Introduction
Australasian emergency departments (ED) routinely test patient alcohol levels following major trauma, but assessment for illicit drugs is uncommon.
Methods
A prospective cross‐sectional ...study of major motor‐vehicle‐related trauma patients attending both adult major trauma centres in Victoria, Australia. All eligible patients had point‐of‐care saliva testing to determine the prevalence of common illicit drugs.
Results
Over 12 months, 1411 patients were screened, 36 refused (2.6%) and 63 were excluded. Of the final 1312 cases included, 173 (13.2%; 95% confidence interval 11.5, 15.1) tested positive to at least one illicit substance, with 133 (76.9%; 69.7, 82.8) positive for meth/amphetamines. One in five had more than one illicit substance detected. Patients testing positive were most frequently in motor vehicles (91.9% vs. 85.6%) and least frequently cyclists (2.3% vs. 4.2%) or pedestrians (5.2% vs. 10.3%), compared to those testing negative. They were younger (mean age 35.4 vs. 43.1 years), more likely to arrive overnight (27.2% vs. 12.1%) or after single vehicle crashes (54.3% vs. 42.3%). Although the initial disposition from ED did not differ, those testing positive were more likely to re‐present within 28 days (13.9% vs. 5.4%).
Discussion and Conclusions
A high prevalence of potentially illicit substances among patients presenting with suspected major trauma supports the need for urgent preventive strategies. The low rate of patient refusal and large numbers screened by ED staff suggests that point‐of care testing for illicit substances in major trauma is acceptable and feasible. This study and ongoing surveillance may be used to inform driver education strategies.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Safewards is an evidence-based practice improvement model to minimise conflict in inpatient mental health units. There is limited published research on implementing Safewards in acute ...medical/surgical care wards.
To identify, from nurses' perspectives, barriers, and facilitators to implement four Safewards interventions in acute medical/surgical care wards.
This article reports qualitative findings from a funded mixed-method evaluation of the Safewards Acute Care Pilot Project. Six focus group interviews comprising 35 nursing staff from four hospitals in Victoria, Australia were completed between April and October 2022. The semi-structured interview guide included questions developed using the Capability, Opportunity, Motivation and Behaviour model. Data was thematically analysed and mapped to a matrix combining Capability, Opportunity, Motivation and Behaviour model and the Theoretical Domains Framework to elucidate barriers and facilitators to implementing four Safewards interventions in acute medical/surgical care wards.
Three components in the Capability, Opportunity, Motivation and Behaviour model and three Theoretical Domains Framework domains were identified as barriers to the adoption of Safewards in acute medical/surgical care wards. Specific barriers included physical opportunity challenges related to the environmental context and resources domains. The key themes included time constraints and competing priorities; lack of physical space and infrastructure; and poor patient uptake due to lack of understanding. Gaps emerged as a psychological capability barrier within the Theoretical Domains Framework knowledge domain. Additionally, resistance to practice changes was associated with the motivation component of the Capability, Opportunity, Motivation and Behaviour model. Conversely, six TDF domains were relevant to facilitating the implementation of the Safewards interventions: memory, attention, and decision processes; physical skills; social influences; social/professional role and identity; goals; and beliefs about consequences. Key facilitators included the Safewards interventions serving as reminders to focus on compassionate nursing care; nursing staff possessing the skillset for interventions; peer pressure and mandated change; supportive and passionate leadership; presence of champions to drive momentum; belief in nursing staff ownership and expertise for leading implementation; personal commitment to improve work environments and care quality; and the belief that Safewards would improve ward culture.
Addressing barriers and leveraging facilitators can inform strategies for enhancing staff capability to implement Safewards in acute care wards. Specifically, a tailored, multilayered approach focusing on leadership support, training, resources, patient input, and feedback can promote effective adoption of the Safewards model and adaptation of discrete interventions.
Safewards adaptation: Addressing barriers like resources, space, and patient awareness; leveraging peer modelling and leadership strategies for success.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective
To determine current clinical practices for managing behavioural emergencies within Victorian public hospital EDs.
