Economic evaluations of interventions to prevent and control health-care-associated infections: a systematic review

Almost 9 million health-care-associated infections have been estimated to occur each year in European hospitals and long-term care facilities, and these lead to an increase in morbidity, mortality, bed occupancy, and duration of hospital stay. The aim of this systematic review was to review the cost-effectiveness of interventions to limit the spread of health-care-associated infections), framed by WHO infection prevention and control core components. The Embase, National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, Health Technology Assessment, Cinahl, Scopus, Pediatric Economic Database Evaluation, and Global Index Medicus databases, plus grey literature were searched for studies between Jan 1, 2009, and Aug 10, 2022. Studies were included if they reported interventions including hand hygiene, personal protective equipment, national-level or facility-level infection prevention and control programmes, education and training programmes, environmental cleaning, and surveillance. The British Medical Journal checklist was used to assess the quality of economic evaluations. 67 studies were included in the review. 25 studies evaluated methicillin-resistant Staphylococcus aureus outcomes. 31 studies evaluated screening strategies. The assessed studies that met the minimum quality criteria consisted of economic models. There was some evidence that hand hygiene, environmental cleaning, surveillance, and multimodal interventions were cost-effective. There were few or no studies investigating education and training, personal protective equipment or monitoring, and evaluation of interventions. This Review provides a map of cost-effectiveness data, so that policy makers and researchers can identify the relevant data and then assess the quality and generalisability for their setting.

Clinical and cost effectiveness of endoscopic bipolar radiofrequency ablation for the treatment of malignant biliary obstruction: a systematic review

Background

Early evidence suggests that using radiofrequency ablation as an adjunct to standard care (i.e. endoscopic retrograde cholangiopancreatography with stenting) may improve outcomes in patients with malignant biliary obstruction.

Objectives

To assess the clinical effectiveness, cost-effectiveness and potential risks of endoscopic bipolar radiofrequency ablation for malignant biliary obstruction, and the value of future research.

Data sources

Seven bibliographic databases, three websites and seven trials registers were searched from 2008 until 21 January 2021.

Review methods

The study inclusion criteria were as follows: patients with biliary obstruction caused by any form of unresectable malignancy; the intervention was reported as an endoscopic biliary radiofrequency ablation to ablate malignant tissue that obstructs the bile or pancreatic ducts, either to fit a stent (primary radiofrequency ablation) or to clear an obstructed stent (secondary radiofrequency ablation); the primary outcomes were survival, quality of life or procedure-related adverse events; and the study design was a controlled study, an observational study or a case report. Risk of bias was assessed using Cochrane tools. The primary analysis was meta-analysis of the hazard ratio of mortality. Subgroup analyses were planned according to the type of probe, the type of stent (i.e. metal or plastic) and cancer type. A de novo Markov model was developed to model cost and quality-of-life outcomes associated with radiofrequency ablation in patients with primary advanced bile duct cancer. Insufficient data were available for pancreatic cancer and secondary bile duct cancer. An NHS and Personal Social Services perspective was adopted for the analysis. A probabilistic analysis was conducted to estimate the incremental cost-effectiveness ratio for radiofrequency ablation and the probability that radiofrequency ablation was cost-effective at different thresholds. The population expected value of perfect information was estimated in total and for the effectiveness parameters.

Results

Sixty-eight studies (1742 patients) were included in the systematic review. Four studies (336 participants) were combined in a meta-analysis, which showed that the pooled hazard ratio for mortality following primary radiofrequency ablation compared with a stent-only control was 0.34 (95% confidence interval 0.21 to 0.55). Little evidence relating to the impact on quality of life was found. There was no evidence to suggest an increased risk of cholangitis or pancreatitis, but radiofrequency ablation may be associated with an increase in cholecystitis. The results of the cost-effectiveness analysis were that the costs of radiofrequency ablation was £2659 and radiofrequency ablation produced 0.18 quality-adjusted life-years, which was more than no radiofrequency ablation on average. With an incremental cost-effectiveness ratio of £14,392 per quality-adjusted life-year, radiofrequency ablation was likely to be cost-effective at a threshold of £20,000 per quality-adjusted life-year across most scenario analyses, with moderate uncertainty. The source of the vast majority of decision uncertainty lay in the effect of radiofrequency ablation on stent patency.

Limitations

Only 6 of 18 comparative studies contributed to the survival meta-analysis, and few data were found concerning secondary radiofrequency ablation. The economic model and cost-effectiveness meta-analysis required simplification because of data limitations. Inconsistencies in standard reporting and study design were noted.

Conclusions

Primary radiofrequency ablation increases survival and is likely to be cost-effective. The evidence for the impact of secondary radiofrequency ablation on survival and of quality of life is limited. There was a lack of robust clinical effectiveness data and, therefore, more information is needed for this indication.

Future work

Future work investigating radiofrequency ablation must collect quality-of-life data. High-quality randomised controlled trials in secondary radiofrequency ablation are needed, with appropriate outcomes recorded.

Study registration

This study is registered as PROSPERO CRD42020170233.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 7. See the NIHR Journals Library website for further project information.

