A review of the antimicrobial activity of thermodynamically stable microemulsions.

Microemulsions are thermodynamically stable, transparent, isotropic mixtures of oil, water and surfactant (and sometimes a co-surfactant), which have shown potential for widespread application in disinfection and self-preservation. This is thought to be due to an innate antimicrobial effect. It is suggested that the antimicrobial nature of microemulsions is the result of a combination of their inherent kinetic energy and their containing surfactants, which are known to aid the disruption of bacterial membranes. This review examines the contemporary evidence in support of this theory.

Tobacco and alcohol-related interventions for people with mild/moderate intellectual disabilities: a systematic review of the literature.

BACKGROUND: The behavioural determinants of health among people with mild/moderate intellectual disabilities (ID) are of increasing concern. With the closure of long-stay institutions, more people with ID are living in the community. As they lead more ordinary and less restricted lives, people with ID may be exposed to social and environmental pressures that encourage them to adopt behaviours that impact negatively on their health. Levels of smoking and alcohol consumption in this client group are of particular concern. METHODS: We undertook a mixed method review of the literature, aiming to assess the Feasibility, Appropriateness, Meaningfulness and Effectiveness (FAME) of interventions designed to address the use of tobacco and/or alcohol in people with mild/moderate ID. Key electronic databases were searched (e.g., Medline, Cochrane Register of Controlled Trials, PsycINFO) from 1996 to 2011. The search was developed using appropriate subject headings and key words (e.g., intellectual disability, tobacco use, alcohol drinking, health promotion). On completion of the database searches, inclusion/exclusion criteria, based on an adaptation of the PICO framework (Population, Intervention, Comparison, Outcomes), were applied. Methodological quality was assessed using a seven-point rating scale. RESULTS: Database searches identified 501 unique records, of which nine satisfied the inclusion criteria. Four focused on tobacco, three on alcohol and two on both tobacco and alcohol. Located in the U.K., the U.S.A. and Australia, the studies aimed to increase knowledge levels and/or change behaviour (e.g., to encourage smoking cessation). One was a randomised controlled trial, one a quasi-experiment and the others were before and after studies and/or case studies. Methodological quality was poor or moderate. The combined studies had a sample size of 341, with ages ranging from 14 to 54 years. The interventions were delivered by professionals (e.g., in health, social care, education) during sessions that spanned a period of three weeks to one academic year. The studies highlighted a number of important issues linked to the appropriateness of interventions for this client group (e.g., use of pictures, quizzes, role play, incentives); however, in the majority of cases the interventions appeared to lack a theoretical framework (e.g., behaviour change theory). The appropriateness of the outcome measures for use with this client group was not tested. One study discussed feasibility (teachers delivering lessons on alcohol and tobacco) and only one was informative in terms of effectiveness, i.e., increasing knowledge of the health and social dangers of smoking and excessive alcohol consumption. CONCLUSIONS: This review is the first to systematically collate evidence on tobacco and alcohol-related interventions for people with ID. While there is currently little evidence to guide practice, the review delivers clear insights for the development of interventions and presents a strong case for more robust research methods. In particular there is a need to test the effectiveness of interventions in large-scale, well-designed trials and to ensure that outcome measures are developed/tailored appropriately for this client group.

Nurse-led central venous catheter service: Christie experience.

The aim of this study was to evaluate the success and complication rate of Nurse-led subclavian central venous catheter (CVC) insertion using the landmark technique. A prospective study was performed on all subclavian CVC insertion between 13/01/03 to 01/07/03. Data recorded included indication for catheter insertion, type of catheter, complications during the procedure and patient satisfaction. A total of 348 subclavian cuffed tunnelled catheters were inserted over the study period. The age group ranged from 31 years to 84 years with a mean age of 53 years. This included 192 women and 156 men. The majority of CVC insertions were through the right subclavian (79%) and were single lumen (76%). In total, complications were encountered in 48 patients (14%). These included misplaced tip in 29 (8%), arterial puncture in 16 (4%), pneumothorax in 3 (1%) and the procedure failed in 3 (1%). Of these multiple complications were seen in 3 (1%). No interventions were required for the pneumothoraces or for the arterial punctures. In conclusion, nurse-led subclavian CVC placements using the landmark technique are both safe and effective.

To clot or not to clot? That is the question in central venous catheters.

