Quality-of-Life Impact of an Investigational Subunit-Adjuvanted Herpes Zoster Vaccine in Adults ≥50 Years of Age

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Efficacy, Immunogenicity and Safety of an Investigational Subunit Adjuvanted Herpes Zoster Vaccine in Adults Aged 60 Years and Older: Results From the ZOE-50 and ZOE-70 Efficacy Studies

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Immunisation for medical researchers: an ethical and practical imperative

we believe it is essential that all researchers who have direct contact with participants are fully immunised

The burden of healthcare-associated Clostridium difficile infection in a non-metropolitan setting

Objective: Healthcare-associated Clostridium difficile infection (HCA-CDI) remains a major cause of morbidity and mortality in industrialized countries. However, few data exist on the burden of HCA-CDI in multi-site non-metropolitan settings. This study examined the introduction of an antimicrobial stewardship programme (ASP) in relation to HCA-CDI rates, and the effect of HCA-CDI on length of stay (LOS) and hospital costs. Methods: A comparative before-and-after intervention study of patients aged ≥16 years with HCA-CDI from December 2010 to April 2016 across the nine hospitals of a non-metropolitan health district in New South Wales, Australia was undertaken. The intervention comprised a multi-site ASP supported by a clinical decision support system, with subsequent introduction of email feedback of HCA-CDI cases to admitting medical officers. Main outcome measures: HCA-CDI rates, comparative LOS and hospital costs, prior use of antimicrobials and proton pump inhibitors, and appropriateness of CDI treatment. Results: HCA-CDI rates rose from 3.07 to 4.60 cases per 10,000 occupied bed-days pre-intervention, and remained stable at 4 cases per 10,000 occupied bed-days post-intervention (P = 0.24). Median LOS (17 vs six days; P \u3c 0.01) and hospital costs (AU$19,222 vs$7861; P \u3c 0.01) were significantly greater for HCA-CDI cases (N = 91) than for matched controls (N = 172). Half of the patients with severe HCA-CDI (4/8) did not receive initial appropriate treatment (oral vancomycin). Conclusions: HCA-CDI placed a significant burden on the regional and rural health service through increased LOS and hospital costs. Interventions targeting HCA-CDI could be employed to consolidate the effects of ASPs

Sedation and analgesia in unconscious palliative care patients: can bispectral index monitoring add to our understanding?

To the best of our knowledge, our unit - the palliative care unit at the Port Kembla Hospital in Warrawong, New South Wales, Australia - is the only one currently evaluating the contribution that BIS-like technology makes to the management of unconscious palliative care patients. The study includes patients who become unconscious as a result of disease progression or palliative sedation. By analyzing BIS data and comparing them with results obtained using standard observational measures of sedation and comfort, we hope to determine the relative worth of subjective and objective assessments. If the BIS proves to be a reliable measure of sedation, there may be a role for it in end-of-life care - it could be used to ensure that end-of-life care practices are evidence-based and that they achieve their stated goals. In this paper, we present some preliminary observations of our first 17 subjects and highlight the implications these observations have for our study and others

Use of romiplostim in patients with chronic idiopathic thrombocytopenic purpura during perioperative period

Introduction In patients with chronic idiopathic thrombocytopenic purpura (cITP), the platelet count tends to be quite variable and, in the majority of cases, specific therapy is not warranted on a regular basis. However, patients with low platelet count (\u3c30 \u3enL) or with bleeding complications would require therapy, such as prednisolone, intravenous immunoglobulin infusions, splenectomy and/or immunosuppression. Romiplostim, a thrombopoietin agonist, has also proven to be useful in improving platelet counts. cITP can be associated with bleeding complications perioperatively. As such, a higher platelet count is warranted (approximately 80 nL), particularly for invasive surgeries, such as orthopaedic surgery, cardio-thoracic surgery, head and neck surgery and abdominal surgery, where risk of bleeding is quite high already. Aim The aim of this study is to evaluate the safety and efficacy of short-term use of romiplostim, perioperatively. Methods Patients with chronic ITP requiring major surgical interventions were enrolled in the study. Patients with malignancies or myelodysplastic syndromes, major bleeding disorders, under 18 years of age or pregnancy were excluded. Conclusion This study has shown that the use of romiplostim is safe and effective in improving platelet counts preoperatively and that this could achieve excellent haemostasis, with no associated bleeding complications or rebound thrombocytopenia. A larger study involving multiple centres is required to verify these findings

