Search

A clinical consensus statement (CCS) on tracheostomy care for adults and children was developed to improve care for this patient population. Statements were identified using a modified Delphi method with the goal to reduce practice variations among tracheostomy patients. Integration of these statements into daily practice in the care setting is the next step for information dissemination. The CCS affected current policies, procedures, protocols, staff education, and patient education. The process of updating practice at a large tertiary care center is described using evidence-based implementation strategies.

Excessive sedation precedes opioid-induced respiratory depression. An evidence-based practice project standardized systematic sedation monitoring by nurses using an opioid sedation scale and respiratory assessment when opioids are administered for pain management. Nurses were educated and documentation updated. Nurses demonstrated increased ability to identify at-risk patients (3.2 pre-implementation; 3.6 post-implementation; 1-4 Likert scale) and reported understanding the tool to assess for oversedation (2.6 pre-implementation; 3.2 post-implementation). Documentation compliance improved, and patient safety was maintained.

Nurses must intervene to provide evidence-based supportive care and symptom management for cancer patients. Oral mucositis, a distressing side effect of cancer treatment, is both a research and clinical priority. Nurses can lead improvements with evidence-based oral mucositis interventions. This article describes application of evidence-based clinical recommendations for oral mucositis across diverse patient populations.

In 2008, the Center for Disease Control (CDC) issued new guidelines for the cleaning of nasopharyngoscope (flexible fiberoptic), videolaryngoscopes, and rigid nasal endoscopes (Rutala et al., 2008). The guidelines outlined the basic process steps and requirements including staff training, competency testing, approved products, personal protective equipment, and appropriate storage. To date, published occurrences of pathogen transmission related to procedures requiring the use of a scope have been associated with failure to follow established cleaning and disinfection guidelines or use of defective equipment (Rutala, 2011). The University of Iowa Hospitals and Clinics (UIHC) established a multi-disciplinary team to review and revise the current policy and to generate implementation recommendations. The team used a systematic evidence-based approach to initiate the changes in practice. The initial project focus was in the Otolaryngology Department due to high scope usage in that patient care area.

Background: Cerebrospinal fluid (CSF) infections associated with external ventricular drain (EVD) placement attract major consequences. Silver impregnation of catheters attempts to reduce infection., Objective: To assess the efficacy of silver catheters against CSF infection., Methods: We performed a randomized, controlled trial involving 2 neurosurgical centers (June 2005 to September 2009). A total of 356 patients requiring an EVD were assessed for eligibility; 325 patients were enrolled and randomized (167 plain, 158 silver); 278 patients were analyzed (140 plain, 138 silver). The primary outcome measure was CSF infection as defined by organisms seen on Gram stain or isolated by culture. Secondary outcome measures included ventriculoperitoneal (VP) shunting., Results: There was a significant difference in infection risk between the 2 study arms: 21.4% (30/140) for plain catheters vs 12.3% (17/138) for silver catheters (P = .0427; 95% confidence interval [CI]: 1.015-3.713). Patients who had an EVD infection had more than double the risk of requiring a VP shunt compared with patients without an EVD infection (45.7% [21/46] vs 19.7% [45/229], respectively, P = .0002; 95% CI: 1.766-6.682). There was also a significant difference in VP shunt risk with infection: plain (55.2%; 16/29) vs the silver arm (29.4%; 5/17); P = .0244 (95% CI: 1.144-11.695). A multivariate analysis demonstrated that infection risk was increased by duration of EVD placement (odds ratio: 1.160), spontaneous intracranial hemorrhage (odds ratio 4.958) and decreased by silver catheters (odds ratio: 0.423)., Conclusion: The study provides Class I evidence that silver-impregnated catheters reduce CSF infection.

The prevalence of Salmonella enterica serotype Paratyphi A infection is increasing, and multidrug resistance is a well-recognized problem. Resistance to fluoroquinolones is common and leads to more frequent use of newer agents like azithromycin. We report the first case of azithromycin resistance and treatment failure in a patient with S. Paratyphi A infection.

