Development of consensus-based national antimicrobial stewardship competencies for UK undergraduate healthcare professional education

BACKGROUND

Healthcare professionals are involved in an array of patient- and medicine-related stewardship activities, for which an understanding and engagement with antimicrobial stewardship (AMS) is important. Undergraduate education provides an ideal opportunity to prepare healthcare professionals for these roles and activities.

AIM

To provide UK national consensus on a common set of antimicrobial stewardship competencies appropriate for undergraduate healthcare professional education.

METHODS

A modified Delphi approach comprising two online surveys delivered to a UK national panel of 21 individuals reflecting expertise in prescribing and medicines management with regards to the education and practice of nurses and midwives, pharmacists, physiotherapists, and podiatrists; and antimicrobial prescribing and stewardship. Data collection took place between October and December 2017.

FINDINGS

A total of 21 participants agreed to become members of the expert panel, of whom 19 (90%) completed round 1 questionnaire, and 17 (89%) completed round 2. Panelists reached a consensus, with consistently high levels of agreement reached, on six overarching competency statements (subdivided into six domains), and 55 individual descriptors essential for antimicrobial stewardship by healthcare professionals.

CONCLUSION

Due to the consistently high levels of agreement reached on competency statements and their associated descriptors, this competency framework should be used to direct education for undergraduate healthcare professionals, and those working in new clinical roles to support healthcare delivery where an understanding of, and engagement with, AMS is important. Although the competencies target basic education, they can also be used for continuing education.

Photo-induced synthesis of tomatidenol-based glycoalkaloids in Solanum phureja tubers

The effect of light exposure on the steroidal glycoalkaloid content of Solanum phureja tubers has been investigated and compared with that in domesticated potato (Solanum tuberosum) tubers. The results indicated that the increase in the concentration of solanidine-based glycoalkaloids, alpha-solanine and alpha-chaconine was broadly similar in both species. However, in the S. phureja tubers, light exposure also induced the synthesis of tomatidenol-based glycoalkaloids. These have been identified as alpha- and beta-solamarine. These glycoalkaloids were not detected in tubers continually stored in darkness.

Infective endocarditis in children following dental extraction and appropriate antibiotic prophylaxis

Infective endocarditis is a rare but important complication of certain types of dental treatment. Antibiotic prophylaxis is routinely prescribed for patients with known congenital heart disease. In this report we describe two patients in whom endocarditis developed within 3 months of the dental procedure, despite appropriate antibiotics. Endocarditis should be actively excluded if patients develop a fever associated with non-specific symptoms following an 'at risk' dental procedure.

End-on aortogram: improved identification of important coronary artery anomalies in tetralogy of Fallot

OBJECTIVE

To identify coronary artery anomalies in patients with tetralogy of Fallot with an aortogram taken with steep caudal and left oblique angulation ("end-on" aortogram).

DESIGN

Prospective evaluation of end-on aortogram in the preoperative angiographic assessment of consecutive patients with tetralogy of Fallot.

SETTING

Regional paediatric cardiology centre.

PATIENTS

34 patients, aged 3 months to 12 years (median age 9 months).

METHODS

An aortogram was performed with steep caudal (38 degrees-45 degrees) and left oblique (0 degrees-30 degrees) angulation under general anaesthetic as part of routine preoperative angiographic assessment.

RESULTS

The origins and courses of the coronary arteries were visualised in all patients and important coronary artery anomalies were identified in four patients: single left coronary artery; single right coronary artery (two patients); separate high origin of left anterior descending. These anomalous coronary vessels crossed the right ventricular outflow tract.

CONCLUSIONS

It is important to identify preoperatively coronary arteries that may interfere with right ventricular outflow tract reconstruction. An aortogram with steep caudal and left oblique angulation is useful in identifying anomalous coronary arteries and more importantly it defines the relation of these vessels to the right ventricular outflow tract.

Idiopathic infantile arterial calcification in two siblings: failure of treatment with diphosphonate

Two siblings with idiopathic infantile arterial calcification are reported. The fetal and postnatal echocardiographic features were a large pericardial effusion, thickened pulmonary and aortic valves, poor pulsation of the descending aorta, and calcification of the great vessels. In one patient calcification was first detected at 33 weeks' gestation. Despite treatment with disodium etidronate both children died.