A rapid priority setting exercise combining existing, emergent evidence with stakeholder knowledge identified broad topic uncertainties

OBJECTIVES

The project aimed to rapidly identify priority topic uncertainties as a first step to identify future systematic review questions of pertinence to key international fecal incontinence (FI) stakeholders (patients, carers, health care professionals, policy makers and voluntary, community, or social enterprise representatives). The paper's aim is to share our methods, experience, and learning with other groups planning to deliver a rapid priority setting exercise.

STUDY DESIGN AND SETTING

An evidence gap map incorporated three evidence streams: emerging evidence identified through horizon scanning; existing evidence identified through systematic searches of bibliographic databases; and FI stakeholder insights collected through an international survey. The evidence gap map was presented during an online workshop with stakeholders, where they shared their expertize to expand, refine, and rank topic uncertainties using ideation techniques, focus group discussions, consensus techniques, and online polling.

RESULTS

The multistep methods used to deliver this priority setting exercise resulted in identification of broad priority topic uncertainties. The methods appear to have high acceptability and engagement with participants but await full evaluation.

CONCLUSION

This project successfully followed robust methodology, building upon frameworks from published priority setting and evidence gap mapping projects while incorporating strong patient and public involvement components.

Interventions for treating obstetric fistula: An evidence gap map

Obstetric fistula is prevalent in low- and middle-income countries, with between 50,000 and 100,000 new cases each year. The World Health Organization aims to eradicate it by 2030 but a clear idea of the extant evidence is unavailable. This evidence map compiled evidence on treatments for obstetric fistula to identify potential knowledge gaps. The protocol for this work was published on the Open Science Framework (DOI: 10.17605/OSF.IO/H7J35). A survey was developed, piloted and distributed online through organisations with an interest in obstetric fistula and snowballing. Results informed the evidence map framework. Searches were run on MEDLINE, Embase, CENTRAL, Global Index Medicus and ScanMedicine on 16 February 2022 to identify potentially eligible systematic reviews, randomised controlled trials, cohort studies and case-control studies. Forward and backward citation chaining was undertaken on relevant systematic reviews and included studies. Studies were screened, coded and assessed for risk of bias by a single reviewer, with a second checking a proportion. The evidence map results were compared to survey results. Thirty-nine people responded to the survey, half of which were clinicians. Of 9796 records identified, 37 reports of 28 studies were included in the evidence map. Many included studies were at some risk of bias; for observational studies, this was predominantly due to lack of controlling for confounders. Most studies (71%) assessed surgical interventions alone. Reporting on other intervention types was limited. Regarding outcome measures most important to survey respondents, 24 studies reported on cure/improvement in obstetric fistula and 20 on cure/improvement in urinary incontinence. Reporting on quality of life, faecal incontinence and sexual function was limited. There is currently little robust evidence to guide patients and practitioners on the most effective treatment option for obstetric fistula. Further research is required to address evidence gaps identified.

76 HOW BLOGS SUPPORT THE TRANSFER OF KNOWLEDGE INTO PRACTICE IN THE FIELD OF DEMENTIA PALLIATIVE CARE: FACILITATORS AND BARRIERS

Background

Blogging can help to maximise the impact of one’s work in academia and beyond by making research findings accessible for multiple knowledge users. As part of the knowledge exchange and dissemination activities of the Model for Dementia Palliative Care Project, this study explored stakeholders’ views of blogs as a means to translate research findings in the field of Dementia Palliative care.

Methods

A web-based survey was developed, piloted, and revised. It was distributed electronically via key dementia and palliative care organisations. Complete responses (N=128) were received from healthcare researchers (n=53), healthcare providers (n=46) and others with an interest in healthcare research (n=29). Data were analysed using descriptive statistics and content analysis

Results

The preferred methods of reviewing research findings were scientific papers, websites and news articles. Respondents read healthcare blogs “sometimes” (39.1%), with <19% reading them “often” or “very often”. Receiving an email notification might increase the likelihood of reading a new blog post for 83% of respondents. Barriers to engaging with blogs included lack of time, preference for other media, lack of awareness regarding available blogs, and concerns about the credibility and source of information. An appropriate length and the author of the blog were key features that encouraged engagement with a blog. Most respondents (37.7 % ‘Yes’ and 23.0% ‘Maybe’) would read Dementia Palliative care blogs by the research team.

Conclusion

Despite respondents choosing a scientific paper as their preferred method to consume research findings, many indicated an openness to reading blogs on their area of interest. Creating concise, relevant, and credible blogs, and suitably promoting them, could increase the impact and reach of healthcare research, such as in the emerging field of dementia palliative care, and thus promote translation of research findings into practice.

75 EVALUATING DEMENTIA PALLIATIVE CARE SERVICES ACROSS IRELAND AND THE UK USING THE RE-AIM FRAMEWORK

Background

Dementia is a life-limiting illness, requiring a Palliative Care (PC) approach from diagnosis. In Ireland, People with Dementia (PwD) and their families rarely receive PC in a timely manner. This study aimed to evaluate five exemplar community-based dementia PC services across Ireland and the UK (as identified by key stakeholders), to inform a new service delivery model.

Methods

Data from semi-structured interviews and focus groups with 29 service providers, and service activity data (n=5), was evaluated using the RE-AIM framework.

