Audit of the use of antimicrobial prophylaxis in nasal surgery at a speciali

Background: In 2002−03 a retrospective audit of the use of surgical antimicrobial prophylaxis (AMP) for elective nasal surgery was undertaken at the Royal Victorian Eye and Ear Hospital (RVEEH). The RVEEH is a publicly funded teaching hospital that provides specialist eye, nose and throat medicine in Victoria, Australia. The aim of the audit was to determine the extent to which the use of antimicrobial prophylaxis in the hospital was consistent with Australian and international evidence-based guidelines and if there was a need for the hospital to develop internal guidelines for the use of AMP.

Methods: The histories of 500 consecutive patients who had undergone nasal surgery within the study period of August 2001 and July 2002 were examined. The data collected from these histories included information such as the patients' age, gender, diagnosis, surgical procedure performed, antimicrobial agents used, and the length of follow up and a range of factors shown in previous studies to increase the risk of surgical site infection.

Results: A total of 306 (72.86%) patients were found to have received antimicrobial agents either prior to admission, during admission or on discharge. Only 24 patients (5.71%) were administered antimicrobials immediately prior to surgery and at no other time.

Conclusions: The findings of this study support the need for further research to examine the appropriateness of the use of AMP at the RVEEH and the need for internal guidelines for its use.

Evaluation of nasopharyngeal oxygen, nasal prongs and facemask oxygen therapy devices in adult patients: a randomised crossover trial

Nasopharyngeal oxygen (NPO) therapy may overcome some of the difficulties associated with nasal prongs and facemask oxygen delivery devices. In response to a lack of published studies of NPO therapy in adults, we conducted a prospective randomised crossover trial to compare the effectiveness of NPO, nasal prongs (NP) and facemasks (FM) when used in an adult population (n=37) from the intensive care unit and general hospital wards. We measured oxygen saturation (Sp[O.sub.2]) using pulse oximetry, oxygen flow (litres per minute), respiration rate (per minute) and comfort using a horizontal visual analogue scale. All three devices were effective in maintaining a Sp[O.sub.2] of [greater than or equal to]95% (NP 97.0[+ or -]1.9, NPO 97.7[+ or -]1.7, FM 98.8[+ or -]1.3%). NPO therapy consumed less oxygen than NP and FM therapy (NP 2.6[+ or -]1.0, NPO 2.2[+ or -]0.9, FM 6.1[+ or -]0.4 l/min, P <0.001). There was no significant difference in patients' respiratory rates (NP 19.9[+ or -]3.2, NPO 19.9[+ or -]3.0, FM 19.8[+ or -]3.1 per minute, P=0.491). In terms of comfort, patients rated NP higher than NPO and FM using a horizontal visual analogue scale (100 mm=most comfortable) (NP 65.5[+ or -]14.3, NPO 62.8[+ or -]19.4, FM 49.4[+ or -]21.4 mm, P <0.001). We conclude that for adult patients, nasal prongs and nasopharyngeal oxygen therapy consume less oxygen and provide greater comfort than facemasks while still maintaining Sp[O.sub.2] [greater than or equal to]95%.

The effect of education on hypothetical and actual oxygen administration decisions

Aim
This study examined the effect of an education intervention on emergency nurses’ decisions related to oxygen administration.

Method
A controlled pre-test/post-test quasi-experimental design was used. The intervention was a written self directed learning package. Outcome measures were (i) factual knowledge measured using parallel form multiple choice questions (MCQs) and (ii) clinical decisions measured using parallel form MCQs, parallel form patient scenarios and clinical practice observation.

Results
Eighty-eight nurses from 4 Melbourne EDs participated in the study (control group: n = 37 and experimental group: n = 51). Subgroups of nurses from the experimental group also participated in the patient scenarios (n = 20) and clinical practice observation (n = 10). Emergency nurses’ knowledge increased as a function of education. Both patient scenario data and clinical practice observation showed decreased selection of nasal cannulae, increased selection of air entrainment masks and a trend towards selection of higher oxygen flow rates following education.

Conclusions
Evaluation of educational interventions in nursing should focus on identifying strategies that enhance learning in a clinical environment, are valid in terms of the clinical context and culture in which they are being used and most importantly, produce sustained improvements in actual clinical practice.

