Standardised concentrations of morphine infusions for nurse/patient-controlled analgesia use in children.

BACKGROUND: Standardizing concentrations of intravenous infusions enables pre-preparation and is effective in improving patient safety by avoiding large deviations from the prescribed concentration that can occur when infusions are made individually in wards and theatres. The use of pre-prepared morphine standardized concentration infusions for paediatric nurse/patient-controlled analgesia (N/PCA) has not been previously investigated. We aimed to establish, implement and evaluate standardized concentrations of morphine in pre-filled syringes (PFS) for use in paediatric N/PCA. METHODS: Concentrations of morphine in PFS for N/PCA were identified that accommodated dosage variation across a 1-50 kg weight range. The use of infusions in PFS was implemented and evaluated using mixed methods involved direct observation of healthcare professionals (HCPs), focus groups and failure mode and effects analysis, a HCP survey and medication incident reports analysis. RESULTS: Standardized concentrations, 3 mg, 10 mg and 50 mg morphine in 50 mL sodium chloride 0.9%, delivered prescribed continuous and bolus doses using programmable smart pumps with variable infusion rates. During the implementation, 175 morphine pre-prepared infusions were administered to 157 children (9.4 ± 5.1 years) in theatres and wards. Time taken to set up a N/PCA was 3.7 ± 1.7 min, a reduction of one third compared with the previous system. The number of incidents associated with N/PCA infusions was reduced by 41.2%, and preparation errors were eliminated. HCPs reported using morphine PFS was an easier and safer system. CONCLUSION: A system using pre-prepared standardized concentrations of morphine for paediatric N/PCA was implemented successfully and sustainably.

C-F Bond Activation of P(C6F5)3 by Ruthenium Dihydride Complexes: Isolation and Reactivity of the "Missing" Ru(PPh3)3H(halide) Complex, Ru(PPh3)3HF.

The major product of the reaction between Ru(IMe4)2(PPh3)2H2 (1; IMe4 = 1,3,4,5-tetramethylimidazol-2-ylidene) and P(C6F5)3 (PCF) is the five-coordinate complex Ru(IMe4)2(PF2{C6F5})(C6F5)H (2), which is formed via a complex series of C-F/P-C bond cleavage and P-F bond formation steps. In contrast, hydrodefluorination of all six ortho C-F bonds in PCF occurs with Ru(PPh3)4H2 to afford Ru(PPh3)3HF (3). NaBArF4 abstracted the fluoride ligand in 3 to give [Ru({η6-C6H5}PPh2)(PPh3)2H][BArF4], while B2pin2 reacted with 3 in C6D6 to yield a mixture of [Ru({η6-C6D6)(PPh3)2H]+ and Ru(PPh3)4H2. The treatment of 3 with HBpin (5 equiv) and HSiR3 (R = Et, Ph; 2 equiv) afforded Ru(PPh3)3(σ-HBpin)H2 and Ru(PPh3)3(SiR3)3H3, respectively. No stable substitution products were generated when 3 was reacted with Me3SiX (X = CF3, C6F5).

Identifying pre-hospital factors associated with outcome for major trauma patients in a regional trauma network: an exploratory study.

BACKGROUND: Major trauma is often life threatening and the leading cause of death in the United Kingdom (UK) for adults aged less than 45 years old. This study aimed to identify pre-hospital factors associated with patient outcomes for major trauma within one Regional Trauma Network. METHOD: Secondary analysis of pre-hospital audit data and patient outcome data from the Trauma Audit Research Network (TARN) was undertaken. The primary outcome used in analysis was 'Status at Discharge' (alive/deceased). Independent variables considered included 'Casualty Characteristics' such as mechanism of injury (MOI), age, and physiological measurements, as well as 'Response Characteristics' such as response timings and skill mix. Binary Logistic Regression analysis using the 'forward stepwise' method was undertaken for physiological measures taken at the scene. RESULTS: The study analysed 1033 major trauma records (mean age of 38.5 years, SD 21.5, 95% CI 37-40). Adults comprised 82.6% of the sample (n = 853), whilst 12.9% of the sample were children (n = 133). Men comprised 68.5% of the sample (n = 708) in comparison to 28.8% women (n = 298). Glasgow Coma Score (GCS) (p < 0.000), Respiration Rate (p < 0.001) and Age (p < 0.000), were all significant when associated with the outcome 'Status at Discharge' (alive/deceased). Isolated bivariate associations provided tentative support for response characteristics such as existing dispatching practices and the value of rapid crew arrival. However, these measurements appear to be of limited utility in predictive modelling of outcomes. DISCUSSION: The complexity of physiological indices potentially complicate their predictive utility e.g. whilst a Systolic Blood Pressure (SBP) of < 90 mmHg serves as a trigger for bypass to a Major Trauma Centre, the utility of this observation is nullified in cases of Traumatic Brain Injury. Analysis suggested that as people age, outcomes from major trauma significantly worsened. This finding is consistent with existing research highlighting the relationship between trauma in elderly patients and poorer outcomes. CONCLUSION: Findings lend further validity to GCS, Respiration Rate and Age as predictive triggers for transport to a Major Trauma Centre. Analysis of interactions between response times, skill mix and triage demand further exploration but tentatively support the 'Golden Hour' concept and suggest a potential 'load and go and play on the way' approach.

Training community matrons in basic cognitive behavioural therapy-based techniques for patients with COPD.

