Solidarity, support and acceptance: a celebration of the person, not the disease.

St Andrew's Hospital provides care for more than 700 patients diagnosed with breast cancer annually. Each person's experience is individual, but created by their interactions with the healthcare providers from diagnosis through to treatment. The ability of St Andrew's Hospital to deliver this care and create the best possible outcomes is crucial to each person's recovery. Those affected by breast cancer and having undergone treatment at St Andrew's Hospital are invited to an annual luncheon where guest speakers provide powerful presentations that align with each person's personal journey post-treatment, providing them the ability to reflect on what bought them here, and how to plan moving forward. A number of exhibitors offering both free and for purchase items or services are available for people to look at, book into or purchase. The highlight of the day is the lingerie fashion parade where women gather the courage to display custom-made lingerie and swimwear, enabling women post-mastectomy to celebrate themselves and not the disease.

Factors that influence the preceptor role: a comparative study of Saudi and expatriate nurses.

OBJECTIVES: The aim of this study was to compare expatriate and Saudi nursing staff's perceptions of factors that influence their role as preceptors of nursing students. METHODS: Descriptive comparative study using a self-administered survey was completed by a convenience sample of eligible nurses (n=285). It was conducted in five different hospitals within the Ministry of Health in the Kingdom of Saudi Arabia. RESULTS: Most preceptors were expatriate nurses (70.5%), while Saudi preceptors represented only 29.5%. The findings show that there is a difference between Saudi and expatriate nurses in their perception of the role, that cultural factors influence the role of expatriate preceptors and that organisational factors influence both groups. CONCLUSIONS: Expatriate preceptors felt that there were cultural obstacles that hindered their role. These findings will contribute to the development of a more contemporary and culturally sensitive preceptorship model.

Dressings for the prevention of surgical site infection.

BACKGROUND: Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured, often with sutures, staples, or clips. Wound dressings applied after wound closure may provide physical support, protection and absorb exudate. There are many different types of wound dressings available and wounds can also be left uncovered (exposed). Surgical site infection (SSI) is a common complication of wounds and this may be associated with using (or not using) dressings, or different types of dressing. OBJECTIVES: To assess the effects of wound dressings compared with no wound dressings, and the effects of alternative wound dressings, in preventing SSIs in surgical wounds healing by primary intention. SEARCH METHODS: We searched the following databases: the Cochrane Wounds Specialised Register (searched 19 September 2016); the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library 2016, Issue 8); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations, MEDLINE Daily and Epub Ahead of Print; 1946 to 19 September 2016); Ovid Embase (1974 to 19 September 2016); EBSCO CINAHL Plus (1937 to 19 September 2016).There were no restrictions based on language, date of publication or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing wound dressings with wound exposure (no dressing) or alternative wound dressings for the postoperative management of surgical wounds healing by primary intention. DATA COLLECTION AND ANALYSIS: Two review authors performed study selection, 'Risk of bias' assessment and data extraction independently. MAIN RESULTS: We included 29 trials (5718 participants). All studies except one were at an unclear or high risk of bias. Studies were small, reported low numbers of SSI events and were often not clearly reported. There were 16 trials that included people with wounds resulting from surgical procedures with a 'clean' classification, five trials that included people undergoing what was considered 'clean/contaminated' surgery, with the remaining studies including people undergoing a variety of surgical procedures with different contamination classifications. Four trials compared wound dressings with no wound dressing (wound exposure); the remaining 25 studies compared alternative dressing types, with the majority comparing a basic wound contact dressing with film dressings, silver dressings or hydrocolloid dressings. The review contains 11 comparisons in total. PRIMARY OUTCOME: SSIIt is uncertain whether wound exposure or any dressing reduces or increases the risk of SSI compared with alternative options investigated: we assessed the certainty of evidence as very low for most comparisons (and low for others), with downgrading (according to GRADE criteria) largely due to risk of bias and imprecision. We summarise the results of comparisons with meta-analysed data below:- film dressings compared with basic wound contact dressings following clean surgery (RR 1.34, 95% CI 0.70 to 2.55), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following clean surgery (RR 0.91, 95% CI 0.30 to 2.78), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- hydrocolloid dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.57, 95% CI 0.22 to 1.51), very low certainty evidence downgraded twice for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following clean surgery (RR 1.11, 95% CI 0.47 to 2.62), very low certainty evidence downgraded once for risk of bias and twice for imprecision.- silver-containing dressings compared with basic wound contact dressings following potentially contaminated surgery (RR 0.83, 95% CI 0.51 to 1.37), very low certainty evidence downgraded twice for risk of bias and twice for imprecision. Secondary outcomesThere was limited and low or very low certainty evidence on secondary outcomes such as scarring, acceptability of dressing and ease of removal, and uncertainty whether wound dressings influenced these outcomes. AUTHORS' CONCLUSIONS: It is uncertain whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI, or whether any particular wound dressing is more effective than others in reducing the risk of SSI, improving scarring, reducing pain, improving acceptability to patients, or is easier to remove. Most studies in this review were small and at a high or unclear risk of bias. Based on the current evidence, decision makers may wish to base decisions about how to dress a wound following surgery on dressing costs as well as patient preference.