Diet and habitat of the powerful owl (Ninox strenua) living near Melbourne

The diet of Powerful Owls (Ninox strenua) living at Christmas Hills, 35km north-east of Melbourne was examined by analysis of 686 regurgitated pellets collected over two years. An aid was also developed to help identify potential mammalian prey species based on hair and skeletal characteristics. The following features were found to be most useful in distinguishing between the three species of arboreal marsupials - Common Ringtail Possum (Pseudocheirus peregrinus), Common Brushtail Possum (Trichosurus vulpecula) and Sugar Glider (Petaurus breviceps): - Cross-sectional width of primary guard hairs. - The size and shape of the nasal, frontal, parietal and squamosal bones of the skull. - Dentition. The size and shape of the upper incisor, canine and premolar teeth. The size and shape of the lower incisor and premolar teeth. - The size of the humerus. The Sugar Glider has a much smaller humerus than that of the Common Ringtail Possum and the Common Brushtail Possum. In the Common Brushtail Possum the entepicondyle ends in a very sharp point but the Common Ringtail Possum this point is not as sharp. - The Common Ringtail Possum’s femur has a very prominent trochanter which projects further than that in the Common Brushtail Possum. The femur of the Sugar Glider is distinguished by having a very large depression between the condyle and the trochanter. - The Common Brushtail Possum’s scapula has a narrower lower blade (relative to length) than that in the Common Ringtail Possum. The scapula of the Sugar Glider is smaller in size than that of the other two possums.The pelvic girdle Of the Common Brushtail Possum has a much wider ischium than those of the Common Brushtail Possum and the Sugar Glider. The ilium of the Sugar is much narrower and smaller than that of the other two possums Mammalian prey was found in 89%, insects in 13% and birds in 10% of the pellets. Of the mammals, Common Ringtail Possums occurred most frequently in the pellets over the year. There was no seasonal difference in the frequency of occurrence of Common Ringtail Possums and Sugar Gliders in pellets. However, Common Brushtail Possums were more likely to be taken in spring than in the other seasons. More adult Common Ringtail Possums were taken as prey than were other age classes over the year, except in summer when high numbers of young were consumed by the owls. The habitat of the Powerful Owl was examined by ground surveys and spotlight surveys in sixteen sites within the Warrandyte-Kinglake Nature Conservation Link. Four categories of survey sites were chosen with the following features. Category A - Sites with a dense understorey of shrubs and small trees, as well as many old trees (>10/ha) which might be suitable for nest hollows. Category B - Sites which lacked a dense understorey of shrubs and small trees and containing few or no old trees suitable for nest hollows. Category C - Sites with a dense understorey of shrubs and small trees but containing few or no old trees suitable for nest hollows. Category D - Sites which lacked a dense understorey of shrubs and small trees but having old trees (>10/ha) which might be suitable for nest hollows. High prey densities strongly correlated with the presence of hollows at these sites. In the light of the results, management recommendations were made for the future conservation of the Powerful Owls living at Christmas Hills. The following recommendations were particularly important: 1. Cleared or semi - cleared land within the Warrandyte Kinglake Nature Conservation Link be revegetated using indigenous species of eucalypts and waffles in order to provide a contiguous native forest corridor for the movement of possums and gliders between the Yarra River Valley and the Kinglake Plateau. 2. Continued planting of Eucalyptus spp. and Acacia spp. in the forested areas of the Warrandyte-Kinglake Nature Conservation Link. 3. Continued protection of healthy living trees to provide a continuous supply of hollow trees. 4. No falling of dead standing trees for firewood collecting as these can provide nest hollows for prey species of the Powerful Owl.

The role of micro-organisms (staphylococcus aureus and Candida Albicans) in the pathogenesis of breast pain and infection in lactation women : study protocol

Background: The CASTLE (Candida and Staphylococcus Transmission: Longitudinal Evaluation) study will investigate the micro-organisms involved in the development of mastitis and “breast thrush” among breastfeeding women. To date, the organism(s) associated with the development of breast thrush have not been identified. The CASTLE study will also investigate the impact of physical health problems and breastfeeding problems on maternal psychological health in the early postpartum period.

