(Mis)Using Pulse Oximetry : A Review of Pulse Oximetry use in Acute Care Medical Wards

Background: Nurses routinely use pulse oximetry (SpO2) monitoring equipment in acute care. Interpretation of the reading involves physical assessment and awareness of parameters including temperature, haemoglobin, and peripheral perfusion. However, there is little information on whether these clinical signs are routinely measured or used in pulse oximetry interpretation by nurses. Aim: The aim of this study was to review current practice of SpO2 measurement and the associated documentation of the physiological data that is required for accurate interpretation of the readings. The study reviewed the documentation practices relevant to SpO2 in five medical wards of a tertiary level metropolitan hospital. Method: A prospective casenote audit was conducted on random days over a three-month period. The audit tool had been validated in a previous study. Results: One hundred and seventy seven episodes of oxygen saturation monitoring were reviewed. Our study revealed a lack of parameters to validate the SpO2 readings. Only 10% of the casenotes reviewed had sufficient physiological data to meaningfully interpret the SpO2 reading and only 38% had an arterial blood gas as a comparator. Nursing notes rarely documented clinical interpretation of the results. Conclusion: The audits suggest that medical and nursing staff are not interpreting the pulse oximetry results in context and that the majority of the results were normal with no clinical indication for performing this observation. This reduces the usefulness of such readings and questions the appropriateness of performing “routine” SpO2 in this context.

Stroma regulates increased epithelial lateral cell adhesion in 3D culture : a role for actin/cadherin dynamics

BACKGROUND: Cell shape and tissue architecture are controlled by changes to junctional proteins and the cytoskeleton. How tissues control the dynamics of adhesion and cytoskeletal tension is unclear. We have studied epithelial tissue architecture using 3D culture models and found that adult primary prostate epithelial cells grow into hollow acinus-like spheroids. Importantly, when co-cultured with stroma the epithelia show increased lateral cell adhesions. To investigate this mechanism further we aimed to: identify a cell line model to allow repeatable and robust experiments; determine whether or not epithelial adhesion molecules were affected by stromal culture; and determine which stromal signalling molecules may influence cell adhesion in 3D epithelial cell cultures. METHODOLOGY/PRINCIPAL FINDINGS: The prostate cell line, BPH-1, showed increased lateral cell adhesion in response to stroma, when grown as 3D spheroids. Electron microscopy showed that 9.4% of lateral membranes were within 20 nm of each other and that this increased to 54% in the presence of stroma, after 7 days in culture. Stromal signalling did not influence E-cadherin or desmosome RNA or protein expression, but increased E-cadherin/actin co-localisation on the basolateral membranes, and decreased paracellular permeability. Microarray analysis identified several growth factors and pathways that were differentially expressed in stroma in response to 3D epithelial culture. The upregulated growth factors TGFβ2, CXCL12 and FGF10 were selected for further analysis because of previous associations with morphology. Small molecule inhibition of TGFβ2 signalling but not of CXCL12 and FGF10 signalling led to a decrease in actin and E-cadherin co-localisation and increased paracellular permeability. CONCLUSIONS/SIGNIFICANCE: In 3D culture models, paracrine stromal signals increase epithelial cell adhesion via adhesion/cytoskeleton interactions and TGFβ2-dependent mechanisms may play a key role. These findings indicate a role for stroma in maintaining adult epithelial tissue morphology and integrity.

Estimation of illuminance on the south facing surfaces for clear skies in Iran

Background: Daylight availability data are essential for designing effectively day lighted buildings. In respect to no available daylight availability data in Iran, illuminance data on the south facing vertical surfaces were estimated using a proper method. Methods: An illuminance measuring set was designed for measuring vertical illuminances for standard times over 15 days at one hour intervals from 9 a.m. to 3 p.m. at three measuring stations (Hamadan, Eshtehard and Kerman). Measuring data were used to confirm predicted by the IESNA method. Results: Measurement of respective illuminances on the south vertical surfaces resulted in minimum values of 10.5 KLx, mean values of 33.59 KLx and maximum values of 79.6 KLx. Conclusion: In this study was developed a regression model between measured and calculated data of south facing vertical illuminance. This model, have a good linear correlation between measured and calculated values (r= 0.892).

