Biomedical subjects
Publications and source records attributed to R Jay.
A&E nurses are increasingly becoming involved in wound suturing, an area traditionally reserved for medical staff. To achieve optimum outcomes, nurses require a good understanding of wound assessment, anaesthesia and suturing techniques.
This paper is an account of a qualitative study of significantly injured patients' experience in the Accident and Emergency department (A&E) and explores the question 'What A&E nursing interventions are effective in providing reassurance and reducing anxiety in patients with significant trauma?' A review of the limited literature available indicates that when a seriously injured patient is admitted to the A&E department, the medical and nursing staff often respond urgently to the physiological crisis without adequate consideration of psychological needs. The research design used a version of the Critical Incident Technique to interview 7 patients who had sustained serious injuries a few days previously. The findings indicate that central to the delivery of emergency care is the individual's transition from their normal independent existence through pre-hospital trauma and into the isolating experience of fear, dependence and the resuscitation room. Different methods of coping were required to meet their needs and regain some control. Methods such as touch, company and information became paramount as did the need to trust the people seen to be in control of their new environment.
Many support surfaces are available, each with advantages and disadvantages, that claim to relieve or reduce the external forces contributing to the development of pressure ulcers. This article describes pressure and shear, and what a patient support surface must do to relieve those forces. Pressure is the vertical force of the weight of the patient's body on the surface. Shear is a horizontal force that causes the bony prominence to move across the tissue as the skin is held in place, and results from patient movement, nurse movement of the patient, and bed movement. There are seven basic requirements a support surface must meet in order to prevent pressure and shear: The surface must (1) conform to bony prominences without resistance, (2) not have significant memory, (3) allow patient immersion, (4) not bottom out, (5) relieve shear caused by patient movement, (6) prevent skin maceration, and (7) provide patient comfort. Six types of support surfaces are listed along with a summary of each surface's theoretical ability to deal with the forces described in this article. Understanding the physical forces that contribute to pressure ulcers, and each support surface's theoretical ability to relieve these forces, should make it easier to choose an appropriate support surface for each patient.
OBJECTIVE: To compare the relative safety and efficacy of a low-molecular-weight heparinoid (ORG 10172) with unfractionated heparin in the prevention of deep vein thrombosis in patients with acute ischemic stroke. DESIGN: Double-blind randomized trial. SETTING: Seven Canadian university-affiliated hospitals. PARTICIPANTS: Eighty-seven patients with acute ischemic stroke resulting in lower-limb paresis. INTERVENTION: Patients received either low-molecular-weight heparinoid, 750 anti-factor Xa units twice daily, or unfractionated heparin, 5000 units subcutaneously twice daily. Treatment was continued for 14 days or until hospital discharge if sooner. MEASUREMENTS: Deep vein thrombosis was diagnosed using 125I-labeled fibrinogen leg scanning and impedance plethysmography. Venography was indicated if either test was positive. Overt hemorrhage, major or minor, was assessed clinically. RESULTS: Venous thrombosis occurred in four patients (9%) given low-molecular-weight heparinoid and in 13 patients (31%) given heparin (relative risk reduction, 71%; 95% CI, 16% to 93%. The corresponding rates for proximal vein thrombosis were 4% and 12%, respectively (relative risk reduction, 63%; P greater than 0.2). The incidence of hemorrhage was 2% in both groups. CONCLUSION: Low-molecular-weight heparinoid, given in a fixed dose of 750 anti-factor Xa units subcutaneously twice daily, is more effective than subcutaneous low-dose heparin for the prevention of deep vein thrombosis in patients with acute ischemic stroke.
We performed a randomized trial comparing two dosing regimens of recombinant tissue plasminogen activator (rt-PA) plus heparin vs heparin alone in the treatment of acute proximal deep vein thrombosis in 83 patients. Of 12 patients who received 0.5 mg/kg rt-PA plus heparin over 4 h, seven (58 percent) had greater than 50 percent lysis of the thrombus, compared with none of 12 who received placebo plus heparin (p = 0.002). Of 28 patients who received 0.5 mg/kg rt-PA over 8 h, repeated in 24 h, six (21 percent) had greater than 50 percent lysis, compared with two (7 percent) of 30 patients who received placebo plus heparin (p = 0.11). The 4-h infusion of rt-PA produced a 40 percent reduction and the 8-h infusion an 11 percent reduction in plasma fibrinogen concentration. At long-term follow-up, three (25 percent) of 12 patients in whom greater than 50 percent lysis was achieved had symptoms of the postphlebitic syndrome, compared with 19 (56 percent) of 34 patients in whom lysis was less than 50 percent (p = 0.07).
