The minimal leak test technique for endotracheal cuff maintenance

Endotracheal tube (ETT) cuff pressure management is an essential part of airway management in intubated and mechanically ventilated patients. Both under- and over-inflation of the ETT cuff can lead to patient complications, with an ideal pressure range of 20-30 cmH₂O defined. A range of techniques are employed to ensure adequate ETT cuff inflation, with little comparative data. We performed an observational cross-sectional study in a tertiary metropolitan ICU, assessing the relationship between the minimal leak test and cuff manometry. Forty-five mechanically ventilated patients, over a three-month period, had ETT cuff manometry performed at the same time as their routine cuff maintenance (minimal leak test). Bedside nurse measurements were compared with investigator measurements. At the endpoint of cuff inflation, 20 of 45 patients (44%) had cuff pressures between 20 and 30 cmH₂O; 11 of 45 patients (24%) had cuff pressures <20 cmH₂O; 14 of 45 patients (31%) had cuff pressures ≥30 cmH₂O. Univariate analysis demonstrated an association between both patient obesity and female gender requiring less ETT cuff volume (P=0.008 and P <0.001 respectively), though this association was lost on multivariate analysis. No association was demonstrated between any measured variables and cuff pressures. Inter-operator reliability in performing the minimal leak test showed no evidence of bias between nurse and investigators (Pearson coefficient = 0.897). We conclude the minimal leak test for maintenance of ETT cuffs leads to both over- and under-inflation, and alternative techniques, such as cuff manometry, should be employed.

Impact of consultant specialty on discharge decisions in patients admitted as medical emergencies to hospitals in the United Kingdom

BACKGROUND

The Society for Acute Medicine's Benchmarking Audit (SAMBA) annually examines Clinical Quality Indicators (CQIs) of the care of patients admitted to UK hospitals as medical emergencies.

AIM

The aim of this study is to review the impact of consultant specialty on discharge decisions in the SAMBA data-set.

DESIGN AND METHODS

Prospective audit of patients admitted to acute medical units (AMUs) on 25 June 2015 to participating hospitals throughout the UK with subgroup analysis.

RESULTS

Eighty-three units submitted patient data from 3138 patients.Nearly 1845 (58%, IQR for units 50-69%) of patients were referrals from Emergency Medicine, 1072 (32%, IQR for units 24-44%) were referrals from Primary Care. The mean age was 65 (SD 20). One hundred and forty-one (4.5%) patients were admitted from care homes and 951 (30%) of patients were at least 'mildly frail' and 407 (13%) had signs of physiological instability. The median and the mean time to being seen by a doctor were 1 h 20 min and 2 h 3 min, respectively. The median and the mean time to being seen by senior specialist were 3 h 55 min and 5 h 56 min, respectively. By 72 h, 29 (1%) patients had died in the AMU, 73 were admitted to critical care units, 1297 (41%) had been discharged to their own home and 60 to nursing or residential homes. For every 100 patients seen specialists in acute medicine discharged 12 more patients than specialists from other disciplines of medicine ( P  < 0.001). The difference remained significant after adjustment for case mix.

CONCLUSION

Specialist in acute care might facilitate discharge in a higher proportion of patients.

Gender differences in compliance with infection control precautions

nfection control teams are constantly looking at ways of improving compliance with infection control precautions. One of the factors affecting compliance, that has not been seriously addressed is gender. This paper looks at research findings relating to gender differences in infection control and discusses the theories proposed to explain these differences, in order to attempt to understand why such differences occur.

NAP SACC UK: protocol for a feasibility cluster randomised controlled trial in nurseries and at home to increase physical activity and healthy eating in children aged 2-4 years

INTRODUCTION

Systematic reviews have identified the lack of intervention studies with young children to prevent obesity. This feasibility study examines the feasibility and acceptability of adapting the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) intervention in the UK to inform a full-scale trial.