Methods
A multi‐centre retrospective study involving all patients who ...attended ED in 2016 at the Alfred, Ballarat, Dandenong, Geelong and Royal Melbourne Hospitals. The primary outcome was the rate of patient presentations with at least one restrictive intervention. Secondary outcomes included the rate of security calls for unarmed threats (Code Grey), legal status under the Mental Health Act at both the time of ED arrival and the restrictive intervention, and intervention details. For each site, data on 100 patients who had a restrictive intervention were randomly extracted for indication and methods of restraint.
Results
In 2016, 327 454 patients presented to the five EDs; the Code Grey rate was 1.49% (95% CI 1.45–1.54). Within the Code Grey population, 942 had at least one restrictive intervention (24.3%, 95% CI 23.0–25.7). Details were extracted on 494 patients. The majority (62.8%, 95% CI 58.4–67.1) were restrained under a Duty of Care. Physical restraint was used for 165 (33.4%, 95% CI 29.3–37.8) patients, 296 were mechanically restrained (59.9%, 95% CI 55.4–64.3), median mechanical restraint time 180 min (IQR 75–360), and 388 chemically restrained (78.5%, 95% CI 74.6–82.0).
Conclusions
Restrictive interventions in the ED largely occurred under a Duty of Care. Care of patients managed under legislation that covers assessment and treatment of mental illness has a strong clinical governance framework and focus on minimising restrictive interventions. However, this is not applied to the majority of patients who experience restraint in Victorian EDs.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
•We model chronic ingestion of environmental lead and cadmium in axenic mice.•We addressed the role of the microbiota in heavy-metal dissemination in organs.•We delineate the direct impact of the ...non-absorbed heavy metals on gut homeostasis.•We measure transport- and oxidative-gene expression in intestine.•It enlightens risk assessment of heavy metals in intestinal disease's susceptibility.
Environmental exposure to pollutants such as heavy metal(s) is responsible for various altered physiological functions which are detrimental for health. The gut microbiota is critical for intestinal homeostasis but its role on xenobiotic handling is not fully understood, especially when continuous sub-chronic exposure is addressed. We first confirmed the essential role of the intestinal microbiome to limit heavy metal body burden by using germ-free mice following 6-weeks oral exposure. Significant increases of cadmium and lead absorption and dissemination in blood and target organs were measured in germ-free mice when compared with conventional specific pathogen free (SPF) mice. Besides the “barrier” function of the luminal microbiota, this may involve specific host-genes such as metallothioneins, which are differentially expressed in the gastrointestinal tract of each group of mice. Considering genes relevant for divalent metal transporters and oxidative pathways, significant differences in basal gene expression were measured between control and germ-free mice. Moreover, the magnitude of induction of these genes upon stimulation by heavy metals varied greatly depending on the dose and type of metal as well as the microbial status of the animal. Collectively, these data illustrate the complex host-microbes interplay occurring with environmental pollutants inside the gut.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Purpose Malignant pleural effusion has a very poor prognosis, raises problems of medical management, and impairs quality of life. The authors report the first experience of a pleural implantable ...access system for the treatment of recurrent symptomatic malignant pleural effusion. Description Prospective follow-up of 29 patients between August 20, 2005 and August 1, 2007 in a single center. Thirty-four pleural implantable access systems were placed in 29 patients (23 patients with breast cancers, 4 patients with bilateral placements, and 1 patient with a replacement) under sedation after the decision of a multidisciplinary meeting. Evaluation Twenty-eight patients obtained partial or complete relief of their dyspnea. Six patients underwent pleurodesis after a maximum of 2 months. Fifteen patients were receiving chemotherapy at the time of placement. Seven patients died at the Institut Curie or in a palliative care unit without returning home. The other 22 patients presented a total of 280 days of hospitalization for 2,717 days of catheter implantation. No placement failures were observed in this series. Two infectious complications (infectious pneumonia and skin infection over the puncture site) and two mechanical complications (expulsion of the port and disconnection between the port and the catheter) were observed and easily treated. One patient had loculation of the pleural cavity develop after 16 thoracenteses making further thoracentesis ineffective. Conclusions The pleural implantable access system is an interesting alternative in terms of efficacy and safety for the outpatient management of malignant pleural effusion. It presents a number of advantages in terms of comfort and infectious risk compared with tunnelled pleural catheters.
