Can nurses do more for patients to reduce vascular access and cardiac complications following PCI?

Percutaneous coronary interventions have increased 50% in Australia, yet vascular and cardiac complications remain ongoing outcome issues for patients. Managing complications is confounded by reduced length of patient stay, yet is an integral component of a cardiac nurses’ scope of practice. The aim of this study was to highlight in and out of hospital vascular and cardiac complications, for twelve months post patient discharge after PCI. Prospective data was collected from the hospital angioplasty database from 1089 consecutive patients who had PCI procedures from 1 January 2005 to 31 December 2006. In hospital vascular complications were reported by 391 (35%) of the 1089 patients, following PCI. Of these, 22.4% had haemorrhage only, 7.1% haematoma only. Cardiac complications in hospital were, one death (0.09%) following PCI, three deaths (0.27%) during the same admission and no incidence of myocardial infarction or bypass surgery. Patients who had PCI in 2005 (525) were telephone followed up after discharge at one and twelve months. Surprisingly, ongoing vascular outcomes were noted, with a 2.5% incidence at one month and 4% at 12 months. Cardiac complications were also identified, 51 (9.7%) patients requiring readmission for repeat angiogram, 19 (3.6%) a repeat PCI and 7 (1.3%) patients undergoing bypass surgery. This review highlights that vascular and cardiac problems are ongoing issues for PCI patients both in and out of hospital. The results suggest that cardiac nurses focus more on improving the monitoring and discharge care of patients and families for recovery after PCI.

Cough and ARI outcomes in urban Indigenous Children

Aim To identify cough epidemiology and outcomes in urban Indigenous children Methods An ongoing prospective cohort study of Indigenous children aged <5 years registered with at an urban Indigenous primary health care centre, Brisbane. Detailed baseline data are collected and, children are followed monthly for 12 months to capture ARI events. Children who develop cough as a symptom at any time over the 12 months have weekly follow-up for four weeks to ascertain cough outcomes. Results To date, 118 children have been enrolled (535 child-months of observation); Respiratory illnesses accounted for 23 (19 %) of overall reported reasons for presentation, however respiratory symptoms were present in 41 (35%) of all visits; a dry cough in 22 (18%), wet cough in 31 (26%). To date, 99 ARI’s have been recorded with an incidence of 18.4 episodes/100 child months. Seventeen children (14.4%) had persistent cough at day 28. Conclusion This is the first study to comprehensively describe the incidence and outcomes of cough in urban Indigenous children. Early data suggest respiratory illnesses are the most common illnesses for which these children seek medical advice and there is a high prevalence of wet cough.

Aggressive surgical interventions for severe stroke: Impact on quality of life, caregiver burden and family outcomes

Introduction: Decompressive hemicraniectomy, clot evacuation, and aneurysmal interventions are considered aggressive surgical therapeutic options for treatment of massive cerebral artery infarction (MCA), intracerebral hemorrhage (ICH), and severe subarachnoid hemorrhage (SAH) respectively. Although these procedures are saving lives, little is actually known about the impact on outcomes other than short-term survival and functional status. The purpose of this study was to gain a better understanding of personal and social consequences of surviving these aggressive surgical interventions in order to aid acute care clinicians in helping family members make difficult decisions about undertaking such interventions. Methods: An exploratory mixed method study using a convergent parallel design was conducted to examine functional recovery (NIHSS, mRS & BI), cognitive status (Montreal Cognitive Assessment Scale, MoCA), quality of life (Euroqol 5-D), and caregiver outcomes (Bakas Caregiver Outcome Scale, BCOS) in a cohort of patients and families who had undergone aggressive surgical intervention for severe stroke between the years 2000–2007. Data were analyzed using descriptive statistics, univariate and multivariate analysis of variance, and multivariate logistic regression. Content analysis was used to analyze the qualitative interviews conducted with stroke survivors and family members. Results: Twenty-seven patients and 13 spouses participated in this study. Based on patient MOCA scores, overall cognitive status was 25.18 (range 23.4-26.9); current functional outcomes scores: NIHSS 2.22, mRS 1.74, and BI 88.5. EQ-5D scores revealed no significant differences between patients and caregivers (p=0.585) and caregiver outcomes revealed no significant differences between male/female caregivers or patient diagnostic group (MCA, SAH, ICH; p=""0.103).<"/span><"/span> Discussion: Overall, patients and families were satisfied with quality of life and decisions made at the time of the initial stroke. There was consensus among study participants that formal community-based support (e.g., handibus, caregiving relief, rehabilitation assessments) should be continued for extended periods (e.g., years) post-stroke. Ongoing contact with health care professionals is valuable to help them navigate in the community as needs change over time.