METHODS AND ANALYSIS

A feasibility cluster randomised controlled trial in 12 nurseries in England, with 6 randomly assigned to the adapted NAP SACC UK intervention: nursery staff will receive training and support from an NAP SACC UK Partner to review the nursery environment (nutrition, physical activity, sedentary behaviours and oral health) and set goals for making changes. Parents will be invited to participate in a digital media-based home component to set goals for making changes in the home. As this is a feasibility study, the sample size was not based on a power calculation but will indicate the likely response rates and intracluster correlations. Measures will be assessed at baseline and 8-10 months later. We will estimate the recruitment rate of nurseries and children and adherence to the intervention and data. Nursery measurements will include the Environmental Policy Assessment and Observation score and the nursery staff's review of the nursery environment. Child measurements will include height and weight to calculate z-score body mass index (zBMI), accelerometer-determined minutes of moderate-to-vigorous physical activity per day and sedentary time, and diet using the Child and Diet Evaluation Tool. Questionnaires with nursery staff and parents will measure mediators. A process evaluation will assess fidelity of intervention delivery and views of participants.

ETHICS AND DISSEMINATION

Ethical approval for this study was given by Wales 3 NHS Research Ethics Committee. Findings will be made available through publication in peer-reviewed journals, at conferences and to participants via the University of Bristol website. Data will be available from the University of Bristol Research Data Repository.

TRIAL REGISTRATION NUMBER

ISRCTN16287377.

The effects of passage through the gut of goats and cattle, and the application of dung as a fertiliser on seedling establishment of Dichrostachys cinerea and Acacia nilotica

Seed pods of Dichrostachys cinerea and Acacia nilotica have higher nutritive value than grasses and other browse plants during the dry season and form an important part of the diet of livestock. Seeds of Acacia may be destroyed during passage through the digestive tract of herbivores whereas seeds of other browse species can remain viable even after mechanical (chewing) and chemical (digestive) scarification. The seedling emergence, seedling establishment and recruitment of D. cinerea and A. nilotica seeds, dispersed by cattle and goats, were measured under natural conditions in the wet and dry seasons following sowing in the dry season. Seeds retrieved from goats and cattle, during the first 3 days and the last 4 days of the recovery period, and control seeds were subjected to the following planting methods: (1) seeds placed on top of the soil with no dung, (2) seeds buried to a depth of 2 cm in the soil with no dung, and (3) seeds buried to a depth of 2 cm in the soil with dung, in the wet and dry seasons. Significantly more A. nilotica and D. cinerea seeds were retrieved from cattle (40.0 ± 3.6% and 25.7 ± 3.9%, respectively), than goats (11.7 ± 3.1% and 13.2 ± 3.8%, respectively). There were significant interactions among animal species, seed-recovery day, planting and season for percentage seedling recruitment. Seedlings from seeds retrieved from goats (12.0 ± 0.06%) had a significantly higher recruitment rate than from seeds retrieved from cattle (7.6 ± 0.05%) and control seeds (i.e. no passage through the gut) (4.1 ± 0.02%). Seedling recruitment rate was higher from seeds recovered from animals in the last 4 days of the recovery period and from D. cinerea than A. nilotica. The planting method of seeds buried to a depth of 2 cm in the soil with no dung had the highest seedling recruitment rate. We conclude that both goats and cattle may facilitate woody plant encroachment by enhancing seedling emergence.

Switching from twice-daily raltegravir plus tenofovir disoproxil fumarate/emtricitabine to once-daily elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate in virologically suppressed, HIV-1-infected subjects: 48 weeks data

BACKGROUND

Pill burden, dosing frequency, and concerns about safety and tolerability are important obstacles to maintaining adequate medication adherence. Raltegravir (RAL) is indicated for twice-daily dosing and when taken with emtricitabine (FTC)/tenofovir disoproxil fumarate (TDF), it becomes a twice-daily multiple-tablet regimen. Elvitegravir (EVG)/cobicistat (COBI)/FTC/TDF, STB, is the first approved once-a-day integrase strand transfer inhibitor (INSTI) containing single-tablet regimen that combines EVG, an INSTI, and COBI, a novel pharmacoenhancer, with the preferred nucleos(t)ide backbone of FTC/TDF.

