A review of the antimicrobial activity of thermodynamically stable microemulsions.

Microemulsions are thermodynamically stable, transparent, isotropic mixtures of oil, water and surfactant (and sometimes a co-surfactant), which have shown potential for widespread application in disinfection and self-preservation. This is thought to be due to an innate antimicrobial effect. It is suggested that the antimicrobial nature of microemulsions is the result of a combination of their inherent kinetic energy and their containing surfactants, which are known to aid the disruption of bacterial membranes. This review examines the contemporary evidence in support of this theory.

Tobacco and alcohol-related interventions for people with mild/moderate intellectual disabilities: a systematic review of the literature.

BACKGROUND: The behavioural determinants of health among people with mild/moderate intellectual disabilities (ID) are of increasing concern. With the closure of long-stay institutions, more people with ID are living in the community. As they lead more ordinary and less restricted lives, people with ID may be exposed to social and environmental pressures that encourage them to adopt behaviours that impact negatively on their health. Levels of smoking and alcohol consumption in this client group are of particular concern. METHODS: We undertook a mixed method review of the literature, aiming to assess the Feasibility, Appropriateness, Meaningfulness and Effectiveness (FAME) of interventions designed to address the use of tobacco and/or alcohol in people with mild/moderate ID. Key electronic databases were searched (e.g., Medline, Cochrane Register of Controlled Trials, PsycINFO) from 1996 to 2011. The search was developed using appropriate subject headings and key words (e.g., intellectual disability, tobacco use, alcohol drinking, health promotion). On completion of the database searches, inclusion/exclusion criteria, based on an adaptation of the PICO framework (Population, Intervention, Comparison, Outcomes), were applied. Methodological quality was assessed using a seven-point rating scale. RESULTS: Database searches identified 501 unique records, of which nine satisfied the inclusion criteria. Four focused on tobacco, three on alcohol and two on both tobacco and alcohol. Located in the U.K., the U.S.A. and Australia, the studies aimed to increase knowledge levels and/or change behaviour (e.g., to encourage smoking cessation). One was a randomised controlled trial, one a quasi-experiment and the others were before and after studies and/or case studies. Methodological quality was poor or moderate. The combined studies had a sample size of 341, with ages ranging from 14 to 54 years. The interventions were delivered by professionals (e.g., in health, social care, education) during sessions that spanned a period of three weeks to one academic year. The studies highlighted a number of important issues linked to the appropriateness of interventions for this client group (e.g., use of pictures, quizzes, role play, incentives); however, in the majority of cases the interventions appeared to lack a theoretical framework (e.g., behaviour change theory). The appropriateness of the outcome measures for use with this client group was not tested. One study discussed feasibility (teachers delivering lessons on alcohol and tobacco) and only one was informative in terms of effectiveness, i.e., increasing knowledge of the health and social dangers of smoking and excessive alcohol consumption. CONCLUSIONS: This review is the first to systematically collate evidence on tobacco and alcohol-related interventions for people with ID. While there is currently little evidence to guide practice, the review delivers clear insights for the development of interventions and presents a strong case for more robust research methods. In particular there is a need to test the effectiveness of interventions in large-scale, well-designed trials and to ensure that outcome measures are developed/tailored appropriately for this client group.

An open phase I study to assess the biological effects of a continuous intravenous infusion of Interleukin-3 followed by Granulocyte Macrophage-Colony Stimulating Factor.

To assess any synergistic stimulatory effect in vivo of Interleukin 3 (IL-3) and Granulocyte Macrophage-Colony Stimulating Factor (GM-CSF) upon white cell and platelet counts, toxicity and antitumour effect, we conducted this phase I study. IL-3 0.25, 0.5 or 5 micrograms/kg/day for 1, 4 or 7 days was given by continuous intravenous (i.v.) infusion to 35 patients with advanced malignancy. 21 of the 35 patients also received sequential or overlapping treatment with continuous i.v. infusion of GM-CSF 1 or 3 micrograms/kg/day for up to 10 days. Monotherapy with IL-3 producted significant dose related increases in platelets and white cell counts. Combinations of IL-3 and GM-CSF also produced increases in white cell counts, but these were no greater than would be expected following GM-CSF treatment alone. There was a trend for platelets to increase more in patients receiving IL-3 and GM-CSF than those receiving IL-3 alone, but this did not reach statistical significance. In general, IL-3 and combinations of IL-3 and GM-CSF were well tolerated and the most common side-effect was fever. A maximum tolerated dose was not reached and antitumour effects were not seen. Future studies using combinations of IL-3 5 micrograms/kg/day and GM-CSF 3 micrograms/kg/day may help to define the optimal therapeutic regimen.

A randomised controlled trial to evaluate the clinical and cost-effectiveness of Hickman line insertions in adult cancer patients by nurses.