Feasibility of an in-patient exercise intervention for children undergoing haematopoietic stem cell transplant

With improving survival rates following HSCT in children, QOL and management of short- and long-term effects need to be considered. Exercise may help mitigate fatigue and declines in fitness and strength. The aims of this study were to assess the feasibility of an inpatient exercise intervention for children undergoing HSCT and observe the changes in physical and psychological health. Fourteen patients were recruited, mean age 10 yr. A 6MWT, isometric upper and lower body strength, balance, fatigue, and QOL were assessed prior to Tx and six wk post-Tx. A supervised exercise program was offered five days per week during the inpatient period and feasibility assessed through uptake rate. The study had 100% program completion and 60% uptake rate of exercise sessions. The mean (±s.d.) weekly activity was 117.5 (±79.3) minutes. Younger children performed significantly more minutes of exercise than adolescents. At reassessment, strength and fatigue were stabilized while aerobic fitness and balance decreased. QOL revealed a non-statistical trend towards improvement. No exercise-related adverse events were reported. A supervised inpatient exercise program is safe and feasible, with potential physiological and psychosocial benefits.

The acceptability, usability and short-term outcomes of Get Real: A web-based program for psychotic-like experiences (PLEs)

Background Psychotic-like experiences (PLEs) are subclinical delusional ideas and perceptual disturbances that have been associated with a range of adverse mental health outcomes. This study reports a qualitative and quantitative analysis of the acceptability, usability and short term outcomes of Get Real, a web program for PLEs in young people. Methods Participants were twelve respondents to an online survey, who reported at least one PLE in the previous 3 months, and were currently distressed. Ratings of the program were collected after participants trialled it for a month. Individual semi-structured interviews then elicited qualitative feedback, which was analyzed using Consensual Qualitative Research (CQR) methodology. PLEs and distress were reassessed at 3 months post-baseline. Results User ratings supported the program's acceptability, usability and perceived utility. Significant reductions in the number, frequency and severity of PLE-related distress were found at 3 months follow-up. The CQR analysis identified four qualitative domains: initial and current understandings of PLEs, responses to the program, and context of its use. Initial understanding involved emotional reactions, avoidance or minimization, limited coping skills and non-psychotic attributions. After using the program, participants saw PLEs as normal and common, had greater self-awareness and understanding of stress, and reported increased capacity to cope and accept experiences. Positive responses to the program focused on its normalization of PLEs, usefulness of its strategies, self-monitoring of mood, and information putting PLEs into perspective. Some respondents wanted more specific and individualized information, thought the program would be more useful for other audiences, or doubted its effectiveness. The program was mostly used in low-stress situations. Conclusions The current study provided initial support for the acceptability, utility and positive short-term outcomes of Get Real. The program now requires efficacy testing in randomized controlled trials.

Quality of life changes during conformal radiation therapy for prostate carcinoma

