Neurological Injury and Cerebral Blood Flow in Single Ventricles Throughout Staged Surgical Reconstruction.

BACKGROUND: Patients with a single ventricle experience a high rate of brain injury and adverse neurodevelopmental outcome; however, the incidence of brain abnormalities throughout surgical reconstruction and their relationship with cerebral blood flow, oxygen delivery, and carbon dioxide reactivity remain unknown. METHODS: Patients with a single ventricle were studied with magnetic resonance imaging scans immediately prior to bidirectional Glenn (pre-BDG), before Fontan (BDG), and then 3 to 9 months after Fontan reconstruction. RESULTS: One hundred sixty-eight consecutive subjects recruited into the project underwent 235 scans: 63 pre-BDG (mean age, 4.8±1.7 months), 118 BDG (2.9±1.4 years), and 54 after Fontan (2.4±1.0 years). Nonacute ischemic white matter changes on T2-weighted imaging, focal tissue loss, and ventriculomegaly were all more commonly detected in BDG and Fontan compared with pre-BDG patients (P<0.05). BDG patients had significantly higher cerebral blood flow than did Fontan patients. The odds of discovering brain injury with adjustment for surgical stage as well as ≥2 coexisting lesions within a patient decreased (63%-75% and 44%, respectively) with increasing amount of cerebral blood flow (P<0.05). In general, there was no association of oxygen delivery (except for ventriculomegaly in the BDG group) or carbon dioxide reactivity with neurological injury. CONCLUSIONS: Significant brain abnormalities are commonly present in patients with a single ventricle, and detection of these lesions increases as children progress through staged surgical reconstruction, with multiple coexisting lesions more common earlier than later. In addition, this study demonstrated that BDG patients had greater cerebral blood flow than did Fontan patients and that an inverse association exists of various indexes of cerebral blood flow with these brain lesions. However, CO2 reactivity and oxygen delivery (with 1 exception) were not associated with brain lesion development. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02135081.

Nursing values stand against those of Brexit.

It is a strange feeling to be working on this article in the middle of June. For as I sit and write there is still uncertainty about the nature of the UK's relationship with the European Union.

Factors affecting linkage to care and engagement in care for newly diagnosed HIV-positive adolescents within fifteen adolescent medicine clinics in the United States.

Early linkage to care and engagement in care are critical for initiation of medical interventions. However, over 50 % of newly diagnosed persons do not receive HIV-related care within 6 months of diagnosis. We evaluated a linkage to care and engagement in care initiative for HIV-positive adolescents in 15 U.S.-based clinics. Structural and client-level factors (e.g. demographic and behavioral characteristics, clinic staff and location) were evaluated as predictors of successful linkage and engagement. Within 32 months, 1,172/1,679 (69.8 %) of adolescents were linked to care of which 1,043/1,172 (89 %) were engaged in care. Only 62.1 % (1,043/1,679) of adolescents were linked and engaged in care. Linkage to care failure was attributed to adolescent, provider, and clinic-specific factors. Many adolescents provided incomplete data during the linkage process or failed to attend appointments, both associated with failure to linkage to care. Additional improvements in HIV care will require creative approaches to coordinated data sharing, as well as continued outreach services to support newly diagnosed adolescents.

Board's eye view - Inappropriate wording.

I WAS surprised to see that the lead news story of Emergency Nurse in June was about 'inappropriate attenders' in emergency departments (EDs).

Whingeing at work.

A FORMER Australian colleague told me a joke recently: 'How can you tell when a plane load of poms has landed at Sydney airport? When they turn the engines off, the whining noise carries on.'

Board's eye view.

LAST AUGUST, Joe Strummer would have passed his 60th birthday. For those of you not as old or lucky as me, Joe was lead singer of The Clash, a UK punk band whose album, London Calling, was declared by Rolling Stone magazine to be the best album of the 1980s.

Putting quality first.

