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1.  The risk for multiple sclerosis in female nurse anaesthetists: a register based study 
Previous studies have suggested that exposure to organic solvents, including volatile anaesthetic agents, may be a risk factor for multiple sclerosis (MS), possibly in combination with genetic and other environmental factors.
To further investigate the role of volatile anaesthetic agents having similar acute toxic effects to other organic solvents.
Female nurse anaesthetists, other female nurses, and female teachers from middle and upper compulsory school levels were identified and retrieved from the 1985 census, Statistics Sweden. By means of the unique personal identity number in Sweden, these individuals were linked with the disability pension registers at The National Social Insurance Board and also with data on hospital care 1985–2000 at The National Board of Health and Welfare.
The cumulative incidence rate ratio of MS was found to be increased in female nurse anaesthetists in relation to other nurses (statistically not significant) and teachers (statistically significant), respectively.
These findings give some support to previous findings of an increased risk for MS in nurse anaesthetists. This is interesting in the context of previous observations of organic solvents in general as a potential risk factor in MS.
PMCID: PMC2078114  PMID: 16709703
exposure; volatile anaesthetic gases; organic solvents; risk
2.  Safety in magnetic resonance units: an update 
Anaesthesia  2010;65(7):766-770.
The number of anaesthetists who are involved in magnetic resonance (MR) units is increasing. Magnetic resonance systems are becoming more powerful and interventional procedures are now possible. This paper updates information relating to safety terminology, occupational exposure, reactions to gadolinium-based contrast agents and the risk of nephrogenic systemic fibrosis. Magnetic resonance examinations of patients with pacemakers are still generally contra-indicated but have been carried out in specialist centres under strictly controlled conditions. As availability of MR increases, so the education of anaesthetists, who are occasionally required to provide a service, must be considered.
Anaesthesia in MR units was first described in the 1980s. Guidelines on the provision of anaesthetic services in MR units were published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) in 2002 [1]. Since then, the number of hospitals with MR units, and hence the number of patients requiring anaesthesia for MR, has increased. While the issues relating to setting up anaesthetic services in MR have not changed, there have been a number of developments that warrant this update:
Safety terminology and guidelines have changed.MR systems utilise higher magnetic-field strengths and more open designs are available.Interventional and intra-operative MR are now routine in some centres.Mobile MR scanners are increasingly used to reduce waiting lists.Although still generally contra-indicated, some patients with pacemakers have been scanned under strictly controlled conditions in specialist centres.‘MR safe’ medical implants are now being produced.New equipment is now available for use in MR.Out-of-hours availability of MR investigations has increased.Reports of allergic reactions to MR contrast media have increased.Gadolinium based contrast agents (Gd-CAs) are associated with a varying degree of risk of nephrogenic systemic fibrosis in patients with impaired renal function.
PMCID: PMC2904502  PMID: 20642539
3.  Children's surgery: a national survey of consultant clinical practice 
BMJ Open  2012;2(5):e001639.
To survey clinical practice and opinions of consultant surgeons and anaesthetists caring for children to inform the needs for training, commissioning and management of children's surgery in the UK.
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) hosted an online survey to gather data on current clinical practice of UK consultant surgeons and anaesthetists caring for children.
The questionnaire was circulated to all hospitals and to Anaesthetic and Surgical Royal Colleges, and relevant specialist societies covering the UK and the Channel Islands and was mainly completed by consultants in District General Hospitals.
555 surgeons and 1561 anaesthetists completed the questionnaire.
32.6% of surgeons and 43.5% of anaesthetists considered that there were deficiencies in their hospital's facilities that potentially compromised delivery of a safe children's surgical service. Almost 10% of all consultants considered that their postgraduate training was insufficient for current paediatric practice and 20% felt that recent Continued Professional Development failed to maintain paediatric expertise. 45.4% of surgeons and 39.2% of anaesthetists considered that the current specialty curriculum should have a larger paediatric component. Consultants in non-specialist paediatric centres were prepared to care for younger children admitted for surgery as emergencies than those admitted electively. Many of the surgeons and anaesthetists had <4 h/week in paediatric practice. Only 55.3% of surgeons and 42.8% of anaesthetists participated in any form of regular multidisciplinary review of children undergoing surgery.