BACKGROUND: The objective of this study was to describe prospectively quality of life (QOL) before and after radiotherapy for patients with prostate carcinoma. METHODS: Forty-three patients with T1-T3 prostate carcinoma who underwent conformal external beam radiation therapy were randomized either to the complete European Organization for Research and Treatment of Cancer (EORTC) QOL questionnaire (EORTC QLQ-C30) or the Medical Outcomes Study Group Short Form Health Survey (SF-36) at baseline, at 3 weeks and 6 weeks after initial treatment, and at 6 weeks and 5 months after the completion of radiotherapy. The measures were self-reported patient QOL, and values are given as the mean +/- standard error of the mean. Changes in QOL are described from baseline to the end of treatment in both questionnaire groups. RESULTS: Emotional role functioning, as measured with the SF-36 questionnaire, significantly improved from 68.2 +/- 9.9 at baseline to 93.3 +/- 5.2 at the end of therapy (P = 0.02). The EORTC QLQ-C30 questionnaire revealed consistent values of emotional functioning during treatment (72.7 +/- 5.9 at baseline) but showed a significant improvement 6 weeks after therapy (89.0 +/- 4.4; P = 0.01). Role functioning deteriorated from 80.1 +/- 6.5 at baseline to 62.5 +/- 8.8 at the end of radiotherapy (P = 0.02). Symptoms of fatigue were shown to increase significantly from 26.9 +/- 6.0 at baseline to 37.7 +/- 7.6 at the end of therapy (P = 0.02). No significant changes in the other dimensions were observed in either questionnaire. CONCLUSIONS: After radiotherapy for prostate carcinoma, patients experience a temporary deterioration of fatigue and role functioning, as measured with the EORTC QLQ-C-30. Despite physical deterioration, the authors observed an improvement in emotional functioning scores with both questionnaires. This may have been due to psychological adaptation and coping.

The influence of a novel simulated learning environment upon student clinical subjective refraction performance: A pilot study

Background: Optometry students are taught the process of subjective refraction through lectures and laboratory based practicals before progressing to supervised clinical practice. Simulated learning environments (SLEs) are an emerging technology that are used in a range of health disciplines, however, there is limited evidence regarding the effectiveness of clinical simulators as an educational tool. Methods: Forty optometry students (20 fourth year and 20 fifth year) were assessed twice by a qualified optometrist (two examinations separated by 4-8 weeks) while completing a monocular non-cycloplegic subjective refraction on the same patient with an unknown refractive error simulated using contact lenses. Half of the students were granted access to an online SLE, The Brien Holden Vision Institute (BHVI®) Virtual Refractor, and the remaining students formed a control group. The primary outcome measures at each visit were; accuracy of the clinical refraction compared to a qualified optometrist and relative to the Optometry Council of Australia and New Zealand (OCANZ) subjective refraction examination criteria. Secondary measures of interest included descriptors of student SLE engagement, student self-reported confidence levels and correlations between performance in the simulated and real world clinical environment. Results: Eighty percent of students in the intervention group interacted with the SLE (for an average of 100 minutes); however, there was no correlation between measures of student engagement with the BHVI® Virtual Refractor and speed or accuracy of clinical subjective refractions. Fifth year students were typically more confident and refracted more accurately and quickly than fourth year students. A year group by experimental group interaction (p = 0.03) was observed for accuracy of the spherical component of refraction, and post hoc analysis revealed that less experienced students exhibited greater gains in clinical accuracy following exposure to the SLE intervention. Conclusions: Short-term exposure to a SLE can positively influence clinical subjective refraction outcomes for less experienced optometry students and may be of benefit in increasing the skills of novice refractionists to levels appropriate for commencing supervised clinical interactions.

Self-reported bruxism : Associated factors among media personnel with or without irregular shift work

