Background High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials of lowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute stroke remains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitric oxide donor, might improve outcome when administered very early after stroke onset. Methods We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled, blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2 or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receive transdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UKbased ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in all participants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053.
Background: Clinical supervision provides support and facilitates professional and personal development. Aim: To identify and synthesise all available qualitative research on palliative care nurses' experiences of clinical supervision. Methods: Guided by the ‘enhancing transparency in reporting the synthesis of qualitative research’ (ENTREQ) statement, eight databases were searched using a systematic search strategy (Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, PsycINFO, Medline, Web of Science, ProQuest, Embase, Psychological and Behavioural Sciences). The findings of all included studies were analysed guided by Thomas and Harden's approach. Confidence in the review findings was determined guided by Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). Findings: Nine qualitative studies were included in this synthesis and four analytic themes were identified: negative experiences and misunderstandings of clinical supervision; clinical supervision needs structure and clarity; supervisor needs to be a conductor and a producer; finding your ‘inner supervisor’. Conclusion: The review illuminates the benefits of clinical supervision as a renewal process for palliative care (PC) nurses, but also highlights the challenges in its provision. Organisations should provide designated time and opportunities for PC nurses to attend clinical supervision sessions during working hours.
Purpose Mandatory COVID‐19 shelter‐in‐place (SIP) orders have been imposed to fight the pandemic. They may also have led to unintended consequences of increased use of controlled substances especially among rural communities due to increased social isolation. Using the data from the American Association of Poison Control Centers, this study tests the hypothesis that the poison control centers received higher rates of calls related to exposures to controlled substances from rural counties than they did from urban counties during the SIP period. Methods Call counts received by the poison control centers between October 19, 2019 and July 6, 2020 due to exposure to controlled substance (methamphetamine, opioids, cocaine, benzodiazepines, and other narcotics) were aggregated to per‐county‐per‐month‐per‐10,000 population exposure rates. A falsification test was conducted to reduce the possibility of spurious correlations. Findings During the study period, 2,649 counties in the United States had mandatory SIP orders. The rate of calls reporting exposure to any of the aforementioned controlled substances among the rural counties was higher (14%; P = .047) relative to the urban counties. This overall increase was due to increases in the rates of calls reporting exposure to opioids (26%; P = .017) and methamphetamine (39%; P = .077). Moreover, the rate of calls reporting exposures at home was also higher among the rural counties (14%; P = .069). Conclusion The mandatory SIP orders may have had an unintended consequence of exacerbating the use of controlled substances at home in rural communities relative to urban communities.
Background/objectivesSeveral centres (Children’s Hospital Philadelphia, Sick Kids Toronto) and organisations (COG) have developed chemotherapy standardisation programmes to reduce risk, increase efficiency and decrease cost associated with the presciption, preparation and administration of chemotherapy in paediatric patients.Most European paediatric chemotherapy protocols use different doses, infusion times, hydration protocols and supportive medicine doses for the same drugs. There is huge variety in how individual patients receive the same drugs. This introduces significant, unnecessary, potential risks and complexity.By 2016 our aim is that all children at our institution should have chemotherapy prescribed, prepared and administered according to a standard institutional protocol.Design/methodsWe set up a multi-disciplinary chemotherapy standardisation group within our department. The project was developed in association with a hospital quality initiative. We reviewed all treatment protocols in use at the current time at OLCH and assessed the variety in chemotherapy administration. We performed staff and parental questionnaires regarding their perceptions of the variety in administration, supportive medicines and discharge times.We held a meeting of all senior departmental management to review and critique the project and multiple staff education sessions to implement the recommended changes.ResultsThere is huge variation in how European protocols mandate that chemotherapy be administered, particularly in protocols using doxorubicin, cisplatin, ifosfamide and cyclophosphamide.We have developed a standard, institutional document which determines how chemotherapy and supportive medicines are administered, limiting variation and risk, increasing staff efficiency and decreasing lengths of hospital admissions.ConclusionThere is unnecessary variation in the way chemotherapy is administered to paediatric patients in Europe. Doses should not be changed, but length of chemotherapy infusion and associated hydration/supportive medicines are extremely varied and there is little evidence to say this is beneficial in terms of patient outcomes. Chemotherapy protocols can be standardised, limiting variation, reducing potential risk and increasing staff and ward efficiencies.
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