Oral mucositis is a frequent side effect of cancer treatment and can lead to delayed treatment, reduced treatment dosage, altered nutrition, dehydration, infections, xerostomia, pain, and higher healthcare costs. Mucositis is defined as "inflammatory lesions of the oral and/or gastrointestinal tract caused by high-dose cancer therapies. Alimentary tract mucositis refers to the expression of mucosal injury across the continuum of oral and gastrointestinal mucosa, from the mouth to the anus" (Peterson, Bensadoun, & Roila, 2008, p. ii122). Evidence demonstrates that oral mucositis is quite distressing for patients. In addition, the majority of oncology nurses are unaware of available guidelines related to the care of oral mucositis. A multidisciplinary Oral Mucositis Committee was formed by the University of Iowa Hospitals and Clinics to develop evidence-based prevention and treatment strategies for adult and pediatric oncology patients experiencing oral mucositis. The first step was implementing an evidence-based nursing oral assessment. The Iowa Model was used to guide this evidence-based practice initiative. The Oral Assessment Guide (OAG) is reliable and valid, feasible, and sensitive to changing conditions. The OAG was piloted on an Adult Leukemia and Bone Marrow Transplant Unit leading to modification and adaptation. The pilot evaluation found 87% of patients had an abnormal oral assessment involving all categories in the tool. Nursing questionnaires showed that staff (8/23; 35% response) felt they were able to identify at risk patients using the OAG (3.3; 1-4 scale), and the tool accurately identifies mucosal changes (2.9; 1-4 scale). A knowledge assessment found nurses correctly identified OAG components 63% of the time. Unlike results from a national survey, most University of Iowa Hospitals and Clinics nurses (63%) were aware of national guidelines for prevention and treatment of oral mucositis. Developing an evidence-based nursing policy and updating documentation systems was done before implementation occurred. Computer-based and printed educational materials were developed for nursing staff caring for oncology patients. Team members were responsible for facilitating adoption in clinical areas. After organizational roll out, the nursing assessment was documented in all patients 87% of the time, and 99% for inpatients. The highest risk population, head and neck cancer patients receiving radiation, had documentation in 88% of audited visits. Other clinics required further work. Changing the system to the electronic medical record created an additional need for integration of the evidence-based practice with housewide documentation of oral assessment being completed 60.9% of the time. Use of an evidence-based assessment is the first step in a comprehensive program to reduce a common and highly distressing side effect of cancer treatment. Nursing documentation of oral assessment is well integrated on inpatient units. Opportunities for improvement remain in ambulatory care. Multidisciplinary team collaborations to expand evidence-based assessment and research questions generated from this work will be shared.

We present the first documented case of Salmonella enterica serotype Agona meningitis in a 6-day-old baby. S. enterica serotype Agona was isolated concurrently from infant cerebrospinal fluid and parental fecal samples, and Salmonella was isolated from breast milk. The role of breast milk in transmission of Salmonella enterica is discussed.

We present the first documented human case of Salmonella enterica serovar Apapa infection, isolated concurrently from a hospital inpatient and a pet lizard. The isolates were identical by biochemical profiling and pulsed-field gel electrophoresis. This rare serotype is known to be associated with reptiles. The current practice for avoiding reptile-associated infections is reviewed.

Infection control education is difficult and time consuming, but there is persuasive evidence to demonstrate its effectiveness. When Infection Control practitioners are educating and influencing healthcare workers, compliance with the well-established guidance on implementation of health service research is advisable, and thus educative efforts must be repeated and administered as part of a concerted and multifaceted approach. Infection Control education must be specifically designed for and targeted at the groups of staff concerned, and medical staff pose especial problems. Recruitment of clinical champions from peer groups, and direct approaches from medical members of the Infection Control team are usually needed. Familiarity with only a limited range of published evidence is needed to answer the majority of clinicians who challenge Infection Control practices, and referral to higher medical and managerial authority is required very infrequently and as a last resort. Some recent initiatives in the NHS in England may make Infection Control education more difficult, and these are reviewed. New sanctions have been made available to hospitals and Infection control teams in the UK with the passing of the Health Act in 2006, and the effects of these allied to educative interventions on benchmarks such as hospitals' MRSA bacteraemia rates will be observed with interest.

