Parental And Clinician Views Of Consent In Neonatal Research

AIM

To determine parental and clinician views of the informed consent process in neonatal research.

METHODS

A questionnaire-based study on the informed consent process. Two questionnaires were developed and distributed to parents and clinicians over a four-month period.

RESULTS

Thirty-four parents (79%) surveyed had consented their baby to a research study. The majority of clinicians (72%) had a preference for antenatal provision of information. A desire to help future babies (97%, n=32) and a belief that their baby's healthcare would directly benefit (72%, n=28) were primary reasons for consenting. The majority (76% n=28) of parents were not in favour of a waiver of consent. However twenty clinicians (56%) agreed that a waiver of consent may be appropriate in neonatal research. Thirty-one (86%) clinicians rated GCP training as important.

DISCUSSION

Parents are generally supportive of neonatal research. Good clinical practice training is essential for clinicians involved in neonatal research.

2018 American Society of Consultant Pharmacists Annual Meeting & Exhibition

Poster abstracts are evaluated based on the following criteria: significance of the problem to healthy aging or medication management; innovativeness of ideas, methods, and/or approach; methodological rigor of methods and approach; presentation of finding; implications identified for future research, practice, and/or policy; and clarity of writing. Submissions are not evaluated through the peer-reviewed process used by The Consultant Pharmacist. Industry support is indicated, where applicable. Presenting author is in italics. The poster abstract presentation is supported by the ASCP Foundation.

Doctors' attitudes towards the introduction and clinical operation of do not resuscitate orders (DNRs) in Ireland

BACKGROUND

Do not resuscitate orders (DNRs) are documents which state that should a patient suffer from cardiopulmonary failure, resuscitation should not be attempted. Internationally, DNRs are often misunderstood and used inappropriately in a clinical setting.

AIMS

The aim of this paper was to determine the current understanding of DNRs and their clinical operation among hospital doctors in Ireland.

METHODS

A cross-sectional, questionnaire-based study was conducted involving doctors from the Cork teaching hospitals. The questionnaire sought information regarding understanding of DNRs and their clinical operation, as well as attitudes regarding the current absence of relevant Irish guidelines. The questionnaire also collected information regarding demographics, clinical specialty, and level of experience.

RESULTS

45.9% (47/103) of all doctors stated that their clinical knowledge was sufficient to draft a DNR, but 48.7% of this group (n = 23) chose the incorrect definition for a DNR when provided with three separate options. Thirty-five percent (n = 36) of all doctors surveyed demonstrated an incorrect understanding of a DNR. Neither specialty nor experience level had any effect on level of understanding of DNRs (p > 0.05). 93.2% (n = 96) agreed that there is a need for introduction of domestic guidelines regarding DNRs. 57.6% (n = 59) would draft more DNRs in the event that such domestic guidelines were in place.

CONCLUSIONS

A substantial proportion of hospital doctors surveyed demonstrated an incomplete understanding of DNRs and their clinical operation. However, the overwhelming majority of the present sample believe that domestic guidelines are needed on the matter.

Cardiovascular Risk Factors of Long-Term Care Workers

Little is known about long-term care workers’ cardiovascular disease (CVD) risk. Thus, the authors used baseline objective and subjective data from 98 long-term care staff participating in a worksite health promotion study to provide a comprehensive CVD assessment. The median age of the sample was 32 years ( SD = 13.38). Nine (12.2%) participants smoked and 27 (37.0%) participants reported exposure to secondhand smoke. The average nightly hours of sleep was 6.5 ( SD = 1.18), with 24 (32%) participants reporting sleeping at least fairly bad. Sixty-eight participants (73.1%) were overweight or obese. The median aerobic activity was 0 ( SD = 18.56). Participants ate on average 27 ( SD = 17.34) servings of high fatty and/or salty foods per week. Although blood pressure and cholesterol levels were within normal limits, this population demonstrated poor behavioral CVD risk factors. Given this finding and the young age of the sample, these workers may be ideal candidates for health promotion efforts before health risk factors are present.

Applying the Social Ecological Model and Theory of Self-Efficacy in the Worksite Heart Health Improvement Project-PLUS

Background: Long-term care (LTC) employees are at high risk for cardiovascular disease. Despite the documented benefits of worksite health promotion (WHP) programs for employees and employers and the potential benefits to residents in LTC facilities, LTC employees are rarely offered WHP programs. Purpose: The purpose of the intervention described in this article is to reduce cardiovascular disease risk factors among LTC workers using a physical activity, nutrition, and stress management WHP implemented during paid work time with 98 LTC staff members. Methods: This article describes a 9-month physical activity, nutrition, and stress management WHP intervention delivered during paid work time to reduce the cardiovascular disease risk of employees working in LTC. The intervention is rooted in the social ecological model and social cognitive theory. The intervention is based on formative research and evidence-based practice recommendations and is specifically designed to reduce barriers to intervention participation (e.g., inconsistent break times and unpredictable resident care needs) and enhance motivators to program participation (e.g., enhanced social support). Results: The intervention is ongoing, but measures are described. Conclusion: As more employers offer WHP programs, it is important that programs are tailored to meet specific employee groups and work environments. This article operationalizes a WHP research protocol with LTC employees that can be applied to reduce cardiovascular disease risk in LTC employees or similar employee groups in similar work environments.

