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BackgroundHigh-sensitivity cardiac troponin I (hs-cTnI) assays promise high diagnostic accuracy for myocardial infarction (MI). In an ED where conventional cTnI was in use, we evaluated an assessment pathway using the new Access hsTnI assay.MethodsThis retrospective analysis recruited ED patients with suspected MI between June and September 2019. All patients received routine care with a conventional cTnI assay (AccuTnI +3: limit of detection (LoD) 10 ng/L, 99th centile upper reference limit (URL) 40 ng/L, abnormal elevation cut-point 80 ng/L). Arrival, then 90-minute or 360-minute cTnI levels for low and non-low risk patients, respectively (ED Assessment of Chest pain score) guided diagnosis and disposition which was at treating physician discretion. The same patients had arrival and 90-minute or 180-minute samples drawn for hs-cTnI levels (Access hsTnI: LoD 2 ng/L, 99th centile URL 10 ng/L (females) and 20 ng/L (males); abnormal elevation above the URL and delta >30%). Treating physicians were blinded to the hs-cTnI results. Using the hs-cTnI values, investigators retrospectively assigned likely diagnosis, disposition and likelihood of a 30-day major adverse cardiac event (MACE). Admission was recommended for significantly rising hs-cTnI elevations. The primary objective was to demonstrate an acceptable unexpected 30-day post-discharge MACE rate of ResultsFor the 935 patients, unexpected 30-day post-discharge MACE rates were 0/935 (0%, 95% CI 0% to 0.4%) with the conventional or novel pathway. For the high-sensitivity and conventional assays, respectively, abnormal elevation rates were 29% (95% CI 26% to 32%) and 19% (95% CI 17% to 22%), for MI were 9% (95% CI 8% to 11%) and 8% (95% CI 6% to 10%), and for hospital admission were 42% (95% CI 39% to 45%) and 43% (95% CI 40% to 47%).ConclusionThe novel pathway using the Access hsTnI assay has an acceptably low 30-day MACE rate.

In contrast to traditional femoral artery access, radial artery access for primary percutaneous coronary intervention (PPCI) in ST-elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding but has higher crossover rates. Therefore, factors associated with crossover warrant exploration as crossover due to technical challenges associated with the radial route may be mitigated.The objective of this study was to identify predictors of radial access failure or crossover to femoral access in PPCI.A systematic review and meta-analysis was undertaken according to the Joanna Briggs Institute Systematic Reviews Checklist with searches conducted in Medline, EMBASE, CINAHL, and SCOPUS databases. Inclusion criteria for this study included patients with STEMI; PPCI; and primary research identifying predictors of radial access failures and/or crossovers, published in English, and after 2010. This study was registered with PROSPERO (CRD42020167122). Statistical analysis was performed using IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, NY) and RevMan version 5.4 (Cochrane Collaboration, London, United Kingdom) with meta-analysis conducted by using the DerSimonian and Laird random-effects method. The National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was utilised for quality and risk of bias assessment, with EndNote software used for citations.Eight observational studies met inclusion criteria, comprising 12,621 patients. Risk of bias of these studies was assessed using the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The mean age was 61.2 ± 12.0 years, and 75.3% were male. Crossover from transradial to transfemoral artery occurred in 529 (4.2%) patients. Reasons for radial access failure included failed puncture (35.3%), peripheral occlusion or tortuosity (24.5%), and radial artery spasm (20.1%). Predictors of crossover included older age (odds ratio [OR], 1.95; 95% confidence interval [CI], 1.44-2.65; p 0.001), female sex (OR, 2.10; 95% Cl, 1.58-2.80; p 0.001), weight ≤65 kg (OR, 2.95; 95% CI, 1.95-4.46; p 0.001), and previous percutaneous coronary intervention (OR, 2.80; 95% Cl, 1.74-4.52; p 0.001).Older age, female sex, weight ≤65 kg, and previous percutaneous coronary intervention were predictors of crossover or failure from the radial to femoral artery. As these predictors are known to be associated with high bleeding and mortality, they should not preclude attempting a radial-first approach in all patients with STEMI. However, as these results were unadjusted, this study warrants further research to thoroughly investigate predictors of radial artery crossover.

