A systematic review of the effect of early mobilisation on length of stay for adults in the intensive care unit.

BACKGROUND: EM has been hypothesized to help prevent the development of ICU acquired weakness and may therefore result in positive outcomes for ICU patients. AIM: To establish the impact of Early mobilisation (EM) on adult Intensive Care Unit (ICU) patients in terms of ICU length of stay (LOS), as well as hospital LOS, duration of mechanical ventilation, mortality, and functional independence. STUDY DESIGN: A Systematic Review. EMBASE, MEDLINE, CINAHL, and the Cochrane Library were searched on 24th November 2020. Included studies and other systematic reviews were hand-searched for further includable studies. The primary outcome was ICU LOS whilst secondary outcomes were duration of MV, mortality, hospital LOS and functional independence. The PRISMA guidelines were utilized to perform the review. Ten randomized controlled trials with a combined total of 1291 patients met inclusion criteria and were scrutinized using the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews. Revman 5.4.1 was used to conduct meta-analysis were possible. RESULTS: Results were limited by the evidence available for inclusion, in particular small sample sizes. However, a trend towards a shorter duration of ICU LOS and duration of mechanical ventilation emerged. There was also a trend towards higher rates of functional independence for intervention groups. Mortality rates appeared unaffected and results of meta-analysis were statistically non-significant (p = 0.90). CONCLUSION: By applying a stricter time limit than previous systematic reviews a trend emerged that the commencement of EM has a positive effect on patient outcomes, in particular ICU LOS. RELEVANCE TO CLINICAL PRACTICE: The evidence base surrounding EM remains poor; however on the balance of the available evidence the application of EM should not be delayed.

The impact of brain tissue oxygenation monitoring on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended in patients with moderate to severe traumatic brain injury: A systematic review.

BACKGROUND: Traumatic brain injuries (TBIs) are one of the leading causes of death or long-term disability around the world. As a result of improvements in supportive care, patients are surviving more severe insults with more pronounced dependency on their families, hospitals, and long-term care facilities. The introduction of brain tissue oxygenation (PbtO2) monitoring aims to recognize episodes of reduced cerebral perfusion with and without associated increased intracranial pressure (ICP). AIM: The aim of this review is to determine the impact of PbtO2 on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended (GOS/GOSE) in patients with moderate to severe TBI. DESIGN: Systematic review with narrative and meta-analysis. All original research in which adult patients undergoing PbtO2 were compared with a control group of traditional ICP/cerebral perfusion pressure (CPP) monitoring. Both randomized controlled trials and observational studies were included in this review. METHODS: Databases were searched in September 2022. The primary outcome of the review was the impact of PbtO2 monitoring on GOS/GOSE, while secondary outcomes were mortality and length of stay (LOS) in the intensive care unit (ICU). RESULTS: Seven studies with a combined number of 770 patients were included in the review. These patients were adults ≥16 years of age. Only two of the studies included found a statistically significant association between PbtO2 monitoring and improved long-term neurological outcomes in patients with TBI (p = .01, p < .01). A meta-analysis of the secondary outcomes identified an associated reduction of mortality in favour of the group treated with PbtO2 monitoring (p < .0001). Results from studies examining LOS in ICU have demonstrated an associated increase of LOS in ICU in patients treated with PbtO2-guided therapy. CONCLUSION: From the studies included in this review, only two found a statistically significant association between PbtO2 monitoring and long-term outcomes. It is unclear whether PbtO2 goal-directed therapy has a positive impact on the long-term neurological functions and mortality of patients suffering from TBI. A multicentre randomized controlled trial may provide further evidence, but not necessarily conclusive. RELEVANCE TO CLINICAL PRACTICE: Further research is warranted to determine the efficacy of the introduction of this new monitoring system to guide local policy change.

What is the impact of patient violence in the emergency department on emergency nurses' intention to leave?

