To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Background: Proper care and maintenance of central lines is essential to prevent central-line–associated bloodstream infections (CLABSI). Our facility implemented a hospital-wide central-line maintenance bundle based on CLABSI prevention guidelines. The objective of this study was to determine whether maintenance bundle adherence was influenced by nursing shift or the day of week. Methods: A central-line maintenance bundle was implemented in April 2018 at a 1,266-bed academic medical center. The maintenance bundle components included alcohol-impregnated disinfection caps on all ports and infusion tubing, infusion tubing dated, dressings, not damp or soiled, no oozing at insertion site greater than the size of a quarter, dressings occlusive with all edges intact, transparent dressing change recorded within 7 days, and no gauze dressings in place for >48 hours. To monitor bundle compliance, 4 non–unit-based nurse observers were trained to audit central lines. Observations were collected between August 2018 and October 2019. Observations were performed during all shifts and 7 days per week. Just-in-time feedback was provided for noncompliant central lines. Nursing shifts were defined as day (7:00 a.m. to 3:00 p.m.), evening (3:00 p.m. to 11:00 p.m.), and night (11:00 p.m. to 7:00 a.m.). Central-line bundle compliance between shifts were compared using multinomial logistic regression. Bundle compliance between week day and weekend were compared using Mantel-Haenszel 2 analysis. Results: Of the 25,902 observations collected, 11,135 (42.9%) were day-shift observations, 11,559 (44.6%) occurred on evening shift, and 3,208 (12.4%) occurred on the night shift. Overall, 22,114 (85.9%) observations occurred on a week day versus 3,788 (14.6%) on a Saturday or Sunday (median observations per day of the week, 2,570; range, 1,680–6,800). In total, 4,599 CLs (17.8%) were noncompliant with >1 bundle component. The most common reasons for noncompliance were dressing not dated (n = 1,577; 44.0%) and dressings not occlusive with all edges intact (n = 1340; 37.4%). The noncompliant rates for central-line observations by shift were 12.8% (1,430 of 1,1,135) on day shift, 20.4% (2,361 of 11,559) on evening shift, and 25.2% (808 of 3,208) on night shift. Compared to day shift, evening shift (OR, 1.74; 95% CI, 1.62–1.87; P < .001) and night shift (OR, 2.29; 95% CI, 2.07–2.52; P < .001) were more likely to have a noncompliant central lines. Compared to a weekday, observations on weekend days were more likely to find a noncompliant central line: 914 of 3,788 (24.4%) weekend days versus 3,685 of 22,114 (16.7%) week days (P < .001). Conclusions: Noncompliance with central-line maintenance bundle was more likely on evening and night shifts and during the weekends.
Non-communicable chronic diseases (NCCDs) are the main cause of morbidity and mortality globally. Demographic aging has resulted in older populations with more complex healthcare needs. This necessitates a multilevel rethinking of healthcare policies, health education and community support systems with digitalization of technologies playing a central role. The European Innovation Partnership on Active and Healthy Aging (A3) working group focuses on well-being for older adults, with an emphasis on quality of life and healthy aging. A subgroup of A3, including multidisciplinary stakeholders in health care across Europe, focuses on the palliative care (PC) model as a paradigm to be modified to meet the needs of older persons with NCCDs. This development paper delineates the key parameters we identified as critical in creating a public health model of PC directed to the needs of persons with NCCDs. This paradigm shift should affect horizontal components of public health models. Furthermore, our model includes vertical components often neglected, such as nutrition, resilience, well-being and leisure activities. The main enablers identified are information and communication technologies, education and training programs, communities of compassion, twinning activities, promoting research and increasing awareness amongst policymakers. We also identified key ‘bottlenecks’: inequity of access, insufficient research, inadequate development of advance care planning and a lack of co-creation of relevant technologies and shared decision-making. Rethinking PC within a public health context must focus on developing policies, training and technologies to enhance person-centered quality life for those with NCCD, while ensuring that they and those important to them experience death with dignity.
Resistance training (RT) and increased dietary protein are recommended to attenuate age-related muscle loss in the elderly. This study examined the effect of a lean red meat protein-enriched diet combined with progressive resistance training (RT+Meat) on health-related quality of life (HR-QoL) in elderly women. In this 4-month cluster randomised controlled trial, 100 women aged 60–90 years (mean 73 years) from self-care retirement villages participated in RT twice a week and were allocated either 160 g/d (cooked) lean red meat consumed across 2 meals/d, 6 d/week or ≥1 serving/d (25–30 g) carbohydrates (control group, CRT). HR-QoL (SF-36 Health Survey questionnaire), lower limb maximum muscle strength and lean tissue mass (LTM) (dual-energy X-ray absorptiometry) were assessed at baseline and 4 months. In all, ninety-one women (91 %) completed the study (RT+Meat (n 48); CRT (n 43)). Mean protein intake was greater in RT+Meat than CRT throughout the study (1·3 (sd 0·3) v. 1·1 (sd 0·3) g/kg per d, P<0·05). Exercise compliance (74 %) was not different between groups. After 4 months there was a significant net benefit in the RT+Meat compared with CRT group for overall HR-QoL and the physical component summary (PCS) score (P<0·01), but there were no changes in either group in the mental component summary (MCS) score. Changes in lower limb muscle strength, but not LTM, were positively associated with changes in overall HR-QoL (muscle strength, β: 2·2 (95 % CI 0·1, 4·3), P<0·05). In conclusion, a combination of RT and increased dietary protein led to greater net benefits in overall HR-QoL in elderly women compared with RT alone, which was because of greater improvements in PCS rather than MCS.