Tutkimuksen kohderyhmänä oli mediatyöntekijöitä, joiden toimenkuva on viime vuosina muuttunut yhä kuormittavammaksi epäsäännöllisen vuorotyön sekä jatkuvien teknisten, organisatoristen ja taloudellisten tekijöiden ristipaineessa. Väitöskirjatutkimus on osa laajempaa tutkimushanketta, joka suunniteltiin selvittämään epäsäännöllisen vuorotyön mahdollisia haittoja. Tutkimusta tukivat taloudellisesti Työsuojelurahasto ja Suomen Hammaslääkäriseura Apollonia sekä resurssipanostuksin Hammaslääketieteen laitos (HY), Työterveyslaitos ja Yleisradio Oy. Bruksismi on tahdosta riippumatonta hampaiden narskuttelua tai yhteenpuristamista. Hampaiden narskuttelu on rytmistä jaksoittain toistuvaa puremalihasten toimintaa, joka esiintyy nukkuessa -tavallisimmin kevyen unen ja havahtumisjaksojen yhteydessä. Valveilla ollessa bruksismi on terveillä ihmisillä lähinnä hampaiden yhteenpuristamista. Yleisen käsityksen mukaan toistuvaa unibruksismia esiintyy noin 10 %:lla ja valveilla tapahtuvaa hampaiden yhteenpuristamista noin 20 %:lla. Aiemmin bruksismi kuului kansainvälisen unihäiriöluokituksen (ICSD 1997) mukaan unen erityishäiriöihin, mutta tuorein luokitus (ICSD 2005) listaa sen unen liikehäiriöihin. Väitöstutkimuksen yleisenä tavoitteena oli kartoittaa koetun bruksismin ja uni- valvehäiriöiden yhteyttä. Tutkimus oli poikittainen vertailututkimus epäsäännöllistä vuorotyötä ja säännöllisiä päivävuoroja tekevien välillä. Mielenkiinto kohdistui myös bruksismin ja kasvojen alueen kivun mahdolliseen yhteyteen. Lisäksi tutkimuksessa selvitettiin joidenkin tunnetusti unen laatua huonontavien psykososiaalisten, neurologisten ja fysiologisten tekijöiden yhteyttä koettuun bruksismiin. Tutkimuksen kohderyhmän muodosti 750 Yleisradion epäsäännöllistä vuorotyötä tekevää työntekijää. Vertailuryhmänä käytettiin samansuuruista satunnaistetusti valittua kaltaistettua Yleisradion työntekijäjoukkoa, joka tekee samankaltaista työtä, mutta säännöllisenä päivätyönä. Kohderyhmälle lähetettiin kyselylomakkeet, jotka kartoittivat koetun bruksismin lisäksi mm. tutkittavien taustatiedot, yleisen terveydentilan, yleisiä koettuja stressioireita ja tuntemuksia, kipuoireita, sekä unen laatua. Lisäksi esitettiin jaksamista ja työympäristöä koskevia kysymyksiä. Kyselyyn vastasi kaikkiaan 874 henkilöä. Kokonaisvastausprosentti oli 58,3 % (53,7 % miehiä). Epäsäännöllistä vuorotyötä tekevien vastausprosentti oli 82,3 % ja säännöllistä päivätyötä tekevien ryhmässä 34,3 %. Työtehtävät sisälsivät ohjelmien toimitus- ja tuottamistyötä, teknistä tuotanto- ja tukityötä, sekä esimies- ja hallintotyötä. Miesten keski-ikä vuorotyöryhmässä oli 45,0 (± 10,6) vuotta ja naisten keski-ikä 42,6 (± 10,7) vuotta, vastaavat luvut päivätyötä tekeville olivat 47,4 (± 9,7) ja 45,5 (± 10,1) vuotta. Vuorotyötä tekevistä oli miehiä 56,6 %, päivätyöryhmässä miehien osuus oli 46,7 %. Usein koettua bruksismia havaittiin koko tutkimusjoukossa 10,6 %:lla. Bruksismin esiintyvyydessä ei ollut merkitsevää eroa epäsäännöllistä vuorotyötä ja päivätyötä tekevien välillä. Kun bruksismia ja stressiä arvioitiin suhteessa tyytyväisyyteen nykyiseen työaikamuotoon, molemmat olivat merkitsevästi vallitsevimpia niillä, jotka halusivat vaihtaa nykyistä työaikamuotoaan. Epäsäännöllistä vuorotyötä tekevät lisäksi ilmoittivat kokevansa enemmän stressiä kuin päivätyötä tekevät sekä olivat tyytymättömämpiä työaikamuotoonsa. Tutkittavista henkilöistä katkonaista unta esiintyi 43,6 %:lla sekä 36,2 % koki unensa virkistämättömäksi. Kasvokipua esiintyi 19,6 %:lla. Usein toistuva bruksaus sekä tyytymättömyys työaikamuotoon olivat erittäin merkitsevästi yhteydessä unihäiriöiden sekä riittämättömän unen oireiden kanssa. Bruksismi ja katkonainen uni osoittautuivat myös kasvokivun taustatekijöiksi. Tutkimus osoitti, että koetulla bruksismilla oli merkitsevä yhteys unihäiriöihin, kasvokipuun, koettuun stressiin ja ahdistuneisuuteen, nuorempaan ikään, runsaampiin hammaslääkäri- ja lääkärikäynteihin sekä siihen että oli tyytymätön työaikamuotoonsa (itse työaikamuoto ei ollut merkitsevä tekijä). Tutkimuksen yhtenä johtopäätöksenä todettiin, että koettu bruksismi voi terveillä työikäisillä henkilöillä olla osa stressaavaa tilannetta ja siihen liittyvää käyttäytymistä. Tämän tiedostaminen terveydenhuollossa voisi olla hyödyllistä.