Dressings for the prevention of surgical site infection.

BACKGROUND: Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured - often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing. OBJECTIVES: To assess the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention. SEARCH METHODS: In February 2014 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library); The Health Technology Assessment Database (HTA) (The Cochrane Library); NHS Economic Evaluation Database (NHSEED) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. There were no restrictions based on language or date of publication or study setting. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressing with no dressing (wound exposure) for the postoperative management of surgical wounds healing by primary intention. DATA COLLECTION AND ANALYSIS: Two review authors performed study selection, risk of bias assessment and data extraction independently. MAIN RESULTS: Twenty RCTs were included (3623 participants). All trials were at unclear or high risk of bias. Twelve trials included people with wounds resulting from surgical procedures with a contamination classification of 'clean', two trials included people with wounds resulting from surgical procedures with a 'clean/contaminated' contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 18 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by primary intention. AUTHORS' CONCLUSIONS: At present, there is insufficient evidence as to whether covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or whether any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

Inadvertent perioperative hypothermia prevention strategies for urology surgical patients who received a blood transfusion: A retrospective analysis.

OBJECTIVES: This study aimed to establish whether hypothermia was present in patients who required a blood transfusion and underwent a urology procedure, as well as identify staff knowledge and understanding. PATIENTS AND METHODS: A staff survey was conducted with respondents from a range of clinical settings, with some staff working across more than one area. A retrospective review of 46 medical records was conducted between January 2021 and July 2022. All data were exported into an Excel spreadsheet and analysed. RESULTS: Staff (70%) were unaware of guidelines informing thermoregulation practices; however, 90% understood the importance of normothermia in the perioperative environment. Medical record review demonstrated temperature monitoring and intervention implementation varied across the perioperative journey, with 20% of patients hypothermic on admission and 89% of the cohort having two or more risk factors. CONCLUSION: There is no formal process for the management of inadvertent perioperative hypothermia throughout the patient journey at the hospital. A variety of intrinsic factors (age, patient comorbidities, American Society of Anaesthesiologists score) and external factors (patient waiting times, anaesthetic modality, type of procedure, environmental influences), impact each patient's risk of inadvertent perioperative hypothermia.

The effectiveness of prophylactic closed incision negative pressure wound therapy compared to conventional dressings in the prevention of periprosthetic joint infection post hip and knee revision arthroplasty surgery: A systematic review.

OBJECTIVE: To evaluate the effectiveness of prophylactic closed incision negative pressure wound therapy (ciNPWT) compared to conventional dressings in the prevention of periprosthetic joint infection (PJI) post hip and knee revision arthroplasty surgery. METHOD: Five databases (MEDLINE, Embase., Emcare, CINAHL and Scopus) were searched with no date or language limits. Two independent reviewers assessed articles against the inclusion criteria and methodological quality of the 3 included studies. Data was extracted using a customised data tool and included the intervention, study methods and outcomes of interest. A meta-analysis was performed, and results presented in narrative form with forest plots. FINDINGS: The three studies, one randomized control trial and two quasi-experimental studies, included 136 intervention and 228 control participants (Sample 364). The PJI rate decreased in the ciNPWT cohort compared to the conservative dressing cohort (2 [1.47%] vs 27 [11.84%]). The reoperation rate was lower in the ciNPWT cohort versus the conventional cohort (4 [2.94%] vs 35 [15.35%]). The rate of wound complications was significantly decreased in the ciNPWT cohort compared to the conventional dressing cohort (14 [10.29%] v 85 [37.28), p=<0.001). CONCLUSION: Prophylactic application of ciNPWT may be effective in reducing wound complications, PJI and reoperation post hip and knee revision arthroplasty surgery. The added cost of ciNPWT may be justified in the reduction of wound complications, PJI and reoperation. Ongoing trials determining if the prophylactic application of ciNPWT post hip and knee revision arthroplasty surgery is beneficial in preventing PJI particularly in high risk patients with additional comorbidities are warranted.

Dressings for the prevention of surgical site infection.

