The impact of enteral feeding protocols on nutritional support in critically ill children

BACKGROUND

Studies have shown that feeding protocols may assist in achieving optimal nutritional care in critically ill children. The present study aimed to assess the impact of enteral feeding protocols on nutritional support practices through a continuous auditing process over a defined period.

MATERIALS AND METHODS

A prospective audit on nutritional practice was initiated in 1994-1995 on all ventilated patients who were admitted for more than a complete 24-h period in the paediatric intensive care unit. The audit was repeated 1997-1998, 2001 and 2005. The collection of data on outcomes included the time taken to initiate nutritional support, the proportion of patients fed via the enteral versus parenteral route, and the proportion of children reaching 50% and 70% of the estimated average requirement (EAR) by day 3. Feeding algorithms and protocols were introduced after each audit with a view to improving practices.

RESULTS

Over the study period, time taken to initiate nutrition support was reduced from 15 h (1994-1995), 8 h (1997-1998), 5.5 h (2001) to 4.5 h (2005). The proportion of patients on parenteral feeds was reduced from 11% (1994-1995) to 4% (2005). An increase was also documented in the percentage of patients receiving a daily energy provision of 50% and 70% of the EAR by day 3 after the initiation of nutritional support (6% in 1994-1995 to 21% in 2005 for 70% of EAR).

CONCLUSION

The present study demonstrates that feeding protocols improve nutritional practices in a paediatric intensive care unit. However, protocol introduction needs to be monitored regularly through audit.

Compliance and side effects of prophylactic oseltamivir treatment in a school in South West England

School closure along with mass prophylactic oseltamivir treatment of pupils have been used in England and elsewhere to contain school outbreaks of influenza A(H1N1)v. We evaluated the protective effect, compliance with and side effects of oseltamivir chemoprophylactic treatment with a ten-day course of 1x 75mg given to 11-12-year-old pupils in one school year in a secondary school in South West England closed for ten days in response to a symptomatic laboratory-confirmed pupil. We distributed a questionnaire to pupils in the affected school year in class after the school had re-opened. Questions included symptoms of flu-like illness, compliance with chemoprophylaxis and side effects. All present on the day, 248 (93.2%) participated. Compliance with chemoprophylaxis was high, 77% took the full course, 91% took at least seven days. Fifty-one percent experienced symptoms such as feeling sick (31.2%), headaches (24.3%) and stomach ache (21.1%). Although some children were ill with flu-like symptoms, those tested did not have A(H1N1)v infection. Compliance with oseltamivir chemoprophylaxis was high, although likely side effects were common. The burden of side effects needs to be considered when deciding on mass oseltamivir chemoprophylaxis in children especially given that the symptoms of A(H1N1)v influenza are generally mild.

The Ludwig pattern of androgenetic alopecia is due to a hierarchy of androgen sensitivity within follicular units that leads to selective miniaturization and a reduction in the number of terminal hairs per follicular unit

BACKGROUND

Hair follicles exist within follicular units (FUs). In utero the central primary hair follicles are surrounded by smaller secondary follicles. Each FU is nourished by a single arborizing arrector pili muscle that attaches circumferentially around the primary follicle with variable attachment to other follicles. Androgenetic alopecia (AA) miniaturizes susceptible scalp hair follicles in a distinctive and reproducible fashion manifesting in different patterns between men and women.

OBJECTIVES

We hypothesized that there is an additional layer to the patterning in AA, with a hierarchy of susceptibility within FUs to AA, and that the diffuse hair loss seen in women with AA is due to a reduction in the number of terminal hairs per FU rather than uniform miniaturization of entire FUs.

METHODS

We compared the mean numbers of FUs and terminal hairs per FU in 4-mm scalp punch biopsies in 24 women with AA with those in 21 controls.

RESULTS

There was no significant difference in the number of FUs; however, women with AA had 2.40 terminal hairs per FU compared with 3.38 in the control group (P=0.0001) associated with a mean increase of 0.6 vellus hairs per FU. Complete miniaturization of all hairs within the FU was not seen.

CONCLUSIONS

Diffuse hair loss in women with AA is due to a reduction in the number of terminal hairs per FU and an increase in the number of vellus hairs. This supports the hypothesis of a hierarchy of susceptibility within FUs to AA. Further investigation is required to ascertain whether secondary and tertiary hair follicles are more susceptible than primary follicles.

Impact of interictal epileptic activity on normal brain function in epileptic encephalopathy: an electroencephalography-functional magnetic resonance imaging study

Using electroencephalography (EEG) in combination with functional magnetic resonance imaging (fMRI), we studied a 9.5-year-old girl who developed cognitive and behavioral regression in association with intense interictal bilaterally synchronous epileptic discharges (IBSEDs) both during the awake state and during sleep. During runs of IBSEDs, EEG-fMRI demonstrated deactivations in the lateral and medial frontoparietal cortices, posterior cingulate gyrus, and cerebellum together with focal relative activations in the right frontal, parietal, and temporal cortices. The deactivations probably reflect the repercussion of the interictal epileptic activity on normal brain function which might cause the neuropsychological regression by inducing repetitive interruptions of neurophysiological function resulting in a chronic state of specific psychomotor impairment. The relative activations could possibly indicate the source of epileptic activity rapidly spreading to other brain regions.