AIM: To establish the relationship between the tip position of tunnelled central venous catheters (CVC) and the incidence of venous thrombosis. MATERIALS AND METHODS: A randomly sampled, retrospective review of 428 CVC inserted into 334 patients was performed. The chest radiograph obtained post-catheter insertion, as well as follow-up radiographs, linograms, venograms and Doppler ultrasounds (US), were reviewed. RESULTS: The median follow-up was 72 days (range 1-720 days), with a total follow-up of 23,040 line days. Venous thrombosis occurred in five out of 191 (2.6%) CVC in a distal position (distal third of the superior vena cava (SVC) or right atrium (RA)), five of 95 (5.3%) in an intermediate position (middle third of the SVC) and 20 of 48 (41.7%) in a proximal position (proximal third SVC or thoracic inlet veins). There was a significant difference in thrombosis rate between lines sited with the tip in a distal compared with a proximal position (p<0.0005). CVC with tips in a proximal position were 16 times more likely to thrombose than those in a distal position. None of the 58 CVC with the tip located in the RA thrombosed or caused complications. CONCLUSION: Distal placement of tunnelled CVC, either in the distal third of the SVC or proximal RA is optimal.

A randomised controlled trial to evaluate the clinical and cost-effectiveness of Hickman line insertions in adult cancer patients by nurses.

OBJECTIVES: To examine the clinical and cost-effectiveness of image-guided Hickman line insertions versus blind Hickman line insertions undertaken by nurses in adult cancer patients. DESIGN: A cost-effectiveness analysis was carried out alongside a randomised controlled trial. SETTING: A large acute cancer centre in Manchester, UK. PARTICIPANTS: Cancer patients due to have a Hickman line insertion who were over 18 years of age and were clinically and physically compliant with specified protocols. INTERVENTIONS: In order to obtain central venous access for the patient, two interventions were investigated: (i) blind insertion of a Hickman line and (ii) image-guided insertion of a Hickman line. Both interventions involved blind venipuncture of the subclavian vein. In the blind arm, the Hickman line was routinely inserted without the use of image guidance at any point in the procedure. Transfer to the interventional X-ray suite and use of image guidance were options immediately available to the operator during the procedure if required. In the image-guided arm, the position of the guidewire was checked before the Hickman line was introduced and later the Hickman line was positioned with the use of X-ray fluoroscopy. MAIN OUTCOME MEASURES: The primary clinical outcome measure was catheter-tip misplacement and this was expected to be higher in the blind arm. When comparing the skill level of the trainer and the trainees, pneumothorax was the primary clinical outcome measure. Other outcomes measures included arterial puncture, haematoma, infection, failed insertion and assistance from other healthcare professionals. RESULTS: No statistically significant difference was found between the mean cost per patient in the two arms of the trial. The only statistically significant difference in clinical outcomes was the frequency of catheter-tip misplacement, which was higher in the blind arm of the trial. At very low costs, the image-guided approach dominates the blind approach as fewer costs and greater benefits are incurred. It is evident that nurses previously inexperienced in the procedure can be trained to insert Hickman lines successfully both at the bedside and under image guidance within a 3-month period. CONCLUSIONS: This report indicates that nurse insertion of Hickman lines in the majority of adult cancer patients is both safe and effective. However, there are a select group of patients for whom image-guided insertion may be preferred. The results reveal that skills and expertise can be transferred from trainer to trainee through a relatively short, but intensive, training course. It is also evident that patients support nurse insertion. Further research is suggested to compare the safety and efficacy of nurse versus doctor insertions in particular subgroups of patients and also to assess the quantity and quality of current service provision in order to inform NHS decision-making in this area.

The education of advanced practice nurses: a contemporary approach.

The Advanced Practice Nursing of Adults and the Elderly graduate program at San Diego State University School of Nursing prepares experienced professional nurses with primary and specialized care (acute or critical care) knowledge and skills to deliver health care to adults and elders across practice settings as nurse practitioners and clinical nurse specialists. Emphasis is placed on health care that is research based and congruent with national standards of practice. This approach to graduate education is congruent with recommendations of professional nursing organizations and responds to the educational needs of professional nurses and the health care needs of adult and elders.

An open phase I study to assess the biological effects of a continuous intravenous infusion of Interleukin-3 followed by Granulocyte Macrophage-Colony Stimulating Factor.

