Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis.

BACKGROUND: Vital signs monitoring is an old hospital practice for patient safety but evaluation of its effectiveness is not widespread. We aimed to identify strategies to improve intermittent or continuous vital signs monitoring in general wards; and their effectiveness in preventing adverse events on general hospital wards. METHODS: Publications searched between 1980 and June 2014 in five databases. Main outcome measures were in-hospital death, cardiac arrest, intensive care unit (ICU) transfers, length of stay, identification of physiological deterioration and activation of rapid response systems. RESULTS: Twenty-two studies assessing the effect of continuous (9) or intermittent monitoring (13) and reporting outcomes on 203,407 patients in-hospital wards across 13 countries were included in this review. Both monitoring practices led to early identification of patient deterioration, increased rapid response activations and improvements in timeliness or completeness of vital signs documentation. Innovative intermittent monitoring approaches are associated with modest reduction in in-hospital mortality over intermittent vital signs monitoring in 'usual care'. However, there was no evidence of significant reduction in ICU transfers or other adverse events with either intermittent or continuous monitoring. CONCLUSIONS: This review of heterogeneous monitoring approaches found no conclusive confirmation of improvements in prevention of cardiac arrest, reduction in length of hospital stay, or prevention of other neurological or cardiovascular adverse events. The evidence found to date is insufficient to recommend continuous vital signs monitoring in general wards as routine practice. Future evaluations of effectiveness need to be undertaken with more rigorous methods and homogeneous outcome measurements.

Non-beneficial treatments in hospital at the end of life: a systematic review on extent of the problem.

PURPOSE: To investigate the extent of objective 'non-beneficial treatments (NBTs)' (too much) anytime in the last 6 months of life in routine hospital care. DATA SOURCES: English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995-April 2015). STUDY SELECTION: All study types assessing objective dimensions of non-beneficial medical or surgical diagnostic, therapeutic or non-palliative procedures administered to older adults at the end of life (EOL). DATA EXTRACTION: A 13-item quality score estimated independently by two authors. RESULTS OF DATA SYNTHESIS: Evidence from 38 studies indicates that on average 33-38% of patients near the EOL received NBTs. Mean prevalence of resuscitation attempts for advanced stage patients was 28% (range 11-90%). Mean death in intensive care unit (ICU) was 42% (range 11-90%); and mean death rate in a hospital ward was 44.5% (range 29-60%). Mean prevalence of active measures including dialysis, radiotherapy, transfusions and life support treatment to terminal patient was 7-77% (mean 30%). Non-beneficial administration of antibiotics, cardiovascular, digestive and endocrine treatments to dying patients occurred in 11-75% (mean 38%). Non-beneficial tests were performed on 33-50% of patients with do-not-resuscitate orders. From meta-analyses, the pooled prevalence of non-beneficial ICU admission was 10% (95% CI 0-33%); for chemotherapy in the last six weeks of life was 33% (95% CI 24-41%). CONCLUSION: This review has confirmed widespread use of NBTs at the EOL in acute hospitals. While a certain level of NBT is inevitable, its extent, variation and justification need further scrutiny.

Common epitope in human immunodeficiency virus (HIV) I-GP41 and HLA class II elicits immunosuppressive autoantibodies capable of contributing to immune dysfunction in HIV I-infected individuals.

We previously reported the identification of highly conserved homologous regions located in the carboxy terminus of the HIV I gp41-envelope (aa 837-844), and the amino-terminal of the beta chain of all human HLA class II antigens (aa 19-25). Murine monoclonal antibodies, raised against synthetic peptides from these homologous regions, bound not only to the isolated peptides, but also to the native gp160 and class II molecules. In this study one-third of sera from HIV I-infected individuals, at different disease stages, were found to react with both the gp41 and class II-derived peptides. These sera also reacted with "native" HLA class II molecules. The potential affects of such autoantibodies on normal immune functions were examined. It was found that in the presence of class II-cross-reactive (but not control) sera, the proliferative responses of normal CD4+ T cells to tetanus toxoid and allogeneic stimuli were markedly decreased. In addition, these sera could eliminate class II-bearing cells by antibody dependent cellular cytotoxicity. Similar affects were seen with affinity-purified IgG antibodies from patients' sera. Thus, the "molecular mimicry" between HIV I and HLA class II antigens, may lead to the generation of autoantibodies in HIV I-infected individuals that may contribute to the early functional impairment of CD4+ T cell observed in many HIV I-infected individuals.