Whilst research has largely focused on the recognition of emotional items, emotion may be a more subtle part of our surroundings and conveyed by context rather than by items. Using ERPs, we investigated which effects an arousing context during encoding may have for item-context binding and subsequent familiarity-based and recollection-based item-memory. It has been suggested that arousal could facilitate item-context bindings and by this enhance the contribution of recollection to subsequent memory judgements. Alternatively, arousal could shift attention onto central features of a scene and by this foster unitisation during encoding. This could boost the contribution of familiarity to remembering. Participants learnt neutral objects paired with ecologically highly valid emotional faces whose names later served as neutral cues during an immediate and delayed test phase. Participants identified objects faster when they had originally been studied together with emotional context faces. Items with both neutral and emotional context elicited an early frontal ERP old/new difference (200-400 ms). Neither the neurophysiological correlate for familiarity nor recollection were specific to emotionality. For the ERP correlate of recollection, we found an interaction between stimulus type and day, suggesting that this measure decreased to a larger extend on Day 2 compared with Day 1. However, we did not find direct evidence for delayed forgetting of items encoded in emotional contexts at Day 2. Emotion at encoding might make retrieval of items with emotional context more readily accessible, but we found no significant evidence that emotional context either facilitated familiarity-based or recollection-based item-memory after a delay of 24 h.

Background With the increasing complexity of procedures being performed in the cardiac catheterisation laboratory, the multidisciplinary team has the challenge of providing safe care to patients who present with a multitude of healthcare needs. Although the use of a surgical safety checklist has become standard practice in operating theatres worldwide, the use of a pre-procedure checklist has not been routinely adopted into interventional cardiology. Objective The aim of this study was to design and evaluate a pre-procedure checklist specific to the cardiac catheterisation laboratory. Method A descriptive, exploratory design was used to develop a specifically designed pre-procedure checklist for use in the cardiac catheterisation laboratory in a private hospital in Melbourne, Australia. The pre-procedure checklist was developed by exploring the multidisciplinary team's opinion regarding the organisation's previous surgical pre-procedure checklist through a pre-implementation survey and focus groups. Following an expert review, and implementation of the proposed pre-procedure checklist, a post-implementation survey was completed. Results Thirty-five (70%) cardiac catheterisation laboratory healthcare professionals completed the pre-implementation survey, with 31 (62%) completing the post-implementation survey. Ninety-one per cent of participants agreed that important clinical information required for interventional procedures was not documented on the previous surgical checklist. A specific checklist was developed from the results of the survey and six focus groups (N = 25) and implemented in the cardiac catheterisation laboratory. In the post-implementation survey, participants identified that the cardiac catheterisation laboratory specific pre-procedure checklist included all relevant clinical information and improved documentation of patient information. Conclusion The development of a specific cardiac catheterisation laboratory pre-procedure checklist has led to an improved transfer of pertinent clinical information required prior to procedures being performed in the unit. The outcome of this study has implications for other cardiac catheterisation laboratories with the potential to standardise practice within interventional cardiology practice and improve patient safety outcomes.

Background: The decline of young people’s wellbeing in the UK and elsewhere has become an increasing focus for attention. In this context, it is encouraging to note some evidence suggesting that pa...

Objective To explore primary research evidence reporting the reason for undergraduate nursing students' engagement with social media as an extracurricular activity. Background The formal integration of social media into nursing education has been discussed extensively in previous research. The influence of social media on nursing students' learning and class engagement has also been explored. However, despite the growing volume of literature examining the formal use of social media by undergraduate nursing students, a broader perspective on how and why nursing students engage with social media as an extracurricular activity has not yet been explored. Design An integrative review. Methods A systematic search was performed to find articles published between 2007-2019 using Ovid MEDLINE, Embase, Ovid Emcare and CINAHL Plus databases and the Google Scholar search engine. The review process is reported according to PRISMA. Results Twelve papers met the inclusion criteria, revealing that undergraduate nursing students engaged with social media for many reasons external to their formal curricula. They engaged with social media to keep in touch with others and to entertain themselves, promote learning, find social support, develop a professional nursing identity, share their experiences as nursing students and locate job opportunities. Conclusion Undergraduate nursing students engaged with social media for numerous reasons. It supported students in their academic and personal lives by keeping them in touch with people around them. The students used social media to identify with the nursing profession; however, its influence on their professional identity development is yet to be fully explored. Relevance to clinical practice Nursing schools should consider the myriad of reasons students engage with social media in order to optimise their professional development. Understanding how nursing students' professional identity develops via social media may be used to help sustain nursing students and support their transition into practice.