Results

‘Reach’ - Caseloads varied significantly between 3-154 active cases. Most services accepted self-referrals; all wanted earlier referrals. Factors influencing reach included co-location, dyadic participation, service flexibility, and others’ awareness of PC appropriateness and the service’s existence.

‘Effectiveness’ - All service users received holistic assessments, person-centred care, advanced care planning, continuity of care, improved service access and ‘care-for-the-carer’. Some services offered complimentary therapies, 24/7 phone support, and bereavement support; these were perceived to improve quality-of-life, comfort, and independence.

‘Adoption’ - Staff were highly invested; some provided their personal numbers to families. Outside staff were more willing to engage (refer/support) if shared governance, training was provided, or already familiar with dementia or the tools. Incentive programmes increased adoption rates.

‘Implementation ’ - All services evolved on an ad-hoc basis, with funding provided by local organisations, and a single ‘driving force’, typically a consultant/nurse. Services heavily relied on volunteers. Perceived “essential” elements included a dyadic approach, MDT involvement, open communication, forming relationships, reflective practices, dedicated staff with problem solving skills, and staff support/training.

‘Maintenance’ - All services continued after initial project funding; three increased their activities/reach over time.

Conclusion

Important features and facilitators of community-based dementia palliative care services have been identified. These results are informing the development of the novel Dementia Palliative Care model for use in Ireland (https://pallcare4dementia.com/).

Rapid priority setting exercise on faecal incontinence for Cochrane Incontinence

Objective

This rapid priority setting exercise aimed to identify, expand, prioritise and explore stakeholder (patients, carers and healthcare practitioners) topic uncertainties on faecal incontinence (FI).

Design

An evidence gap map (EGM) was produced to give a visual overview of emerging trial evidence; existing systematic review-level evidence and FI stakeholder topic uncertainties derived from a survey. This EGM was used in a knowledge exchange workshop that promoted group discussions leading to the prioritisation and exploration of FI stakeholder identified topic uncertainties.

Results

Overall, a mismatch between the existing and emerging evidence and key FI stakeholder topic uncertainties was found. The prioritised topic uncertainties identified in the workshop were as follows: psychological support; lifestyle interventions; long-term effects of living with FI; education; constipation and the cultural impact of FI. When these six prioritised topic uncertainties were explored in more depth, the following themes were identified: education; impact and burden of living with FI; psychological support; healthcare service improvements and inconsistencies; the stigma of FI; treatments and management; culturally appropriate management and technology and its accessibility.

Conclusions

Topic uncertainties identified were broad and wide ranging even after prioritisation. More research is required to unpick the themes emerging from the in-depth discussion and explore these further to achieve a consensus on deliverable research questions.

P-P21 Endoscopic bipolar radiofrequency ablation for treating biliary obstruction caused by unresectable cancer: systematic review of clinical and cost effectiveness

Background

Early evidence suggests using radiofrequency ablation (RFA) as an adjunct to stenting may improve outcomes in patients with malignant biliary obstruction. RFA can be deployed either at the initial stent insertion or to clear tumour ingrowth in a previously placed stent.

Methods

To assess the clinical and cost effectiveness and potential risks of RFA for malignant biliary obstruction. MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL, HTA and DARE, 3 websites and 7 trial registers were searched from 2008 to 2021. Study inclusion criteria were: malignant biliary obstruction; intervention as endoscopic RFA, either to fit a stent (primary RFA) or to clear a blocked stent (secondary RFA); primary outcomes were survival, quality of life or procedure-related adverse events. Risk of bias was assessed using the RoB 2.0 and ROBINS-I tools. Primary analysis was meta-analysis of the hazard ratio of mortality.

Results

68 studies (1742 patients) were identified but only 2 randomised trials, 1 retrospective case-control study and 3 retrospective cohort studies reported a hazard ratio of death for primary RFA compared to stent-only control. The pooled hazard ratio of mortality for primary RFA compared to stent-only was 0.34 (95% confidence interval (CI) 0.21 to 0.55). There was moderate heterogeneity (I2 = 53%) however studies were consistently in favour of primary RFA. There was insufficient evidence available to analyse effectiveness in secondary RFA. No evidence relating to quality of life. There was no evidence of increased risk of cholangitis (risk ratio 1.15, 95% CI 0.63 to 2.12) or pancreatitis (risk ratio 1.34, 95% CI 0.55 to 3.25), but there was an increase in cholecystitis (risk ratio 11.47, 95% CI 2.28 to 57.66). Inconsistencies in standard reporting and study design were noted e.g. adverse outcomes and lack of standardised comparator groups. RFA was estimated to cost £2,659 and produced 0.18 QALYs more than no RFA on average. With an ICER of £14,392/QALY, RFA was likely to be cost-effective at a threshold of £20,000/QALY. The source of the vast majority of decision uncertainty lay in the effect of RFA on stent patency.

Conclusions

Primary RFA is associated with increased survival and appears cost-effective. The evidence for the impact of secondary RFA on survival and of quality of life is limited. There was no increase in the risk of post-ERCP cholangitis or pancreatitis but increased risk of cholecystitis. High quality RCTs to investigate primary and secondary RFA are needed with accurate documentation of quality of life, adverse event rates and survival.