There are significant obstacles to consultant surgeons and anaesthetists providing a competent surgical service for children. Postgraduate curricula must meet the needs of trainees who will be expected to include children in their caseload as consultants. Trusts must ensure appropriate support for consultants to maintain paediatric skills and provide the necessary facilities for a high-quality local surgical service.
PMCID: PMC3488724  PMID: 23075572
Paediatric Surgery
4.  Discrepant perceptions of communication, teamwork and situation awareness among surgical team members 
To assess surgical team members’ differences in perception of non-technical skills.
Questionnaire design.
Operating theatres (OTs) at one university hospital, three teaching hospitals and one general hospital in the Netherlands.
Sixty-six surgeons, 97 OT nurses, 18 anaesthetists and 40 nurse anaesthetists.
All surgical team members, of five hospitals, were asked to complete a questionnaire and state their opinion on the current state of communication, teamwork and situation awareness at the OT.
Ratings for ‘communication’ were significantly different, particularly between surgeons and all other team members (P ≤ 0.001). The ratings for ‘teamwork’ differed significantly between all team members (P ≤ 0.005). Within ‘situation awareness’ significant differences were mainly observed for ‘gathering information’ between surgeons and other team members (P < 0.001). Finally, 72–90% of anaesthetists, OT nurses and nurse anaesthetists rated routine team briefings and debriefings as inadequate.
This study shows discrepancies on many aspects in perception between surgeons and other surgical team members concerning communication, teamwork and situation awareness. Future research needs to ascertain whether these discrepancies are linked to greater risk of adverse events or to process as well as systems failures. Establishing this link would support implementation and use of complex team interventions that intervene at multiple levels of the healthcare system.
PMCID: PMC3055275  PMID: 21242160
patient safety; quality of care; teamwork; communication; surgery
5.  Governing the surgical count through communication interactions: implications for patient safety 
Quality & Safety in Health Care  2006;15(5):369-374.
Intermittently, the incidence of retained surgical items after surgery is reported in the healthcare literature, usually in the form of case studies. It is commonly recognised that poor communication practices influence surgical outcomes.
To explore the power relationships in the communication between nurses and surgeons that affect the conduct of the surgical count.
A qualitative, ethnographic study was undertaken. Data were collected in three operating room departments in metropolitan Melbourne, Australia. 11 operating room nurses who worked as anaesthetic, instrument and circulating nurses were individually observed during their interactions with surgeons, anaesthetists, other nurses and patients. Data were generated through 230 h of participant observation, 11 individual and 4 group interviews, and the keeping of a diary by the first author. A deconstructive analysis was undertaken.
Results are discussed in terms of the discursive practices in which clinicians engaged to govern and control the surgical count. The three major issues presented in this paper are judging, coping with normalisation and establishing priorities.
The findings highlight the power relationships between members of the surgical team and the complexity of striking a balance between organisational policy and professional judgement. Increasing professional accountability may help to deal with the issues of normalisation, whereas greater attention needs to be paid to issues of time management. More sophisticated technological solutions need to be considered to support manual counting techniques.
PMCID: PMC2565825  PMID: 17074876
6.  Assessment of fitness for surgical procedures and the variability of anaesthetists' judgments. 
British Medical Journal  1980;280(6213):509-512.
Ten anaesthetists were asked to make judgments on fitness for elective operation on data derived from 200 patients. The extent of their agreement was measured using a kappa statistic, and clusters of anaesthetists who agreed well with each other were identified. Using an alternative technique, the "true" fitness category of each patient was estimated using a maximum likelihood method which estimated the error involved in making judgments on limited amounts of information. It was possible to compare the performance of each anaesthetist against the consensus and to measure deviation on an "optimism--pessimism" continuum. A simple questionnaire predicted fitness for operation by all 10 anaesthetists in 96% of cases.
