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Leg ulcer treatment is a substantial aspect of primary care nursing. Approximately 70 per cent of all leg ulcers are venous and research suggests that such ulcers are highly likely to recur unless appropriate aftercare is provided. Kenneth Ripley reviews local practice provision by the nursing intervention team in the light of best-evidence and provides guidance and recommendations for enhancing patient care and outcome. [ABSTRACT FROM AUTHOR]

New NMC standards for mentors came into force this month. Kenneth Ripleyoutlines the standards and makes recommendations for improving practice. [ABSTRACT FROM AUTHOR]

Kenneth Ripley discusses the evidence-base underpinning skin care in incontinent patients, evaluates the care provided by the local community nursing team and makes recommendations for improving practice. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Immunizations and other cost-effective preventive services remain underused by many children, especially those living in poverty. Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns, we designed and tested an intervention combining these strategies. We studied whether a system of semiannual assessment and feedback, coupled with financial incentives, could improve pediatric preventive care in a Medicaid health maintenance organization (HMO). METHODOLOGY: We randomly assigned primary care sites serving children in a Medicaid HMO to one of three groups: a feedback group (where physicians received written feedback about compliance scores), a feedback and incentive group (where physicians received feedback and a financial bonus when compliance criteria were met), and a control group. We evaluated compliance with pediatric preventive care guidelines through semiannual chart audits during the years 1993 to 1995. RESULTS: Compliance with pediatric preventive care improved dramatically in the study period. Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores (from 56%-73%), as well as scores for immunizations (from 62%-79%) and other preventive care (from 54%-71%). However, no significant differences were observed between either intervention group and the control group, nor were there any interaction (group-by-time) effects. CONCLUSIONS: Feedback to physicians, with or without financial incentives, did not improve pediatric preventive care in this Medicaid HMO during a time of rapid, secular improvements in care. Possible explanations include the context and timing of the intervention, the magnitude of the financial incentives, and lack of physician awareness of the intervention. [ABSTRACT FROM AUTHOR]

Letermovir is an antiviral agent indicated for primary prophylaxis of cytomegalovirus (CMV) infection and disease in adult allogeneic hematopoietic stem cell transplant recipients. In this case, UL97 mutation that conferred resistance to ganciclovir was seen in a patient 8 months after renal transplant. We report the off-label use of letermovir with adjunct hyperimmune CMV immunoglobulin in the successful treatment of CMV disease. This report is the first to use this combination for treatment of CMV infection with a high viral load. It contributes to the limited available literature supporting the use of letermovir in the treatment of resistant CMV, where current therapeutic options can be suboptimal due to adverse effects and the risk of cross-resistance., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We read, write, and discuss the option of adding new agents to the armamentarium of antibiotic therapy very frequently. However, the past and present has taught us that resistance is likely to develop to any and all kinds of antibiotics. Here we start with an overview of potential future antibiotics from novel sources and targets that may circumvent most known resistance mechanisms. The other future options for antibiotic discovery include antibiotic hybridization, harvesting, and modifying natural antimicrobial peptides from eukaryote and prokaryote organisms. Non bacteriostatic and bactericidal agents that have the potential of becoming therapeutic agents include bacterial attachment inhibitors, bacteriophages, and live microbial vectors. In this review, we have incorporated all the possible avenues that might be useful in the future. However, none is more important than relearning the judicious use of antibiotics based on microbiology, pharmacology, and genetics.

The first written record of intervention against what later came to be known as an infectious disease was in the early seventeenth century by a Buddhist nun. She dried 3 to 4 wk old scabs from patients with mild smallpox and asked well people to inhale the powder. More than a century later in 1796, Edward Jenner described vaccination against smallpox by using cowpox that later was found to be caused by cowpox virus which is non-pathogenic for humans. Another century later in 1890, Robert Koch published the Koch's Postulates allowing the study of pathogenic bacteria and subsequently the study of agents to fight them. The first chemical cure for disease was reported by Paul Erhlich in 1909 in the form of an arsenic compound to treat syphilis. One hundred and ten years since then a lot has happened in the area of preventing and treating infectious diseases with significant contribution to increase in human lifespan. This is the only area of medicine in which treatment (antimicrobial agent) is used to eradicate a replicating biological agent inside the human host. The potential of this second biological agent to mutate under the selection pressure of antibiotics making them resistant was recognized in the 1940s. But the indiscriminate use of antibiotics for over 70 y has led to the present crisis of resistance in major pathogens with increased morbidity and mortality. In this review, we have incorporated all the possible avenues that might be useful in the future. However, none is more important than relearning the judicious use of antibiotics based on microbiology, pharmacology, and genetics.

