What matters to families about the healthcare of preterm or low birth weight infants

Introduction

Preterm and low birth weight (LBW) infants have complex long-term healthcare needs. The impact on families of caring for a sick infant is increasingly understood, with consequences for attachment and bonding and parental health and wellbeing immediately after birth and beyond. In this qualitative evidence synthesis, we aimed to understand what matters to families about the care provided to preterm or LBW infants in hospital and the community.

Methods

We searched nine databases and the reference lists of included studies for eligible studies using qualitative methods examining the views of families on healthcare for preterm or LBW infants. We used the Critical Appraisal Skills Programme checklist for qualitative studies to assess study quality and the GRADE-CERQual approach to assess confidence in each review finding. Studies were sampled after data saturation, and thematic synthesis techniques were used for analysis.

Results

203 studies were eligible for inclusion. We selected 49 studies from 25 countries for the analysis, based on methodological quality, data richness and on ensuring representation from settings with varying resources. Eight analytical themes were identified. Confidence in most results was moderate to high. What mattered to carers was a positive outcome for the child; active involvement in care; support to cope at home after discharge; emotional support for the family; the healthcare environment; their information needs were met; logistical support was available; and positive relationships with staff.

Conclusions

Enabling a positive post-natal period for families of small and sick infants is difficult. Experiences of care for preterm or LBW infants vary, but we found high consistency in what matters to families. This information can be used to shape global recommendations on support for infants and carers. More research is needed on what matters to parents who receive community-based care, especially in low resource settings.

Key messages

• We found high consistency across settings in what matters to families in the care of preterm infants.

• Understanding carers views and values ensures that care can be planned to meet the needs of infants and families.

AB0393 SURVIVAL ON JANUS KINASE INHIBITORS VERSUS OTHER ADVANCED THERAPIES IN RHEUMATOID ARTHRITIS

Background

Four Janus Kinase inhibitors (JAKi) are licensed in the UK for treating rheumatoid arthritis (Upadacitinib, Tofacitinib, Filgotinib and Baricitinib). Several analyses have examined the survival in these groups of drugs and found them more likely to be tolerated more or equivalently than other modes of action. Recent data suggested an age influence on survival on these drugs.

Objectives

To study the overall survival rates of JAKi compared to the other biologic treatments in a single centre cohort.

Methods

We analysed patients commencing advanced treatments (anti-Tumour necrosis factor, Interleukin 6 blocker, Rituximab and Abatacept) between February 2011 and October 2021. Variables examined included gender and age. The time on drug was compared between JAKi and other treatments using student’s T test. Chi squared test was used to compare categorical variables. A Cox regression model was fitted to compare length of stay on each agent JAKi length of stay was compared to length of stay on other agents combined.

Results

592 patients were included in the analysis. 168 (28%) were started on JAKi. 435 (73.48%) were females. Mean age at drug start was 60.6 years (SD 13.5). The numbers on drug were Filgotinib n=10, Tofacitinib n=35, Upadacitinib n=37, Baricitinib n=86, Adalimumab n=211, Abatacept n=36, Certolizumab n=18, Etanercept n=112, Golimumab n=21 and Tocilizumab n=26. 93 (15.7%) discontinued their drug, mostly due to lack of efficacy. Mean number of days on any biologic treatment was 918.9 (SD 711.5). Patients on JAKi had a significantly shorter survival on drug 652.7 days vs 1024.4 days (P<0.001).

There were no significant differences in age and gender between the groups. Univariate regression showed a hazard ratio of 1.19 (95%CI 0.75,1.98). This remained non-significant after adjusting for age and gender (1.18 95%CI 0.71,1.95). The only predictor of stoppage was age (HR 1.03 95%CI 1.01,1.04).

Conclusion

In this relatively large observational study, there was no difference in predictors of stoppage between JAKi and other advanced therapies. Increasing age was found to be a predictor for stoppage. This is in line with other reports in the literature. Further work looking at the impact of serology and disease activity will be performed.

