Clinical Care Protocols Research Articles

23 NEONATAL PHYSIOLOGICAL STATUS OF CLONED AND CONTROL CALVES

Health problems and mortality rates of cloned calves are major limitations of cloning technology and represent substantial economic losses as well as justifiable animal health and welfare concerns. The objectives of this study were to compare neonatal viability and physiological status of cloned and control calves. Cloned (Holstein, n = 5; Hereford, n = 3) and control (embryo transfer: Holstein, n = 3; Hereford, n = 3) calves were carried in the same group of Hereford × Angus crossbred recipient dams and were delivered by Cesarean section at term (Days 273–280) following induced labor. Additional calves (Holstein, n = 3; Hereford, n = 2) resulting from AI and delivered vaginally by their natural dams (Days 269–279) following spontaneous initiation of parturition were included as normal controls to evaluate the effects of the induction procedure. Physical evaluations and measurements of blood biochemistry (19 parameters), gases and electrolytes (9 parameters), and complete blood counts (18 parameters) were performed within 10 min of birth and at 1, 6, 12, 18, 24, 36, and 48 h after birth. Cloned calves were observed with increased occurrence of flexural limb deformities (4/8 clones, 0/9 controls; P < 0.05) and developmental delays of physical adjustment parameters such as time to suckle and stand (5/8 clones requiring >3 h; P < 0.05). Cloned calves were more variable than, but not different from, controls for most blood parameters measured. Compared with controls, at birth clones exhibited reduced red blood cell counts (6.8 and 8.6 × 109 cells/mL, clones and controls, respectively; P < 0.01), plasma bicarbonate (23.1 vs. 26.2 mmol/L; P < 0.05), and plasma glucose (39.4 vs. 73.6 mg/dL; P < 0.05). Blood urea nitrogen concentrations in clones tended to be elevated beginning 24 h after birth and were significantly greater than those in controls by 48 h (13.4 vs. 7.4 mg/dL; P < 0.01). Echocardiographic measurements at 24 h of age varied between groups (Table 1) and were indicative of circulatory abnormalities likely originating in utero for clones. The results of this study identified the physiological differences between clones and controls at birth and may be useful in the development of clinical-care protocols to maximize the health and survival of cloned calves. Table 1. Echocardiographic characteristics of cloned and control calves

Multimodal approach to rapid discharge after endoscopic thoracic sympathectomy

After a large experience (more than 10 years) with bilateral endoscopic thoracic sympathectomy (ETS) surgery on an outpatient basis, we studied prospectively a multimodal approach to rapid discharge patients undergoing this procedure. One hundred and seventeen consecutive patients, aged 13-60 years, ASA physical status I or II, undergoing outpatient ETS under general anaesthesia were enrolled in this study. All patients were managed using a predefined multimodal clinical care protocol consisting of a general balanced anaesthesia. Basic demographic information was collected from each patient. Duration of surgery and anaesthesia and times to PACU and home discharge were recorded as well as intraoperative and postoperative complications like nausea and vomiting. Surgery took 41.4 +/- 22.1 min and anaesthesia lasted 63 +/- 21.5 min. Time between induction of anaesthesia and beginning of surgery and end of surgery to extubation was 15.0 +/- 2.0 and 7.2 +/- 3.1 min, respectively. It took 4.9 +/- 1.5 min from extubation to OR discharge. Time from PACU arrival to discharge was 12.8 +/- 6.3 min. Time of hospital stay was 132 +/- 18 min. No patient experienced vomiting and two had nausea, representing an incidence of 1.7%. The only anaesthetic cause for hospital admission was a severe allergic reaction. Multimodal management to rapid discharge after ETS surgery did result in a short time to patient discharge. We confirm that endoscopic thoracic sympathectomy can be performed safely on an outpatient basis with brief postoperative hospital care and a low rate of complications.

Clinical guidelines and care protocols.

Clinical guidelines and care protocols are intended to provide information, based on an appraisal of the current best evidence of clinical and cost-effectiveness, regarding therapeutic interventions for given conditions. With the establishment of the National Collaborating Centre for Nursing as a part of National Institute for Clinical Excellence (NICE), it is anticipated that an increasing number of clinical guidelines that focus on aspects of nursing care will be developed at a national level. The Department of Health also aims to introduce nationally agreed multidisciplinary care protocols which will dictate how certain conditions are to be managed. These developments have the potential to enhance healthcare provision and nursing practice. However, they also introduce potential dilemmas for nurses. This paper discusses some of the issues involved in the development and implementation of clinical guidelines and care protocols in intensive care nursing.

