Multispecialty tracheostomy experience.

INTRODUCTION: Tracheostomy is a common surgical procedure used to create a secure airway in patients, now performed by a variety of specialties, with a notable rise in critical care environments. It is unclear whether this rise is seen in units with large head and neck surgery departments, and how practice in such units compares with the rest of the UK. METHODS: A three-year retrospective audit was carried out between anaesthetic, surgical and critical care departments. All tracheostomy procedures were recorded anonymously. RESULTS: A total of 523 tracheostomies were performed, 66% of which were in men. The mean patient age was 60 years. The majority (83%) were elective, performed for various indications, while the remaining 17% were emergency tracheostomies performed for pending airway obstruction. A fifth of the tracheostomies were percutaneous procedures. Most emergency tracheostomies (78%) were performed by otolaryngology. Three cricothyroidotomies were performed within critical care and theatres. Complications related to tracheostomy occurred in 47 cases (9%), most commonly lower respiratory tract infection. The mean time to decannulation was 12.8 days. CONCLUSIONS: This paper discusses the findings of a comprehensive, multispecialty audit of tracheostomy experience in a large health board, with over 150 tracheostomies performed annually. Elective cases form the majority although there is a significant case series of emergency tracheostomies performed for a range of pathologies. Around a quarter of those requiring tracheostomy ultimately died, mostly as a result of advanced cancer.

La Crosse Virus Vectors Are Host-Seeking and Ovipositing After 1700 H in Eastern Tennessee.

La Crosse virus (LACV) is transmitted via the bites of infected Aedes mosquitoes (Ae. triseriatus, Ae. albopictus, and Ae. japonicus) and causes La Crosse encephalitis, which is the most commonly diagnosed arbovirus in eastern Tennessee children. This study identified host-seeking and oviposition activity of LACV vectors over a diel period, as it relates to traditional working hours. Nineteen sites in Knox County, TN, were monitored with host-seeking (Centers for Disease Control and Prevention [CDC] miniature light traps) and oviposition traps (CDC gravid traps) during 2 diel periods (0900-1700 h and 1700-900 h). We collected 2,444 adult mosquitoes, comprising 19 different species of which 1,337 (54.7%) were LACV vectors: Ae. albopictus (1,207 specimens), Ae. triseriatus (85 specimens), and Ae. japonicus (45 specimens). These species were active throughout the sampling period, but significantly more were collected from 1700-0900 h. The CDC gravid trap was the most effective method for monitoring Ae. japonicus; there were no trap effects or trap × time interactive effects for Ae. albopictus or Ae. triseriatus. Overall, significantly more LACV vectors were collected from 1700-0900 h compared to 0900-1700 h. Information gathered in this study improves vector surveillance, helps communities control mosquito populations, and minimizes nontarget effects.

Evaluating Surveillance Methods for Arboviral Vectors of La Crosse Virus and West Nile Virus of Southern Appalachia.

To monitor mosquito-borne diseases, public health departments conduct mosquito and pathogen surveillance. Our objective was to evaluate mosquito monitoring methods for collecting La Crosse virus (LACV) and West Nile virus (WNV) vectors (Aedes and Culex mosquitoes, respectively) in southern Appalachia. Centers for Disease Control and Prevention (CDC) light traps baited with carbon dioxide (CO(2)), CDC light traps baited with CO(2) and BG lure, BG-Sentinel traps baited with CO(2), gravid traps baited with oak (Quercus)-water infusion, and resting traps were compared in eastern Tennessee in 2013. Traps operated at 8 different urban sites throughout Knox County were randomly assigned to and rotated among 6 plots within each site. Results were specific for each vector; the BG-Sentinel trap was the best method for Aedes triseriatus, the CDC trap baited with CO(2) and BG lure was the best method for Ae. albopictus, and the gravid trap was the best method for Ae. japonicus. Culex erraticus collections varied by week and trapping method, indicating no single method was best, but the questing traps collected more mosquitoes. There was no significant trapping difference for Cx. pipiens complex in this region using the methods tested. The results suggest using a combination of trapping methods when sampling for LACV and/or WNV mosquito vectors in southern Appalachia. Effective trapping methods are necessary to enable accurate surveillance, improve control methods, enhance understanding of dispersal, and use for early detection of vectors and pathogens.

Reaction time-monitored patient-maintained propofol sedation: a pilot study in oral surgery patients.

