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PubMed2000

Outpatient care of the cystic fibrosis patient after lung transplantation.

Lung transplantation has become an accepted treatment for respiratory failure due to cystic fibrosis (CF). Effective means of patient selection, surgical technique, immunosuppression, and post-transplant management permit survival as good as that of transplant patients with other diseases. The new lungs do not acquire the CF ion transport abnormalities but are subject to the usual post-transplant complications. CF problems in other organ systems persist and may be worsened by some of the immunosuppressive regimens. Prolonged survival increases the risk of age-related CF and other complications. Effective medical management requires expert knowledge of CF and lung transplantation and of how their problems interact, and good communications among the participating care teams.

Antibiotic Prophylaxis↗

PubMedDate not supplied

Enhancing the role of case managers with specialty populations: development and evaluation of a palliative care education program.

Palliative home care is an important component of the care system for patients at the end of life and case management is considered an essential element of the Canadian home care system. Case managers play a critical role in allocating resources, thus influencing the costs and the viability of palliative home care. Case management education programs focused on care coordination with specialty palliative care populations are nonexistent. An education program targeted at improving the knowledge and skills of case managers in allocating resources to palliative care populations was developed and pilot-tested in a metropolitan Canadian city home care program. Core curriculum was based on an initial learning needs assessment and used case-based problem solving to enhance case-management skills. An improvement in knowledge was noted on posttests and case managers described increased comfort and confidence in their role as case managers to this patient population. Home care organizations caring for palliative care populations must ensure case managers are prepared for case management roles with specialty populations if the home is to be rendered an appropriate and viable care setting for patients at the end of life.

Canada↗

PubMedDate not supplied

Difficult pain syndromes: bone pain, visceral pain, and neuropathic pain.

Cancer pain is prevalent in approximately two thirds of all cancer patients and can undermine the quality of life in this patient population. Uncontrolled pain can cause physical as well as psychological distress in cancer patients. As the disease progresses in cancer, pain and suffering increase. Knowledge about pain management is paramount in the comprehensive treatment of cancer patients. Difficult cancer pain syndromes may arise from interruption of bone, viscera, and neural structures by malignant spread of the disease. Familiarity with opioids, adjuvants, and procedures that can abate pain in cancer patients is discussed in a practical manner for clinical application in this text.

Bone Neoplasms↗

PubMed2006

Natural history and chemotherapy effectiveness for advanced adenocarcinoma of the small bowel: a retrospective review of 113 cases.

BACKGROUND: Small bowel adenocarcinoma is a rare cancer that has generally been considered resistant to chemotherapy, although little has been published on the role of chemotherapy. A retrospective analysis was conducted of patients with advanced small bowel adenocarcinoma to explore chemotherapy use, and gain knowledge for ongoing management and future clinical trials. PATIENTS AND METHODS: All patients with advanced adenocarcinoma of the small bowel treated at Princess Margaret Hospital (PMH) between 1986 and 2004 were identified through the cancer registry. The medical records were reviewed for patient characteristics, treatment and outcome data. Survival statistics were estimated using the Kaplan Meier survival curves and Cox proportional regression model. RESULTS: Data on 113 patients was reviewed. Forty-four patients received palliative chemotherapy with an overall response rate (ORR) of 36% during a first or second line regimen (9% complete responses and 27% partial responses). Newer chemotherapy regimens including gemcitabine and irinotecan combinations appeared to have higher ORR, than older fluorouracil-based regimens. Some patients responded to more than one line of chemotherapy. Palliative chemotherapy predicted for overall survival (OS) in a multivariate analysis (HR 0.47, P = 0.035). CONCLUSION: Chemotherapy appears to have activity in adenocarcinoma of the small bowel. Prospective trials evaluating patient benefit are required to confirm this activity using newer systemic therapies, until such time retrospective reviews such as this will continue to guide treatment decisions.

Adenocarcinoma↗

PubMed1996

Audit of postoperative pain control. Influence of a dedicated acute pain nurse.