Disclosure of Interests

Nauman Bakhtiar: None declared, Leanne Gray: None declared, Syed Mujtaba Bilgrami Grant/research support from: Grants for BSR & EULAR Conferences in the past., Lesley Ottewell: None declared, Fiona Wood: None declared, Marwan Bukhari Speakers bureau: Bristol-Myers Squib, UCB celltech, Roche/Chugai, Pfizer, Abbvie, Merck, Mennarini, Sanofi-aventis, Eli-Lilly, Janssen, Amgen, Novartis and Gilead

Development of a core outcome set for the evaluation of interventions to enhance trial participation decisions on behalf of adults who lack capacity to consent: a mixed methods study (COnSiDER Study)

BACKGROUND

Trials involving adults who lack capacity to provide consent rely on proxy or surrogate decision-makers, usually a family member, to make decisions about participation. Interventions to enhance proxy decisions about trial participation are now being developed. However, a lack of standardised outcome measures limits evaluation of these interventions. The aim of this study was to establish an agreed standardised core outcome set (COS) for use when evaluating interventions to improve proxy decisions about trial participation.

METHODS

We used established methods to develop the COS including a consensus study with key stakeholder groups comprising those who will use the COS in research (researchers and healthcare professionals) and patients or their representatives. Following a scoping review to identify candidate items, we used a modified two-round Delphi survey to achieve consensus on core outcomes, with equivocal items taken to a consensus meeting for discussion. The COS was finalised following an online consensus meeting in October 2020.

RESULTS

A total of 28 UK stakeholders (5 researchers, 10 trialists, 3 patient/family representatives, 7 recruiters and 3 advisors/approvers) participated in the online Delphi survey to rank candidate items from the scoping review (n = 36) and additional items proposed by participants (n = 1). Items were broadly grouped into three categories: how family members make decisions, their experiences of making decisions, and the personal aspects that influence the decision. Following the Delphi survey, 27 items were included and ten items exhibited no consensus which required discussion at the consensus meeting. Sixteen participants attended the meeting, including additional patient/family representatives invited to increase representation from this key group (n = 2). We reached consensus for the inclusion of 28 outcome items, including one selected at the consensus meeting.

CONCLUSIONS

The study identified outcomes that should be measured as a minimum in all evaluations of interventions to enhance proxy decisions about trials. These relate to the process of decision-making, proxies' experience of decision-making, and factors that influence decision-making such as understanding. Further work with people with impairing conditions and their families is needed to explore their views about the COS and to identify appropriate outcome measures and timing of measurement.

TRIAL REGISTRATION

The study is registered on the COMET database ( https://www.comet-initiative.org/Studies/Details/1409 ).

1113 Surgical Innovators or Spin Doctors: Reporting of Expectations for Robotic Gastrointestinal Surgery

Introduction

The use of robotics in gastrointestinal surgery is an increasingly popular area of surgical innovation. Despite uncertainty regarding clinical benefits, gastrointestinal surgery centres continue to introduce robotic services. This may be motivated by perceived benefits, in lieu of substantial empirical benefits. We aimed to summarise the expected advantages and disadvantages of robotic techniques in gastrointestinal surgery, as reported by study authors.

Method

A systematic review was undertaken by the trainee led RoboSurg Collaborative. Searches were conducted on of Embase, Medline, the Cochrane Library and Web of Science. Articles were double screened by abstract, then full text. All primary studies reporting outcomes following robotic cholecystectomy or oesophagectomy were included. Reports of expected benefits and disadvantages or robotic techniques were extracted verbatim, and summarised using descriptive statistics.

Results

We included 192 studies. An expected benefit was reported in 161 (84%). Of those, 127 (79%) expected robotics to have an intra-operative advantage, such as reduced operative time, improved dexterity and improved visualisation. Post-operative benefits, such as reduced recovery time and shorter length of hospital stay, were expected in 72 (45%). Expected disadvantages were reported in 96 (50%) of the included studies. Of those, 74 (77%) expected robotics to have intra-operative disadvantages such as increased operative times and lack of tactile feedback. Increased cost was another commonly expected limitation.

Conclusions

Study authors reported perceived benefits more frequently than disadvantages. Perceived benefits were more commonly advantageous to the surgeon rather than the patient. There were directly conflicting perceptions of how robotic techniques affect operative times.

