Emergency department visits in patients with low acuity conditions: Factors associated with resource utilization.

OBJECTIVES: To identify health beliefs of emergency department (ED) patients with low acuity conditions and how these affect ambulance (AMB) utilization. METHODS: We performed a prospective, observational study on a convenience sample of patients 18years or older, who presented to the ED of an urban, academic hospital with an Emergency Severity Index (ESI) triage level of 4 or 5. Demographics, treatment, and disposition data were obtained along with self-administered surveys. Characteristics of patients with low acuity conditions who presented to the ED by AMB were compared to the patients who came to the ED by private transportation (PT). Data were analyzed with the chi-square test, t-test, and Mann-Whitney test. RESULTS: A total of 197 patients (97 AMB and 100 PT) were enrolled. Compared to PT, AMB patients were more likely to: be insured (82% vs. 56%; p=0.000), have a primary care provider (62% vs. 44%; p=0.048), and lack a regular means of transportation (53% vs. 33%; p=0.005). Three surveys were used the SF-8, Short Test of Functional Health Literacy in Adults [STOFHLA], and Health Belief Model [HBM]. Answers to HBM showed patients perceive that their illness required care within one hour of arrival (38% vs. 21%; p=0.04), have used an ambulance in the past year (76% vs. 33%; p=0.001) and to utilize an ambulance in the future for similar concerns (53% vs. 15%; p=0.000). AMB patients were more likely to call an ambulance for any health concern (p=0.035) and felt that there were enough ambulances for all patients in the city (p=0.01). There were no differences in age, employment, level of income and education, nor hospital admission rate between groups. CONCLUSIONS: Ambulance use in low-acuity ED patients is associated with misperceptions regarding severity of illness and resource allocation as well as limited access to private transportation. Understanding patient perceptions of illness and other barriers to receiving care is imperative for the development of interventions aimed at enabling change in health behaviors such as the elective use of limited resources.

Design and Rationale of a Randomized Trial of a Care Transition Strategy in Patients With Acute Heart Failure Discharged From the Emergency Department: GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure).

GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure) is a multicenter randomized trial of a patient-centered transitional care intervention in patients with acute heart failure (AHF) who are discharged either directly from the emergency department (ED) or after a brief period of ED-based observation. To optimize care and reduce ED and hospital revisits, there has been significant emphasis on improving transitions at the time of hospital discharge for patients with HF. Such efforts have been almost exclusively directed at hospitalized patients; individuals with AHF who are discharged from the ED or ED-based observation are not included in these transitional care initiatives. Patients with AHF discharged directly from the ED or after a brief period of ED-based observation are randomly assigned to our transition GUIDED-HF strategy or standard ED discharge. Patients in the GUIDED arm receive a tailored discharge plan via the study team, based on their identified barriers to outpatient management and associated guideline-based interventions. This plan includes conducting a home visit soon after ED discharge combined with close outpatient follow-up and subsequent coaching calls to improve postdischarge care and avoid subsequent ED revisits and inpatient admissions. Up to 700 patients at 11 sites will be enrolled over 3 years of the study. GUIDED-HF will test a novel approach to AHF management strategy that includes tailored transitional care for patients discharged from the ED or ED-based observation. If successful, this program may significantly alter the current paradigm of AHF patient care. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02519283.

Outcomes following the treatment of bicondylar tibial plateau fractures with fine wire circular frame external fixation compared to open reduction and internal fixation: A systematic review.

PURPOSE: The aim of this study was to determine whether circular frame external fixation provides better outcome and fewer complications when compared to open reduction internal fixation. METHODS: A systematic search was carried out and studies were critically appraised with narrative data synthesis. RESULTS: The systematic search yielded 131 titles and following a rigorous review only five articles were found to directly compare the two treatment methods. CONCLUSIONS: Fine wire frame external fixation offers a modest advantage of better soft tissue outcomes. All in all, there is no current high-level evidence to suggest that newer osteosynthesis plates provide better results.

Targeted biological therapies reach the heart: the case of serelaxin for heart failure.