The inadequacies of conventional intramuscular opioid analgesia have fueled an expansion in the use of patient-controlled analgesia and epidural analgesia after surgery. This is not always accompanied by increased education and specialist supervision of ward staff and patients. A survey in our hospital prior to the appointment of an Acute Pain Nurse showed an unacceptable incidence of side effects when epidural analgesia was employed on ordinary surgical wards. More surprisingly, efficacy of patient-controlled analgesia was found to be low. Frequent review of patients and regular education of ward staff by a specialist Pain Nurse have achieved a substantial reduction in side effects of epidural analgesia and improvement in efficacy of patient-controlled analgesia. We have shown that the advantages of patient-controlled analgesia can be largely negated by failure to address deficiencies in knowledge of pain management among ward staff and patients.

Acute Disease↗

PubMed2005

Chinese nurses' use of non-pharmacological methods in children's postoperative pain relief.

AIM: This paper reports a study describing Chinese nurses' use of non-pharmacological methods for relieving 6- to 12-year-old children's postoperative pain and factors related to this. BACKGROUND: Non-pharmacological methods are stated to be effective in relieving children's postoperative pain when used independently or in conjunction with medication. However, little is known about the use of these methods by Chinese nurses. METHODS: A questionnaire survey was carried out in 2002 with a convenience sample of 187 nurses working at 12 surgical wards in five hospitals of Fujian Province, China. A Likert-type instrument was used, and the average response rate was 98%. Descriptive statistics and content analysis were used to analyse the data. RESULTS: The most commonly used non-pharmacological methods were giving preparatory information, comforting/reassurance, creating a comfortable environment, distraction, and positioning. Positive reinforcement and helping with daily activities were used less often, and transcutaneous electrical nerve stimulation was not used at all. Many nurse background factors were statistically significantly related to their use of pain alleviation methods. Furthermore, many factors limited their use of non-pharmacological methods, the most common being that there were too few nurses for the work that had to be done, followed by nurses' lack of knowledge about pain management. CONCLUSIONS: While Chinese nurses used versatile non-pharmacological methods in school-aged children's postoperative pain relief, there remains a need for more education about pain management and for more frequent use of these methods in clinical care.

Adult↗

PubMed2006

Climate change may account for the decline in British ring ouzels Turdus torquatus.

1. Climate change is already affecting biodiversity, but the number of species for which reliable models relate weather and climate to demographic parameters is low. 2. We modelled the effect of temperature and rainfall on the breeding success and territory occupancy of ring ouzels Turdus torquatus (L.) in northern Britain, using data from a range of study areas, including one where there was a long-term decline in ring ouzel abundance. 3. Timing of breeding was significantly related to meteorological variables affecting birds in the early spring, though there was no evidence that laying dates had advanced. Breeding success was not significantly related to weather variables; instead, over 90% of annual variation in this parameter could be explained by density dependence. 4. Annual change in territory occupancy was linked to rainfall and temperature the preceding summer, after the main breeding season and to rainfall in the wintering grounds 24 months previously, coincident with the period of juniper Juniperus sp. (L.) flowering. High temperature in late summer, intermediate levels of late summer rainfall, and high spring rainfall in Morocco 24 months previously all had negative impacts on territory occupancy the following year. 5. All three weather variables have changed over recent decades, with a significant increase in summer temperature, a significant decrease in summer rainfall, and a nonsignificant decline in Moroccan spring rainfall. A model based on these trends alone predicted an annual decline in occupancy of 3.6% (compared with an observed decline of 1.2%), and suggested that increased summer temperatures may underlie declines in the British ring ouzel population. 6. Changes in summer temperature after the main breeding period could affect the survival rates of adult and/or juvenile birds. An improved understanding of the post-breeding ecology of ring ouzels is required to elucidate the mechanisms and causes of this relationship. Such knowledge might allow management aimed at buffering the impacts of climate change on ring ouzels.

Animal Migration↗

PubMed2005

Teaching and learning population and preventive health: challenges for modern medical curricula.