BACKGROUND: Surgical wounds (incisions) heal by primary intention when the wound edges are brought together and secured - often with sutures, staples, clips or glue. Wound dressings, usually applied after wound closure, provide physical support, protection from bacterial contamination and absorb exudate. Surgical site infection (SSI) is a common complication of surgical wounds that may delay healing. OBJECTIVES: To evaluate the effects of wound dressings for preventing SSI in people with surgical wounds healing by primary intention. SEARCH STRATEGY: We searched the Cochrane Wounds Group Specialised Register (searched 10 May 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011 Issue 2); Ovid MEDLINE (1950 to April Week 4 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, May 9, 2011); Ovid EMBASE (1980 to 2011 Week 18); EBSCO CINAHL (1982 to 6 May 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing alternative wound dressings or wound dressings with leaving wounds exposed for postoperative management of surgical wounds healing by primary intention. DATA COLLECTION AND ANALYSIS: Two review authors performed study selection, risk of bias assessment and data extraction independently. MAIN RESULTS: Sixteen RCTs were included (2578 participants). All trials were at unclear or high risk of bias. Nine trials included people with wounds resulting from surgical procedures with a contamination classification of 'clean', two trials included people with wounds resulting from surgical procedures with a 'clean/contaminated' contamination classification and the remaining trials evaluated people with wounds resulting from various surgical procedures with different contamination classifications. Two trials compared wound dressings with leaving wounds exposed. The remaining 14 trials compared two alternative dressing types. No evidence was identified to suggest that any dressing significantly reduced the risk of developing an SSI compared with leaving wounds exposed or compared with alternative dressings in people who had surgical wounds healing by secondary intention. AUTHORS' CONCLUSIONS: At present, there is no evidence to suggest that covering surgical wounds healing by primary intention with wound dressings reduces the risk of SSI or that any particular wound dressing is more effective than others in reducing the rates of SSI, improving scarring, pain control, patient acceptability or ease of dressing removal. Most trials in this review were small and of poor quality at high or unclear risk of bias. However, based on the current evidence, we conclude that decisions on wound dressing should be based on dressing costs and the symptom management properties offered by each dressing type e.g. exudate management.

Factors affecting procurement of wound care products: a qualitative study of hospital managers and clinicians.

Objective To identify factors that influence procurement and disinvestment decisions for wound care products in the acute care setting. Methods A qualitative descriptive study was undertaken. Eighteen face-to-face semi-structured interviews were conducted with purposively sampled senior clinical and non-clinical managers from three Australian acute care hospitals with responsibility for consumables procurement and disinvestment decisions. Data were coded and analysed thematically. Results Three main themes (Systems and triggers, Evidence-free zone, Getting the governance right) with sub-themes were identified that reflect that: (1) procurement processes were often ad hoc and workarounds common. Disinvestment was poorly understood and opportunities were missed to reduce use of low value products ; (2) product selection was commonly based on clinician preference, contractual obligations and information from industry representatives; and (3) improved evidence-based governance and processes are needed to connect procurement and disinvestment decisions and to minimise the influences of clinician preference and industry representatives on product selection. Conclusions Systematic and evidence-based approaches are needed to strengthen procurement and disinvestment decisions related to consumables such as wound care products and to minimise the purchasing of low-value products Decision-making frameworks should consider cost and clinical effectiveness and enable the identification of opportunities to disinvest from low-value products. What is known about the topic? High volume-low unit cost healthcare consumables such as wound care products are a major component of healthcare expenditure. Disinvestment from low-value wound care products has potential to improve patient outcomes and optimise health resources. What does this paper add? Disinvestment was poorly understood and considered in isolation from procurement decisions. Procurement decisions were rarely informed by research evidence, with clinicians exercising considerable freedom to make purchasing decisions based on product preference and industry information. Frameworks and guidelines are needed to guide procurement and disinvestment decision-making for wound care products. What are the implications for practitioners? New models for procurement and disinvestment decision-making for wound care products could help to strengthen decision-making processes, facilitate evidence-based product choices and also prompt consideration of removal of low-value products.

The Balanced Scorecard: a tool to monitor IPL curriculum implementation: January 2020.

This article was migrated. The article was marked as recommended. Introduction: Implementing interprofessional learning (IPL) in health profession curriculum is difficult despite widespread acknowledgement of the importance of interprofessional collaborative health care practice. The aim of this study was to develop a balanced scorecard using a Delphi technique to document and monitor implementation of IPL in a faculty of health and medical sciences. Methods/Results: Twenty-four academic teachers and health service clinical supervisors completed two electronic questionnaires as part of a two stage Delphi survey. Consensus (70% agreement/disagreement) was achieved for 27/36 items in round one and for all 10 items in round two. Ten performance metrics were subsequently identified. Discussion: The Delphi was an efficient and effective method for identifying performance metrics for monitoring faculty IPL implementation. With a strong focus on learning outcomes and assessment, the scorecard will enable the faculty to formally monitor implementation of our IPL strategy over time. A follow up process of identifying data sources for reporting against each of the scorecard items has already highlighted gaps in our current practices, predominantly in staff professional development and assessment.

Engaging consumers in safety and quality at Royal Adelaide hospital.

Objective The objective of this study was to elicit barriers and enablers of safe, high-quality care as identified by consumers, and to position consumers as 'possessors' of valuable knowledge related to systems and practices (as they had experienced these directly) rather than the receivers of knowledge and information. The central aim was to develop recommendations for consumer input into quality improvement, generated from the analysis of narrative accounts of their experiences. Methods The four-phase methodology adopted for this project involved the development of quality improvement strategies as identified (phase one) and validated (phase two) by consumers through the conduct of discovery interviews with 30 consumers over the age of 18 years who had experienced an adverse event. Clinicians and quality managers were then provided with an opportunity to validate the strategies identified through participation in a focus group (phase three). All data collected through discovery interviews and focus groups were transcribed and entered into the Joanna Briggs Institute Qualitative Assessment and Review Manager for analysis. The final phase of the study involved integrating this process of consumer involvement and of identified improvement strategies into the quality improvement program of Royal Adelaide Hospital. Results A total of 28 findings were entered into the Joanna Briggs Institute Qualitative Assessment and Review Manager for analysis. The process of meta-synthesis embodied in these programs involves the aggregation or synthesis of findings or conclusions. Six categories and four syntheses were derived through this process with key themes relating to assessment and prevention strategies, a necessity for improved education and communication, the hospital environment and the potential life impact that the experience of an adverse event may have. Conclusion Consumers identified a number of strategies that could contribute to improved safety and clinical outcomes in hospital and a reduction in adverse events. This current study provides a solid foundation upon which future research may be conducted.