High temperatures-related elderly mortality varied greatly from year to year : important information for heat-warning systems

We examined the variation in association between high temperatures and elderly mortality (age ≥ 75 years) from year to year in 83 US cities between 1987 and 2000. We used a Poisson regression model and decomposed the mortality risk for high temperatures into: a “main effect” due to high temperatures using lagged non-linear function, and an “added effect” due to consecutive high temperature days. We pooled yearly effects across both regional and national levels. The high temperature effects (both main and added effects) on elderly mortality varied greatly from year to year. In every city there was at least one year where higher temperatures were associated with lower mortality. Years with relatively high heat-related mortality were often followed by years with relatively low mortality. These year to year changes have important consequences for heat-warning systems and for predictions of heat-related mortality due to climate change.

Subacute effects of ecstasy on mood : an exploration of associated risk factors

Ecstasy use may result in lowered mood, anxiety or aggression in the days following use. Yet, few studies have investigated what factors increase the risk of experiencing such symptoms. Ecstasy users (at least once in the last 12 months) who subsequently took ecstasy (n=35) over the next week, were compared on measures of mood, sleep, stress and drug use, with those who abstained (n=21) that week. Measures were administered the week prior to ecstasy use and 1 and 3 days following use, or the equivalent day for abstainers. Mood symptoms were assessed using the Kessler-10 self-report psychological distress scale, a subjective mood rating (1-10), and the depression, anxiety and hostility items of the clinician-rated Brief Psychiatric Rating Scale. Timeline followback methods were used to collect information on drug use and life stress in the past month. Self-reported sleep quality was also assessed. Ecstasy use was not associated with subacute depressive, anxiety or aggressive symptoms. Rather, lowered mood and increased psychological distress were associated with self-reported hours and quality of sleep obtained during the 3-day follow up. These findings highlight the importance of considering sleep disruption in understanding the short-term mood effects of ecstasy use.

Dying in hospital: medical failure or natural outcomes?

The purpose of this study was to describe patterns of medical and nursing practice in the care of patients dying of oncological and hematological malignancies in the acute care setting in Australia. A tool validated in a similar American study was used to study the medical records of 100 consecutive patients who died of oncological or hematological malignancies before August 1999 at The Canberra Hospital in the Australian Capital Territory. The three major indicators of patterns of end-of-life care were documentation of Do Not Resuscitate (DNR) orders, evidence that the patient was considered dying, and the presence of a palliative care intention. Findings were that 88 patients were documented DNR, 63 patients' records suggested that the patient was dying, and 74 patients had evidence of a palliative care plan. Forty-six patients were documented DNR 2 days or less prior to death and, of these, 12 were documented the day of death. Similar patterns emerged for days between considered dying and death, and between palliative care goals and death. Sixty patients had active treatment in progress at the time of death. The late implementation of end-of-life management plans and the lack of consistency within these plans suggested that patients were subjected to medical interventions and investigations up to the time of death. Implications for palliative care teams include the need to educate health care staff and to plan and implement policy regarding the management of dying patients in the acute care setting. Although the health care system in Australia has cultural differences when compared to the American context, this research suggests that the treatment imperative to prolong life is similar to that found in American-based studies.

Editorial

In May 2011, the Centre for Crime and Justice Studies published Lessons for the Coalition: an end of term report on New Labour and Criminal Justice (Silvestri, 2011). In that collection I described Labour's performance on environmental issues as ‘too little too late’. The UK experienced a period of Blair/Brown environmental governance that demonstrated ‘symbolic success but real failure’. Amongst New Labour's environmental achievements were the establishment of the Climate Change Act 2008, the creation of the Department of Energy and Climate Change and the establishment of numerous green quangos to oversee and implement a range of environmental policies. However, these steps forward were seemingly threatened by the early days of a Cameron-led coalition where austerity measure, trade and the abolition of green quangos were on the cards. In sum, I concluded ‘future UK government report cards on the environment do not look good’ (Walters, 2011). After two and half years of a Conservative/Liberal Democratic coalition, and much rhetoric about it being ‘the greenest government ever’, the interim report card for the Cameron government on environmental matters is grim reading indeed. The demise of green quangos, record carbon emissions, renewable energies policies stultified, environmental criminality and victimisation all but ignored, and billions of pounds lost to environmental corporate fraudsters are just some of the headlines of Tory inspired governance with much environmental rhetoric and no environmental results.