Previous volunteer studies of an effect-site controlled patient-maintained sedation system using propofol have demonstrated a risk of oversedation. We have incorporated a reaction time monitor into the handset to add an individualised patient-feedback mechanism. This pilot study assessed if the reaction time-feedback modification would prove safe and effective in 20 healthy patients receiving sedation while undergoing oral surgery. All patients successfully sedated themselves without reaching any unsafe endpoints. All 20 maintained verbal contact throughout. The mean (SD) lowest peripheral blood oxygen saturation was 98.0 (2.1)% breathing room air. No patient required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.6 (0.5) µg.ml(-1). The present system was found to be safe and effective, allowing oral surgery treatment under conscious sedation, but preventing oversedation.

Platelet and coagulation activation markers in myeloproliferative diseases: relationships with JAK2 V6I7 F status, clonality, and antiphospholipid antibodies.

BACKGROUND AND OBJECTIVES: Patients with myeloproliferative disease (MPD) have an increased risk of thrombosis. We studied markers of platelet and coagulation activation in a large cohort of patients with MPD (n = 118) and related this to Janus Kinase 2 (JAK2) V617 F mutation status, a marker of clonality, and the presence of antiphospholipid antibodies (APA), all of which have been associated with thrombosis in MPD. METHODS: D-dimer, thrombin-antithrombin complexes (TAT), prothrombin fragments 1 + 2 (F(1+2)), soluble E-selectin (sE-selectin), and soluble P-selectin (sP-selectin) levels were compared between patients and hypertensive controls (n = 127). Assays for lupus anticoagulant (LA), anticardiolipin antibodies (ACA), antibeta2 glycoprotein 1 antibodies (anti-beta(2)GP1), and antiprothrombin antibodies (alpha-Pro) were also performed. The JAK2 V617F mutation status was determined in the cohort using amplification refractory mutation system (ARMS) polymerase chain reaction. Disease clonality was determined in 54 patients using the HUMARA assay. RESULTS: sP-selectin was significantly increased in patients with MPD (P

Nursing record systems: effects on nursing practice and health care outcomes.

BACKGROUND: A nursing record system is the record of care planned and/or given to individual patients/clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice. OBJECTIVES: To assess the effects of nursing record systems on nursing practice and patient outcomes. SEARCH STRATEGY: We searched The Cochrane Library, the EPOC trial register (October 2002), MEDLINE, Cinahl, Sigle, and databases of the Royal College of Nursing, King's Fund, the NHS Centre for Reviews and Dissemination, and the Institute of Electrical Engineers up to August 1999; and OCLC First Search, Department of Health database, NHS Register of Computer Applications and the Health Visitors' Association database up to the end of 1995. We hand searched the Journal of Nursing Administration (1971-1999), Computers in Nursing (1984-1999), Information Technology in Nursing (1989-1999) and reference lists of articles. We also hand searched the major health informatics conference proceedings. We contacted experts in the field of nursing informatics, suppliers of nursing computer systems, and relevant Internet groups. To update the review the Medline, Cinahl, British Nursing Index, Aslib Index to Theses databases were all searched from 1998 to 2002. The Journal of Nursing Administration, Computers in Nursing, Information Technology in Nursing were all hand searched up to 2002. The searches of the other databases and grey literature included in the original review, were not updated (except for Health Care Computing Conference and Med Info) as the original searches produced little relevant material. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series comparing one kind of nursing record system with another, in hospital, community or primary care settings. The participants were qualified nurses, students or health care assistants working under the direction of a qualified nurse and patients receiving care recorded and/or planned using nursing record systems. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Eight trials involving 1497 people were included. In three studies of client held records, there were no overall positive or negative effects, although some administrative benefits through fewer missing notes were suggested. A paediatric pain management sheet study showed a positive effect on the children's pain intensity. A computerised nursing care planning study showed a negative effect on documented nursing care planning, although two other computerised nursing information studies showed an increase in recording but no change in patient outcomes. Care planning took longer with these computerised systems, but the numbers of patients and nurses included in these studies was small. A controlled before-and-after study of two paper nursing record systems showed improvement in meeting documentation standards. REVIEWER'S CONCLUSIONS: No evidence was found of effects on practice attributable to changes in record systems. Although there is a paucity of studies of sufficient methodological rigour to yield reliable results in this area, it is clear from the literature that it is possible to set up randomised trials or other quasi-experimental designs needed to produce evidence for practice. The research undertaken so far may have suffered both from methodological problems and faulty hypotheses. Qualitative nursing research to explore the relationship between practice and information use, could be used as a precursor to the design and testing of nursing information systems.