Effectiveness of nurse-led cardiac clinics in adult patients with a diagnosis of coronary heart disease.

Background Coronary heart disease is the major cause of illness and death in Western countries and this is likely to increase as the average age of the population rises. Consumers with established coronary heart disease are at the highest risk of experiencing further coronary events. Lifestyle measures can contribute significantly to a reduction in cardiovascular mortality in established coronary heart disease. Improved management of cardiac risk factors by providing education and referrals as required has been suggested as one way of maintaining quality care in patients with established coronary heart disease. There is a need to ascertain whether or not nurse-led clinics would be an effective adjunct for patients with coronary heart disease to supplement general practitioner advice and care. Objectives The objective of this review was to present the best available evidence related to nurse-led cardiac clinics. Inclusion criteria This review considered any randomised controlled trials that evaluated cardiac nurse-led clinics. In the absence of randomised controlled trials, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Participants were adults (18 years and older) with new or existing coronary heart disease. The interventions of interest to the review included education, assessment, consultation, referral and administrative structures. Outcomes measured included adverse event rates, readmissions, admissions, clinical and cost effectiveness, consumer satisfaction and compliance with therapy. Results Based on the search terms used, 80 papers were initially identified and reviewed for inclusion; full reports of 24 of these papers were retrieved. There were no papers included that addressed cost effectiveness or adverse events; and none addressed the outcome of referrals. A critical appraisal of the 24 remaining papers identified a total of six randomised controlled trials that met the inclusion criteria. Two studies addressed nurse-led clinics for patients diagnosed with angina, one looked at medication administration and the other looked at educational plans. A further four studies compared secondary preventative care with a nurse-led clinic and general practitioner clinic. One specifically compared usual care versus shared care introduced by nurses for patients awaiting coronary artery bypass grafting. Of the remaining three studies, two have been combined in the results section, as they are an interim report and a final report of the same study. Because of inconsistencies in reporting styles and outcome measurements, meta-analysis could not be performed on all outcomes. However, a narrative summary of each study and comparisons of specific outcomes assessed from within each study has been developed. Although not all outcomes obtained statistical significance, nurse-led clinics were at least as effective as general practitioner clinics for most outcomes. Recommendations The following recommendations are made: • The use of nurse-led clinics is recommended for patients with coronary heart disease (Level II). • Utilise nurse-led clinics to increase clinic attendance and follow-up rates (Level II). • Nurse-led clinics are recommended for patients who require lifestyle changes to decrease their risk of adverse outcomes associated with coronary heart disease (Level II).

Effectiveness of nurse-led cardiac clinics in adult patients with a diagnosis of coronary heart disease.

BACKGROUND: Coronary heart disease is the major cause of illness and death in Western countries and this is likely to increase as the average age of the population rises. Consumers with established coronary heart disease are at the highest risk of experiencing further coronary events. Lifestyle measures can contribute significantly to a reduction in cardiovascular mortality in established coronary heart disease. Improved management of cardiac risk factors by providing education and referrals as required has been suggested as one way of maintaining quality care in patients with established coronary heart disease. There is a need to ascertain whether or not nurse-led clinics would be an effective adjunct for patients with coronary heart disease to supplement general practitioner advice and care. OBJECTIVES: The objective of this review was to present the best available evidence related to nurse-led cardiac clinics. INCLUSION CRITERIA: This review considered any randomised controlled trials that evaluated cardiac nurse-led clinics. In the absence of randomised controlled trials, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Participants were adults (18 years and older) with new or existing coronary heart disease. The interventions of interest to the review included education, assessment, consultation, referral and administrative structures. Outcomes measured included adverse event rates, readmissions, admissions, clinical and cost effectiveness, consumer satisfaction and compliance with therapy. RESULTS: Based on the search terms used, 80 papers were initially identified and reviewed for inclusion; full reports of 24 of these papers were retrieved. There were no papers included that addressed cost effectiveness or adverse events; and none addressed the outcome of referrals. A critical appraisal of the 24 remaining papers identified a total of six randomised controlled trials that met the inclusion criteria. Two studies addressed nurse-led clinics for patients diagnosed with angina, one looked at medication administration and the other looked at educational plans. A further four studies compared secondary preventative care with a nurse-led clinic and general practitioner clinic. One specifically compared usual care versus shared care introduced by nurses for patients awaiting coronary artery bypass grafting. Of the remaining three studies, two have been combined in the results section, as they are an interim report and a final report of the same study. Because of inconsistencies in reporting styles and outcome measurements, meta-analysis could not be performed on all outcomes. However, a narrative summary of each study and comparisons of specific outcomes assessed from within each study has been developed. Although not all outcomes obtained statistical significance, nurse-led clinics were at least as effective as general practitioner clinics for most outcomes.Recommendations The following recommendations are made.