Acute heart failure (AHF) is one of the most important causes of mortality, morbidity and rising healthcare costs. Despite this, there has been minimal advancement in the management of AHF and the treatment continues to focus on symptomatic improvement using vasodilators, diuretics and inotropes, none of which have shown any mortality benefits. Though originally thought of as a reproductive hormone, relaxin is now recognized as a potent vasodilator that modulates systemic and renal vascular tone, resulting in pre- and after-load reduction and a decrease in cardiac workload. A single intravenous infusion of relaxin over 48 hours has been shown to provide significant dyspnea relief among AHF patients, with an ongoing study to evaluate its potential for mortality benefit. This article provides an insight into the pharmacology of this novel therapy for AHF with an eye towards future clinical applications.

Factors causing stress in women with babies 0-3 months old and their coping styles.

This study was conducted in order to identify the factors that cause stress in women who have babies aged 0-3 months and the ways to deal with stress. This descriptive study was conducted in outpatient clinics for newborns. The sample consisted of 322 women. Data were collected through a questionnaire and Ways of Coping with Stress Inventory. It was found that most of the women became stressed because of problems regarding self-care, baby care and social life. Women mostly used ineffective coping styles to cope with stress.

Effect of recirculation on organic matter removal in a hybrid constructed wetland system.

This research project aimed to determine the technologically feasible and applicable wastewater treatment systems which will be constructed to solve environmental problems caused by small communities in Turkey. Pilot-scale treatment of a small community's wastewater was performed over a period of more than 2 years in order to show applicability of these systems. The present study involves removal of organic matter and suspended solids in serially operated horizontal (HFCW) and vertical (VFCW) sub-surface flow constructed wetlands. The pilot-scale wetland was constructed downstream of anaerobic reactors at the campus of TUBITAK-MRC. Anaerobically pretreated wastewater was introduced into this hybrid two-stage sub-surface flow wetland system (TSCW). Wastewater was first introduced into the horizontal sub-surface flow system and then the vertical flow system before being discharged. Recirculation of the effluent was tested in the system. When the recirculation ratio was 100%, average removal efficiencies for TSCW were 91 +/- 4% for COD, 83 +/- 10% for BOD and 96 +/- 3% for suspended solids with average effluent concentrations of 9 +/- 5 mg/L COD, 6 +/- 3 mg/L BOD and 1 mg/L for suspended solids. Comparing non-recirculation and recirculation periods, the lowest effluent concentrations were obtained with a 100% recirculation ratio. The effluent concentrations met the Turkish regulations for discharge limits of COD, BOD and TSS in each case. The study showed that a hybrid constructed wetland system with recirculation is a very effective method of obtaining very low effluent organic matter and suspended solids concentrations downstream of anaerobic pretreatment of domestic wastewaters in small communities.

The transcultural nursing concept: a study of nursing students in Turkey.

BACKGROUND: Cultural differences are known to be pronounced in Turkey, and some difficulties are encountered in patient care. Cultural sufficiency in providing health care to the patients is of great importance in satisfactory care delivery. AIM: To determine the cultural diversity that the students experienced between the patients and themselves while providing care to patients. Knowledge of transcultural nursing was also investigated. DESIGN AND METHODS: This was a descriptive study. The population comprised of 650 undergraduate students attending the nursing schools of three universities. A total of 622 students were included in the sample. The survey method was used for data collection. Percentages and chi-square test were used. RESULTS: Most of the students (85.5%) had experienced cultural differences while giving care to their patients and 73.8% did not know the definition of this concept. The issues where cultural differences were experienced to the highest degree were differences in dialect and pronunciation (53.4%), differences of language (37%), traditions and customs of the individual (30.7%), and religious belief and sect (30.2%). It was found that the grade the students were in had a significant effect on the experience of cultural differences (P<0.05). CONCLUSIONS: The majority of students experience cultural diversity in patient care. It is thought that transcultural care placed in curriculum even as a separate course will guide nursing students in all stages of patient care. Thus, the effect of cultural diversity in patient care can be minimized with the help of education.

Mobbing against nurses in the workplace in Turkey.