Oral Cancer in Tehran, Iran: An approach for understanding disease burden

Suusyöpä Teheranissa, Iranissa 1993-2003 Tämän väitöskirjan tavoitteena oli kuvata suusyövän yleisyyttä ja siihen vaikuttavia tekijöitä Teheranissa, Iranissa tutkimalla suusyöpäpotilaita, suusyöpäkasvainten ominaisuuksia, potilaille tehtyjä diagnooseja ja niiden viivästymistä sekä heidän selviytymistä sairaudestaan. Suusyöpäkasvainten tietoja kerättiin 1042 suusyöpäpotilaalta. Nämä tiedot kerättiin 30 suurimman Teheranilaissairaalan potilaskortistoista vuosien 1993-2003 ajalta. Eloonjäämisanalyysiä varten tiedot kerättiin vuosien 1996-2003 arkistoista 470 suusyöpä- ja 82 huulisyöpäpotilaan osalta ja heitä seurattiin vuoden 2005 loppuun. Potilaan kokemien ensioireiden ja lopullisen syöpädiagnoosin välistä viivettä varten kerättiin tiedot Teheranilaisista sairaaloista 100 peräkkäisen suusyöpäpotilaan tiedoista vuosien 2004-2006 välillä. Ns diagnostinen viive jaettiin kahteen osaan: 1) ensioireiden ja ensimmäisen sitä seuranneen lääkärikäynnin väli ja 2) ensimmäisen lääkärikäynnin ja lopullisen diagnoosin välinen ero. Useimmat suusyövät olivat pitkälle edenneitä diagnoosin tekemisen hetkellä, kasvain oli siis yli 4 senttimetriä halkaisijaltaan ja/tai kaulan alueen imusolmukkeissa oli jo etäpesäkkeitä. Eloonjäämistodennäköisyys viiden vuoden aikavälillä oli suusyöpäpotilaille 30% ja huulisyöpäpotilaille 62%, mitkä olivat merkittävästi alempia kuin yleisesti länsimaissa vastaavat luvut. Tämä tutkimus osoitti, että keskimääräinen diagnostinen viive oli korkea (7,2 kk, SD 7,5), erityisesti kun niitä verrataan kehittyneimpien terveydenhuoltojärjestelmien vastaaviin tietoihin. Yleensä potilaasta aiheutuva viive oli huomattavan suuri ensioireiden ja lopullisen diagnoosin välisestä ajasta. Tässä tutkimuksessa tehtyjen havaintojen pohjalta on perusteltua esittää kehitettäväksi ennaltaehkäisevä tiedotusohjelma, jossa kansalaiset voisivat saada enemmän tietoa suusyövästä, sen ensioireista jotta he hakeutuisivat aikaisemmin hoitoon. Lisäksi terveydenhoitohenkilöstöä, erityisesti hammaslääkärejä ja suuhygienistejä tulisi kouluttaa varhaisen diagnoosin tekemiseksi, jotta Iranissa tehtävien suusyöpähoitojen lopputulokset paranisivat.