Prevention and management of shoulder pain in the hemiplegic patient.

OBJECTIVE: The objective of this review was to summarise the best available research related to the prevention and management of shoulder pain in the hemiplegic patient. INCLUSION CRITERIA: This review considered all studies that included hemiplegic patients post-cerebral vascular accident (CVA). Interventions of interest were any treatments or programs used to manage or prevent shoulder pain secondary to hemiplegia. The primary outcomes of interest were those related to pain. This review considered any randomised controlled trials (RCT) that evaluated the effectiveness of interventions that addressed shoulder pain in hemiplegic patients. In the absence of RCT, other research designs such as non-randomised controlled trials, time series and case series were also considered for inclusion in a narrative summary. SEARCH STRATEGY: The search sought to find both published and unpublished studies. Databases were searched up to February 2002 and included Medline, CINAHL, Current Contents, Cochrane Library, Expanded Academic Index, Electronic Collections Online, Turning Research Into Practice (TRIP), Dissertation Abstracts and Proceedings First. The reference lists of all studies identified were searched for additional studies. ASSESSMENT OF METHODOLOGICAL QUALITY: All studies were checked for methodological quality by two reviewers and data was extracted using a data extraction tool. RESULTS: Current research evaluating the effectiveness of treatment interventions on hemiplegic shoulder pain is very limited. The studies were very diverse in their nature of research. There has been no replication of studies, with the studies found using different populations, interventions or outcome measures. Not one study could be compared with another. Meta-analysis was unable to be performed not only because of inadequate reporting of results, but more often due to differences between the studies' participants and the range of interventions used. The diversity in interval post-CVA also makes it difficult to make any comparisons between studies. For this reason the review is in narrative form. CONCLUSIONS: With this limited evidence, no single intervention has been identified that offers a dramatic effect in terms of treating pain in the hemiplegic shoulder. There is potential for some benefits for the patient's functional and comfort status, thereby improving their quality of life and maximising their social participation.Preventive interventions demonstrated that a shoulder positioning policy had no statistically significant effect on pain. Strapping within 48 h significantly delayed the onset of pain and current research evaluating exercise is not limited to just one area of exercise, but a diverse range, making it difficult to make any comparisons. Some studies did suggest evidence of improvement, albeit limited. However, some of the exercise techniques aggravated shoulder pain. Treatment interventions demonstrated that electromyogram biofeedback cannot be evaluated as a stand-alone therapy as it is used in conjunction with relaxation therapy. Intra-articular Triamcinolone Acetonide injections in a small RCT have not been proven to be beneficial, and are associated with a high incidence of side-effects. Different exercise techniques may aggravate shoulder pain more than others (e.g. Bobath technique compared to cryotherapy). The systematic review on the effectiveness of functional electrical stimulation was used for prevention and treatment and concluded that there is currently no evidence for effect.

Clinical effectiveness of different approaches to peritoneal dialysis catheter exit-site care.

OBJECTIVE: The objective of this review was to appraise and synthesise the best available evidence on the clinical effectiveness of peritoneal dialysis catheter exit-site care. INCLUSION CRITERIA: This review considered all randomised controlled trials that evaluated the effectiveness of peritoneal exit-site care. In the absence of randomised controlled trials, other controlled research designs such as non-randomised controlled trials were considered for inclusion in a narrative summary to enable the identification of current approaches and possible future strategies. Participants of interest were adults with chronic renal failure on maintenance peritoneal dialysis. Interventions of interest were those used to manage peritoneal catheter exit sites, and included types of dressings, frequency of dressings, types of skin care, and use of topical antiseptic or antimicrobial agents. SEARCH STRATEGY: The search sought to find both published and unpublished studies. An initial limited search of MEDLINE and CINAHL databases was undertaken to identify key words contained in the title or abstract, and index terms used to describe relevant articles. A second extensive search was undertaken using all identified key words and index terms. The third step was a search of the reference lists and bibliographies of all relevant articles. METHODOLOGICAL QUALITY: All identified studies that met the inclusion criteria were assessed for methodological validity by two reviewers prior to inclusion in the review. Critical appraisal of studies focused on identifying bias in selection, performance, attrition and detection. RESULTS: This review found few studies of sufficient quality to meet the inclusion criteria. The included studies often utilised historical control groups, potentially confounding measurement of their outcomes. The outcome measures varied considerably, thus meta-analysis was not possible. CONCLUSIONS: This review suggests topical mupirocin may reduce the risk of exit-site infection; however, the clinical effectiveness of any one antibiotic, antiseptic or dressing procedure was not established for the prevention or reduction of exit-site infection rates or peritonitis. This review has underlined large gaps in the existing knowledge on the care of exit sites in patients on peritoneal dialysis.