Telemedicine versus face to face patient care: effects on professional practice and health care outcomes.

BACKGROUND: Telemedicine is the use of telecommunications technology for medical diagnosis and patient care. From its beginnings telemedicine has been used in a variety of health care fields, although widespread interest among healthcare providers has only now become apparent with the development of more sophisticated technology. OBJECTIVES: To assess the effects of telemedicine as an alternative to face-to-face patient care. SEARCH STRATEGY: We searched the Effective Practice and Organisation of Care Group's specialised register, The Cochrane Library, MEDLINE (1966-August 1999), EMBASE (to 1996), Cinahl (to August 1999), Inspec (to August 1996), Healthstar (1983-1996), OCLC, Sigle (to 1999), Assia, SCI (1981-1997), SSCI (1981-1997), DHSS-Data. We hand searched the Journal of Telemedicine and Telecare (1995-1999), Telemedicine Journal (1995-1999) and reference lists of articles. We also hand searched conference proceedings and contacted experts in countries identified as having an interest in telemedicine. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series comparing telemedicine with face-to-face patient care. The participants were qualified health professionals and patients receiving care through telemedicine. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Seven trials involving more than 800 people were included. One trial was concerned with telemedicine in the emergency department, one with video-consultations between primary health care and the hospital outpatients department, and the remainder were concerned with the provision of home care or patient self-monitoring of chronic disease. The studies appeared to be well conducted, although patient numbers were small in all but one. Although none of the studies showed any detrimental effects from the interventions, neither did they show unequivocal benefits and the findings did not constitute evidence of the safety of telemedicine. None of the studies included formal economic analysis. All the technological aspects of the interventions appear to have been reliable, and to have been well accepted by patients. REVIEWER'S CONCLUSIONS: Establishing systems for patient care using telecommunications technologies is feasible, but there is little evidence of clinical benefits. The studies provided variable and inconclusive results for other outcomes such as psychological measures, and no analysable data about the cost effectiveness of telemedicine systems. The review demonstrates the need for further research and the fact that it is feasible to carry out randomised trials of telemedicine applications. Policy makers should be cautious about recommending increased use and investment in unevaluated technologies.

Nursing record systems: effects on nursing practice and health care outcomes.

BACKGROUND: A nursing record system is the record of care planned and/or given to individual patients/clients by qualified nurses or other caregivers under the direction of a qualified nurse. Nursing record systems may be an effective way of influencing nurse practice. OBJECTIVES: To assess the effects of nursing record systems on nursing practice and patient outcomes. SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE, Cinahl, Sigle, and databases of the Royal College of Nursing, King's Fund, the NHS Centre for Reviews and Dissemination, and the Institute of Electrical Engineers up to August 1999; and OCLC First Search, Department of Health database, NHS Register of Computer Applications and the Health Visitors' Association database up to the end of 1995. We hand searched the Journal of Nursing Administration (1971-1999), Computers in Nursing (1984-1999), Information Technology in Nursing (1989-1999) and reference lists of articles. We also hand searched the major health informatics conference proceedings. We contacted experts in the field of nursing informatics, suppliers of nursing computer systems, and relevant Internet groups. SELECTION CRITERIA: Randomised trials, controlled before and after studies and interrupted time series comparing one kind of nursing record system with another, in hospital, community or primary care settings. The participants were qualified nurses, students or health care assistants working under the direction of a qualified nurse and patients receiving care recorded and/or planned using nursing record systems. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. MAIN RESULTS: Six trials involving 1407 people were included. In three studies of client held records, there were no overall positive or negative effects, although some administrative benefits through fewer missing notes were suggested. A paediatric pain management sheet study showed a positive effect on the children's pain intensity. A computerised nursing care planning study showed a negative effect on documented nursing care planning. A controlled before-and-after study of two paper nursing record systems showed improvement in meeting documentation standards. REVIEWER'S CONCLUSIONS: No evidence was found of effects on practice attributable to changes in record systems. Although there is a paucity of studies of sufficient methodological rigour to yield reliable results in this area, it is clear from the literature that it is possible to set up randomised trials or other quasi-experimental designs needed to produce evidence for practice. The research undertaken so far may have suffered both from methodological problems and faulty hypotheses.

