Bovine tuberculosis and badgers in Britain: relevance of the past.

The European badger (Meles meles) has been identified as a wildlife reservoir of bovine tuberculosis and a source of transmission to cattle in Britain and Ireland. Both behavioural ecology and statistical ecological modelling have indicated the long-term persistence of the disease in some badger communities, and this is postulated to account for the high incidence of bovine tuberculosis in cattle across large tracts of England and Wales. This paper questions this consensus by using historical cartographic evidence to show that tuberculosis in cattle had a very different spatial distribution before 1960 to the present day. Since few of the badgers collected in road traffic accidents between 1972 and 1990 had tuberculosis in counties such as Cheshire, where the disease had until shortly before that been rife in the cattle population, the role of badgers as reservoirs in spreading disease in similar counties outside the south-west of England has to be questioned.

Pain assessment and management in critically ill postoperative and trauma patients: a multisite study.

BACKGROUND: Pain in critically ill patients is undertreated. OBJECTIVES: To examine patients' perceptions of pain and acute pain management practices in a large metropolitan area to provide direction for improvements in pain relief. METHODS: In a descriptive, correlational study, data were collected from 213 patients in 13 hospitals. Interviews with patients, chart reviews, and interviews with nurse leaders were used to examine institutional and individual approaches to pain management. RESULTS: Twenty-eight percent of patients did not recall an explanation of a pain management plan, and 64% were often in moderate to severe pain while in the intensive care unit. High pain intensity correlated with wait for an analgesic (P < .001), expectations of less pain (P < .001), and longer stay in the intensive care unit (P < .001). Low satisfaction correlated with expectations of less pain (P < .001), often being in moderate to severe pain (P < .001), and long wait for an analgesic (P < .001). In the first 24 hours postoperatively, only 54% of patients had a numerical pain rating documented; 91% had a pain description. The amount of opioid given on postoperative day 1 was influenced by pain intensity (P < .001), the patient's age (P = .03), type of surgery (P = .002), and route of analgesic (P < .001). Only 33% of patients had nonpharmacological pain interventions documented. CONCLUSIONS: Despite moderate to severe pain, patients are generally satisfied with their pain relief. Measuring patients' satisfaction alone is not a reliable outcome for determining the effectiveness of pain management. Realistic expectations of patients about their pain may enhance coping, increase satisfaction, and decrease pain intensity after surgery.

Left ventricular assist as a viable alternative for cardiac transplantation.

Implantation of left ventricular assist systems (LVASs) is becoming more prevalent for patients with end-stage heart disease who are awaiting cardiac transplantation. The original intent of the LVAS was to provide an alternative to transplantation, but until recently, the LVAS has been approved only as a bridge to transplantation. Now that bridging to transplantation for patients with LVASs has exceeded 2-year periods, permanent implantation is being done as an alternative to transplantation. This article reviews the fundamental components of the HeartMate Vented Electric LVAS (Thermo Cardiosystems, Inc, Woburn, MA) with a focus on patient complications and nursing implications. Additionally, the intraoperative implantation procedure is presented. Finally, ethical and financial considerations related to permanent LVAS implantation are discussed.

Analysis of clinical trends in a program of emergent ECLS for cardiovascular collapse.

Between June 1986 and October 1995, 81 patients were emergently resuscitated with a portable extracorporeal life support (ECLS) system. Venoarterial perfusion was achieved using a centrifugal pump (BioMedicus; Medtronic, Anaheim, CA) and a hollow fiber oxygenator (BARD in 56 patients; Medtronic heparin-bonded MAXIMA, [MAXIMA, Medtronic, Minneapolis, MN] in the last 25 patients. The ECLS system was used at various locations in the hospital with the setup, priming, and initiation of perfusion done by ECLS trained intensive care unit nurses. Clinical data in these patients were reviewed to analyze variables influencing survival and trends that develop as the authors' experience accumulated and the technology evolved. The indication for ECLS was cardiac arrest in 68 patients and refractory cardiogenic shock in 13 patients. Thirty-five patients (43.2%) survived > 24 hrs after termination of ECLS, whereas 20 patients (24.7%) are long-term survivors (> 30 days). The ECLS system permitted an additional therapeutic surgical intervention in 45 cases. Patients who had a surgically remediable problem were more likely to survive. Prolongation of cardiopulmonary resuscitation beyond 30 mins before initiation of ECLS correlated with a decreased likelihood of survival.