Gene-based pleiotropy across migraine with aura and migraine without aura patient groups

Introduction: It is unclear whether patients diagnosed according to International Classification of Headache Disorders criteria for migraine with aura (MA) and migraine without aura (MO) experience distinct disorders or whether their migraine subtypes are genetically related. Aim: Using a novel gene-based (statistical) approach, we aimed to identify individual genes and pathways associated both with MA and MO. Methods: Gene-based tests were performed using genome-wide association summary statistic results from the most recent International Headache Genetics Consortium study comparing 4505 MA cases with 34,813 controls and 4038 MO cases with 40,294 controls. After accounting for non-independence of gene-based test results, we examined the significance of the proportion of shared genes associated with MA and MO. Results: We found a significant overlap in genes associated with MA and MO. Of the total 1514 genes with a nominally significant gene-based p value (pgene-based ≤ 0.05) in the MA subgroup, 107 also produced pgene-based ≤ 0.05 in the MO subgroup. The proportion of overlapping genes is almost double the empirically derived null expectation, producing significant evidence of gene-based overlap (pleiotropy) (pbinomial-test = 1.5 × 10–4). Combining results across MA and MO, six genes produced genome-wide significant gene-based p values. Four of these genes (TRPM8, UFL1, FHL5 and LRP1) were located in close proximity to previously reported genome-wide significant SNPs for migraine, while two genes, TARBP2 and NPFF separated by just 259 bp on chromosome 12q13.13, represent a novel risk locus. The genes overlapping in both migraine types were enriched for functions related to inflammation, the cardiovascular system and connective tissue. Conclusions: Our results provide novel insight into the likely genes and biological mechanisms that underlie both MA and MO, and when combined with previous data, highlight the neuropeptide FF-amide peptide encoding gene (NPFF) as a novel candidate risk gene for both types of migraine.

Effect of waiting time on health outcomes and service utilization : A prospective randomized study on patients admitted to hospital for hip or knee replacement

Although the principle of equal access to medically justified treatment has been promoted by official health policies in many Western health care systems, practices do not completely meet policy targets. Waiting times for elective surgery vary between patient groups and regions, and growing problems in the availability of services threaten equal access to treatment. Waiting times have come to the attention of decision-makers, and several policy initiatives have been introduced to ensure the availability of care within a reasonable time. In Finland, for example, the treatment guarantee came into force in 2005. However, no consensus exists on optimal waiting time for different patient groups. The purpose of this multi-centre randomized controlled trial was to analyse health-related quality of life, pain and physical function in total hip or knee replacement patients during the waiting time and to evaluate whether the waiting time is associated with patients health outcomes at admission. This study also assessed whether the length of waiting time is associated with social and health services utilization in patients awaiting total hip or knee replacement. In addition, patients health-related quality of life was compared with that of the general population. Consecutive patients with a need for a primary total hip or knee replacement due to osteoarthritis were placed on the waiting list between August 2002 and November 2003. Patients were randomly assigned to a short waiting time (maximum 3 months) or a non-fixed waiting time (waiting time not fixed in advance, instead the patient followed the hospitals routine practice). Patients health-related quality of life was measured upon being placed on the waiting list and again at hospital admission using the generic 15D instrument. Pain and physical function were evaluated using the self-report Harris Hip Score for hip patients and a scale modified from the Knee Society Clinical Rating System for knee patients. Utilization measures were the use of home health care, rehabilitation and social services, physician visits and inpatient care. Health and social services use was low in both waiting time groups. The most common services used while waiting were rehabilitation services and informal care, including unpaid care provided by relatives, neighbours and volunteers. Although patients suffered from clear restrictions in usual activities and physical functioning, they seemed primarily to lean on informal care and personal networks instead of professional care. While longer waiting time did not result in poorer health-related quality of life at admission and use of services during the waiting time was similar to that at the time of placement on the list, there is likely to be higher costs of waiting by people who wait longer simply because they are using services for a longer period. In economic terms, this would represent a negative impact of waiting. Only a few reports have been published of the health-related quality of life of patients awaiting total hip or knee replacement. These findings demonstrate that, in addition to physical dimensions of health, patients suffered from restrictions in psychological well-being such as depression, distress and reduced vitality. This raises the question of how to support patients who suffer from psychological distress during the waiting time and how to develop strategies to improve patients initiatives to reduce symptoms and the burden of waiting. Key words: waiting time, total hip replacement, total knee replacement, health-related quality of life, randomized controlled trial, outcome assessment, social service, utilization of health services

