Promoting speaking-up behaviours among nurses working in the care for older people: A scoping review.

AIM: To explore interventions employed to foster speaking-up behaviours of registered nurses (RNs) working in the care of older people. DESIGN: Scoping review. METHODS: The updated Joann Briggs Institute scoping review methodological guidelines were followed. DATA SOURCES: CINAHL, PubMed, PsycINFO, and Scopus were searched. RESULTS: A total of 1691 titles and abstracts were screened, resulting in 11 articles that met the inclusion criteria. Analysis focused upon intervention types, methodologies, speaking up strategies, barriers and effectiveness. Education was the most used intervention. CONCLUSION: There is a lack of published research on successful interventions to promote speaking-up behaviours in the care of older people, particularly relating to poor care practices. Evidence of speaking-up interventions in the residential aged care setting is absent. This highlights the need to develop strategies to support the RN to lead and enable others to raise care concerns. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Developing strategies that enable staff, care recipients and their families to speak up about care concerns is a vital future area for nursing practice development. Nursing leadership of such strategies is central to improving the quality of care for older people, particularly those living in residential aged care. IMPACT: Older people receiving care should feel respected and be treated humanely. Evidence suggests this is often not the case. This review found a paucity of interventions to promote speaking-up about poor care practices among RNs working in the care of older people. Future research needs to address this, to empower RNs and improve the care afforded to older people. REPORTING METHOD: The PRISMA-ScR (Tricco et al., Annals of Internal Medicine, 169, 467-473, 2018) were adhered to throughout this scoping review. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution in this review.

Specialist early parenting intervention: Effectiveness of a novel nurse-led approach for rural families.

BACKGROUND: Rural Australian families report lower access to specialist early parenting services than urban families. To address the early parenting needs of rural families with children aged 0-3, a novel specialist-nursing early parenting service, Tresillian To You, was implemented for five rural communities in New South Wales, Australia. This study aimed to investigate the initial impact and reach of the service. METHODS: Convenience sampling was used to recruit 36 parents who attended the service. Of these, 34 completed structured pre-and-post intervention phone interviews. Additional data were collected from the parent and child health record. Data were imported into SPSS for descriptive and inferential data analysis. FINDINGS: All parent participants were mothers, with a mean age of 31.5 (SD 4.582). Sleep and settling was the primary reason for referral (78%, n = 28). Following service engagement, statistically significant improvements were seen in parent adjustment (95% CI = -1.71, -0.52, p < .001), parent comprehensibility (95% CI = -1.81, -0.42, p = .003), and parent perception of child sleep (95% CI = 16.3, 34.9, p < .001). Families from non-target communities (n = 15) reported a higher level of need at baseline, compared with families from target rural communities (n = 21). Following service engagement, a similar level of benefit was reported between both groups. DISCUSSION: Preliminary evidence suggests that this new service may be an effective method of providing specialist early parenting intervention for families in rural communities. PRACTICE IMPLICATIONS: The provision of effective nurse-led specialist early child and family interventions may help to alleviate early parenting difficulty for rural families, leading to improvements in child and family outcomes.

Under Prepared for Practice: A Qualitative Study of Mental Health Nurse Undergraduate Workforce Preparation in Australia.

Internationally there are both current and looming mental health workforce shortages. Mental health nurses who have received specialist education are a vital component to respond to these challenges. AIM: This qualitative study aimed to better understand the efficacy and product quality of mental health nurse workforce preparation through pre-registration nurse education in Australia. METHOD: To meet this aim 19 educators representing 13 different universities were qualitatively interviewed. RESULTS: Thematic analysis found four themes (1) Graduates are under-prepared for safe mental health nurse practice; (2) Essential mental health nurse capabilities are missing in graduates; (3) Barriers to graduate preparation, and (4) Negative impacts of inadequate graduate preparation. DISCUSSION: Findings from this study suggest future workforce shortages would be best addressed through direct undergraduate entry for mental health nursing Implications for Practice: All nurse undergraduate training needs significantly enhanced mental health theory and placement within the course.

