Causes, assessment and treatment of malnutrition in older people.

Malnutrition is a growing problem in the UK with as many as 14% of people aged over 65 at risk. It is of particular concern in care homes where more than one third of residents are undernourished. Weight loss is not the only symptom of malnourishment and nurses should examine any changes to a person's health and well-being to identify causes. Regular monitoring of patients' risk of malnutrition through use of screening assessments, such as the Malnutrition Universal Screening Tool, ensures undernourishment is identified early. As the population ages, it is more important than ever that the implications of malnutrition are recognised and addressed.

An observational, retrospective, UK and Ireland audit of patient adherence to subcutaneous interferon beta-1a injections using the RebiSmart(®) injection device.

BACKGROUND: Poor adherence to disease-modifying drugs is associated with an increased risk of relapse in patients with multiple sclerosis. However, adherence is difficult to assess objectively. RebiSmart(®) (Merck Serono SA, Geneva, Switzerland), a device for subcutaneous (sc) injection of interferon (IFN) ß-1a, features an electronic injection log that can assist in objective monitoring of adherence. OBJECTIVE: To assess adherence to sc IFN ß-1a injections using data from RebiSmart(®). METHODS: This was a single-group, observational, retrospective audit. Adherence data were collected from patients with relapsing multiple sclerosis in the United Kingdom and Ireland who had been prescribed sc IFN ß-1a and had been using RebiSmart(®) for a minimum of 24 months. RESULTS: In total, 225 patients were included in the full analysis set; 72% were in the United Kingdom, and 28% were in Ireland. Overall, the mean age was 44.1 years, and 73% were women. Patients received sc IFN ß-1a 44 µg (68%) or 22 µg (32%) three times per week. Mean adherence over the course of 24 months was 95.0% (median, 99.4%), and similar values were observed across all periods. The proportion of patients with 80% or higher adherence was 92.0% at 12 months and 91.1% at 24 months. CONCLUSION: High adherence to sc IFN ß-1a was observed across all patient groups using RebiSmart(®), according to 2-year treatment adherence data. This may be partly attributed to the expert support patients received, supplemented by routine and regular contact from the MySupport patient-support program, as well as the self-motivation of patients who persisted with treatment for 2 or more years.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 2: Can ultrasound be used to diagnose clavicle fractures in children?

A short cut review was carried out to establish ultrasonography was as good as radiography at detecting fracture clavicles in children. 580 papers were found using the reported searches, of which 5 presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is that ultrasonography is sensitive at detecting clavicular fractures in children.

Negotiated dying: a grounded theory of how nurses shape withdrawal of treatment in hospital critical care units.

BACKGROUND: The process of withdrawal of treatment in critical care environments has created ethical and moral dilemmas in relation to end of life care in the UK and elsewhere. Common within this discourse is the differing demands made on health professionals as they strive to provide care for the dying patient and family members. Despite reports that withdrawal of treatment is a source of tension between those nurses and doctors involved in the process, the role of the nurse in facilitating withdrawal of treatment has received relatively little attention. OBJECTIVES: To illustrate how differing dying trajectories impact on decision-making underpinning withdrawal of treatment processes, and what nurses do to shape withdrawal of treatment. DESIGN: Qualitative methods of enquiry using clinical vignettes and applying Charmaz's grounded theory method. METHODS AND SETTINGS: Single audio-recorded qualitative interviews with thirteen critical care nurses from four intensive care specialities: cardiac; general; neurological and renal were carried out. Interviews were facilitated by an end-of-life vignette developed with clinical collaborators. FINDINGS: Across critical care areas four key dying trajectories were identified. These trajectories were shaped by contested boundaries associated with delayed or stalled decision-making around how withdrawal of treatment should proceed. Nurses provided end of life care (including collaborative and action-oriented skills) to shape the dying trajectory of patients so as to satisfy the wishes of the patient and family, and their own professional aims. CONCLUSIONS: Differing views as to when withdrawal of treatment should commence and how it should be operationalised appeared to be underpinned by the requirements of the role that health professionals fulfil, with doctors focusing on making withdrawal of treatment decisions, and nurse's being tasked with operationalising the processes that constitute it. Multidisciplinary teams need a 'shared' understanding of each other's roles, responsibilities, aims, and motivations when planning and implementing the dying trajectory of withdrawal of treatment.