Management of nipple pain and/or trauma associated with breast-feeding.

OBJECTIVE: The objective of this systematic review was to present the best available evidence related to the management of nipple pain, post childbirth in breast-feeding women. The specific objective of the review was to determine the effectiveness of interventions used by and for breast-feeding women to prevent and/or reduce nipple pain and trauma. SELECTION CRITERIA: The review considered all studies that included women who breast-fed with or without painful or traumatised nipples of any aetiology post childbirth.Interventions of interest were: (i) interventions aimed to prevent or reduce pain and/or trauma to nipples post commencement of breast-feeding; and (ii) treatments for painful or traumatised nipples post commencement of breast-feeding.The primary outcomes of interest were those related to the prevention and treatment of nipple pain and/or trauma in women post childbirth, in terms of:This review considered randomised-controlled trials (RCT) that evaluated the effectiveness of interventions and treatments associated with breast-feeding practices. In the absence of RCTs other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion in a narrative summary to enable the identification of current practices and possible future strategies. SEARCH STRATEGY: The search sought to find both published and unpublished studies in the English language. Databases were searched up to and including August 2002 and included MEDLINE, CINAHL, Current Contents, Cochrane Library, Expanded Academic Index, Electronic Collections Online, Turning Research Into Practice (TRIP), The Australian Breast-feeding Association Lactation Resource Centre, Dissertation Abstracts and Proceedings First. The reference lists of all identified studies were searched for additional studies. ASSESSMENT OF METHODOLOGICAL QUALITY: All studies were checked for methodological quality using two reviewers, and data were extracted using a data extraction tool. RESULTS: There is a plethora of research that evaluates the effectiveness of the many interventions used to prevent or treat nipple pain and or trauma for breast-feeding women. Most of the studies were heterogeneous with regard to sample demographics, interventions evaluated and outcomes assessed. For this reason the majority of the review is in narrative form, with graphical presentation via meta-view graphs of the more statistically significant outcomes. Consistent information given in education sessions to breast-feeding women would assist in identifying which type of instruction is the most effective; however, different education information was given in the studies or no details were supplied as to what education was actually given.Many of the RCTs in this review were based on small sample sizes and specific sociocultural settings. Small sample sizes limit the ability to reliably generalise findings, as there is a risk of false positive results. Furthermore, in some cases, studies did not attain statistical significance although they may have if larger sample sizes had been used. These are common limitations associated with RCTs. The authors of this review recommend full consideration be given to the sample size and study setting prior to implementation of the review recommendations in order to determine applicability to varied clinical settings. The results section highlights sample size issues for each included study.With this limited evidence, no single intervention was identified that offers a dramatic effect in terms of treating pain and or trauma in breast-feeding women. However, there is potential for some benefits for reducing pain and increasing comfort and thereby maximising breast-feeding duration. CONCLUSIONS: In terms of prevention, warm water compresses are recommended for the prevention of nipple pain, and simply keeping the nipples clean and dry is recommended for the prevention of cracked nipples. In terms of treatment, warm water compresses are recommended for the reduction of nipple pain, and expressed breast-milk reduces the duration of cracked nipples. Hydrogel dressings were associated with a high incidence of infections and their use cannot be recommended. Systemic antibiotics are recommended if a positive culture for Staphylococcus aureus is obtained.Education for positioning and attachment of the baby to the breast for breast-feeding women needs further studies to assess whether it is more effective as a preventative measure for nipple pain and/or trauma. Warm water compresses warrant further investigation into their effectiveness in nipple pain. Studies assessing the impact of engorgement, pacifiers and feeding bottles on nipple pain and/or trauma are suggested.Further investigation of the interventions used in many of these studies could be conducted using one intervention at a time in comparison to no treatment. Specific research priorities should include RCTs to assess: (i) lanolin in comparison to no treatment; (ii) lanolin and shells in comparison to no treatment; and (iii) expressed breast-milk in comparison to no treatment.

Vital signs.