OBJECTIVE: To estimate the total economic impact of peripheral intravenous catheter (PIVC) or cannula insertion and use in adult Australian EDs, including those cannulas that remain unused for therapeutic purposes. METHODS: Searches on Australian government websites were conducted to find rates of insertion, complications and cost of cannula; following this, gaps in national data sets were filled with MEDLINE and PubMed searches to estimate the total cost of cannula use in Australian EDs. Once the data were collected, totals were combined to establish an estimated cost for the listed categories. RESULTS: The estimated cost of cannulation in Australia may be up to A$594 million per year, including the cost of insertion (equipment and staff), cost of complications such as Staphylococcus aureus bacteraemia and phlebitis, and patient-centred costs (lost patient productivity, infiltration, occlusion and dislodgement). Approximately A$305.9 million is attributed to unused cannulas and approximately 11 790 days of clinician time is spent annually inserting cannula that remains idle. CONCLUSION: The figures developed in the present study represent an important educational opportunity to encourage thoughtful consideration of all interventions, no matter how small. ED cannula insertion represents a large economic and health cost to Australia's health system, many of which remain unused. There are no national data sets that record complications associated with PIVCs and we highlight the urgent need for improved data.

How nursing students perceive themselves as potential nurses in the future is defined as their nursing professional identity. Many undergraduate nursing students present positive attitudes regarding the use of social media. However, the influence of social media usage by undergraduate nursing students on the development of their professional identity is yet to be determined.To determine the relationship between social media usage by undergraduate nursing students and the development of their professional identity.Descriptive, correlational, cross-sectional study.Two universities in western Saudi Arabia.Undergraduate nursing students who used social media.An online questionnaire was designed, and its contents were validated. It was then distributed via a Qualtrics link to students' email addresses and via social media between 4th September 2019 and 28th October 2019. Descriptive analysis including frequencies, percentages, medians, and interquartile ranges were reported. Additionally, a number of non-parametric tests were conducted to investigate the relationships in question.In total, 484 questionnaires were included in the analysis. The participants who used social media for educational (p = 0.004), or for professional purposes (p = 0.015) had high scores on the PI scale. The professional identity scores were also positively associated among the participants who followed nurses (p 0.001), shared their nursing experiences (p 0.001), and acted as societal educators about the nursing profession (p 0.001) on social media platforms.Engagement with social media positively influenced undergraduate nursing students in the development of their professional identity. However, it is notable that the pedagogy of nursing education has been slow to adopt social media into nursing curricula. Nursing students require guidance in terms of how to use social media for their professional development.

Background The role of nurses in antimicrobial stewardship is understated and not well understood. Nurses can have a significant impact on the development of antimicrobial resistant bacteria in hospitals and the wider community through their management of intravenous antibiotics. Objective To investigate the nurse's role in antimicrobial stewardship and examine best practice for preparing, administering and disposing of intravenous antibiotics. Methods A systematically conducted scoping review was used. Seven databases were searched for published articles. Retrieved articles were screened for eligibility against pre-set inclusion and exclusion criteria with eligible full-text articles included in the synthesis. Reference lists of eligible articles and social media were reviewed to identify further sources of literature. Results Forty-three sources of evidence were included. The extracted data indicate that a part of the nurse's role in antimicrobial stewardship is to monitor judicious antibiotic prescribing practices. Other than literature related to medication errors, there was limited research describing best practice when preparing, administering and disposing of intravenous antibiotics. There was also little evidence of consistent policy, guidelines and education for nurses’ practice related to antimicrobial stewardship. Conclusions The evidence for best practice when nurses prepare, administer and dispose of intravenous antibiotics in hospitals is scarce. When nurses use best practice to manage intravenous antibiotics, the risk of antimicrobial resistant bacteria developing is minimised. The role of nurses in antimicrobial stewardship needs to be supported through education and evidence-based guidelines. Tweetable abstract: Nurse work practices may prevent the development and spread of antimicrobial resistant bacteria

