Journal articles on the topic 'Jamaica General Trained Nurses Association'

The aim of this study was to investigate the results of the red reflex test and to associate these results with neonatal variables. This descriptive study was conducted with 190 newborns in a public maternity hospital. A total of 187 infants presented no alteration and three presented suspect results. Different shades of reflex color were observed: 50 (26.3%) presented red; 34 (17.9%) orange-red, 92 (48.4%) orange, 11 (5.8%) light yellow and three (1.6%) milky white spots. Statistically significant associations between the color gradient instrument and neonatal variables were found: weight (p=0.03), gestational age (p=0.019) and oxygen therapy (p=0.024). Nurses trained to practice and evaluate this test may become professionals in the potential for the prevention of childhood blindness.

In China, chronic wounds are an important issue. However, wound care knowledge and the skill of health care professionals varies among hospitals and cities. A training program in wound care in China was completed in 2015 and achieved great success. To facilitate expertise in wound healing in China, a sequential training project supported by the Wound Healing Union and the Chinese Medical Doctor Association was initiated. The aim of the training program was mainly to improve experience and skills in wound healing. Until December 2016, a total of 301 medical staffs, including 134 physicians and 167 nurses, have been trained. Most of the doctors (92 of 134) and nurses (142 of 167) were from Grade IIIA/B hospitals, and there were no doctors and nurses from community hospitals. Most participants were satisfied about the training program, and more nurses were satisfied (79%) than doctors (60%). All trainees have completed 4½ months of training and passed a final examination.

Over the past decade, multiple clinical reports have demonstrated that the use of propofol sedation for gastrointestinal endoscopy by gastroenterologists and trained endoscopy nurses is safe and effective in appropriately selected patients. Proposed benefits of propofol sedation include rapid onset of action, improved patient comfort and rapid clearance, as well as prompt recovery and discharge from the endoscopy unit. As a result of medical evidence, a number of international professional societies have endorsed the use of propofol in gastrointestinal endoscopy. In Canada, no formal guidelines currently exist. In the present article, the Clinical Affairs Committee of the Canadian Association of Gastroenterology presents a position statement, incorporating updated information on the use of propofol sedation for endoscopy in adult patients.

ABSTRACT Landstuhl Regional Medical Center’s response to the coronavirus disease 2019 pandemic included a plan to provide just-in-time training for nursing staff and paraprofessionals from throughout the organization in the event that it became overwhelmed with more critically ill patients than the facility was staffed to manage. Training conducted was a combination of online learning from the Society of Critical Care Medicine and the Association of Critical Care Nurses as well as a 2-hour block of hands-on skills. The three competencies for floating staff from Wright’s Method for Competency Assessment were utilized in the training process, allowing trainees to (1) learn to fly, (2) market themselves in a positive way, and (3) understand crisis management options. Quick implementation of the plan led to over 125 nurses and paraprofessionals receiving the education and training in preparation for the pandemic response. The article further discusses training topics covered and the competency expectations for non-critical care nurses trained.

Background and objectiveFew studies have examined the relationship between dietary patterns and antioxidant status. We aimed to explore the association between major dietary patterns and oxidative stress biomarkers including serum protein carbonyl (PC), ceruloplasmin and total antioxidant capacity (TAC).MethodIn this cross-sectional study, we randomly selected 320 female nurses aged 20–45 years. General information of participants was collected by trained interviewers. Their weight and height were measured and dietary intakes were determined by the 147-food-item semiquantitative food frequency questionnaire. Dietary patterns were derived by principal component analysis of yielding 25 food groups. In this study, 90 subjects were randomly selected from all participants with serum levels of PC, ceruloplasmin and TAC measured further. To determine the association between dietary patterns’ score and oxidative stress biomarkers, multiple linear regression analysis was conducted.ResultsThree dietary patterns were derived: healthy, unhealthy and traditional. After adjusting for several confounding factors, the unhealthy dietary pattern was inversely related to the serum concentration of ceruloplasmin and PC (p<0.05). The relationship between other dietary patterns and antioxidant biomarkers was not significant.ConclusionsAccording to the results of this study, unhealthy dietary patterns may have an adverse effect on serum ceruloplasmin.

ObjectivesWe explored the relationship between the experience level of nurses and the peritonitis risk in peritoneal dialysis (PD) patients.MethodsOur observational cohort study followed 305 incident PD patients until a first episode of peritonitis, death, or censoring. Patients were divided into 3 groups according to the work experience in general medicine of their nurses—that is, least experience (<10 years), moderate experience (10 to <15 years), and advanced experience (≥15 years). Demographic characteristics, baseline biochemistry, and residual renal function were also recorded. Multivariate Cox regression was used to analyze the association of risks for all-cause and gram-positive peritonitis with patient training provided by nurses at different experience levels.ResultsOf the 305 patients, 91 were trained at the initiation of PD by nurses with advanced experience, 100 by nurses with moderate experience, and 114 by nurses with the least experience. Demographic and clinical variables did not vary significantly between the groups. During 13 582 patient–months of follow-up, 129 first episodes of peritonitis were observed, with 48 episodes being attributed to gram-positive organisms. Kaplan–Meier analysis showed that training by nurses with advanced experience predicted the longest period free of first-episode gram-positive peritonitis. After adjustment for some recognized confounders, the advanced experience group was still associated with the lowest risk for first-episode gram-positive peritonitis. The level of nursing experience was not significantly correlated with all-cause peritonitis risk.ConclusionsThe experience in general medicine of nurses might help to lower the risk of gram-positive peritonitis among PD patients. These data are the first to indicate that nursing experience in areas other than PD practice can be vital in the training of PD patients.

BACKGROUND: Pain assessment and management are recognized as major problems in critical care settings. However, little is known about pain management practices related to medical procedures performed in the ICU, particularly removal of chest tubes. OBJECTIVES: To describe practices related to chest tube removal in the United States, with an emphasis on pain assessment and management. METHODS: A survey instrument was developed and mailed to 995 members of the American Association of Critical-Care Nurses who cared for patients with chest tubes. They were asked about chest tube removal practices in their institutions. RESULTS: Chest tubes are removed primarily by physicians and house staff, although 11% of respondents reported that specially trained nurses removed the tubes. Only 16% indicated that a prescription for pain medication was routinely available before chest tube removal. The drug administered most frequently was intravenous morphine sulfate, but the dose varied considerably. Nurses were generally satisfied (65.6%) with practices related to chest tube removal in their unit; nurses who were not satisfied (34.4%) wished to see better pain management practices (45%), removal of tubes by the patient's assigned nurse (17.8%), a protocol for tube removal (13.9%), notification of the nurse before removal (12.2%), and other changes (10%). CONCLUSIONS: Practices associated with chest tube removal, especially pharmacologic management of procedure-related pain, vary in critical care units. Caregivers are advised to develop practice policies to guide decisions about management of acute pain in this patient population.

The development of peritoneal dialysis (PD) programmes in lower-resource countries is challenging. This article describes the learning points of establishing PD programmes in three countries in South Asia (Nepal, Sri Lanka and Pakistan). The key barriers identified were government support (financial), maintaining stable supply of PD fluids, lack of nephrologist and nurse expertise, nephrology community bias against PD, lack of nephrology trainee awareness and exposure to this modality. To overcome these barriers, a well-trained PD lead nephrologist (PD champion) is needed, who can advocate for this modality at government, professional and community levels. Ongoing educational programmes for doctors, nurses and patients are needed to sustain the PD programmes. Support from well-established PD centres and international organisations (International Society of Peritoneal Dialysis (ISPD), International Society of Nephrology (ISN), International Pediatric Nephrology Association (IPNA) are essential.

This cross-sectional study evaluates the prevalence and extent to which high risk for obstructive sleep apnea (OSA) is associated with general obesity and central obesity among college students in Punta Arenas, Chile. Risk for OSA was assessed using the Berlin Questionnaire and trained research nurses measured anthropometric indices. Overweight was defined as body mass index (BMI) of 25–29.9 kg/m2 and general obesity was defined as BMI≥30 kg/m2. Central obesity was defined as waist circumference ≥90 centimeters (cm) for males and ≥80 cm for females. Multivariate logistic regression models were fit to obtain adjusted odds ratios (OR) and 95% confidence intervals (CI). Prevalence of high risk for OSA, general obesity, and central obesity were 7.8%, 12.8%, and 42.7%, respectively. Students at high risk for OSA had greater odds of general obesity (OR 9.96; 95% CI: 4.42–22.45) and central obesity (OR 2.78; 95% CI 1.43–5.40). Findings support a strong positive association of high risk for OSA with obesity.