Epidemiology of porcine non-specific colitis on Scottish farms.

The objective of this study was to investigate epidemiological risk factors for porcine non-specific colitis (NSC). Forty-seven Scottish pig farms, with and without a clinical history of diarrhoea during the growing period (15-40 kg), were selected. The study included farm visits, clinical inspection of pigs, completion of farm management questionnaires, pathological tests into the cause of the diarrhoea and analysis of the non-starch polysaccharide (NSP) content of feeds. The results from 17 farms designated as NSC and 10 control farms suggest dietary associations with NSC. Farms with NSC fed diets with significantly higher levels of NSPs, especially containing the sugars glucose, arabinose and xylose. Few management factors were identified, although the high prevalence of infectious colitis reduced the power of the study.

A systems science perspective on the capacity for change in public hospitals.

Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the "3 + 3 Decision Framework" proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.

Proceedings of the 12th International Conference on Rapid Response Systems and Medical Emergency Teams.

Rapid Response Teams (RRTs) have been introduced into hospitals worldwide in an effort to improve the outcomes of deteriorating hospitalised patients. Recently, there has been increased awareness of the need to develop systems other than RRTs for deteriorating patients. In May 2016, the 12th International Conference on Rapid Response Systems and Medical Emergency Teams was held in Melbourne. This represented a collaboration between the newly constituted International Society for Rapid Response Systems (iSRRS) and the Australian and New Zealand Intensive Care Society. The conference program included broad ranging presentations related to general clinical deterioration in the acute care setting, as well as deterioration in the emergency department, during pregnancy, in the paediatric setting, and deterioration in mental health status. This article briefly summarises the key features of the conference, links to presentations, and the 18 abstracts of the accepted free papers.

Vital signs monitoring and nurse-patient interaction: A qualitative observational study of hospital practice.

BACKGROUND: High profile safety failures have demonstrated that recognising early warning signs of clinical and physiological deterioration can prevent or reduce harm resulting from serious adverse events. Early warning scoring systems are now routinely used in many places to detect and escalate deteriorating patients. Timely and accurate vital signs monitoring are critical for ensuring patient safety through providing data for early warning scoring systems, but little is known about current monitoring practices. OBJECTIVE: To establish a profile of nurses' vital signs monitoring practices, related dialogue, and adherence to health service protocol in New South Wales, Australia. METHODS: Direct observations of nurses' working practices were conducted in two wards. The observations focused on times of the day when vital signs were generally measured. Patient interactions were recorded if occurring any time during the observation periods. Participants (n=42) included nursing staff on one chronic disease medical and one acute surgical ward in a large urban teaching hospital in New South Wales. RESULTS: We observed 441 patient interactions. Measurement of vital signs occurred in 52% of interactions. The minimum five vital signs measures required by New South Wales Health policy were taken in only 6-21% of instances of vital signs monitoring. Vital signs were documented immediately on 93% of vitals-taking occasions and documented according to the policy in the patient's chart on 89% of these occasions. Nurse-patient interactions were initiated for the purpose of taking vital signs in 49% of interactions, with nurse-patient discourse observed during 88% of all interactions. Nurse-patient dialogue led to additional care being provided to patients in 12% of interactions. CONCLUSION: The selection of appropriate vital signs measured and responses to these appears to rely on nurses' clinical judgement or time availability rather than on policy-mandated frequency. The prevalence of incomplete sets of vital signs may limit identification of deteriorating patients. The findings from this study present an important baseline profile against which to evaluate the impact of introducing continuous monitoring approaches on current hospital practice.

The response of human dermal microvascular endothelial cells to hypoxia.