Safety and complexity

PURPOSE

Current thinking about "patient safety" emphasises the causal relationship between the work environment and the delivery of clinical care. This research draws on the theory of normal accidents to extend this analysis and better understand the "organisational factors" that threaten safety.

DESIGN/METHODOLOGY/APPROACH

Ethnographic research methods were used, with observations of the operating department setting for 18 month and interviews with 80 members of hospital staff. The setting for the study was the Operating Department of a large teaching hospital in the North-West of England.

FINDINGS

The work of the operating department is determined by inter-dependant, "tightly coupled" organisational relationships between hospital departments based upon the timely exchange of information, services and resources required for the delivery of care. Failures within these processes, manifest as "breakdowns" within inter-departmental relationships lead to situations of constraint, rapid change and uncertainty in the work of the operating department that require staff to break with established routines and work with increased time and emotional pressures. This means that staff focus on working quickly, as opposed to working safely. ORIGINALITY VALUE: Analysis of safety needs to move beyond a focus on the immediate work environment and individual practice, to consider the more complex and deeply structured organisational systems of hospital activity. For departmental managers the scope for service planning to control for safety may be limited as the structured "real world" situation of service delivery is shaped by inter-department and organisational factors that are perhaps beyond the scope of departmental management.

Improving the management and referral of patients with transient ischaemic attacks: a change strategy for a health community

PROBLEM

Rapid referral and management of patients with transient ischaemic attacks is a key component in the national strategy for stroke prevention. However, patients with transient ischaemic attacks are poorly identified and undertreated.

DESIGN AND SETTING

Before and after evaluation of quality improvement programme with controlled comparison in three primary care trusts reflecting diverse populations and organisational structures in an urban district in the North of England.

KEY MEASURES FOR IMPROVEMENT

The proportion of patients receiving antiplatelet drugs and safe driving advice on referral to a specialty clinic, and the numbers of referrals, adjusted for age, to the specialist clinic before and after the improvement programme.

STRATEGIES FOR CHANGE

Interviews with patient and professionals to identify gaps and barriers to good practice; development of evidence based guidelines for the management of patients with transient ischaemic attacks; interactive multidisciplinary workshops for each primary care trust with feedback of individual audit results of referral practice; outreach visits to teams who were unable to attend the workshops; referral templates and desktop summaries to provide reminders of the guidelines to clinicians; incorporation of standards into professional contracts.

EFFECTS OF CHANGE

A significant improvement occurred in identification and referral of patients with transient ischaemic attacks to specialist clinics, with a 41% increase in referrals from trained practices compared with control practices. There were also significant improvements in the early treatment and safety advice provided to patients before referral.

LESSONS LEARNT

A strategic approach to effective quality improvement across a diverse health community is feasible and achievable. Careful planning with patient and professional involvement to develop a tailored and multifaceted quality improvement programme to implement evidence based practice can work in very different primary care settings. Key components of the effectiveness of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication, and use of established networks and opinion leaders.

Rules and guidelines in clinical practice: a qualitative study in operating theatres of doctors' and nurses' views

BACKGROUND

The current orthodoxy within patient safety research and policy is characterised by a faith in rules based systems which limit the capacity for individual discretion, and hence fallibility. However, guidelines have been seen as stifling innovation and eroding trust. Our objectives were to explore the attitudes towards guidelines of doctors and nurses working together in surgical teams and to examine the extent to which trusting relationships are maintained in a context governed by explicit rules.

METHODS

Fourteen consultant grade surgeons of mixed specialty, 12 consultant anaesthetists, and 15 nurses were selected to reflect a range of roles. Participant observation was combined with semi-structured interviews.

RESULTS

Doctors' views about the contribution of guidelines to safety and to clinical practice differed from those of nurses. Doctors rejected written rules, instead adhering to the unwritten rules of what constitutes acceptable behaviour for members of the medical profession. In contrast, nurses viewed guideline adherence as synonymous with professionalism and criticised doctors for failing to comply with guidelines.

CONCLUSIONS

While the creation of a "safety culture" requires a shared set of beliefs, attitudes and norms in relation to what is seen as safe clinical practice, differences of opinion on these issues exist which cannot be easily reconciled since they reflect deeply ingrained beliefs about what constitutes professional conduct. While advocates of standardisation (such as nurses) view doctors as rule breakers, doctors may not necessarily regard guidelines as legitimate or identify with the rules written for them by members of other social groups. Future safety research and policy should attempt to understand the unwritten rules which govern clinical behaviour and examine the ways in which such rules are produced, maintained, and accepted as legitimate.