To assess any synergistic stimulatory effect in vivo of Interleukin 3 (IL-3) and Granulocyte Macrophage-Colony Stimulating Factor (GM-CSF) upon white cell and platelet counts, toxicity and antitumour effect, we conducted this phase I study. IL-3 0.25, 0.5 or 5 micrograms/kg/day for 1, 4 or 7 days was given by continuous intravenous (i.v.) infusion to 35 patients with advanced malignancy. 21 of the 35 patients also received sequential or overlapping treatment with continuous i.v. infusion of GM-CSF 1 or 3 micrograms/kg/day for up to 10 days. Monotherapy with IL-3 producted significant dose related increases in platelets and white cell counts. Combinations of IL-3 and GM-CSF also produced increases in white cell counts, but these were no greater than would be expected following GM-CSF treatment alone. There was a trend for platelets to increase more in patients receiving IL-3 and GM-CSF than those receiving IL-3 alone, but this did not reach statistical significance. In general, IL-3 and combinations of IL-3 and GM-CSF were well tolerated and the most common side-effect was fever. A maximum tolerated dose was not reached and antitumour effects were not seen. Future studies using combinations of IL-3 5 micrograms/kg/day and GM-CSF 3 micrograms/kg/day may help to define the optimal therapeutic regimen.

Effect of a standardized rewarming protocol and acetaminophen on core temperature after coronary artery bypass.

BACKGROUND: Cardiac surgical patients who require hypothermic cardiopulmonary bypass experience hypothermia, normothermia, and hyperthermia during the early postoperative period. Research-based rewarming protocols are needed to manage temperature variations. OBJECTIVE: To describe the effect of a standardized rewarming protocol and acetaminophen on the following outcome variables: core temperature, peak core temperature, rewarming time, and hyperthermia. METHODS: Patients (N = 60) were rewarmed using a standardized rewarming protocol. Electric heating blankets were used for subjects with core temperatures less than 36 degrees C on admission to the intensive care unit; other subjects were covered with cotton bath blankets. Subjects were also assigned to one of three acetaminophen groups (650 mg at 38.1 degrees C, 650 mg at 37 degrees C, 1300 mg at 37 degrees C). RESULTS: Using the protocol, subjects warmed to normothermia in 3.6 to 6 hours. The 16-hour core temperature thermal curves of heating blanket versus cotton bath blanket subjects differed significantly; thermal curves of the acetaminophen groups were similar. Peak core temperature was significantly lower in heating blanket subjects and unaffected by acetaminophen group. The onset of hyperthermia was not significantly affected by the method of rewarming (electric heating blanket versus cotton blankets) or acetaminophen group. Rewarming time was significantly longer for electric heating blanket subjects. CONCLUSIONS: Our results indicate that mildly hypothermic subjects rewarmed with electric heating blankets during the early postoperative period have lower peak core temperatures and longer rewarming times than those rewarmed with cotton bath blankets. Acetaminophen administration at normothermia does not significantly affect peak core temperature or the onset of hyperthermia.

Nutritional management of the metabolically stressed patient.

The nutritional management of the critically ill metabolically stressed patient has changed drastically within the last two decades. Alterations in carbohydrate, fat, and protein metabolism following severe injury affect effective substrate utilization and the provision of nutritional or metabolic support. This article describes the acute alterations in carbohydrate, fat, and protein metabolism during severe metabolic stress; reviews nutritional assessment and requirements during metabolic stress; and presents recent findings that influence nutritional support during metabolic stress. The role of gut in the provision of nutritional support and the pharmacologic properties of select enteral nutrients are reviewed.

Effects of interleukin-6 on mobilization of primitive haemopoietic cells into the circulation.

