The seamless transition from student to intern: from theory to practice

Many publications have highlighted a lack of practical competencies in recently qualified interns. Consultation between the University of Queensland and the Medical Education Unit at Redcliffe Hospital identified key areas where intervention could lead to greater work readiness, and the development of a complementary programme of practical workshops to remedy those deficiencies. A variety of content experts introduced the Graduate Medical Course 3 and 4 students to a range of practical skills during a dedicated lunch time one hour workshop each week over a period of 30 weeks. Several sessions were audited by the trainers though the majority of sessions used self-evaluation by the participants. There was an overall self-reported increase in the ability to perform the tasks from 25% before the session to 90% afterwards. Seven of the participants are returning to the hospital as interns, and a follow-up survey will be performed to judge the usefulness of the programme.

An innovative approach to goal setting and reporting in a complex organization

Managing multiple priorities and achieving sustainable outcomes is a challenge for leaders across health care organizations. One academic health science centre set about to address this challenge through the development of an innovative annual goal and objectives process that aligned every unit/department around organizational priorities. The results have enabled exceptional outcomes for individuals, teams, patients/families and the organization as a whole.

Food allergy is associated with an increased risk of asthma

BACKGROUND

The atopic march is well documented, but the interrelationship of food allergy (FA) and asthma is not well understood.

OBJECTIVE

The aim of this study was to examine the strength of the association and temporal relationships between FA and asthma.

METHODS

This analysis included 271 children >or=6 years (older group) and 296 children <6 years (younger group) from a family-based FA cohort in Chicago, IL. Asthma was determined by parental report of physician diagnosis. FA status was determined based on the type and timing of clinical symptoms after ingestion of a specific food, and results of prick skin test (Multi-Test II) and allergen-specific IgE (Phadia ImmunoCAP). Analyses were carried out using logistic regression accounting for important covariates and auto-correlations among siblings. Kaplan-Meier curves were used to compare the time to onset of asthma with the FA status.

RESULTS

Symptomatic FA was associated with asthma in both older [odds ratio (OR)=4.9, 95% confidence interval (CI): 2.5-9.5] and younger children (OR=5.3, 95% CI: 1.7-16.2). The association was stronger among children with multiple or severe food allergies, especially in older children. Children with FA developed asthma earlier and at higher prevalence than children without FA (Cox proportional hazard ratio=3.7, 95% CI: 2.2-6.3 for children >or=6 years, and hazard ratio=3.3, 95% CI: 1.1-10 for children <6 years of age). No associations were seen between asymptomatic food sensitization and asthma.

CONCLUSIONS

Independent of markers of atopy such as aeroallergen sensitization and family history of asthma, there was a significant association between FA and asthma. This association was even stronger in subjects with multiple food allergies or severe FA.

Familial aggregation of food allergy and sensitization to food allergens: a family-based study

BACKGROUND

The increasing prevalence of food allergy (FA) is a growing clinical and public health problem. The contribution of genetic factors to FA remains largely unknown.

OBJECTIVE

This study examined the pattern of familial aggregation and the degree to which genetic factors contribute to FA and sensitization to food allergens.

METHODS

This study included 581 nuclear families (2,004 subjects) as part of an ongoing FA study in Chicago, IL, USA. FA was defined by a set of criteria including timing, clinical symptoms obtained via standardized questionnaire interview and corroborative specific IgE cut-offs for > or =95% positive predictive value (PPV) for food allergens measured by Phadia ImmunoCAP. Familial aggregation of FA as well as sensitization to food allergens was examined using generalized estimating equation (GEE) models, with adjustment for important covariates including age, gender, ethnicity and birth order. Heritability was estimated for food-specific IgE measurements.

RESULTS

FA in the index child was a significant and independent predictor of FA in other siblings (OR=2.6, 95% CI: 1.2-5.6, P=0.01). There were significant and positive associations among family members (father-offspring, mother-offspring, index-other siblings) for total IgE and specific IgE to all the nine major food allergens tested in this sample (sesame, peanut, wheat, milk, egg white, soy, walnut, shrimp and cod fish). The estimated heritability of food-specific IgE ranged from 0.15 to 0.35 and was statistically significant for all the nine tested food allergens.

CONCLUSION

This family-based study demonstrates strong familial aggregation of FA and sensitization to food allergens, especially, among siblings. The heritability estimates indicate that food-specific IgE is likely influenced by both genetic and environmental factors. Together, this study provides strong evidence that both host genetic susceptibility and environmental factors determine the complex trait of IgE-mediated FA.

Pregnancy and cystic fibrosis

A 20-year old parturient with moderate to severe cystic fibrosis presented for an Elective Caesarean Delivery at 31 weeks gestation due to intra-uterine growth retardation and persistent maternal weight loss. The procedure was successfully performed using a combined spinal-epidural anaesthetic technique. A review of the literature is presented and the anaesthetic implications of pregnancy in cystic fibrosis patients are discussed.

Assessing the impact of late treatment effects in cervical cancer: an exploratory study of women?s sexuality

Cancer survivorship has become a major issue due to people living longer with the effects of cancer treatment. A key issue in this area are the 'iatrogenic effects' of cancer treatments and their adverse impact on the quality of long-term patient survival. This paper considers the late physical effects of treatment for cervical cancer, in particular psychosocial problems associated with sexuality. The aim of this paper was to explore women's sexuality following treatment for cervical cancer. A qualitative phenomenological design was used to explore the lived experiences of a purposive sample of 13 women 2-3 years after treatment, using in-depth interviewing. The findings demonstrate that cancer treatment can result in a number of late physical effects, including bladder and bowel dysfunction. Moreover, the physical problems led to sexual difficulties experienced several years after treatment. Concerns were expressed by patients about perceived psychosexual difficulties encountered as a result of treatment. In conclusion, the study raises issues associated with the management of late treatment effects and its impact on sexuality. The findings underline the need for effective communication of possible iatrogenic effects of treatment during follow-up care and a need for research to consider the advice and information that women require about long-term treatment effects.