OBJECTIVES: To examine the clinical and cost-effectiveness of image-guided Hickman line insertions versus blind Hickman line insertions undertaken by nurses in adult cancer patients. DESIGN: A cost-effectiveness analysis was carried out alongside a randomised controlled trial. SETTING: A large acute cancer centre in Manchester, UK. PARTICIPANTS: Cancer patients due to have a Hickman line insertion who were over 18 years of age and were clinically and physically compliant with specified protocols. INTERVENTIONS: In order to obtain central venous access for the patient, two interventions were investigated: (i) blind insertion of a Hickman line and (ii) image-guided insertion of a Hickman line. Both interventions involved blind venipuncture of the subclavian vein. In the blind arm, the Hickman line was routinely inserted without the use of image guidance at any point in the procedure. Transfer to the interventional X-ray suite and use of image guidance were options immediately available to the operator during the procedure if required. In the image-guided arm, the position of the guidewire was checked before the Hickman line was introduced and later the Hickman line was positioned with the use of X-ray fluoroscopy. MAIN OUTCOME MEASURES: The primary clinical outcome measure was catheter-tip misplacement and this was expected to be higher in the blind arm. When comparing the skill level of the trainer and the trainees, pneumothorax was the primary clinical outcome measure. Other outcomes measures included arterial puncture, haematoma, infection, failed insertion and assistance from other healthcare professionals. RESULTS: No statistically significant difference was found between the mean cost per patient in the two arms of the trial. The only statistically significant difference in clinical outcomes was the frequency of catheter-tip misplacement, which was higher in the blind arm of the trial. At very low costs, the image-guided approach dominates the blind approach as fewer costs and greater benefits are incurred. It is evident that nurses previously inexperienced in the procedure can be trained to insert Hickman lines successfully both at the bedside and under image guidance within a 3-month period. CONCLUSIONS: This report indicates that nurse insertion of Hickman lines in the majority of adult cancer patients is both safe and effective. However, there are a select group of patients for whom image-guided insertion may be preferred. The results reveal that skills and expertise can be transferred from trainer to trainee through a relatively short, but intensive, training course. It is also evident that patients support nurse insertion. Further research is suggested to compare the safety and efficacy of nurse versus doctor insertions in particular subgroups of patients and also to assess the quantity and quality of current service provision in order to inform NHS decision-making in this area.

Effect of a standardized rewarming protocol and acetaminophen on core temperature after coronary artery bypass.

BACKGROUND: Cardiac surgical patients who require hypothermic cardiopulmonary bypass experience hypothermia, normothermia, and hyperthermia during the early postoperative period. Research-based rewarming protocols are needed to manage temperature variations. OBJECTIVE: To describe the effect of a standardized rewarming protocol and acetaminophen on the following outcome variables: core temperature, peak core temperature, rewarming time, and hyperthermia. METHODS: Patients (N = 60) were rewarmed using a standardized rewarming protocol. Electric heating blankets were used for subjects with core temperatures less than 36 degrees C on admission to the intensive care unit; other subjects were covered with cotton bath blankets. Subjects were also assigned to one of three acetaminophen groups (650 mg at 38.1 degrees C, 650 mg at 37 degrees C, 1300 mg at 37 degrees C). RESULTS: Using the protocol, subjects warmed to normothermia in 3.6 to 6 hours. The 16-hour core temperature thermal curves of heating blanket versus cotton bath blanket subjects differed significantly; thermal curves of the acetaminophen groups were similar. Peak core temperature was significantly lower in heating blanket subjects and unaffected by acetaminophen group. The onset of hyperthermia was not significantly affected by the method of rewarming (electric heating blanket versus cotton blankets) or acetaminophen group. Rewarming time was significantly longer for electric heating blanket subjects. CONCLUSIONS: Our results indicate that mildly hypothermic subjects rewarmed with electric heating blankets during the early postoperative period have lower peak core temperatures and longer rewarming times than those rewarmed with cotton bath blankets. Acetaminophen administration at normothermia does not significantly affect peak core temperature or the onset of hyperthermia.

The metabolic response to injury in the surgical/trauma patient.

Following tissue injury or surgical intervention, critically ill patients experience metabolic alterations that may either eventually resolve or progress to Hypermetabolic Multiple Systems Organ Failure. An understanding of these processes allows critical care nurses to monitor their patients' clinical status following trauma or surgical intervention and fosters an appreciation of patients' nutritional needs.

Nurse-led central venous catheter service: Christie experience.

The aim of this study was to evaluate the success and complication rate of Nurse-led subclavian central venous catheter (CVC) insertion using the landmark technique. A prospective study was performed on all subclavian CVC insertion between 13/01/03 to 01/07/03. Data recorded included indication for catheter insertion, type of catheter, complications during the procedure and patient satisfaction. A total of 348 subclavian cuffed tunnelled catheters were inserted over the study period. The age group ranged from 31 years to 84 years with a mean age of 53 years. This included 192 women and 156 men. The majority of CVC insertions were through the right subclavian (79%) and were single lumen (76%). In total, complications were encountered in 48 patients (14%). These included misplaced tip in 29 (8%), arterial puncture in 16 (4%), pneumothorax in 3 (1%) and the procedure failed in 3 (1%). Of these multiple complications were seen in 3 (1%). No interventions were required for the pneumothoraces or for the arterial punctures. In conclusion, nurse-led subclavian CVC placements using the landmark technique are both safe and effective.