Twenty-seven patients with advanced adenocarcinoma were studied. Groups of three patients received interleukin-6 (IL-6) in doses ranging from 0.5 to 20 micrograms/kg by daily subcutaneous injection on days 1-7 and 22-49. Four patients received IL-6 2.5 micrograms/kg/d with GM-CSF 5 micrograms/kg/d and three patients received IL-6 2.5 micrograms/kg/d with IL-3 5 micrograms/kg/d. Circulating platelet numbers increased 1.65-fold during IL-6 treatment, in a dose-dependent fashion (P = 0.01). This increase is inferior to that expected from laboratory studies. No significant change in total WBC was seen after IL-6 alone. After treatment with IL-6, significant increases in numbers of circulating mononuclear cells (2.2-fold, P = 0.006) and GM-CFC numbers (3.2-fold, P = 0.01) were seen, but there were no changes in circulating megakaryocyte-CFC numbers. In contrast, after treatment with IL-6 and GM-CSF, larger increases in both circulating GM-CFC (20-fold, P = 0.04) and megakaryocyte-CFC numbers (18-fold, P = 0.03) were seen. Increases in blood progenitors after treatment with IL-6 and IL-3 did not achieve statistical significance. The ability of peripheral blood mononuclear cells to generate and sustain long-term haemopoiesis in vitro was similar in IL-6-treated patients to that in untreated control subjects. No significant changes in the incidence of bone marrow progenitors or their cycling status (assessed by thymidine suicide) were seen. These data suggest that IL-6 alone will not be clinically useful to mobilize blood progenitor cells in cancer patients.

VAD chemotherapy as remission induction for multiple myeloma.

A total of 142 patients with multiple myeloma received VAD as remission induction therapy. Seventy-five were previously untreated and 67 had relapsed (31) or refractory disease (36). Vincristine (total dose 1.6 mg) was infused with doxorubicin 36 mg m-2 by continuous ambulatory pump over 4 days. In addition, oral dexamethasone 40 mg day-1 was given for 4 days. Intermittent dexamethasone was only given to 19 patients. Courses were repeated every 21 days. The overall response rate was 84% [27% complete response (CR)] in previously untreated patients and 61% (3% CR) in patients with relapsed and refractory disease. The median survival was 36 months for untreated patients and 10 months for those who had received prior therapy. VAD was well tolerated; however, despite prophylaxis, 54% patients received antibiotics at some time during therapy and 37% had dyspepsia. Twenty-three patients subsequently received a transplant (eight allografts, eight marrow autografts and seven peripheral blood stem cell transplants). Eight have died-four in the allogeneic group and four in the autologous group. The overall median survival of transplanted patients has not yet been reached. VAD is an effective, out-patient therapy for inducing remission in multiple myeloma. Post-remission therapy needs to be optimised, but it is likely that the needs of previously untreated patients may be different from those with relapsed and refractory disease.

Focus on research utilization.

This column focuses on research utilization in future issues. In this article, the coeditors of this column review the differences between the conduct of research and research utilization, describe the decision-making process for research utilization, and discuss the Agency for Health Care Policy and Research Clinical Practice Guidelines.

Haemopoietic progenitor and myeloid cell kinetics in humans treated with interleukin-3 and granulocyte/macrophage colony-stimulating factor in combination.

Patients with advanced adenocarcinoma of the colon, rectum or pancreas were entered into trials for evaluation of treatment with sequential doses of IL-3 and GM-CSF. They received 0.25 to 5 micrograms IL-3/kg/d for up to 7 days, followed by 1 microgram GM-CSF/kg/day for a maximum of 10 further days. We assessed the kinetics of bone-marrow cell proliferation and of blood production using tritiated thymidine labelling in vitro and in vivo. Megakaryocytic-CFC were unaffected but proliferation rates of GM-CFC and BFU-E were increased. Progenitor cells were mobilized (12-fold over baseline) into the peripheral blood. The proliferative activity of maturing cells in the marrow was increased (cell-cycle times were reduced by at least 30%). This translated into amplified blood cell production (WCC approximately 30 x 10(9)/l), a 2.2-fold increase in platelet counts and significant eosinophilia. Newly generated neutrophils appeared in the circulation at the normal time and their peripheral half-life was also normal. The calculated 3.2-fold amplification in neutrophil production required nearly 2 extra divisions in the marrow, shared between the progenitors and the proliferating granulocytic cells. The results were compared with those of a previous trial using GM-CSF only, although at a 10-fold higher dose level. Comparable levels of peripheral neutrophils were obtained in both trials but significant ineffective granulopoiesis developed in the earlier study. This was overcome in the present study, the priming dose of IL-3 apparently giving the latitude to utilize lower doses of GM-CSF with less risk of complications.

Nutritional management of the metabolically stressed patient.