P97 Protocol for a Systematic Review of Robotic Anti-reflux surgery to Examine Reporting of an Innovative Procedure: The RoboSurg Study

Background

Innovation in surgery is growing. The rigour of reporting of innovation must therefore be examined to ensure evaluations are thorough and transparent. The Idea, Development, Exploration, Assessmemt, Long-term follow-up (IDEAL) framework was developed in 2009 to help researchers evaluate innovative procedures. However, it is not known whether the IDEAL principles have been adopted into the reporting of robotic surgery. The aim of this study is to identify and summarise published literature for robotically assisted anti-reflux surgery, to understand whether evaluations are being performed in a robust way.

Methods

Systematic literature searches were undertaken to identify studies relating to robotic anti-reflux surgery. All primary research studies pertaining to robotically-assisted surgery for adults with symptomatic gastro-oesophageal reflux disease were included. Studies examining multiple interventions, where the outcomes could not be separated, were excluded. Data will be doubly extracted using tailored online forms. Data extraction themes include: study characteristics, technique description and evolution, governance/ethical factors and outcome reporting. Data will be synthesised into tables and summarised in a narrative synthesis. A meta-analysis will not be performed as we aim to examine reporting, rather than the efficacy of robotically-assisted anti-reflux surgery.

Results

824 abstracts were identified, of which 80 were included for full text review. Summarised data will be used to propose a standard of reporting which will inform future work in the field.

Conclusion

The findings will feed in to the other six arms of RoboSurg to examine reporting in robotic upper gastrointestinal surgery more generally.

THU0205 RESPONSE TO SMALL MOLECULES IS MOSTLY DRIVEN BY PATIENT GLOBAL ASSESSMENT OF DISEASE: A REAL WORLD OBSERVATION

Background:

Two Small molecules (Tofacitinib and Baricitinib) have been licensed in the UK for the use in rheumatoid arthritis. Their licensing came from several studies that showed good efficacy with baricitinib (1) study showing superior efficacy to adalimumab and tofacitinib showing non inferiority to TNF drugs (2). The response has also been shown in patient reported outcomes (find reference). Response when measure using the DAS score has two relatively subjective components (tender joints and patient global assessment) and two relatively objective components (Swollen joints and inflammatory markers)

Objectives:

To determine in a real world setting if the response to small molecules is mostly due to a drop in subjective or objective components of the DAS score

Methods:

A retrospective chart review was done on all new starters on small molecules in a district hospital in the North of England. Data were collected at baseline, three months and six months from October 2018 to date. Drop in the components of the DAS28 score was calculated and overall drop in DAS28 was modelled as the explanatory variable using linear regression modelling. This was the done Adjusting for age gender and duration of disease. Sensitivity of the model was examined using a logistic model of EULAR moderate/good response and using adjusted R squared estimates for linear model of improvement of the DAS28 score.

Results:

76 patients were included in the analysis from 85 starters on small molecules.61 (71.8 %) were on baricitinib and the baseline median DAS28 score was .5.97 (IQR 5.35,6.55)The median drop at three months in the DAS28 score was 2.42 (IQR 1.33,3.31). and at six months was 2.77 (IQR 2.01,3.83). There was numerical relative increased efficacy of baricitinib but this was not statistically significant (DAS drop at three months 2.54 IQR 1.73,3.09 vs 2.12 IQR 1.51,3.5). The relative contribution of the individual components of the DAS score to the drop ae in DAS are shown in table 1 below. Sensitivity analysis looking at predictors of a DAS drop of >0.6 confirmed this finding.

Table 1.

Results of the adjusted linear regression models.

Component of DAS dropping at three monthsAdjusted R squared at 3 monthsAdjusted R squared at six monthsSwollen Joints0.120.05Tender Joints0.280.18Patient global assessment0.310.48Erythrocyte sedimentation rate0.040.17

Conclusion:

In this real world observational study, there was a good response to both small molecules with numerical better response to baricitinib. Tender joint count and patient global response accounted for more of the drop in DAS28 than swollen joints and inflammatory markers. At six months the biggest contributor to response was patient global assessment. This shows that JAK inhibitors might mediate their response initially mostly through pain modulation then by inflammation as exposure to drug continues.