Rising to the challenge: The motivation to champion routine intimate partner violence screening in rural emergency departments.

OBJECTIVE: To understand the motivations of champions who worked to bring about system and practice change that supported routine screening for intimate partner violence (IPV) in two rural emergency departments (EDs). INTRODUCTION: Practice changes are required to achieve routine and effective identification and response to IPV. Nurses play a significant role in affecting such practice change. This paper identifies the motivations of champions in the ED setting who successfully brought about such change. SETTING: The EDs of two Level 5 tertiary hospitals within a rural Local Health District (LHD) of New South Wales, Australia. PARTICIPANTS: Twenty-three individuals who identified as champions and worked to introduce routine IPV screening in two rural hospital EDs. DESIGN: Qualitative longitudinal semi-structured interviews employing a process of constant comparison and an interpretive framework to analyse data thematically. Interviews were carried out between June and August 2017 and again between July and August 2019. RESULTS: Over the period of the study, routine screening was established, and screening rates steadily increased from a low baseline to a significantly higher rate. Three aspects of champion motivation emerged from the analysis: formation of an identity as a champion, making a difference to a significant social justice issue and providing quality and community-relevant care. CONCLUSIONS: This study is the first study to report on champions and their motivation as they supported IPV practice change in the ED. The findings highlight the capacity for innovation in rural health services, with important implications for other settings looking to translate similar programs. Understanding motivating factors may assist in improved utilisation and support for champions. This is vital if champions are to bring about required practice change within their service and ensure the needs of individuals experiencing IPV are effectively met.

Workforce strategies to address children's mental health and behavioural needs in rural, regional and remote areas: A scoping review.

INTRODUCTION: Children living in rural, regional and remote locations experience challenges to receiving services for mental illness and challenging behaviours. Additionally, there is a lack of clarity about the workforce characteristics to address the needs of this population. OBJECTIVE: To scope the literature on the rural, regional and remote child mental health and behavioural workforce and identify barriers and enabling mechanisms to mental health service provision. DESIGN: A scoping review utilising the Joanna Briggs Institute methodology. A database search was undertaken using Medline, CINAHL, PsycINFO, ProQuest and Scopus to identify papers published 2010-2023. Research articles reporting data on mental health workforce characteristics for children aged under 12 years, in rural, regional or remote locations were reviewed for inclusion. FINDINGS: Seven hundred and fifty-four papers were imported into Covidence with 22 studies being retained. Retained studies confirmed that providing services to meet the needs of children's mental health is an international challenge. DISCUSSION: The thematic analysis of the review findings highlighted four workforce strategies to potentially mitigate some of these challenges. These were: (1) The use of telehealth for clinical services and workforce upskilling; (2) Role shifting where non mental health professionals assumed mental health workforce roles; (3) Service structure strategies, and (4) Indigenous and rural cultural factors. CONCLUSION: A range of potential strategies exists to better meet the needs of children with mental health and behavioural issues. Adapting these to specific community contexts through co-design and production may enhance their efficacy.

The Impact of an Online Post-Graduate Interdisciplinary Mental Health Programme on Graduates' Confidence and Practice.

This study aimed to examine the experiences of graduates of online interdisciplinary postgraduate mental health programmes in Australia. The program was delivered in 6-week terms. Seven graduates from diverse backgrounds were interviewed about their experiences with the course and its impact on their practice, confidence, professional identity, views on mental health service users, and their motivation for additional learning. The interviews were recorded and transcribed and underwent thematic content analysis. The graduates reported an increase in confidence and knowledge after completing the course, which led to a change in their views and attitudes towards service users. They appreciated the examination of psychotherapies and motivational interviewing, and applied their newly acquired skills and knowledge in their practice. The course was found to have improved their clinical practice. This study highlights a departure from traditional pedagogical approaches in mental health skill acquisition, as the entire program was delivered online. There is a need for further research to determine who might benefit most from this mode of delivery and to verify the competencies acquired by graduates in real-world situations. Online mental health courses are a feasible option and have been positively received by graduates. To enable graduates to participate in transforming mental health services, systemic change and recognition of their capabilities, particularly those from non-traditional backgrounds, is required. The results of this study suggest the potential for online postgraduate programs to play a significant role in transforming mental health services.