Personal protective equipment (PPE) is essential for healthcare worker (HCW) safety. Conservation of PPE for clinical use during the COVID-19 pandemic reduced its availability for training, necessitating an innovative approach to sourcing high physical resemblance PPE (HPR-PPE). We present a case study of crowd-sourcing of HPR-PPE to train HCWs. Survey results indicated that HPR-PPE enabled high-fidelity practise of PPE application and removal, aided procedure recall, improved user confidence and was sufficiently similar to medical-grade PPE. HPR-PPE provided a novel and cost-effective alternative. We also demonstrated that medical-grade PPE can be sourced from non-medical institutions and businesses during a pandemic.

Background ‘Gold standard’ sepsis care encompasses the recognition and treatment of sepsis within one hour of emergency department (ED) presentation. Early treatment of patients with sepsis reduces mortality. The aim of this study was to examine the effect that the nurse allocated Australasian Triage Scale (ATS) Category allocation had on ED patient treatment for severe sepsis and septic shock. Methods A two-year retrospective observational cohort study from a single major metropolitan ED, including all patients with severe sepsis or septic shock. Results Sixty patients were included in this study. Sepsis was recognised at triage for the majority of patients (n = 38, 63%), and most were allocated an ATS Category Two (n = 39). Almost half of the patients received all elements of the sepsis bundle within one hour of arrival (n = 27,45%). Patients allocated an ATS Category One or Two had a shorter time to lactate collection (p = 0.003), blood culture procurement (p = 0.009) and intravenous antibiotic administration (p = 0.021) compared with patients who were allocated ATS Category Three or Four. Conclusions Most patients presenting with sepsis were recognised by the triage nurse and allocated a high acuity ATS category accordingly. As sepsis is a time-critical condition and a high acuity triage allocation reduces time to treatment, we recommend all Australian EDs should implement a standard approach to sepsis triage by allocating an ATS Category of One or Two to all patients suspected of having sepsis, thus reflecting the urgency of their disease.

Across the world, from our unique place within multi-disciplinary health teams, nurses are preparing for, working to overcome, or recovering from the first waves of the worst pandemic humanity has seen in a century. While in the media, nurses are predominantly depicted providing direct patient care; we are also well represented at every level of pandemic response from advising governments to leading research, coordinating public health teams, and strategizing humanitarian responses to COVID-19. Nurses comprise the largest component of the health workforce, playing a key role in developing practice, and preserving the core values of health systems globally. Through the agency of sound expertise and credo, nurses underwrite best practice and advocate for health equity. During this pandemic, nurses continue to research, inform policy, and where appropriate, effect change to the full extent of their expertise for the benefit of public health [1,2]. Nurse expertise in infection prevention and control, critical care, palliative care, and public health will constitute the difference between the success and failure of global health systems to hold or collapse, and the preservation or loss of countless lives. Central to all of these roles is our adaptability and our capacity to preserve human dignity and ease suffering. Nurses see and practice healthcare through a different lens to other health professions and are often described as the linchpin of health systems. We are the group of healthcare professionals with the closest and most constant proximity to patients and are often exposed to danger and moral dilemmas, facing impossible choices in the context of overwhelming need amid resource constraints. Nurses are uniquely placed to convene multi-disciplinary health professional teams for patient safety and wellbeing [3]. Nursing care is the greatest investment made in healthcare and accordingly has the greatest impact on patient outcomes. With this in mind, we face an extraordinary challenge to respond to a situation that is without precedent, highly uncertain, and changing constantly in countries worldwide. As leading nurse scholars and clinicians, we focus here on critical aspects of the pandemic response, moving from populations to systems, to people, incorporating both curative and palliative considerations. We provide practical, solution-based perspectives in a humble effort to help mitigate health risks and to strengthen the health service response.