AIM: The aim of the study was to determine whether the nurses have been exposed to mobbing or not, and to reveal the causes of the mobbing between 3 November 2008 and 31 December 2008. METHODS: This research was a mixed method study involving survey and focus group interviews. The sample was calculated using sample calculation formula, and 206 nurses were included in the survey study. Four focus group interviews were later carried out with 16 nurses. The survey method and semi-structured question form were used to collect data. The percentage and chi-square were used to evaluate the quantitative data, and for the analysis of the qualitative data, descriptive analyses were made through direct quotations from the nurses' statements. FINDINGS: According to the mobbing scale, 9.7% of the nurses had been exposed to mobbing, but according to their own declarations, 33% had been exposed. Some of the nurses (25.2%) who expressed that they had been exposed to mobbing reported that the executor of mobbing was the head nurse and 9.2% said that the reason for mobbing was 'communication problems'. Nurses under 25 years of age and those who work in intensive care units are apparently exposed to mobbing more frequently than others (P<0.05). CONCLUSIONS: It is suggested that head nurses' mobbing behaviours should be determined and they should be educated about leadership. Nurses should be educated about assertiveness to prevent mobbing. The necessary measures should be adopted to solve the 'communication problems', which are shown as a major reason for mobbing.

Traditional practices used by infertile women in Turkey.

BACKGROUND: Numerous traditional methods are used in the treatment of infertility around the world. AIM: To identify the traditional practices of infertile women using one clinic in Ankara, Turkey. DESIGN AND METHODS: The population comprised all women (5700) who attended one infertility outpatient clinic in 2007. The sample was calculated using sample calculation formula and 410 women were included in the study. The survey method was used for data collection. FINDINGS: Of the responding women, 27.3% had tried a traditional practice, and 67.8% who tried traditional practices used an herbal mixture. The reason for the women's use of a traditional practice was 'hope' (66.9%), and 15.2% of them had experienced an adverse effect related with traditional practice. Maternal education level, perceived economic status, duration of marriage all significantly affected the use of traditional practices (P<0.05). The women who had received unsuccessful medical treatment for infertility and who had experienced side effects after medical treatment had a higher rate of use of traditional practice (P<0.05). CONCLUSIONS: Almost one in three of the women who responded to the questionnaire had tried traditional methods, and some experienced adverse effects related to the practice. For couples with infertility problems, educational programmes and consultation services should be organized with respect to their traditional culture. Women should be informed about the hazards of traditional practices and avoidance of harmful practices, and continuous emotional support must be provided for infertile couples. In the future, nursing staff should play a much larger role in these supportive services.

Modelling and evaluation of nitrogen removal performance in subsurface flow and free water surface constructed wetlands.

With the aim of protecting drinking water sources in rural regions, pilot-scale subsurface water flow (SSF) and free water surface flow (FWS) constructed wetland systems were evaluated for removal efficiencies of nitrogenous pollutants in tertiary stage treated wastewaters (effluent from the Pasaköy biological nutrient removal plant). Five different hydraulic application rates and emergent (Canna, Cyperus, Typhia sp., Phragmites sp., Juncus, Poaceae, Paspalum and Iris) and floating (Pistia, Salvina and Lemna) plant species were assayed. The average annual NH4-N, NO3-N and organic-N treatment efficiencies were 81, 40 and 74% in SSFs and 76, 59 and 75% in FWSs, respectively. Two types of the models (first-order plug flow and multiple regression) were tried to estimate the system performances. Nitrification, denitrification and ammonification rate constants (k20) values in SSF and FWS systems were 0.898 d-1 and 0.541 d(-1), 0.486 d(-1) and 0.502 d(-1), 0.986 d(-1) and 0.908, respectively. Results show that the first-order plug flow model clearly estimates slightly higher or lower values than observed when compared with the other model.

Nitrogen management in reservoir catchments through constructed wetland systems.