Methods/Design: The CASTLE study is a longitudinal descriptive study designed to investigate the role of Staphylococcus spp (species) and Candida spp in breast pain and infection among lactating women, and to describe the transmission dynamics of S. aureus and Candida spp between mother and infant. The relationship between breastfeeding and postpartum health problems as well as maternal psychological well-being is also being investigated. A prospective cohort of four hundred nulliparous women who are at least thirty six weeks gestation pregnant are being recruited from two hospitals in Melbourne, Australia (November 2009 to June 2011). At recruitment, nasal, nipple (both breasts) and vaginal swabs are taken and participants complete a questionnaire asking about previous known staphylococcal and candidal infections. Following the birth, participants are followed-up six times: in hospital and then at home weekly until four weeks postpartum. Participants complete a questionnaire at each time points to collect information about breastfeeding problems and postpartum health problems. Nasal and nipple swabs and breast milk samples are collected from the mother. Oral and nasal swabs are collected from the baby. A telephone interview is conducted at eight weeks postpartum to collect information about postpartum health problems and breastfeeding problems, such as mastitis and nipple and breast pain.

Discussion: This study is the first longitudinal study of the role of both staphylococcal and candidal colonisation in breast infections and will help to resolve the current controversy about which is the primary organism in the condition known as breast thrush. This study will also document transmission dynamics of S. aureus and Candida spp between mother and infant. In addition, CASTLE will investigate the impact of common maternal physical health symptoms and the effect of breastfeeding problems on maternal psychological well-being.

General anaesthesia or conscious sedation for painful procedures in childhood cancer: the family's perspective

Background: Until recently, midazolam sedation was routinely used in our institution for bone marrow aspirates and lumbar punctures in children with cancer. It has been perceived by many doctors and nurses as being well tolerated by children and their families.

Aim: To compare the efficacy of inhalational general anaesthesia and midazolam sedation for these procedures.

Methods: A total of 96 children with neoplastic disorders, who received either inhalational general anaesthesia with sevoflurane, nitrous oxide, and oxygen (GA) or sedation with oral or nasal midazolam (SED) as part of their routine preparation for procedures were studied. The experiences of these childen were examined during their current procedure and during their first ever procedure. Main outcome measures were the degree of physical restraint used on the child, and the levels of distress and pain experienced by the child during the current procedure and during the first procedure. The family‘s preference for future procedures was also determined.

Results: During 102 procedures under GA, restraint was needed on four occasions (4%) when the anaesthetic mask was first applied, minimal pain was reported, and children were reported as distressed about 25% of the time. During 80 SED procedures, restraint was required in 94%, firm restraint was required in 66%, the child could not be restrained in 14%, median pain score was 6 (scale 0 (no pain) to 6 (maximum pain)), and 90% of the parents reported distress in their child. Ninety per cent of families wanted GA for future procedures. Many families reported dissatisfaction with the sedation regime and raised concerns about the restraint used on their child.

Conclusions: This general anaesthetic regime minimised the need for restraint and was associated with low levels of pain and distress. The sedation regime, by contrast, was much less effective. There was a significant disparity between the perceptions of health professionals and those of families with respect to how children coped with painful procedures.

Mycoplasmas in Australian fur seals (Arctocephalus pusillus doriferus) : identification and association with abortion

Bacteria from the genus Mycoplasma are common inhabitants of the respiratory, gastrointestinal, and genital tracts of mammals. The understanding of the pathological significance of mycoplasmas in seals is poor, as few studies have utilized the specific culture techniques required to isolate these bacteria. The current study surveyed for the Mycoplasma species present in Australian fur seals (Arctocephalus pusillus doriferus) and investigated the association between infection and pathology. Mycoplasmas were found in the nasal cavities of 55/80 (69%) of apparently healthy individuals. Isolates from 18 individuals were investigated through 16S ribosomal RNA sequencing, and 3 species were identified: M. zalophi, M. phocae, and Mycoplasma sp. (GenBank no. EU714238.1), all of which had previously been isolated from Northern Hemisphere pinnipeds. In addition, mycoplasmas were isolated from the lungs of 4 out of 16 juveniles and 1 out of 5 adults sampled at necropsy. Isolates obtained were M. zalophi, Mycoplasma sp. EU714238.1, and M. phocicerebrale, but infection was not associated with lung pathology in these age classes. Inflammatory disease processes of the heart and/or lungs were present in 12 out of 32 (38%) aborted fetuses on microscopic examination. Predominant findings were interstitial pneumonia, pericarditis, and myocarditis. Mycoplasma phocicerebrale was isolated from the thymus of an aborted fetus, and 3 out of 11 (27%) fetuses with inflammatory heart or lung lesions were PCR-positive for Mycoplasma. In conclusion, several species of Mycoplasma are part of the normal flora of the nasal cavity of Australian fur seals, and some mycoplasmas may be associated with abortion in this species of seal.