The role of champions in leading domestic violence and abuse practice improvement in health care: A scoping review.

AIM: To describe and synthesize evidence for champions of domestic violence practice improvement in health care and highlight implications for leadership and nurse management. BACKGROUND: Globally, health care leaders have been tasked with improving service responses to domestic violence. Evidencing the role of champions, and how managers may harness champions in improving responses to domestic violence, is an important factor in successfully leading change in this field. EVALUATION: A scoping review was conducted using four electronic databases (Proquest, PubMed, Medline and PsycINFO). KEY ISSUES: Eleven studies were included. Champion characteristics, roles, and factors influencing their impact were distilled. Barriers to the success of champions were identified as were four aspects of the champion role: mentor and expert advice; communication and engagement; strategic advocacy, coordination and project leadership; personal and emotional support. CONCLUSIONS: The review highlighted that champions involved in domestic violence project implementation have unique aspect to their role, along with characteristics reported in the broader champion literature. As an emerging field, there is evidence that domestic violence champions play an important role in mentoring and supporting health care workers to effectively change their practice. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers and leaders need to understand the champion construct and the roles that champions enact to generate domestic violence and abuse system and practice change. Further research is required to provide guidance.

The association between vegetation size and surgical treatment on 6-month mortality in left-sided infective endocarditis.

AIMS: In left-sided infective endocarditis (IE), a large vegetation >10 mm is associated with higher mortality, yet it is unknown whether surgery during the acute phase opposed to medical therapy is associated with improved survival. We assessed the association between surgery and 6-month mortality as related to vegetation size. METHODS AND RESULTS: Patients with definite, left-sided IE (2008-2012) from The International Collaboration on Endocarditis prospective, multinational registry were included. We compared clinical characteristics and 6-month mortality (by Cox regression with inverse propensity of treatment weighting) between patients with vegetation size ≤10 mm vs. >10 mm in maximum length by surgical treatment strategy. A total of 1006 patients with left sided IE were included; 422 with a vegetation size ≤10 mm (median age 66.0 years, 33% women) and 584 (median age 58.4 years, 34% women) patients with a large vegetation >10 mm. Operative risk by STS-IE score was similar between groups. Embolic events occurred in 28.4% vs. 44.3% (P < 0.001), respectively. Patients with a vegetation >10 mm was associated with higher 6-month mortality (25.1% vs. 19.4% for small vegetation, P = 0.035). However, after propensity adjustment, the association with higher mortality persisted only in patients with a large vegetation >10 mm vs. ≤10 mm: hazard ratio (HR) 1.55 (1.27-1.90); but only in patients with large vegetation managed medically [HR 1.86 (1.48-2.34)] rather than surgically [HR 1.01 (0.69-1.49)]. CONCLUSION: Left-sided IE with vegetation size >10 mm was associated with an increased mortality at 6 months in this observational study but was dependent on treatment strategy. For patients with large vegetation undergoing surgical treatment, survival was similar to patients with smaller vegetation size.

Mental health nurse psychotherapists are well situated to improve service shortfalls in Australia: findings from a qualitative study.