Dermal microvascular endothelial cells (DMEC) exposed to hypoxic conditions show a rapid induction of several proteins that do not increase in other cell types placed in a similar environment. These DMEC proteins differ from the well-characterized stress proteins that have been observed in a wide variety of cultured cell types. The DMEC proteins are induced rapidly, within 2-4 h, and are expressed transiently. They include a group of acidic proteins (pI approximately 5-5.2) with molecular weights in the range 100,000-120,000 and at least one glycoprotein (pI 5.1, M(r) 57,000) that is probably expressed on the cell surface. In some primary DMEC cell strains, this response is accompanied by a transient overall increase in protein synthesis. The oxygen-regulated proteins (ORP) that are induced in most other cell types under hypoxic conditions show little variation in their rate of synthesis in DMEC within the first 24 h. The response of DMEC differs from that of umbilical vein endothelial cells (UVEC) and from spindle-shaped cells derived from DMEC, that show a response to hypoxia that is similar to most other cell types. The changes seen in DMEC proteins take place in the same time scale as ischemia-reperfusion injury and may reflect the specialized change of functions of the microvasculature observed under conditions of hypoxic stress in vivo.

The P2X7 ATP receptor in the kidney: a matter of life or death?

P2X7 is an intriguing membrane receptor for the extracellular nucleotide ATP, which functions as a ligand-gated ion channel; it can activate cell membrane permeabilization and also has a wide range of downstream signaling pathways, including mediation of inflammatory responses and modulation of cell turnover. Despite recent identification of P2X7 receptor protein in the renal tract, the biological and potential pathological functions of this receptor and its signaling cascades in the kidney are not yet fully understood. P2X7 receptor protein is expressed in normal kidney development, predominantly in the condensing mesenchyme, and later in the maturing and adult derivatives of the ureteric bud. Glomerular expression of the molecule is scarce in normal kidney, but is upregulated in chronic and inflammatory conditions, suggesting a role in the inflammatory response or in repair and remodeling in these settings. P2X7 receptor expression in the adult collecting ducts of murine kidney, as well as the collecting duct cysts in autosomal recessive polycystic kidney disease, has been described and agonists of the receptor can modulate the development of renal cysts in an in vitro model of cyst formation derived from the cpk/cpk mouse. Further investigation of the function of the P2X7 receptor in normal and abnormal kidneys might lead to novel therapeutic targets in a wide range of renal diseases.

Reliability of intra-abdominal pressure measurements using the modified Kron technique.

OBJECTIVES: Assessment of intra-abdominal pressure (IAP) and the likelihood of abdominal compartment syndrome using valid and reliable measures is an important tool in the assessment of critically ill patients. The current method of relying on a single IAP per measurement period to determine patient clinical status raises the question: is a single intermittent IAP measurement an accurate indicator of clinical status or should more than one measurement be taken per measurement period? METHODS: This study sought to assess the reliability of IAP measurements. Measurements were taken using the modified Kron technique. A total of two transvesical intra-abdominal pressure measurements were undertaken per patient using a standardized protocol. Recordings were taken at intervals of 5 minutes. RESULTS: The majority of participants (58%) were surgical patients. Thirty-two were males and the mean age was 58 years (SD: 16·7 years). The concordance correlation coefficient between the two measurements was 0·95. Both the scatter and Bland-Altman plots demonstrate that the comparisons of two measurements are highly reproducible. CONCLUSION: The findings of this study suggest that conducting two IAP measurements on single patient produce comparable results; therefore, there appears to be no advantage in doing two IAP measurements on a single patient. The measurement of an IAP requires the implementation of a standardized protocol and competent and credentialed assessors trained in the procedure.

Findings of the first ANZICS conference on the role of intensive care in Rapid Response Teams.

