Evaluation of a sterile surgical skin marker to indicate the optimal vein for venepuncture in the blood donation setting.

BACKGROUND AND OBJECTIVES: Phlebotomy is a central task for blood donation; however, not all blood donors have veins that are easy to see or feel. This study aimed to determine whether use of a surgical skin marker to highlight the donors' vein location and direction prior to venepuncture increased blood donation success. METHODS: All blood donors who participated in this study were eligible to donate according to Australian guidelines. Ten donor centres with phlebotomy success rates <95% were selected. A randomized cluster trial design assigned five sites to test the skin marking device and five sites as controls. Single-use sterile Gentian violet skin marker pens were used to mark donors' veins. Phlebotomy site skin bacterial load after using the skin marking device was tested on a subset of 100 donors. Phlebotomy success rates and donor adverse events were recorded. RESULTS: Of the control donors, 6993 had successful phlebotomies and 225 failed. Of the skin marker donors, 6998 had successful phlebotomies and 248 failed. No statistically significant differences in phlebotomy success were found between the two groups (OR: 0·91, 96·4% CI [96·0, 96·8], P-value 0·348). CONCLUSION: The use of skin marker pens did not increase overall phlebotomy success rate. There was no increase in phlebotomy site skin bacterial load, and amendments to standard skin disinfection techniques were not required. Blood donors were not concerned about the pen mark on their arms. Generally, staff indicated that the markers may be valuable to assist with phlebotomies for donors with difficult or deep veins.

Evaluation of a tool to score donor vein suitability for blood donation.

BACKGROUND AND OBJECTIVES: Phlebotomy is a central task for whole blood donation, yet there are no published standards regarding systematic donor vein assessment or the impact of vein quality on successful blood donation. Blood donation failures and related adverse events are highly predictive of donors not returning for future blood donation. A specific blood donation vein scoring tool was assessed to measure donor vein suitability for whole blood collection and investigate the correlation of the donor's veins with donation outcomes. MATERIALS AND METHODS: The vein assessment tool consisted of three questions using a 5-point Likert-type scale to measure responses. Two phlebotomists performed blinded assessments of each donor's veins on each arm using the tool. The individual measures were then aggregated to provide a total vein score out of 12. Inter-rater reliability of the vein score tool was assessed by calculating the intraclass correlation coefficient for absolute agreement. RESULTS: Fifty-seven phlebotomists across four fixed blood donation centres performed paired vein assessments on 553 blood donors. The intraclass correlation coefficient indicated moderate inter-rater reliability was achieved. The median scores for viable donations were 10, for non-viable donations were 6·5 and for failed phlebotomies were 4. Donation histories of donors with lower vein scores indicated lower success during blood donation. CONCLUSION: The vein score tool appears to be predictive of a successful donation outcome, however, since there was not a suitably high correlation between the scores of the two assessors, further refinement of the tool will be required prior to wider use.

Does using applied muscle tension at strategic time points during donation reduce phlebotomist- and donor-reported vasovagal reaction rates? A three-armed randomized controlled trial.

BACKGROUND: Vasovagal reactions (VVRs) have a negative impact on donor safety and return. Applied muscle tension (AMT) increases blood pressure temporarily and has been suggested as a way to reduce donors' risk of VVRs. This study evaluated whether using AMT at three different time points during the donation procedure reduces the VVR symptoms reported by donors and the VVR reactions recorded by phlebotomists. STUDY DESIGN AND METHODS: A three-arm, multicenter, open-label randomized controlled trial was used to compare VVR symptoms and reaction rates between those practicing AMT during the entire donation (n = 244) to practicing AMT at VVR high-risk time points (n = 250) to a standard blood donation control group (n = 240). All participants were asked to drink 500 mL of water in the waiting area, and an even distribution of new and repeat donors was sought across conditions. RESULTS: Across all conditions, donors reported few VVR symptoms and the rate of reporting did not differ significantly across conditions. However, donors who practiced AMT at strategic time points had a significantly lower number of phlebotomist-registered VVRs in comparison to the other two study groups, with these rates not varying by sex or donor status. Greater compliance by donors with AMT instructions was observed in those asked to practice AMT at strategic time points compared to those asked to practice AMT during the entire donation. CONCLUSION: Practicing AMT at VVR high-risk time points reduces the number of phlebotomist-registered VVRs.

Facilitating donor compliance with strategies to prevent vasovagal reactions: comparison of web-based and in-center approaches.