Context-Responsive Anticoagulation Reduces Complications in Pediatric Extracorporeal Membrane Oxygenation

Purpose: We sought to determine the impact of a comprehensive, context-responsive anticoagulation and transfusion guideline on bleeding and thrombotic complication rates and blood product utilization during extracorporeal membrane oxygenation (ECMO).

Design: Single-center, observational pre- and post-implementation cohort study.

Setting: Academic pediatric hospital.

Patients: Patients in the PICU, CICU, and NICU receiving ECMO support.

Interventions: Program-wide implementation of a context-responsive anticoagulation and transfusion guideline.

Measurements: Pre-implementation subjects consisted of all patients receiving ECMO between January 1 and December 31, 2012, and underwent retrospective chart review. Post-implementation subjects consisted of all ECMO patients between September 1, 2013, and December 31, 2014, and underwent prospective data collection. Data collection included standard demographic and admission data, ECMO technical specifications, non-ECMO therapies, coagulation parameters, and blood product administration. A novel grading scale was used to define hemorrhagic complications (major, intermediate, and minor) and major thromboembolic complications.

Main Results: Seventy-six ECMO patients were identified: 31 during the pre-implementation period and 45 in the post-implementation period. The overall observed mortality was 33% with no difference between groups. Compared to pre-implementation, the post-implementation group experienced fewer major hemorrhagic and major thrombotic complications and less severe hemorrhagic complications and received less RBC transfusion volume per kg.

Conclusions: Use of a context-responsive anticoagulation and transfusion guideline was associated with a reduction in hemorrhagic and thrombotic complications and reduced RBC transfusion requirements. Further evaluation of guideline content, compliance, performance, and sustainability is needed.

A systematic review of the complications of high-risk third molar removal and coronectomy: development of a decision tree model and preliminary health economic analysis to assist in treatment planning

Coronectomy is an alternative surgical technique for the management of high-risk third molars. It involves the removal of the crown of a tooth and the deliberate retention of the roots, thereby avoiding injury to the inferior alveolar nerve (IAN). Previous studies have suggested that it reduces the risk of nerve injury when compared with surgical extraction. The purpose of this study was to systematically review the incidence of complications following coronectomy such as IAN injury, pain, dry socket, infection, root migration, and need for re-operation. A comparative cost analysis of coronectomy and surgical extraction was done based on the results of the review. This provides an insight into the economic implications of the two procedures. A search through the MEDLINE database via Ovid, PubMed, Scopus, EMBASE via Ovid, and Web of Science, was carried out to extract randomised and non-randomised controlled trials. Four studies fulfilled the inclusion criteria. A meta-analysis was conducted to measure the overall effect of each outcome. The pooled odds ratio (OR) for IAN injury was 0.16 (95% CI 0.01 to 0.39). Coronectomy reduced this risk by 84%. Dry socket may occur less frequently following coronectomy whereas infection did not show a higher incidence with either intervention. Root migration was found to occur in 13%-85% of cases and the average incidence of re-operation was 2.2%. The ratio of the average costs was 1.12 favouring coronectomy if cone-beam computed tomography (CBCT) was not done prior to the procedure. If a scan was taken routinely for coronectomy, the cost ratio marginally favoured extraction. Coronectomy reduced the risk of nerve injury in high-risk third molars. Definitive conclusions, however, cannot be made for outcomes such as the need for re-operation, which may alter the cost ratio of coronectomy:extraction, as higher quality studies with longer follow-up are needed.

Primary Care Transformation

Primary care transformation will usher in a new era of advanced team-based care with extensive roles beyond the physician to build authentic healing relationships with patients. Smart technology will support these relationships, empower and engage patients, and build confidence that their health care team will take excellent care of them. Investments need to shift from catastrophic hospital-based care to proactive prevention and wellness, pushing us to think of health beyond health care. Systems need to build a culture of continuous improvement, supported by data-driven improvement science, and keep a sharp focus on the patient experience of care.

The Comparative Judgements of Generally and Specifically Gifted Children

Different groups of children were compared on sentence verification tasks. The children were either academically, musically or artistically gifted, and there were two forms of the task. In one, a picture was followed by a sentence, and in another, one sentence was followed by another. Subjects had to decide as quickly as possible whether or not the second proposition logically confirmed the first. In the picture-sentence condition results from all groups could be fitted to the constituent comparison model for sentence verification proposed by Carpenter and Just (1975). For the sentence-sentence condition, however, the observed results diverged from those predicted by the model. The results are explained in terms of different degrees of linguistic processing capacities of the subjects, and they demonstrate the importance which verbal-logical congruence has for children. Artistically able children had difficulties in processing subject/object incongruence in sentence pairs whereas musically able children had more problems in processing above/below incongruence.

The Spatial or Temporal Organization of Short-Term Memory

Children were shown three visually displayed digits. The digits were exposed successively in three windows in such a way, that the left-to-right order never corresponded with the temporal-sequential order. When asked to recall or recognize the digits, normal children responded in terms of temporal order. Deaf, autistic and some subnormal children, recalled or recognized the spatial, i.e. the left-to-right order. The relationship between hearing and/or speech and the temporal ordering of visual displays is discussed.