Outcomes following inpatient rehabilitation : a seven year perspective

Introduction: Improving physical and cognitive functioning is a key objective of multi-disciplinary inpatient geriatric rehabilitation. Outcomes relevant to minimum functional ability required for older adults to successfully participate in the community have been reported. However, there has been little investigation reporting outcomes of older inpatients receiving multi-disciplinary rehabilitation being discharged home from geriatric rehabilitation units. This study aims to investigate characteristics and physical and cognitive outcomes of this cohort. Method: The Princess Alexandra Hospital Geriatric and Rehabilitation Unit is the largest rehabilitation unit in Queensland. Multidisciplinary health professionals enter admission and discharge functional and clinical outcomes along with demographic information into a purpose designed database for all patients. Data collected between 2005 and 2011 was analysed using descriptive statistics. Results: During the seven-year period, 4120 patients were admitted for rehabilitation; 2126 (52%) were female, mean age of 74 years (Standard Deviation 14). Primary reasons for admission were for reconditioning post medical illness or surgical admission (n = 1285, 31%), and 30% (n = 1233) admitted for orthopaedic reasons. Of these orthopaedic admissions, 6.6% (n = 82) were for elective surgery, and 46% (n = 565) were for fractured neck-of-femurs. 76% (n = 3130) of patients were discharged home, 13% (n = 552) to residential care facilities and 10% (n = 430) were discharged to an alternative hospital setting or passed away during their admission. Mean length of stay was 44 days (SD 39) Preliminary analysis of FIM outcomes shows a mean motor score of 53 (SD = 19) on admission which significantly improved to 71 (SD = 18) by discharge. There was no change on FIM cognitive score (28 (SD7) vs 29 (SD 6). Conclusion: Geriatric patients have significant functional limitations even on discharge from inpatient rehabilitation; though overall cognition is relatively intact. Orthopaedic conditions and general deconditioning from medical/surgical admissions are the main reasons for admission. The majority of people receiving rehabilitation are discharged home.

Outcomes following inpatient rehabilitation of lower limb amputees

Introduction: Lower-limb amputations are a serious adverse consequence of lifestyle related chronic conditions and a serious concern among the aging population in Australia. Lower limb amputations have severe personal, social and economic impacts on the individual, healthcare system and broader community. This study aimed to address a critical gap in the research literature by investigating the physical functioning and social characteristics of lower limb amputees at discharge from tertiary hospital inpatient rehabilitation. Method: A cohort study was implemented among patients with lower limb amputations admitted to a Geriatric Assessment and Rehabilitation Unit for rehabilitation at a tertiary hospital. Conventional descriptive statistics were used to examine patient demographic, physical functioning and social living outcomes recorded for patients admitted between 2005 and 2011. Results: A total of 423 admissions occurred during the study period, 313 (74%) were male. This sample included admissions for left (n = 189, 45%), right (n = 220, 52%) and bilateral (n = 14, 3%) lower limb amputations, with 15 (3%) patients dying whilst an inpatient. The mean (standard deviation) age was 65 (13.9) years. Amputations attributed to vascular causes accounted for 333 (78%) admissions; 65 (15%) of these had previously had an amputation. The mean (SD) length of stay in the rehabilitation unit was 56 (42) days. Prior to this admission, 123 (29%) patients were living alone, 289 (68%) were living with another and 3 (0.7%) were living in residential care. Following this amputation related admission, 89 (21%) patients did not return to their prior living situation. Of those admitted, 187 (44%) patients were discharged with a lower limb prosthesis. Conclusion: The clinical group is predominately older adults. The ratio of males to females was approximately 3:1. Over half did not return to walking and many were not able to return to their prior accommodation. However, few patients died during their admission.