BACKGROUND: Research has documented beneficial effects of water loading (WL) and applied muscle tension (AMT) on reducing self-reported vasovagal reactions (VVRs) in whole blood (WB) donors. However, the optimal approach to reducing VVRs using these strategies in routine blood collection practice is not known. This study evaluated the effectiveness of embedding newly developed web-based and on-site donor education materials to increase the use of these two prevention techniques during blood collection. STUDY DESIGN AND METHODS: Two studies were conducted with WB donors. In Study 1, donors (n = 375) were randomly allocated to evaluate one of three forms of educational materials (video, webpage, card) in an online questionnaire. In Study 2, donors (n = 598) were randomly assigned to view either off-site web-based or in-center educational materials and were surveyed after donation to assess compliance to the VVR prevention procedure and to self-report VVR. RESULTS: In Study 1, donors rated the video as having the highest message appeal and indicated greater likelihood to use AMT compared to the webpage and card. No differences were found in likelihood to use WL. In contrast, in Study 2, greater adherence to VVR prevention strategies was observed in donors who received the in-center instruction card in comparison to those who received the web-based materials. Examination of viewing data indicated that only a small number of donors had seen the web-based materials. No significant effects of the techniques were found on self-reported VVRs. CONCLUSION: Providing on-site instructions is the most effective method to increase donor compliance to VVR prevention techniques.

The infectious disease blood safety risk of Australian hemochromatosis donations.

BACKGROUND: It has been suggested that blood donors with hereditary hemochromatosis may pose an increased infectious disease risk and adversely affect recipient outcomes. This study compares the infectious disease risk of whole blood (WB) donors enrolled as therapeutic (T) donors to voluntary WB donors to evaluate the safety of blood products provided by the T donors. STUDY DESIGN AND METHODS: This was a retrospective cohort study of all WB donations at the Australian Red Cross Blood Service who donated between January 1, 2011, and December 31, 2013, comparing a yearly mean of 11,789 T donors with 107,773 total donations and a yearly mean of 468,889 voluntary WB donors with 2,584,705 total donations. We compared postdonation notification of infectious illnesses, bacterial contamination screening results, and positive tests for blood borne viruses in T and WB donors. RESULTS: Rates of transfusion-transmissible infections in donations destined for component manufacture were significantly lower in therapeutic donations compared to voluntary donations (8.4 vs. 21.6 per 100,000 donations). Bacterial contamination (43.0 vs. 45.9 per 100,000 donations) and postdonation illness reporting (136.2 vs. 110.8 per 100,000 donations) were similar in both cohorts. CONCLUSIONS: The Australian therapeutic venisection program enables T donors to provide a safe and acceptable source of donated WB that has a low infectious disease risk profile.

Therapeutic venesection at the Australian Red Cross Blood Service: impact of the High Ferritin Application on management of hereditary haemochromatosis.

BACKGROUND: Therapeutic venesection is an established treatment for hereditary haemochromatosis. The C282Y homozygotes and C282Y/H63D compound heterozygotes are the most likely human haemochromatosis protein (HFE) variants to cause iron over-load. The principal indications for treatment include iron overload, which is detected through measurement of hepatic iron concentration or a liver biopsy, or suspected iron-overload on the basis of elevated serum ferritin levels. Venesection is not indicated for other HFE genetic variants or in patients with isolated hyperferritinaemia in the absence of the main HFE gene mutations. The Australian Red Cross Blood Service provides a therapeutic venesection program. Since January 2013, referral has been conducted electronically using the novel, web-based High Ferritin Application. OBJECTIVE: The aim of this article is to provide information regarding implementation of the High Ferritin Application and document its im-pact on referral patterns. DISCUSSION: This referral process is based on nationally endorsed, evidence-based algorithms, which have markedly reduced the number of unnecessary therapeutic venesections. An estimated 4000 unnecessary venesections are averted each year and this equates to a saving of $1.4 million.

Alternative therapeutic options for medical management of epilepsy in apes.

Phenobarbital has been the primary antiepileptic drug used in primates, but the dosage required for seizure control is frequently associated with significant side effects. Newer antiepileptic drugs and adjunctive therapies currently being used in human medicine provide additional options for treatment of nonhuman primates. This report describes different drug regimes used for control of epileptic seizures in apes at the Milwaukee County Zoo (Milwaukee, Wisconsin, U.S.A.), including the addition of acetazolamide to phenobarbital, levetiracetam, carbamazepine, and the use of extended cycle oral contraceptives to assist seizure control in female apes with catamenial epilepsy.