Although it is known that zinc has several beneficial roles in the context of gut inflammation, the underlying mechanisms have not been extensively characterized. Zinc (Zn) is known to be the primary ...physiological inducer of the expression of the metallothionein (MT) superfamily of small stress‐responsive proteins. The expression of MTs in various tissues is induced or enhanced (including the gastrointestinal tract (GIT)) by a variety of stimuli, including infection and inflammation. However, the MTs’ exact role in inflammation is still subject to debate. In order to establish whether or not MTs are the sole vectors in the Zn‐based modulation of intestinal inflammation, we used transcriptomic and metagenomic approaches to assess the potential effect of dietary Zn, the mechanisms underlying the MTs’ beneficial effects, and the induction of previously unidentified mediators. We found that the expression of endogenous MTs in the mouse GIT was stimulated by an optimized dietary supplementation with Zn. The protective effects of dietary supplementation with Zn were then evaluated in mouse models of chemically induced colitis. The potential contribution of MTs and other pathways was explored via transcriptomic analyses of the ileum and colon in Zn‐treated mice. The microbiota’s role was also assessed via fecal 16S rRNA sequencing. We found that high‐dose dietary supplementation with Zn induced the expression of MT‐encoding genes in the colon of healthy mice. We next demonstrated that the Zn diet significantly protected mice in the two models of induced colitis. When comparing Zn‐treated and control mice, various genes were found to be differentially expressed in the colon and the ileum. Finally, we found that Zn supplementation did not modify the overall structure of the fecal microbiota, with the exception of (i) a significant increase in endogenous Clostridiaceae, and (ii) some subtle but specific changes at the family and genus levels. Our results emphasize the beneficial effects of excess dietary Zn on the prevention of colitis and inflammatory events in mouse models. The main underlying mechanisms were driven by the multifaceted roles of MTs and the other potential molecular mediators highlighted by our transcriptomic analyses although we cannot rule out contributions by other factors from the host and/or the microbiota.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Safewards is an internationally adopted framework that provides interventions to reduce conflict and containment in healthcare settings. This systematic review evaluated the effect of Safewards on ...conflict and containment events in inpatient units and the perceptions of staff and consumers. Quantitative, qualitative, and mixed‐methods studies were considered for inclusion. Following the Joanna Briggs Institute methodology, two reviewers independently screened, appraised, and extracted data. Qualitative data were synthesized using inductive‐thematic analysis. Quantitative and qualitative data were integrated with a convergent‐segregated approach and presented in tabular and narrative format. A search of 13 databases and grey literature yielded 14 studies of variable methodological quality. Four studies reported reduced rates of conflict and one study reported reductions that were not statistically significant. Six studies reported reductions in rates of containment, three studies found no statistical significance and one study reported statistically significant reductions at follow‐up. Staff and consumers in four studies reported an improved experience of safety. Three themes were developed as follows: (i) therapeutic hold, cohesion, support and the environment, (ii) conflict, containment and the experience of safety, and (iii) the complexities of adapting and embedding change. This review found most staff and consumers reported Safewards improved therapeutic relationships, cohesion, and ward atmosphere. Staff and consumers reported improved ward atmosphere, leading to consumer‐centred, recovery‐oriented care. Safewards improved the experience of safety from the perspective of staff and consumers when combined with ongoing training, leadership and time for consolidation. While results are promising they should be used cautiously until more robust evidence is established.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