The nutritional management of the critically ill metabolically stressed patient has changed drastically within the last two decades. Alterations in carbohydrate, fat, and protein metabolism following severe injury affect effective substrate utilization and the provision of nutritional or metabolic support. This article describes the acute alterations in carbohydrate, fat, and protein metabolism during severe metabolic stress; reviews nutritional assessment and requirements during metabolic stress; and presents recent findings that influence nutritional support during metabolic stress. The role of gut in the provision of nutritional support and the pharmacologic properties of select enteral nutrients are reviewed.

Consequences of trauma: systemic inflammation and multiple organ dysfunction.

Critically injured patients are at risk for systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). MODS is a clinical syndrome of progressive physiologic dysfunction of organ systems. Trauma patients are at high risk for SIRS/MODS because of circulatory shock with tissue hypoxemia, tissue injury, and infection. Organ dysfunction may be a direct consequence of an insult (primary MODS) or may manifest latently (secondary MODS) and involves organs not initially injured. Management of SIRS/secondary MODS requires control/elimination of the source of inflammation, maintenance of tissue oxygenation, nutritional/metabolic support, support for individual organs, and effective pain control.

Immune function of patients receiving recombinant human interleukin-6 (IL-6) in a phase I clinical study: induction of C-reactive protein and IgE and inhibition of natural killer and lymphokine-activated killer cell activity.

Interleukin-6 (IL-6) is a cytokine that acts on a variety of cell types, including myeloid progenitor cells and B and T lymphocytes. It has been found to activate cytotoxic T cells and natural killer (NK) cells and to induce T-cell-mediated antitumour effects in animal models. In a phase I clinical trial of recombinant human IL-6, 20 patients with advanced cancer were entered to receive daily subcutaneous injections of IL-6 over 7 days followed by a 2-week observation period and another 4 weeks of daily IL-6 injections. Doses varied between 0.5 microgram/kg and 20 micrograms/kg body weight and immune functions were monitored throughout. At all dose levels IL-6 administration led to a marked increase in serum levels of C-reactive protein and a moderate rise in complement factor C3. The proportions of CD4, CD8 or HLA-DR lymphocytes in peripheral blood did not alter with IL-6 treatment nor did the in vitro proliferation of peripheral blood mononuclear cells induced by either phytohaemagglutinin, pokeweed mitogen or fixed Staphylococcus aureus. By contrast, NK cell activity, lymphokine-activated killer (LAK) cell activity and proliferation induced by in vitro culture with interleukin-2 (IL-2) were suppressed at doses exceeding 2.5 micrograms/kg. Serum IgE levels were consistently elevated over the IL-6 dose range but IgM, IgG and IgA levels were unaffected. In summary there is a dose-dependent induction of acute-phase proteins by in vivo IL-6 treatment. At higher IL-6 doses there is a suppressive effect on NK and LAK activity measured in vitro. IL-6 may thus be useful in combination cytokine therapies that seek to suppress LAK and favour cytotoxic T lymphocyte responses. The rise in IgE levels in response to IL-6 was unexpected and suggests a more pivotal role than previously known for the control of IgE production; this could include IgE-related diseases.

Caring for patients with ventricular assist devices.

The purpose of this article is to stimulate nursing research questions and potential areas for study related to patients with ventricular assist devices. Multidisciplinary research is needed, and nurses should play a key role in developing database variables and research for patients with this technology.

Effects of intravenous magnesium sulphate in acute myocardial infarction.

This column reviews the results of second Leicester Intravenous Magnesium Sulphate Intervention Trial (LIMIT-2), a clinical study investigating the effects of intravenous magnesium sulphate on 28-day mortality and morbidity in suspected AMI patients. Many LIMIT-2 subjects also received thrombolytic and anti-platelet therapy, differentiating findings of this study from earlier results. Implications for practice, education, and future research are discussed.

Post-cardiac surgery patterns of social and sexual activity.

The hallmark for recovery from cardiac surgery may be the full return to social and sexual activity. Three studies are reviewed that examine the level of social and sexual adjustment at three points in time following surgery: 4 to 10 weeks, 3 to 6 months, and 12 months. Implications for practice and further research are discussed.

Research connections: nursing practice and ECG monitoring.

This article reviews and critiques the study by Drew et al that describes the electrocardiographic monitoring practices of critical care nurses. The study was conducted with a national sample and documented standards of practice. The implications for practice, education, and research are addressed.