Ultrasonographic monitoring of fetal development in unrestrained bonobos (Pan paniscus) at the Milwaukee County Zoo.

The bonobo, Pan paniscus, is one of the most endangered primate species. In the context of the Bonobo Species Survival Plan(®), the Milwaukee County Zoo established a successful breeding group. Although the bonobo serves as a model species for human evolution, no prenatal growth curves are available. To develop growth graphs, the animals at the Milwaukee County Zoo were trained by positive reinforcement to allow for ultrasound exams without restraint. With this method, the well being of mother and fetus were maintained and ultrasound exams could be performed frequently. The ovulation date of the four animals in the study was determined exactly so that gestational age was known for each examination. Measurements of biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) were used to create growth curves. Prenatal growth of P. paniscus was compared with the data of humans and the common chimpanzee, P. troglodytes. With respect to cranial structures, such as BPD and HC, humans have significant acceleration of growth compared with P. paniscus and P. troglodytes. In P. paniscus, growth of AC was similar to HC throughout pregnancy, whereas in humans AC only reaches the level of HC close to term. Growth rate of FL was similar in humans and the two Pan species until near day 180 post-ovulation. After that, the Pan species FL growth slowed compared with human FL. The newly developed fetal growth curves of P. paniscus will assist in monitoring prenatal development and predicting birth dates of this highly endangered species.

Prognosis of isolated mild to moderate fetal cerebral ventriculomegaly: a systematic review.

AIMS: To ascertain risk of aneuploidy, infection and neurological abnormality for the fetus diagnosed with isolated mild (10.1-12.0 mm) to moderate (12.1-15.0 mm) cerebral ventriculomegaly and to compare the neurological outcome between symmetrical vs. asymmetrical and stable vs. progressive ventriculomegaly. METHODS: A systematic review was conducted. Literature was identified by searching two bibliographical databases between 1980 and 2009 without language restrictions. The data extracted were inspected for heterogeneity. Overall rates and confidence intervals (CIs) for each prognostic factor were calculated. When comparative data existed, the odds ratio (OR) was calculated. RESULTS: The search strategy yielded 2150 relevant citations of which 28 studies were included in the review. The overall rate of infection and chromosomal abnormality was 1.5 and 5% (95% CI 3, 7), respectively. The risk of neurological abnormality regardless of karyotype or infection screen was 14% (95% CI 10, 18) and this reduced to 12% (95% CI 9, 15) when both chromosomes and infection screen were normal. The risk of neurological abnormality was significantly lower in stable compared to progressive ventriculomegaly [OR 0.29 (95% CI 0.15, 0.58)]. No significant differences were detected when symmetrical vs. asymmetrical ventriculomegaly were compared [OR 0.91 (95% CI 0.34, 2.41)]. CONCLUSION: This systematic review provides the physician with some estimates of prognosis in cases of isolated mild to moderate ventriculomegaly.

A primary care cardiovascular risk reduction clinic in Canada was more effective and no more expensive than usual on-demand primary care--a randomised controlled trial.

The objective of this randomised controlled trial was to compare the effects and expense of three approaches to care (1) proactive cardiovascular risk reduction (CaRR) clinic; (2) nurse telephone calls; or (3) usual care for people with cardiovascular risk factors in a Primary Care, Health Service Organisation (HSO) in Ontario, Canada. Subjects included consenting patients with an identified cardiovascular disease (CVD) risk factor identified from the HSO computerised patient information system in 2004. Patients were excluded if they were mentally incompetent, <18 years of age, in a nursing home, or not English speaking. Of 1570 eligible subjects, 523 (33.3%) verbally declined, 145 (9.2%) could not be contacted, and 249 (15.9%) were not needed. The final sample size was 653 (41.6%), 634 completed the follow-up (97%). The Cardiovascular Risk Score, Health and Social Service Utilisation, Montgomery-Asberg Depression Rating, Billings and Moos Indices of Coping, Personal Resource and Self-Efficacy Questionnaires were measured at baseline and 1-year follow-up by clinical examination and telephone interview. Cardiovascular risk scores were reduced in all treatment groups after 1 year. The proportions of subjects showing reduction in risk score greater than or equal to 10% was greatest in the CaRR group (69.2%) compared with Nurse Phone intervention (57.8%) and Usual Care (59.0%) (M-Hchi(2) = 4.33, df = 1, P = 0.037, CaRR-Usual Care). Self-efficacy scores showed the greatest improvements in the CaRR clinic. This effect was achieved with no significant difference in total person per annum costs for direct and indirect health and social service utilisation between all three groups. A CaRR clinic is more effective in reducing CVD risk after 1 year compared with nurse phone intervention and usual care with no additional expense found.