METHODS

This was a 48-week prospective, single-arm open-label study of the switch to STB in virologically sup-pressed HIV-1-infected adult patients on FTC/TDF and twice-daily RAL for at least 6 months. Objectives were to evaluate the tolerability and safety of a regimen simplification to once-a-day STB, while maintaining viral suppression through 48 weeks.

RESULTS

Forty-eight individuals in the United States were enrolled. The median age was 44 years, 96% were male, and 83% were White. The median time on RAL + FTC/TDF treatment prior to enrollment was 34 months. Ninety-six percent of participants cited regimen simplification as the reason to enroll in the switch study. At base-line, the median CD4 count was 714 cell/µL and estimated glomerular filtration rate (eGFR) was 105 mL/min. At week 48, all assessed study participants remained viro-logically suppressed to the lower limit of quantification (HIV-1 RNA<50 copies/mL) and maintained high CD4 cell count (median, 751 cells/mL) and stable eGFR (median, 100.5 mL/min). STB was well tolerated with no discontinuations, no study drug-related serious adverse events, and no study drug-related grade 3/4 adverse events.

CONCLUSIONS

All participants switching to 1 tablet once-a-day STB from a twice-daily RAL + FTC/TDF regimen remained virologically suppressed. STB was well tolerated. Switching to STB may be a viable option for virologically suppressed patients wanting to simplify from a twice-daily RAL-containing regimen.

Racial/Ethnic Variability in Hypertension Prevalence and Risk Factors in National Health Interview Survey

Objective. Hypertension is one of the leading causes of death attributed to cardiovascular diseases, and the prevalence varies across racial/ethnic groups, with African Americans being disproportionately affected. The underlying causes of these disparities are not fully understood despite volume of literature in this perspective. We aimed in this current study to examine ethnic/racial disparities in hypertension utilizing Hispanics as the base racial/ethnic group for comparison. Research Design and Methods. We utilized the National Health Interview Survey (NHIS), which is a large cross-sectional survey of the United States non-institutionalized residents to investigate the racial/ethnic disparities in hypertension after the adjustment of other socio-economic, demographic, and prognostic risk factors. The study participants were adults (n = 30,852). Data were analyzed using Chi square statistic, and logistic regression model. Results. There were statistically significant differences by race/ethnicity with respect to income, education, marital status, smoking, alcohol, physical activities, body mass index, and age, P < 0.01, but not insurance coverage, P > 0.01. Hispanic ethnicity (18.9%) compared to either non-Hispanic white (27.7%) or non-Hispanic black (35.5%) was associated with the lowest prevalence of hypertension. Race/ethnicity was a single independent predictor of hypertension, with non-Hispanic black more likely to be hypertensive compare with Hispanic, prevalence odds ratio (POR), 2.38, 99% Confidence Interval (CI), 2.17–2.61 and non-Hispanic white, POR, 1.64, 99% CI, 1.52–1.77. After controlling for the confounding variables, the racial/ethnic differences in hypertension persisted. Conclusions. Racial/ethnic disparities in hypertension persisted after controlling for potential predictors of hypertension in NHIS, implying the inability of known hypertension risk factors to account for racial/ethnic variability in hypertension in US.

Determinants of performance of supplemental immunization activities for polio eradication in Uttar Pradesh, India: social mobilization activities of the Social mobilization Network (SM Net) and Core Group Polio Project (CGPP)

Background

The primary strategy to interrupt transmission of wild poliovirus in India is to improve supplemental immunization activities (SIAs) and routine immunization coverage in priority districts. The CORE Group, part of the Social Mobilization Network (SM Net), has been successful in improving SIA coverage in high-risk areas of Uttar Pradesh (UP). The SM Net works through community level mobilisers (from the CORE Group and UNICEF) and covers more than 2 million children under the age of five. In this paper, we examine the reasons the CORE Group had been successful through exploration of which social mobilization activities of the CORE Group predicted better performance of SIAs.