Objective: To assess use of free nicotine patches by Indigenous people when offered a brief intervention for smoking cessation, and to assess changes in smoking behaviour at six months., Methods: We conducted a pre and post study in three Indigenous communities in the Northern Territory., Results: Forty Indigenous smokers self-selected to receive free nicotine patches and a brief intervention for smoking cessation, and 71 chose the brief intervention only. Eighty-four per cent of participants were followed up; 14% of participants could not be located. Fifteen per cent of the nicotine patches group (10% with CO validation) and 1% (CO validated) of the brief intervention only group reported that they had quit at six months. Seventy-six per cent of the nicotine patches group and 51% of the brief intervention only group had reduced their consumption of tobacco. No participant completed a full course of patches. One possible side effect--the experience of bad dreams--was attributed in one community to the person concerned having been 'sung' or cursed., Conclusions: Free nicotine patches might benefit a small number of Indigenous smokers. Cessation rates for the use of both nicotine patches and brief intervention alone were lower than those in other populations, possibly because the study was conducted in a primary care setting and because of barriers to cessation such as widespread use of tobacco in these communities and the perception of tobacco use as non-problematic.

Airborne bacteria introduced during routine joint replacement surgery are known to be an important source of joint sepsis with disastrous results. Recently, Robinson et al. [Robinson AHN, Bentley G, Drew S, Anderson J, Ridgway GL. Suction tip contamination in the ultraclean air operating theatre. Ann R Coll Surg Engl 1993; 75: 254-6] have demonstrated that the conventional surgical sucker forms a focus for airborne pathogens which results in septic loosening of hip prostheses. Similarly, the potential contamination of theatre light handles, commonly used during total hip and knee replacements, gives cause for concern. To assess if there was any evidence of contamination, we cultured bacterial swabs taken from the light handles before and after 15 such procedures, all of which were held in a conventional orthopaedic operating theatre. Fortunately, our study found no reason to stop the use of light handles in joint replacement operations.

We investigated the bacterial contamination of commonly used intravenous anaesthetic agents. Ten trainee anaesthetists drew up four syringes each of propofol, midazolam, thiopentone, 0.9% saline and a culture medium control using their normal practice. A set of syringes was cultured at the time of drawing up and at 2, 4 and 8 h afterwards. No anaesthetist washed his or her hands before drawing up the drugs. Six anaesthetists capped the syringes using sheathed needles. Eight syringes were contaminated with bacteria. Coagulase-negative staphylococci were isolated from six syringes (four sheathed and two unsheathed) and an Acinetobacter sp. from two syringes (one sheathed and one unsheathed). No bacteria were cultured from the midazolam syringes. However, two syringes from each of the other solutions were contaminated. This implies that one syringe was contaminated when it was drawn up, at 2 h a further two had detectable contamination, two more were contaminated at 4 h and three more at 8 h. We cannot recommend drawing up drugs at the start of a list for use later in the day. They should be used immediately after drawing up. Basic hand washing before drawing up drugs may reduce contamination.

The factor structure, reliability, and validity of a 49-item scale designed to measure Stockholm Syndrome (also referred to as "traumatic bonding" and "terror bonding"), that is, bonding with an abusive partner, were assessed for college women in heterosexual dating relationships. Factor analysis identified three major factors: Core Stockholm Syndrome, characterized by cognitive distortions and other strategies for coping with abuse; Psychological Damage, marked by depression, low self-esteem, and loss of sense of self; and Love-Dependence, typified by the feeling that one cannot survive without one's partner's love. The scale and factors had excellent internal consistency and good test-retest reliabilities. They correlated negatively with the Marlowe-Crowne Social Desirability scale and positively with Horowitz, Wilner, & Alvarez' (1979) Impact of Event Scale, Hyler and Rieder's (1987) Borderline Personality Disorder Scale, Hatfield and Sprecher's (1986) Passionate Love Scale, and Straus' (1979) Verbal Aggression and Violence scales of the Conflict Tactics Scales.