Characterization of pulmonary rehabilitation programs in Canada in 2005.

BACKGROUND: Pulmonary rehabilitation (PR) is recognized as the prevailing standard of care for patients with chronic respiratory conditions. National surveys of PR programs provide important information regarding the structure, content and organization of these programs. OBJECTIVE: To conduct a national survey to characterize adult PR across Canada, in terms of program distribution, utilization, content and outcome measures. METHODS: A cross-sectional descriptive study in which questionnaires were mailed to PR programs connected with hospitals or identified through the Canadian Lung Association was performed. RESULTS: Of the 98 PR programs identified, over 90% of patients in the programs had chronic obstructive pulmonary disease (COPD) and 57% of the programs were outpatient. Inpatient programs accounted for only 10% of the total. The main program components included supervised lower extremity strength (77%), cycle (72%) and treadmill (70%) training, education (75%) and breathing retraining (68%). Over 80% of patients completed their programs and 90% of patients were enrolled in a follow-up component. Physical therapists, dieticians, respiratory therapists and respirologists were the most commonly identified health care providers. The most commonly used outcome measures were the 6 min walk test and disease-specific quality of life questionnaires. CONCLUSION: There were similarities in program format, content, staffing, follow-up and funding among Canadian PR programs. The marked shortfall between the national PR capacity and the prevalence of COPD meant that only 1.2% of the COPD population had access to PR.

Changes in children's behavior and costs for service use associated with parents' response to treatment for dysthymia.

OBJECTIVE: This study examined differences in children's behavior and expenditures for health and social services used when their parents with dysthymia did or did not respond to antidepressant therapy. METHOD: Children ages 4 to 16 years of consenting parents enrolled in a treatment trial for dysthymia who did and did not respond to treatment were compared at baseline and 24 months. The responder was a parent with at least a 40% reduction in his or her baseline depressive symptoms using the Montgomery Asberg Depression Rating Scale. Children's behavior was measured using the Child Behavior Checklist, and expenditures for health and social services use was measured in Canadian dollars using the Health and Social Service Utilization Questionnaire. RESULTS: Children of parents with dysthymia who responded to treatment had significantly greater reductions in emotional symptoms at 2-year follow-up than children of nonresponders, along with an economically important (not statistically significant) reduction in expenditures for health and social services use. CONCLUSIONS: Reductions in parental symptoms of dysthymia may be associated with reductions in childhood behavioral problems and in expenditures for the child's use of services.

High incidence of deformity in aquatic turtles in the John Heinz National Wildlife Refuge.

The John Heinz National Wildlife Refuge is subject to pollution from multiple sources. We studied development of snapping turtle (Chelydra serpentina) and painted turtle (Chrysemys picta) embryos from the refuge from 2000 through 2003. Mean annual deformity rate of pooled painted turtle clutches over four years ranged from 45 to 71%, while that of snapping turtle clutches ranged from 13 to 19%. Lethal deformities were more common than minor or moderate deformities in embryos of both species. Adult painted turtles had a higher deformity rate than adult snapping turtles. Snapping turtles at JHNWR had high levels of PAH contamination in their fat. This suggests that PAHs are involved in the high level of deformities. Other contaminants may also play a role. Although the refuge offers many advantages to resident turtle populations, pollution appears to place a developmental burden on the life history of these turtles.

Burden of dysthymia and comorbid illness in adults in a Canadian primary care setting: high rates of psychiatric illness in the offspring.

BACKGROUND: The burden of comorbid dysthymia and other comorbid psychiatric illnesses in a Canadian primary care setting was measured. Two groups of primary care patients: those who scored positive for comorbid dysthymia versus those who scored negative for any psychiatric disorder were compared. METHODS: This was a cross-sectional survey in a Health Service Organization (HSO) in Ontario, Canada. The subjects were patients of the HSO. The main outcome measures were: health status, mood, social adjustment, coping ability, children's psychiatric disorders, child development, family function, and health and social service utilization. RESULTS: Of the 6280 eligible adults who were patients at the HSO, 68.9% consented to be screened for psychiatric disorders; 5.1% screened positive for dysthymia, of which 90% had at least one comorbid psychiatric disorder. The following statistically significant differences were found between people with dysthymia and other comorbid psychiatric disorders versus people without any psychiatric disorder. People with dysthymia were more likely to have worse health status, worry more about their health, and report levels of pain that impaired their function; they had higher MADRS depression scores, lower social role function scores, lower social adjustment scores, and lower coping ability. More children of people with comorbid dysthymia met criteria for one or more childhood psychiatric disorders and there were more families with a parent with dysthymia that were dysfunctional. People with dysthymia used a greater proportion of health and social services, had higher per person annual health care costs (excluding hospital services), and had higher per person annual indirect costs (lost wages). CONCLUSION: This analysis demonstrated the burden of illness and costs that this disorder imposes on individuals, their families, and society as a whole.