References:

[1]N Engl J Med. 2017 Feb 16;376(7):652-662

[2]N Engl J Med. 2014 Jun 19;370(25):2377-86

Disclosure of Interests: :

Clerin Joseph: None declared, Syed Mujtaba Bilgrami Speakers bureau: Pfizer, Lesley Ottewell: None declared, Leanne Gray: None declared, William Mitchell: None declared, Fiona Wood: None declared, Marco Massarotti: None declared, Marwan Bukhari Speakers bureau: Bristol-Myers Squib, UCB celltech, Roche/Chugai, Pfizer, Abbvie, Merck, Mennarini, Sanofi-aventis, Eli-Lilly, Janssen, Amgen and Novartis.

General dental practitioners' perceptions of antimicrobial use and resistance: a qualitative interview study

BACKGROUND

Dentists are responsible for 9-10% of all antibiotics dispensed in primary care in the UK, many of which may be provided contrary to clinical guidelines. Since antibiotic consumption has been identified as a major cause of antibiotic resistance, dental prescribing may be a significant contributor to this important public health problem.Objective This study aims to explore general dental practitioners' (GDPs) perceptions and attitudes towards antibiotic use and resistance.

METHOD

Qualitative interview study with 19 purposively sampled GDPs working in Wales. A set of open-ended questions were developed and amended during semi-structured telephone interviews. Interviews were recorded, transcribed verbatim and codes were developed using thematic analysis.

RESULTS

Perceptions of antibiotic use and resistance varied widely between practitioners, particularly with respect to the prevalence and impact of resistant strains on the management of dentoalveolar infection, and the impact of dental prescribing on the emergence of resistance. GDPs reported that their antibiotic prescribing decisions were driven by both clinical pressures and wider public health considerations.

CONCLUSIONS

Interventions to enhance the quality of antibiotic prescribing in primary care dentistry should address issues associated with inappropriate prescribing as well as providing education about the causes, prevalence and impact of antibiotic resistance.

'You are just left to get on with it': qualitative study of patient and carer experiences of the transition to secondary progressive multiple sclerosis

OBJECTIVES

Although the transition to secondary progressive multiple sclerosis (SPMS) is known to be a period of uncertainty for clinicians, who may find progressive disease challenging to objectively identify, little research has explored the experiences of patients and carers specifically during this transition period. Our objective was to explore what patients and their carers understand about their disease stage and describe their experiences and perspectives on the transition to SPMS.

DESIGN

Semistructured qualitative interviews and subsequent validation focus groups were analysed using inductive thematic analysis.

SETTING

South East Wales, UK.

PARTICIPANTS

20 patients with MS and 13 carers were interviewed. Eight patients and two carers participated in focus groups.

RESULTS

Four main themes around disease progression were identified. 'Realisation' describes how patients came to understand they had SPMS while 'reaction' describes their response to this realisation. The 'realities' of living with SPMS, including dealing with the healthcare system during this period, were described along with 'future challenges' envisaged by patients and carers.

CONCLUSIONS

Awareness that the transition to SPMS has occurred, and subsequent emotional reactions and coping strategies, varied widely between patients and their carers. The process of diagnosing the transition was often not transparent and some individuals wanted information to help them understand what the transition to SPMS meant for them.

Is the BTS/SIGN guideline confusing? A retrospective database analysis of asthma therapy

Background:

The British guideline on the management of asthma produced by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) describes five steps for the management of chronic asthma. Combination therapy of a long-acting β₂-agonist (LABA) and an inhaled corticosteroid (ICS) is recommended as first-line therapy at step 3, although the dose of ICS at which to add a LABA is subject to debate.

Aims:

To classify the inhaled therapy prescribed to patients with asthma in NHS Forth Valley according to two interpretations of the BTS/SIGN guideline and to evaluate the use of combination therapy in this population.

Methods:

A retrospective analysis including patients from 46 general practitioner surgeries was conducted. Patients with physician-diagnosed asthma were classified according to the BTS/SIGN guideline based on treatment prescribed during 2008. Patient characteristics were evaluated for the overall step classification, and specifically for therapy in step 3.

Results:

12,319 patients were included. Guideline interpretation resulted in a shift of 9.2% of patients (receiving medium-dose ICS alone) between steps 2 and 3. The largest proportion of patients (32.3%) was classified at step 4. Age, sex, smoking status, chronic obstructive pulmonary disease co-morbidity, and utilisation of short-acting β₂-agonists and oral corticosteroids all correlated with step; however, no differences in these characteristics were evident between low-dose combination therapy and medium-dose ICS alone at step 3.

