Mixed venous oxygen saturation monitoring revisited : thoughts for critical care nursing practice

Background Less invasive methods of determining cardiac output are now readily available. Using indicator dilution technique, for example has made it easier to continuously measure cardiac output because it uses the existing intra-arterial line. Therefore gone is the need for a pulmonary artery floatation catheter and with it the ability to measure left atrial and left ventricular work indices as well the ability to monitor and measure a mixed venous saturation (SvO2). Purpose The aim of this paper is to put forward the notion that SvO2 provides valuable information about oxygen consumption and venous reserve; important measures in the critically ill to ensure oxygen supply meets cellular demand. In an attempt to portray this, a simplified example of the septic patient is offered to highlight the changing pathophysiological sequelae of the inflammatory process and its importance for monitoring SvO2. Relevance to clinical practice SvO2 monitoring, it could be argued, provides the gold standard for assessing arterial and venous oxygen indices in the critically ill. For the bedside ICU nurse the plethora of information inherent in SvO2 monitoring could provide them with important data that will assist in averting potential problems with oxygen delivery and consumption. However, it has been suggested that central venous saturation (ScvO2) might be an attractive alternative to SvO2 because of its less invasiveness and ease of obtaining a sample for analysis. There are problems with this approach and these are to do with where the catheter tip is sited and the nature of the venous admixture at this site. Studies have shown that ScvO2 is less accurate than SvO2 and should not be used as a sole guiding variable for decision-making. These studies have demonstrated that there is an unacceptably wide range in variance between ScvO2 and SvO2 and this is dependent on the presenting disease, in some cases SvO2 will be significantly lower than ScvO2. Conclusion Whilst newer technologies have been developed to continuously measure cardiac output, SvO2 monitoring is still an important adjunct to clinical decision-making in the ICU. Given the information that it provides, seeking alternatives such as ScvO2 or blood samples obtained from femorally placed central venous lines, can unnecessarily lead to inappropriate treatment being given or withheld. Instead when using ScvO2, trending of this variable should provide clinical determinates that are useable for the bedside ICU nurse, remembering that in most conditions SvO2 will be approximately 16% lower.

Is age a factor in the success or failure of remote monitoring in heart failure? Telemonitoring and structured telephone support in elderly heart failure patients

Background There are few data regarding the effectiveness of remote monitoring for older people with heart failure. We conducted a post-hoc sub-analysis of a previously published large Cochrane systematic review and meta-analysis of relevant randomized controlled trials to determine whether structured telephone support and telemonitoring were effective in this population. Methods A post hoc sub-analysis of a systematic review and meta-analysis that applied the Cochrane methodology was conducted. Meta-analyses of all-cause mortality, all-cause hospitalizations and heart failure-related hospitalizations were performed for studies where the mean or median age of participants was 70 or more years. Results The mean or median age of participants was 70 or more years in eight of the 16 (n=2,659/5,613; 47%) structured telephone support studies and four of the 11 (n=894/2,710; 33%) telemonitoring studies. Structured telephone support (RR 0.80; 95% CI=0.63-1.00) and telemonitoring (RR 0.56; 95% CI=0.41-0.76) interventions reduced mortality. Structured telephone support interventions reduced heart failure-related hospitalizations (RR 0.81; 95% CI=0.67-0.99). Conclusion Despite a systematic bias towards recruitment of individuals younger than the epidemiological average into the randomized controlled trials, older people with heart failure did benefit from structured telephone support and telemonitoring. These post-hoc sub-analysis results were similar to overall effects observed in the main meta-analysis. While further research is required to confirm these observational findings, the evidence at hand indicates that discrimination by age alone may be not be appropriate when inviting participation in a remote monitoring service for heart failure.

A history of environmental management in the field in Queensland : episodes of activity

This paper reviews a wide range of literature on environmental management in the field in Queensland, and analyzes this by period and by author. An episodic pattern of activities since European settlement is evident. Periods of exploration (pre-1950) and inventory- compilation (ca. 1950-1970) were followed by two decades of media and non-government organization campaigning (ca. 1970-1990), then an era dominated by government regulatory action (ca. 1990-2010). These eras dominated public perception of what was happening in environmental practice. They were delineated by historic ‘interventions’ (summarily, the end of World War II, the 1971 inflationary crisis, and computerization respectively).