BACKGROUND: Vital signs traditionally consist of blood pressure, temperature, pulse rate and respiratory rate, and are an important component of monitoring the patient's progress during hospitalisation. An initial search of the literature indicated that there was a vast volume of published information relating to this topic; however, there had been no previous attempt to systematically review this literature. This review was therefore initiated to identify, appraise and summarise the best available evidence relating to the measurement of vital signs in hospital patients. OBJECTIVES: The objectives of this review were to present the best available information related to the monitoring of patient vital signs with regard to their purpose, limitations, optimal frequency of measurements, and what measures should constitute vital signs. The review also sought to identify additional issues of importance related to the individual parameters of temperature measurement, blood pressure assessment, pulse rate measurement and respiratory rate measurement. REVIEW METHODS: This review considered all studies that related to the objectives and included neonatal, paediatric and/or adult hospital patients. The outcome measures of interest were those related to the accuracy of, required frequency of or the need for vital signs. The review also considered any study addressing some aspect of vital signs measurement to ensure all issues of importance were identified. The search sought to find both published and unpublished studies. Databases searched included CINAHL, Medline, Current Contents, Cochrane Library, Embase and Dissertation Abstracts. The references of all identified studies were examined for additional references. All studies were checked for methodological quality, and data was extracted using a data extraction tool. RESULTS: Although a variety of measures may be useful additions to the traditional four vital sign parameters, only pulse oximetry and smoking status have been shown to change patient care and outcomes. There are suggestions that vital sign monitoring has become a routine procedure, but little useful information was identified in regard to the optimal frequency of vital sign measurement. It was noted that many of the important issues related to vital sign measurement have not been investigated through research.There is currently only limited research related to respiratory rate as a vital sign; however, its value as an indicator of serious illness has not been reliably established. There is only limited research relating to pulse rate measurements. Although routinely used for all hospital patients, the ability to detect serious physiological changes by assessment of pulse rate has not been rigorously evaluated. Many factors were identified that could potentially influence the accuracy of blood pressure measurement. Auscultation is accurate for the measurement of systolic blood pressure using phase I Korotkoff sound as the reference point, and for diastolic pressure if phase V Korotkoff sounds are used. Cuff size can influence accuracy, in that using a cuff that is too narrow will likely overestimate blood pressure and a cuff that is too wide will underestimate the pressure. Research suggests that blood pressure should be measured on the upper arm, while the arm is resting at approximate heart level. Studies have shown that healthcare workers often measure blood pressure in an incorrect and inaccurate way, and this is of some concern. However, a small number of studies suggest that education programs can be effective in improving blood pressure measurement techniques. The largest volume of research identified during this review related to the measurement of temperature. For accurate measurement of oral temperatures the thermometer should be positioned in either the left or right posterior sublingual pocket and remain in the mouth for 6-7 min. Although oxygen therapy and different types of breathing patterns will not influence accuracy of oral temperature measurements, hot or cold liquids will. For the measurement of tympanic temperatures, an ear tug should be used to help straighten the external auditory canal and so ensure measurement accuracy. The presence of impacted cerumen will likely result in inaccurate measurements. The only potential harm as a result of measuring vital signs was associated with glass mercury thermometers, in terms of rectal perforation, the risk of mercury poisoning was not clearly established. CONCLUSIONS: Although there has been considerable research undertaken on many specific aspects of vital sign measurement, there is an urgent need for further primary research into the more general issues such as what parameters should be measured, the optimal frequency of measurements and the role of new technology in patient monitoring.

Effectiveness of individual therapy and group therapy in the treatment of schizophrenia.

BACKGROUND: There is no simple, single treatment for schizophrenia and present approaches are based on clinical research and experience. Pharmacotherapy is the most common treatment for schizophrenia; however, unwanted side-effects are often problematic, and medications do not provide important coping skills. These skills are provided through forms of psychotherapy. Psychotherapy has been examined from a range of perspectives, including the effectiveness of group and individual treatments on behaviours and symptoms of schizophrenia. This review reports on the effectiveness of forms of group and individual therapy. OBJECTIVES: The objective of this review was to present the best available information on the use of group therapy and individual therapy in the treatment of schizophrenia. This review summarises the findings of all relevant studies relating to these interventions. This review attempted to answer the question: which is more effective in improving symptoms in patients with schizophrenia, group or individual therapy? INCLUSION CRITERIA: The review included adult patients with schizophrenia. Interventions of interest were forms of group and individual therapy aimed at lessening the symptoms of schizophrenia. For the purposes of this review, individual therapy was regarded as a one-to-one interaction between a patient and a therapist, and group therapy excluded family therapy. Studies that examined symptom reduction, including measures of mental state, quality of life and social function, were included in this review. This review attempted to determine the efficacy of group and individual therapy in the treatment of schizophrenia. Therefore, randomised or pseudo-randomised controlled trials that address the use or comparison of these treatment modalities were included. High-quality systematic reviews of evidence of effectiveness were also included. RESULTS: Based on the search terms used, 28 references relating to the use of some form of group or individual therapy, in the treatment of chronic schizophrenia, were identified. Of these, nine were excluded for not meeting the stated inclusion criteria and 19 were included in the analysis (17 trials and two systematic reviews). From these studies numerous treatment types were compared for the management of chronic schizophrenia. Meta-analysis was not possible given the level of heterogeneity in trial methods and measurement scales. RECOMMENDATIONS: The following recommendations are made.

Comparing the effectiveness of cognitive behaviour therapy using individual or group therapy in the treatment of depression.