Breakthrough Medication in Unresponsive Palliative Care Patients: Indications, Practice, and Efficacy

Context: An unresponsive patient\u27s need and their response to breakthrough medication is determined by clinical assessment and/or observational measures. How closely these methods match the patient\u27s experience is unknown. Objectives: Determine the efficacy and effectiveness of breakthrough medication in unresponsive patients and the perception of patient comfort made by nurses and family. Methods: A prospective study of breakthrough medication in unresponsive patients. The Richmond Agitation-Sedation Scale (RASS) and Patient Comfort Score (PCS) were compared with time-matched Bispectral Index (BIS) Scores. The effects of opioid vs. opioid + benzodiazepine breakthroughs and the relation between synchronous nurse and family measurements of the PCS were evaluated. Analysis of variance and paired t-tests were used for BIS analyses and nonparametric Mann-Whitney tests for RASS and PCS. Results: Significant reductions at 30 and 60 minutes after breakthrough medication were noted for BIS (P \u3c 0.0004), RASS (P = 0.043 and 0.004, respectively), and PCS (P \u3c 0.0004). A direct comparison of the effect of opioid breakthrough medication vs. opioid plus benzodiazepine revealed no significant difference (BIS, P = 0.512; RASS, P = 0.195; PCS, P = 0.119). Of the 157 synchronous nurse and family measures of patient comfort, families rated patient discomfort significantly higher than nurses (P \u3c 0.0004). Conclusion: This study provides additional evidence for the efficacy and effectiveness of breakthrough medication and the merit of observational measures in determining a patient\u27s response. The onset of action is evident at 30 minutes after injection. Family assessment of patient comfort may be more nuanced than that of nurses, and they not uncommonly rate patient discomfort higher than nurses

Managing advanced dementia, advance care planning for dementia patients

Aims: To trial a staff education and training program designed to facilitate the adoption of a palliative care approach for residents with end stage dementia in aged care facilities. Methods: A cluster randomised controlled trial of 12 residential aged care facilities in regional and rural setting with 530 residents in the intervention and 520 in the control facilities. The intervention was delivering a tailor made evaluated education tool and training program for aged care staff conducted in two stages. The outcomes recorded were Incidence of presentations to Emergency Department, hospital admissions and mortality. Results: Post intervention a signifi cant difference was observed in Emergency presentations χ2 = 18.8, p \u3c 0.0001; OR = 0.44; 95% CI 0.31–0.65, 8.8% of intervention residents versus 17.88% of control residents. (The intervention group had a −5.88% reduction in Emergency presentations and control group an increase of 14.6%.) Similar results were found for the number of hospital admissions (intervention 6.9% versus control 11.3%), χ2 = 6.16, p \u3c 0.013; OR = 0.58 95%CI 0.38 to 0.89. The mortality was not signifi cantly different p = 0.6. Conclusions: A specifi c education and training program can signifi cantly reduce emergency presentations and hospital admissions without compromising resident care or mortality. Training is a crucial and cost effective way to improve care at end of life in dementia

Correlation Between Observational Scales of Sedation and Comfort and Bispectral Index Scores

Context: When palliative care patients enter the phase of unconsciousness preceding death, it is standard practice to initiate or continue a subcutaneous infusion of an opioid plus or minus a sedative. The doses are determined somewhat empirically and adjustments are based on clinical assessment and observational measures of sedation and comfort. Following reports that these observational measures could be misleading, this study assesses their validity by comparing them with an objective measure of sedation, the Bispectral Index Score (BIS). Objective: The objective of this study was to determine the validity of the Richmond Agitation and Sedation Scale (RASS) and the Patient Comfort Score (PCS) in assessing sedation and comfort in unconscious patients. Methods: Forty eligible and consenting patients were monitored from the onset of unconsciousness (unresponsiveness) until death. Measures of sedation (RASS) and comfort (PCS) were made by the attending nurse every four hours. Correlation coefficients examined the relationship between fourth hourly RASS and PCS and time-matched BISs. Results: A significant correlation was found between RASS and BIS and PCS and BIS. Sedation and comfort scores were concentrated at the lower end of the respective scales, whereas time-matched BISs were widely scattered with scores ranging from near full awareness to deep sedation. Conclusions: Compared with BIS, both RASS and PCS appear to be relatively blunt instruments at the lower end of their respective scales. Due caution should be taken interpreting and making clinical decisions based solely on the RASS and PCS and, by extension, other observational measures of patient comfort and sedation