'Finishing up' on country: challenges and compromises

A core consideration in the care of Indigenous patients at the end of life is their place of death. Dying in community can be of paramount importance to Indigenous people. This paper reports the experiences of the Top End Palliative Care Service with respect to the barriers and solutions in the return of Indigenous patients to community for end-of-life care. These barriers include not only those associated with the significant distances and remoteness in the Northern Territory but, also, spiritual and cultural factors, which often influence healthcare delivery.

Cold atmospheric pressure plasma and decontamination. Can it contribute to preventing hospital-acquired infections?

Healthcare-associated infections (HCAIs) affect ∼4.5 million patients in Europe alone annually. With the ever-increasing number of 'multi-resistant' micro-organisms, alternative and more effective methods of environmental decontamination are being sought as an important component of infection prevention and control. One of these is the use of cold atmospheric pressure plasma (CAPP) systems with clinical applications in healthcare facilities. CAPPs have been shown to demonstrate antimicrobial, antifungal and antiviral properties and have been adopted for other uses in clinical medicine over the past decade. CAPPs vary in their physical and chemical nature depending on the plasma-generating mechanism (e.g. plasma jet, dielectric barrier discharge, etc.). CAPP systems produce a 'cocktail' of species including positive and negative ions, reactive atoms and molecules (e.g. atomic oxygen, ozone, superoxide and oxides of nitrogen), intense electric fields, and ultraviolet radiation (UV). The effects of these ions have been studied on micro-organisms, skin, blood, and DNA; thus, a range of possible applications of CAPPs has been identified, including surface decontamination, wound healing, biofilm removal, and even cancer therapy. Here we evaluate plasma devices, their applications, mode of action and their potential role specifically in combating HCAIs on clinical surfaces.

Clinical handover in acute psychiatric and community mental health settings

This study collected an area-wide snapshot of current handover practice in psychiatric settings which included acute care units and community mental health centres. The study was conducted in two stages. Firstly, a questionnaire was sent to all clinical mental health staff within an area-wide health service regarding normal handover procedures and processes. The second part of the study used non-participant observers to evaluate actual handovers in inpatient and community settings. Of the 1125 surveys distributed in stage one, 380 (34%) were returned completed. Of the 40 handovers observed in stage two in which 637 patients were discussed, 40% included at least one consultant psychiatrist or registrar as a participant. Almost all the handovers were completed face-to-face in a specific location with a set time and duration. Eighty-six per cent of respondents reported that deteriorating patients were escalated for rapid response. The results of the survey and structured observations support the issues emerging from the literature from medical, surgical and clinical team handovers. Additionally, the issue of identifiers for deterioration of a psychiatric patient emerged as an area worthy of further investigation and incorporation into clinical handover education and training for psychiatric services.

The determination of Miconazole and its related production impurities together with basic solution stability studies using a sub 2 μm chromatographic column

A selective and sensitive method for the analysis of Miconazole and its associated impurities is developed. The separation is carried out using a Thermo Scientific Hypersil Gold C18 Column (50 mm x 4.6 mm i.d., 1.9 µm particle size) with a mobile phase of acetonitrile-methanol-ammonium acetate (1.5 w/v) (30:32:38 v/v) at a flow rate of 2.5 mL/min and UV detection at 235 nm. The method is validated according to ICH guidelines with respect to precision, accuracy, linearity, specificity, robustness, and limits of detection and quantification. All parameters examined are found to be well within the stated guidelines. Naturally aged samples are also tested to determine sample stability. A profile of sample and impurity breakdown was presented. The analysis time was more than halved from just under 20 min (the current European Pharmacopeia Method) to under 8 min (developed method) and the method is applicable for assay and related substance determination.

Comparison in maternal body composition between Caucasian Irish and Indian women

The use of body mass index (BMI) for the diagnosis of obesity has limitations, especially when comparing ethnic groups with different body proportions. The aim of this prospective study was to compare maternal body composition in early pregnancy between Caucasian Irish and Indian women. A total of 81 Indian women and 81 Irish Caucasian women were matched for age, parity and BMI. Maternal weight and height were measured, and body composition analysed using bioelectrical impedance. The Irish women were taller and weighed more than the Indian women (p<0.001). At any given BMI, the Indian women had a higher total body fat percentage, visceral fat level and high fat percentage than the Irish women (p=0.024, 0.001 and 0.001, respectively). Our findings suggest that lower BMI cut-offs should be used for screening for gestational diabetes mellitus in Indian women attending our antenatal services.

Are women in early pregnancy following the national pyramid recommendations?

Appropriate nutrition in pregnancy is fundamental for maternal and fetal health, and the long-term physiological wellbeing of the offspring. We aimed to determine whether a sample of pregnant women met the national guidelines for healthy eating during pregnancy, and to examine if compliance differs when analysed by Body Mass Index (BMI) category. Subjects completed a 24-hr dietary recall, and had their BMI calculated. The mean age was 27.8 years. The mean BMI was 25.1 kg/m2, with 32 (31.7%) subjects overweight and 14 (13.9%) obese based on BMI category. Although the majority of subjects thought that they had a healthy diet, less than half met the recommended guidelines for each individual food group with achievement of the dairy group being particularly low. Achievement of food group recommendations was not influenced by BMI category. Public health messages on healthy eating guidelines need to be clearly communicated to pregnant women.