Conclusions:

Further studies are needed to evaluate prescribing decisions in asthma. Guideline recommendations regarding the use of ICS dose escalation versus combination therapy need to be clarified relative to the published evidence.

Changes to inhaled corticosteroid dose when initiating combination inhaler therapy in long-acting β agonist-naïve patients with asthma: a retrospective database analysis

Retrospective prescribing data were obtained from 46 general practice surgeries in NHS Scotland. Patients with asthma who were naïve to previous long-acting β agonist therapy and initiated combination inhaler therapy in 2008-2009 were classified according to the inhaled corticosteroid (ICS) dose in their combination inhaler compared with the highest dose of ICS they received before initiation. Among the 685 patients (541 (79.0%) who had been prescribed an ICS previously), those originally on low-, medium- or high-dose ICS were changed to high-dose combination therapy in 122/250 (48.8%), 94/151 (62.3%) or 85/113 (75.2%) cases in each ICS dose category, respectively. These results suggest that evaluation of appropriate high-dose ICS prescribing in general practice is needed.

The patient with acute muscular weakness

Proximal muscle weakness can present acutely or subacutely to the Acute Medical Unit. Early diagnosis of the underlying pathology is essential due to life threatening complications such as respiratory failure and cardiac disturbances as well as causing significant levels of disability. The diagnosis requires thorough history-taking and examination to discern evidence of true weakness, assess its onset, distribution and severity followed by extensive investigations including a CK level, which if high should raise suspicion of rhabdomyolysis. Assessment of respiratory function should be done promptly to identify patients with associated respiratory muscle weakness and treatment should not be delayed waiting for definitive and confirmatory investigations. Poor response to treatment is unusual when diagnosis is correct; this raises the possibility of an alternative diagnosis.

Ophthalmic manifestation of Candida: case report and review of the literature

Candidemia in the pediatric burn population poses a management dilemma due to the paucity of good clinical data to guide treatment decisions. Whilst candidemia is less common than bacteremia in pediatric burns patients, it is associated with significant morbidity and mortality. We report a case of candidemia in an infant with 40% burns with ophthalmic complications secondary to nappy rash. We review the investigation and management of ocular candidemia.

Use of the Internet by burns patients, their families and friends

INTRODUCTION

The Internet has also become an increasingly important source of health-related information. However, with this exponential increase comes the problem that although the volume of information is huge, the quality, accuracy and completeness of the information are questionable, not only in the field of medicine. Previous studies of single medical conditions have suggested that web-based health information has limitations. The aim of this study was to evaluate Internet usage among burned patients and the people accompanying them to the outpatient clinic.

METHODS

A customised questionnaire was created and distributed to all patients and accompanying persons in the adult and paediatric burns clinics. This investigated computer usage, Internet access, usefulness of Internet search and topics searched.

RESULTS

Two hundred and ten people completed the questionnaire, a response rate of 83%. Sixty three percent of responders were patients, parents 21.9%, spouses 3.3%, siblings, children and friends the remaining 10.8%. Seventy seven percent of attendees had been injured within the last year, 11% between 1 and 5 years previously, and 12% more than 5 years previously. Seventy four percent had computer and Internet access. Twelve percent had performed a search. Topics searched included skin grafts, scarring and scar management treatments such as pressure garments, silicone gel and massage.

DISCUSSION

This study has shown that computer and Internet access is high, however a very small number actually used the Internet to access further medical information. Patients with longer standing injuries were more likely to access the Internet. Parents of burned children were more frequent Internet users. As more burn units develop their own web sites with information for patients and healthcare providers, it is important to inform patients, family members and friends that such a resource exists. By offering such a service patients are provided with accurate, reliable and easily accessible information which is appropriate to their needs.

Development of a national burn network: providing a co-ordinated response to a burn mass casualty disaster within the Australian health system

With the threat of terrorist activity ever present since the incidents in Bali and Jakarta, the Australian health system must be prepared to manage another mass burn casualty disaster. The Australian and New Zealand Burns Association (ANZBA) highlighted the lack of a national burn disaster response before the 2000 Olympics. With the limited number of burn beds available and the protracted length of stay after such injuries, any state or territory could be overwhelmed with relatively few patient admissions. In 2002, the Australian Health Minister's Conference called for a solution. The objective of this paper is to provide an overview of the process and development of the Australian National Burn Network, which underpins the National Burn Disaster Response (AUSBURNPLAN).