Introduction:High rates of mortality and morbidity result from disasters of all types, including armed conflicts. Overwhelming numbers of casualties with a myriad of illnesses and patterns of injuries are common in armed conflicts, leading to unpredictable workloads for hospital health care providers (HCPs). Identifying domains of hospital HCPs’ core competency for armed conflicts is essential to inform standards of care, educational requirements, and to facilitate the translation of knowledge into safe and quality care.Objective:The objective of this study is to identify the common domains of core competencies among HCPs working in hospitals in armed conflict areas.Methods:A scoping review was conducted using the Joanna Briggs Institute framework. The review considered primary research and peer-reviewed literature from the following databases: Ovid Medline, Ovid EmCare, Embase, and CINAHL, as well as the reference lists of articles identified for full-text review. Eligibility criteria were outlined a priori to guide the literature selection.Results:Four articles met the inclusion criteria. The studies were conducted in different countries and were published from 2011 through 2017. The methods included three surveys and one Delphi study.Conclusion:This review maps the scope of knowledge, skills, and attitudes required by HCPs who are practicing in hospitals in areas of major armed conflict. Incorporation of identified core competency domains can improve the future planning, education, and training, and may enhance the HCPs’ response in armed conflicts.

Women have generally worse outcomes after myocardial infarction (MI) compared to men. The reasons for these disparities are multifactorial. At the beginning is the notion-widespread in the community and health care providers-that women are at low risk for MI. This can impact on primary prevention of cardiovascular disease in women, with lower use of preventative therapies and lifestyle counselling. It can also lead to delays in presentation in the event of an acute MI, both at the patient and health care provider level. This is of particular concern in the case of ST elevation MI (STEMI), where "time is muscle". Even after first medical contact, women with acute MI experience delays to diagnosis with less timely reperfusion and percutaneous coronary intervention (PCI). Compared to men, women are less likely to undergo invasive diagnostic testing or PCI. After being diagnosed with a STEMI, women receive less guideline-directed medical therapy and potent antiplatelets than men. The consequences of these discrepancies are significant-with higher mortality, major cardiovascular events and bleeding after MI in women compared to men. We review the sex disparities in pathophysiology, risk factors, presentation, diagnosis, treatment, and outcomes for acute MI, to answer the question: are they due to biology or bias, or both?

Australians with lived experience of mental illness die on average 10 or more years earlier than the general population. Cardiometabolic disorders, including cardiovascular disease and diabetes mellitus, are common causes of premature death in this cohort. Little is known about cardiometabolic monitoring practices in mental health inpatient units. The aim of this study was to examine the characteristics of cardiometabolic monitoring and physical health assessments of adult mental health consumers within the first 72 hours of admission to an inpatient unit. We implemented a retrospective descriptive exploratory design by medical record audit. Data were collected using a pre-validated audit tool, adapted with recent literature and policy, from a randomly selected sample of consumers admitted to three acute mental health adult inpatient units of a large Australian metropolitan health service in 2016. Of 228 consumers, the mean age was 37.5 (range 18-64) years and 51.3% were women. Cardiometabolic risks were common, yet most consumers received incomplete cardiometabolic monitoring. While few consumers (15%) were diagnosed with cardiometabolic comorbidities, 67.5% were prescribed psychotropic medications with high cardiometabolic risk. Compliance with recommended cardiometabolic monitoring varied considerably between risk factors: for example, blood pressure was measured in 56.1% of consumers, whereas waist circumference was never recorded. There were no statistically significant associations between cardiometabolic monitoring completion and sex or cardiometabolic risk. These findings demonstrate the need for increased education and awareness of cardiometabolic risk and identify a critical gap between physical health assessment practices and recommendations for this cohort.

Background Radial access for primary percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) is associated with reduced mortality and bleeding, when compared to femoral access. However, radial access failure may be associated with an increased door-to-device (DTD) time. Aims To identify predictors of radial access failure requiring crossover to femoral artery access during primary PCI. Methods From 2013 to 2020, 2,256 consecutive patients treated for PPCI at a single tertiary hospital were prospectively recruited into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariable logistic regression was used to identify independent predictors of radial to femoral access crossover. Results From 2,256 STEMI patients, primary radial access was used in 1,778 (78.8%), with 171 (9.6%) experiencing radial-to-femoral crossover. Patients with failed versus successful radial access experienced longer DTD times (67 mins, interquartile range [IQR] 46–99 vs 54 mins [IQR 39-78]; p