Abstract Background Human life expectancy has increased rapidly in recent decades. Regular exercise can promote health, but the effect of exercise on mortality is not yet well understood. Objective To investigate the association of exercise with mortality in the older people. Methods We used data from annual health check-ups of the older citizens of Taipei in 2006. Participants were interviewed by trained nurses using a structured questionnaire to collect data on demographics and lifestyle behaviours. Overnight fasting blood was collected for measuring blood glucose, liver and renal function and lipid profiles. Exercise frequency was categorised into no exercise, 1–2 times in a week and more than 3–5 times in a week. All-cause mortality was ascertained from the National Registration of Death. All participants were followed up until death or December 312012, whichever came first. Kaplan–Meier curves and Cox proportional hazard analysis were used to investigate the association between exercise and all-cause mortality. Results In total, 42,047 older people were analysed; 22,838 (54.32%) were male and with a mean (SD) age of 74.58 (6.32) years. Kaplan–Meier curves of all-cause mortality stratified by exercise frequency demonstrated significant findings (Log-rank P &lt; 0.01). Multivariate Cox regression analysis showed that older people with higher exercise levels had a significantly decreased risk of mortality (moderate exercise HR = 0.74, 95% CI: 0.68–0.81, high exercise HR = 0.65, 95% CI: 0.59–0.70) after adjusting for potential confounders, with a significant trend (P for trend&lt;0.01). Conclusions Older people with increased exercise levels had a significantly decreased risk of all-cause mortality.

Acute cardiovascular care has progressed considerably since the last position paper was published 10 years ago. It is now a well-defined, complex field with demanding multidisciplinary teamworking. The Acute Cardiovascular Care Association has provided this update of the 2005 position paper on acute cardiovascular care organisation, using a multinational working group. The patient population has changed, and intensive cardiovascular care units now manage a large range of conditions from those simply requiring specialised monitoring, to critical cardiovascular diseases with associated multi-organ failure. To describe better intensive cardiovascular care units case mix, acuity of care has been divided into three levels, and then defining intensive cardiovascular care unit functional organisation. For each level of intensive cardiovascular care unit, this document presents the aims of the units, the recommended management structure, the optimal number of staff, the need for specially trained cardiologists and cardiovascular nurses, the desired equipment and architecture, and the interaction with other departments in the hospital and other intensive cardiovascular care units in the region/area. This update emphasises cardiologist training, referring to the recently updated Acute Cardiovascular Care Association core curriculum on acute cardiovascular care. The training of nurses in acute cardiovascular care is additionally addressed. Intensive cardiovascular care unit expertise is not limited to within the unit’s geographical boundaries, extending to different specialties and subspecialties of cardiology and other specialties in order to optimally manage the wide scope of acute cardiovascular conditions in frequently highly complex patients. This position paper therefore addresses the need for the inclusion of acute cardiac care and intensive cardiovascular care units within a hospital network, linking university medical centres, large community hospitals, and smaller hospitals with more limited capabilities.

Purpose: To assess the knowledge, attitude and practice regarding epilepsy among nurses within the Asutifi North District with the aim of understanding their subjective experiences and knowledge on epilepsy in a sociocultural context and how their attitude shape their practice towards people with epilepsy. Methodology: The study employed an exploratory descriptive cross-sectional design. The study population consisted of nurses who have been licensed by the Nursing and Midwifery Council of Ghana and working in government facilities. The exclusion criteria were private health facilities, non-trained health professionals and other health professionals without nursing background, and student nurses on clinical attachment during the period of study in the district. Multistage sampling technique was used to select the study participants from the communities. A standard statistical formula was used to arrive at a sample size of 102. Data was collected by using a semi-structured questionnaire. Descriptive statistics involving frequencies and percentages were used in representing data. Responses on other items were cross-tabulated. The statistical tool that was used for analyzing the data was by STATA version 12.Results: Findings showed that 67.7% (69/102) of the nurses were aware of the causes of epilepsy, 59.8% have low level of knowledge on the disease. Though 82.4% of the nurses suspect people with epilepsy to have mental illness, 70.6% of the nurses had positive attitude towards epilepsy. However, 52.9% exhibited poor practices towards the disease. The socio-demographic characteristics of religion (Muslim) (p=0.017), area of specialty (RMN) (p=0.045) as well as close family relationship with epilepsy (p=0.001) were significantly associated with knowledge on epilepsy. Factors that were found to influence attitude towards epilepsy were sex (Female) (p=0.037), religion (Muslim) (p=0.012) and specialty area (RMN) (p=0.054). The area of specialty statistically influences their practices on epilepsy (p=0.001). There was no statistically significant association between knowledge on epilepsy and practice (p=0.134). However, attitude significantly related to practices on epilepsy (p=0.008) and indicated that negative attitude was more likely to be associated with poor practice.Conclusion: Nurses at the Asutifi North District tended to have low knowledge, positive attitude and poor practices on epilepsy.Recommendation: The Ghana Health Service in collaboration with the Ministry of Health should run intermediary workshops, at least every six months, to train nurses in epilepsy diagnoses to reduce the treatment gap. The health directorate should raise awareness and educate the communities on epilepsy to reduce stigma. Enhancing nursing education and training on epilepsy by the Ministry of Health and its agencies is imperative to improving health care delivery for people living with the disease.

ObjectivesTo investigate the prevalence of non-psychotic mental health disorders (MHDs) and the association between exposure to all forms of intimate partner violence (IPV) during pregnancy and MHDs.DesignCross-sectional population-based study conducted in the Northern Province of Rwanda and Kigali city.Participants and settingsTotally, 921 women who gave birth ≤13 months before being interviewed were included. Simple random sampling was done to select villages, households and participants. Community health workers helped to identify eligible participants and clinical psychologists, nurses or midwives conducted face-to-face interviews. The collected data were analysed using descriptive statistics and bivariable and multivariable logistic regression modellingResultsThe prevalence rates of generalised anxiety disorder, suicide ideation and post-traumatic stress disorder (PTSD) were 19.7%, 10.8% and 8.0%, respectively. Exposure to the four forms of IPV during pregnancy was highly associated with the likelihood of meeting diagnostic criteria for each of the non-psychotic MHDs investigated. Physical, psychological and sexual violence, showed the strongest association with PTSD, with adjusted ORs (aORs) of 4.5, 6.2 and 6.3, respectively. Controlling behaviour had the strongest association with major depressive episode in earlier periods with an aOR of 9.2.ConclusionIPV and MHDs should be integrated into guidelines for perinatal care. Moreover, community-based services aimed at increasing awareness and early identification of violence and MHDs should be instituted in all villages and health centres in Rwanda. Finally, healthcare providers need to be educated and trained in a consistent manner to manage the most challenging cases quickly, discreetly and efficiently.

Abstract The objective of the virtual Operation Main Street (OMS) program was to provide a live, interactive experience to educate audiences anywhere in the world about modern pork production. National Pork Board’s OMS began in 2004 to train pork producers to share their stories to improve the image of pig farming. Since its inception, they have trained &gt;1,300 producers influencing &gt;240,000 people However, there are locations that don’t have access to OMS speakers, and because presenters use slides, it doesn’t provide a real-time experience of being in the barn. Therefore, the virtual OMS was developed through a collaborative effort between the National Pork Board, Eidson & Partners, and South Dakota State University (SDSU). After a formal interview process, students participate in a 2-day OMS training. Students are trained to cover a set of defined speaking points, but discuss them in their own words. Each live tour is conducted in the SDSU Swine Unit, and is done entirely by the student on her/his own cellphone. Tours last approximately 10 minutes, with the audience asking questions at any time through a moderator at the venue. The first virtual tour was given on December 7, 2017, and since then there have been a total of 133 tours impacting 24,558 people. Audiences include Veterinary Colleges, high schools, the American Association of Critical Care Nurses, and the Association of Nutrition and Foodservice Professionals. In the last year, 51 tours were given to 1,678 people in 22 different states. Respondents to a Google survey offered at the end of every virtual tour stated the presentation and tour resulted in a &gt;60% increase in a positive opinion of the pork industry. Virtual OMS is an impactful method to dispel myths about modern pig farming, and creates a personal connection between the faces of pork production and consumers.

The Mental Health Project in BiH (PMZ BiH), Phase II, is a continuation of Phase I of the Mental Health Project. Direct results are: strengthened competencies and skills of multidisciplinary teams to provide better mental health services. In co-operation with sister associations from BiH, Swiss experts have supported the further strengthening of nursing staff in mental health through: support for the development of sister documentation, support in updating clinical guides with a focus on sister practice and providing training and / or direct support to selected members of sister associations in regarding the application of sister documentation and instructions for acting in their work.Assessment of the capacity of professional associations and specific needs of mental health professionals, realized within the BiH Mental Health Project, resulted in the signing of the Memorandum of Understanding and Cooperation between the above mentioned associations:1. Association of nurses and technicians in FBiH “UMSTFBiH”2. Association of nurses and technicians of the Republic of Srpska (Section nurses and technicians in the field of mental health of Republika Srpska)3. Udruženje “Medicinar” District Brčkowho implemented the Project: “Strengthening Nursing Competencies within the Center for the Protection of Mental Health”.Targeted sisterhood interventions will improve the orientation of the mental health system to the patient, provide health care with respect and understanding, and effectively treat patients. Interventions will contribute to better health outcomes, a better quality of life for mental health users and the general well-being of people with mental disorders, as well as those at risk of having a mental disorder.The project encompasses 40 centers for the protection of mental health in BiH with one representative - a medical nurse / technician. The acquired knowledge and skills, trained nurses / technicians, were passed on to other employees in the centers.The users with whom the sister documentation is applied are more satisfied with the speed and method of obtaining professional help. In 55.51% of respondents, the time of establishing the final diagnosis and condition is shortened. In 44.49% of users who are already in treatment in the centers, the deterioration of the disease is prevented by the introduction of a faster and better quality service.