OBJECTIVE: This paper reports the capabilities of mental health nurse (MHN) psychotherapists in Australia and their perceptions on how to best utilize their skills. METHOD: An MHN is a registered nurse with recognized specialist qualifications in mental health nursing. One hundred and fifty three MHNs completed an online survey; 12 were interviewed. RESULTS: Three themes were derived from a qualitative analysis of the aggregated data: psychotherapy skills of MHN psychotherapists are under-utilized; these nurses bridge gaps between biomedical and psychosocial service provision; and equitable access to rebates in the primary care sector is an obstacle to enabling access to services. CONCLUSIONS: MHN psychotherapists are a potentially valuable resource to patients in tertiary and primary health care. They offer capacity to increase access to specialist psychotherapy services for complex and high risk groups, while being additionally capable of meeting patients' physical and social needs. Equitable access to current funding streams including Medicare rebates can enable these outcomes.

The impact of caregiving on the health status of regional carers in Australia: Findings from a mixed-method study.

While it is known that informal carers provide the majority of caregiving in Australia, there remains limited understanding of the challenges that regional carers face in their caring role and the impact of the caregiving role on carer well-being. OBJECTIVE: The aim of this study was to better understand the health status of caregivers as the person they care for was entering the National Disability Support Scheme. DESIGN: This is a mixed-methods study. SETTING: The study was undertaken in regional New South Wales, Australia. PARTICIPANTS: Seventy-five carers were enrolled into the study. All lived in regional New South Wales. MAIN OUTCOME MEASURE: The World Health Organization Well-being Index was used for quantitative data collection, and semi-structured interviews were undertaken for the collection of qualitative data. RESULT: Quantitative data indicated that carers from Aboriginal or Torres Strait Islander backgrounds and those from low socio-economic status had significantly lower scores on the well-being index. Two key qualitative categories were evident describing carer's journey to resilience by (a) adjusting to reality predominantly through cognitive reframing strategies and (b) carers accessing external supports. CONCLUSION: The health status of regional carers who are predominantly women is experiencing low levels of well-being. While many of these carers have initiated successful coping responses to the challenges of caring, there is an urgent need to increase the supports available to this population. As the recent National Disability Support Scheme is embedded, it is of importance to monitor if there are improvements in the health status of carers over time.

Achieving therapeutic gains for regional youth with emergent mental health issues through parental family system-based groups: Findings from a qualitative study.

OBJECTIVE: This paper reports findings from a study that sought to better understand the experiences of parents and their children with emergent mental health challenges following the parent's participation in a nurse-led therapeutic group. DESIGN: This was an explorative qualitative study using semi-structured interviews which were then thematically analysed. SETTING: Findings from this single-site study are drawn from regional Australia. PARTICIPANTS: Twenty parents and seven of their children aged between 13 and 24. INTERVENTIONS: Family systems based therapeutic group intervention delivered to the parents of young people attending headspace. MAIN OUTCOME MEASURE: In line with qualitative research approaches, the participants lived experience was the outcome measure. RESULT: Three key themes were found in the data: (a) improved parent-child relationships, (b) understanding and being understood and (c) multi-generational perspectives. CONCLUSION: Regional and remote regions are challenged with comparatively fewer and less diverse services for youth mental health than in urban centres. Findings from this exploratory study highlight that young people can experience therapeutic gains where their parents are the recipients of the intervention. Recommendations from these findings include pursuing further research on the therapeutic gains of parental family system-based groups.

Association between the timing of surgery for complicated, left-sided infective endocarditis and survival.