Effects of sequential changes from conventional ventilation to high-frequency oscillatory ventilation at increasing mean airway pressures in an ovine model of combined lung and head injury

BACKGROUND

The objective of this study was to determine the intracranial, cardiovascular and respiratory changes induced by conversion to high-frequency oscillator ventilation from conventional mechanical ventilation at increasing airway pressures.

METHODS

In this study, 11 anaesthetized sheep had invasive cardiovascular and intracranial monitors placed. Lung injury was induced by saline lavage and head injury was induced by inflation of an intracranial balloon catheter. All animals were sequentially converted from conventional mechanical ventilation to high-frequency oscillator ventilation at target mean airway pressures of 16, 22, 28, 34 and 40 cm H(2)O. The mean airway pressure was achieved by adjusting positive end expiratory pressure while on conventional mechanical ventilation, and continuous distending pressures while on high-frequency oscillator ventilation. Cerebral lactate production, oxygen consumption and venous oximetry were measured and analysed in relation to changes in transcranial Doppler flow velocity. Transcranial Doppler profiles together with other physiological parameters were measured at each airway pressure.

RESULTS

Cerebral perfusion pressure was significantly lower during high-frequency oscillator ventilation than during conventional mechanical ventilation (CMV: 45, 34, 22, 6, 9 mmHg vs. HFOV: 33, 20, 19, 5, 5 mmHg at airway pressures mentioned above, P = 0.02). Intracranial pressure and cerebrovascular resistance increased with increasing intrathoracic pressures (P = 0.001). Cerebral metabolic indices demonstrated an initial increase in anaerobic metabolism followed by a decrease in cerebral oxygen consumption progressing to cerebral infarction as intrathoracic pressures were further increased in a stepwise fashion. Arterial PaCO(2) increased significantly after converting from conventional mechanical ventilation to high-frequency oscillator ventilation (P = 0.001). However, no difference was observed between conventional mechanical ventilation and high-frequency oscillator ventilation when intracranial pressure, metabolic and transcranial Doppler indices were compared at equivalent mean airway pressures.

CONCLUSIONS

The use of high positive end expiratory pressure with conventional mechanical ventilation or high continuous distending pressure with high-frequency oscillator ventilation increased intracranial pressure and adversely affected cerebral metabolic indices in this ovine model. Transcranial Doppler is a useful adjunct to intracranial pressure and intracranial venous saturation monitoring when major changes in ventilation strategy are adopted.

Retention of tracheal intubation skills by novice personnel: a comparison of the Airtraq�and Macintosh laryngoscopes

Direct laryngoscopic tracheal intubation is a potentially lifesaving manoeuvre, but it is a difficult skill to acquire and to maintain. These difficulties are exacerbated if the opportunities to utilise this skill are infrequent, and by the fact that the consequences of poorly performed intubation attempts may be severe. Novice users find the Airtraq laryngoscope easier to use than the conventional Macintosh laryngoscope. We therefore wished to determine whether novice users would have greater retention of intubation skills with the Airtraq rather than the Macintosh laryngoscope. Twenty medical students who had no prior airway management experience participated in this study. Following brief didactic instruction, each took turns performing laryngoscopy and intubation using the Macintosh and Airtraq devices in easy and simulated difficult laryngoscopy scenarios. The degree of success with each device, the time taken to perform intubation and the assistance required, and the potential for complications were then assessed. Six months later, the assessment process was repeated. No didactic instruction or practice attempts were provided on this latter occasion. Tracheal intubation skills declined markedly with both devices. However, the Airtraq continued to provide better intubating conditions, resulting in greater success of intubation, with fewer optimisation manoeuvres required, and reduced potential for dental trauma, particularly in the difficult laryngoscopy scenarios. The substantial decline in direct laryngoscopy skills over time emphasise the need for continued reinforcement of this complex skill.

Critical care nurses' responses to patient photographs displayed at the bedside

Photographs of patients placed at the bedside by family or friends are a common sight in the intensive care unit. Few studies have shown that displaying patient photographs can have the following effects: motivate staff in caring for the patient by creating a reminder of the patient's preillness state; enhance the empathetic bond between nurse and patient; personalize care in a highly technical environment; and improve the communication between the nurse, patient, and family.

Audit of Mobile Intensive Care Ambulance Service

The transfer of critically ill patients between hospitals carries significant risk. The Mobile Intensive Care Ambulance Service (MICAS) in Ireland was established in 1996 to provide a ground transfer service between hospitals for critically ill patients. The aim of this audit was to determine if a centralised retrieval system for interhospital transport of critically ill patients in Ireland by MICAS is safe and efficient. 484 critically ill patients transported by MICAS between April 1996 and December 2004 were studied retrospectively. There were no patient deaths during transfer. 47% of transfers were between hospitals in the greater Dublin area. 45% were from regional centres to Dublin. 93% of patients required airway intervention before transfer (intubation or tracheostomy) and 32% needed inotropic support during transfer. The MICAS data confirm the demand for interhospital transport of critically ill patients and suggest that transfer using a centralised retrieval system is safe.