IntroductionHalf of all patients with cancer experience cachexia, with the prevalence rising above 80% in the last weeks of life. Cancer cachexia (CC) is a complex relational experience that involves the patient–family dyad. There are no studies on the association between the psychoeducational component and the rehabilitative component of dyads for supporting more functional relationships in the management of CC.The primary objective of this study is to evaluate the feasibility of a psychoeducational intervention combined with a rehabilitative intervention on dyads.The secondary objective is to improve the quality of life (QoL) and acceptability of the intervention.Methods and analysisThis mixed-methods study with a nonpharmacological interventional prospective includes 30 consecutive cancer patients with cachexia and refractory cachexia and their caregivers, assisted by the Specialised Palliative Care Team. The recruitment will last 1 year. The intervention involves two components: (1) psychoeducational intervention: 3 weekly face-to-face consultations between dyads and trained nurses to help the dyads cope with involuntary weight loss and strengthening dyadic coping resources and (2) rehabilitation intervention: 3 biweekly educational sessions between dyads and trained physiotherapists focused on self-management, goal-setting, physical activity with three home exercise sessions per week.The primary endpoint will be in adherence to the intervention, indicated by a level of completion greater than or equal to 50% in both components. The secondary endpoints will be QoL (Functional Assessment of Anorexia-Cachexia Therapy), caregiver burden (Zarit Burden), physical performance (Hand-Grip strength and 30 seconds sit-to-stand test), and the acceptability of the intervention (ad hoc semi-structured interviews with the dyads and the healthcare professionals).Ethics and disseminationThe study was approved by the Ethics Committee Area Vasta Emilia Nord, Azienda USL-IRCSS Reggio Emilia, Italy, number: 73/2019/SPER/IRCCSRE. The authors will provide the dissemination of the results through publication in international scientific journals.Trial registration numberNCT04153019.

Background The high risk and low volume of medical emergencies, combined with long periods between training sessions, on 2 progressive care units at Mayo Clinic, Rochester, Minnesota, established the importance of transforming how nursing staff are trained to respond to medical emergencies. Objectives To increase confidence levels and improve nursing performance during medical emergencies via in situ simulation. Methods An in situ, mock code quality improvement program was developed and implemented to increase nurses’ confidence while improving nursing performance when responding to medical emergencies. For 2 years, each unit conducted mock codes and collected data related to confidence levels and response times based on the recommendations in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Results In those 2 years, nursing staff response times for calling for help improved 12%, time elapsed before initiating compressions improved 52%, and time to initial defibrillation improved 37%. Additionally, staff showed an increase in perceived confidence levels. Staff reported their appreciation of the opportunity for hands-on practice with the equipment, reinforcing their knowledge and refining their medical emergency skills. Conclusions In situ mock codes significantly improve response times and increase staff confidence levels. In situ mock codes are a quick and efficient way to provide hands-on practice and allow staff to work as a team.

ObjectiveThis study aimed to assess the cost-effectiveness of telehealthcare in heart failure patients as add-on to usual care.DesignA cost-utility analysis was conducted from a public payer perspective alongside the randomised controlled TeleCare North trial.SettingThe North Denmark Region, Denmark.ParticipantsThe study included 274 heart failure patients with self-reported New York Heart Association class II-IV.InterventionsPatients in the intervention group were provided with a Telekit consisting of a tablet, a digital blood pressure monitor, and a scale and were instructed to perform measurements one to two times a week. The responsibility of the education, instructions and monitoring of the heart failure (HF) patients was placed on municipality nurses trained in HF and telemonitoring. Both groups received usual care.Outcome measuresCost-effectiveness was reported as incremental net monetary benefit (NMB). A micro-costing approach was applied to evaluate the derived savings in the first year in the public health sector. Quality-adjusted life-years (QALY) gained were estimated using the EuroQol 5-Dimensions 5-Levels questionnaire at baseline and at a 1-year follow-up.ResultsData for 274 patients were included in the main analysis. The telehealthcare solution provided a positive incremental NMB of £5164. The 1-year adjusted QALY difference between the telehealthcare solution and the usual care group was 0.0034 (95% CI: −0.0711 to 0.0780). The adjusted difference in costs was -£5096 (95% CI: −8736 to −1456) corresponding to a reduction in total healthcare costs by 35%. All sensitivity analyses showed the main results were robust.ConclusionsThe TeleCare North solution for monitoring HF was highly cost-effective. There were significant cost savings on hospitalisations, primary care contacts and total costs.Trial registration numberClinicalTrials.gov:NCT02860013.

Abstract Background and Objectives We examined the association between turnover of registered nurses (RNs) and certified nurse assistants (CNAs) and perceived patient safety culture (PSC) in nursing homes (NHs). Research Design and Methods In 2017, we conducted PSC survey using the Agency for Healthcare Research and Quality- developed and -validated instrument for NHs. A random sample of 2,254 U.S. NHs was identified. Administrators, directors of nursing (DONs), and nurse unit leaders served as respondents. Responses were obtained for 818 facilities from 1,447 individuals. The instrument contained 42 items relating to 12 PSC domains and turnover rates. PSC domains were based on five-point Likert scale items. A positive response was defined as “agree” or “strongly agree” (4–5 on the Likert scale). For CNAs low turnover was defined as &lt;35%, and for RNs &lt;15%. Facility-level and market-competition characteristics were included. Bivariate comparisons employed analysis of variance and chi-square tests. In multivariable models, we fit separate linear regressions for the average positive PSC score and for each of the 12 PSC domains, including turnover rates, NH, and market factors. Results In NHs with low turnover, the overall PSC scores were 4.04% (RNs) and 6.28% (CNAs) higher than in NHs with high turnover. Teamwork, staffing, and training/skills were associated with CNA but not RN turnover. Discussion and Implications The effect of turnover on PSC depends on who leaves and to a lesser extent on the organizational characteristics. In NHs, improvements in PSC may depend on the ability to retain a well-trained and skilled nursing staff.

ObjectiveTo quantify the implementation of the third Joint British Societies’ Consensus Recommendations for the Prevention of Cardiovascular Disease (JBS3) after coronary event.MethodsUsing a cross-sectional survey design, patients were consecutively identified in 36 specialist and district general hospitals between 6 months and 2 years, after acute coronary syndrome or revascularisation procedure and invited to a research interview. Outcomes included JBS3 lifestyle, risk factor and therapeutic management goals. Data were collected using standardised methods and instruments by trained study nurses. Blood was analysed in a central laboratory and a glucose tolerance test was performed.Results3926 eligible patients were invited to participate and 1177 (23.3% women) were interviewed (30% response). 12.5% were from black and minority ethnic groups. 45% were persistent smokers, 36% obese, 52.9% centrally obese, 52% inactive; 30% had a blood pressure >140/90 mm Hg, 54% non-high-density lipoprotein ≥2.5 mmol/L and 44.3% had new dysglycaemia. Prescribing was highest for antiplatelets (94%) and statins (85%). 81% were advised to attend cardiac rehabilitation (86% <60 years vs 79% ≥60 years; 82% men vs 77% women; 93% coronary artery bypass grafting vs 59% unstable angina), 85% attended if advised; 69% attended overall. Attenders were significantly younger (p=0.03) and women were less likely to attend (p=0.03).ConclusionsPatients with coronary heart disease (CHD) are not being adequately managed after event with preventive measures. They require a structured preventive cardiology programme addressing lifestyle, risk factor management and adherence to cardioprotective medications to achieve the standards set by the British Association for Cardiovascular Prevention and Rehabilitation and JBS3 guidelines.