Knowledge and expectations of women undergoing cancer genetic risk assessment: a qualitative analysis of free-text questionnaire comments

Individuals undergoing cancer genetic risk assessment have been found to have a poor understanding of the process, which may affect how well they cope with learning their risk. This paper reports free-text data from questionnaires completed by women undergoing a randomised controlled trial of a psychological intervention. Of the 268 women undergoing genetic assessment for familial breast/ovarian cancer risk who were invited to take part in the trial, 157 women returned research questionnaires. Of these, 97 women provided free-text comments upon referral to a cancer genetics clinic, 62 provided comments whilst waiting for risk information (average, moderate or high), and 36 women provided comments following notification of risk. This paper reports a thematic analysis of the free-text data. Themes reflected individuals' poor knowledge and uncertainty about genetic risk assessment. How well individuals responded to learning their risk depended upon whether expectations had been met. Regardless of risk, individuals undergoing cancer genetic risk assessment are likely to benefit from increased information about its process and timescales, and access to increased psychological support. Free-text comments can provide valuable data about individuals' expectations and knowledge of genetics services.

Automatic spike sorting for neural decoding

While various automated spike sorting techniques have been developed, their impact on neural decoding has not been investigated. In this paper we extend previous Gaussian mixture models and expectation maximization (EM) techniques for automatic spike sorting. We suggest that good initialization of EM is critical and can be achieved via spectral clustering. To account for noise we extend the mixture model to include a uniform outlier process. Automatically determining the number of neurons recorded per electrode is a challenging problem which we solve using a greedy optimization algorithm that selects models with different numbers of neurons according to their decoding accuracy. We focus on data recorded from motor cortex and evaluate performance with respect to the decoding of hand kinematics from firing rates. We found that spike trains obtained by our automated technique result in more accurate neural decoding than those obtained by human experts.

First response, rehabilitation, and outcomes of hand and upper limb function: survivors of the bali bombing disaster. A case series report

In October 2002, two bombs exploded in Bali injuring hundreds, and killing 202 people. The purpose of this paper is to report the organization of the first response, rehabilitation strategies, and outcome of a series of patients evacuated to the Royal Perth Hospital (RPH), a civilian hospital in Australia. The initial medical response in Bali was primarily conducted by holidaying health professionals supporting the hospital on the island. The Australian Defence Force was primarily responsible for the ongoing acute clinical management during the evacuation and repatriation of survivors to all major burn units in Australia. At the RPH, hospital adaptations included novel staffing and treatment strategies to sustain a team effort beyond the acute phase of the disaster to manage the surge of 28 patients (15% of yearly admissions) in 7 days. Data collected were related to service delivery and patient outcomes (shoulder active range of motion, grip strength, and the Burns Specific Health Scale). Data were compared to baseline, similar data collected during normal practice and population norms. Bali patients received 3.2% more therapy treatment sessions and 6.8% less contact hours than usual protocols. Shoulder AROM recovered to normal limits by 3 months postdischarge. Grip strength for women was shown to reach population norms by 1 month after discharge and by 6 months for males. Self-rated physical recovery exceeded major burn population norms at 6 months postdischarge. Physical therapy outcome measures demonstrated upper limb recovery as usual in the Bali group, despite a mass casualty situation. To achieve this required support from the multidisciplinary team, in combination with community, government, and hospital administrative assistance.

Burns first aid information on the Internet

The Internet is an increasingly important source of health-related information. However, the growth of the Internet and its use as a medical delivery tool should be viewed with caution. One of the key concerns is that although the volume of information is huge, the quality, accuracy and completeness of the information is questionable. The aim of this study was to evaluate burns first aid information on the Internet. The search term used was "first aid for burns" and the first 25 hits from each search engine were analysed by one of the observers. We gathered basic information on the web sites--such as the country of origin, language in which the information was offered, accessibility, relevance and whether the site was commercial, organisational or academic. Quality and technicality of the web sites were assessed and scored. The mean quality score was 4.7/15 (31.5%) The mean technical score was 6.1 of 12 (51.1%). When the total score was categorised by percentage, none of the web sites ranked in the excellent category, 1 was very good, 4 were good, 6 were fair and the majority, 36, were poor. Based on the quality score only, two web sites were in the excellent category and two were very good. For technicality one web site was excellent and three were very good. This study has shown first aid information on the Internet is largely of poor quality, that the technical information provided is inadequate and that the sites include a significant amount of grossly inaccurate information. The few sites that contain excellent technical information make up a very small proportion of what is available. Therefore, the average Internet user may not encounter these resources, instead gaining knowledge from sites of questionable value.