Activation of B cells by anti-CD40 provides an excellent model to investigate the direct effect of various cytokines on Ig production. Using this culture system, we examined the effect of IL-2 alone or in combination with other cytokines. IL-2 alone had only a moderate effect on Ig production by anti-CD40-activated B cells if compared with the effect of IL-10. However, IL-2 significantly augmented the synthesis of IgM, IgA, and IgG, including all IgG subclasses by anti-CD40-activated B cells cultured in the presence of IL-10. Both IgD- and IgD+ B cells showed an increase of IL-10-induced Ig production if IL-2 was added to the culture. The addition of IL-2 also increased immunoglobulin synthesis by anti-CD40/IL-10-activated B cells from patients with common variable immunodeficiency (CVI) and defective IL-2 production, suggesting that in a subgroup of CVI patients the IL-2 deficiency may contribute to the observed hypogammaglobulinemia. In contrast, the addition of IL-2 had a suppressive effect on IgE and IgG4 production by B cells cultured in the presence of anti-CD40 and IL-4. These data demonstrate that IL-2 plays an active role in the regulation of Ig production via CD40 by anti-CD40-activated B cells.

As a part of a project concerning the development of hearing, some features of the morphological development of the inferior colliculus were studied in a marsupial, the Northern quoll or native cat (Dasyurus hallucatus). Marsupials are of particular interest in developmental studies because much embryonic development occurs outside the uterus, in the pouch. Nissl-stained material was prepared from pouch-young at various ages between 11 and 81 days, and for a number of adults. Four pouch-young were injected with tritiated thymidine and killed later during pouch life. The inferior colliculus is first recognizable in pouch-young aged 23 days, when it is bordered by a cell-sparse ring of tissue. By this time, the labelling patterns following injections of tritiated thymidine made on days 7-9 suggest that migration of cells to the inferior colliculus from the ventricular germinal zone has been largely completed. At 81 days, close to the time when the young move out of the pouch, the adult cytoarchitecture--a central nucleus flanked by dorsal and lateral cortical regions--is clear. Cell areas expand monotonically as a function of age. The period of days 45-50 is associated with a large expansion of cell volume and a concomitant decrease in packing density. It is likely that functional connections are forming during this period, which may herald the onset of hearing in the quoll. Total cell numbers increase to a peak at day 36, fall to a minimum at day 50, and rise again to the adult value. The second increase is likely to be a phase of glial proliferation, in part associated with the onset of myelination. This increase correlates with departure of the young from the pouch.

We used the T-cell-dependent antigen, bacteriophage (phage) phi X174, to study antibody synthesis in patients, guinea pigs, and dogs with complement component deficiencies (C2, C4, C3, C7); in patients with adhesion molecule deficiencies (CD11/CD18 or sialylated Lewisx); and in patients with the hyper IgM (HIM) syndrome (absence of functional gp39 expression by activated T cells). Patients and guinea pigs deficient in early complement components, patients deficient in CD11/CD18, and patients lacking functional gp39 on activated T cells responded to repeated phage immunizations with depressed antibody titers, lack of or inadequate amplification, and failure to switch from IgM to IgG, suggesting that defective T-cell-B-cell interaction is the cause of the antibody deficiency observed in these patients.

To analyze the importance of cell surface-associated molecules in modulating the immune response by facilitating T/B cell interaction, we used the T cell-dependent antigen, bacteriophage phi X174. Taking advantage of "experiments of nature", we studied specific antibody synthesis in patients with deficiencies of complement components or of the adhesion molecule CD11/CD18 (leukocyte adhesion defect, LAD) and guinea pigs and dogs with early complement component deficiency. Following intravenous injection of bacteriophage phi X174 into normal subjects or animals, a primary response consisting of IgM, a secondary response consisting of IgM and IgG, and a tertiary, predominantly IgG response can be distinguished. Patients and guinea pigs deficient of early complement component and LAD patients responded to repeated phage immunization with depressed antibody titers, lack of or inadequate amplification, and failure to switch from IgM to IgG, suggesting a defect in generating antigen-specific memory cells. Several mechanisms have to be considered: (i) The complement portion of the antigen-antibody complement complex facilitates the accumulation and trapping of antigen in lymphoid organs, thus improving the response to Ag at low concentrations. (ii) Immune complexes preferentially bind to antigen-specific B cells, cells expressing Fc receptors, or CR2 and CR3, the receptors for C3bi. (iii) The weak binding established between the MHC-II/Ag complex and the TCR complex is strengthened through the binding of several adhesion molecule pairs. (iv) Receptor-ligand binding initiates activation signals. The concept of binding/signaling via interacting molecules is further supported by the observation that mAb 60.3, recognizing the beta chain of CD11/CD18, blocks in vitro synthesis of antibody to bacteriophage by primed PBMC.