Methods

We carried out a secondary data analysis of routine monitoring information collected by the CORE Group and the Government of India for SIAs. These data included information about vaccination outcomes of SIAs in CORE Group areas and non-CORE Group areas within the districts where the CORE Group operates, along with information about the number of various social mobilization activities carried out for each SIA. We employed Generalized Linear Latent and Mixed Model (GLLAMM) statistical analysis methods to identify which social mobilization activities predicted SIA performance, and to account for the intra-class correlation (ICC) between multiple observations within the same geographic areas over time.

Results

The number of mosque announcements carried out was the most consistent determinant of improved SIA performance across various performance measures. The number of Bullawa Tollies carried out also appeared to be an important determinant of improved SIA performance. The number of times other social mobilization activities were carried out did not appear to determine better SIA performance.

Conclusions

Social mobilization activities can improve the performance of mass vaccination campaigns. In the CORE Group areas, the number of mosque announcements and Bullawa Tollies carried out were important determinants of desired SIA outcomes. The CORE Group and SM Net should conduct sufficient numbers of these activities in support of each SIA. It is likely, however, that the quality of social mobilization activities (not studied here) is as or more important than the quantity of activities; quality measures of social mobilization activities should be investigated in the future as to how they determine vaccination performance.

"State of the Nation"--the Society for Acute Medicine's Benchmarking Audit 2013 (SAMBA '13)

BACKGROUND

Benchmarking is important to improve quality of care.

AIM

To audit the performance of Acute Medical Units (AMUs) against the clinical quality indicators published by the Society for Acute Medicine (SAM).

METHODS

24-hour data collection on the 20th of June 2013 with follow-up data at 72 hours.

RESULTS

43 units submitted data on 1425 patients. 76% of patients had early warning scores recorded within 30 minutes of admission, 95% of patients had been seen by a competent decision maker within four hours. 79% of patients were seen by a consultant physicians within the appropriate period of time.

CONCLUSION

The difference in compliance with quality standards between UK units opens opportunities for learning. The reasons why some units perform better than others require further investigation.

A day in the life of the AMU--the Society for Acute Medicine's benchmarking audit 2012 (SAMBA '12)

BACKGROUND

The absence of published data for benchmarking serves as a disincentive for Acute Medical Units to improve care.

AIM

To test feasibility of a national audit in Acute Medicine for compliance with common standards.

METHODS

On line questionnaire with summary data for patients admitted to participating Acute Medicine Units over a 24-hour-period.

RESULTS

30 units submitted summary data. The mean number of admission was 36 (SD 14). Compliance with standards around timing of junior and senior review was highly variable. In almost all other standards only a small number of units achieved high reliability with compliance of more than 90%.

CONCLUSION

SAMBA provides a data set that can be used for local and national benchmarking and quality improvement work. Annual audit might be beneficial to track improvements.

Television viewing associated with adverse dietary outcomes in children ages 2-6

The aim of this paper was to systematically review the evidence for the association between television viewing and diet in children ages 2-6. Data sources included PubMed, PsycINFO, EMBASE, ERIC, SportDISCUS, Sociological Abstracts, Web of Science and hand searches of reference lists of relevant articles. Twelve studies were reviewed in which the relationship between television viewing and diet was assessed in children between the ages of 2 and 6. All but one study reported significant relationship between television viewing time and adverse dietary outcomes. Parent-reported television viewing time was used to assay child television viewing in all included studies. Food frequency survey was the most frequent method of dietary assessment, and parent served as proxies for children in all studies. Lower fruit and/or vegetable intake was the most frequently reported dietary outcome, followed by increased energy intake with increased television viewing. The majority of studies reported adverse dietary outcomes with as little as 1 h of daily television exposure. While these results are consistent with recommendations from child health advocates to limit television viewing in young children, they also suggest that further efforts to limit television viewing in young children may be needed to aid in obesity prevention.