AIM: To examine the impact that patient violence, experienced in the emergency department, has on emergency nurses' intention to leave their job. BACKGROUND: Emergency departments have become known for their overcrowding, chaos, unpredictability and violence. Emergency nurses are at high risk of experiencing workplace violence, which is cited in the literature as having a direct effect on general nurses' intention to leave. A high rate of nursing turnover may lead to short staffing, jeopardize the quality of patient care and increase overcrowding and wait times. EVALUATION: A systematic review was undertaken in CINAHL, Medline and Psych INFO databases using published data until November 2021. Six articles were included, and PRISMA guidelines were adhered it. KEY ISSUES: Workplace violence in the emergency department had a direct impact on emergency nurses' intention to leave and decreased their job satisfaction. Verbal abuse is the most experienced form of workplace violence. CONCLUSIONS: Workplace violence experienced by emergency nurses in the emergency department had a direct positive impact on their intention to leave and subsequently negative impact on their job satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: This review may inform clinical decision-making and aid in the development of clinical practice guidelines for a workplace violence prevention programme, specific to the emergency department.

Legislating for advocacy: The case of whistleblowing.

BACKGROUND: The role of nurses as patient advocates is one which is well recognised, supported and the subject of a broad body of literature. One of the key impediments to the role of the nurse as patient advocate is the lack of support and legislative frameworks. Within a broad range of activities constituting advocacy, whistleblowing is currently the subject of much discussion in the light of the Mid Staffordshire inquiry in the United Kingdom (UK) and other instances of patient mistreatment. As a result steps to amend existing whistleblowing legislation where it exists or introduce it where it does not are underway. OBJECTIVE: This paper traces the development of legislation for advocacy. CONCLUSION: The authors argue that while any legislation supporting advocacy is welcome, legislation on its own will not encourage or enable nurses to whistleblow.

'Sometimes You Have No Choice but to Give Them Medication': Experiences of Nurses Caring for People With Auditory Hallucinations in an Acute Unit.

The aim of this study was to explore psychiatric nurse's experiences of caring for people with auditory hallucinations in an acute unit. A qualitative study was conducted using thematic analysis. The study involved semi-structured interviews with 18 acute unit nurses all of whom provided interventions to patients with auditory hallucinations. Overall, participants identified their role in the management of risk within an acute unit, the importance of their therapeutic role and a perceived over-reliance on medication administration as a primary nursing intervention. These findings thus demonstrate the personal and professional conflict that nurses face when working in an acute unit with patients who experience auditory hallucinations. Nurses are in a prime position to provide effective interventions and assistance for people with auditory hallucinations in an acute unit. The findings of this study indicate that mental health nurses may require additional support and education to provide care in a truly recovery-based manner, with training in specific interventions and engagement skills for people who hear voices. Due to an unpredictable environment and sometimes high-risk workplace, nurses may also benefit from organisational assistance in this area.

Psychiatric nurse's perceptions of their interactions with people who hear voices: A qualitative systematic review and thematic analysis.

WHAT IS KNOWN ON THE SUBJECT?: There is no qualitative systematic review of nurses' perceptions of their interactions with people hearing voices. There are some studies exploring the interventions provided by community psychiatric nurses to people hearing voices; these give a sense of what interactions may contain. WHAT THE PAPER ADDS TO THE EXISTING KNOWLEDGE?: Nurses across both community and inpatient mental healthcare settings feel uncertain about how to interact with people hearing voices, sometimes feeling like they can do little to help. Their interactions are affected by the workplace culture, education and training and concern for their own safety. Nurses rely on a therapeutic relationship for all interactions. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This is an under investigated area of mental healthcare. None the less this qualitative systematic review highlights that nurses are unclear about how to interact with service users hearing voices with the resultant outcome that service users in great distress may only be receiving minimal benefit from their interactions with the nurses caring for them. ABSTRACT: Aims and Objectives The aim of this qualitative systematic review and thematic analysis was to identify and synthesize results from studies that explored psychiatric nurses' perceptions of their interactions with service users experiencing auditory hallucinations (hearing voices). Method Qualitative systematic review and thematic analysis. Results Five studies that met the inclusion criteria were identified. Nurses reported that they felt uncertain about what to do for service users hearing voices, struggled to have interactions with voice hearers, but greatly valued the therapeutic relationship with service users. Nurses also reported that they required more education and training on how to interact effectively with people hearing voices. Finally, various workplace challenges were identified as an important factor mediating nurse interaction with service users hearing voices. Discussion Existing evidence shows that nurses lack clarity about how they can interact effectively and in a way that helps service users who are hearing voices. Significant barriers that they must overcome in order to be more certain of their role in caring for people hearing voices are difficult to engage service users and workplace challenges that were not conducive to helpful interactions and conversations. Implications for Practice Nurses caring for people hearing voices require more and better education and training with a view to them becoming more confident and competent when interacting with this service user group. Furthermore, healthy workplace cultures and maintaining a safe environment are necessary for effective caring interactions with people hearing voices.