In this study, nitrogen removal was investigated in pilot-scale subsurface flow (SSF) and in free water surface flow (FWS) constructed wetlands installed in the campus of TUBITAK-Marmara Research Center, Gebze, near Istanbul, Turkey. The main purposes of this study are to apply constructed wetlands for the protection of water reservoirs and to reuse wastewater. Experiments were carried out at continuous flow reactors. The effects of the type of plants on the removal were investigated by using emergent (Canna, Cyperus, Typhia spp., Phragmites spp., Juncus, Poaceae, Paspalum and Iris.), submerged (Elodea, Egeria) and floating (Pistia, Salvina and Lemna) marsh plants at different conditions. During the study period HLRs were 30, 50, 70, 80 and 120 L m(2)d(-1) respectively. The average annual NH4-N, NO(3)-N, organic N and TN treatment efficiencies in SSF and FWS wetlands are 81% and 68%, 37% and 49%, 75% and 68%, 47% and 53%, respectively. Nitrification, denitrification and ammonification rate constant (k20) values in SSF and FNS systems have been found as 0.898 d(-1) and 0.541 d(-1), 0.488 d(-1) and 0.502 d(-1), 0.986 d(-1) and 0.908 respectively. Two types of the models (first-order plug flow and multiple regression) were tried to estimate the system performances.

The use of a principal axis model to examine individual plant harvest index in four grain legumes.

BACKGROUND AND AIMS: A principal axis model (PAM) has been proposed to enable the selection of crop ideotypes. The PAM enables plant-to-plant variability within crops to be quantified and compared. The aim of this paper is to validate the PAM for four grain legumes. METHODS: Four grain legumes (Cicer arietinum, Lens culinaris, Lupinus angustifolius, Pisum sativum) were used to quantify the influence of plant-to-plant variability on crop yields. To create variability, populations of 10, 100 and 400 plants m(-2) were established 'on-the-square' with sowing depths of 2, 5 and 10 cm. Further, a central plant was treated with nitrogen and the impact of this on its four neighbouring plants was examined. Seeds were sown and plants harvested individually by hand. KEY RESULTS: Mean individual plant seed weight (SWT) and plant weight (PWT) decreased as plant population increased but there was a consistent and strong (R2 > 0.90) linear relationship between SWT and PWT, with a negative SWT-axis intercept in all species. These components form the basis of the principal axis model (PAM). The PAM was used to summarize the performance of individual plants within a crop and quantify the variability caused by N treatment and the lowest and highest yielding individual plants. A negative SWT-axis intercept indicated that a minimum plant weight (MPW) was required for seed production and therefore the relationship between plant harvest index (PHI) and PWT was asymptotic. The heaviest MPW was calculated for plants grown at the lowest plant population and it was species-dependent, being higher in the larger seeded species. CONCLUSIONS: Agronomic or physiological characteristics that lead to variability in PWT within a population will decrease PHI, and crop yield. The PAM may be useful in breeding programmes to identify plant phenotypes that minimize this plant-to-plant variability.

Scintigraphic evaluation of paired renal allografts from the same cadaveric donor.

The aim of this study was to compare the outcome of paired grafts in renal recipients from the same cadaveric donor using quantitative Tc-99m DTPA scintigraphy. Fifty recipients from 25 cadaveric donors were followed for a median period of 3 years. Serial Tc-99m DTPA scintigraphy was performed starting on the third posttransplant day and images evaluated quantitatively. The quantitative parameters included Hilson's perfusion index, time to maximum activity, time to half of maximum activity, the ratio of the graft activity at 20 to 3 minutes, and glomerular filtration rate. In the early postoperative period, 20 of 25 paired kidneys showed similar performances. At the end of the first year 22 of 25 pairs showed a similar evolution. At the end of the third year, the number was 21 of 25. We concluded that if cold ischemia time was prudent, there was no difference in graft outcome between the first and the second recipient of a renal transplant from the same cadaveric donor.

Protein C, S and antithrombin III levels in patients with acute mechanical valve thrombosis.

