Digital intervention increases influenza vaccination rates for people with diabetes in a decentralized randomized trial

People with diabetes (PWD) have an increased risk of developing influenza-related complications, including pneumonia, abnormal glycemic events, and hospitalization. Annual influenza vaccination is recommended for PWD, but vaccination rates are suboptimal. The study aimed to increase influenza vaccination rate in people with self-reported diabetes. This study was a prospective, 1:1 randomized controlled trial of a 6-month Digital Diabetes Intervention in U.S. adults with diabetes. The intervention group received monthly messages through an online health platform. The control group received no intervention. Difference in self-reported vaccination rates was tested using multivariable logistic regression controlling for demographics and comorbidities. The study was registered at clinicaltrials.gov: NCT03870997. A total of 10,429 participants reported influenza vaccination status (5158 intervention, mean age (±SD) = 46.8 (11.1), 78.5% female; 5271 control, Mean age (±SD) = 46.7 (11.2), 79.4% female). After a 6-month intervention, 64.2% of the intervention arm reported influenza vaccination, vers us 61.1% in the control arm (diff = 3.1, RR = 1.05, 95% CI [1.02, 1.08], p = 0.0013, number needed to treat = 33 to obtain 1 additional vaccination). Completion of one or more intervention messages was associated with up to an 8% increase in vaccination rate (OR 1.27, 95% CI [1.17, 1.38], p < 0.0001). The intervention improved influenza vaccination rates in PWD, suggesting that leveraging new technology to deliver knowledge and information can improve influenza vaccination rates in high-risk populations to reduce public health burden of influenza. Rapid cycle innovation could maximize the effects of these digital interventions in the future with other populations and vaccines.

A patient and relative centred evaluation of treatment escalation plans: a replacement for the do-not-resuscitate process

The Treatment Escalation Plan (TEP) was introduced into our trust in an attempt to improve patient involvement and experience of their treatment in hospital and to embrace and clarify a wider remit of treatment options than the Do Not Resuscitate (DNR) order currently offers. Our experience suggests that the patient and family are rarely engaged in DNR discussions. This is acutely relevant considering that the Mental Capacity Act (MCA) now obliges these discussions to take place. The TEP is a form that the doctor completes, ideally with the competent patient or close relative, documenting what treatment options would be appropriate if that patient were to become acutely unwell. Ventilation of the lungs, cardiac resuscitation, renal replacement therapy, intravenous fluids and antibiotics are all discussed. The study evaluated patient and relative experiences with the TEP. 55 patients or their relatives were interviewed regarding their experience of the TEP and thoughts regarding the process. 96% of patients and relatives evaluated thought that the TEP was a good idea. Free text comments were all positive and only 34% of patients claimed to feel anxious when completing the form. Following this study, the TEP has been expanded hospital wide and into the community within our trust. Discussions are currently taking place in hospitals within our region to introduce the TEP form into other local trusts.

A case of acute upper and lower airway obstruction due to retropharyngeal haemorrhage secondary to acquired haemophilia A

We report the first known case of acute upper and lower airway obstruction due to retropharyngeal haemorrhage secondary to acquired haemophilia A. The patient required tracheal intubation and ventilation followed by surgical tracheostomy, prior to transfer to the intensive care unit for management of her coagulopathy with recombinant clotting factor products under the care of the haematologists.

Respiratory failure after tracheal extubation in a patient with halo frame cervical spine immobilization--rescue therapy using the Combitube airway

A 78-yr-old man, with halo frame cervical spine immobilization, suffered rapid respiratory deterioration after tracheal extubation in the intensive care unit. Control of the airway was difficult as bag-valve-mask ventilation was ineffective, tracheal intubation was known to be difficult from management of a previous episode of respiratory failure on the ward, and laryngeal mask insertion proved impossible. Rescue therapy using a Combitube airway is described and discussed.

Percutaneous tracheostomy in the intensive care unit

Percutaneous tracheostomy is now established in intensive care practice. However, discussion continues on many aspects of the procedure. This update reviews recent studies of bedside percutaneous tracheostomy, which suggest that the commonly used techniques are safe in terms of short and long-term complications. The introduction of percutaneous tracheostomy into an intensive care unit has training implications, particularly for surgeons. The timing of percutaneous tracheostomy in critically ill patients, and the use of the technique in children remain controversial.

The discovery of orally available thrombin inhibitors: optimisation of the P1 pharmacophore

Thrombin inhibitors have been designed with the replacement of the strongly basic guanidine P1 pharmocophore with a group that exploits the lipophilicity of the S1 pocket. The approach has lead to the discovery of potent thrombin inhibitors demonstrating good intra-duodenal absorption.

Studies towards the identification of potent, selective and bioavailable thrombin inhibitors

The application of selection criteria, based on potency and physicochemical parameters, to a candidate library of thrombin inhibitors is described. The utility of the approach is exemplified by the discovery of a potent, selective and bioavailable thrombin inhibitor 62.

The discovery of orally available thrombin inhibitors: studies towards the optimisation of CGH1668

The chemical optimisation of CGH1668 1 is described employing an in vivo model of absorption to determine the influence on bioavailability of single point modifications to five key molecular templates. The discovery of an orally bioavailable and selective thrombin inhibitor, 24, highlights the utility of this approach.