Time for change? A qualitative exploration of the educational preparation and subsequent continuing professional development needs of nurse and midwife prescribers.

AIM/OBJECTIVE: The aim of this study was to explore nurse and midwife prescribers' perception of their educational preparation for the role and identify continuing professional development (CPD) requirements to generate practitioner-based knowledge with the potential to inform education and research, policy and practice. BACKGROUND: Educational preparation for the nurse and midwife prescribing role has remained relatively unchanged since its introduction and follows a model whereby practitioners engage in theoretical learning and learning situated within the clinical environment, facilitated by a dedicated medical mentor. No significant examination of this preparation has been undertaken in Ireland since 2009. DESIGN: This was a qualitative study, guided by elements associated with hermeneutic phenomenology. METHODS: Following research ethics approval and informed consent, 16 participants from 2 maternity hospitals participated in one-to-one audio recorded semi-structured interviews. RESULTS: Participants experience of the education programme varied with some acknowledging the importance of a broad pharmacological module whereas others believed it to be irrelevant given their prescribing scope was in many instances quiet narrow. The experience of being mentored by a medical doctor ranged from a positive learning experience to one which did not contribute to learning. Barriers to engaging with CPD were identified along with advancements in the practice arena which identify additional CPD requirements. CONCLUSIONS: This study has generated practitioner-based knowledge which provides direction for future developments in the educational preparation of nurse and midwife prescribers, particularly around pharmacology and mentorship and outlines specific CPD requirements for practitioners.

Recurrence of urothelial carcinoma of the bladder: a role for insulin-like growth factor-II loss of imprinting and cytoplasmic E-cadherin immunolocalization.

PURPOSE: This study documents the frequency of insulin-like growth factor-II (IGF-II) loss of imprinting (LOI) in a series of 87 bladder tissues. E-cadherin (CDH1) immunolocalization was also investigated due to the known redistribution of this adherence protein to the cytoplasm following exogenous exposure to IGF-II. EXPERIMENTAL DESIGN: Informative IGF-II cases were identified following DNA-PCR amplification and subsequent sequencing of the transcribable ApaI RFLP in exon 9 of IGF-II. Similar approaches using primer-specific cDNA templates identified the imprinting status of IGF-II in these informative cases. CDH1 cellular localization was assessed on a tissue microarray platform of 114 urothelial carcinoma of the bladder (UCB) cases (70 pT(a) noninvasive and 44 pT(1) lamina propria invasive) using the commercially available Novocastra antibody. RESULTS: IGF-II LOI was evident in 7 of 17 (41%) UCB tumors and 4 of 11 (36%) tumor-associated normal urothelial samples. Two of four pT(1) grade 3 tumors, the subject of much debate concerning their suitability for radical cystectomy, showed LOI at the IGF-II locus. In those tumors showing IGF-II LOI, 4 of 7 (57%) displayed concomitant CDH1 cytoplasmic staining. In contrast, only 3 of 10 (30%) IGF-II maintenance of imprinting tumors had concomitant CDH1 cytoplasmic localization. UCB cell lines displaying cytoplasmic CDH1 immunolocalization expressed significantly higher levels of IGF-II (CAL29, HT1376, and RT112) compared with RT4, a cell line displaying crisp membranous CDH1 staining. Finally, cytoplasmic CDH1 staining was an independent predictor of a shorter time to recurrence independent of tumor grade and stage. CONCLUSIONS: We suggest that CDH1 cytoplasmic immunolocalization as a result of increased IGF-II levels identifies those nonmuscle invasive presentations most likely to recur and therefore might benefit from more radical nonconserving bladder surgery.

The evaluation of an early graduate educational intervention.