Intra-amniotic ureaplasma infection : adverse outcomes vary depending on gestation

Background: Ureaplasmas are the most prevalent bacteria isolated from preterm deliveries and the prognosis for neonates varies depending on the gestation at delivery. Ureaplasmas vary their surface-exposed antigen (MBA, a virulence mechanism) during chronic intra-amniotic infections, but it is not known when changes first occur during gestation. Method: U. parvum serovar 3 (2x10e7CFU) was injected intra-amniotically (IA) into six experimental cohorts of pregnant ewes (of n=7), 3 days (d) or 7d before delivery at either: 100d, 124d or 140d gestation (term=145d). Control ewes received IA 10B broth. Fetuses were delivered surgically and ureaplasmas cultured from amniotic fluid (AF), chorioamnion, fetal lung (FL) and umbilical cord. Ureaplasmas were tested by western blot to demonstrate MBA variation. Results: The highest number of ureaplasmas were recovered from FL at 100d gestation after 3 days of infection (p<0.03). Six of 7(86%) 100d–3d FL demonstrated an ureaplasma MBA variant, but only 17% and 15% of FL showed an MBA variant after 3d infection at 124d and 140d gestation respectively. Greatest variation of the MBA occurred in AF and FL at 124d gestation after 7d infection. The least MBA variation was observed at 140d; however, at this time the most severe histological chorioamnionitis was observed. Conclusions: After intra-amniotic ureaplasma injections, higher numbers of ureaplasmas gained access to the FL at 100d gestation than observed at later gestations. This may exacerbate the adverse outcomes for neonates delivered early in gestation. In late gestation, ureaplasma MBA variation was minimal, but chorioamnionitis was the most severe. Adverse pregnancy outcomes associated with IA ureaplasma infection may vary depending on the duration of gestation, the number of ureaplasmas isolated from the fetal tissues and the degree of MBA variation.

Transportation : implications for accessibility for older people

Objective: This research investigates older people’s use of transportation to develop strategies for age-friendly transportation within the community. Methods: Data for this study was derived from Global Positioning System (GPS) tracking of thirteen people aged 55 years and older, together with self-report information recorded in travel diaries about daily activities undertaken outside the home over a period of seven days. Semi-structured interviews were aided by individual maps to investigate engagement in out-of-home activities and verify the recorded GPS data. Results: Overall, participants were highly reliant on the car for daily commuting. Walking, biking and public transport options were unattractive due to environmental conditions, accessibility and usability. Conclusion: Participation within the community and access to services is facilitated by private and public transportation. It is therefore critical to address accessibility and usability issues faced by older people to enable them to maintain their mobility, and ensure access to services, especially when driving ceases.

Incident investigation training needs for the Australasian rail industry

A core component for the prevention of re-occurring incidents within the rail industry is rail safety investigations. Within the current Australasian rail industry, the nature of incident investigations varies considerably between organisations. As it stands, most of the investigations are conducted by the various State Rail Operators and Regulators, with the more major investigations in Australia being conducted or overseen by the Australian Transport Safety Bureau (ATSB). Because of the varying nature of these investigations, the current training methods for rail incident investigators also vary widely. While there are several commonly accepted training courses available to investigators in Australasia, none appear to offer the breadth of development needed for a comprehensive pathway. Furthermore, it appears that no single training course covers the entire breadth of competencies required by the industry. These courses range in duration between a few days to several years, and some were run in-house while others are run by external consultants or registered training organisations. Through consultations with rail operators and regulators in Australasia, this paper will identify capabilities required for rail incident investigation and explore the current training options available for rail incident investigators.