Venous thromboembolism is a common post-operative complication in patients following hip surgery. 125I-fibrinogen leg scanning and impedance plethysmography (IPG), are often used in the detection of venous thrombi in such patients. Information on the sensitivity and specificity of these non-invasive tests for the diagnosis of venous thrombosis following hip surgery is relevant for both patient management and for choosing the appropriate outcome measure for clinical trials evaluating new prophylactic regimens. We determined the sensitivity and specificity of the IPG alone, the 125I-fibrinogen leg scan alone, as well as the combined use of the two tests from a retrospective analysis of 685 hip surgery patients who participated in clinical trials of anti-thrombotic prophylaxis. These patients were followed prospectively with non-invasive tests. Bilateral venography was attempted either when one or both screening tests became positive or on day 10-14 post-operatively if both screening tests remained negative. Adequate venography was obtained in 1,010 (73.7%) legs and thrombi were identified in 198 (19.6%) legs. The sensitivities of the IPG and leg scanning were 12.9% and 44.6% respectively; the corresponding specificities were 98.1% and 95.0%. The sensitivity of a positive result on one or both screening tests was 49.6% with a specificity of 93.9%. Therefore, leg scanning and IPG, even in combination, are not sufficiently accurate to be recommended as the only strategy for the diagnosis of venous thrombosis following hip surgery. Venography should be considered in all patients undergoing surveillance testing either when one or both of the screening tests become positive or on day 10-14 if the screening tests remain negative.
The prothrombin time (PT) is frequently performed to monitor anticoagulant therapy. Although relatively simple to perform, it requires venipuncture and laboratory resources for sample handling and analysis. A recently developed capillary whole blood device that uses fingerstick samples was evaluated. Paired capillary whole blood and reference plasma PTs were performed in 858 samples from 732 subjects. The PT for normal volunteers (n = 193) was 11.8 +/- 0.9 seconds with the use of the new instrument and 12.1 +/- 0.5 seconds with the use of the reference method. In samples from 539 patients receiving anticoagulants, the correlation coefficient between the two methods was 0.96. Venous whole blood without anticoagulant and capillary whole blood gave equivalent results, which suggests that the fingersticks do not effect the quality of the specimen. Variation in hematocrit between 23.4% (0.34) and 53.8% (0.538) did not alter the performance of the instrument. The new instrument is easy to use and may allow testing by nonlaboratory personnel and patients. It obviates the need for venipuncture, provides immediate results, and appears to be comparable in accuracy to current reference methods.
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We have previously reported that long-term therapy with warfarin is effective for preventing recurrent venous thromboembolism in patients with proximal-vein thrombosis but that there is an appreciable risk of hemorrhage. To determine whether that risk could be reduced without a loss of effectiveness, we randomly allocated 96 patients with proximal-vein thrombosis to a group receiving less intense anticoagulant therapy, with a mean prothrombin time of 26.9 seconds using the Manchester comparative reagent (corresponding Simplastin time, 15 seconds), or a group given more intense therapy, with a mean Simplastin time of 19.4 seconds (corresponding prothrombin time 41 seconds with the Manchester comparative reagent) (P less than 0.001). Two of 47 patients (4 per cent) in the less intensely treated group had hemorrhagic complications, as compared with 11 of 49 patients (22 per cent) in the more intensely anticoagulated group (P = 0.015 by the two-tailed test). This difference was due to minor bleeding episodes. The frequency of recurrent venous thromboembolism was low in both groups (2 per cent). Our findings indicate that less intense anticoagulant therapy is associated with a low frequency of recurrent venous thromboembolism (2 per cent) and a reduced risk of hemorrhage.
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A solid-phase radioimmunoassay system has been developed based on the use of antibodies covalently linked to polymer-coated iron oxide (EnzacrylR). An electro-magnet is employed both to mix the particles during incubation (by switching the field on and off) and to separate the antibody-bound and free fractions. This obviates the need for vertical rotation and for the time-consuming, multiple centrifugations required with conventional solid phase procedures. The system is universally applicable and methods have been established for the assay of thyroxine, human placental lactogen and digoxin. The thyroxine assay was employed as a model and it was shown that the results obtained for serum samples correlated closely with those using a routine liquid-phase radioimmunoassay. The applicability of employing a second antibody linked to the iron oxide particles was also studied.
Besides the seven basic support surface requirements for prevention and treatment of pressure ulcers, more than 30 additional factors should be considered by the clinician when selecting support surfaces to meet the needs of individual patients. These other considerations can be grouped into five categories: cost effectiveness; patient care; psychosocial issues, including patient comfort and clinician satisfaction; safety, reliability, and service issues; and equipment and logistical considerations. Future research on support surfaces should focus not only on wound outcomes, but also on these other factors.