Where angels fear to tread? Mapping women and men in India.

"The authors have produced the ¿Atlas of Women and Men in India', using material from the 1991 Census, mainly at district level. The Atlas may be unacceptable to Indian geographers because it seeks to question the authority of numerical data and of maps, and to Western geographers because this is ¿mapping before we understand the process'. The authors introduce maps of the sex ratio in India and explore through a map of changes in the sex ratio 1981-91 some numerical, analytical, and ethical problems of such mapping. The Indian feminist activists consulted want the Atlas for advocacy: does this justify its production?"

Developing and implementing a standard of care for intra-aortic balloon counterpulsation.

This article summarizes the process for developing one standard of care for IABC within an integrated hospital system. Practice variations and new research findings create a need to review and update standards of care regularly. Assessing current practice, reviewing the literature, and consulting experts are part of the development process. Implementation of a new standard is a multifaceted challenge that involves several educational strategies. Evaluation of a standard of care is accomplished by assessing quality outcome indicators.

Effects of a bedbath on mixed venous oxygen saturation and heart rate in coronary artery bypass graft patients.

OBJECTIVE: To determine the physiologic effects of a bedbath on critically ill patients. METHODS: Thirty hemodynamically stable coronary artery bypass graft patients were studied less than 24 hours after surgery in a repeated measures, quasi-experimental design. Study sites were the medical/surgical and coronary intensive care units of a large community hospital in the south-central United States. Two bedbaths consisting of bathing and turning phases were given to subjects early (mean, 3.6 hours) and late (mean, 18.5 hours) in the immediate postoperative period. Mixed venous oxygen saturation (Svo2) and heart rate were recorded at 1-minute intervals before, during, and for 5 minutes after each bedbath. RESULTS: Mean Svo2 decreased from baseline during the bathing phase of early and late bedbaths 1.6% and 1.9%, respectively, whereas mean heart rate increased from baseline 3.2% and 1%, respectively. During the turning phase, mean Svo2 decreased from baseline 9.2% and 12.1%, respectively, whereas mean heart rate increased from baseline 5.2% and 1.8%, respectively. Svo2 declined to less than 53% in 10 (33%) subjects during both early and late bedbaths. The most severe decreases in Svo2 occurred during early bedbaths and were usually associated with coughing, shivering, and/or agitation. CONCLUSIONS: Early bedbaths caused more dramatic declines in Svo2 than late bedbaths. Coughing, shivering, and agitation accentuated Svo2 declines and could be prevented by waiting to bathe coronary artery bypass graft patients until 1 day postoperatively. Routine bathing, at least in the early postoperative period, should be reconsidered.

Respiratory consequences of multisystem crisis: the adult respiratory distress syndrome.

This article reviews adult respiratory distress syndrome as it is associated with multiple organ dysfunction and systemic inflammatory response. The pathophysiology of adult respiratory distress syndrome is discussed and related to the clinical presentation. Included in the clinical presentation is a discussion of respiratory and hemodynamic alterations, lung mechanics, and oxygen delivery and consumption alterations. Conventional therapeutic modalities for treatment of adult respiratory distress syndrome are reviewed in addition to new ventilatory approaches. New approaches to ventilation and oxygenation included in this article are pressure control ventilation, inverse ratio ventilation, permissive hypercapnia, and extracorporeal therapy. New pharmacologic therapy for the treatment of adult respiratory distress syndrome is also reviewed in this article.

Postoperative coagulopathies.

Because complications associated with postoperative coagulopathies are significant, prevention, early evaluation, and appropriate management are essential. The etiologies of postoperative coagulopathies are multifactorial and can be evaluated by a systematic clinical approach. Treatment should not be arbitrary but directed at specific defects. This article reviews the normal hemostatic mechanisms and presents the etiologies and current management strategies for common postoperative coagulopathies.