MY GRANDMOTHER used to keep an ornament inscribed: 'It is not the hours you put in that count, but what you put in to the hours', a message intended to remind those who read it that quality is more important than quantity. I was reminded of this when hearing of the government's latest healthcare plans.

Subarachnoid haemorrhage: case study and literature review.

More younger people are affected by subarachnoid haemorrhage (SAH) than by any other form of stroke, and fatality rates are high (van Gijn et al 2007). Classic signs and symptoms include sudden onset of 'thunderclap' headache but patients can present with atypical symptoms such as neck stiffness. For patients who survive SAH, the psychosocial consequences can be devastating and can affect their families or carers. This article describes the management of one patient who attended an emergency department with atypical symptoms of SAH, and discusses the incidence of, investigations into, and treatment for SAH.

Scaphoid fracture: diagnosis and management.

Nurses working in first-contact settings commonly assess and manage patients with suspected or actual injury to the scaphoid bone. In this article, lack of consensus on the assessment of such injuries, and on which treatment regimen and imaging techniques should be used, is discussed. The importance of being aware of the risk of avascular necrosis of the bone after injury is also emphasised.

Keeping up standards.

The current level of debate concerning the four-hour operational standard, evidenced in last month's Board's Eye View (Emergency Nurse. 16, 3, 37) and recently published letters, is most heartening.

Responsible behaviour.

I read with interest in a news article last month details of Andy Burnham's recent experiences as health minister (Emergency Nurse, February).

HIV Testing, Care Referral, and Linkage to Care Intervals Affect Time to Engagement in Care for Newly Diagnosed HIV-Infected Adolescents in 15 Adolescent Medicine Clinics in the United States.

OBJECTIVE: To examine how the time from HIV testing to care referral and from referral to care linkage influenced time to care engagement for newly diagnosed HIV-infected adolescents. METHODS: We evaluated the Care Initiative, a care linkage and engagement program for HIV-infected adolescents in 15 US clinics. We analyzed client-level factors, provider type, and intervals from HIV testing to care referral and from referral to care linkage as predictors of care engagement. Engagement was defined as a second HIV-related medical visit within 16 weeks of initial HIV-related medical visit (linkage). RESULTS: At 32 months, 2143 youth had been referred. Of these, 866 were linked to care through the Care Initiative within 42 days and thus eligible for study inclusion. Of the linked youth, 90.8% were ultimately engaged in care. Time from HIV testing to referral (eg, ≤7 days versus >365 days) was associated with engagement [adjusted odds ratio = 2.91; 95% confidence interval (CI): 1.43 to 5.94] and shorter time to engagement (adjusted hazard ratio = 1.41; 95% CI: 1.11 to 1.79). Individuals with shorter care referral to linkage intervals (eg, ≤7 days versus 22-42 days) engaged in care faster (adjusted hazard ratio = 2.90; 95% CI: 2.34 to 3.60) and more successfully (adjusted odds ratio = 2.01; 95% CI: 1.04 to 3.89). CONCLUSIONS: These data address a critical piece of the care continuum and can offer suggestions of where and with whom to intervene to best achieve the care engagement goals outlined in the US National HIV/AIDS Strategy. These results may also inform programs and policies that set concrete milestones and strategies for optimal care linkage timing for newly diagnosed adolescents.

The role of the physiotherapist practitioner in emergency departments: a critical appraisal.