Objective: In Ethiopia, only a few studies were conducted to determine factors contributing to antiretroviral treatment failure, in general, and there are no published data in the study area, in particular. Thus, the aim of the study was to assess the determinants of first-line treatment failure among adult HIV patients on antiretroviral treatment at Nekemte Specialized Hospital, western Ethiopia. Methods: The hospital-based 1:2 unmatched case–control study was conducted in Nekemte Specialized Hospital from 1 August to 30 September, 2019, on 252 HIV-positive patients receiving antiretroviral treatment (86 cases and 166 controls). Cases were selected from patients who were switched to second-line antiretroviral treatment regimen after first-line antiretroviral treatment failure. Controls were from those who are on the first-line antiretroviral regimens for at least 6 months. Data were collected by two trained clinical nurses. Record review and an interviewer-administered questionnaire were used to collect data. Data were entered into Epi-Data, version 7.2.2, and then exported to SPSS, version 25, for analysis. The association between treatment failure and each covariate was assessed by bivariate analysis to identify candidate variables at p value < 0.25. All candidate variables were entered into multivariate analysis done in stepwise backward likelihood ratio to declare statistical significance association at p value < 0.05, 95% confidence interval. Results: Data from a total of 252 (86 cases and 166 controls) patients were extracted at a response rate of 98.4%. Statistically higher odds of first-line treatment failure were observed among those who started treatment at an advanced stage (Baseline World Health Organization stage 3 o r4 (adjusted odds ratio = 3.12, 95% confidence interval: 1.55–6.26), lower Baseline CD4 count < 100 cells (adjusted odds ratio = 3.06, 95 % confidence interval: 1.45–6.50), lack of participation in a support group (adjusted odds ratio = 4.03, 95% confidence interval: 1.98–8.21), history of antiretroviral treatment discontinuation for greater than 1 month (adjusted odds ratio = 2.36, 95% confidence interval: 1.17–4.78) and poor adherence to antiretroviral treatment (adjusted odds ratio = 3.09, 95% confidence interval: 1.54–6.19). Conclusion: Antiretroviral treatment initiation at an advanced stage, lower CD4 count, no participation in a support group, and poor adherence were determinants of treatment first-line antiretroviral treatment failure. Therefore, health care providers and program developers should give special attention to; early diagnosis and start of treatment, encouraging patients to participate in a support group, trace patients early, and attentively follow patients to improve their adherence to antiretroviral treatment.

Background:It is unknown whether in the disease course of rheumatoid arthritis (RA), inflammation recurs in the same joints over time or is more variable in joint locations. Joint involvement patterns over time might provide clues about the underlying mechanisms causing local joint inflammation.Objectives:The aim of this study is to assess if local joint inflammation at presentation of RA tends to recur or persist in the same joints.Methods:Data from the BeSt study were used, a treat-to-target (DAS≤2.4) trial in newly diagnosed RA (ACR 1987 criteria) patients. During 10 years, for each patient 68 joints were assessed three-monthly (41 visits) by trained nurses for swelling (yes/no) and tenderness.We analyzed the association between local joint swelling at baseline and later swelling of the same joint using a multilevel mixed-effects logistic regression model. Models were adjusted for joint location and for timepoint, with joints clustered within patients. A sensitivity analysis was done for the 25% most affected joints (MCP 1-3, PIP 2-3, wrists and MTP 2-4).To investigate whether later swelling of a joint is predicted by baseline swelling of that same joint specifically, rather than by baseline swelling in general, a permutation test with 1000 permutations was performed. A p-value <0.05 indicates that joint swelling is better predicted by its baseline swelling than by baseline swelling of randomly selected other joints.In a separate model, with an interaction term between baseline swelling and previous visit swelling (yes/no), we evaluated if the association between baseline swelling and later local swelling was influenced by whether later swelling was persistent (swelling at both the current and previous visit) or recurrent (swelling at current visit but not at the previous visit).Results:The 508 patients had a median (IQR) follow-up duration of 10 (6-10) years. At baseline, 8,137/34,423 (24%) assessed joints were scored as swollen. Baseline swelling was subsequently persistent in 21% of the joints with a median (IQR) duration of 1 (1-2) visit (± 3 months after baseline). In addition, after resolution of initial swelling, swelling recurred at least once in 46% of the joints with baseline swelling.Baseline swelling was significantly associated with swelling in the same joint during follow-up (OR 2.37, 95% CI 2.30-2.43). A sensitivity analysis of the most affected joints showed similar results (OR 2.10 [95% CI 2.03-2.19]).The permutation test showed a significant result with p<0.001, indicating that joint swelling is better predicted by baseline swelling of that same joint than by baseline swelling of other joints.The association between baseline swelling and later local swelling was weaker in case of persistent swelling than in case of recurrent swelling (interaction term baseline swelling * swelling at previous timepoint ‘yes’: OR 0.80 [95% CI 0.75-0.85]).Conclusion:In newly diagnosed RA, over median 10 years of treatment to target DAS≤2.4, baseline swelling persisted in 21% of the joints, for median 3 months after baseline. Local recurrence after initial resolution occurred in 46% of the joints. Baseline joint swelling was significantly associated with local joint swelling during follow-up, even when taking into account the higher a priori chance of swelling in the joints that are most often affected, and joint swelling during follow-up was better predicted by baseline swelling of that particular joint than by baseline swelling of other joints. Local persistence and recurrence of joint swelling despite DAS≤2.4 steered treatment adjustments suggest that local joint conditions or even joint memory play a role in mechanisms of joint inflammation.Acknowledgements:We would like to thank all patients for their contribution as well as the rheumatologists who participated in the BeSt study group. We would also like to thank all other rheumatologists and trainee rheumatologists who enrolled patients in these studies, and all research nurses for their contributions.Disclosure of Interests:Sascha Heckert: None declared, Sytske Anne Bergstra: None declared, Xanthe Matthijssen: None declared, Yvonne Goekoop-Ruiterman: None declared, F. Fodili: None declared, Cornelia Allaart Grant/research support from: The original BeSt study was supported by a government grant from the Dutch insurance companies, with additional funding from Schering-Plough B.V. and Janssen B.V., Thomas Huizinga: None declared

Background: Monkeypox (MPX) is a viral zoonoses characterized by pustular rashes similar to smallpox. It is endemic in the Democratic Republic of Congo and West Africa. The outbreak of MPX was first reported outside Africa in 2003 following horizontal infection of Prairie dogs by imported African rodents. Two distinct clades are known, the Central (more severe) and the West African clade (Mild). In Nigeria, the first confirmed case of MPX was in a 4-year old child in 1971. This was followed by a lull of 39 years. Since September 2017, sporadic outbreaks have been reported in 17 states across Nigeria. As at week 36 of 2019, Akwa Ibom reported ten suspected cases with one lab-confirmed. Methods: We revised MPX case definition and constituted a team comprising of State DSNO, Laboratory and RRT from NCDC. We identified retrospective cases from the state line list, their contacts traced and samples collected. We carried out a case-control study on the 3 cases in Mkpat Enin LGA. Twenty-one (21) pre-tested (KAP) questionnaire was administered to health care workers (HCW) and community members to access knowledge awareness and risk perception of MPX. HCWs were trained, and community sensitization carried out. We accessed the capacity of IDH Uyo to manage MPX cases and conducted a case-control study to determine the odds of association of MPX with individuals in contact with confirmed MPX cases at Mkpat Enin LGA. Results: Eight new cases identified during active case search were negative of MPX. The level of awareness of MPX amongst HCW was high (n=20); pre-test score 16.5(85%) and 18 (90%) posttest. Knowledge of clinical presentation of MPX amongst HCW was also high 17(85%). There was a high-risk perception of MPX 18(90%), assessment of best practice 16 (76%) and proper sample collection 15 (75%). CM awareness of MPX (n=20) was at 12(62%), health-seeking behaviour at 2(11%) and the consumption of giant rats and monkeys at 12(86%). There was a weak association of transmission of infection by MPX cases to individuals in contact with them {(OR=0.333, (0.0673, 1.6516), Fisher exact 0.1756}. We identified a general apathy by HCW (Nurses) at the IDH Uyo to accept and manage MPX cases. Conclusion: The high HCW and community awareness negates the poor health-seeking behaviour of members of Ekpat Enin community due to paucity of funds to access health care or rejection by HF within the area. Monkeys and giant rats are delicacies high within the community hence a risk factor in MPX zoonoses. Consequently, individuals who consume such delicacies or come into contact with confirmed cases are at times likely to contact MPX.