Infection in acute burn wounds following the Bali bombings: a comparative prospective audit

INTRODUCTION

Bacterial colonisation and invasive bacterial infection remain the major causes of mortality and morbidity following severe burn thus ongoing surveillance of patients and monitoring of infection facilitates early intervention to minimise the risk of sepsis. The circumstances of the Bali bombings in October 2002, provided an opportunity to analyse the ramifications of lengthy transfer times, delayed resuscitation and topical treatment, on the primary incidence of burn wound infection (BWI).

METHOD

This prospective clinical audit investigated the primary incidence of BWI between the usual burn patients admitted to the Burn Unit at Royal Perth Hospital, Western Australia, and a number of survivors from the Bali bombings during a 3-month audit period in 2002. BWI was identified using the Peck et al. proposed definitions for the surveillance of burn wound infections. These include impetigo, surgical wound related infection, cellulitis and invasive infection of unexcised wounds.

RESULTS

The incidence of primary BWI in the Bali-tourist group (68.2%) compared with the standard WA group (18.2%) was significant (p=0.001).

CONCLUSION

Sensitive assessment criteria allowed for early identification of wound infection. A clinically significant difference in the Bali-tourist group is probably related to the circumstances of their injury.

A partnership in burn care education - Nepal and australia

This paper describes some of the issues related to an education partnership which has been developed over the last four years between the Royal Perth Hospital Burn Team in Australia and the Bir Hospital Burn Team in Kathmandu, Nepal. The paper provides an insight into the preparation and collaboration required from both teams and describes some practical ideas to assist those who may be considering educating others in a developing burn service outside their catchment area.

Burn first aid in Western Australia—Do healthcare workers have the knowledge?

Burn injuries treated with adequate immediate first aid are associated with more favourable outcomes, limiting tissue damage and subsequent morbidity including the need for surgery. Cool running water at a temperature of between 10-15 degrees C for 20 to 30 minutes is considered adequate burn first aid treatment. A prospective audit of all new patients (n=227) with burns, attending the minor burn facility at Royal Perth Hospital showed only 88 (39%) patients received appropriate first aid. Fifty percent of patients receiving inappropriate first aid, had this delivered by his or her primary health care contact. This study aims to determine the knowledge of burns first aid among healthcare workers (HCW) and compare this to the general population. A customized survey was performed, four sample cases were included with 4 possible answers in a multiple choice format. All case studies asked the participant to record immediate first aid management. On a case by case basis, burn first aid knowledge was fair but overall knowledge very poor, only 18.8% of respondents achieving 4 correct responses. The uptake of first aid courses was high among HCW at 75% but particularly low among the NHCW at 28%. Our study has shown the value of performing such a course, with a statistically significant (p=0.00) difference between participants who had completed a first aid course and those that had not. The purpose of this study was to quantify knowledge of burns first aid with a view to providing directed education, studies have shown the success of multimedia campaigns. It has been shown that good first aid improves the outcome for the burn patient and this study demonstrates that participation in a first aid course improves knowledge. It is justifiable to progress toward compulsory first aid courses which include first aid of the burns patient to improve outcomes for the community as a whole.

Minor burn injuries in adults presenting to the regional burns unit in Western Australia: A prospective descriptive study

INTRODUCTION

Western Australia is the largest state in Australia, accounting for approximately one third of the Australian continent. The adult Burns Unit in Western Australia is at Royal Perth Hospital, which provides for the whole adult population of approximately 1.8 million, 80% of which live in and around the state capital city, Perth (approx. 1.4 million). The unit also offers a minor burn care facility.

METHODS

The aim of this study was to perform the first prospective review of minor burn injuries in Western Australia, to classify patient demographics, injury patterns and primary treatment.