Development of a real time monitor and multivariate method for long term diagnostics of atmospheric pressure dielectric barrier discharges: application to He, He/N2, and He/O2 discharges

In this paper we present the development and application of a real time atmospheric pressure discharge monitoring diagnostic. The software based diagnostic is designed to extract latent electrical and optical information associated with the operation of an atmospheric pressure dielectric barrier discharge (APDBD) over long time scales. Given that little is known about long term temporal effects in such discharges, the diagnostic methodology is applied to the monitoring of an APDBD in helium and helium with both 0.1% nitrogen and 0.1% oxygen gas admixtures over periods of tens of minutes. Given the large datasets associated with the experiments, it is shown that this process is much expedited through the novel application of multivariate correlations between the electrical and optical parameters of the corresponding chemistries which, in turn, facilitates comparisons between each individual chemistry also. The results of these studies show that the electrical and optical parameters of the discharge in helium and upon the addition of gas admixtures evolve over time scales far longer than the gas residence time and have been compared to current modelling works. It is envisaged that the diagnostic together with the application of multivariate correlations will be applied to rapid system identification and prototyping in both experimental and industrial APDBD systems in the future.

Polycystic ovary syndrome and the peripheral blood white cell count

This retrospective cross-sectional study examined if the white cell count (WCC) is increased in women with polycystic ovary syndrome (PCOS) and if so, is it due to PCOS or to the associated obesity? Body mass index (BMI) was calculated and body composition was measured using bioelectrical impedance analysis. Of the 113 women studied, 36 had PCOS and 77 did not. The mean WCC was higher in the PCOS group compared with the non-PCOS group (8.9 × 10(9)/l vs 7.4 × 10(9)/l p = 0.002). This increase was due to a higher neutrophil count (5.6 × 10(9)/l vs 4.3 × 10(9)/l; p = 0.003). There was a leucocytosis (WCC >11 × 10(9)/l) present in 19% of the PCOS group compared with 1% in the non-PCOS group (p < 0.001). The neutrophil count was abnormally high (>7.7 × 10(9)/l) in 14% of the PCOS group compared with 4% in the non-PCOS group (p < 0.001). On regression analysis, however, the only independent variable which explained both the increased WCC and the increased neutrophil count was PCOS. We found that PCOS is associated with an increased WCC due to increased neutrophils, which supports the evidence that PCOS is associated with low-grade inflammation. The increase appears to be due to the underlying PCOS, and not to the increased adiposity associated with PCOS.

Looked after children in Dublin and their mental health needs

Children in care in Ireland have increased by 27% in the last decade. This population is recognized to be among the most vulnerable. This study aims to describe their placement histories, service use and mental health needs. Data was obtained on 174 children (56.5% of eligible sample) with a mean age of 10.83 (SD = 5.04). 114 (65.5%) were in care for three years or more. 29 (16.7%) did not have a SW and 49 (37.7%) had no GP 50 (28.7%) were attending CAMHS. Long term care, frequent placement changes and residential setting were significantly related with poorer outcomes and increased MH contact. Given the increase in numbers in care and the overall decrease in resource allocation to health and social care, individual care planning and prioritizing of resources are essential.

Epstein-Barr virus-associated hemophagocytic lymphohistiocytosis in adults characterized by high viral genome load within circulating natural killer cells

Epstein-Barr virus (EBV)-associated hemophagocytic lymphohistiocytosis (HLH) is a rare and aggressive disease usually encountered in the context of primary EBV infection. In most analyzed cases, EBV has been found predominantly in T cells. We describe the novel finding of high EBV genome numbers within circulating natural killer cells in adult patients with EBV-HLH.

Clinical practice recommendations for bipolar disorder

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of bipolar disorder in adults that are informative, easy to assimilate and facilitate clinical decision-making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. These preliminary recommendations underwent extensive consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for bipolar disorder (bipolar CPR) summarise evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of bipolar disorder. Further, the novel style and practical approach should promote their uptake and implementation.

Clinical practice recommendations for depression

OBJECTIVE

To provide clinically relevant evidence-based recommendations for the management of depression in adults that are informative, easy to assimilate and facilitate clinical decision making.

METHOD

A comprehensive literature review of over 500 articles was undertaken using electronic database search engines (e.g. MEDLINE, PsychINFO and Cochrane reviews). In addition articles, book chapters and other literature known to the authors were reviewed. The findings were then formulated into a set of recommendations that were developed by a multidisciplinary team of clinicians who routinely deal with mood disorders. The recommendations then underwent consultative review by a broader advisory panel that included experts in the field, clinical staff and patient representatives.

RESULTS

The clinical practice recommendations for depression (Depression CPR) summarize evidence-based treatments and provide a synopsis of recommendations relating to each phase of the illness. They are designed for clinical use and have therefore been presented succinctly in an innovative and engaging manner that is clear and informative.

CONCLUSION

These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and consideration of individual factors in the management of depression. Further, the novel style and practical approach should promote uptake and implementation.