Background: Guidelines recommend that all non–ST-segment elevation acute coronary syndrome (NSTEACS) patients with high-risk features receive a coronary angiogram. We hypothesised that the widely reported gender disparity in the use of angiography might be the result of women more frequently being stratified into the lower-risk category. Objectives: The aim of the study was to review studies reporting risk stratification of NSTEACS patients by gender, compare risk profiles, and assess impact on use of coronary angiography. Methods: PubMed, Scopus, and EMBASE databases were searched on June 17, 2014, using MeSH terms/subheadings and/or key words with no further limits. The search revealed 1230 articles, of which 25 met our objective. Results: Among the 28 risk-stratified populations described in the 25 articles, women were more likely to be stratified as high-risk in 13 studies; men were more likely to be stratified as high-risk in 3 studies. After meta-analyses, women had a 23% higher odds of being stratified as high-risk than did men (P = .001). Lower-risk patients were more likely to receive an angiogram in 15 study populations. Conclusions: Contrary to our hypothesis, this review showed that women with NSTEACS are more likely than men to be considered high-risk when stratified using a range of risk assessment methods. Lower rates of angiography in women form part of a broader treatment-risk paradox, which may involve gender bias in the selection of patients for invasive therapy.

Background Previous research has addressed nursing course components such as clinical placements that affect students' socialisation processes and the development of their professional identities. Social media is an increasingly important factor that has not yet been explored in-depth in terms of its influence on the development of the professional identity of nursing and is a major gap in our knowledge and understanding of undergraduate nurses' development. Objective To understand the influence of social media usage on the development of undergraduate nursing students' professional identity. Design Descriptive qualitative study. Setting Two universities in Saudi Arabia. Participants Sixteen undergraduate nursing students. Methods Semi-structured and audio-recorded interviews were undertaken between November 2018 and January 2019. The transcribed data were thematically analysed using NVivo 12. Results Three main themes emerged: Learning about nursing professional identity through social media, adopting the identity of nursing, and students sharing their understanding of nursing professional identity via social media. Students used social media to learn about the nursing profession, and this helped them to develop a sense of belonging to the nursing profession. The students also used social media to share their experiences as nursing students and to enhance society's understanding of the importance of the nursing profession. Conclusion Undergraduate nursing students should be encouraged to develop their professional identity through socialisation. Social media can facilitate the socialisation process of undergraduate nursing students by connecting them with members of the nursing community.

Aims To characterize the trajectory in the years leading up to 2018 in pharmaceutical opioid and heroin morbidity in Victoria, Australia, and to assess the effect on that trajectory of reformulation of oxycodone to a form that could not be easily snorted or injected. Design Interrupted time-series analyses of population-level data before versus after reformulation of oxycodone, stratified by sex. Setting Victoria, Australia. Participants The population of Victoria aged 12+ years. Measurements Ambulance patient care and emergency department (ED) records were examined using both fixed-code and free-text fields, with each record manually cleaned and checked by trained coders. These were used to derive the output variables providing an index of harm: rates of opioid-related ambulance attendances and ED attendances for pharmaceutical opioids and heroin. The input variable was pre- versus post-oxycodone reformulation. Findings There were 30 045 opioid-related ambulance attendances from January 2012 to October 2018 (54% heroin-related), and 10 113 ED attendances from July 2008 to June 2018 (39% heroin-related). There was an increase in the rate (events per 100 000 people per year) of all opioid ED attendances from 2008 to 2018 [increase = 0.063; 95% confidence interval (CI) = 0.049, 0.078]. Pharmaceutical opioid ED attendances decreased from 2014 onwards (slope change = -0.083; 95% CI = -0.108, -0.059). Heroin-related ED attendances increased from 2014 to 2018; 11 324 heroin-related ambulance attendances and 1980 ED attendances were observed from April 2014 to June 2018, compared with the respective estimates of 8176, and 1661 had the pre-April 2014 trend continued (ambulance slope change = 0.296, 95% CI = 0.104, 0.489; ED slope change = 0.026, 95% CI = 0.005, 0.046). The inflection point of 2014 coincided with the re-formulation of oxycodone. Conclusion In Victoria, Australia, there appears to have been a trend starting around mid-2014 of increasing heroin-related harm, and a flattening of the increase or a decrease of harms relating to pharmaceutical opioids. These changes may, in part, reflect reformulation of oxycodone to reduce the extent to which it can be injected or snorted.