BACKGROUND: In patients with active infective endocarditis (IE), the relationship between timing of surgery and survival is uncertain. The objective was to evaluate clinical characteristics associated with timing of surgery and the association between surgical timing and 6-month survival in complicated, left-sided IE. METHODS: In a prospective, multicenter, observational registry (The International Collaboration on Endocarditis-PLUS, registry from 2008 to 2012), clinical factors associated with timing of surgery during the index hospitalization were determined among 485 adult patients with definite, complicated, left-sided IE who underwent cardiac surgery during their index hospitalization. The relationship between early surgical intervention (<7 days from admission to surgery center) and outcome after surgery was analyzed. The primary end point of the study was 6-month survival. RESULTS: The median time to surgery from admission to surgical center was 7 (interquartile range 2-15) days. Patients who underwent earlier surgery were more likely transferred to the surgical center (74.2% vs 46.4%, P < .001) and had a lower percentage of preexisting heart failure (before IE diagnosis) (6.0% vs 17.3%, P < .001) but higher rate of acute heart failure (53.2% vs 38.4%, P = .001). Variables independently associated with surgery <7 days from admission were patient transfer, acute heart failure, and nonelective surgical status (C-index = 0.84), but predicted operative risk was not. Cox proportional hazards modeling with inverse probability of treatment weighting found that earlier surgery was associated with a trend toward higher 6-month mortality compared with later surgery (hazard ratio = 1.68, 95% CI 0.97-2.96; P = .065), particularly surgery within 2 days of admission or transfer. Mortality was significantly associated with operative risk and complicated IE, including Staphylococcus aureus infection and presence of abscess. CONCLUSIONS: Earlier surgery in IE is strongly associated with acute heart failure and surgical urgency. After adjustment for operative risk and IE complications, earlier surgery <7 days from admission was associated with a trend toward higher 6-month overall mortality compared with surgery later in the index hospitalization.

Envisioning successful teamwork: An exploratory qualitative study of team processes used by nursing teams in a paediatric hospital unit.

AIMS AND OBJECTIVES: To explore how team processes support nursing teams in hospital units during every day work. BACKGROUND: Due to their close proximity to patients, nurses are central to the process of maintaining patient safety. Globally, changes in models of care delivery by nurses, inclusive of team nursing are being considered. DESIGN AND METHODS: This qualitative study used purposive sampling in a single hospital and participants were nurses employed to work on a paediatric unit. Data were collected using nonparticipant observation. Thematic analysis was used to analyse and code data to create themes. RESULTS: Three clear themes emerged. Theme 1: "We are a close knit team"; Behaviours building a successful team - outlines expectations regarding how members are to behave when establishing, nurturing and managing a team. Theme 2: "Onto it"; Ways of interacting with each other - Identifies the expected pattern of relating within the team which contribute to shared understanding and actions. Theme 3: "No point in second guessing"; Maintaining a global view of the unit - focuses on the processes for monitoring and reporting signals that team performance is on course or breaking down and includes accepting responsibility to lead the team and team members having a widespread sensitivity to what needs to happen. CONCLUSION: Essential to successful teamwork is the interplay and mutuality of team members and team leaders. RELEVANCE TO CLINICAL PRACTICE: Leadership behaviours exhibited in this study provide useful insights to how informal and shared or distributed leadership of teams may be achieved. Without buy-in from team members, teams may not achieve successful desired outcomes. It is not sufficient for teams to rely on current successful outcomes, as they need to be on the look-out for new ways to ensure that they can anticipate possible risks or threats to the team before harm is done.

The use of emotional intelligence capabilities in clinical reasoning and decision-making: A qualitative, exploratory study.

AIMS AND OBJECTIVES: To explore clinical nurses' experiences of using emotional intelligence capabilities during clinical reasoning and decision-making. BACKGROUND: There has been little research exploring whether, or how, nurses employ emotional intelligence (EI) in clinical reasoning and decision-making. DESIGN: Qualitative phase of a larger mixed-methods study. METHODS: Semistructured qualitative interviews with a purposive sample of registered nurses (n = 12) following EI training and coaching. Constructivist thematic analysis was employed to analyse the narrative transcripts. RESULTS: Three themes emerged: the sensibility to engage EI capabilities in clinical contexts, motivation to actively engage with emotions in clinical decision-making and incorporating emotional and technical perspectives in decision-making. CONCLUSION: Continuing to separate cognition and emotion in research, theorising and scholarship on clinical reasoning is counterproductive. RELEVANCE TO CLINICAL PRACTICE: Understanding more about nurses' use of EI has the potential to improve the calibre of decisions, and the safety and quality of care delivered.

Increasing nurses' emotional intelligence with a brief intervention.