Integrin αvβ3 mediates upregulation of epidermal growth-factor receptor expression and activity in human ovarian cancer cells

Upon overexpression of integrin αvβ3 and its engagement by vitronectin, we previously showed enhanced adhesion, proliferation, and motility of human ovarian cancer cells. By studying differential expression of genes possibly related to these tumor biological events, we identified the epidermal growth-factor receptor (EGF-R) to be under control of αvβ3 expression levels. Thus in the present study we characterized αvβ3-dependent changes of EGF-R and found significant upregulation of its expression and activity which was reflected by prominent changes of EGF-R promoter activity. Upon disruption of DNA-binding motifs for the transcription factors p53, ETF, the repressor ETR, p50, and c-rel, respectively, we sought to identify DNA elements contributing to αvβ3-mediated EGF-R promoter induction. Both, the p53- and ETF-mutant, while exhibiting considerably lower EGF-R promoter activity than the wild type promoter, retained inducibility by αvβ3. Mutation of the repressor motif ETR, as expected, enhanced EGF-R promoter activity with a further moderate increase upon αvβ3 elevation. The p50-mutant displayed EGF-R promoter activity almost comparable to that of the wild type promoter with no impairment of induction by αvβ3. However, the activity of an EGF-R promoter mutant displaying a disrupted c-rel-binding motif did not only prominently decline, but, moreover, was not longer responsive to enhanced αvβ3, involving this DNA element in αvβ3-dependent EGF-R upregulation. Moreover, αvβ3 did not only increase the EGF-R but, moreover, also led to obvious co-clustering on the cancer cell surface. By studying αvβ3/EGF-R-effects on the focal adhesion kinase (FAK) and the mitogen activated protein kinases (MAPK) p44/42 (erk−1/erk−2), having important functions in synergistic crosstalk between integrins and growth-factor receptors, we found for both significant enhancement of expression and activity upon αvβ3/VN interaction and cell stimulation by EGF. Upregulation of the EGF-R by integrin αvβ3, both receptor molecules with a well-defined role as targets for cancer treatment, might represent an additional mechanism to adapt synergistic receptor signaling and crosstalk in response to an altered tumor cell microenvironment during ovarian cancer progression.

Assessing exposure to polybrominated diphenyl ethers (PBDEs) for workers in the vicinity of a large recycling facility

Increased levels of polybrominated diphenyl ethers (PBDEs) can occur particularly in dust and soil surrounding facilities that recycle products containing PBDEs. This may be the source of increased exposure for nearby workers and residents. To investigate, we measured PBDE levels in soil, office dust and blood of workers at the closest workplace (i.e. within 100m) to a large automotive shredding and metal recycling facility in Brisbane, Australia. The workplace investigated in this study was independent of the automotive shredding facility and was one of approximately 50 businesses of varying types within a relatively large commercial/industrial area surrounding the recycling facility. Concentrations of PBDEs in soils were at least an order of magnitude greater than background levels in the area. Congener profiles were dominated by larger molecular weight congeners; in particular BDE-209. This reflected the profile in outdoor air samples previously collected at this site. Biomonitoring data from blood serum indicated no differential exposure for workers near the recycling facility compared to a reference group of office workers, also in Brisbane. Unlike air, indoor dust and soil sample profiles, serum samples from both worker groups were dominated by congeners BDE-47, BDE-153, BDE-99, BDE-100 and BDE-183 and was similar to the profile previously reported in the general Australian population. Estimated exposures for workers near the industrial point source suggested indoor workers had significantly higher exposure than outdoor workers due to their exposure to indoor dust rather than soil. However, no relationship was observed between blood PBDE levels and different roles and activity patterns of workers on-site. These comparisons of PBDE levels in serum provide additional insight into the inter-individual variability within Australia. Results also indicate congener patterns in the workplace environment did not match blood profiles of workers. This was attributed to the relatively high background exposures for the general Australian population via dietary intake and the home environment.