[Acute maternal anterior poliomyelitis in a non-endemic zone]

The authors report the case of a 26 year old woman with acute anterior poliomyelitis contracted during the vaccination of her baby. Despite having been herself vaccinated in infancy she was not protected against the poliovirus. The clinical interest of this uncommon case is a severe paralytic state with definitive paraplegia. The authors suggest serologic testing of patients born before 1967 especially if they are at risk of encountering the virus.

Balloon dilatation of the aortic valve for congenital aortic stenosis in childhood

Balloon dilatation of the aortic valve was attempted in 34 consecutive children aged 16 months to 17 years (median 7 years), weight range 9-60 (median 22) kg. Previous surgical valvotomy had been performed in two patients (twice in one of them). The valve was not crossed in one patient. In the remaining 33 patients the pressure difference between the left ventricle and the ascending aorta during systole was reduced from 71 (30) to 28 (19) mm Hg. In 24 patients recatheterisation 2-19 (mean 9) months later showed gradients that were similar to those immediately after balloon dilatation (35 (20) v 31 (20) mm Hg). The two patients with the highest residual gradients immediately after balloon dilatation showed a spontaneous reduction in gradient at repeat catheterisation, whereas the patient who had twice had previous surgical valvotomy showed an increase in gradient from 37 to 99 mm Hg over nine months and required aortic root replacement. Balloon dilatation was repeated in two patients and this caused a further reduction in gradient. New aortic regurgitation occurred in nine (27%) patients (grade I, 8; grade II, 1) and aortic regurgitation was exacerbated (grade I to II) in two of the nine with pre-existing aortic regurgitation. External iliac artery avulsion occurred in one (3%) patient and two (6%) required intravenous streptokinase because the femoral artery became occluded. There were no other complications. Open valvotomy was performed in the child in whom the valve was not crossed, but no other child required aortic valve operation. Balloon dilatation of the aortic valve gave reasonable short term palliation and was well tolerated. It is an alternative to surgical valvotomy for initial palliation of congenital aortic stenosis in many children.

Balloon dilatation of unoperated aortic coarctation: immediate results and one year follow up

Fifteen patients aged 1-19 years (mean 10.9) with previously unoperated aortic coarctation underwent percutaneous balloon angioplasty between January 1985 and February 1986. Nine (60%) were hypertensive at presentation. Under general anaesthetic the systolic coarctation gradient was 24-50 mm Hg (mean 29) and the coarctation diameter was 4-9 mm (mean 5.5). Meditech balloon catheters 8-18 mm in diameter were inflated 1-4 times at 410-760 kPa. After dilatation the systolic coarctation gradient decreased to 0-20 mm Hg (mean 6) and the coarctation diameter increased to 7-20 mm (mean 12). One patient developed a fusiform aneurysm of the aorta at the coarctation site immediately after the procedure. At reinvestigation 6-16 months (mean 12.5) after dilatation 14 of the 15 patients were normotensive. In 13 patients the residual coarctation gradient was 0-10 mm Hg (mean 3). Two patients had recoarctation with residual gradients of 20 and 24 mm Hg and underwent successful repeat dilatation. One patient had developed a small discrete aneurysm at the coarctation site. Balloon angioplasty is thus a safe and effective method of relieving unoperated aortic coarctation. The frequency of aortic aneurysm and recoarctation is small and probably related to balloon size. This early experience is encouraging, but long term results and further experience are required before this approach is used to treat coarctation generally.

Anomalous mitral 'cleft' with abnormal ventriculo-arterial connection: anatomical findings and surgical implications

Seven specimens with a 'cleft' mitral valve associated with anomalous chordal fixation and abnormal ventriculo-arterial connection are presented. Four were associated with a discordant ventriculo-arterial connection, two with double-outlet right ventricle, and one with double-outlet left ventricle. In six the chordae from the cleft were attached to the anterior border of a small ventricular septal defect. In the seventh the chordae were attached to an accessory papillary muscle in the left ventricular outflow tract. These clefts differ from those of atrioventricular defects. The cleft is more anterior, there are no septal defects of the atrioventricular canal type, and no deficiency of the basal ventricular septum. Mitral regurgitation or left ventricular outlet obstruction are possible consequences of the anomaly.