There is excessive use of both broad spectrum and niched antibiotics for urinary tract infections (UTIs) in hospital and ambulatory setting in spite of clear guidelines on appropriate use. Majority of antibiotics prescribed in United States for UTIs are for nonspecific indications such as positive urine cultures in the absence of symptoms, etc. For these conditions especially asymptomatic bacteriuria, a large proportion of the antibiotics prescribed are unlikely to provide clinical benefit to patients. Asymptomatic bacteriuria (ASB) is a common finding in healthy women and persons with underlying urological abnormalities. Guidelines from Infectious Diseases Society of America (IDSA) clearly define the use of antibiotics in ASB only in pregnant patients and in individuals prior to undergoing invasive urological procedures. IDSA updated the guidelines in 2019 on the use of antibiotics for UTI in special groups such as patients with neutropenia, solid organ transplants, and non-urologic surgery. Considering the implications of antibiotic resistance in the setting of indiscriminate use, there is definitely a need to improve their use in asymptomatic bacteriuria as well as in UTIs. In this review, we follow case-based approach to identify the barriers to appropriate antibiotic prescribing practices in renal transplant recipients.

Assistant practitioners, also known as associate practitioners, provide support to the registered healthcare workforce, practising with advanced knowledge and skills. Assistant practitioners require substantial training to obtain the skills and knowledge required for the role. This article identifies the challenges trainee assistant practitioners may encounter, and makes recommendations for how they can be best supported. The core areas where trainee assistant practitioners require support from their colleagues and mentors are workload, role clarity, mentoring, academic challenge and recognition as learners.

Background: High levels of behaviour problems are found in children with language impairments, but less is known about the level and nature of language impairment in children with severe behavioural problems. In particular, previous data suggest that at primary age, receptive impairments are more closely related to behaviour problems, whereas expressive language has a closer link at a later age., Aims: The study assessed expressive and receptive language problems in boys excluded from primary and secondary schools, to investigate the extent of impairment, the pattern of relations between age, receptive and expressive language, and relations with different aspects of behaviour., Sample: Nineteen boys (8 - 16 years of age) who had been excluded from school and 19 non-excluded controls matched for age and school participated., Method: The sample was given assessments of: receptive language from the British Picture Vocabulary Scale (BPVS), and Wechsler Objective Language Dimensions (WOLD); expressive-language evaluations from the Wechsler Intelligence Scale for Children (WISC); auditory working memory evaluations from the Clinical Evaluation of Language Fundamentals (CELF); verbal reasoning (from the WISC); and non-verbal IQ assessments Raven's matrices. Teachers completed behaviour ratings using the Strengths and Difficulties Questionnaire (SDQ)., Results: Excluded boys were significantly poorer than controls on expressive measures but similar on receptive language and non-verbal IQ. Boys excluded from primary school were poorer than controls on auditory working memory. Expressive problems were linked with high levels of emotional symptoms., Conclusion: Many of the excluded boys had previously unidentified language problems, supporting the need for early recognition and assessment of language in boys with behaviour problems. Expressive problems in particular may be a risk factor.

Pharmaceutical costs have been rising dramatically since 1995, growing 16.6% in 1998 alone. This rate of increase is more than four times that of all health care spending. Employers, managed care organizations and consumers are looking anew for ways to stem these rising costs, without denying patients effective care. Therefore, this Issue Brief is especially timely because it investigates how patient copayments and financial incentives for physicians affect drug spending in managed care.

Objectives: This prospective, multicenter trial was aimed at defining efficacy and safety of low energy shocks during atrial fibrillation in a diverse cohort of patients., Background: Experimental studies in sheep and preliminary data in humans have suggested that low energy internal shocks delivered between right atrial and coronary sinus electrode catheters may terminate atrial fibrillation., Methods: Biphasic 3/3-ms R wave synchronous shocks were delivered between two electrode catheters in the right atrium and coronary sinus. The defibrillation protocol started with a test shock of 20 V, and shocks increased in 40-V steps until restoration of sinus rhythm or a maximum of 400 V. Shock delivery was withheld after short RR intervals. In 141 patients with atrial fibrillation, the protocol was carried out under sedation in case the shock was associated with discomfort. The atrial arrhythmia was paroxysmal (< or = 7 days) in 50 patients, chronic (> 30 days) in 53, intermediate (> 7 days, < or = 30 days) in 18 and induced in 20. Underlying heart disease was present in 88 patients (62%)., Results: Paroxysmal atrial fibrillation was successfully terminated in 46 (92%) of 50 patients, chronic atrial fibrillation in 37 (70%) of 53, intermediate in 16 (89%) of 18 and induced in 16 (80%) of 20. Mean conversion threshold was 1.8 J (213 V) in the induced group, 2.0 J (229 V) in the paroxysmal group, 2.8 J (272 V) in the intermediate group and 3.6 J (311 V) in the chronic group. The conversion voltage was significantly (p < 0.001) higher in the chronic group than in the other groups of atrial fibrillation and increased significantly with the duration of atrial fibrillation and with left atrial size (p < 0.05). Of 1,779 R wave synchronized shocks delivered with a mean (+/-SD) preceding RR interval of 676 +/- 149 ms, no ventricular arrhythmia was induced. The latter may occur after unsynchronized shocks., Conclusions: Low energy transvenous shocks in patients with atrial fibrillation are effective and safe, provided that shocks are properly synchronized to R waves with preceding RR intervals that meet appropriate cycle length criteria. This study provides data that may be useful in the development of an implanted atrial defibrillator.