Apical localization of zinc transporter ZnT4 in human airway epithelial cells and its loss in a murine model of allergic airway inflammation

The apical cytoplasm of airway epithelium (AE) contains abundant labile zinc (Zn) ions that are involved in the protection of AE from oxidants and inhaled noxious substances. A major question is how dietary Zn traffics to this compartment. In rat airways, in vivo selenite autometallographic (Se-AMG)-electron microscopy revealed labile Zn-selenium nanocrystals in structures resembling secretory vesicles in the apical cytoplasm. This observation was consistent with the starry-sky Zinquin fluorescence staining of labile Zn ions confined to the same region. The vesicular Zn transporter ZnT4 was likewise prominent in both the apical and basal parts of the epithelium both in rodent and human AE, although the apical pools were more obvious. Expression of ZnT4 mRNA was unaffected by changes in the extracellular Zn concentration. However, levels increased 3-fold during growth of cells in air liquid interface cultures and decreased sharply in the presence of retinoic acid. When comparing nasal versus bronchial human AE cells, there were significant positive correlations between levels of ZnT4 from the same subject, suggesting that nasal brushings may allow monitoring of airway Zn transporter expression. Finally, there were marked losses of both basally-located ZnT4 protein and labile Zn in the bronchial epithelium of mice with allergic airway inflammation. This study is the first to describe co-localization of zinc vesicles with the specific zinc transporter ZnT4 in airway epithelium and loss of ZnT4 protein in inflamed airways. Direct evidence that ZnT4 regulates Zn levels in the epithelium still needs to be provided. We speculate that ZnT4 is an important regulator of zinc ion accumulation in secretory apical vesicles and that the loss of labile Zn and ZnT4 in airway inflammation contributes to AE vulnerability in diseases such as asthma.

Use of a photographic manipulation tool to assess corneal vascular response

Purpose. Corneal vasculature change in contact lens wearers has been linked to the level of hypoxia within the cornea. To assess the impact a treatment has on limbal vessels, a sensitive method of measurement and quantification is required.

Methods. A group of 21 highly myopic, hydrogel wearers, with preexisting signs of corneal hypoxia, were enrolled into a study where they wore sifilcon A silicone hydrogel lenses (Dk/t = 117), on a daily wear basis for 9 months. At all scheduled visits, photographs were taken of the superior, inferior, temporal, and nasal limbal regions which were then imported into Adobe Photoshop. A red-free filter was applied to enhance the contrast of the blood columns. In each quadrant, the length of the longest visible blood column was measured and the blood columns that penetrated >0.5 mm into the cornea were counted. A control group of 11 non-lens wearers was recruited. Their photographs were taken at the beginning of the study and 9 months later. An independent, masked observer assessed the photographs.

Results. There was a significant decrease in the maximum penetration of the blood column in all quadrants (p < 0.001) from baseline to the 9-month visit (e.g., superior: baseline 0.84 ± 0.39 mm; 9 months 0.63 ± 0.20 mm). There was also significant reduction in the number of visible blood columns longer than 0.5 mm in each quadrant (p < 0.001) from baseline to 9 months in all quadrants (e.g., superior: baseline 14.0 ± 8.2; 9 months 6.5 ± 6.0). The control group showed no change over time for the maximum blood column length (p = 0.638) or the number of columns >0.5 mm (p = 0.341).

Conclusions. A group of highly myopic subjects exhibited reduction in the maximum length and number of blood columns in the cornea when refit with a highly permeable silicone hydrogel material. The use of photography, along with Adobe Photoshop software, provides a reliable way of measuring corneal vascular responses over time.