BACKGROUND: Mechanical prosthetic heart valve thrombosis is a serious complication with an incidence of 1-6%. The reduction in active vitamin-K dependent protein C and S levels caused by warfarin treatment also results in a prothrombotic state. This study was conducted to investigate the connection between protein C (PC), protein S (PS), antithrombin III (ATIII) deficiency and prosthetic mechanical valve thrombosis. METHODS: Twenty-nine of the 283 patients who underwent valve replacement with St. Jude medical prosthesis had mechanical valve thrombosis (group 2). The rest were considered as group 1. Twelve of the 29 patients (41.4%) had isolated aortic valve replacement, 12 had isolated mitral valve replacement (41.4%) and 5 patients had double valve replacement (17.2%). Most of the patients had rheumatic valve disease at their 1st operation. The mean time of occurrence for mechanical valve occlusion was 4.1+/-1.0 years following surgery. RESULTS: The values of PC, PS and ATIII were obtained when the mechanical valves stuck or at routine follow-up. PC, PS and ATIII levels were significantly lower in the mechanical valve thrombosis group. PC levels were 75.4+/-37.6% and 49.9+/-32.2% in group 1 and 2, respectively (p=0.001). PC, PS and ATIII values were mostly lower in the 2nd group but this difference only became significant after at least 2 years of warfarin usage. CONCLUSIONS: Natural anticoagulant levels can be low during the use of warfarin. In which case the dose can be increased in order to hold the international normalized ratio (INR) at 3-3.5. However, more frequent follow-up is required and patients should be investigated for hypercoagulation states or deficiency in anticoagulant proteins. Patients referred to hospital with any mechanical valve thrombosis or recurrent thromboembolism should be evaluated for hypercoagulant proteins.

Treatment of wastewater by natural systems.

Experimental results from a pilot-scale constructed wetland (CW) treatment plant have been described. The study was conducted at two different systems: continuous and batch. In the continuous system, the treatment yields were monitored in different loading conditions in 1-year period. The pilot plant consists of two serially connected tanks settled up with fillers; Cyperus was used as treatment media and wastewater between the two tanks was recycled periodically. Chemical oxygen demand (COD) and suspended solid (SS) removal efficiencies were obtained as 90% and 95%, respectively. The effluent COD concentration at an average loading of 122 g COD/m2 day was satisfactory for the Turkish Water Pollution Control Regulation. This means that a 0.8 m2 of garden area per person is required. Other removal values for the same conditions were as follows: total Kjeldahl nitrogen (TKN) was 77%, total nitrogen (TN) was 61%, and PO4(3-) -P was 39%. The batch experimental systems consist of 12 pairs of serially connected tanks, with each pair having a surface area of 1 m2. Each set was filled with sewage once a day, and the wastewater between the paired tanks was recycled periodically by the pump. Each pair of tanks was filled with materials such as gravel, peat, and perlite. Seven of them were vegetated with Phragmites, Cyperus, Rush, Iris, Lolium, Canna, and Paspalum, while the other five were not seeded. The best performances were obtained by Iris for COD (% 94), by Canna for ammonia nitrogen (% 98), and by Iris for total nitrogen (% 90) and phosphorus (% 55) removal.

Circulating interleukin-1 beta, interleukin-6, tumor necrosis factor-alpha, and soluble ICAM-1 in patients with chronic stable angina and myocardial infarction.

The changes in serum concentrations of cytokines such as interleukin-1 (IL-1) beta, interleukin-6 (IL-6), tumor necrosis factor (TNF) alpha and a soluble-intercellular adhesion molecule (sICAM-1) has been investigated in patients with stable angina and acute myocardial infarction. Thirty-four patients with stable angina (SA), 15 with acute myocardial infarction (AMI), and 20 subjects in the control (C) group were included in the study. The mean serum concentrations of sICAM-1, IL-1-beta, IL-6, and TNF-alpha differed significantly among the three groups. Serum concentrations of IL-1 beta, sICAM-1, and TNF-alpha were comparable in the AMI and SA groups and higher than those found in the C group (p < 0.001). The serum concentration of IL-6 was more than twice as high in the AMI group as compared to the other two groups (p < 0.001). The mean serum concentrations of IL-1 beta, TNF-alpha, and IL-6 were comparable in the AMI and SA groups and higher than in the C group.