Rapid Response Teams (RRTs) are specialised teams introduced into hospitals to improve the outcomes of deteriorating ward patients. Although Rapid Response Systems (RRSs) were developed by the intensive care unit (ICU) community, there is variability in their delivery, and consultant involvement, supervision and leadership appears to be relatively infrequent. In July 2014, the Australian and New Zealand Intensive Care Society (ANZICS) convened the first conference on the role of intensive care medicine in RRTs in Australia and New Zealand. The conference explored RRSs in the broader role of patient safety, resourcing and staffing of RRTs, effect on ICU workload, different RRT models, the outcomes of RRT patients and original research projects in the area of RRSs. Issues around education and training of both ICU registrars and nurses were examined, and the role of team training explored. Measures to assess the effectiveness of the RRS and RRT at the level of health system and hospital, team performance and team effectiveness were discussed, and the need to develop a bi-national ANZICS RRT patient database was presented. Strategies to prevent patient deterioration in the 'pre-RRT' period were discussed, including education of ward nurses and doctors, as well as an overarching governance structure. The role of the ICU in deteriorating ward patients was debated and an integrated model of acute care presented. This article summarises the findings of the conference and presents recommendations on the role of intensive care medicine in RRTs in Australia and New Zealand.

Correlation between kinetics of soluble CD4 interactions with HIV-1-Env-expressing cells and inhibition of syncytia formation: implications for mechanisms of cell fusion and therapy for AIDS.

OBJECTIVES: To study the kinetics of the interactions between soluble (s) CD4 and HIV-1-Env-expressing cells in relation to subsequent events leading to cell fusion and inhibition of syncytia formation. DESIGN: Vaccinia-HIV-1 (Env)-infected CD4- T-cells were used to study the kinetics of sCD4-gp120/41 interactions and syncytia formation (with CD4+ T-cells) under identical conditions. METHODS: sCD4 association and dissociation rates for HIV-1-Env-expressing cells, and quantification of sCD4-induced gp120 shedding was determined by a quantitative flow cytometry assay. Syncytia inhibition was measured in the continuous presence of sCD4, or after washing of HIV-1-Env-expressing cells following pre-incubation with sCD4. RESULTS: The kinetics of syncytia inhibition correlated with sCD4 binding when sCD4 was maintained during the culture. When Env-expressing cells, which had been pre-incubated with sCD4, were washed to remove unbound sCD4, no syncytia formation inhibition was observed, even following sCD4-induced shedding of greater than 50% of surface gp120 molecules. CONCLUSIONS: The lack of syncytia inhibition seen after removal of unbound sCD4, even after pre-incubation of cells under saturation and gp120 shedding conditions, indicated that sufficient numbers of fusogenic molecules remained on the sCD4-treated cells. In addition, fast dissociation of pre-bound sCD4 occurred in culture. These results are important for understanding HIV-1-Env-mediated cell fusion and AIDS therapy.

Production of antibodies against murine class II antigens using unconjugated synthetic peptides of the beta chain region 63-78.

synthetic peptides corresponding to residues 63-78 of the first domain of the beta chain of murine I-A/I-E class II antigens were used in the unconjugated rather than the traditional protein-conjugated form to immunize (129J X B6)F1 mice. The sequences made represented the four haplotypes; Ak beta, Ad beta, Abm-12 beta and Ed beta. These sequences were selected on the basis of computer algorithms used to predict surface accessibility and main-chain flexibility profiles, and by reported hypervariability and site-directed mutagenesis experiments of these regions. Factors such as the use of complete Freund's adjuvant, a continuous immunization regime, and the sex of the mice used were found to influence the amount of anti-peptide antibody produced when unconjugated peptide was used as the immunogen. Antibodies produced were shown by FACS analysis to react with I-A/I-E class II antigens expressed on the lymphocyte surface. These findings indicate that the use of unconjugated synthetic peptides representing sequences of proteins which are in close proximity to disulfide bonds may be an advantage over conventional methods of peptide conjugation to proteins.

Fluid resuscitation in diabetic emergencies--a reappraisal.