Handheld Flyback driven coaxial dielectric barrier discharge: Development and characterization

The development of a handheld single and triple chamber atmospheric pressure coaxial dielectric barrier discharge driven by Flyback circuitry for helium and argon discharges is described. The Flyback uses external metal-oxide-semiconductor field-effect transistor power switching technology and the transformer operates in the continuous current mode to convert a continuous dc power of 10-33 W to generate a 1.2-1.6 kV 3.5 micros pulse. An argon discharge breakdown voltage of approximately 768 V is measured. With a 50 kHz, pulse repetition rate and an argon flow rate of 0.5-10 argon slm (slm denotes standard liters per minute), the electrical power density deposited in the volume discharge increases linearly at a rate of 75+/-20% mW/cm(3) per 1 slm of gas. Electrical power transfer efficiency between the secondary Flyback coil and the discharge volume increases from 0.1% to 0.65%. Neutral argon gas forced convection analysis yields a similar energy loss rate to the electrical discharge process. Optical emission spectroscopy studies of the expanding discharge plume into ambient air reveal that the air climatically controls the plume chemistry to produce an abundance of neutral argon atoms and molecular nitrogen.

Alcohol--how much is too much?

The aims of this study were to examine perceptions of what a sample of students and graduates consider an excessive alcohol intake to be and it's effect on their health. 115 University College Cork (UCC) students and 133 UCC graduates were questioned about their opinions of an acceptable weekly intake of alcohol. The results reveal dramatic changes in drinking habits over recent decades. Students began drinking earlier than graduates and are far more accepting of greater amounts of alcohol being consumed. The student's average opinion of what constituted an excessive weekly alcohol intake was 26.5 units of alcohol/week whereas the graduates felt over 18 units/week was too much. We concluded that even amongst these highly educated cohorts there is a low level of awareness of safe limits of alcohol consumption.

Inhibition of Testosterone-Induced Hyperplasia of the Prostate of Sprague-Dawley Rats by Pumpkin Seed Oil

The oil from the pumpkin (Cucurbita pepo) seed is claimed to be useful in the management of benign prostatic hyperplasia. This investigation seeks to examine the effect of pumpkin seed oil on testosterone-induced hyperplasia of the prostate of rats. Hyperplasia was induced by subcutaneous administration of testosterone (0.3 mg/100 g of body weight) for 20 days. Simultaneous oral administration of either pumpkin seed oil (2.0 and 4.0 mg/100 g of body weight) or corn oil (vehicle) was also given for 20 days. The weights of the rats were recorded weekly, and the influence of testosterone and pumpkin seed oil on the weight gain of the rats was examined. On day 21, rats were sacrificed, and the prostate was removed, cleaned, and weighed. The prostate size ratio (prostate weight/rat body weight) was then calculated. Neither testosterone nor pumpkin seed oil had any significant influence on the weight gain of the rats. Testosterone significantly increased prostate size ratio (P < .05), and this induced increase was inhibited in rats fed with pumpkin seed oil at 2.0 mg/100 g of body weight. The protective effect of pumpkin seed oil was significant at the higher pumpkin seed oil dose (P < .02). We conclude pumpkin seed oil can inhibit testosterone-induced hyperplasia of the prostate and therefore may be beneficial in the management of benign prostatic hyperplasia.

Prehospital activated charcoal: the way forward

OBJECTIVES

Single dose activated charcoal (SDAC) may be an effective method of gastric decontamination when administered to patients within an hour of drug overdose. However, few patients who may benefit from this treatment attend an emergency department within this timeframe. The authors sought to determine the current attitudes of ambulance NHS trusts to recent recommendations that the administration of SDAC should be considered as a prehospital therapy.

METHODS

A postal questionnaire was used to determine the current level of use of prehospital activated charcoal by ambulance NHS trusts, the incidence of associated complications, and barriers preventing the routine use of prehospital SDAC.

RESULTS

A completed questionnaire was returned by 36 of the 39 ambulance NHS trusts in the UK (response rate 92%). Currently none of the trusts that responded to the questionnaire provides prehospital SDAC as an intervention. The most common barriers to the provision of prehospital SDAC are the current lack of evidence in the medical literature proving it is effective in improving patient outcome and the lack of a recognised protocol for its administration. Other issues included concerns regarding potential complications, ambulance turnaround times, lack of availability of SDAC, and lack of funding.

CONCLUSIONS

A lack of published evidence proving efficacy remains the most important factor in preventing the routine administration of SDAC to appropriate patients in the prehospital environment. Further research in this setting is required to determine the usefulness of this therapy.

Making an IMPACT on emergency department flow: improving patient processing assisted by consultant at triage

OBJECTIVES

To assess whether initial patient consult by senior clinicians reduces numbers of patients waiting to be seen as an indirect measure of waiting time throughout the emergency department (ED).

METHODS

An emergency medicine consultant and a senior ED nurse (G or F grade), known as the IMPACT team, staffed the triage area for four periods of four hours per week, Monday to Friday between 9 am to 5 pm for three months between December 2001 and February 2002 when staffing levels permitted. Patients normally triaged by a nurse in this area instead had an early consultation with the IMPACT team. Data were collected prospectively on all patients seen by the IMPACT team. The number of patients waiting to be seen (for triage, in majors and in minors) was assessed every two hours during the IMPACT sessions and at corresponding times when no IMPACT team was operational.