People with chronic obstructive pulmonary disease (COPD) experience anxiety and depression with a higher prevalence than the general population. Despite this, they are under-represented in mental health services on a national scale, but do regularly have contact with health-care professionals such as community matrons. We aimed to explore the process of CBT-based skills supervision and the practical implications for community matrons using CBT-based techniques with COPD clients as part of their standard practice. Twenty community matrons took part in a 2-day CBT-based skills training programme. Measurements of their knowledge and understanding of CBT-based skills were taken before and following the training. Additionally, they completed written feedback relating to the training. They were then supervised by CBT therapists for 6 months. Written feedback was obtained following this and some supervisors participated in a 1-hour focus group to discuss the process. Community matrons' knowledge and understanding of CBT-based techniques significantly improved following training, although findings did indicate that merely training did not always seamlessly translate into effective practice. Supervisor feedback suggested that it would be beneficial for community matrons to share positive practice of their use of basic CBT-based techniques among peers to maximise the perceived value of this approach.

Ni(I) and Ni(II) ring-expanded N-heterocyclic carbene complexes: C-H activation, indole elimination and catalytic hydrodehalogenation.

Reaction of the bulky 6-membered N-heterocyclic carbene 6-Mes with Ni(cod)(2) gives a C-H activated 6-Mes nickel(II) complex, but the novel three-coordinate Ni(I) species Ni(6-Mes)(PPh(3))Br if the reaction is performed in the presence of Ni(PPh(3))(2)Br(2). The Ni(I) complex is a precursor for the catalytic hydrodehalogenation of aryl halides.

Distinct subdomain organization and molecular composition of a tight junction with adherens junction features.

Most polarized epithelia constrain solute diffusion between luminal and interstitial compartments using tight junctions and generate mechanical strength using adherens junctions. These intercellular junctions are typically portrayed as incongruent macromolecular complexes with distinct protein components. Herein, we delineate the molecular composition and subdomain architecture of an intercellular junction between sensory and non-sensory cells of the inner ear. In this junction, claudins partition into claudin-14 and claudin-9/6 subdomains that are distinguishable by strand morphology, which contrasts with in vitro data that most claudins co-assemble into heteromeric strands. Surprisingly, canonical adherens junction proteins (p120ctn, alpha- and beta-catenins) colocalize with the claudin-9/6 subdomain and recruit a dense cytoskeletal network. We also find that catenins colocalize with claudin-9 and claudin-6, but not claudin-14, in a heterologous system. Together, our data demonstrate that canonical tight junction and adherens junction proteins can be recruited to a single junction in which claudins partition into subdomains and form a novel hybrid tight junction with adherens junction organization.

Acting the part.

The implementation of two key policies highlighted the need to support nurses and midwives to challenge colleagues effectively. To overcome the difficulties this presented, an innovative training package using drama provided participants with practical tips and a safe environment to practise newly developed skills. The programme was well evaluated but further work needs to be undertaken to evaluate its impact upon practice.

Deafness in Claudin 11-null mice reveals the critical contribution of basal cell tight junctions to stria vascularis function.

Generation of a strong electrical potential in the cochlea is uniquely mammalian and may reflect recent evolutionary advances in cellular voltage-dependent amplifiers. This endocochlear potential is hypothesized to dramatically improve hearing sensitivity, a concept that is difficult to explore experimentally, because manipulating cochlear function frequently causes rapid degenerative changes early in development. Here, we examine the deafness phenotype in adult Claudin 11-null mice, which lack the basal cell tight junctions that give rise to the intrastrial compartment and find little evidence of cochlear pathology. Potassium ion recycling is normal in these mutants, but endocochlear potentials were below 30 mV and hearing thresholds were elevated 50 dB sound pressure level across the frequency spectrum. Together, these data demonstrate the central importance of basal cell tight junctions in the stria vascularis and directly verify the two-cell hypothesis for generation of endocochlear potential. Furthermore, these data indicate that endocochlear potential is an essential component of the power source for the mammalian cochlear amplifier.

The use of phosphate enemas in the treatment of constipation.

Phosphate enemas are commonly used by community nurses in the treatment of constipation. This article reports on a literature review of evidence relating to their use. No evidence was found to support the use of these enemas conclusively, although a number of articles reported risks, contraindications, and complications. Phosphate enemas should therefore be used with caution and nurses should be aware of the contraindications associated with their use.

An actin molecular treadmill and myosins maintain stereocilia functional architecture and self-renewal.

We have previously shown that the seemingly static paracrystalline actin core of hair cell stereocilia undergoes continuous turnover. Here, we used the same approach of transfecting hair cells with actin-green fluorescent protein (GFP) and espin-GFP to characterize the turnover process. Actin and espin are incorporated at the paracrystal tip and flow rearwards at the same rate. The flux rates (approximately 0.002-0.04 actin subunits s(-1)) were proportional to the stereocilia length so that the entire staircase stereocilia bundle was turned over synchronously. Cytochalasin D caused stereocilia to shorten at rates matching paracrystal turnover. Myosins VI and VIIa were localized alongside the actin paracrystal, whereas myosin XVa was observed at the tips at levels proportional to stereocilia lengths. Electron microscopy analysis of the abnormally short stereocilia in the shaker 2 mice did not show the characteristic tip density. We argue that actin renewal in the paracrystal follows a treadmill mechanism, which, together with the myosins, dynamically shapes the functional architecture of the stereocilia bundle.

A national audit of chronic constipation in the community.

This article presents the first available data on current national bowel-care standards. It involves 923 patients based at home or in residential/nursing homes. The baseline findings indicate problems of poorly controlled constipation, a high level of impaction and high use of rectal interventions. All the patients have been receiving laxatives regularly and 42 per cent were on combination laxative therapy. The audit provides evidence of complex, ineffective and/or inappropriate laxative prescribing linked to sub-optimal bowel care.