On 11 March 2020, the World Health Organization declared the coronavirus disease, more commonly known as COVID-19, a pandemic due to the number of individuals and countries affected including their socioeconomic status along with mortality rate. Center for Disease Control and Prevention and other funding agencies working to minimize the spread of COVID-19; as a result, many changes in our daily lives are being suggested.1 They continuously monitored the outbreak of COVID-19 and also issued the guidelines for both health care professionals and consumers. Allowing medical care includes telehealth coverage, nutritious, and wholesome food as per the COVID-19 response during this state of a public health emergency. During the outbreak of COVID-19, the pharmacies and wholesale market are facing a shortage of personal protective equipments (PPEs) due to besotted usage by doctors, nurses, paramedical staff, and the common public to protect themselves from the contagious and infectious diseases. Regarding the concern of health safety for medical health professionals are very cautious in regard with fighting against the COVID-19 and demanding for PPEs that is much legal, logical and necessary as per the guidelines of WHO.2 Three doctors have died during the treatment of coronavirus affected patients and >75 doctors are affected from the disease.3 After this act doctors protest in the Southwestern Pakistan City of Quetta for demanding of PPEs including protective kits for health care professionals for coronavirus medical gear; among them, 67 doctors were arrested as said by the union representative of Young Doctor Association (YDA).4 As per 13 April, 2020 more than 5374 are Covid-19 patients and 93 deaths are faced due to shortage of PPEs; as Secretary-General Pakistan Medical Association Qaiser Sajjad, explained in a press conference on April 5th that “Doctors are Frontline soldiers in the fight against the Corona and we need more and more doctors are ready to provide their services to reduced the collapse and overburden of the health care worker against for COVID-19’’.5 Health care workers that are fighting ‘’unarmed’’ against COVID-19 should be fully equipped with PPEs including surgical mask, N-95 respirator, gloves, goggles, gowns, face shields, hand sanitizer. For screening of COVID-19; trained frontline health care professionals are appointed with proper triage system to reduce the overburden and transformation of infection to other individuals. 6 N-95, N100 respirator, surgical masks, and suit kits are dire needs of the health care professional. These PPEs are discarded after each visit of doctor/paramedical staff to patients while the crowd of ill patients has been growing with a limited supply of PPEs. Some well-known and literate peoples started to buy these PPEs like masks, gloves, overalls, and other medical equipment items for their families. Officials of public and private hospitals are claiming the unavailability of PPEs, worried about their health including their families. Including PPEs, other medical products used for diagnostic and treatment purposes are also hoarded and steep high in priced by the distributers. Hospitals and other health facilities are naïve of PPEs. 7 Making exporters /distributer millionaire by exporting with higher prices in the supermarket with extremely exorbitant rates, for that federal health and other agencies are claimed that nexus of distributors/importers of medical equipment cause shortage of PPEs.8 The purpose of this note is to outline public health and social measures useful for slowing or stopping the spread of COVID-19 at the national or community level. These measures include detecting, contact tracing, isolating cases, quarantine case, physical and social distancing including mass gathering, international traveling measures. Till that no vaccine and specific medicines are available to reduce the diameter of this pandemic to save the life of individuals.9 During the pandemic situation; the national command and control system is working with good efforts with significantly increasing the health budget for national health issues by increasing the number of beds hospitals, intensive care units, equipment including ventilators, and other PPEs. Training to doctors, nurses, and other paramedical staff is done with higher priority to provide higher quality care to critically ill patients. By use of electronic and social media; community education concerning such issues is going on at best level for the prevention of such outbreaks.10

From its beginning, mankind suffered injuries through falling, fire, drowning and human aggression [1]. Although the frequency and the kinetics modifiy over millennia, trauma continues to represent an important cause of morbidity and mortality even in the modern society [1]. Significant progresses in the trauma surgery were due to military conflicts, which next to social sufferance came with important steps in injuries’ management, further applied in civilian hospitals. The foundation of modern trauma systems was started by Dominique Jean Larrey (1766-1842) during the Napoleonic Rin military campaign from 1792. The wounded who remained on the battlefield till the end of the battle to receive medical care, usually more than 24 hours, from that moment were transported during the conflict with flying ambulances to mobile hospitals. Starting with the First World War, through the usage of antiseptics, blood transfusions, and fracture management, the mortality decreased from 39% in the Crimean War (1853–1856) to 10%. One of the most preeminent figures of the Second World War was Michael DeBakey, who created the Mobile Army Surgical Hospitals (MASH), concept very similar to the Larrey’s unit. In 1941, in England, Birmingham Accident Hospital was opened, specially designed for injured people, this being the first trauma center worldwide. During the Golf War (1990–1991) the MASH were used for the last time, being replaced by Forward Surgical Teams, very mobile units satisfying the necessities of the nowadays infantry [1]. Nowadays, trauma meets the pandemic criteria, everyday 16,000 people worldwide are dying, injuries representing one of the first five causes of mortality for all the age groups below 60 [2]. A recent 12-month analysis of trauma pattern in the Emergency Hospital of Bucharest revealed 141 patients, 72.3% males, with a mean age of 43.52 ± 19 years, and a mean New Injury Severity Score (NISS) of 27.58 ± 11.32 [3]. The etiology was traffic related in 101 (71.6%), falls in 28 (19.9%) and crushing in 7 (5%) cases. The overall mortality was as high as 30%, for patients with a mean NISS of 37.63 [3]. At the scene, early recognition of severe injuries and a high index of suspicion according to trauma kinetics may allow a correct triage of patients [4]. A functional trauma system should continuously evaluate the rate of over- and under-triage [5]. The over-triage represents the transfer to a very severe patient to a center without necessary resources, while under-triage means a low injured patient referred to a highly specialized center. If under-triage generates preventable deaths, the over-triage comes with a high financial and personal burden for the already overloaded tertiary centers [5]. To maximize the chance for survival, the major trauma patients should be transported as rapid as possible to a trauma center [6]. The initial resuscitation of trauma patients was divided into two time intervals: ten platinum minutes and golden hour [6]. During the ten platinum minutes the airways should be managed, the exsanguinating bleeding should be stopped, and the critical patients should be transported from the scene. During the golden hour all the life-threatening lesions should be addressed, but unfortunately many patients spend this time in the prehospital setting [6]. These time intervals came from Trunkey’s concept of trimodal distribution of mortality secondary to trauma, proposed in 1983 [7]. This trimodal distribution of mortality remains a milestone in the trauma education and research, and is still actual for development but inconsistent for efficient trauma systems [8]. The concept of patients’ management in the prehospital setting covered a continuous interval, with two extremities: stay and play/treat then transfer or scoop and run/ load and go. Stay and play, usually used in Europe, implies airways securing and endotracheal intubation, pleurostomy tube insertion, and intravenous lines with volemic replacement therapy. During scoop and run, used in the Unites States, the patient is immediately transported to a trauma center, addressing the immediate life-threating injuries during transportation. In the emergency department of the corresponding trauma center, the resuscitation of the injured patients should be done by a trauma team, after an orchestrated protocol based on Advanced Trauma Life Support (ATLS). The modern trauma teams include five to ten specialists: general surgeons trained in trauma care, emergency medicine physicians, intensive care physicians, orthopedic surgeons, neurosurgeons, radiologists, interventional radiologists, and nurses. In the specially designed trauma centers, the leader of the trauma team should be the general surgeon, while in the lower level centers this role may be taken over by the emergency physicians. The implementation of a trauma system is a very difficult task, and should be tailored to the needs of the local population. For example, in Europe the majority of injuries are by blunt trauma, while in the United States or South Africa they are secondary to penetrating injuries. In an effort to analyse at a national level the performance of trauma care, we have proposed a national registry of major trauma patients [9]. For this registry we have defined major trauma as a New Injury Severity Score higher than 15. The maintenance of such registry requires significant human and financial resources, while only a permanent audit may decrease the rate of preventable deaths in the Romanian trauma care (Figure 1) [10]. Figure 1 - The website of Romanian Major Trauma Registry (http://www.registrutraume.ro). USA - In the United States of America there are 203 level I centers, 265 level II centers, 205 level III or II centers and only 32 level I or II pediatric centers, according to the 2014 report of National Trauma Databank [11]. USA were the first which recognized trauma as a public health problem, and proceeded to a national strategy for injury prevention, emergency medical care and trauma research. In 1966, the US National Academy of Sciences and the National Research Council noted that ‘’public apathy to the mounting toll from accidents must be transformed into an action program under strong leadership’’ [12]. Considerable national efforts were made in 1970s, when standards of trauma care were released and in 1990s when ‘’The model trauma care system plan’’[13] was generated. The American College of Surgeons introduced the concept of a national trauma registry in 1989. The National Trauma Databank became functional seven years later, in 2006 being registered over 1 million patients from 600 trauma centers [14]. Mortality from unintentional injury in the United States decreased from 55 to 37.7 per 100,000 population, in 1965 and 2004, respectively [15]. Due to this national efforts, 84.1% of all Americans have access within one hour from injury to a dedicated trauma care [16]. Canada - A survey from 2010 revealed that 32 trauma centers across Canada, 16 Level I and 16 Level II, provide definitive trauma care [18]. All these centers have provincial designation, and funding to serve as definitive or referral hospital. Only 18 (56%) centers were accredited by an external agency, such as the Trauma Association of Canada. The three busiest centers in Canada had between 798–1103 admissions with an Injury Severity Score over 12 in 2008 [18]. Australia - Australia is an island continent, the fifth largest country in the world, with over 23 million people distributed on this large area, a little less than the United States. With the majority of these citizens concentrated in large urban areas, access to the medical care for the minority of inhabitants distributed through the territory is quite difficult. The widespread citizens cannot be reached by helicopter, restricted to near-urban regions, but with the fixed wing aircraft of the Royal Flying Doctor Service, within two hours [13]. In urban centers, the trauma care is similar to the most developed countries, while for people sparse on large territories the trauma care is far from being managed in the ‘’golden hour’’, often extending to the ‘’Golden day’’ [19]. Germany - One of the most efficient European trauma system is in Germany. Created in 1975 on the basis of the Austrian trauma care, this system allowed an over 50% decreasing of mortality, despite the increased number of injuries. According to the 2014 annual report of the Trauma Register of German Trauma Society (DGU), there are 614 hospitals submitting data, with 34.878 patients registered in 2013 [20]. The total number of cases documented in the Trauma Register DGU is now 159.449, of which 93% were collected since 2002. In the 2014 report, from 26.444 patients with a mean age of 49.5% and a mean ISS of 16.9, the observed mortality was 10% [20]. The United Kingdom - In 1988, a report of the Royal College of Surgeons of England, analyzing major injuries concluded that one third of deaths were preventable [21]. In 2000, a joint report from the Royal College of Surgeons of England and of the British Orthopedic Association was very suggestive entitled "Better Care for the Severely Injured" [22]. Nowadays the Trauma Audit Research network (TARN) is an independent monitor of trauma care in England and Wales [23]. TARN collects data from hospitals for all major trauma patients, defined as those with a hospital stay longer than 72 hours, those who require intensive care, or in-hospital death. A recent analysis of TARN data, looking at the cost of major trauma patients revealed that the total cost of initial hospital inpatient care was £19.770 per patient, of which 62% was attributable to ventilation, intensive care and wards stays, 16% to surgery, and 12% to blood transfusions [24]. Global health care models Countries where is applied Functioning concept Total healthcare costs from GDP Bismarck model Germany Privatized insurance companies (approx. 180 nonprofit sickness funds). Half of the national trauma beds are publicly funded trauma centers; the remaining are non-profit and for-profit private centers. 11.1% Beveridge model United Kingdom Insurance companies are non-existent. All hospitals are nationalized. 9.3% National health insurance Canada, Australia, Taiwan Fusion of Bismarck and Beveridge models. Hospitals are privatized, but the insurance program is single and government-run. 11.2% for Canada The out-of-pocket model India, Pakistan, Cambodia The poorest countries, with undeveloped health care payment systems. Patients are paying for more than 75% of medical costs. 3.9% for India GDP – gross domestic product Table 1 - Global health care models with major consequences on trauma care [17]. Traumas continue to be a major healthcare problem, and no less important than cancer and cardiovascular diseases, and access to dedicated and timely intervention maximizes the patients’ chance for survival and minimizes the long-term morbidities. We should remember that one size does not fit in all trauma care. The Romanian National Trauma Program should tailor its resources to the matched demands of the specific Romanian urban and rural areas.