The quantity of literature available on the role of physiotherapist practitioners in EDs is severely limited, a situation that probably reflects the relatively recent introduction of the role. The quality of the literature, too, is variable; much of it is generalised and intended for presentation at conferences rather than as detailed analysis for publication. Nevertheless, the literature does identify two of the major benefits of employing physiotherapist practitioners in EDs: they enhance the ability of departments to meet government targets by reducing waiting times, and they are popular with patients. The extent to which physiotherapist practitioners might serve as an educational resource for other emergency care team members is also discussed. The disadvantages of employing physiotherapist practitioners in EDs mostly relate to their caseloads being so specific that, in smaller EDs in particular, there may simply be too few patients to make the role worthwhile. This can be offset, however, by the potential benefits of employing physiotherapist practitioners in review clinics. The narrow focus of practice and clinical skills identified in this review can however fragment the care that physiotherapist practitioners provide. Physiotherapist practitioners may not be trained in applying POP, for example, so cannot care for some patients continuously from admission to discharge or referral. These disadvantages should influence and guide training programmes, and inform individual EDs, when the introduction of physiotherapist practitioners is being considered. They may also aid decision making about what combination of staff EDs should employ, and what specific roles should be undertaken by different members of staff. The role of physiotherapist practitioners is fairly new and has been evaluated using different criteria that depend on the expectations of the role, which in turn are shaped by the rationale behind the role's introduction. This variation in role according to professional and service demands was acknowledged in work by Callaghan (2004), who also notes that the scope of practice of physiotherapist practitioners depends on local need, and that the future development of the role should have a more robust and larger evidence base. Much of the published evaluative activity focuses on the effect on service provision and patient satisfaction. This may be because these are more readily measured and can reflect on the objectives of those implementing the role. While the data identified in the literature are of value, more are needed to justify the position of physiotherapist practitioners in emergency care. These data should include information concerning patient episode times, patient satisfaction and the extent to which physiotherapist practitioners enable other practitioners to manage the care of other groups of emergency care attenders more effectively and quickly. It should also attempt to quantify the benefit of the role as an educational resource. More work needs to be undertaken concerning the nature and benefit of the role in different environments such as minor injury units or walk-in centres, as well as medium sized and large emergency departments. Similarly, the amount by which the role enhances physiotherapy services by encouraging staff retention and recruitment, and the development of new career pathways, also needs to be assessed. It is still too early to accurately describe how the role has fulfilled these expectations at Solihull. However, there are many physiotherapists now interested in working within the role should it continue and expand.

Relationship of cerebral blood flow to aortic-to-pulmonary collateral/shunt flow in single ventricles.

OBJECTIVE: Patients with single ventricle can develop aortic-to-pulmonary collaterals (APCs). Along with systemic-to-pulmonary artery shunts, these structures represent a direct pathway from systemic to pulmonary circulations, and may limit cerebral blood flow (CBF). This study investigated the relationship between CBF and APC flow on room air and in hypercarbia, which increases CBF in patients with single ventricle. METHODS: 106 consecutive patients with single ventricle underwent 118 cardiac magnetic resonance (CMR) scans in this cross-sectional study; 34 prior to bidirectional Glenn (BDG) (0.50±0.30 years old), 50 prior to Fontan (3.19±1.03 years old) and 34 3-9 months after Fontan (3.98±1.39 years old). Velocity mapping measured flows in the aorta, cavae and jugular veins. Analysis of variance (ANOVA) and multiple linear regression were used. Significance was p<0.05. RESULTS: A strong inverse correlation was noted between CBF and APC/shunt both on room air and with hypercarbia whether CBF was indexed to aortic flow or body surface area, independent of age, cardiopulmonary bypass time, Po2 and Pco2 (R=-0.67--0.70 for all patients on room air, p<0.01 and R=-0.49--0.90 in hypercarbia, p<0.01). Correlations were not different between surgical stages. CBF was lower, and APCs/shunt flow was higher prior to BDG than in other stages. CONCLUSIONS: There is a strong inverse relationship between CBF and APC/shunt flow in patients with single ventricle throughout surgical reconstruction on room air and in hypercarbia independent of other factors. We speculate that APC/shunt flow may have a negative impact on cerebral development and neurodevelopmental outcome. Interventions on APC may modify CBF, holding out the prospect for improving neurodevelopmental trajectory. TRIAL REGISTRATION NUMBER: NCT02135081.