PMCID: PMC1601404  PMID: 7370563
7.  Description of local adaptation of national guidelines and of active feedback for rationalising preoperative screening in patients at low risk from anaesthetics in a French university hospital 
OBJECTIVE: To describe the effect of local adaptation of national guidelines combined with active feedback and organisational analysis on the ordering of preoperative investigations for patients at low risk from anaesthetics. DESIGN: Assessment of preoperative tests ordered over one month, before and after local adaptation of guidelines and feedback of results, combined with an organisational analysis. SETTING: Motivated anaesthetists in 15 surgical wards of Bordeaux University Hospital, Region Aquitain, France. SUBJECTS: 42 anaesthetists, 60 surgeons, and their teams. MAIN OUTCOME MEASURES: Number and type of preoperative tests ordered in June 1993 and 1994, and the estimated savings. RESULTS: Of 536 patients at low risk from anaesthetics studied in 1993 before the intervention 80% had at least one preoperative test. Most (70%) tests were ordered by anaesthetists. Twice the number of preoperative tests were ordered than recommended by national guidelines. Organisational analysis indicated lack of organised consultations and communication within teams. Changes implemented included scheduling of anaesthetic consultations; regular formal multidisciplinary meetings for all staff; preoperative ordering decision charts. Of 516 low risk patients studied in 1994 after the intervention only 48% had one or more preoperative tests ordered (p < 0.05). Estimated mean (SD) saving for one year if changes were applied to all patients at low risk from anaesthesia in the hospital 3.04 (1.23) mFF. CONCLUSIONS: A sharp decrease in tests ordered in low risk patients was found. The likely cause was the package of changes that included local adaptation of national guidelines, feedback, and organisational change.
PMCID: PMC2483578  PMID: 10178152
8.  Cancer in printing workers in Denmark. 
OBJECTIVES--To study the cancer incidence in printing workers in Denmark. METHODS--The cohort of 15,534 men and 3593 women working in the printing industry in 1970 were followed up for death, emigrations, and incident cancer cases until the end of 1987. Their cancer incidence was compared with that of all economically active people in Denmark. The smoking and drinking habits reported by members of the printing trade unions at a survey in 1972 were compared with habits reported by members of other trade unions. RESULTS--Lung, bladder, renal pelvis, and primary liver cancers were in excess among the printing workers. The excess risks of lung cancer among the factory workers in newspaper and magazine production, of bladder cancer in typographers in printing establishments, of renal pelvis cancer in typographers and lithographers, and of primary liver cancer among lithographers and bookbinders exceeded those expected based on the reported smoking and drinking habits. CONCLUSION--Our results indicate, in line with a previous study from Manchester, that work with rotary letterpress printing was associated with an increased risk of lung cancer. The inconsistent results from studies on bladder cancer in printing workers may point to a risk confined to a certain subgroup. The sixfold risk of primary liver cancer in Danish lithographers warrants studies in other countries.
PMCID: PMC1128354  PMID: 8535493
9.  Combined effects of smoking, anti-EBNA antibodies, and HLA-DRB1*1501 on multiple sclerosis risk(e–Pub ahead of print) 
Neurology  2010;74(17):1365-1371.
To examine the interplay between smoking, serum antibody titers to the Epstein-Barr virus nuclear antigens (anti-EBNA), and HLA-DR15 on multiple sclerosis (MS) risk.
Individual and pooled analyses were conducted among 442 cases and 865 controls from 3 MS case-control studies—a nested case-control study in the Nurses' Health Study/Nurses' Health Study II, the Tasmanian MS Study, and a Swedish MS Study. Conditional logistic regression models were used to calculate odds ratios (ORs) and 95% CIs for the association between smoking, anti-EBNA titers, HLA-DR15, and MS risk. Study estimates were pooled using inverse variance weights to determine a combined effect and p value.
Among MS cases, anti-EBNA titers were significantly higher in ever smokers compared to never smokers. The increased risk of MS associated with high anti-EBNA Ab titers was stronger among ever smokers (OR = 3.9, 95% CI = 2.7–5.7) compared to never smokers (OR = 1.8, 95% CI = 1.4–2.3; p for interaction = 0.001). The increased risk of MS associated with a history of smoking was no longer evident after adjustment for anti-EBNA Ab titers. No modification or confounding by HLA-DR15 was observed. The increased risk of MS associated with ever smoking was only observed among those who had high anti-EBNA titers (OR = 1.7, 95% CI = 1.1–2.6).
