phase 56 photographs, together with a random selection of nine photographs from the same set, were presented to 473 nurses. In the second phase, the 56 photographs were presented twice to 86 other nurses with an interval of one month and in a different order. All the nurses were familiar with the European Pressure Ulcer Advisory Panel classification. They did not receive any additional training on classification, and were asked to classify the lesions as normal skin, blanchable erythema, pressure ulcers (four grades, European Pressure Ulcer Advisory Panel classification) or incontinence lesions., Results: In the first phase, the multirater-Kappa for the 473 participating nurses was 0.37 (P < 0.001). Non-blanchable erythema was often confused with blanchable erythema and incontinence lesions. Also incontinence lesions were frequently not correctly classified. The intrarater agreement was low (kappa = 0.38). In the second phase, the interrater agreement was not significantly different in both sessions. The intrarater agreement was 0.52., Conclusion: Both the interrater and intrarater reliability of the European Pressure Ulcer Advisory Panel classification of lesion photographs by nurses was very low. Differentiation between pressure ulcers and incontinence lesions seems to be difficult.

Objectives: To identify independent predictors for development of pressure ulcers in hospitalized patients and to develop a simple prediction rule for pressure ulcer development., Design: The Prevention and Pressure Ulcer Risk Score Evaluation (prePURSE) study is a prospective cohort study in which patients are followed up once a week until pressure ulcer occurrence, discharge from hospital, or length of stay over 12 weeks. Data were collected between January 1999 and June 2000., Setting: Two large hospitals in the Netherlands., Participants: Adult patients admitted to the surgical, internal, neurological and geriatric wards for more than 5 days were eligible. A consecutive sample of 1536 patients was visited, 1431 (93%) of whom agreed to participate. Complete follow up data were available for 1229 (80%) patients., Main Outcome Measures: Occurrence of a pressure ulcer grade 2 or worse during admission to hospital., Results: Independent predictors of pressure ulcers were age, weight at admission, abnormal appearance of the skin, friction and shear, and planned surgery in coming week. The area under the curve of the final prediction rule was 0.70 after bootstrapping. At a cut off score of 20, 42% of the patient weeks were identified as at risk for pressure ulcer development, thus correctly identifying 70% of the patient weeks in which a pressure ulcer occurred., Conclusion: A simple clinical prediction rule based on five patient characteristics may help to identify patients at increased risk for pressure ulcer development and in need of preventive measures.

Patients undergoing surgery are prone to develop pressure ulcers during surgery. The aim of this study was to identify pressure ulcer risk indicators in patients undergoing surgery which lasted more than four hours. A prospective follow-up study was conducted in 208 patients. Data on presence or absence of pressure ulcers and risk indicators were collected preoperatively, during surgery, and postoperatively. The results show that of the many indicators recorded, the only predictor of pressure ulcers was length of surgery. Because it is not possible to influence the length of the surgery, prevention should primarily be aimed at decreasing pressure and shearing forces during surgery., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Pieris brassicae L. butterflies secrete miriamides onto their eggs. These avenanthramide alkaloids are strong oviposition deterrents when sprayed onto a cabbage leaf. However, these compounds could not be detected in cabbage leaves from which egg batches had been removed two days after deposition and that still showed oviposition deterrency. It was concluded that the miriamides were not directly responsible for the avoidance by females of occupied leaves while searching for an oviposition site. Evidence was obtained that cabbage leaves themselves produce oviposition deterrents in response to egg batches. Fractions containing potent oviposition deterrents could be isolated from surface extracts of leaves from which previously laid egg batches had been removed. The term host marking pheromone that was used previously is not applicable in this case.

The Isoelastic prosthesis for the metacarpophalangeal joint was used in 68 rheumatoid joints. The average follow-up period was 3 years and 3 months. The subjective score for pain, appearance, and usefulness as well as the functional outcome was determined by means of a modified Green test. All subjective scores improved postoperatively, whereas function did not change significantly. Preoperative range of motion values were not available. The extension deficit after operation was 26 degrees, the average flexion 63 degrees, and the total range of motion 37 degrees. Grip strength improved only slightly. Complications included four cases of delayed wound healing and four metacarpal fractures after operation. The Isoelastic prosthesis gives satisfactory results in rheumatoid arthritis patients. The intraoperative insertion is easy and the material is well tolerated. In vivo, the implant itself is rigid enough to resist ulnar drift, although osteolysis around the plastic surface has caused recurrence of ulnar deformity.

Adult females of several lepidopteran species avoid oviposition near conspecific eggs. Laboratory and field studies indicate that visual factors as well as chemical host markers may be involved in egg avoidance behavior. The oviposition-deterring pheromones (ODP) of two pierids,P. brassicae andP. rapae have been studied in considerable detail. The ODPs are probably produced in the female accessory glands and contain volatile and nonvolatile components. They are perceived by nonspecialized antennal or tarsal receptors, respectively. The ODP ofP. brassicae affects oviposition ofP. rapae females and vice versa. ODPs show promise for insect control programs, but more information on oviposition behavior in the presence of ODP under field conditions is required.

Eggs ofPieris rapae (L.) contain a water- and methanol-soluble oviposition-deterring pheromone (ODP) that is avoided by ovipositing females offered treated and untreated cabbage leaves in a choice situation. Water extracts of female accessory glands also deter oviposition. Egg washes and gland extracts stimulate a contact chemoreceptor in sensilla on the fore tarsi. Electroantennogram (EAG) recordings show that antennal receptors respond to volatiles from conspecific eggs, but not to volatiles from eggs ofMamestra brassicae. No differences were detected between North American and European insects with regard to production and perception of ODP. These results differ from conclusions in the literature based upon field observations. It is concluded that this discrepancy in due to methodological differences.

Cabbage leaves sprayed with a water solution of the oviposition-deterrent pheromone ofPieris brassicae remain deterrent to ovipositing females for at least 14 days. Under laboratory conditions, the pheromone, when dried on a glass surface, retains activity for a period of at least 7 weeks. After 7 days under vacuum conditions, some pheromone is still present, indicating a low volatility and / or high stability of (an active fraction of) the pheromone. After 125 eggs are slowly rinsed with 300 ml water, they still release detectable quantities of the pheromone.