OBJECTIVES: The objective of this review was to present the best available information on the use of cognitive behaviour therapy using either group cognitive therapy (GCT) or individual cognitive therapy (ICT) in the treatment of depression. The primary question to be addressed in this review was: For the treatment of long-term depression, using a cognitive behavioural approach, is group therapy or individual therapy the most effective? INCLUSION CRITERIA: Studies that included adolescents or adults with long-term depression and a measured Beck Depression Inventory (BDI) value of ≥12 or Hamilton Rating Scale for Depression (HRSD) of ≥14 were included. Interventions of interest were forms of cognitive behaviour therapy utilising either an individual or group approach. For the purpose of this review individual therapy was regarded as a one-to-one interaction between the patient and the therapist. Group therapy excluded family therapy. This review excluded studies that involved pharmacotherapy alone as the only intervention and studies that involved combined group and individual treatment. Outcome measures of interest were reduction in depression inventory scores, specifically the BDI and/or the HRSD. This study considered any randomised or pseudo-randomised controlled trials that addressed the use or comparison of GCT or ICT. RESULTS: Individual and group cognitive behavioural therapies for moderately or severely depressed adults (BDI ≥ 14) were comparable with each other in effectiveness and both were superior to providing no treatment at all. Individual cognitive therapy was equal to or better than tricyclic antidepressant drugs given at recommended therapeutic dosages for depressed people with a mean BDI of 30. This information was based on level II evidence. RECOMMENDATIONS: The following recommendations were made for adults:1 Either GCT or ICT can be used to treat moderate to severe depression. The choice of therapy should be dependent upon the clinician's perceived receptiveness of the particular patient to group or individual treatment.2 The use of computer-assisted therapy is a useful adjunct to GCT in moderate to severely depressed patients.3 ICT can effectively replace pharmacotherapy in moderate to severely depressed patients if the patient is opposed to being treated with drug therapy.4 GCT has not been compared to pharmacotherapy so no direct recommendation can be given as to its effectiveness as a replacement therapy.The following recommendations were made for adolescents:1 Either GCT or ICT can be used to treat moderately depressed adolescents (BDI ≥ 14).2 More research is needed to determine the effectiveness of GCT or ICT in severely depressed adolescents (BDI ≥ 20).

Management of short-term indwelling urethral catheters to prevent urinary tract infections.

BACKGROUND: This systematic review updates a previous review published in 2000. The objective of this review was to present the best available evidence relating to the prevention of catheter-associated urinary tract infections (UTI). SELECTION CRITERIA: This review considered randomised controlled trials (RCTs) of adult patients with short-term urethral catheters. In the absence of RCTs, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Interventions of interest were those related to the prevention of catheter-related UTI and included: sterile versus non-sterile insertion technique, special coatings to catheters versus standard non-coated catheters, the use of flush solutions, the use of solutions added to urinary drainage bag, maintenance of a closed urinary drainage circuit, the use of antireflux valves, antibiotic creams applied to the external meatus-catheter interface, meatal care regimens, education programs, and changed care delivery practices. This review was limited to short-term urethral catheters, and so studies evaluating long-term or suprapubic catheters were excluded. The primary outcome of interest was the difference in the rates of UTI between experimental intervention and the control. SEARCH STRATEGY: The search included both published and unpublished studies with an initial limited search of MEDLINE and CINAHL databases undertaken to identify key words contained in the title or abstract, and index terms used to describe relevant interventions. A second extensive search used all identified key words and index terms. The third step included a search of the reference lists and bibliographies of relevant articles. The databases searched included: CINAHL, MEDLINE, Current Contents, Cochrane Library, Expanded Academic Index, and Embase. The Dissertation Abstracts International database was searched for unpublished studies. ASSESSMENT OF METHODOLOGICAL QUALITY: Methodological quality was assessed using a standardised checklist. Critical appraisal and data extraction were conducted by two independent reviewers; discrepancies were addressed through discussion with a third reviewer as required. RESULTS: There was no significant difference in infection rate using either sterile surgical or non-sterile insertion technique. The use of water for cleansing prior to catheter insertion was recommended. There was no additional benefit from specific meatal care other than standard daily personal hygiene and removal of debris. Infection rates were similar for both latex and silicone catheters. Comparisons between silver and Teflon coating clearly favoured the silver alloy coating. The use of a complex closed drainage system in the intensive care environment did not confer any additional benefit. Studies comparing types of junction seals and use of junction seals either prior to or following catheterisation found no clear benefit from using either preconnected sealed systems or sealed systems with the addition of silver releasing devices. Neither the addition of chlorhexidine nor hydrogen peroxide to the drainage bag was found to be effective at reducing UTI rates. The findings indicated there was a higher incidence of bacteriuria associated with Foley catheters compared with intermittent catheterisation (P < 0.025). A single RCT examined the effect on UTI rates of routine bag changes against no routine bag change. Routine bag changes were not advantageous in reducing the risk of infection. CONCLUSIONS: Current RCT evidence suggests the use of a surgical sterile catheterisation technique is not required, and that tap water is sufficient for cleaning genitalia. Following insertion, daily hygiene around the meatal area is as effective as catheter toilets; and catheters impregnated with silver may reduce the incidence of catheter associated bacteriuria. Sealed (e.g. taped, presealed) drainage systems should not be relied upon as the sole mechanism for prevention of bacteriuria. The addition of antibacterial solutions to drainage bags and the routine change of drainage bags had no effect on catheter associated infection. However, most of the recommendations arising from this review were based on single studies, often with limited numbers of participants. There is an urgent need to replicate these studies in other clinical settings.