Relationship between alcohol abuse upper gastro-intestinal haemorrhage and nutritional status during acute hospital admission

This thesis is concerned with the effect of alcohol consumption on the pathogenesis of bleeding from the upper gastrointestinal tract via nutritional pathways. Altered nutritional status is a frequently recognised clinical accompaniement of heavy alcohol consumption in hospitalized patients. Similarly, upper gastrointestinal bleeding is frequently accompanied by the presence of heavy alcohol consumption. Nevertheless, the clinical quantification of alcohol intake is often descriptive, so that a link between alcohol use and upper gastrointestinal haemorrhage via nutritional mechanisms has been only generally defined. In the literature review, the methods of defining alcohol use and abuse, using interview, biochemical and haematological techniques are noted. The relationship between alcohol abuse and nutrient imbalances is reviewed, especially in relation to possible effects on the gastrointestinal tract, appetite and eating habits. A further section reviews the relationship between alcohol use and anatomical lesions of the upper gastrointestinal tract likely to lead to bleeding. Following the chapter in which the methods used in this thesis are described. Chapter 4 seeks to describe the study population and its subgroups in this thesis in relation to interview, biochemical and haematological methods. Alcohol use is defined in relation to (1) a clinical classification of heavy or light drinking, based on a questionnaire administered in Casualty, (2) a quantified method of determining alcohol consumption during a subsequent ward dietetic assessment, (3) in relation to a biochemical definition (recent drinking and non-drinking), and a classification of (1) and (2) called, for the purposes of this thesis, 'alcohol abusers' and 'nonabusers'. Heavy, regular and recent drinkers and alcohol abusers tend to be male and younger than light, infrequent and nonrecent drinkers and nonabusers. Chapter 5 relates the nutritional status of those patients admitted acutely to hospital in relation to the groups defined in Chapter 4, Nutritional status is defined in terms of food intake, anthropometry, biochemical and haematological parameters. Different methods of defining alcohol use give rise to different patterns of nutritional impairment. Chapter 6 relates the nutritional status of those patients admitted acutely to hospital in relation to the presence or absence of an endoscopically defined site of upper gastrointestinal bleeding. A difference is seen between those bleeding from a Mailory-weiss tear and other sites of bleeding, similarly, biochemical differences in nutritional status emerge between those patients who presented in shock, and those who did not. Chapter 7 explores the relationships between biochemical markers of nutritional status and haemostatic variables in the groups of abusers/non-abusers, the various sites of primary bleeding/controls, and shock/non-shock. Serum copper appears to be related to altered haemostasis in a manner not apparently described elsewhere.

The current pattern of hepatitis B virus infectiion in Australia

Summary. There is little recent data of the seroprevalence of hepatitis B in Australia. We have surveyed a large cohort of endoscopy patients attending a teaching hospital in central Sydney, and related the presence of hepatitis B virus (HBV) markers with putative risk factors for exposure using the SAS statistical package. Of the 2115 patients tested: 2.1% (45/2115) were HBV surface antigen positive, 0.75% (14/2115) viraemic, 9.5% (200/2115) anti-HBs and anti-HBc positive, 20.1% (430/2115) vaccinated (anti-HBs only) and the remaining 70% were susceptible. The adjusted OR of HBV infection was significantly increased in patients who had been diagnosed with human immunodeficiency virus (36.3-fold), born in Asia or Pacific islands (12.4-fold), born in North Africa, Middle East & Mediterranean countries (6-fold) or born abroad elsewhere in the world (2.7-fold), had household contact with someone diagnosed with hepatitis between 1980 and 1990 (3.9-fold), injected drugs between 1980 and 1990 (4.4-fold), resided in a military establishment for 3 months (2.3-fold) or in a hospital for 3 months (2.2-fold), never been vaccinated for hepatitis B (2.8-fold), received blood transfusion due to an accident and/or a haemorrhage (1.92-fold) and finally been a male gender (1.59-fold). The prevalence of HBV in this hospital population was higher than predicted on the basis of notifications to the passive surveillance scheme. Most HBV patients had multiple risk factors for infection, but the hierarchy of odds ratios provides a rational basis for targeted programmes to identify asymptomatic HBV carriers who might benefit from treatment.

Thromboyytic therapy for acute ischaemic stroke : successful implementation in an Australian tertiary hospital

Background: The use of tissue-type plasminogen activator (t-PA) in ischaemic stroke outside of experienced stroke centres remains controversial. The aim of this study was to present the initial experience with t-PA in patients with ischaemic stroke at an institution with no prior experience in i.v. stroke thrombolysis and to compare results to published reports.