BACKGROUND: Emotional intelligence (EI) is associated with a wide range of personal, professional and social benefits with numerous applications evident for nursing education and clinical practice. Despite growing support for increasing the focus on EI in nursing and nurse education, empirical evidence for the effectiveness of training to increase EI is sparse. The aim with this study was to test the effect of a brief EI training program for registered nurses. METHODS: We conducted a cross-site quasi-experimental study measuring nurses' EI pre- (T1) and three months post- (T2) EI training with a matched (untrained) control group (total n = 60). EI training consisted of a five-hour workshop, a 30-minute one-on-one feedback session, and an individualised follow-up reminder sent via SMS. RESULTS: Training resulted in a significant increase in EI scores over baseline levels for the trained group while scores for the control group did not increase. CONCLUSION: This pilot study has provided clear evidence of the applicability and efficacy of a low-cost training intervention for nursing staff in a real world setting.

Fully automated 5-plex fluorescent immunohistochemistry with tyramide signal amplification and same species antibodies.

The ability to simultaneously visualize the presence, abundance, location and functional state of many targets in cells and tissues has been described as a true next-generation approach in immunohistochemistry (IHC). A typical requirement for multiplex IHC (mIHC) is the use of different animal species for each primary (1°Ab) and secondary (2°Ab) antibody pair. Although 1°Abs from different species have been used with differently labeled species-specific 2°Abs, quite often the appropriate combination of antibodies is not available. More recently, sequential detection of multiple antigens using 1°Abs from the same species used a microwaving treatment between successive antigen detection cycles to elute previously bound 1°Ab/2°Ab complex and therefore to prevent the cross-reactivity of anti-species 2°Abs used in subsequent detection cycles. We present here a fully automated 1°Ab/2°Ab complex heat deactivation (HD) method on Ventana's BenchMark ULTRA slide stainer. This method is applied to detection using fluorophore-conjugated tyramide deposited on the tissue and takes advantage of the strong covalent bonding of the detection substrate to the tissue, preventing its elution in the HD process. The HD process was characterized for (1) effectiveness in preventing Ab cross-reactivity, (2) impact on the epitopes and (3) impact on the fluorophores. An automated 5-plex fluorescent IHC assay was further developed using the HD method and rabbit 1°Abs for CD3, CD8, CD20, CD68 and FoxP3 immune biomarkers in human tissue specimens. The fluorophores were carefully chosen and the narrow-band filters were designed to allow visualization of the staining under fluorescent microscope with minimal bleed through. The automated 5-plex fluorescent IHC assay achieved staining results comparable to the respective single-plex chromogenic IHC assays. This technology enables automated mIHC using unmodified 1°Abs from same species and the corresponding anti-species 2°Ab on a clinically established automated platform to ensure staining quality, reliability and reproducibility.

The role of emotion in clinical decision making: an integrative literature review.

BACKGROUND: Traditionally, clinical decision making has been perceived as a purely rational and cognitive process. Recently, a number of authors have linked emotional intelligence (EI) to clinical decision making (CDM) and calls have been made for an increased focus on EI skills for clinicians. The objective of this integrative literature review was to identify and synthesise the empirical evidence for a role of emotion in CDM. METHODS: A systematic search of the bibliographic databases PubMed, PsychINFO, and CINAHL (EBSCO) was conducted to identify empirical studies of clinician populations. Search terms were focused to identify studies reporting clinician emotion OR clinician emotional intelligence OR emotional competence AND clinical decision making OR clinical reasoning. RESULTS: Twenty three papers were retained for synthesis. These represented empirical work from qualitative, quantitative, and mixed-methods approaches and comprised work with a focus on experienced emotion and on skills associated with emotional intelligence. The studies examined nurses (10), physicians (7), occupational therapists (1), physiotherapists (1), mixed clinician samples (3), and unspecified infectious disease experts (1). We identified two main themes in the context of clinical decision making: the subjective experience of emotion; and, the application of emotion and cognition in CDM. Sub-themes under the subjective experience of emotion were: emotional response to contextual pressures; emotional responses to others; and, intentional exclusion of emotion from CDM. Under the application of emotion and cognition in CDM, sub-themes were: compassionate emotional labour - responsiveness to patient emotion within CDM; interdisciplinary tension regarding the significance and meaning of emotion in CDM; and, emotion and moral judgement. CONCLUSIONS: Clinicians' experienced emotions can and do affect clinical decision making, although acknowledgement of that is far from universal. Importantly, this occurs in the in the absence of a clear theoretical framework and educational preparation may not reflect the importance of emotional competence to effective CDM.