Somatisation project: The recognition and management of Somatisation in hospital and general practice (GP)

The Somatisation Project (SP) was one of eight sub-projects of the South Australian HealthPlus Coordinated Care Trial. This trial involved the enrolment of an original cohort of 4,600 subjects. Of these, 124 subjects (89 intervention and 35 controls) suffering from GP diagnosed somatisation disorder (SD) constituted the SP cohort. One of the tasks required by the trial was to develop evidence-based, clinical protocols for systematic use at the GP level. The aims of the trial were to coordinate the care of patients suffering from chronic and complex disorders using systematic, behavioural care planning; the use of clinical care protocols and the provision of a designated care coordinator (GP), supported by a service coordinator.Objectives: This paper aims to: describe the development of the somatisation projectpresent the findings and implication from the audit of 5826 case recordsdescribe the development of the “containment” protocol for use in GPpresent some preliminary outcome data.Results: A Clinical A...

Stress: The chiropractic patients' self-perceptions

Background: Psychosocial stress pervades modern life and is known to have an impact on health. Pain, especially chronic back pain, is influenced by stress. Various strategies have been shown to successfully reduce stress and its consequences. Objectives: This study explores stress as a potential disease trigger among chiropractic patients. Method: A descriptive study was undertaken to ascertain the stress perceptions of chiropractic patients. Purposive sampling of chiropractic practices and convenience sampling of patients was undertaken. Patients were allocated to 1 of 4 groups according to their presentation: acute, chronic biomechanical, fibromyalgia, or maintenance care. Participating patients were requested to complete a questionnaire. Results: Of the 138 patients attending 1 of 10 participating chiropractic clinics, more than 30% regarded themselves as moderately to severely stressed, and over 50% felt that stress had a moderate or greater effect on their current problem. Some 71% of patients felt it would be helpful if their chiropractic care included strategies to help them cope with stress, and 44% were interested in taking a self-development program to enhance their stress management skills. Conclusion: Patient perceptions are known to be important in health care. A number of chiropractic patients perceive they are moderately or severely stressed. Interventions that reduce stress, or even the patient's perception of being stressed, may be construed as valid, non-specific clinical interventions. It may be timely for chiropractors to actively contemplate including stress management routinely in their clinical care protocols. (J Manipulative Physiol Ther 1999; 22:395–8)

Working in syndicate groupstowards the development of clinical care protocols: a study into the professional learning of undergraduate nursing students

Group work is an important element in nurse education and practice, and is an issue of consistent relevance given the increasing emphasis on collaborative and multidisciplinary working, and the fact that most nurses' work involves them in a variety of groups.This study is ongoing research, and considers the experiences of five groups, each comprising four final year nursing undergraduate students working in syndicate groups. The students are working towards the creation and development of clinical care protocols.The study method is grounded theory. Data have been collected over 3 academic years, with thegroup facilitator as researcher. The data management involves tape recording meetings and transcribing these, with continual reduction and analysis of the data. Findings from early analysis suggest that important phenomena, for example 'resistance’, 'tangible action goals’, and the concept of 'closure’, play a key part in the way in which the groups under study have functioned.

Provision of mouth care by nursing staff for cancer patients in Scotland: Current status and the role of training

Oral disease is common in patients with cancer and mouth care is an important element of palliative care. Responsibility for provision of this care usually falls to nursing staff. This study aimed to determine the level of mouth care provided by nurses for patients with cancer in Scottish hospices and in the community within Scotland, and to assess the value of a training pack in oral disease and oral care. Fifteen hospices, 52 Macmillan nurses and 112 district nurses were invited to participate. Responses to an initial questionnaire confirmed the important role of nurses in providing mouth care, but highlighted significant deficiencies in training, particularly for district nurses, and a lack of formal protocols in this area. There was little interaction with professional dental staff. Training packs, including clinical photographs and simple mouth care protocols were sent to 15 hospices, 20 Macmillan nurses and 45 district nurses. A follow-up questionnaire six weeks later showed that the packs had been very well received and had resulted in significant changes to mouth care practices of many of the users. However, 34% of the respondents felt that further training would still be beneficial.

Protocols for clinical care

This paper describes the work of the DILEMMA project to provide protocol-based decision support in a variety of clinical domains. We give an outline of the generic protocol model that DILEMMA has produced, and the protocol task manager (PTM) software developed to assist protocol use in routine clinical practice. We summarise the validation of the model carried out to date, and take a quick look at the place of protocols in the wider context of clinical decision support.