Smoking appears to enhance the association between high anti-EBNA titer and increased multiple sclerosis (MS) risk. The association between HLA-DR15 and MS risk is independent of smoking. Further work is necessary to elucidate possible biologic mechanisms to explain this finding.
= antibody titers to the Epstein-Barr virus nuclear antigens;
= Epstein-Barr virus;
= multiple sclerosis;
= Nurses' Health Study;
= Nurses' Health Study II;
= Northern Sweden Health and Disease Study Cohort;
= odds ratio.
PMCID: PMC2875934  PMID: 20375311
10.  Evaluation of the quality of drug therapy among elderly patients in nursing homes 
To evaluate drug therapy quality among elderly nursing home residents. Secondary aims were to compare quality in young and old elderly and to determine whether number of prescribers affected quality of drug therapy.
A cross-sectional population-based register study.
Nursing home residents in the Gothenburg area using the multi-dose system (e.g. patients who get their drugs machine dispensed into one unit for each dose occasion, a service offered by the National Corporation of Pharmacies).
All nursing home residents aged 65 years and older.
Main outcome measures
The quality of drug therapy assessed using five quality indicators for the elderly recently introduced by the Swedish National Board of Health and Welfare; number of prescribed drugs per resident.
Over 70% of residents had one or more potentially inappropriate prescription. Younger nursing home residents (65–79 years) had significantly (p < 0.001) lower quality of drug therapy than older residents (80 + ). The average number of prescribing physicians per resident was high at almost four per resident. An increasing number of prescribers per resident was associated with a higher number of drugs prescribed and a lower quality of drug therapy.
Computerized quality assurance systems can provide support for healthcare providers. Quality indicators should be modified to give maximum support for users.
PMCID: PMC3389457  PMID: 17354153
Drugs; elderly; family practice; nursing home; prescribing; quality indicators
11.  A survey of surgical team members’ perceptions of near misses and attitudes towards Time Out protocols 
BMC Surgery  2013;13:46.
Medical errors are inherently of concern in modern health care. Although surgical errors as incorrect surgery (e.g., wrong patient, wrong site, or wrong procedure) are infrequent, they are devastating events to experience. To gain insight about incidents that could lead to incorrect surgery, we surveyed how surgical team members perceive near misses and their attitudes towards the use of Time Out protocols in the operating room. We hypothesised that perceptions of near-miss experiences and attitudes towards Time Out protocols vary widely among surgical team members.
This cross-sectional study (N = 427) included surgeons, anaesthetists, nurse anaesthetists, and operating room nurses. The questionnaire consisted of 14 items, 11 of which had dichotomous responses (0 = no; 1 = yes) and 3 of which had responses on an ordinal scale (never = 0; sometimes = 1; often = 2; always = 3). Items reflected team members’ experience of near misses or mistakes; their strategies for verifying the correct patient, site, and procedure; questions about whether they believed that these mistakes could be avoided using the Time Out protocol; and how they would accept the implementation of the protocol in the operating room.
In the operating room, 38% of respondents had experienced uncertainty of patient identity, 81% had experienced uncertainty of the surgical site or side, and 60% had prepared for the wrong procedure. Sixty-three per cent agreed that verifying the correct patient, site, and procedure should be a team responsibility. Thus, only nurse anaesthetists routinely performed identity checks prior to surgery (P ≤ 0.001). Of the surgical team members, 91% supported implementation of a Time Out protocol in their operating rooms.
The majority of our surgical personnel experienced near misses with regard to correct patient identity, surgical site, or procedure. Routines for ensuring the correct patient, site, and surgical procedure must involve all surgical team members. We find that the near-miss experiences are a wake-up call for systematic risk reducing efforts and the use of checklists in surgery.
PMCID: PMC3851944  PMID: 24106792
Surgery; Operating room; Near misses; Medical errors; Checklist
12.  Survey of the use of rapid sequence induction in the accident and emergency department 
Objectives—To determine the current position regarding the use of rapid sequence induction (RSI) by accident and emergency (A&E) medical staff and the attitudes of consultants in A&E and anaesthetics towards this.
Methods—A questionnaire was designed that was distributed to consultant anaesthetists and A&E physicians in hospitals receiving over 50 000 new A&E patients per year.