Consequences of trauma: systemic inflammation and multiple organ dysfunction.

Critically injured patients are at risk for systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). MODS is a clinical syndrome of progressive physiologic dysfunction of organ systems. Trauma patients are at high risk for SIRS/MODS because of circulatory shock with tissue hypoxemia, tissue injury, and infection. Organ dysfunction may be a direct consequence of an insult (primary MODS) or may manifest latently (secondary MODS) and involves organs not initially injured. Management of SIRS/secondary MODS requires control/elimination of the source of inflammation, maintenance of tissue oxygenation, nutritional/metabolic support, support for individual organs, and effective pain control.

Research connections: nursing practice and ECG monitoring.

This article reviews and critiques the study by Drew et al that describes the electrocardiographic monitoring practices of critical care nurses. The study was conducted with a national sample and documented standards of practice. The implications for practice, education, and research are addressed.

Pediatric cholesterol testing.

This article discusses a recent study in which current total cholesterol values of 295 adults were compared to baseline (childhood) values obtained 16 years earlier when subjects participated in a school health screening and intervention program. Results demonstrated that adult total cholesterol values were significantly related to childhood values. Findings do not support limiting pediatric cholesterol testing to children with positive familial histories of either hyperlipidemia or early manifestations of coronary artery disease. Current recommendations regarding pediatric cholesterol testing may soon require reevaluation.

Effects of intravenous magnesium sulphate in acute myocardial infarction.

This column reviews the results of second Leicester Intravenous Magnesium Sulphate Intervention Trial (LIMIT-2), a clinical study investigating the effects of intravenous magnesium sulphate on 28-day mortality and morbidity in suspected AMI patients. Many LIMIT-2 subjects also received thrombolytic and anti-platelet therapy, differentiating findings of this study from earlier results. Implications for practice, education, and future research are discussed.

Research connections.

Sleep pattern disturbance is a recognized phenomenon during the postoperative period of hospitalized adult cardiac surgical patients. Sleep disturbances may decrease healing and tissue repair and delay recovery. The nursing research study reviewed and critiqued in this column investigated the effect of a specific intervention (taped ocean sounds) on sleep in hospitalized postoperative coronary artery bypass graft patients. Implications for clinical practice and further research are discussed.

Monitoring right ventricular function.

A new catheter developed by Edwards Critical-Care Division measures right ventricular ejection fraction and calculates right ventricular stroke volume, end-systolic volume, and end-diastolic volume. The nurse can thus assess a patient's right ventricular function curves using the relationship between stroke volume and end-diastolic volume. This article critiques a study that used this new technology and discusses implications for clinical practice and nursing research.

Physiologic and psychologic responses to cardiac pacemakers.

Three studies are discussed in this column. In one, it is concluded that noninvasive temporary pacing is safe and effective for short-term uses. Another study showed that a structured teaching program on pacemaker implantation improved patient knowledge but did not affect their endocrine or psychologic responses. In the third study, it was concluded that children can experience healthy psychosocial adaptation to a pacemaker.

Treating hyperlipidemia.

Studies are reviewed that describe a nurse-managed clinic for treating hypercholesterolemia and two large drug trials that demonstrated a lowered risk of coronary artery disease associated with antilipid therapy.

Variables influencing cardiovascular function.

Two studies are reviewed, one regarding the effects of music therapy on psychophysiologic stress in coronary care unit patients and one regarding the effects of age and gender on cardiovascular autonomic reactivity in healthy adults. Music therapy is determined to be safe for coronary care unit patients and effective in modulating the psychophysiologic manifestations of stress. The second study suggests that age--gender interactions may influence autonomic cardiovascular responsiveness. It is suggested that older adults be taught methods to reduce straining, so that rapid transient changes in blood pressure are avoided.

Nutritional management of the metabolically stressed patient.

The nutritional management of the critically ill metabolically stressed patient has changed drastically within the last two decades. Alterations in carbohydrate, fat, and protein metabolism following severe injury affect effective substrate utilization and the provision of nutritional or metabolic support. This article describes the acute alterations in carbohydrate, fat, and protein metabolism during severe metabolic stress; reviews nutritional assessment and requirements during metabolic stress; and presents recent findings that influence nutritional support during metabolic stress. The role of gut in the provision of nutritional support and the pharmacologic properties of select enteral nutrients are reviewed.

Caring for patients with ventricular assist devices.

The purpose of this article is to stimulate nursing research questions and potential areas for study related to patients with ventricular assist devices. Multidisciplinary research is needed, and nurses should play a key role in developing database variables and research for patients with this technology.

Coping and heart disease.

This column reviews three studies on coping that provide nurses with a base for identifying individuals with particular coping needs and styles. The studies focus on Type A behavior and coping. Type A behavior and gender differences, and responses of spouses of patients with a first myocardial infarction.