RESULTS

There was an overall reduction in the number of patients waiting to be seen in the department from 18.3 to 5.5 (p<0.0001) at formal two hourly assessments. The largest difference was seen in minors. Of the patients seen at triage by the IMPACT team, 48.9% were discharged home immediately after assessment and treatment. With the IMPACT team present, no patient waited more than four hours for initial clinical consult.

CONCLUSIONS

By using a senior clinical team for initial patient consultation, the numbers of patients waiting fell dramatically throughout the ED. Many patients can be effectively treated and discharged after initial consult by the IMPACT team.

Hepatocellular damage from non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for the management of rheumatological disorders, and as analgesics and antipyretics. Hepatotoxicity is an uncommon, but potentially lethal complication, which usually occurs within 12 weeks of starting therapy. It can occur with all NSAIDs, but appears to be more common with diclofenac and particularly sulindac. Female patients aged >50 years, with autoimmune disease, and those on other potentially hepatotoxic drugs, appear to be particularly susceptible. Liver function test abnormalities generally settle within 4-6 weeks of stopping the causative drug. However, some patients may develop acute liver failure and successful orthotopic liver transplantation may be undertaken in such patients. Recent in vitro animal studies have shown that the mechanism of diclofenac toxicity relates both to impairment of ATP synthesis by mitochondria, and to production of active metabolites, particularly n,5-dihydroxydiclofenac, which causes direct cytotoxicity. Mitochondrial permeability transition (MPT) has also been shown to be important in diclofenac-induced liver injury, resulting in generation of reactive oxygen species, mitochondrial swelling and oxidation of NADP and protein thiols. Physicians and hepatologists must be vigilant to the hepatotoxic potential of any NSAID, as increased awareness, surveillance and reporting of these events will lead to a better understanding of the risk factors and the pathophysiology of NSAID-related hepatotoxicity.

Accident and emergency medicine--still a useful 'apprenticeship'?

The objective of this study was to compare the expressed confidence of senior house officers (SHOs) at performing practical medical procedures before and after working in an accident and emergency (A&E) post. The extent of formal teaching of these skills and opportunity for independent performance of them was also assessed. A postal questionnaire was sent to all SHOs completing an A&E post in the Trent region of the United Kingdom. Doctors were asked to grade their subjective confidence at performing listed practical skills before and after working in A&E. Eighty-four replies from 120 questionnaires were received (70% response rate). There was a significant improvement in confidence ( <0.0001) for all the skills studied after working in A&E. The proportion of doctors who received instruction varied for each of the skills. The expressed confidence of SHOs in performing practical procedures improved dramatically after working in A&E. Although remaining a valuable 'apprenticeship' for junior doctors, structured training is inadequate in the accident and emergency SHO post.

The efficacy and safety of nutritional supplement use in a representative sample of adults in the North/South Ireland Food Consumption Survey

OBJECTIVE

To describe the current use of nutritional supplements and their contribution to micronutrient intakes in a representative sample of Irish adults, to evaluate the impact of supplement use on the adequacy of micronutrient intakes and to assess the risk to supplement users of exceeding tolerable upper intake levels (UL).

STUDY DESIGN AND SUBJECTS

Food intake data were collected in 1379 (662 male and 717 female) randomly selected Irish adults aged 18 to 64 years using a 7-day food diary. The current use of nutritional supplements was assessed using a self-administered questionnaire and respondents entered each supplement as it was consumed into the food diary.

RESULTS

Twenty-three per cent of respondents regularly used nutritional supplements. Twice as many women used supplements as men. The intakes of micronutrients were significantly higher (P<0.001) in supplement users than in non-users. Micronutrient intakes from food sources were similar in male users and non-users of supplements, but were significantly higher (P<0.01) in female users, by 3 to 13%, for Fe, Mg, Mn, vitamins C and E and niacin than in non-users. The percentage of female users between 18 and 50 years who had mean Fe intakes below the average requirement (AR) (10 mg) decreased from 50 to 25 when the contribution from supplements was included. The use of supplements reduced the percentage of men who had mean intakes below the AR for Zn from 19 to 13, for riboflavin from 14 to 6 and for vitamin A from 20 to 5, and reduced the percentage of women with intakes below the AR for Ca from 23 to 16 and for riboflavin from 23 to 14. Twenty-one women out of 80 aged between 18 and 50 years, who consumed supplemental folate, achieved the intake of 600 microg recommended to prevent neural tube defects. Twenty-two per cent of the women who took iron and 15% of the women who took vitamin B6 in supplemental form had mean daily intakes that exceeded that UL for these nutrients. Supplement users did not exceed the UL for the other micronutrients.

CONCLUSIONS

Supplementation appears to be beneficial in promoting adequate intakes of some micronutrients, particularly Fe and folate in women aged 18-50 years and vitamin A in men. There appears to be little risk to supplement users of experiencing adverse side effects due to excessive intakes of micronutrients.

Low risk of central venous thrombosis with nontunnelled central venous catheters

142 noncuffed, nontunnelled, single lumen central venous catheters were inserted in 103 patients with haematological malignancy. Insertion related complications were minimal and no symptomatic catheter-related central venous thrombosis occurred. Nontunnelled central venous catheters are an excellent alternative to the more commonly used tunnelled devices in terms of convenience, cost-effectiveness and low incidence of side effects.