Literature points to a gap which exists in the preparedness of new nursing/midwifery graduates for clinical practice. In Ireland, a two year programme was established in 2013 for all new graduates employed by the public health system. This paper provides a report on the evaluation of the programme which aimed to gauge the impact of the programme on student experience, stakeholder opinion and on health service delivery. A mixed methods approach, combining qualitative and quantitative methodologies, was utilised. Students who undertook the programme, along with non-student stakeholders, were invited to participate. The quantitative element involved an online evaluation survey which was administered to all students participating in the programme, while the qualitative element involved interviews with the participants. Students believed the programme to be relevant to their practice and positively evaluated the use of blended learning, the support of tutors and the contribution to their professional development. Non-student stakeholders also positively evaluated the programme, but the direct impact on clinical practice was not particularly evident. The evaluation offers a positive view of this initiative and broadly supports the concept of early graduate education programmes. A number of recommendations are offered for the development of future programmes.

Gene expression profile of inflammatory neutrophils: alterations in the inhibitors of apoptosis proteins during spontaneous and delayed apoptosis.

Inflammatory mediators delay neutrophil apoptosis, which contributes to the persistence of inflammation. The mechanisms responsible for this delay and resistance to Fas antibody-induced apoptosis are unknown but are dependent on protein synthesis. These proteins have been shown to inhibit caspase activity central to the induction of apoptosis. The inhibitors of apoptosis proteins have been shown to inhibit caspase activity and prevent apoptosis in a number of cellular systems. We hypothesize that the regulation of neutrophil apoptosis is dependent on the expression of the IAPs. c-IAP-1, c-IAP-2, and XIAP are expressed in the neutrophil at both the mRNA and protein level, but their relative protein expression is low compared with other cell types. The in vitro aging of human neutrophils results in their induction of apoptosis, which is associated with the loss of c-IAP-1 expression. The pancaspase inhibitor (zVAD-FMK) and LPS, which delay spontaneous apoptosis, also prevented this loss of c-IAP-1. Gene chip microarrays have shown that LPS increases c-IAP-1 and c-IAP-2 mRNA expression in neutrophils. However, this does not correspond to an increase in protein. Neutrophils from septic patients with delayed apoptosis show an increase in XIAP, with no change in cIAP-1 or cIAP-2 mRNA, demonstrating that different mechanisms contribute to the delay in neutrophil apoptosis. This study demonstrates that the loss of IAP expression may facilitate the induction of neutrophil apoptosis, and preventing this loss of IAP expression may represent a more significant contribution to delayed apoptosis rather than an increase in their expression.

Effects of the dual 5 alpha-reductase inhibitor dutasteride on apoptosis in primary cultures of prostate cancer epithelial cells and cell lines.

BACKGROUND: The profound reduction in serum dihydrotestosterone (DHT) observed with the dual 5 alpha-reductase inhibitor (5ARI) dutasteride makes it an attractive agent for prostate cancer therapy. The objective of the current study was to determine whether dutasteride would induce apoptosis in a range of prostate epithelial cell lines and primary cultures. METHODS: Both human prostate androgen-sensitive cell lines (PwR-1E, PNT-2, LNCaP, and PC3[AR2]) and an androgen-independent cell line (PC-3) were grown to confluence. Primary epithelial cells extracted from fresh prostate cancer radical prostatectomy specimens also were grown to confluence under optimal conditions. Total cellular protein was extracted to confirm cytokeratin 18 and antihuman alpha-methylacyl-CoA racemase (AMACR) expression of the primary cells. Apoptosis was assessed by propidium iodide DNA staining and flow cytometry after 24 hours of culture in from 0 microM to 10 microM of dutasteride. RESULTS: Dutasteride induced a dose-dependent increase in apoptosis in the androgen-sensitive prostate cell lines PwR-1E, PNT-2, and LNCaP and in the androgen receptor-expressing PC3(AR2) cell line. However, there was no significant apoptosis noted in the parental PC-3 cells. Of 16 primary epithelial cultures that were treated, 7 cultures were induced to undergo apoptosis, and 9 cultures were unresponsive. All primary cultures were positive for cytokeratin 18 expression, confirming their epithelial phenotype. Responder epithelial cells were positive for AMACR expression. CONCLUSIONS: The results of the current study confirmed that dutasteride differentially induced apoptosis in a subset of prostate cell lines and primary prostate epithelial cells. Understanding the cellular phenotype may indicate susceptible cells.