The prominent role of the CD40 receptor in B cell responses led us to investigate the role of the gp39-CD40 interaction in a group of primary immunodeficient patients with defective antibody production. Here we report that patients with hyper-IgM syndrome (HIM) have a defective gp39-CD40 interaction. B cells from HIM patients express functional CD40, but their T cells do not bind CD40-Ig. These patients expressed normal levels of gp39 mRNA, but these mRNAs encode defective gp39 proteins owing to mutations in the extracellular domain of gp39. Soluble recombinant forms of gp39 containing these mutations were unable to bind CD40 and drive normal B cell proliferation. The gene encoding gp39 was mapped to Xq26, the X chromosome region where the gene responsible for HIM had previously been mapped. These data suggest that a defect in gp39 is the basis of X-linked HIM.

We evaluated longterm outcome in 21 pediatric patients with biopsy proven eosinophilic fasciitis (EF), 4 followed in our rheumatology clinic and 17 reported in the literature. Two-thirds of these patients developed residual cutaneous fibrosis, while one-third enjoyed complete resolution of disease. Children under age 7 years were twice as likely as those over age 7 years to experience disease progression to cutaneous fibrosis [relative risk = 2.0 (95% confidence intervals 1.2, 3.4)]. Fourteen of 17 patients with extensive disease at diagnosis (involvement of 3-4 extremities +/- trunk) progressed to cutaneous fibrosis whereas all 4 patients with minimal disease (involvement of 1-2 extremities) at onset resolved completely. We detected no association between progression to cutaneous fibrosis and sex of patient, duration of symptoms prior to therapy, type of therapy, history of prior physical stress, or laboratory variables at diagnosis.

Resistance to desiccation and to skin fatty acids was measured in three groups of methicillin-resistant Staphylococcus aureus (MRSA) strains and a group of control strains. Organisms from a large outbreak on a special care baby unit (SCBU), where MRSA had been isolated from staff hands but not from the environment, were significantly more sensitive to drying than strains from a burns unit where extensive environmental contamination had been demonstrated. MRSA from other wards, in the same hospital but not associated with large outbreaks, gave heterogeneous results. Fatty-acid resistance, determined by an agar dilution method, was not associated with strain origin. Some epidemic strains of MRSA were relatively sensitive to desiccation, and the abilities of such strains to spread widely on a SCBU by the hand-borne route could not be explained by enhanced resistance to skin fatty acids.

The use of caloric testing is widespread in hospital audiology departments. This paper describes contamination of the caloric water tanks with the organism Acinetobacter anitratus and the changes in practice instituted to eliminate this risk to patients.

Neurogenesis in the auditory pathway of the marsupial Dasyurus hallucatus was studied. Intraperitoneal injections of tritiated thymidine (20-40 microCi) were made into pouch-young varying from 1 to 56 days pouch-life. Animals were killed as adults and brain sections were prepared for autoradiography and counterstained with a Nissl stain. Neurons in the ventral cochlear nucleus were generated prior to 3 days pouch-life, in the superior olive at 5-7 days, and in the dorsal cochlear nucleus over a prolonged period. Inferior collicular neurogenesis lagged behind that in the medial geniculate, the latter taking place between days 3 and 9 and the former between days 7 and 22. Neurogenesis began in the auditory cortex on day 9 and was completed by about day 42. Thus neurogenesis was complete in the medullary auditory nuclei before that in the midbrain commenced, and in the medial geniculate before that in the auditory cortex commenced. The time course of neurogenesis in the auditory pathway of the native cat was very similar to that in another marsupial, the brushtail possum. For both, neurogenesis occurred earlier than in eutherian mammals of a similar size but was more protracted.