Chronotropically incompetent patients benefit most from sensor driven rate response during exercise. Postural syncope may occur despite the chronotropic response because of the failure of currently available sensors to respond physiologically to postural changes. Seven chronotropically incompetent patients with postural syncope who had a dual chamber rate adaptive pacemaker (Circadia) that modulates heart rate in response to temperature change were studied with respect to: (1) response to exercise; and (2) head-up tilt (HUT). During exercise, continuous-wave Doppler of aortic velocities and two-dimensional echocardiographic derived measurements of left ventricular systolic function were used to assess cardiac function. Patients exercised longer (by an average of 168 sec) in the DDDR compared to the DDI mode (P = 0.013). Increase in exercise duration was due mostly to the sensor driven increase during DDDR pacing. During DDDR pacing, heart rate increased from 71 +/- 6 to 121 +/- 17 ppm compared to 70 +/- 1 to 103 +/- 21 ppm for the DDI pacing (P = 0.038). Stroke volume as assessed by Doppler derived stroke distance (SD) contributed more significantly to the cardiac output increase during exercise in the DDI mode (SD increased from 13.4 +/- 4 to 18 +/- 7 cm in DDI compared to 13 +/- 4 to 14 +/- 2 cm in DDDR mode), although these mechanisms were insufficient to fully compensate for failure of appropriate chronotropic response. In response to the HUT, right ventricular temperature increased from 36.78 degrees C +/- 0.29 degrees C to 36.89 degrees +/- 0.28 degrees C (P = 0.0002), and heart rate increased from 54 +/- 3 to 71 +/- 8 ppm (P = 0.0003) in the DDDR mode. No significant change in heart rate occurred in the DDI mode in response to the HUT. Strong positive correlation of temperature and heart rate was noted in all patients in response to HUT (P = 0.001, R2 = 0.755-0.976). We conclude that temperature sensor responds physiologically to exercise and HUT. Therefore, temperature sensing rate adaptive dual chamber pacing may be appropriate for chronotropically incompetent patients with posture related syncope.

Antitachycardia devices need more accurate means to identify arrhythmias. Previous studies have found that sinus rhythm can be distinguished from a variety of tachyarrhythmias by algorithms that are based on time-domain and frequency-domain analysis of intracardiac electrograms. Amplitude distribution analysis (time-domain) and power density spectral analysis (frequency-domain) are two of the techniques that have seemed to hold promise. However, previous studies have not evaluated whether lead maturation or drugs such as lidocaine, propranolol, verapamil, or isoproterenol can interfere with the ability of these algorithms to distinguish among cardiac rhythms. In the present study, five dogs had permanent atrial pacing leads placed. On a series of days, recordings were made from the atrial leads during sinus rhythm and induced sustained atrial fibrillation, both before and after administration of cardioactive drugs. For up to 1 month after implantation, progressive lead maturation did not prevent differentiation of atrial fibrillation from sinus rhythm by either amplitude distribution analysis or power density spectral analysis. However, the difference between the power density spectra of sinus rhythm and atrial fibrillation became progressively less with time. Isoproterenol, lidocaine, verapamil, and propranolol had no consistent effects on amplitude distribution analysis of atrial electrograms during sinus rhythm or atrial fibrillation. However, there were marked effects of drugs on amplitude distribution characteristics in individual dogs. Propranolol and lidocaine produced consistent changes in power density spectra during sinus rhythm and atrial fibrillation, respectively; both drugs reduced the ability of power density spectral analysis to differentiate sinus rhythm from atrial fibrillation.(ABSTRACT TRUNCATED AT 250 WORDS)

Implantable devices that provide antitachycardia and defibrillation capability currently have limited ability to distinguish among different cardiac rhythms. We have investigated three methods of electrogram analysis: rate, irregularity, and amplitude distribution. In 35 episodes in 19 patients, we applied these three algorithms to 15 s recorded passages of ventricular electrograms during supraventricular tachycardia (N = 11), ventricular tachycardia (N = 11), and ventricular fibrillation (N = 13). Each was individually paired with a recording of sinus rhythm from the same patient. All recordings were obtained during standard electrophysiologic testing. Each algorithm was successful at distinguishing the tachyarrhythmias from sinus rhythm at one or more levels of algorithm parameterization. Rate alone discriminated supraventricular tachycardia from ventricular fibrillation but did not distinguish between supraventricular and ventricular tachycardia. Rate combined with irregularity distinguished between ventricular tachycardia and ventricular fibrillation, but did not discriminate between ventricular and supraventricular tachycardia. Although the amplitude distribution algorithm was unable to separate perfectly any of the three tachyarrhythmias, it provided the best performance in separating supraventricular and ventricular tachycardia (82 percent sensitivity and specificity). We conclude that algorithms based on rate, irregularity, and amplitude distribution analysis of ventricular electrograms may distinguish sinus rhythm from tachyarrhythmias, but may not distinguish among tachyarrhythmias.