Relationships between self-reported bicycling injuries and perceived risk of cyclists in Queensland, Australia

The focus of governments on increasing active travel has motivated renewed interest in cycling safety. Bicyclists are up to 20 times more likely to be involved in serious injury crashes than drivers so understanding the relationship among factors in bicyclist crash risk is critically important for identifying effective policy tools, for informing bicycle infrastructure investments, and for identifying high risk bicycling contexts. This study aims to better understand the complex relationships between bicyclist self reported injuries resulting from crashes (e.g. hitting a car) and non-crashes (e.g. spraining an ankle) and perceived risk of cycling as a function of cyclist exposure, rider conspicuity, riding environment, rider risk aversion, and rider ability. Self reported data from 2,500 Queensland cyclists are used to estimate a series of seemingly unrelated regressions to examine the relationships among factors. The major findings suggest that perceived risk does not appear to influence injury rates, nor do injury rates influence perceived risks of cycling. Riders who perceive cycling as risky tend not to be commuters, do not engage in group riding, tend to always wear mandatory helmets and front lights, and lower their perception of risk by increasing days per week of riding and by increasing riding proportion on bicycle paths. Riders who always wear helmets have lower crash injury risk. Increasing the number of days per week riding tends to decrease both crash injury and non crash injury risk (e.g. a sprain). Further work is needed to replicate some of the findings in this study.

Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: Results from the Nutrition Care Day Survey 2010

Background & aims The Australasian Nutrition Care Day Survey (ANCDS) ascertained if malnutrition and poor food intake are independent risk factors for health-related outcomes in Australian and New Zealand hospital patients. Methods Phase 1 recorded nutritional status (Subjective Global Assessment) and 24-h food intake (0, 25, 50, 75, 100% intake). Outcomes data (Phase 2) were collected 90-days post-Phase 1 and included length of hospital stay (LOS), readmissions and in-hospital mortality. Results Of 3122 participants (47% females, 65 ± 18 years) from 56 hospitals, 32% were malnourished and 23% consumed ≤ 25% of the offered food. Malnourished patients had greater median LOS (15 days vs. 10 days, p < 0.0001) and readmissions rates (36% vs. 30%, p = 0.001). Median LOS for patients consuming ≤ 25% of the food was higher than those consuming ≤ 50% (13 vs. 11 days, p < 0.0001). The odds of 90-day in-hospital mortality were twice greater for malnourished patients (CI: 1.09–3.34, p = 0.023) and those consuming ≤ 25% of the offered food (CI: 1.13–3.51, p = 0.017), respectively. Conclusion The ANCDS establishes that malnutrition and poor food intake are independently associated with in-hospital mortality in the Australian and New Zealand acute care setting.

The impact of malnutrition and decreased food intake on length of stay, readmission, and mortality in acute care patients

Rationale: The Australasian Nutrition Care Day Survey (ANCDS) evaluated if malnutrition and decreased food intake are independent risk factors for negative outcomes in hospitalised patients. Methods: A multicentre (56 hospitals) cross-sectional survey was conducted in two phases. Phase 1 evaluated nutritional status (defined by Subjective Global Assessment) and 24-hour food intake recorded as 0, 25, 50, 75, and 100% intake. Phase 2 data, which included length of stay (LOS), readmissions and mortality, were collected 90 days post-Phase 1. Logistic regression was used to control for confounders: age, gender, disease type and severity (using Patient Clinical Complexity Level scores). Results: Of 3122 participants (53% males, mean age: 65±18 years) 32% were malnourished and 23% consumed�25% of the offered food. Median LOS for malnourished (MN) patients was higher than well-nourished (WN) patients (15 vs. 10 days, p<0.0001). Median LOS for patients consuming �25% of the food was higher than those consuming �50% (13 vs. 11 days, p<0.0001). MN patients had higher readmission rates (36% vs. 30%, p = 0.001). The odds ratios of 90-day in-hospital mortality were 1.8 times greater for MN patients (CI: 1.03 3.22, p = 0.04) and 2.7 times greater for those consuming �25% of the offered food (CI: 1.54 4.68, p = 0.001). Conclusion: The ANCDS demonstrates that malnutrition and/or decreased food intake are associated with longer LOS and readmissions. The survey also establishes that malnutrition and decreased food intake are independent risk factors for in-hospital mortality in acute care patients; and highlights the need for appropriate nutritional screening and support during hospitalisation. Disclosure of Interest: None Declared.