Neonatal asphyxia is a state of hypoxia and hypercapnia caused by failure to breathe spontaneously and regularly soon after birth. Heat shock proteins (HSPs) are a ubiquitous and diverse group of highly conserved proteins which are rapidly up-regulated following periods of cellular stress including exposure to heat, ultraviolet irradiation, or chemical toxicity. The aim of the current study was to explore whether there is a relation between serum levels of HSP27 and neonatal asphyxia in a small sample of newborns. A total of 25 healthy newborns and 25 newborns diagnosed with neonatal asphyxia were recruited form Imam Reza Hospital, Mashhad, Iran. The Apgar score was recorded at one minute after delivery by trained nurses and newborns with the Apgar score of less than 7 were considered to be asphyctic. The mean birth weight of newborns in the case and control groups were 3110.47±613.5 g and 3230.4±584.83 g, respectively (P=0.4). Moreover, the mean maternal age of infants in the case group was higher than the mean maternal age of infants in the control group (31.1±6.1 vs. 30.1±5.0). Although it was marginally significant, the level of HSP27 was higher in the case group than the control group (0.23±0.08 vs. 0.19±0.09; P=0.07). Levels of HSP27 were found to be higher in newborns with neonatal asphyxia compared with healthy controls. © 2019 Tehran University of Medical Sciences. All rights reserved. Acta Med Iran 2019;57(5):303-307.

Abstract Background The use of a ‘do not interrupt’ vest during medication administration rounds is recommended but there have been no controlled randomized studies to evaluate its impact on reducing administration errors. We aimed to evaluate the impact of wearing such a vest on reducing such errors. The secondary objectives were to evaluate the types and potential clinical impact of errors, the association between errors and several risk factors (such as interruptions), and nurses’ experiences. Methods This was a multicenter, cluster, controlled, randomized study (March–July 2017) in 29 adult units (4 hospitals). Data were collected by direct observation by trained observers. All nurses from selected units were informed. A ‘Do not interrupt’ vest was implemented in all units of the experimental group. A poster was placed at the entrance of these units to inform patients and relatives. The main outcome was the administration error rate (number of Opportunities for Error (OE), calculated as one or more errors divided by the Total Opportunities for Error (TOE) and multiplied by 100). Results We enrolled 178 nurses and 1346 patients during 383 medication rounds in 14 units in the experimental group and 15 units in the control group. During the intervention period, the administration error rates were 7.09% (188 OE with at least one error/2653 TOE) for the experimental group and 6.23% (210 OE with at least one error/3373 TOE) for the control group (p = 0.192). Identified risk factors (patient age, nurses’ experience, nurses’ workload, unit exposition, and interruption) were not associated with the error rate. The main error type observed for both groups was wrong dosage-form. Most errors had no clinical impact for the patient and the interruption rates were 15.04% for the experimental group and 20.75% for the control group. Conclusions The intervention vest had no impact on medication administration error or interruption rates. Further studies need to be performed taking into consideration the limitations of our study and other risk factors associated with other interventions, such as nurse’s training and/or a barcode system. Trial registration The PERMIS study protocol (V2–1, 11/04/2017) was approved by institutional review boards and ethics committees (CPP Ile de France number 2016-A00211–50, CNIL 21/03/2017, CCTIRS 11/04/2016). It is registered at ClinicalTrials.gov (registration number: NCT03062852, date of first registration: 23/02/2017).