Co-incidental diagnosis of an extradural abscess while siting an extradural catheter for postoperative analgesia

Extradural abscess is a rare but serious complication of the extradural route of administration of analgesic drugs. We report a case of spontaneous extradural abscess diagnosed during placement of an extradural catheter for analgesia after a negative diagnostic laparotomy. Magnetic resonance imaging is the usual diagnostic tool of choice. This, and subsequent surgery, confirmed the diagnosis suspected after drainage of pus through the Tuohy needle.

An audit of treatment withdrawal in one hundred patients on a general ICU

The audit found that 72.6% of patients who died had treatment withdrawn. Three organ failures were most often present in patients when treatment was withdrawn. Withdrawal of treatment did not mean the cessation of care. Variation in involvement was demonstrated with different consultants.

Tag team parenting of children with cancer

During their child's treatment period for cancer, parents have identified many needs they experienced (Mercer & Ritchie, 1997). This article describes findings from a subset of those parents who were interviewed in order to determine what resources they believed were necessary to meet their needs. The parents (n = 20), representing families who lived in close proximity to the major children's tertiary hospital as well as families who were distanced from the major center, described resources that included informational, emotional, and instrumental support. Although most parents indicated that information was readily available to them, many parents described a lack of instrumental support, such as respite care or financial assistance. When resources were inadequate, it was often because informal support from family and friends was unavailable. Single parents and parents of children with solid tumors indicated that they had fewer resources. The findings demonstrate the experience of parents during their children's treatment period and indicate the need for identifying family supports early in the treatment period.

Home community cancer care: parents' perspectives

This article reports on the results of a survey on the needs of parents of children with cancer and explores the needs of the parents, the parents' perceived importance of the needs, and whether the needs have been met. The study was designed to identify any differences in needs between parents whose children received all of their care at the major tertiary center (n = 16) and parents whose children received at least some of their care in their local community (n = 40). There were no significant differences between the two groups. Parents reported that their important needs for information were met, but other needs (financial assistance, time, and rest) were unmet. Findings indicate that health care providers who care for families of children with cancer need to perform careful individual assessments throughout the treatment period.

Comparison of the efficacy and tolerability of topical levocabastine and sodium cromoglycate in the treatment of seasonal allergic rhinoconjunctivitis in children

Children (n = 110) with seasonal allergic rhinoconjunctivitis were randomized to receive either twice daily 0.05% levocabastine eye drops and nasal spray plus twice daily topical placebos or 2% sodium cromoglycate eye drops and nasal spray four times daily for a period of 4 weeks. Patients were required to use the nasal sprays as directed and the eye drops only when required. The results obtained suggest that topical levocabastine is at least as effective as sodium cromoglycate for the treatment of this condition. After 2 weeks treatment the effect of therapy on nasal symptoms was considered to be excellent or good in 72% of levocabastine-treated patients and 54% of patients on sodium cromoglycate (p = 0.009), with corresponding values for ocular symptoms of 81% and 57% in the two groups, respectively (p < 0.05). Investigator assessments also revealed that the severity of sneezing and lacrimation were significantly lower in the levocabastine group at this time (p < 0.05). After 4 weeks of treatment, patient diary data revealed that levocabastine was at least as effective as sodium cromoglycate with intergroup differences attaining statistical significance in favor of the topical antihistamine for nasal congestion (p < 0.05). Both agents were well-tolerated with no significant differences in the incidence or type of adverse reactions in the two treatment groups.

Tourette's syndrome in New Zealand. A postal survey

It has become increasingly evident that Tourette's syndrome (TS) is not as rare as was once thought and substantial cohorts from various parts of the world have been reported. The clinical characteristics seem independent of culture as they appear to occur with some degree of uniformity irrespective of the country of origin. We investigated the point prevalence and report the clinical characteristics of TS in New Zealand. Forty probable cases were identified and the symptoms were similar to those described in cohorts from other parts of the world.

Injury to the pre-pubertal vas deferens. II. Experimental repair

We have previously shown that the human vas deferens does not change in cross-sectional size between birth and the middle of puberty. This suggests that if the human vas is injured prior to mid-puberty, repair by a traditional microsurgical vasovasostomy may be technically difficult. We propose that a chromic stent can be used to assist in the repair of vas injured before mid-puberty. This hypothesis was tested in Sprague-Dawley rats. At three weeks of age, male offspring were divided into three groups (eight to nine rats/group): 1) Sham group--a sham operation at three weeks, 2) VV group--bilateral transection of vasa at three weeks followed by a delayed repair at eight weeks by microsurgical vasovasostomy without a stent, 3) Stent group--bilateral transection of vasa at three weeks followed by immediate repair by aligning the lumens with a 6-0 chromic intravasal stent (suture) and holding the transected ends together with several seromuscular sutures. At four months all rats were fertility tested and a score was given to each rat (mean number of concepti among three females for each male rat). Analysis of anastomotic patency by flow rates and histology was performed. There was no statistical difference in the mean fertility score of 6.85 in the Stent group compared to 7.83 in the Sham group. However, a fertility score of 0.71 in the VV group was significantly decreased compared to the Stent and Sham group (p = .0003), despite no statistical difference between the groups in patency. This suggests that a recognized injury to the pre-pubertal human vas should be immediately repaired and the repair can be done using 6-0 chromic suture as an intravasal stent to help align the lumina of the smaller pre-pubertal vas.