Cost and outcomes of assessing patients with chest pain in an Australian emergency department

Objectives: We sought to characterise the demographics, length of admission, final diagnoses, long-term outcome and costs associated with the population who presented to an Australian emergency department (ED) with symptoms of possible acute coronary syndrome (ACS). Design, setting and participants: Prospectively collected data on ED patients presenting with suspected ACS between November 2008 and February 2011 was used, including data on presentation and at 30 days after presentation. Information on patient disposition, length of stay and costs incurred was extracted from hospital administration records. Main outcome measures: Primary outcomes were mean and median cost and length of hospital stay. Secondary outcomes were diagnosis of ACS, other cardiovascular conditions or non-cardiovascular conditions within 30 days of presentation. Results: An ACS was diagnosed in 103 (11.1%) of the 926 patients recruited. 193 patients (20.8%) were diagnosed with other cardiovascular-related conditions and 622 patients (67.2%) had non-cardiac-related chest pain. ACS events occurred in 0 and 11 (1.9%) of the low-risk and intermediate-risk groups, respectively. Ninety-two (28.0%) of the 329 high-risk patients had an ACS event. Patients with a proven ACS, high-grade atrioventricular block, pulmonary embolism and other respiratory conditions had the longest length of stay. The mean cost was highest in the ACS group ($13 509; 95% CI, $11 794–$15 223) followed by other cardiovascular conditions ($7283; 95% CI, $6152–$8415) and non-cardiovascular conditions ($3331; 95% CI, $2976–$3685). Conclusions: Most ED patients with symptoms of possible ACS do not have a cardiac cause for their presentation. The current guideline-based process of assessment is lengthy, costly and consumes significant resources. Investigation of strategies to shorten this process or reduce the need for objective cardiac testing in patients at intermediate risk according to the National Heart Foundation and Cardiac Society of Australia and New Zealand guideline is required.

The need for cost-effectiveness analyses of antimicrobial stewardship programmes: A structured review

The cost effectiveness of antimicrobial stewardship (AMS) programmes was reviewed in hospital settings of Organisation for Economic Co-operation and Development (OECD) countries, and limited to adult patient populations. In each of the 36 studies, the type of AMS strategy and the clinical and cost outcomes were evaluated. The main AMS strategy implemented was prospective audit with intervention and feedback (PAIF), followed by the use of rapid technology, including rapid polymerase chain reaction (PCR)-based methods and matrix-assisted laser desorption/ionisation time-of-flight (MALDI-TOF) technology, for the treatment of bloodstream infections. All but one of the 36 studies reported that AMS resulted in a reduction in pharmacy expenditure. Among 27 studies measuring changes to health outcomes, either no change was reported post-AMS, or the additional benefits achieved from these outcomes were not quantified. Only two studies performed a full economic evaluation: one on a PAIF-based AMS intervention; and the other on use of rapid technology for the selection of appropriate treatment for serious Staphylococcus aureus infections. Both studies found the interventions to be cost effective. AMS programmes achieved a reduction in pharmacy expenditure, but there was a lack of consistency in the reported cost outcomes making it difficult to compare between interventions. A failure to capture complete costs in terms of resource use makes it difficult to determine the true cost of these interventions. There is an urgent need for full economic evaluations that compare relative changes both in clinical and cost outcomes to enable identification of the most cost-effective AMS strategies in hospitals.