Introduction In December 2010, Nespresso, the world’s leading brand of premium-portioned coffee, opened a flagship “boutique” in Sydney’s Pitt Street Mall. This was Nespresso’s fifth boutique opening of 2010, after Brussels, Miami, Soho, and Munich. The Sydney debut coincided with the mall’s upmarket redevelopment, which explains Nespresso’s arrival in the city: strategic geographic expansion is key to the brand’s growth. Rather than panoramic ubiquity, a retail option favoured by brands like McDonalds, KFC and Starbucks, Nespresso opts for iconic, prestigious locations. This strategy has been highly successful: since 2000 Nespresso has recorded year-on-year per annum growth of 30 per cent. This has been achieved, moreover, despite a global financial downturn and an international coffee market replete with brand variety. In turn, Nespresso marks an evolution in the coffee market over the last decade. The Nespresso Story Founded in 1986, Nespresso is the fasting growing brand in the Nestlé Group. Its headquarters are in Lausanne, Switzerland, with over 7,000 employees worldwide. In 2012, Nespresso had 270 boutiques in 50 countries. The brand’s growth strategy involves three main components: premium coffee capsules, “mated” with specially designed machines, and accompanied by exceptional customer service through the Nespresso Club. Each component requires some explanation. Nespresso offers 16 varieties of Grand Crus coffee: 7 espresso blends, 3 pure origin espressos, 3 lungos (for larger cups), and 3 decaffeinated coffees. Each 5.5 grams of portioned coffee is cased in a hermetically sealed aluminium capsule, or pod, designed to preserve the complex, volatile aromas (between 800 and 900 per pod), and prevent oxidation. These capsules are designed to be used exclusively with Nespresso-branded machines, which are equipped with a patented high-pressure extraction system designed for optimum release of the coffee. These machines, of which there are 28 models, are developed with 6 machine partners, and Antoine Cahen, from Ateliers du Nord in Lausanne, designs most of them. For its consumers, members of the Nespresso Club, the capsules and machines guarantee perfect espresso coffee every time, within seconds and with minimum effort—what Nespresso calls the “ultimate coffee experience.” The Nespresso Club promotes this experience as an everyday luxury, whereby café-quality coffee can be enjoyed in the privacy and comfort of Club members’ homes. This domestic focus is a relatively recent turn in its history. Nestlé patented some of its pod technology in 1976; the compatible machines, initially made in Switzerland by Turmix, were developed a decade later. Nespresso S. A. was set up as a subsidiary unit within the Nestlé Group with a view to target the office and fine restaurant sector. It was first test-marketed in Japan in 1986, and rolled out the same year in Switzerland, France and Italy. However, by 1988, low sales prompted Nespresso’s newly appointed CEO, Jean-Paul Gillard, to rethink the brand’s focus. Gillard subsequently repositioned Nespresso’s target market away from the commercial sector towards high-income households and individuals, and introduced a mail-order distribution system; these elements became the hallmarks of the Nespresso Club (Markides 55). The Nespresso Club was designed to give members who had purchased Nespresso machines 24-hour customer service, by mail, phone, fax, and email. By the end of 1997 there were some 250,000 Club members worldwide. The boom in domestic, user-friendly espresso machines from the early 1990s helped Nespresso’s growth in this period. The cumulative efforts by the main manufacturers—Krups, Bosch, Braun, Saeco and DeLonghi—lowered the machines’ average price to around US $100 (Purpura, “Espresso” 88; Purpura, “New” 116). This paralleled consumers’ growing sophistication, as they became increasingly familiar with café-quality espresso, cappuccino and latté—for reasons to be detailed below. Nespresso was primed to exploit this cultural shift in the market and forge a charismatic point of difference: an aspirational, luxury option within an increasingly accessible and familiar field. Between 2006 and 2008, Nespresso sales more than doubled, prompting a second production factory to supplement the original plant in Avenches (Simonian). In 2008, Nespresso grew 20 times faster than the global coffee market (Reguly B1). As Nespresso sales exceeded $1.3 billion AU in 2009, with 4.8 billion capsules shipped out annually and 5 million Club members worldwide, it became Nestlé’s fastest growing division (Canning 28). According to Nespresso’s Oceania market director, Renaud Tinel, the brand now represents 8 per cent of the total coffee market; of Nespresso specifically, he reports that 10,000 cups (using one capsule per cup) were consumed worldwide each minute in 2009, and that increased to 12,300 cups per minute in 2010 (O’Brien 16). Given such growth in such a brief period, the atypical dynamic between the boutique, the Club and the Nespresso brand warrants closer consideration. Nespresso opened its first boutique in Paris in 2000, on the Avenue des Champs-Élysées. It was a symbolic choice and signalled the brand’s preference for glamorous precincts in cosmopolitan cities. This has become the design template for all Nespresso boutiques, what the company calls “brand embassies” in its press releases. More like art gallery-style emporiums than retail spaces, these boutiques perform three main functions: they showcase Nespresso coffees, machines and accessories (all elegantly displayed); they enable Club members to stock up on capsules; and they offer excellent customer service, which invariably equates to detailed production information. The brand’s revenue model reflects the boutique’s role in the broader business strategy: 50 per cent of Nespresso’s business is generated online, 30 per cent through the boutiques, and 20 per cent through call centres. Whatever floor space these boutiques dedicate to coffee consumption is—compared to the emphasis on exhibition and ambience—minimal and marginal. In turn, this tightly monitored, self-focused model inverts the conventional function of most commercial coffee sites. For several hundred years, the café has fostered a convivial atmosphere, served consumers’ social inclinations, and overwhelmingly encouraged diverse, eclectic clientele. The Nespresso boutique is the antithesis to this, and instead actively limits interaction: the Club “community” does not meet as a community, and is united only in atomised allegiance to the Nespresso brand. In this regard, Nespresso stands in stark contrast to another coffee brand that has been highly successful in recent years—Starbucks. Starbucks famously recreates the aesthetics, rhetoric and atmosphere of the café as a “third place”—a term popularised by urban sociologist Ray Oldenburg to describe non-work, non-domestic spaces where patrons converge for respite or recreation. These liminal spaces (cafés, parks, hair salons, book stores and such locations) might be private, commercial sites, yet they provide opportunities for chance encounters, even therapeutic interactions. In this way, they aid sociability and civic life (Kleinman 193). Long before the term “third place” was coined, coffee houses were deemed exemplars of egalitarian social space. As Rudolf P. Gaudio notes, the early coffee houses of Western Europe, in Oxford and London in the mid-1600s, “were characterized as places where commoners and aristocrats could meet and socialize without regard to rank” (670). From this sanguine perspective, they both informed and animated the modern public sphere. That is, and following Habermas, as a place where a mixed cohort of individuals could meet and discuss matters of public importance, and where politics intersected society, the eighteenth-century British coffee house both typified and strengthened the public sphere (Karababa and Ger 746). Moreover, and even from their early Ottoman origins (Karababa and Ger), there has been an historical correlation between the coffee house and the cosmopolitan, with the latter at least partly defined in terms of demographic breadth (Luckins). Ironically, and insofar as Nespresso appeals to coffee-literate consumers, the brand owes much to Starbucks. In the two decades preceding Nespresso’s arrival, Starbucks played a significant role in refining coffee literacy around the world, gauging mass-market trends, and stirring consumer consciousness. For Nespresso, this constituted major preparatory phenomena, as its strategy (and success) since the early 2000s presupposed the coffee market that Starbucks had helped to create. According to Nespresso’s chief executive Richard Giradot, central to Nespresso’s expansion is a focus on particular cities and their coffee culture (Canning 28). In turn, it pays to take stock of how such cities developed a coffee culture amenable to Nespresso—and therein lays the brand’s debt to Starbucks. Until the last few years, and before celebrity ambassador George Clooney was enlisted in 2005, Nespresso’s marketing was driven primarily by Club members’ recommendations. At the same time, though, Nespresso insisted that Club members were coffee connoisseurs, whose knowledge and enjoyment of coffee exceeded conventional coffee offerings. In 2000, Henk Kwakman, one of Nestlé’s Coffee Specialists, explained the need for portioned coffee in terms of guaranteed perfection, one that demanding consumers would expect. “In general”, he reasoned, “people who really like espresso coffee are very much more quality driven. When you consider such an intense taste experience, the quality is very important. If the espresso is slightly off quality, the connoisseur notices this immediately” (quoted in Butler 50). What matters here is how this corps of connoisseurs grew to a scale big enough to sustain and strengthen the Nespresso system, in the absence of a robust marketing or educative drive by Nespresso (until very recently). Put simply, the brand’s ascent was aided by Starbucks, specifically by the latter’s success in changing the mainstream coffee market during the 1990s. In establishing such a strong transnational presence, Starbucks challenged smaller, competing brands to define themselves with more clarity and conviction. Indeed, working with data that identified just 200 freestanding coffee houses in the US prior to 1990 compared to 14,000 in 2003, Kjeldgaard and Ostberg go so far as to state that: “Put bluntly, in the US there was no local coffee consumptionscape prior to Starbucks” (Kjeldgaard and Ostberg 176). Starbucks effectively redefined the coffee world for mainstream consumers in ways that were directly beneficial for Nespresso. Starbucks: Coffee as Ambience, Experience, and Cultural Capital While visitors to Nespresso boutiques can sample the coffee, with highly trained baristas and staff on site to explain the Nespresso system, in the main there are few concessions to the conventional café experience. Primarily, these boutiques function as material spaces for existing Club members to stock up on capsules, and therefore they complement the Nespresso system with a suitably streamlined space: efficient, stylish and conspicuously upmarket. Outside at least one Sydney boutique for instance (Bondi Junction, in the fashionable eastern suburbs), visitors enter through a club-style cordon, something usually associated with exclusive bars or hotels. This demarcates the boutique from neighbouring coffee chains, and signals Nespresso’s claim to more privileged patrons. This strategy though, the cultivation of a particular customer through aesthetic design and subtle flattery, is not unique. For decades, Starbucks also contrived a “special” coffee experience. Moreover, while the Starbucks model strikes a very different sensorial chord to that of Nespresso (in terms of décor, target consumer and so on) it effectively groomed and prepped everyday coffee drinkers to a level of relative self-sufficiency and expertise—and therein is the link between Starbucks’s mass-marketed approach and Nespresso’s timely arrival. Starbucks opened its first store in 1971, in Seattle. Three partners founded it: Jerry Baldwin and Zev Siegl, both teachers, and Gordon Bowker, a writer. In 1982, as they opened their sixth Seattle store, they were joined by Howard Schultz. Schultz’s trip to Italy the following year led to an entrepreneurial epiphany to which he now attributes Starbucks’s success. Inspired by how cafés in Italy, particularly the espresso bars in Milan, were vibrant social hubs, Schultz returned to the US with a newfound sensitivity to ambience and attitude. In 1987, Schultz bought Starbucks outright and stated his business philosophy thus: “We aren’t in the coffee business, serving people. We are in the people business, serving coffee” (quoted in Ruzich 432). This was articulated most clearly in how Schultz structured Starbucks as the ultimate “third place”, a welcoming amalgam of aromas, music, furniture, textures, literature