Der Beitrag beschaftigt sich mit der Frage, ob Arbeitnehmer, die aus dem Anwendungsbereich der Tarifvertrage (insbesondere aufgrund ihres hohen Verdienstes) herausfallen, den Schutzvorschrift en des Arbeitszeitgesetzes unterworfen sind. Hierbei werden insbesondere auch der Begriff des leitenden Angestellten und die Moglichkeit der Einfuhrung einer Verdienstgrenze diskutiert. Daneben beleuchtet der Beitrag die arbeitszeitrechtliche und die vertragsrechtliche Behandlung von Reisezeiten eines Arbeitnehmers. Hierbei wird zuerst erortert, ob die Zeit, die ein Arbeitnehmer wahrend einer Dienstreise in Bus, Bahn, Auto etc. verbringt, Arbeitszeit im Sinne des Arbeitszeitgesetzes ist. In einem zweiten Schritt wird untersucht, ob die Reisezeit zu verguten ist.

Aim This paper presents a discussion of classification and regression tree analysis and its utility in nursing research. Background Classification and regression tree analysis is an exploratory research method used to illustrate associations between variables not suited to traditional regression analysis. Complex interactions are demonstrated between covariates and variables of interest in inverted tree diagrams. Design Discussion paper. Data sources English language literature was sourced from eBooks, Medline Complete and CINAHL Plus databases, Google and Google Scholar, hard copy research texts and retrieved reference lists for terms including classification and regression tree* and derivatives and recursive partitioning from 1984–2013. Discussion Classification and regression tree analysis is an important method used to identify previously unknown patterns amongst data. Whilst there are several reasons to embrace this method as a means of exploratory quantitative research, issues regarding quality of data as well as the usefulness and validity of the findings should be considered. Implications for Nursing Research Classification and regression tree analysis is a valuable tool to guide nurses to reduce gaps in the application of evidence to practice. With the ever-expanding availability of data, it is important that nurses understand the utility and limitations of the research method. Conclusion Classification and regression tree analysis is an easily interpreted method for modelling interactions between health-related variables that would otherwise remain obscured. Knowledge is presented graphically, providing insightful understanding of complex and hierarchical relationships in an accessible and useful way to nursing and other health professions.

Polydnaviruses (PDVs) are symbiotic viruses carried by endoparasitic wasps and transmitted to caterpillar hosts during parasitization. Although they share several features, including a segmented dsDNA genome, a unique life cycle where replication is restricted to the wasp host, and immunodepressive/developmental effects on the caterpillar host, PDVs carried by ichneumonid and braconid wasps (referred to as ichnoviruses and bracoviruses, respectively) have different evolutionary origins. In addition, ichnoviruses (IVs) form two distinct lineages, with viral entities found in wasps belonging to the subfamilies Campopleginae and Banchinae displaying strikingly different virion morphologies and genomic features. However, the current description for banchine IVs is based on the characterization of a single species, namely that of the Glypta fumiferanae IV (GfIV). Here we provide an ultrastructural and genomic analysis of a second banchine IV isolated from the wasp Apophua simplicipes, and we show that this virus shares many features with GfIV, including a multi-nucleocapsid virion, an aggregate genome size of ~300 kb, genome segments

Background Early acute coronary syndrome (ACS) care occurs in the emergency department (ED). Death and disability from ACS are reduced with access to evidence-based ACS care. In this study, we aimed to explore if gender influenced access to ACS care. Methods A retrospective descriptive study was conducted for 288 (50% women, n=144) randomly selected adults with ACS admitted via the ED to three tertiary public hospitals in Victoria, Australia from 1.1.2013 to 30.6.2015. Results Compared with men, women were older (79 vs 75.5 years; p =0.009) less often allocated triage category 2 (58.3 vs 71.5%; p =0.026) and waited longer for their first electrocardiograph (18.5 vs 15min; p =0.001). Fewer women were admitted to coronary care units (52.4 vs 65.3%; p =0.023), but were more often admitted to general medicine units (39.6 vs 22.9%; p =0.003) than men. The median length of stay was 4days for both genders, but women were admitted for significantly more bed days than men (IQR 3–7 vs 2–5; p =0.005). Conclusions There were a number of gender differences in ED care for ACS and women were at greater risk of variation from evidence-based guidelines. Further research is needed to understand why gender differences exist in ED ACS care.