A comparison of welfare outcomes for weaner and mature Bos indicus bulls surgically or tension band castrated with or without analgesia: 2. Responses related to stress, health and productivity

Tension banding castration of cattle is gaining favour because it is relatively simple to perform and is promoted by retailers of the banders as a humane castration method. Two experiments were conducted, under tropical conditions using Bos indicus bulls comparing tension banding (Band) and surgical (Surgical) castration of weaner (7–10 months old) and mature (22–25 months old) bulls with and without pain management (NSAID (ketoprofen) or saline injected intramuscularly immediately prior to castration). Welfare outcomes were assessed using a range of measures; this paper reports on some physiological, morbidity and productivity-related responses to augment the behavioural responses reported in an accompanying paper. Blood samples were taken on the day of castration (day 0) at the time of restraint (0 min) and 30 min (weaners) or 40 min (mature bulls), 2 h, and 7 h; and days 1, 2, 3, 7, 14, 21 and 28 post-castration. Plasmas from day 0 were assayed for cortisol, creatine kinase, total protein and packed cell volume. Plasmas from the other samples were assayed for cortisol and haptoglobin (plus the 0 min sample). Liveweights were recorded approximately weekly to 6 weeks and at 2 and 3 months post-castration. Castration sites were checked at these same times to 2 months post-castration to score the extent of healing and presence of sepsis. Cortisol concentrations (mean ± s.e. nmol/L) were significantly (P < 0.05) higher in the Band (67 ± 4.5) compared with Surgical weaners (42 ± 4.5) at 2 h post-castration, but at 24 h post-castration were greater in the Surgical (43 ± 3.2) compared with the Band weaners (30 ± 3.2). The main effect of ketoprofen was on the cortisol concentrations of the mature Surgical bulls; concentrations were significantly reduced at 40 min (47 ± 7.2 vs. 71 ± 7.2 nmol/L for saline) and 2 h post-castration (24 ± 7.2, vs. 87 ± 7.2 nmol/L for saline). Ketoprofen, however, had no effect on the Band mature bulls, with their cortisol concentrations averaging 54 ± 5.1 nmol/L at 40 min and 92 ± 5.1 nmol/L at 2 h. Cortisol concentrations were also significantly elevated in the Band (83 ± 3.0 nmol/L) compared with Surgical mature bulls (57 ± 3.0 nmol/L) at weeks 2–4 post-castration. The timing of this elevation coincided with significantly elevated haptoglobin concentrations (mg/mL) in the Band bulls (2.97 ± 0.102 for mature bulls and 1.71 ± 0.025 for weaners, vs. 2.10 ± 0.102 and 1.45 ± 0.025 respectively for the Surgical treatment) and evidence of slow wound healing and sepsis in both the weaner (0.81 ± 0.089 not healed at week 4 for Band, 0.13 ± 0.078 for Surgical) and mature bulls (0.81 ± 0.090 at week 4 for Band, 0.38 ± 0.104 for Surgical). Overall, liveweight gains of both age groups were not affected by castration method. The findings of acute pain, chronic inflammation and possibly chronic pain in the mature bulls at least, together with poor wound healing in the Band bulls support behavioural findings reported in the accompanying paper and demonstrate that tension banding produces inferior welfare outcomes for weaner and mature bulls compared with surgical castration.

Patient Safety - A Psychological Perspective

This comprehensive book takes a psychological perspective on patient safety. It is based on the most recent theoretical and empirical research evidence from psychology (including clinical, work, and organizational psychology) and adjacent social and behavioral sciences such as human factors. Factors that influence safety-related experiences, behaviors, and outcomes of patients and professionals working in clinical settings such as medical practices and hospitals are reviewed, structured, and critically evaluated. Consistent with the complexity of the topic, the author takes a multi-level approach to patient safety, which includes a review of individual, team, and organizational factors and outcomes. The book describes how these factors, by themselves and in combination, can facilitate or impede patient safety. Individual factors include safety-relevant knowledge, skills, abilities, and personality traits such as conscientiousness and emotional stability. Team factors include group communication, training, and leadership. Finally, organizational factors include the safety culture and climate. Throughout the book, different evidence-based intervention programs are described that can help practitioners promote patient safety and prevent accidents. The book is a valuable resource for both researchers and practitioners interested in understanding, maintaining, and improving patient safety in a variety of applied settings. It is based on the most up-to-date research evidence from psychology and neighboring disciplines, and it is written in a clear and non-technical language understandable for a wide audience.