Results—A total of 140 replies were received (a response rate of 72%). The breakdown of results is shown. There was wide difference of opinion between anaesthetists and A&E consultants as to who performs RSI at present in their A&E departments, however two thirds of anaesthetists thought A&E staff with appropriate training and support should attempt RSI either routinely or in certain circumstances.
Conclusions—A&E staff in several hospitals routinely undertake RSI and the majority of A&E consultants thought that RSI would be undertaken by A&E staff if an anaesthetist were unavailable. There is disagreement regarding the length of anaesthetic training required before A&E medical staff should undertake RSI.
PMCID: PMC1725352  PMID: 10718228
13.  High Annual Risk of Tuberculosis Infection among Nursing Students in South India: A Cohort Study 
PLoS ONE  2011;6(10):e26199.
Nurses in developing countries are frequently exposed to infectious tuberculosis (TB) patients, and have a high prevalence of TB infection. To estimate the incidence of new TB infection, we recruited a cohort of young nursing trainees at the Christian Medical College in Southern India. Annual tuberculin skin testing (TST) was conducted to assess the annual risk of TB infection (ARTI) in this cohort.
Methodology/Principal Findings
436 nursing students completed baseline two-step TST testing in 2007 and 217 were TST-negative and therefore eligible for repeat testing in 2008. 181 subjects completed a detailed questionnaire on exposure to tuberculosis from workplace and social contacts. A physician verified the questionnaire and clinical log book and screened the subjects for symptoms of active TB. The majority of nursing students (96.7%) were females, almost 84% were under 22 years of age, and 80% had BCG scars. Among those students who underwent repeat testing in 2008, 14 had TST conversions using the ATS/CDC/IDSA conversion definition of 10 mm or greater increase over baseline. The ARTI was therefore estimated as 7.8% (95%CI: 4.3–12.8%). This was significantly higher than the national average ARTI of 1.5%. Sputum collection and caring for pulmonary TB patients were both high risk activities that were associated with TST conversions in this young nursing cohort.
Our study showed a high ARTI among young nursing trainees, substantially higher than that seen in the general Indian population. Indian healthcare providers and the Indian Revised National TB Control Programme will need to implement internationally recommended TB infection control interventions to protect its health care workforce.
PMCID: PMC3192164  PMID: 22022565
14.  Use of intravenous cannulae by junior hospital doctors. 
Postgraduate Medical Journal  1993;69(811):389-391.
One hundred junior hospital doctors were surveyed to investigate their use of intravenous cannulae. Anaesthetists inserted more cannulae per day than non-anaesthetists and were more likely to use local anaesthetic and wear gloves, although most doctors never or rarely did so. Anaesthetists were also more knowledgeable than non-anaesthetists about the sizes of cannulae they used and the sizes available, although there was considerable ignorance overall in this regard. Many doctors regularly place themselves at risk and expose their patients to unnecessary pain during intravenous cannula insertion, and have little knowledge about the cannulae they use.
PMCID: PMC2399826  PMID: 8346136
15.  Body size and risk of MS in two cohorts of US women 
Neurology  2009;73(19):1543-1550.
To examine whether obesity during childhood, adolescence, or adulthood is associated with an increased risk of multiple sclerosis (MS).
Women in the Nurses’ Health Study (n = 121,700) and Nurses’ Health Study II (n = 116,671) provided information on weight at age 18 and weight and height at baseline, from which body mass index was derived. Women also selected silhouettes representing their body size at ages 5, 10, and 20. Over the total 40 years of follow-up in both cohorts combined, we confirmed 593 cases of MS. Cox proportional hazards models, adjusting for age, latitude of residence, ethnicity, and cigarette smoking, were used to estimate the rate ratios and 95% confidence intervals (CI).
Obesity at age 18 (body mass index ≥30 kg/m2) was associated with a greater than twofold increased risk of MS (multivariate relative riskpooled = 2.25, 95% CI: 1.50-3.37, p trend <0.001). After adjusting for body size at age 20, having a large body size at ages 5 or 10 was not associated with risk of MS, whereas a large body size at age 20 was associated with a 96% increased risk of MS (95% CI: 1.33-2.89, p trend = 0.009). No significant association was found between adult body mass and MS risk.