A vision-based three-dimensional capture system for maxillofacial assessment and surgical planning.

We describe a vision-based three-dimensional facial data capture system designed for the planning of maxillofacial operations. We describe the system requirements and outline the methods used to develop a complete three-dimensional facial capture system. Our approach is based upon imaging the face using two stereo-pair sets of cameras. Scale-space-based stereo-matching is then used to recover correspondences between each of the captured stereo-pairs. Photogrammetric routines based on adjustment of bundles are used off-line to calibrate the system by imaging a single object that references all cameras to the same co-ordinate frame. This calibration scheme allows us to convert stereo correspondences to world points for each pair of cameras without the need for any subsequent fusion of data. Initial results show that we are able to capture key facial landmarks to within 0.5 mm.

Assessing the impact of information on evidence-based nursing practice: the EVINCE (Establishing the Value of Information to Nursing Continuing Education) project.

One of the aims of the EVINCE study (Establishing the Value of Information to Nursing Continuing Education) was to assess the impact of information obtained from information and library services about nursing knowledge, competencies, and practice. Survey methods included a critical incident type survey of the patterns of information need and use among a random sample of more than 200 nursing, midwifery, and health visiting staff at five sites and a survey of 776 searches and requests presented to 13 different information services. Questionnaire surveys were followed by selected interviews. Results indicated that information seeking in practice was often prompted by a combination of purposes, with 41 percent of information-seeking incidents involving patient care purposes combined with informal or formal education. The profile of information requests seen by the information service differed, there being more emphasis on formal education and research. Nursing professionals value highly the information obtained from information and library services, and information that helps in evidence-based practice is a priority. Information skills are varied, suggesting that much support for critical appraisal is necessary.

EVINCE: The value of information in developing nursing knowledge and competence.

The aims of the EVINCE research project included examination of the impact of information on the clinical knowledge and practice of nurses, midwives and health visitors. EVINCE (Establishing the Value of Information to Nursing Continuing Education) was funded by the British Library R&D Department for 1 year, from 1 November 1995 to 31 October 1996. The methods employed (based on those used in the Value project) included a critical incident type study to establish patterns of information need and use among a random sample of nursing professionals. The nature of the impact of information obtained on present and future competencies was assessed from a survey of the searches and requests presented to library and information services. Nurses, midwives and health visitors did value the information (96% of respondents agreed that there was, or would be an effect on future practice through enhanced competence in one or more areas). The impact findings can be used to guide a more precise assessment of information needs.

A three-dimensional imaging system for archiving dental study casts: a preliminary report.

Dental study casts form an essential part of patient records for both diagnostic and medicolegal purposes. Storage of study casts poses major problems because of inconvenience and cost of mass storage. Various methods for recording and storage of study casts are discussed. A new biostereometric technique for digitally recording and storing dental casts, and using the recent advances in stereophotogrammetry, is presented. Archiving dental casts in a digital format would reduce problems of mass storage and provide new benefits such as duplication of casts and use in clinical and research studies.

Evaluating methodologies for assessing the value of information: sifting the evidence.

The article evaluates methodologies for studying the clinical benefits of information provision and use, particularly the impact on clinical decision making (and hence on patient care). The problems of replication of research are discussed, and the ways in which the Value Project consolidated and extended previous studies are considered. Comparisons among studies demonstrate that some of the impact findings are qualitatively and quantitatively similar, but there are also some contradictory findings. Methodological variations and differences in health care cultures account for some of the differences. Implications for the reliability and validity of these methods for assessing the value of information to clinicians are considered.

Comparing and using assessments of the value of information to clinical decision-making.

This paper discusses the Value project, which assessed the value to clinical decision-making of information supplied by National Health Service (NHS) library and information services. The project not only showed how health libraries in the United Kingdom help clinicians in decision-making but also provided quality assurance guidelines for these libraries to help make their information services more effective. The paper reviews methods and results used in previous studies of the value of health libraries, noting that methodological differences appear to affect the results. The paper also discusses aspects of user involvement, categories of clinical decision-making, the value of information to present and future clinical decisions, and the combination of quantitative and qualitative assessments of value, as applied to the Value project and the studies reviewed. The Value project also demonstrated that the value placed on information depends in part on the career stage of the physician. The paper outlines the structure of the quality assurance tool kit, which is based on the findings and methods used in the Value project.