Determining the optimal cut-off scores for the Workplace Bullying Inventory.

BACKGROUND: Over the past two decades, there has been considerable research into workplace bullying. One area that remains poorly developed is a tool with the capacity to accurately differentiate between exposed and unexposed employees. AIM: To determine optimal cut-off scores for the Workplace Bullying Inventory (WBI) that accurately classify cases of exposure to workplace bullying. DISCUSSION: Secondary analysis of data collected from Australian public sector employees ( n =2,197) was conducted. Receiver operator characteristic (ROC) curve analysis was used with a minimum sensitivity of 80%, to determine those scores on the WBI that corresponded with the highest accuracy of the tool to distinguish cases from non-cases. The results suggest using a cut score of 29 from the total score on the WBI (possible range: 18-90). When compared to a sum-score from a single dichotomous self-report variable, the cut-off score estimated a more conservative bullying rate. The single-item rate was potentially inflated by misconceptions about what constitutes bullying in the workplace. CONCLUSION: Employing validated cut-off points for exposure provides an objective threshold for establishing exposure to workplace bullying. The results of the analysis provide a more rigorous approach to quantifying exposure to workplace bullying, in a tool that has been designed and tested in the nursing workforce. This is the first such tool with empirically-derived, discriminant accuracy. IMPLICATIONS FOR PRACTICE: It is common for nurse researchers to employ sum-scores from single items to identify exposure to workplace bullying. By providing reliable cut-off points for exposure, this study offers standardised, diagnostic accuracy for researchers, clinicians and managers.

Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis.

BACKGROUND: Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined. METHODS AND RESULTS: The International Collaboration on Endocarditis-PLUS (ICE-PLUS) is a prospective cohort of consecutively enrolled patients with definite IE from 29 centers in 16 countries. We included patients from ICE-PLUS with definite left-sided, non-cardiac device-related IE who were enrolled between September 1, 2008, and December 31, 2012. A total of 1296 patients with left-sided IE were included. Surgical treatment was performed in 57% of the overall cohort and in 76% of patients with a surgical indication. Reasons for nonsurgical treatment included poor prognosis (33.7%), hemodynamic instability (19.8%), death before surgery (23.3%), stroke (22.7%), and sepsis (21%). Among patients with a surgical indication, surgical treatment was independently associated with the presence of severe aortic regurgitation, abscess, embolization before surgical treatment, and transfer from an outside hospital. Variables associated with nonsurgical treatment were a history of moderate/severe liver disease, stroke before surgical decision, and Staphyloccus aureus etiology. The integration of surgical indication, Society of Thoracic Surgeons IE score, and use of surgery was associated with 6-month survival in IE. CONCLUSIONS: Surgical decision making in IE is largely consistent with established guidelines, although nearly one quarter of patients with surgical indications do not undergo surgery. Operative risk assessment by Society of Thoracic Surgeons IE score provides prognostic information for survival beyond the operative period. S aureus IE was significantly associated with nonsurgical management.

Transapical JenaValve in a patient with mechanical mitral valve prosthesis.

We report the first case of transcatheter aortic valve replacement implantation using JenaValve™ in a patient with mechanical mitral valve prosthesis. We believe that the design features of this valve may be particularly suited for use in this setting.