and free WiFi. This transformed the café experience twofold. First, sensory overload masked the dull homogeny of a global chain with an air of warm, comforting domesticity—an inviting, everyday “home away from home.” To this end, in 1994, Schultz enlisted interior design “mastermind” Wright Massey; with his team of 45 designers, Massey created the chain’s decor blueprint, an “oasis for contemplation” (quoted in Scerri 60). At the same time though, and second, Starbucks promoted a revisionist, airbrushed version of how the coffee was produced. Patrons could see and smell the freshly roasted beans, and read about their places of origin in the free pamphlets. In this way, Starbucks merged the exotic and the cosmopolitan. The global supply chain underwent an image makeover, helped by a “new” vocabulary that familiarised its coffee drinkers with the diversity and complexity of coffee, and such terms as aroma, acidity, body and flavour. This strategy had a decisive impact on the coffee market, first in the US and then elsewhere: Starbucks oversaw a significant expansion in coffee consumption, both quantitatively and qualitatively. In the decades following the Second World War, coffee consumption in the US reached a plateau. Moreover, as Steven Topik points out, the rise of this type of coffee connoisseurship actually coincided with declining per capita consumption of coffee in the US—so the social status attributed to specialised knowledge of coffee “saved” the market: “Coffee’s rise as a sign of distinction and connoisseurship meant its appeal was no longer just its photoactive role as a stimulant nor the democratic sociability of the coffee shop” (Topik 100). Starbucks’s singular triumph was to not only convert non-coffee drinkers, but also train them to a level of relative sophistication. The average “cup o’ Joe” thus gave way to the latte, cappuccino, macchiato and more, and a world of coffee hitherto beyond (perhaps above) the average American consumer became both regular and routine. By 2003, Starbucks’s revenue was US $4.1 billion, and by 2012 there were almost 20,000 stores in 58 countries. As an idealised “third place,” Starbucks functioned as a welcoming haven that flattened out and muted the realities of global trade. The variety of beans on offer (Arabica, Latin American, speciality single origin and so on) bespoke a generous and bountiful modernity; while brochures schooled patrons in the nuances of terroir, an appreciation for origin and distinctiveness that encoded cultural capital. This positioned Starbucks within a happy narrative of the coffee economy, and drew patrons into this story by flattering their consumer choices. Against the generic sameness of supermarket options, Starbucks promised distinction, in Pierre Bourdieu’s sense of the term, and diversity in its coffee offerings. For Greg Dickinson, the Starbucks experience—the scent of the beans, the sound of the grinders, the taste of the coffees—negated the abstractions of postmodern, global trade: by sensory seduction, patrons connected with something real, authentic and material. At the same time, Starbucks professed commitment to the “triple bottom line” (Savitz), the corporate mantra that has morphed into virtual orthodoxy over the last fifteen years. This was hardly surprising; companies that trade in food staples typically grown in developing regions (coffee, tea, sugar, and coffee) felt the “political-aesthetic problematization of food” (Sassatelli and Davolio). This saw increasingly cognisant consumers trying to reconcile the pleasures of consumption with environmental and human responsibilities. The “triple bottom line” approach, which ostensibly promotes best business practice for people, profits and the planet, was folded into Starbucks’s marketing. The company heavily promoted its range of civic engagement, such as donations to nurses’ associations, literacy programs, clean water programs, and fair dealings with its coffee growers in developing societies (Simon). This bode well for its target market. As Constance M. Ruch has argued, Starbucks sought the burgeoning and lucrative “bobo” class, a term Ruch borrows from David Brooks. A portmanteau of “bourgeois bohemians,” “bobo” describes the educated elite that seeks the ambience and experience of a counter-cultural aesthetic, but without the political commitment. Until the last few years, it seemed Starbucks had successfully grafted this cultural zeitgeist onto its “third place.” Ironically, the scale and scope of the brand’s success has meant that Starbucks’s claim to an ethical agenda draws frequent and often fierce attack. As a global behemoth, Starbucks evolved into an iconic symbol of advanced consumer culture. For those critical of how such brands overwhelm smaller, more local competition, the brand is now synonymous for insidious, unstoppable retail spread. This in turn renders Starbucks vulnerable to protests that, despite its gestures towards sustainability (human and environmental), and by virtue of its size, ubiquity and ultimately conservative philosophy, it has lost whatever cachet or charm it supposedly once had. As Bryant Simon argues, in co-opting the language of ethical practice within an ultimately corporatist context, Starbucks only ever appealed to a modest form of altruism; not just in terms of the funds committed to worthy causes, but also to move thorny issues to “the most non-contentious middle-ground,” lest conservative customers felt alienated (Simon 162). Yet, having flagged itself as an ethical brand, Starbucks became an even bigger target for anti-corporatist sentiment, and the charge that, as a multinational giant, it remained complicit in (and one of the biggest benefactors of) a starkly inequitable and asymmetric global trade. It remains a major presence in the world coffee market, and arguably the most famous of the coffee chains. Over the last decade though, the speed and intensity with which Nespresso has grown, coupled with its atypical approach to consumer engagement, suggests that, in terms of brand equity, it now offers a more compelling point of difference than Starbucks. Brand “Me” Insofar as the Nespresso system depends on a consumer market versed in the intricacies of quality coffee, Starbucks can be at least partly credited for nurturing a more refined palate amongst everyday coffee drinkers. Yet while Starbucks courted the “average” consumer in its quest for market control, saturating the suburban landscape with thousands of virtually indistinguishable stores, Nespresso marks a very different sensibility. Put simply, Nespresso inverts the logic of a coffee house as a “third place,” and patrons are drawn not to socialise and relax but to pursue their own highly individualised interests. The difference with Starbucks could not be starker. One visitor to the Bloomingdale boutique (in New York’s fashionable Soho district) described it as having “the feel of Switzerland rather than Seattle. Instead of velvet sofas and comfy music, it has hard surfaces, bright colours and European hostesses” (Gapper 9). By creating a system that narrows the gap between production and consumption, to the point where Nespresso boutiques advertise the coffee brand but do not promote on-site coffee drinking, the boutiques are blithely indifferent to the historical, romanticised image of the coffee house as a meeting place. The result is a coffee experience that exploits the sophistication and vanity of aspirational consumers, but ignores the socialising scaffold by which coffee houses historically and perhaps naively made some claim to community building. If anything, Nespresso restricts patrons’ contemplative field: they consider only their relationships to the brand. In turn, Nespresso offers the ultimate expression of contemporary consumer capitalism, a hyper-individual experience for a hyper-modern age. By developing a global brand that is both luxurious and niche, Nespresso became “the Louis Vuitton of coffee” (Betts 14). Where Starbucks pursued retail ubiquity, Nespresso targets affluent, upmarket cities. As chief executive Richard Giradot put it, with no hint of embarrassment or apology: “If you take China, for example, we are not speaking about China, we are speaking about Shanghai, Hong Kong, Beijing because you will not sell our concept in the middle of nowhere in China” (quoted in Canning 28). For this reason, while Europe accounts for 90 per cent of Nespresso sales (Betts 15), its forays into the Americas, Asia and Australasia invariably spotlights cities that are already iconic or emerging economic hubs. The first boutique in Latin America, for instance, was opened in Jardins, a wealthy suburb in Sao Paulo, Brazil. In Nespresso, Nestlé has popularised a coffee experience neatly suited to contemporary consumer trends: Club members inhabit a branded world as hermetically sealed as the aluminium pods they purchase and consume. Besides the Club’s phone, fax and online distribution channels, pods can only be bought at the boutiques, which minimise even the potential for serendipitous mingling. The baristas are there primarily for product demonstrations, whilst highly trained staff recite the machines’ strengths (be they in design or utility), or information about the actual coffees. For Club members, the boutique service is merely the human extension of Nespresso’s online presence, whereby product information becomes increasingly tailored to increasingly individualised tastes. In the boutique, this emphasis on the individual is sold in terms of elegance, expedience and privilege. Nespresso boasts that over 70 per cent of its workforce is “customer facing,” sharing their passion and knowledge with Club members. Having already received and processed the product information (through the website, boutique staff, and promotional brochures), Club members need not do anything more than purchase their pods. In some of the more recently opened boutiques, such as in Paris-Madeleine, there is even an Exclusive Room where only Club members may enter—curious tourists (or potential members) are kept out. Club members though can select their preferred Grands Crus and checkout automatically, thanks to RFID (radio frequency identification) technology inserted in the capsule sleeves. So, where Starbucks exudes an inclusive, hearth-like hospitality, the Nespresso Club appears more like a pampered clique, albeit a growing one. As described in the Financial Times, “combine the reception desk of a designer hotel with an expensive fashion display and you get some idea what a Nespresso ‘coffee boutique’ is like” (Wiggins and Simonian 10). Conclusion Instead of sociability, Nespresso puts a premium on exclusivity and the knowledge gained through that exclusive experience. The more Club members know about the coffee, the faster and more individualised (and “therefore” better) the transaction they have with the Nespresso brand. This in turn confirms Zygmunt Bauman’s contention that, in a consumer society, being free to choose requires competence: “Freedom to choose does not mean that all choices are right—there are good and bad choices, better and worse choices. The kind of choice eventually made is the evidence of competence or its lack” (Bauman 43-44). Consumption here becomes an endless process of self-fashioning through commodities; a process Eva Illouz considers “all the more strenuous when the market recruits the consumer through the sysiphian exercise of his/her freedom to choose who he/she is” (Illouz 392). In a status-based setting, the more finely graded the differences between commodities (various places of origin, blends, intensities, and so on), the harder the consumer works to stay ahead—which means to be sufficiently informed. Consumers are locked in a game of constant reassurance, to show upward mobility to both themselves and society. For all that, and like Starbucks, Nespresso shows some signs of corporate social responsibility. In 2009, the company announced its “Ecolaboration” initiative, a series of eco-friendly targets for 2013. By then, Nespresso aims to: source 80 per cent of its coffee through Sustainable Quality Programs and Rainforest Alliance Certified farms; triple its capacity to recycle used capsules to 75 per cent; and reduce the overall carbon footprint required to produce each cup of Nespresso by 20 per cent (Nespresso). This information is conveyed through the brand’s website, press releases and brochures. However, since such endeavours are now de rigueur for many brands, it does not register as particularly innovative, progressive or challenging: it is an unexceptional (even expected) part of contemporary mainstream marketing. Indeed, the use of actor George Clooney as Nespresso’s brand ambassador since 2005 shows shrewd appraisal of consumers’ political and cultural sensibilities. As a celebrity who splits his time between Hollywood and Lake Como in Italy, Clooney embodies the glamorous, cosmopolitan lifestyle that Nespresso signifies. 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