Obese adolescents have an increased risk of developing multiple sclerosis (MS). Although the mechanisms of this association remain uncertain, this result suggests that prevention of adolescent obesity may contribute to reduced MS risk.
= 25-hydroxyvitamin D;
= body mass index;
= confidence interval;
= multiple sclerosis;
= Nurses’ Health Study;
= Nurses’ Health Study II;
= relative risk.
PMCID: PMC2777074  PMID: 19901245
16.  Dietary intake of vitamin D during adolescence and risk of multiple sclerosis 
Journal of neurology  2010;258(3):479-485.
Adolescence may be an important etiological period in the development of multiple sclerosis (MS), and studies suggest that adequate vitamin D nutrition is protective. Here, the authors examined whether dietary intake of vitamin D during adolescence decreases the risk of MS in adulthood. In 1986 in the Nurses’ Health Study and in 1998 in the Nurses’ Health Study II (NHSII), women completed a food frequency questionnaire regarding their dietary intake during adolescence. From this, daily intake of vitamin D was calculated. Adolescent diet was available for 379 incident MS cases confirmed over the combined 44 years of follow-up in both cohorts, and for 67 prevalent cases in the NHSII who had MS at baseline (1989). Cox proportional hazards models were used to calculate relative risk estimates and 95% confidence intervals. Total vitamin D intake during adolescence was not associated with MS risk. Intake of ≥400 IU/day of vitamin D from multivitamins was associated with a non-statistically significant reduced risk (RR compared to no intake = 0.73, 95% CI: 0.50–1.07, P = 0.11), whereas intake of whole milk, an important source of dietary vitamin D, was associated with an increased risk. The possibility of opposite effects of vitamin D and milk intake on MS risk should be considered in future studies.
PMCID: PMC3077931  PMID: 20945071
Multiple sclerosis; Vitamin D; Cohort study; Epidemiology
17.  Pain control after surgery: a survey of current practice. 
A questionnaire was sent to 302 qualified nurses in an attempt to elicit their current practice of administering postoperative analgesics, knowledge of the drugs, opinions regarding prescribing habits and comments on how pain control could be improved; 211 nurses replied (70% response). Knowledge was good but practice poor in that 56% give less than six doses postoperatively and the majority of nurses do not give analgesics until the patient is in pain; 66% thought the amount of analgesic given was a poor indication of pain experienced; 62% felt that prescribing by doctors was inconsistent and 90% thought it could be improved. Deficiencies in communication between anaesthetists, nurses and patients were highlighted. The nurses wished for more involvement in pain management and for more education of patients preoperatively. A selection of comments is included and possible simple methods for improving pain control are discussed.
PMCID: PMC2498209  PMID: 3966777
18.  The Relationship between Handedness and Risk of Multiple Sclerosis 
Left-handedness has been studied as a marker for in utero exposure to sex steroid hormones, and an increased risk of autoimmune and immune disorders among left-handed individuals has been suggested.
This study examines the relationship between hand preference and risk of multiple sclerosis (MS), a presumed autoimmune disorder of unknown etiology.
The study population comprised participants in the Nurses’ Health Study, an ongoing prospective cohort study of 121,701 female nurses in the United States with follow-up from 1976–2002. The nurses were asked to report their natural hand preference (right, left, ambidextrous, forced to change).
During follow-up 210 incident MS cases were confirmed. A 62 percent increased risk of MS was observed among women who were naturally left-handed as compared to those who were naturally right-handed (95 percent CI: 1.04–2.53).
This study suggests a modest increase in risk of MS among left-handed women. Further investigation of this relationship is suggested in other populations including both males and females. While the current results suggest that prenatal exposure to sex hormones may play a role in MS risk, direct examination of the relationship between in-utero hormone exposure and hand preference is necessary before any conclusions can be drawn.
PMCID: PMC2771381  PMID: 19389750
Multiple Sclerosis; Cohort Study; Functional Laterality; Hormones; Epidemiology; Risk Factors; Prenatal exposure delayed effects
19.  Spontaneous abortions and malformations in the offspring of nurses exposed to anaesthetic gases, cytostatic drugs, and other potential hazards in hospitals, based on registered information of outcome. 