Lymphomatoid granulomatosis in a 10 year old boy

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Kidney ageing and renal excretion of amylase

In a cross-sectional study, the amylase to creatinine clearance ratio (ACCR) was determined in 180 patients, age range 18-93 years. An inverse correlation was found between ACCR and creatinine clearance (r = -0.40, p less than 0.001) in keeping with the known inverse relationship between the sieving fraction of macromolecules and the glomerular filtration rate. The fractional clearance of amylase was not significantly affected by amylasemia nor by age when the creatinine clearance was also considered in a multiple regression analysis. No increase in ACCR was observed in patients with low molecular weight proteinuria or with induced urine dilution. The authors assume that the tubular reabsorption of amylase is minimal and that the enhancement of ACCR in the elderly mainly reflects modifications in the glomerular filtration dynamics.

The ECG in aortic stenosis. Value of TAVF and QV6

Fifty patients with a mean age of 9.2 years (range, 1.2 to 17.5 years) had cardiac catheterization performed under standardized conditions plus a scalar ECG the previous day. Twenty different direct measurements and 25 derived measurements from the ECG were correlated with the resting peak systolic gradient across the aortic valve. Some of the best correlations were with the measured TAVF, TV6, QV6, and the sum of SV1 + RV6 with r values between .33 and .59. Another group of different patients with isolated aortic stenosis were studied with measurements of the important ECG segments. The r value of this "test" series was similar to that of the original group, so the groups were pooled. The best three-term regression equation involved TAVF, QV6, and the sum (SV1 + RV6), with r = .636. A scoring system was also devised to predict severity. If the TAVF is 0.1 mV or less or the TV6 is 0.3 mV or less or if there is no Q in V6, the gradient may be high. In our series, the ECG estimation of resting peak systolic gradient across the aortic valve in aortic stenosis was enhanced by the inclusion of TAVF and QV6 in the regression equation, as well as SV1 + RV6.

The use of slow-scan video for CME in a remote area

Since August 1977 a slow-scan video system has been operating in a remote area of northwestern Ontario, Canada. This system, using regular dial-up telephone lines, interconnects the local hospital, five remote communities, and two teaching hospitals in Toronto, 1,000 miles distant. Since August 1978 the system has been used on a regular basis for continuing medical education programs, graduate medical education including X-ray rounds, medical rounds, nursing rounds, in-service education, and patient education. These CME programs for physicians have been accepted for study credits by the College of Family Physicians of Canada.

Telemedicine links patients in Sioux Lookout with doctors in Toronto

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Clinicopathological correlations in aphasiology by means of computerized axial tomography: interest of using printout and prospective considerations

This study was undertaken following a first paper describing cerebral clinicopathological correlations in aphasiology using computerized axial tomography. Its originality lies in the fact that we studied the correlations starting from the lesional sites and deducing the aphasiologic diagnosis. Our conclusions are similar but show that a small proportion of the patients do not follow the usual pattern of correlations. In view of future prospective studies, the authors emphasize the importance of information to analyze and compare well-individualized clinical syndromes. We suggest that such clinicopathological correlations could be used in other fields of neuropsychology.

Blood saving techniques: indications and contraindications

Pre- and peroperative blood saving can be realised in different ways, without inducing important changes in the biological parameters of the organism. Different replacement solutions are studied in detail. Three principal techniques are as follows: a) The peroperative autotransfusion consists in recovering the blood lost in the operative field during the surgical intervention, filtering it and transfusing it at the end of surgery. b) The peroperative normodilution consists in collecting a certain amount of blood (till up 2 l.) from the patients before operation; it is replaced by plasma expanders and transfused at the end of operation. c) The third technique, called the 'frog leap', consists in collecting blood during the weeks preceding surgery, in various amounts in function of the importance of the estimated blood loss. This blood is stored and transfused during intervention.