Infections in the heart transplant recipient.

The overall incidence of infection after transplantation has decreased with improved immunosuppressive agents, increased knowledge and use of prophylaxis, and better detection and treatment of infection. Nevertheless, infection continues to be a major cause of morbidity and mortality in heart transplant recipients. The knowledgeable nurse in any setting who cares for a transplant recipient must be aware of the lifelong susceptibility to common and opportunistic infections. The transplant recipient and his or her family must also be aware of the risks of early opportunistic infection. Infection is a lifelong concern for all persons on immunosuppressant medications, and the individual must learn appropriate precautions to reduce this risk. Hand washing and avoidance of infected individuals are the most important self-care actions that the transplant patient should adopt. Recipients must also learn to monitor for subtle signs of infection. The nurse is responsible for teaching self-care to patients and family members. Ultimately, a team effort by the patient, family, nurses, and physicians can reduce the risk of infection in this vulnerable population.

Sertraline and/or interpersonal psychotherapy for patients with dysthymic disorder in primary care: 6-month comparison with longitudinal 2-year follow-up of effectiveness and costs.

BACKGROUND: There is little information on the long-term effects and costs of a combination of Sertraline and interpersonal psychotherapy (IPT) for the treatment of dysthymia in primary care. METHODS: In a single-blind, randomized clinical trial, 707 adults (18-74 years of age inclusive) with DSM-IV dysthymic disorder, with or without past and/or current major depression, as an acute or chronic episode, in a community-based primary care practice in Ontario, Canada, were randomized to treatment with either Sertraline alone (50-200 mg), or IPT alone (10 sessions), or Sertraline plus IPT combined. In the acute treatment phase (first 6 months) all groups received full active treatment. This was followed by an additional 18-month naturalistic follow-up phase. Subjects were assessed for effectiveness of treatment in reducing depressive symptoms using the Montgomery Asberg Depression Rating Scale (MADRS) at 6 months and twice again during the 18-month follow-up by blind independent observers. Treatment costs and subjects' use of other health and social services were also investigated. RESULTS: At 6 months, 586 subjects completed the MADRS questionnaire. There was a significant difference (P=0.025) in mean MADRS scores: 14.3 (Group I); 14.9 (Group II); 16.8 (Group III), using analysis of covariance. Response (40% improvement) rates were 60.2% for Sertraline alone, 46.6% for IPT alone, and 57.5% for Sertraline augmented by IPT (P=0.02). At 2 years, 525 subjects were retained for follow-up. There was no statistically significant difference between Sertraline alone and Sertraline plus IPT in symptom reduction. However, both were more effective than IPT alone in reducing depressive symptoms (P=0.03). There was a statistically significant difference between groups in costs for use of health and social services. The IPT treatment groups had the lower costs for use of health and social services. CONCLUSIONS: Sertraline or Sertraline plus IPT was more effective than IPT alone after 6 months. Over the long term (2 years), all three treatments provide reasonably effective treatment for reducing symptoms of dysthymia, but Sertraline or combining Sertraline with IPT is more effective than IPT alone. Of these two more effective treatments, subjects in the Sertraline plus IPT group had less health and social service costs by $480 per person over 2 years. These findings underscore the effects of combining pharmacotherapy and psychotherapy and the economic value of this more comprehensive treatment of dysthymia in primary care.

The challenge of managing the care of older heart transplant recipients.

Age is perhaps the most controversial exclusion criterion for heart transplantation. One concern focuses on whether chronological or functional age is the better predictor of positive outcomes when considering heart transplantation for an elderly patient with end-stage heart disease. Another concern is related to the philosophical and ethical rationale for allocation of scarce resources to those near the end of a normal life expectancy. However, the number of people who are older than age 65 years and have received a donor heart has increased and will continue to due to aging of the people who received a transplant a decade ago, as well as the growing number of people who undergo heart transplantation after the age of 65. In either case, the nurse must be aware of age-related concerns in this vulnerable population.