OBJECTIVES: This study aimed to formally identify medical students' attitudes towards population and preventive health issues addressed in the University of Queensland's Bachelor of Medicine, Bachelor of Surgery (MBBS) programme, in response to informal student reports that population and preventive health issues were largely just matters of "common sense". METHODS: Year 2 medical students were surveyed in 1999 and 2000 using a custom-designed instrument incorporating Likert scales and requests for qualitative responses. A sample of students participated in semistructured interviews. RESULTS: A total of 341 students (71%) responded to the survey. Students' attitudes towards general population health issues were overwhelmingly positive, and more than 60% of students reported having a more positive attitude towards psychosocial and preventive health issues than they had when they commenced the MBBS programme. Just over half of the students, however, considered population and preventive health issues to be matters of common sense. Students reported poor role modelling by the faculty in relation to population and preventive health issues, with only 41% of students indicating they perceived a positive attitude towards psychosocial and preventive health issues in the School of Medicine. Qualitative data indicated that some students fear that the opportunity cost of dedicating study time to population and preventive health issues might endanger their future clinical knowledge, skills and management of patients. CONCLUSIONS: These findings have important implications for modern medical curricula. The challenge in teaching population health issues is to balance students' needs to understand and apply the principles of population and preventive health and the biopsychosocial model of patient care, with the need for them to be confident they will be able to practise safely if they do so.

Attitude of Health Personnel↗

PubMed2005

Squeezing the antibiotic balloon: the impact of antimicrobial classes on emerging resistance.

The ongoing problem of emerging antimicrobial resistance has been likened to a balloon where settling one specific issue results in a 'bulge' of even worse problems. However, much has been learned about how to best use our critical antibacterial agents in ways to avoid or even repair some of the resistance damage that has been done. A compilation of current literature strongly suggests that to slow the development of resistance to antimicrobial agents it is optimal to use drugs with more than one mechanism of action or target, to prescribe those with demonstrated ability to minimise or reverse resistance problems, and to avoid underdosing of potent antibiotics. The most recent information also indicates that it is best to limit empirical use of beta-lactam plus fluoroquinolone combination therapy, since these two classes activate some common resistance responses, and using them together can facilitate multidrug resistance in important pathogens, particularly Pseudomonas aeruginosa and Acinetobacter species. This review discusses the role of each major antimicrobial class on resistance development and presents specific strategies for combating the growing problem of multidrug-resistant bacteria. We now have the knowledge to better manage our antimicrobial agent prescribing practices, but finding the will and resources to apply our understanding remains a formidable challenge.

Anti-Bacterial Agents↗

PubMed1984

Ocular manifestations of the neurocutaneous syndromes.

Ocular involvement occurs frequently in the disorders known as neurocutaneous syndromes or phakomatoses. Recognition of characteristic eye lesions in the context of related skin and systemic abnormalities may be crucial to making the diagnosis of a neurocutaneous syndrome. Ocular disease in these conditions may be the cause of serious morbidity, leading to blindness or disfigurement, but successful treatment is often possible. All clinicians involved in the care of patients with neurocutaneous syndromes should have some familiarity with their ophthalmologic aspects. This review deals with ocular manifestations of neurofibromatosis, tuberous sclerosis, Sturge-Weber syndrome, von Hippel-Lindau disease, ataxia telangiectasia, and Bloch-Sulzberger syndrome. Clinical signs and symptoms, differential diagnosis, and natural history are considered in detail, with brief discussion of pathophysiology and management. No specialized knowledge of eye disease in general is presumed.

Ataxia Telangiectasia↗

PubMed2006

Cognitive correlates of financial abilities in mild cognitive impairment.

OBJECTIVES: To investigate the cognitive correlates of financial abilities in mild cognitive impairment (MCI). DESIGN: Controlled, matched-sample, cross-sectional analysis regressing five cognitive composites on financial performance measures. SETTING: University medical and research centers. PARTICIPANTS: Forty-three persons with MCI and 43 normal controls. MEASUREMENTS: The Financial Capacity Instrument (FCI) and a comprehensive neurocognitive battery. RESULTS: Patients with MCI performed significantly worse than controls on cognitive domains of executive function, memory, and language and on FCI domains of financial conceptual knowledge, bank statement management, and bill payment. Patients with MCI also needed significantly more time to complete a multistep financial task and were significantly more likely than controls to make errors on this task. Stepwise regression models revealed that, within the MCI group, attention and executive function were significant correlates of FCI performance. CONCLUSION: Although impaired memory is the cardinal deficit in MCI, the neurocognitive basis of lower functional performance in MCI appears to be emergent declines in abilities to selectively attend, self-monitor, and temporally integrate information. Compromised performance on cognitive measures of attention and executive function may constitute clinical markers of lower financial abilities and should be evaluated for its relationship to functional ability in general. These cognitive domains may be appropriate targets of future intervention studies aimed at preservation of functional independence in people with MCI.