The first objective in diabetic ketoacidosis is to restore the circulating volume and improve tissue perfusion. In any form of hypovolaemic shock the most efficient way of restoring circulating volume is to be use colloid solutions rather than crystalloids. At least three times the amount of crystalloid must be used to achieve the same effect. The historical reason for using isotonic saline in diabetic ketoacidosis is related not to its similarity to the fluid lost, but to its supposed efficiency in correcting the circulating volume. Excess crystalloid expands the interstitial space which results in pulmonary oedema, peripheral oedema and possibly cerebral oedema. Although currently difficult to define precisely in their more subtle forms, they all produce adverse pathophysiological effects. The fluid loss in diabetic ketoacidosis is equivalent to "half-normal" saline, a relatively hypotonic solution. As well as causing extensive oedema, resuscitation with isotonic saline can increase serum sodium and osmolarity while not providing free water to replace the intracellular losses.

Continuous intragastric pH measurement in the critically ill and treatment with parenteral ranitidine.

Continuous measurement of gastric pH using a flexible pH electrode attached to a NG tube was performed in nineteen critically ill patients. The gastric pH readings correlated well with hourly intermittent pH values using indicator strips. Hypotension, physiotherapy and septicaemia was consistently associated with falls in gastric pH. A continuous infusion of Ranitidine, a H2-receptor antagonist, was titrated against the continuously measured gastric pH in an attempt to keep it above a pH of 4. This was successfully achieved in sixteen of the nineteen patients using widely variable doses of Ranitidine. The three patients whose gastric pH remained low all had severe septicaemia.

Mediastinal emphysema simulating acute pericarditis.

A case of extensive subcutaneous emphysema, retropneumoperitoneum and mediastinal emphysema is described. The mediastinal emphysema was associated with signs and symptoms of pericardial tamponade, and previously undocumented ECG changes, consistent with acute pericarditis, were noted.

Quality of life outcomes after intensive care. Comparison with a community group.

OBJECTIVE: Compare the health related quality of life of intensive care patients with a community sample. DESIGN: Self-completed questionnaire posted to a consecutive sample of 238 patients 16 months after discharge from an intensive care unit (ICU) and to a random community sample (n = 242). SETTING: The Liverpool Hospital is the main referral and teaching hospital in a community of 620,000 people. It has a ten-bed general ICU. PATIENTS AND PARTICIPANTS: All patients admitted to the ICU over 8 months with a length of stay > or = 24 h and a sample drawn from the community telephone directory. MEASUREMENTS AND MAIN RESULTS: The self completed questionnaire contained physical and psychosocial health and quality of life (QOL) scales. Analysis of variance indicated that ICU patients were more physically ill and anxiously depressed than the community sample. Sixty-three per cent of patients had not attained full health, were functionally impaired and had a poorer QOL than those patients who had returned to full health and the community. Psychosocial health (apart from anxious depression) was related to the level of perceived physical health rather than to whether or not they had been admitted to the ICU. Those subjects not in full health had poorer interpersonal relationships, less positive attitudes about life, more anxious depression and more suicidal depression. CONCLUSIONS: ICU patients following discharge have worse perceived health and more anxiety than others in the community. Sixty-three per cent of patients had a poorer QOL and functional health than those who returned to full health and those in the community.

Intra-abdominal pressure measurement using a modified nasogastric tube: description and validation of a new technique.

OBJECTIVE: This study assessed the accuracy of an intragastric method of measuring intra-abdominal pressure (IAP). DESIGN: Prospective sequential study with simultaneous paired measurement of gastric and urinary bladder pressures. SETTING: Operating theatre, University Teaching Hospital. PATIENTS: 9 patients undergoing laparoscopic cholecystectomy were studied. INTERVENTIONS: Intraperitoneal pressures were monitored during peritoneal insufflation at laparoscopy up to a pressure of 20 mmHg. MEASUREMENTS AND RESULTS: Intra-abdominal pressure measurements were recorded simultaneously using a gastric balloon and urinary catheter. Gastric pressure may be up to 4 mmHg higher or 3 mmHg lower than urinary bladder pressure. CONCLUSIONS: Intra-abdominal pressure can be measured easily in this new fashion, allowing a continuous pressure trend to be obtained without interfering with urinary output estimation.