A single-institution pilot clinical trial was performed combining nonmyeloablative chemotherapy and the adoptive transfer of tumor-infiltrating lymphocytes with interleukin-2 in patients with metastatic melanoma. Nineteen patients were enrolled with 13 patients (68%) successfully completing treatment. An overall response rate (partial and complete responses) of 26% by intention to treat was achieved with a median follow-up time of 10 months. Of the 13 treated patients, there were 2 complete responses and 3 partial responses (38% response rate among treated patients), along with 4 patients with stable disease ranging from 2+ to 24+months. Three of the 4 patients with stable disease have had disease control without additional therapy, including one at 24+ months. Adoptive therapy with infiltrating lymphocytes is labor intensive but feasible and has a high response rate in treated patients.

Aims and Objectives: This article analyzes the literature describing factors affecting nurses' triage of emergency department (ED) patients with potential acute coronary syndrome (ACS), with particular attention paid to gender-based differences. Introduction: Acute coronary syndrome is one of the most time-critical conditions requiring ED nurse triage. This literature review will provide examination of how triage nurses prioritize patients with possible ACS, reflecting on challenges specifically associated with evaluating women for ACS in the ED. The article presents a description of the research findings that may help improve the timely revascularization of ACS in women. Methods: An electronic search of EBSCOhost CINAHL, Health Source Nursing Academic Edition, MEDLINE, Psychology and Behavioral Sciences Collection databases, online theses, the Cochrane Library, the Joanna Briggs Institute, and National Guideline Clearinghouse resources were used to identify all relevant scientific articles published between 1990 and 2010. Google and Google Scholar search engines were used to undertake a broader search of the World Wide Web to improve completeness of the search. This search technique was augmented by hand searching these articles' reference lists for publications missed during the primary search. Results: Review of the literature suggests factors such as patient age, sex, and symptoms at ED presentation affect the accuracy of nurses' triage of ACS, particularly for women. However, research examining delays due to ED triage is scant and has predominantly been undertaken by one researcher. Little research has examined triage of ACS specifically in women. Conclusions: The literature search revealed a small number of articles describing challenges associated with nurse triage of women with ACS. Although most of this published research is North American, the themes uncovered are well supported by broader international research on acute assessment and management of women's ACS. These include the following: gender-based differences in the presentation of ACS can preclude early identification of ACS, advanced patient age often correlates with missed or delayed diagnosis of ACS, and there appears to be a general bias against managing women for ACS in parity with men's disease. Relevance to Practice: Early reperfusion therapy is critical for optimal health outcomes in ACS. Triage nurses are ideally placed to minimize time to treatment for ACS. An understanding of the issues related to clinical decision making and triage allocation of women with ACS at triage is necessary to ensure appropriate treatment. © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins.

dickson vv, worrall-carter l, kuhn l & riegel b (2011) Journal of Nursing and Healthcare of Chronic Illness3, 99–108 Whose job is it? Gender differences in perceived role in heart failure self-care Aim. To describe gender differences in perceived role in heart failure (HF) self-care and to explore how an individual’s perception of their role influences self-care behaviours. Specifically, two hypotheses were tested: (1) there are gender-specific differences in perceived self-care roles in HF and (2) there are differences in self-care secondary to a patient’s perceived role. Background. Gender differences in roles are ubiquitous in all societies. Rarely have these roles been examined as they contribute to performance of self-care in adults with chronic illnesses. Methods. Secondary analysis of three mixed methods studies (n = 99) of adults with chronic heart failure. Data were collected between 2006–2008. Conclusions. Two dominant perceived roles in self-care were identified: (1) active and (2) passive. These were further categorised according to the degree of independence described by participants in self-care decision making: (1) primary responsibility (27%), (2) collaboration (22%) and (3) reliant upon direction from others (51%). Relevance to clinical practice. Clinicians are encouraged to assess the individual’s perceived role in HF self-care as part of the self-care education process. Understanding patient perceptions of their role may help guide education, which may be particularly useful for those patients most likely to defer to others for HF management advice.