Patient safety in elderly hip fracture patients: design of a randomised controlled trial

<p>Abstract</p> <p>Background</p> <p>The clinical environment in which health care providers have to work everyday is highly complex; this increases the risk for the occurrence of unintended events. The aim of this randomised controlled trial is to improve patient safety for a vulnerable group of patients that have to go through a complex care chain, namely elderly hip fracture patients.</p> <p>Methods/design</p> <p>A randomised controlled trial that consists of three interventions; these will be implemented in three surgical wards in Dutch hospitals. One surgical ward in another hospital will be the control group. The first intervention is aimed at improving communication between care providers using the SBAR communication tool. The second intervention is directed at stimulating the role of the patient within the care process with a patient safety card. The third intervention consists of a leaflet for patients with information on the most common complications for the period after discharge. The primary outcome measures in this study are the incidence of complications and adverse events, mortality rate within six months after discharge and functional mobility six months after discharge. Secondary outcome measures are length of hospital stay, quality and completeness of information transfer and patient satisfaction with the instruments.</p> <p>Discussion</p> <p>The results will give insight into the nature and scale of complications and adverse events that occur in elderly hip fracture patients. Also, the implementation of three interventions aimed at improving the communication and information transfer provides valuable possibilities for improving patient safety in this increasing patient group. This study combines the use of three interventions, which is an innovative aspect of the study.</p> <p>Trial registration</p> <p>The Netherlands National Trial Register <a href="http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1562">NTR1562</a></p

Contrast medium-induced nephropathy. Aspects on incidence, consequences, risk factors and prevention

Contrast media-induced nephropathy (CIN) is a well-known complication of radiological examinations employing iodine contrast media (I-CM). The rapid development and frequent use of coronary interventions and multi-channel detector computed tomography with concomitant administration of relatively large doses of I-CM has contributed to an increasing number of CIN cases during the last few years. Reduced renal function, especially when caused by diabetic nephropathy or renal arteriosclerosis, in combination with dehydration, congestive heart failure, hypotension, and administration of nephrotoxic drugs are risk factors for the development of CIN. When CM-based examinations cannot be replaced by other techniques in patients at risk of CIN, focus should be directed towards analysis of number and type of risk factors, adequate estimation of GFR, institution of proper preventive measures including hydration and post-procedural observation combined with surveillance of serum creatinine for 1-3 days. For the radiologist, there are several steps to consider in order to minimise the risk for CIN: use of “low-“ or “iso-osmolar” I-CM and dosing the I-CM in relation to GFR and body weight being the most important as well as utilizing radiographic techniques to keep the I-CM dose in gram iodine as low as possible below the numerical value of estimated GFR. There is as yet no pharmacological prevention that has been proven to be effective

Early Adolescent Depressive Symptoms: Prediction from Clique Isolation, Loneliness, and Perceived Social Acceptance

This study examined whether clique isolation predicted an increase in depressive symptoms and whether this association was mediated by loneliness and perceived social acceptance in 310 children followed from age 11–14 years. Clique isolation was identified through social network analysis, whereas depressive symptoms, loneliness, and perceived social acceptance were assessed using self ratings. While accounting for initial levels of depressive symptoms, peer rejection, and friendlessness at age 11 years, a high probability of being isolated from cliques from age 11 to 13 years predicted depressive symptoms at age 14 years. The link between clique isolation and depressive symptoms was mediated by loneliness, but not by perceived social acceptance. No sex differences were found in the associations between clique isolation and depressive symptoms. These results suggest that clique isolation is a social risk factor for the escalation of depressive symptoms in early adolescence. Implications for research and prevention are discussed

Prevention of acute kidney injury and protection of renal function in the intensive care unit

Acute renal failure on the intensive care unit is associated with significant mortality and morbidity. To determine recommendations for the prevention of acute kidney injury (AKI), focusing on the role of potential preventative maneuvers including volume expansion, diuretics, use of inotropes, vasopressors/vasodilators, hormonal interventions, nutrition, and extracorporeal techniques. A systematic search of the literature was performed for studies using these potential protective agents in adult patients at risk for acute renal failure/kidney injury between 1966 and 2009. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, and use of potentially nephrotoxic drugs and radiocontrast media. Where possible the following endpoints were extracted: creatinine clearance, glomerular filtration rate, increase in serum creatinine, urine output, and markers of tubular injury. Clinical endpoints included the need for renal replacement therapy, length of stay, and mortality. Studies are graded according to the international Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) group system Several measures are recommended, though none carries grade 1A. We recommend prompt resuscitation of the circulation with special attention to providing adequate hydration whilst avoiding high-molecular-weight hydroxy-ethyl starch (HES) preparations, maintaining adequate blood pressure using vasopressors in vasodilatory shock. We suggest using vasopressors in vasodilatory hypotension, specific vasodilators under strict hemodynamic control, sodium bicarbonate for emergency procedures administering contrast media, and periprocedural hemofiltration in severe chronic renal insufficiency undergoing coronary intervention

Biogenic precipitation of manganese oxides and enrichment of heavy metals at acidic soil pH.

Natural Mn oxides are largely biogenic in origin, formed via the microbial oxidation of Mn(II). These minerals are extremely efficient scavengers of heavy metals, yet to date microbial Mn oxide precipitation and subsequent heavy metal sorption have received little attention in mining-impacted environments, where heavy metal concentrations are elevated but (bio)geochemical conditions are typically unfavourable for both abiotic and biogenic Mn oxide precipitation, featuring acidic pH and low organic carbon contents. Here we investigate the formation of Mn oxide (bio)geochemical barrier layers, and the immobilisation of heavy metals in these layers, in soil profiles from a former uranium mining site in Ronneburg, Germany. Detailed soil profiling shows the site has an acidic soil pH that varies from 4.7 to 5.1 and Eh values from 640 to 660 mV. Using synchrotron X-ray diffraction and X-ray absorption spectroscopy, together with scanning electron microscopy and electron microprobe analysis, we find that the dominant Mn oxide present in the Mn oxide layers is a poorly crystalline hexagonal birnessite, akin to synthetic δ-MnO2, covering and cementing quartz grains. Using phylogenetic analysis based on 16S rDNA, we identify and characterise six strains of manganese oxidising bacteria (MOB) from the acidic Mn oxide layers which we subsequently culture to produce poorly crystalline hexagonal birnessite akin to that found at the study site. Specifically, we identify three Gram-positive spore-forming firmicutes affiliated to Bacillus safensis, Bacillus altitudinis and Brevibacillus reuszeri, which are able to oxidise Mn after initiating spore formation, two Gram-positive actinobacteria belonging to the genera Arthrobacter and Frondihabitans, and one Gram-negative proteobacteria belonging to the genus Sphingomonas. Geochemical thermodynamic speciation modelling indicates that the abiotic precipitation of Mn oxides in the Mn oxide layers is unfavourable and we suggest that the Mn oxides in the (bio)geochemical barriers at our study site are biogenically precipitated in an acidic soil environment. To our knowledge, this is the first report to identify the above six bacterial strains, and specifically identify spore-forming bacteria, as MOB in an acidic soil environment. We find that the poorly crystalline hexagonal birnessite precipitated in the Mn oxide layers efficiently immobilises Ba, Ni, Co, Cd, Zn and Ce, and as such we find that MOB and biogenically precipitated Mn oxides can exert a strong control on the fate and mobility of metals in mining-impacted environments