Aged↗

PubMedDate not supplied

Second-trimester termination of pregnancy: nursing care.

Termination of pregnancy because of fetal abnormalities is a physically and emotionally painful event. Prostaglandin E2 (PGE2) intravaginal suppositories are an effective method for inducing labor. Patient care and pain management require both knowledge and sensitivity on the part of the nurse.

Abortion, Therapeutic↗

PubMedDate not supplied

Prevalence of caseous lymphadenitis and usage of caseous lymphadenitis vaccines in sheep flocks.

OBJECTIVE: To estimate the prevalence of caseous lymphadenitis (CLA), determine the current usage of vaccines against CLA and to measure the effectiveness of these vaccines on sheep farms. DESIGN AND POPULATION: A survey was undertaken on 223 sheep flocks in New South Wales, Victoria and Western Australia. METHOD: The prevalence of CLA was measured by conventional inspection techniques at abattoirs in lines of sheep that could be traced back to a farm. Managers of the flocks were sent a questionnaire about their vaccine practices, management practices and knowledge of CLA. RESULTS: The average prevalence of CLA in adult sheep in these flocks was 26% and varied from 20% in Western Australia to 29% in New South Wales. About 43% of sheep producers used CLA vaccines; only 12% used them as recommended. Awareness of CLA was highest in Western Australia. More producers would use CLA vaccine if they knew the prevalence of CLA in their flock and producers obtained most information about CLA from vaccine resellers. CONCLUSIONS: Only 10 to 15% of producers are currently achieving effective CLA control through the use of recommended CLA vaccination programs. In Western Australian flocks more than 25% of effectively vaccinated ewes will be sent to abattoirs in the 2 to 3 years after this study. However, large decreases in the prevalence of CLA can be achieved by about 70% of producers by either making adjustments to their vaccination programs or buying a vaccine with a CLA component. Two or three key facts on effective CLA vaccination could be made available at the point of sale of vaccines and from abattoirs that reported the prevalence of CLA to farmers.

Animals↗

PubMed1986

Deaths from asthma in New Zealand.

We report the first complete population based study of childhood deaths due to asthma. All deaths ascribed to asthma in New Zealand children aged 0-14 were investigated as part of a two year national study of mortality from asthma. The 16 children who died from asthma all developed asthma by the age of 4; 15 had a family history of asthma, and 12 had associated atopic disorders. Disturbed pyschosocial relationships were evident in eight families. Seven children died in less than three hours from the onset of their final attack. All children died outside hospital. Mortality from asthma in Maori children (3.14 per 100 000) was five times that of European children. With hindsight, factors which if avoided could have led to a different outcome were identified in eleven cases. The circumstances surrounding these deaths were similar to those described for adults with asthma; this study, however, underlines the importance of parental care and knowledge in the management of children with asthma. Inadequate long term medical care, underassessment of severity by family and doctors, failure of the family to call for help when required, and inadequate responses of medical services contributed to the fatalities. Excess beta2 sympathomimetic dosage or overreliance on home nebulisers were uncommon. Most childhood deaths from asthma should be prevented by increased family awareness, better assessment of severity, improved long term treatment, and rapid access to emergency medical care.

Adolescent↗

PubMed1993

Is the cold chain for vaccines maintained in general practice?