Methods: Prospective audit of 888 patients with consecutive stroke and transient ischaemic attack admitted to a 426-bed tertiary referral hospital from March 2003 to October 2005. Main outcome measures were treatment rate, exclusion criteria, protocol violations, intracerebral haemorrhage, disability (modified Rankin scale) and mortality at 3 months.

Results: Over the study period, 72 patients received t-PA (11% of ischaemic strokes). The main reason for exclusion was presentation beyond 3 h of onset (44%); if all eligible patients had arrived within 3 h, treatment rate was estimated at 32.5%. Protocol violations occurred in 15 (21%) patients. There were seven (10%) asymptomatic intracerebral haemorrhage and one (1%) non-fatal symptomatic intracerebral haemorrhage. At 3 months, 37% had achieved excellent recovery (modified Rankin scale 0–1) and seven (10%) had died. The delivery and outcomes associated with the use of t-PA were comparable to the results of the National Institute of Neurological Disorders and Stroke trial and meta-analysis of open-labelled studies.

Conclusion: With appropriate infrastructure and protocols, previously inexperienced tertiary referral centres can replicate the experience and outcome measures reported by clinical trials of t-PA in patients with stroke.

Stressor categorization : acute physical and psychological stressors elicit distinctive recruitment patterns in the amygdala and in medullary noradrenergic cell groups

It has been hypothesized that the brain categorizes stressors and utilizes neural response pathways that vary in accordance with the assigned category. If this is true, stressors should elicit patterns of neuronal activation within the brain that are category-specific. Data from previous immediate–early gene expression mapping studies have hinted that this is the case, but interstudy differences in methodology render conclusions tenuous. In the present study, immunolabelling for the expression of c-fos was used as a marker of neuronal activity elicited in the rat brain by haemorrhage, immune challenge, noise, restraint and forced swim. All stressors elicited c-fos expression in 25–30% of hypothalamic paraventricular nucleus corticotrophin-releasing-factor cells, suggesting that these stimuli were of comparable strength, at least with regard to their ability to activate the hypothalamic–pituitary–adrenal axis. In the amygdala, haemorrhage and immune challenge both elicited c-fos expression in a large number of neurons in the central nucleus of the amygdala, whereas noise, restraint and forced swim primarily elicited recruitment of cells within the medial nucleus of the amygdala. In the medulla, all stressors recruited similar numbers of noradrenergic (A1 and A2) and adrenergic (C1 and C2) cells. However, haemorrhage and immune challenge elicited c-fos expression in subpopulations of A1 and A2 noradrenergic cells that were significantly more rostral than those recruited by noise, restraint or forced swim. The present data support the suggestion that the brain recognizes at least two major categories of stressor, which we have referred to as ‘physical’ and ‘psychological’. Moreover, the present data suggest that the neural activation footprint that is left in the brain by stressors can be used to determine the category to which they have been assigned by the brain.

Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approach

Aim.  To evaluate the existing literature to inform nursing management of people undergoing percutaneous coronary intervention. Background.  Percutaneous coronary intervention is an increasingly important revascularisation strategy in coronary heart disease management and can be an emergent, planned or rescue procedure. Nurses play a critical role in delivering care in both the independent and collaborative contexts of percutaneous coronary intervention management. Design.  Systematic review. Method.  The method of an integrative literature review, using the conceptual framework of the patient journey, was used to describe existing evidence and to determine important areas for future research. The electronic data bases CINAHL, Medline, Cochrane and the Joanna Briggs data bases were searched using terms including: (angioplasty, transulminal, percutaneous coronary), nursing care, postprocedure complications (haemorrhage, ecchymosis, haematoma), rehabilitation, emergency medical services (transportation of patients, triage). Results.  Despite the frequency of the procedure, there are limited data to inform nursing care for people undergoing percutaneous coronary intervention. Currently, there are no widely accessible nursing practice guidelines focusing on the nursing management in percutaneous coronary intervention. Findings of the review were summarised under the headings: Symptom recognition; Treatment decision; Peri-percutaneous coronary intervention care, describing the acute management and Postpercutaneous coronary intervention management identifying the discharge planning and secondary prevention phase. Conclusions.  Cardiovascular nurses need to engage in developing evidence to support guideline development. Developing consensus on nurse sensitive patient outcome indicators may enable benchmarking strategies and inform clinical trial design. Relevance to clinical practice.  To improve the care given to individuals undergoing percutaneous coronary intervention, it is important to base practice on high-level evidence. Where this is lacking, clinicians need to arrive at a consensus as to appropriate standards of practice while also engaging in developing evidence. This must be considered, however, from the central perspective of the patient and their family.