Edg8/S1P5: an oligodendroglial receptor with dual function on process retraction and cell survival

Endothelial differentiation gene (Edg) proteins are G-protein-coupled receptors activated by lysophospholipid mediators: sphingosine-1-phosphate (S1P) or lysophosphatidic acid. We show that in the CNS, expression of Edg8/S1P5, a high-affinity S1P receptor, is restricted to oligodendrocytes and expressed throughout development from the immature stages to the mature myelin-forming cell. S1P activation of Edg8/S1P5 on O4-positive pre-oligodendrocytes induced process retraction via a Rho kinase/collapsin response-mediated protein signaling pathway, whereas no retraction was elicited by S1P on these cells derived from Edg8/S1P5-deficient mice. Edg8/S1P5-mediated process retraction was restricted to immature cells and was no longer observed at later developmental stages. In contrast, S1P activation promoted the survival of mature oligodendrocytes but not of pre-oligodendrocytes. The S1P-induced survival of mature oligodendrocytes was mediated through a pertussis toxin-sensitive, Akt-dependent pathway. Our data demonstrate that Edg8/S1P5 activation on oligodendroglial cells modulates two distinct functional pathways mediating either process retraction or cell survival and that these effects depend on the developmental stage of the cell.

Evacuation decisions in a chemical air pollution incident: cross sectional survey

OBJECTIVE

To compare the health outcomes in sheltered and evacuated populations after a chemical incident in a plastics factory.

DESIGN

Cross sectional survey.

SETTING

Urban area in southwest England.

PARTICIPANTS

1750 residents from the area exposed to the chemical smoke, of which 472 were evacuated and the remaining 1278 were advised to shelter indoors.

MAIN OUTCOME MEASURE

Number of adverse health symptoms. A case was defined by the presence of four or more symptoms.

MAIN RESULTS

1096 residents (63%; 299 evacuated, 797 sheltered) provided data for analyses. The mean symptom score and proportion of cases were higher in evacuated people than in the sheltered population (evacuated: symptom score 1.9, cases 19.7% (n = 59); sheltered: symptom score 1.0, cases 9.5% (n = 76); P < 0.001 for both). The difference between the two groups attenuated markedly at the end of two weeks from the start of the incident. The two main modifiable risk factors for the odds of becoming a case were evacuation (odds ratio 2.5, 95% confidence interval 1.7 to 3.8) and direct exposure to smoke for more than two hours on the first day of the incident (2.0, 1.7 to 2.3). The distance of residence from the factory or level of exposure before intervention (first six hours) had little effect on the odds of a person becoming a case.

CONCLUSIONS

Sheltering may have been a better protective action than evacuation in this chemical incident, which is consistent with the prevailing expert view. Although this study has limitations, it is based on a real event. Evacuations carry their own risks and resource implications; increased awareness may help to reduce unnecessary evacuations in the future.

Antitussive activity of iodo-resiniferatoxin in guinea pigs

BACKGROUND

Iodo-resiniferatoxin (I-RTX) has recently been described as an ultra potent antagonist of the transient receptor potential vanilloid-1 (TRPV1).

METHODS

The ability of I-RTX to inhibit cough induced by inhalation of two putative TRPV1 stimulants (capsaicin and citric acid) was tested in non-anaesthetised guinea pigs.

RESULTS

Pretreatment with I-RTX either intraperitoneally (0.03-0.3 micromol/kg) or by aerosol (0.1-3 microM) reduced the number of coughs produced by inhalation of citric acid (0.25 M) and capsaicin (30 microM) in a dose dependent manner. Capsazepine (CPZ) also reduced citric acid and capsaicin induced cough, but the activity of I-RTX was 10-100 times more potent than CPZ in all the experimental conditions tested.

CONCLUSIONS

I-RTX is a novel and potent antitussive drug which inhibits cough mediated by agents possibly acting via TRPV1 activation.

Re-thinking accountability: trust versus confidence in medical practice

In seeking to prevent a reoccurrence of scandals such as that involving cardiac surgery in Bristol, the UK government has adopted a model of regulation that uses rules and surveillance as a way of both improving the quality of care delivered and increasing confidence in healthcare institutions. However, this approach may actually act to reduce confidence and trust while also reducing the moral motivation of practitioners. Accountability in health care is discussed, and it is suggested that openness about the difficult dilemmas that arise when practitioners have a duty to be accountable to more than one audience may be an alternative means of restoring trust. A greater emphasis on the sharing of information between individual health professionals and their patients would increase trust and would allow patients to hold their doctors to account for the quality of care they receive. Concentrating more on developing trust by the sharing of information and less on the futile search for complete confidence in systems and rules may improve the quality of care delivered while also nurturing the moral motivation of professionals upon which the delivery of high quality health care depends.

Outbreak of Escherichia coli O157 associated with a busy bathing beach

Between 7 and 20 August 1999 a Public Health Department was notified of seven cases of Escherichia coli O157 infection. Phage typing demonstrated that four were related and three unrelated. The investigation centred around the three cases of E. coli O157 phage type 21/28 who visited the same beach during the last week of July. The fourth related infection was identified as a result of the investigation. Although the investigation failed to identify a source of infection, interviews with the families of the four related cases suggested that they had occupied the same part of the beach on the same day and so it is possible that a contaminated area of beach was the source. We believe this to be the first outbreak of E. coli O157 to be associated with a bathing beach.