Metrics of the normal cornea : anterior segment imaging with the Visante OCT

Purpose:  The purpose of the study was to obtain anterior segment biometry for 40 normal eyes and to measure variables that may be useful to design large diameter gas permeable contact lenses that sit outside the region normally viewed by corneal topographers. Also, the distribution of these variables in the normal eye and how well they correlated to each other were determined.

Methods:  This is a cross-sectional study, in which data were collected at a single study visit. Corneal topography and imaging of the anterior segment of the eye were performed using the Orbscan II and Visante OCT. The variables that were collected were horizontal K reading, central corneal/scleral sagittal depth at 15 mm chord, and nasal and temporal angles at the 15 mm chord using the built-in software measurement tools.

Results:  The central horizontal K readings for the 40 eyes were 43 ± 1.73 D (7.85 ± 0.31 mm), with ± 95% confidence interval (CI) of 38.7 (8.7 mm) and 46.6 D (7.24 mm). The mean corneal/scleral sagittal depth at the 15 mm chord was 3.74 ± 0.19 mm and the range was 3.14 to 4.04 mm. The average nasal angle (which was not different from the temporal angle) at the 15 mm chord was 39.32 ± 3.07 degrees and the ± 95%CI was 33.7 and 45.5 degrees. The correlation coefficient comparing the K reading and the corneal/scleral sagittal depth showed the best correlation (0.58, p < 0.001). The corneal/scleral sagittal depth at 15 mm correlated less with the nasal angle (0.44, p = 0.004) and the weakest correlation was for the nasal angle at 15 mm with the horizontal readings (0.32, p = 0.046).

Conclusion:  The Visante OCT is a valuable tool for imaging the anterior segment of the eye. The Visante OCT is especially effective in providing the biometry of the peripheral cornea and sclera and may help in fitting GP lenses with a higher percentage of initial lens success, when the corneal sag and lens sag are better matched.

Clinical evaluation of long-term users of two contact lens care preservative systems

Purpose: To clinically evaluate long-term users of two different contact lens care preservative systems and to investigate whether prolonged use is associated with an increase in the prevalence of dry eye.

Methods: Eighty-nine wearers of group IV hydrogel or silicone hydrogel lenses participated in this one-visit, investigator-masked study. Subjects were required to have consistently used a polyhexamethylene biguanide (PHMB) or polyquaternium-1 (PQT) based solution for 2 years. Consistent use was defined as 80% for the past 2 years and 100% for the past year. Clinical assessments included: average and comfortable wear time; overall and end-of-day comfort; signs of dryness, discomfort, burning or stinging, grittiness or scratchiness and visual changes; non-invasive and fluorescein break-up-time; pre-ocular tear film lipids, tear meniscus height, Schirmer and fluorescein clearance tests; limbal and bulbar hyperemia; palpebral roughness; corneal and conjunctival staining; lens front surface wetting; and lens film deposits.

Results: Significantly more grittiness or scratchiness was reported by subjects using a PHMB-containing system (67% vs. 44%; P = 0.02). Palpebral roughness and hyperemia were significantly greater in the PHMB group wearing group IV lenses (P = 0.01 and P = 0.05, respectively). Corneal staining was significantly higher in the PHMB users in all four peripheral sectors (P < 0.01). Nasal and temporal conjunctival staining was also significantly higher for users of PHMB-containing systems (P < 0.05). Front surface lens wettability was significantly better for group IV PQT users compared to PHMB users (P = 0.008), with 84% vs. 72%, respectively, with lenses graded by the investigator as having good or excellent wettability. Significantly higher levels of lens front surface film deposits were noted with PHMB users (P = 0.007), with 58% of group IV lenses treated with PHMB compared with 38% of group IV lenses treated with PQT showing some lens front surface film deposition. No significant differences between the two preservative system groups were noted for the range of dry eye evaluations nor the remaining clinical assessments.

Conclusions: Differences in both ocular and lens characteristic were observed between long-term users of two preservative systems used in many contact lens multi-purpose solutions. The findings from this study did not support the hypothesis that prolonged use of PHMB-containing solutions leads to dry eye. Additional studies including a larger sample size and perhaps longer use of the systems could help to further elucidate differences in clinical performance between systems.