Because individuals develop dementia as a manifestation of neurodegenerative or neurovascular disorder, there is a need to develop reliable approaches to their identification. We are undertaking an observational study (Ontario Neurodegenerative Disease Research Initiative [ONDRI]) that includes genomics, neuroimaging, and assessments of cognition as well as language, speech, gait, retinal imaging, and eye tracking. Disorders studied include Alzheimer’s disease, amyotrophic lateral sclerosis, frontotemporal dementia, Parkinson’s disease, and vascular cognitive impairment. Data from ONDRI will be collected into the Brain-CODE database to facilitate correlative analysis. ONDRI will provide a repertoire of endophenotyped individuals that will be a unique, publicly available resource.
It is postulated that endogenous oxidative mechanisms are a major factor in the continuing death of dopaminergic neurons and the progression of Parkinson's disease. Scientific evidence in support of, and negating, the free radical auto-toxicity and dopamine toxicity concepts is reviewed. There is conflicting evidence whether free radicals are involved in the toxicity of l-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and attempts to prevent the toxicity of MPTP with antioxidant therapy have had variable results. The oxidation of dopamine by monoamine oxidase produces toxic metabolites however animal studies with high dose longterm levodopa and MPTP have failed to show clear evidence for autoxidation. Firm supportive evidence is obtained from the monoamine oxidase B inhibitor experience which demonstrated a block of the toxicity of MPTP in animals and probable prolongation of the course of human Parkinson's disease.
The scientific data available is inconclusive but there is significant hope of retarding progressive catecholaminergic neuron degenerative changes by augmenting the free radical scavenging system with antioxidants (such as Vitamin E) and slowing catecholamine oxidation by monoamine oxidase B inhibition. Careful clinical trials with these agents must be performed.
Thirty-seven patients with advanced Parkinson’s disease who initially tolerated, and responded to bromocriptine therapy were followed for 12 to 50 (mean 28) months. Using a method of gradual increase of bromocriptine, with concomitant levodopa reduction, the peak effect of the drug was apparent by three months, at which time the mean daily dose of bromocriptine was 23.9 mg and Sinemet (levodopa + carbidopa) had been reduced by 34 percent.
Eight patients had sustained improvement without further drug changes for an average of 29 (range 14–50) months. After periods of improvement varying between 3 and 30 months, 29 patients had a fall-off from peak effect. Peak effect was regained in 21 of these 29 patients for an average of 16 additional months by initially increasing bromocriptine or Sinemet, or by eventually increasing both drugs. The main adverse effect was a confusional state which necessitated late withdrawal of bromocriptine in four patients. The best results were in younger patients with end-of-dose deterioration and levodopa induced dyskinesias.
With cautious introduction, and intermittent dosage adjustment, bromocriptine can be of long-term benefit to patients with advanced Parkinson’s disease. The majority of patients have a gradual late fall-off in effect which can frequently be reversed with dosage adjustment.
Using a method of a gradual increase of bromocriptine with a concomitant reduction of Sinemet® (levodopa 250 mg + carhidopa 25 mg), 19 patients with advanced Parkinson’s disease have been treated for periods of up to 22 months and 16 of them have shown improvements of varying degrees. Eighteen patients were able to tolerate bromocriptine addition, with early transient adverse effects occurring in seven cases. In contrast to several previously reported studies, it was found necessary to withdraw bromocriptine in only one case.
With the drugs currently available, bromocriptine has a role in the management of patients with advanced Parkinson’s disease. The method described here may allow a greater number of patients to be given a trial with this drug.
Deprenyl is a synthetic, selective inhibitor of the monoamine oxidase-B enzyme system. The mechanism of its beneficial effect in early and advanced Parkinson’s disease is not settled. Increased striatal dopamine accumulation, sensitization of surviving dopamine neurons with increased dopamine production and reduced nigro-striatal toxicity may all contribute. The standard daily dose of deprenyl is 10 mg. Selectivity may be lost at higher doses. Deprenyl is especially indicated in untreated patients, improving up to 50 percent of patients with mild motor fluctuations. Major symptomatic benefit also occurs in occasional levodopa treated patients. Adverse effects are common, however. Increase dyskinesias, confusion and hallucinations, nausea and postural hypotension may necessitate drug withdrawal or the use of low dose regimens. Caution should be exercised with older patients, those with ulcer disease, which may be worsened by deprenyl, and individuals with active ischemic heart disease where the safety of this drug is not yet clear.