RESULTS AND CONCLUSION

Two hundred and twenty seven patients were referred to the minor burn facility at Royal Perth Hospital (RPH) during the study period. One hundred and three patients (45%) sustained a scald, a further 44 (19%) received a flame burn. Thirty-seven (16%) patients sustained a contact burn, 18 (7.8%) patients attended the clinic with a chemical burn. Sixty percent of all patients reviewed had burns less than one percent. Only 39% of all our patients received adequate first aid. Sixty one percent of all patients received inadequate or inappropriate first aid. This study highlights a number of important issues. The over representation of metropolitan patients coupled with the low numbers of aboriginal patients reinforces the need for rural burns education. The best service we can provide is education on burns prevention and primary management. There are a number of other areas we hope to address in the future, the high incidence of domestic accidents, home safety must be a priority, coupled with seasonal promotional campaigns to address issues such as car radiator injuries. The most striking, and perhaps the most worrying finding in this study is the poor application of basic first aid principles. This is something that is unacceptable, needs further investigation and the lack of basic knowledge needs to be addressed at all levels of the community.

A silver coated dressing reduces the incidence of early burn wound cellulitis and associated costs of inpatient treatment: Comparative patient care audits

In 2000 and 2002, the Royal Perth Hospital (RPH) Burn Unit, Western Australia, conducted two 'before and after' patient care audits comparing the effectiveness and cost of Silvazine (silver sulphadiazine and chlorhexidine digluconate cream) and Acticoat, a new dressing product for in-patient treatment of early burn wounds. The main outcome variables were: burn wound cellulitis, antibiotic use and cost of treatment. Two patient care audits and a comparative sample were used. The two regimes audited were, 'standard treatment' of twice daily showers or washes with 4% chlorhexidine soap and Silvazine cream as a topical dressing (2000, n=51), compared with the 'new treatment' of daily showers of the burn wound with 4% chlorhexidine soap and the application of an Acticoat dressing (2002, n=19). In 2002, costs were also examined using a sample of matched pairs (n=8) of current and previous patients. The main findings were: when using Acticoat the incidence of infection and antibiotic use fell from 55% (28/51) and 57% (29/51) in 2000 to 10.5% (2/19) and 5.2% (1/19) in 2002. The total costs (excluding antibiotics, staffing and surgery) for those treated with Silvazine were US$ 109,357 and those treated with Acticoat were US$ 78,907, demonstrating a saving of US$ 30,450 with the new treatment. The average length of stay (LOS) in hospital was 17.25 days for the Silvazine group and 12.5 days for the Acticoat group-a difference of 4.75 days. These audits demonstrate that Acticoat results in a reduced incidence of burn wound cellulitis, antibiotic use and overall cost compared to Silvazine in the treatment of early burn wounds.

Maintaining physical therapy standards in an emergency situation: Solutions after the Bali bombing disaster

In a mass casualty event, treatment is traditionally provided in a 'best for the most' fashion. This paper examines the challenges encountered by physical therapists while providing rehabilitation to 28 survivors who suffered burns after the terrorist bombing in Bali, Indonesia. Individual patient input was achieved with routine outcome measures and workload statistics. Workforce expansion, maintenance of treatment quality, and other practical initiatives used in order to achieve this goal are discussed.

Repositioning the patient: the implications of being ‘at risk’

In the modern era of biomedical practice, genetic knowledge has redefined the idea of 'the patient' to include those who are 'at risk' of disease alongside those who are already sick. For such individuals, it is risk itself that constitutes the raison d'être of medical intervention. Using data from interviews with 58 users of a UK cancer genetics service together with data derived from clinical consultations, we consider the way such patients or clients make sense of a cancer genetic risk estimate and how they integrate genetic risk information into their lifeworld. In particular, we note that patient-clients who are 'at risk' tend to see themselves in a liminal position betwixt the healthy and the sick, and that such individuals consequently seek recourse to systems of medical surveillance that can continuously monitor their state of health. Our analysis also revealed the fact that many of those deemed by professionals to be at low risk of inheriting cancer-related mutations subsequently strove to be re-categorised as being at moderate or high risk of an adverse outcome. A number of explanations concerning lay health beliefs, lay 'representations' of health and the nature of the patient-client's lifeworld are examined and assessed in order to account for this apparent paradox.