A new continuous flow electrophoretic separator for cells and macromolecules was built and tested in laboratory experiments and in the microgravity environment of space flight. Buffer flows upward in a 120-cm long flow chamber, which is 6 cm wide X 1.5 mm thick in the laboratory version and 16 cm wide X 3.0 mm thick in the microgravity version. Electrophoretic subpopulations are collected in 197 fractions spanning 16 cm at the upper end of the chamber. The electrode buffer is recirculated through front and back cooling chambers, which are also electrode chambers. Ovalbumin and rat serum albumin were used as test proteins in resolution and throughout tests; resolution of these two proteins at 25% total w/v concentration in microgravity was the same as that found at 0.2% w/v concentration in the laboratory. Band spreading caused by Poiseuille flow and conductance gaps was evaluated using polystyrene microspheres in microgravity, and these phenomena were quantitatively the same in microgravity as in the laboratory. Rat anterior pituitary cells were separated into subpopulations enriched with cells that secrete specific hormones; growth-hormone-secreting cells were found to have high electrophoretic mobility, whereas prolactin-secreting cells were found to have low electrophoretic mobility. Cultured human embryonic kidney cells were separated into several electrophoretic subfractions that produced different plasminogen activators; a medium-high-mobility subpopulation and a medium-low-mobility subpopulation each produced a different molecular form of urokinase, whereas a high- and an intermediate-mobility subpopulation produced tissue plasminogen activator. Canine pancreatic islets of Langerhans cells were separated into subpopulations, which, after reaggregation into pseudoislets, were found to be enriched with cells that secrete specific hormones; insulin-secreting beta cells were found in lowest mobility fractions, whereas glucagon-secreting alpha cells were found in the highest mobility fractions. Results of particle electrophoresis experiments were comparable in microgravity and in the laboratory, since cell densities that overloaded the carrier buffer (resulting in zone sedimentation) were avoided, and a 500-fold increase in protein throughput was achieved without compromising resolution in microgravity.

A sensitive and specific competitive enzyme immunoassay (EIA) for rat growth hormone was developed using reagents from the National Institutes of Arthritis, Diabetes, Digestive Diseases and Kidney, Bethesda, Md. In this assay soluble growth hormone and growth hormone adsorbed to a solid-phase support compete for monkey anti-growth hormone antibody binding sites. The immobilized antibody-growth hormone complex is detected and quantified using goat anti-monkey immunoglobin G covalently conjugated to horse radish peroxidase. Therefore a high concentration of soluble growth hormone in the sample will result in low absorbance detection from the colored products of the enzyme reaction. Assay parameters were optimized by investigating the concentration of reagents and the reaction kinetics in each of the assay steps. The assay can be performed in 27 hours. A sensitivity range of 0.19 ng to 25 ng in the region of 10 to 90% binding was obtained. Near 50% binding (3 ng) the intraassay coefficient of variation (CV) was 5.54% and the interassay CV was 5.33%. The correlation coefficient (r2) between radioimmunoassay and EIA was 0.956 and followed the curve Y = 0.78X + 1.9. Selected applications were described as follows. Alkaline extracts of pituitary tissue increase 2 fold in GH content after mercaptoethanol treatment. Alkaline extracts of pituitary tissue chromatographed on HPLC molecular sieving columns showed selective enhancement of rat growth hormone content based upon molecular weight. Fractions representing a molecular weight greater than 200 kD were enhanced 6 fold. Fractions whose molecular weight range was 22 kD to 50 kD were enhanced 2 fold. This assay provides a reliable alternative to RIA and offers the major advantage of eliminating radioactive reagents and counting equipment.

The characterization of a 20 kilodalton (20 kD) variant of rat growth hormone is reported. The 20 kD variant from rat pituitary gland extracts was identified on Western immunoblots of polyacrylamide gels. It was also shown that pituitary tissue maintained in culture secretes the 20 kD form. A rat growth hormone cDNA fragment was used as a probe in S1 nuclease mapping experiments of rat pituitary poly (A) mRNA to detect the presence of two growth hormone mRNAs in the rat pituitary gland. The protected mRNAs correspond to the predicted sizes that would encode the 22 kD and 20 kD forms of growth hormone. The site of variation between the mRNAs maps to a potential alternative 3' splice site in the 5' end of exon 3 of the coding sequence. The results support the hypothesis that the 20 kD variant in rat is the product of an mRNA alternatively spliced in exon 3, as is the case for the human growth hormone.