Nurses working in selected departments of general hospitals in Finland were collected from a central register on health personnel in Finland. Using the Hospital Discharge Register and the Register of Congenital Malformations, case nurses were selected who had had a spontaneous abortion (N = 217) or a malformed child (N = 46) between the years 1973 and 1979. Controls consisted of three nurses who had had a normal birth; the control nurses were matched for age and hospital of employment. Information on exposure in the first trimester of pregnancy was sought through the head nurses of the hospitals. No significant increase in risk of spontaneous abortion or of malformation was observed after exposure to anaesthetic gases (odds ratio for spontaneous abortion 1.2), sterilising gases and soaps, or x-rays. Handling of cytostatic drugs did not affect the frequency of spontaneous abortion but was associated with malformations in the offspring. The odds ratio, based on eight cases, was 4.7 (p = 0.02) when the logistic model was adopted. The results suggest that the exposures investigated, other than cytostatic drugs, do not cause a strong reproductive risk. Further studies are needed, particularly on cytostatic drugs.
PMCID: PMC1052422  PMID: 3925060
20.  Obstetric Anaesthesia Services in the United Kingdom 
British Medical Journal  1971;1(5740):101-103.
In a survey of obstetric anaesthetic services in the United Kingdom questionnaires were sent to 398 hospital maternity units and 347 general-practitioner maternity units, of which 344 and 272 respectively were returned. Many hospitals were unable to provide an anaesthetist for obstetric surgery only, and few consultant anaesthetist sessions were allocated to obstetric surgery, particularly in regional hospitals in England and Wales. Constant supervision of junior anaesthetic staff with under 12 months' experience was lacking in several hospitals. Endotracheal intubation is widely used throughout the United Kingdom. Though regional analgesic techniques are used by most anaesthetists it is impossible to provide a 24-hour regional analgesic service in all but a few hospitals.
PMCID: PMC1795676  PMID: 5539159
21.  Percutaneous exposure incidents in nurses: Knowledge, practice and exposure to hepatitis B infection 
Hepatitis Monthly  2011;11(3):186-190.
Nurses are at risk of percutaneous exposure incidents (PEIs), which may lead to serious or even fatal blood-borne infections.
To determine the prevalence of PEIs in the last year, among nurses and to assess their knowledge about and frequency of safe method of practice in exposure to blood-borne pathogens (especially, to HBV).
Materials and Methods
A cross-sectional study in 2008 was conducted on 138 nurses working in general surgery and obstetrics/gynecology services of Qazvin University of Medical Sciences, Qazvin, Central Iran. A questionnaire for assessment of risk factors for contracting HBV infection was completed by nurses.
Overall, the prevalence of needle stick injury (NSI) and direct exposure to body fluids were 52.9% (95% CI: 44.5%-61.3%) and 65.4% (95% CI: 57.4% - 73.8%), respectively. There was no statistically significant difference between the two studied centers in terms of sharp injuries; however, the rate of repeated NSI (number per each year ≥3) and mucocutaneous exposures were significantly higher in the general surgery ward. The overall coverage of vaccination in the two studied centers was 96.3%, but the rate of accurate answers to many questions pertaining to knowledge and practice were less than 50%.
Nurses are still at significant risk for developing NSI and mucocutaneous exposure. Continuous educational programs (especially by highlighting the seriousness of the problem) are necessary for improving this situation because inadequate education might increase unsafely practice.
PMCID: PMC3206680  PMID: 22087141
Knowledge; Practice; Exposure; Hospital; Needlestick
22.  Prenatal and Perinatal Factors and Risk of Multiple Sclerosis 
Epidemiology (Cambridge, Mass.)  2009;20(4):611-618.
A potential role of prenatal and perinatal exposures in autoimmunity has been hypothesized, but few studies have examined the relation between various prenatal and perinatal factors and risk of multiple sclerosis (MS).