OBJECTIVE: To investigate the cold chain for vaccines and compliance with the local code of practice for storage. DESIGN: In a random sample of general practices orders for live vaccines (oral polio and measles, mumps, and rubella) were accompanied by a cold chain monitor which was activated on leaving the supplying pharmacy. The monitors were read at specified intervals and when all vaccines in the order had been used. Structured interview was used to check compliance with the local code of practice on storage. SETTING: West Berkshire and Aylesbury Vale district health authorities. SUBJECTS: 16 (25%) general practices in West Berkshire, and 13 (50%) in Aylesbury Vale. MAIN OUTCOME MEASURES: Compliance with code of practice. Changes in the cold chain monitor. RESULTS: For six key requirements within the code of practice compliance varied from 70% to 0%. Only 16 of 29 practices had a named person responsible for vaccine storage and only four were aware of the local code of practice. Vaccine was stored for longer and more breaks in the cold chain occurred in West Berkshire than in Aylesbury Vale. The potency of some vaccines in 10 of 26 orders became suspect before use. CONCLUSIONS: Knowledge of appropriate management of the cold chain in two districts was poor. Breaks in the chain were more frequent and compromised potency more likely when vaccine had been stored for more than eight weeks. Problems in maintaining the cold chain indicate the need for continuing audit, which should become a prerequisite for payments to general practitioners for immunisation.

Cold Temperature↗

PubMed2005

[Psychodrugs in the elderly].

Based on the following realities, general knowledge on the management of psychodrugs in the elderly population is necessary for any physician: high prescription of psychodrug in this population, up to 25% of the elderly may require this treatment at any time, and good therapeutic response. To achieve good compliance to the psychiatric treatment by the elderly patient, the pharmacokinetic characteristics and interactions in this population must be well known to avoid the appearance of significant side effects. These side effects may induce the patient to drop out of the treatment or to even have at risk side effects. A review on the pharmacodynamic and pharmacokinetic characteristics related with psychodrugs in the elderly is done in this article. Based on this, the three large groups of anxiolytic, antidepressive and antipsychotic psychodrugs are reviewed.

Aged↗

PubMed1998

Chemical meningitis from bile reflux in a lumbar-gallbladder shunt.

OBJECTIVE AND IMPORTANCE: The gallbladder is used to divert cerebrospinal fluid (CSF) in patients with hydrocephalus when all other sites have been exhausted. This is seen in hydrocephalic patients who have reached teenage years but have undergone multiple shunt revisions, abdominal operations and repeated neck vein cannulations during childhood. One complication of the lumbar-gallbladder shunt is discussed as well as its pathophysiologic theory and management. CLINICAL PRESENTATION: A case of a patient with a lumbar-gallbladder shunt who developed chemical meningitis from reflux of bile into the CSF space is presented. The patient presented with generalized seizures. INTERVENTION: Included: ventilatory support, externalization of the shunt, correction of the metabolic abnormalities and administration of anticonvulsants and steroids. CONCLUSION: This case illustrates an unusual occurrence of reflux of bile into the CNS through a lumbar-gallbladder shunt in a patient with long-term complex communicating hydrocephalus. It also demonstrates its mode of presentation and successful management. To our knowledge, this is the first case report of its kind.

Adult↗

PubMed1994

Countertransference issues in staff caregivers who work to rehabilitate catastrophic-injury survivors.

Countertransference reactions experienced by caregivers who work to rehabilitate victims of catastrophic physical lesions arise from the fundamental characteristics of catastrophic lesions: they are life threatening, life altering, anatomy altering, and restoration to pre-illness normalcy virtually never occurs. No true preparation is possible: Major physical and psychological work is required to rebuild a traumatized personality and a damaged body so that a life of quality is possible. Countertransference refers to (therapist's) unconscious reaction to patient transference, i.e., to aspects of the patient's behavior that are the product of unconscious factors in the patient's personality, as well as the meanings attached by caregivers to patient's impairment and rehabilitation struggles. Countertransference reactions arise in caregivers from two sources: (1) Socially universal sources: the demands posed by patients' regression; patients' misplaced aggression; patients' thwarting of staff's (narcissistic) professionalism; the threat of obligatory identification; staff disgust at patient's body damage. (2) Individualized sources: individual residues of caregivers' own developmental experience (conscious and unconscious) with issues such as dependency, aggression, sexuality, self-esteem and autonomy. Solutions involve understanding and mastering the distinction between feelings and actions, and sparing patients from two actions: Assault or abandonment. Suggestions for management include better knowledge of basic psychodynamics; working toward continuous self-awareness; special group meetings; and selective use of educationally oriented psychiatric consultations. Three case examples are offered.

Activities of Daily Living↗