Managing women with acute physiological deterioration: student midwives performance in a simulated setting

OBJECTIVE: Midwives' ability to manage maternal deterioration and 'failure to rescue' are of concern with questions over knowledge, clinical skills and the implications for maternal morbidity and, mortality rates. In a simulated setting our objective was to assess student midwives' ability to assess, and manage maternal deterioration using measures of knowledge, situation awareness and skill, performance. METHODS: An exploratory quantitative analysis of student performance based upon performance, ratings derived from knowledge tests and observational ratings. During 2010 thirty-five student, midwives attended a simulation laboratory completing a knowledge questionnaire and two video, recorded simulated scenarios. Patient actresses wearing a 'birthing suit' simulated deteriorating, women with post-partum and ante-partum haemorrhage (PPH and APH). Situation awareness was, measured at the end of each scenario. Applicable descriptive and inferential statistical tests were, applied to the data. FINDINGS: The mean total knowledge score was 75% (range 46-91%) with low skill performance, means for both scenarios 54% (range 39-70%). There was no difference in performance between the scenarios, however performance of key observations decreased as the women deteriorated; with significant reductions in key vital signs such as blood pressure and blood loss measurements. Situation, awareness scores were also low (54%) with awareness decreasing significantly (t(32)=2.247, p=0.032), in the second and more difficult APH scenario. CONCLUSION: Whilst knowledge levels were generally good, skills were generally poor and decreased as the women deteriorated. Such failures to apply knowledge in emergency stressful situations may be resolved by repetitive high stakes and high fidelity simulation.

Ian Jacobs - resuscitation leader, educator and researcher

Ian Jacobs BAppSc (WAIT), DipEd (Murd), PhD (WAust), RN, FRCNA, FACAP, FERC, Chairman of the Australian Resuscitation Council and co-chair of the International Liaison Committee On Resuscitation died suddenly on the 19th October 2014. He collapsed due to a cerebral haemorrhage while on the job, having delivered a critically ill patient to the Emergency Department of the Royal Perth Hospital, sadly he did not recover. This article reveals something of his enormous influence on and contributions to nursing, pre-hospital and emergency medicine, critical care and resuscitation on a national, and international scale.

Spontaneously reported haemorrhagic adverse events associated with rivaroxaban and dabigatran in Australia

Objectives: The objective of our study was to describe spontaneously reported haemorrhagic adverse events associated with rivaroxaban and dabigatran in Australia. Methods: Data were sourced from the Australian Therapeutic Goods Administration (TGA) Database of Adverse Event Notifications between June 2009 and May 2014. Records of haemorrhagic adverse events in which rivaroxaban or dabigatran was considered as a potential cause were analysed. Results: There were 240 haemorrhagic adverse events associated with rivaroxaban and 504 associated with dabigatran. Age was specified for 164 (68%) haemorrhages associated with rivaroxaban, of which 101 occurred in people aged ⩾75 years. Age was specified for 437 (87%) haemorrhages associated with dabigatran, of which 300 occurred in people aged ⩾75 years. Time from treatment initiation to haemorrhage was specified for 122 (51%) haemorrhages associated with rivaroxaban, with 69 (57%) haemorrhages occurring within 30 days of rivaroxaban initiation. Time from treatment initiation to haemorrhage was specified for 253 (50%) haemorrhages associated with dabigatran, with 123 (49%) haemorrhages occurring within 30 days of dabigatran initiation. Gastrointestinal (GI) haemorrhages were the most frequent type of haemorrhages associated with both rivaroxaban (n = 105, 44%) and dabigatran (n = 302, 60%). Data were available on the severity of haemorrhage for 101 (42%) haemorrhages associated with rivaroxaban, with haemorrhage leading to death in 17 people. The severity of haemorrhage was specified for 384 (76%) haemorrhages associated with dabigatran, with haemorrhage leading to death in 61 people. Conclusions: Our study highlights the need for research on the haemorrhagic complications of anticoagulation in clinical care. A considerable proportion of reported haemorrhagic events occurred within 30 days of rivaroxaban and dabigatran initiation. This highlights the importance of considering bleeding risk at the time of treatment initiation.