The study population included participants in the Nurses’ Health Studies, 2 prospective cohorts that together comprise 238,381 female nurses, who self-reported exposure to prenatal and perinatal factors. In addition, 35,815 nurses’ mothers participated by providing detailed information regarding experiences surrounding their daughter’s birth. The following prenatal and perinatal factors were studied in relation to MS: fetal growth, birth season, preterm birth, mode of delivery, maternal weight gain, medical conditions, medication use, diethylstilbestrol exposure, prenatal health care, maternal activity level, maternal obstetric history, parental age, and prenatal and childhood passive smoke exposure.
The sample included 723 confirmed MS cases, including 383 with diagnosis after reporting prenatal and perinatal factors. Few associations were observed. These included an increased risk among women whose mothers reported late initiation of prenatal care (after the first trimester) (27 cases, rate ratio = 1.6; 95% confidence interval = 1.0–2.4), diabetes during pregnancy (2 cases; 10;2.5–42), and maternal prepregnancy overweight/obesity (20 cases; 1.7; 1.0–2.7). Results also suggested a possible increase in incident MS risk among women with prenatal diethylstilbestrol exposure (9 cases; 1.8; 0.93–3.5).
This study provides modest support for a role of prenatal factors in MS risk. The results should be interpreted cautiously due to the limited statistical power, potential for exposure misclassification, and possibility of chance findings.
PMCID: PMC3132937  PMID: 19333127
23.  Practice of preoperative assessment by anaesthetists. 
The practice of preoperative assessment in 24 departments of anaesthesia in Great Britain and Ireland was surveyed. Most departments had no rigid policies governing assessment, and many served several hospitals. There was little evidence that admission procedures of patients scheduled for surgery or the organisation of operating lists took account of the problems encountered by anaesthetists undertaking preoperative assessment. From the participating departments 415 anaesthetists completed a questionnaire of their individual practice. Most (57%) visited at least 80% of their patients preoperatively, but 22% saw less than 50% of patients. The detection of potential anaesthetic problems and the establishment of rapport with patients were highly rated reasons for conducting such visits. Failure to visit was often related to organisational defects within the hospital service, and anaesthetists saw little prospect of improving these defects. The demands created by the needs of preoperative assessment on the one hand, and the need for a rapid turnover of surgical patients and financial stringency on the other, conflict, and this conflict is not easily reconciled.
PMCID: PMC1416463  PMID: 3926208
24.  Simulation and anaesthesia 
Indian Journal of Anaesthesia  2012;56(1):14-20.
Training in anaesthesia relies on the duration and quality of clinical experience. It involves exposure to a range of interventions. This works well in routine cases, but when an uncommon and life-threatening event occurs, the anaesthetist needs to carry out multiple tasks simultaneously. Aviation has remarkable similarities with the practice of anaesthesia. Over the years, the aviation industry has used simulation to train and assess individuals very effectively. Anaesthetists face rapidly evolving clinical situations. This needs appropriate decision-making and communication with others in the theatre team. Simulation, using current technology, offers innovative and reproducible training experience. It enables standardised scenario building and reflective learning. Various non-technical aspects of an anaesthetist's day-to-day work could also be addressed to during such training. The technology could be used very effectively for the assessment of competence too. Simulation has been used for technology development and appraisal over the years.
PMCID: PMC3327064  PMID: 22529414
ACRM; ANTS; fidelity; fixation errors; simulation; simulator; situation awareness
25.  The nurse's role in immediate postoperative care. 
British Medical Journal  1977;1(6070):1119-1202.
From the time that a patient leaves the care of the anaesthetist after an operation until he wakes in the ward his physiological state should be continuously and expertly supervised. Postoperative nurses are provided only when the operating theatre has a recovery room. A survey among consultants and nurses in one region showed that many surgical units did not have recovery rooms and that inexperienced ward nurses were often sent to collect patients. The survey showed that most nurses were competent to care for unconscious patients so long as an emergency did not arise. In many hospitals the facilities for the safe nursing of postoperative patients were totally inadequate. The very least that is needed is good communications with the anaesthetist, adequate lighting, and a source of oxygen and suction. Because of the shortage of nurses likely to have to care for postanaesthetic patients early on and to train them accordingly. Nevertheless, recovery nurses, whose sole responsibility is to care for a patient until be has recovered from anaesthesia, should be appointed for all busy surgical units.
PMCID: PMC1606846  PMID: 67869

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