Do food ecosystems feed gut ecosystems? And if so… fuel the immune system? Recent developments in metagenomics have provided researchers tools to open the “black box” of microbiome science. These ...novel technologies have enabled the establishment of correlations between dysbiotic microbial communities and many diseases. The complex interaction of the commensal microbiota with the immune system is a topic of substantial interest due to its relevance to health. The human gastrointestinal tract is composed of an immense number of resident and transient microorganisms. Both may play a direct and vital role in the maintenance of human health and well-being. An understanding of the interactions and mechanisms through which commensal and food-derived microbes shape host immunity and metabolism may yield new insights into the pathogenesis of many immune-mediated diseases. Consequently, by manipulating the contribution of food microbiota to the functionality of the gut ecosystem, there is great hope for development of new prophylactic and therapeutic interventions. This paper presents some insights and comments on the possible impact of exogenous fermented food microbes on the gut homeostasis. We shed light on the similar features shared by both fermented food microbes and probiotics. In particular, the key role of microbial strains as part of food ecosystems for health and diseases is discussed through the prism of fermented dairy products and gut inflammation.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Although the heavy metals cadmium (Cd) and lead (Pb) are known environmental health concerns, their long-term impacts on gut ecology and susceptibility to gastrointestinal autoimmune diseases have ...not been extensively investigated. We sought to determine whether subchronic oral exposure to Cd or Pb is a risk factor for the development and progression of inflammatory bowel disease (IBD). Mice were exposed to various doses of CdCl2 or PbCl2 in drinking water for 1, 4 or 6 weeks prior to infection with Salmonella, the induction of colitis with dextran sodium sulfate (DSS) or trinitrobenzene sulfonic acid (TNBS). In human cell-based models, exposure to Cd and Pb is associated with reduced transepithelial electric resistance and changes in bacteria-induced cytokine responses. Although 1- and 6-week exposures did not have clear effects on the response to Salmonella infectious challenges, 1-week short-term treatments with CdCl2 tended to enhance intestinal inflammation in mice. Unexpectedly, subchronic exposure to Cd and (to a lesser extent) Pb significantly mitigated some of the symptoms of DSS-induced colitis and reduced the severity of TNBS colitis in a dose-dependent manner. The possible adaptive and immunosuppressive mechanisms by which heavy metals might reduce intestinal inflammation are explored and discussed.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Previous reports showed limited efficacy of immune checkpoint inhibitors as single-agent treatment for non-small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) mutation or ...ALK/ROS1 fusion. We aimed at evaluating the efficacy and safety of immune checkpoint inhibitor combined with chemotherapy and bevacizumab (when eligible) in this patient subgroup.
We conducted a French national open-label multicentre non-randomised non-comparative phase II study in patients with stage IIIB/IV NSCLC, oncogenic addiction (EGFR mutation or ALK/ROS1 fusion), with disease progression after tyrosine kinase inhibitor and no prior chemotherapy. Patients received platinum, pemetrexed, atezolizumab, bevacizumab (PPAB cohort) or, if not eligible to bevacizumab, platinum–pemetrexed–atezolizumab (PPA cohort). The primary end-point was the objective response rate (RECIST v1.1) after 12 weeks, evaluated by blind independent central review.
71 patients were included in PPAB cohort and 78 in PPA cohort (mean age, 60.4/66.1 years; women 69.0%/51.3%; EGFR mutation, 87.3%/89.7%; ALK rearrangement, 12.7%/5.1%; ROS1 fusion, 0%/6.4%, respectively). After 12 weeks, objective response rate was 58.2% (90% confidence interval CI, 47.4–68.4) in PPAB cohort and 46.5% (90% CI, 36.3–56.9) in PPA cohort. Median progression-free survival and overall survival were 7.3 (95% CI 6.9–9.0) months and 17.2 (95% CI 13.7–NA) months in PPAB cohort and 7.2 (95% CI 5.7–9.2) months and 16.8 (95% CI 13.5–NA) months in PPA cohort, respectively. Grade 3–4 adverse events occurred in 69.1% of patients in PPAB cohort and 51.4% in PPA cohort; Grade 3–4 atezolizumab-related adverse events occurred in 27.9% and 15.3%, respectively.
Combination approach with atezolizumab with or without bevacizumab and platinum-pemetrexed achieved promising activity in metastatic EGFR-mutated or ALK/ROS1-rearranged NSCLC after tyrosine kinase inhibitor failure, with acceptable safety profile.
•Single-agent immune checkpoint inhibitor has not shown efficacy for non-small cell lung cancer with epidermal growth factor receptor mutation or ALK fusion.•Chemo-immunotherapy ± bevacizumab shows an acceptable objective response rate for a 2/3-line treatment.•The progression-free survival in both cohorts is interesting in this subgroup of patients.•Tolerance is acceptable in both treatment arms.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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