The results obtained with high and low dose bromocriptine therapy were compared in a review assessing the per cent of patients showing improvement (not taking account of the extent of improvement). It is concluded that the response rate with low dose bromocriptine is as good as that obtained with high dose therapy for both de novo and levodopa treated patients. The incidence of adverse effects is similar in the high and low dose treatment groups: More levodopa reduction results in a higher daily bromocriptine requirement. A statistical analysis of 61 bromocriptine-levodopa treated patients showed no positive correlation between bromocriptine dose and severity or duration of Parkinson’s disease.
Dystonia must be accurately diagnosed so that treatment can be administered promptly. However, dystonia is a complex disorder, with variable presentation, which can delay diagnosis.
Data were gathered by questionnaire from 866 patients with dystonia or hemifacial spasm (HFS) treated in 14 movement disorders centres in Canada injecting botulinum toxin, to better understand the path to diagnosis, wait times and obstacles to treatment.
Most participants were female (64.1%), mean age was 58 years, and patients consulted an average of 3.2 physicians before receiving a dystonia or HFS diagnosis. Many patients (34%) received other diagnoses before referral to a movement disorders clinic, most commonly “stress” (42.7%). A variety of treatments were often received without a diagnosis. The mean lag time between symptom onset and diagnosis was 5.4 years. After the decision to use botulinum toxin, patients waited a mean of 3.1 months before treatment. The most common diagnoses were cervical dystonia (51.6% of patients), HFS (20.0%) and blepharospasm (9.8%).
Survey results show that diagnosis of dystonias or of HFS, and therefore, access to treatment, is delayed. An educational program for primary care physicians may be helpful to decrease the time to diagnosis and referral to a specialist centre for treatment.
The early treatment of Parkinson's disease continues to be controversial as our understanding of the etiology of the disease remains incomplete. Ideally an intervention that reverses or protects against further damage to dopaminergic neurons would be initiated once the symptoms of the disease are recognized. Unfortunately, there are no currently available therapies that have been shown to have a major impact on the progression of the disease. However, delaying effective symptomatic therapy beyond a point of significant disability does result in increased mortality. Concerns have been raised regarding the potential toxicity of levodopa on remaining nigral neurons. Although there is little support for this concept, levodopa is associated with important complications. The development of new symptomatic treatments has made the management of early Parkinson's disease even more complex and requires that many different factors be considered prior to initiating therapy in an attempt to minimize current and future disability caused by the disease and its treatment.
The Triassic Lashly Formation occurs to the east of Mount Brooke at Coombs Hills. Previously established informal members B, C, and D of the Lashly Formation are now identified at Coombs Hills. Lashly Formation member D passes up into a poorly exposed interval of silicic shard-bearing fine-grained sandstone and tuff, which is correlated with the Jurassic Shafer Peak Formation of north Victoria Land and Hanson Formation of the Beardmore Glacier region. Lashly Formation members C and D are intruded by three phreatic explosion pipes, resulting from emplacement of Ferrar Dolerite intrusions at depth and associated explosive steam generation. These pipes, ranging up to 180 m in horizontal dimension, comprise sedimentary clasts in a sand matrix, most of which was locally derived. Pipe margins are mainly ill defined and adjacent country rock is commonly disaggregated or shattered, although retaining stratigraphic order. Locally, thin basalt intrusions have interacted with coal beds.
To determine the impact of a multifocused interventional program on sharps injury rates.
Sharps injury data were collected prospectively over a 9-year period (1990-1998). Pre- and postinterventional rates were compared after the implementation of sharps injury prevention interventions, which consisted of administrative, work-practice, and engineering controls (ie, the introduction of an anti-needlestick intravenous catheter and a new sharps disposal system).
Sharps injury data were collected from healthcare workers employed by a mid-sized, acute-care community hospital.
Preinterventional annual sharps injury incidence rates decreased significantly from 82 sharps injuries/1,000 worked full-time-equivalent employees (WFTE) to 24 sharps injuries/1,000 WFTE employees postintervention (P<.0001), representing a 70% decline in incidence rate overall. Over the course of the study, the incidence rate for sharps injuries related to intravenous lines declined by 93%, hollow-bore needlesticks decreased by 75%, and non-hollow-bore injuries decreased by 25%.
The implementation of a multifocused interventional program led to a significant and sustained decrease in the overall rate of sharps injuries in hospital-based healthcare workers.
The performance of seven Parkinson patients on a discrete pursuit tracking task was studied under alleviated (medicated) and unalleviated (non-medicated) conditions, and compared with the performance of seven non-Parkinson subjects matched for age and gender. All subjects completed 2,000 responses on the tracking task, which provided variations in directional probability and the distance to be moved. Overall, results suggested that once given sufficient practice to learn a novel task, and when under drug control, Parkinson patients were not significantly different from their age-matched controls. Two exceptions where Parkinson patients evidenced slower responses were noted: (a) their ability to make decisions when movement direction was less predictable: and (b) when they had to readjust their motor responses after an unexpected movement error.