Characteristics of Medicaid-Covered Emergency Department Visits Made by Nonelderly Adults: A National Study

BACKGROUND

The Affordable Care Act has added millions of new Medicaid enrollees to the health care system. These patients account for a large proportion of emergency department (ED) utilization.

OBJECTIVE

Our aim was to characterize this population and their ED use at a national level.

METHODS

We used the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) to describe demographics and clinical characteristics of nonelderly adults (≥18 years old and ≤64 years old) with Medicaid-covered ED visits. We defined frequent ED users as individuals who make ≥4 ED visits/year and business hours as 8 am to 5 pm. We used descriptive statistics to describe the epidemiology of Medicaid-covered ED visits.

RESULTS

NHAMCS included 21,800 ED visits by nonelderly adults in 2010, of which 5,659 (24.09%) were covered by Medicaid insurance. Most ED visits covered by Medicaid were made by patients who are young (25 and 44 years old) and female (67.95%; 95% confidence interval [CI] 66.00-69.89). A large proportion of the ED visits covered by Medicaid were revisits within 72 h (14.66%; 95% CI 9.13-20.19) and from frequent ED users (32.32%; 95% CI 24.29-40.35). Almost half of all ED visits covered by Medicaid occurred during business hours (45.44%; 95% CI 43.45-47.43).

CONCLUSIONS

The vast majority of Medicaid enrollees who used the ED were young females, with a large proportion of visits occurring during business hours. Almost one-third of all visits were from frequent ED users.

The at-risk medical student--what more can we do?

Securing a place in medical school is extremely difficult-students who are successful all have similar high levels of academic achievement. So why do some students, and not others, have difficulty with the course, and in some cases, leave the programme? Studies on medical school attrition offer valuable insight into why medical students under-perform. Identification of the 'at-risk' student can trigger additional support and early remediation, helping some students remain in their chosen profession.

Abstract 204: Emergency Department Visits for Heart Failure and Subsequent Hospitalization or Observation Unit Admission

Background: Although the majority of hospitalizations for heart failure (HF) originate in the emergency department (ED), many of these patients might be adequately treated and released in the ED or managed for a short period in an observation unit. Both ED and observation management have been shown to reduce costs and avoid the penalties related to rehospitalization. The purpose of this study was to examine trends in ED visits for HF and disposition following these visits. Because of increasing policy pressure to reduce rehospitalization for HF, we hypothesized that the number of HF patients hospitalized by ED providers decreased over time with a concurrent increase in admissions to the observation unit. We further hypothesized that the overall number of ED visits for HF decreased as a result of improved therapy for HF the last two decades.

Methods: We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) to estimate rates and characteristics of ED visits for HF between 2002 and 2010. The primary outcome was the discharge disposition from the ED. Regression models were fit to estimate trends and predictors of hospitalization and admission to an observation unit.

Results: The number of ED visits for HF remained stable over the period, from 914,739 in 2002 to 848,634 in 2010 (annual change -0.7%; 95% CI -3.7% - +2.5%). Of these visits, 74.2% led to hospitalization while 3.1% led to observation unit admission (Figure). The likelihood of hospitalization did not change during the period (adjusted prevalence ratio (aPR) 1.00; 95% CI 0.99-1.01 for each additional year) while admission to observation increased annually (aPR 1.11; 95% CI 1.00-1.23). We observed significant regional differences: as compared to other regions, patients in the Northeast were more likely to be hospitalized (aPR 1.15; 95% CI 1.07-1.22) but less likely to be admitted to an observation unit (aPR 0.43; 95% CI 0.19-1.02).

Conclusions: The number of ED visits for HF has remained stable in the last decade. Although observation unit admissions increased during this period, they constituted a relatively small number of dispositions and did not appear to attenuate the substantial number of ED visits that resulted in hospitalization. Opportunities may exist to reduce hospitalizations by increasing short term management of HF in the observation unit.

Bacteriophage adhered to mucus provide a novel mucosal immune system (P3166)

Mucosal surfaces serve as a primary entry point for multiple pathogens and are therefore principal sites of immune defense. Here we demonstrate through in vitro and in silico studies that increased phage adherence to the host mucosal layer, provides a novel immune defense mechanism. We show that compared to the surrounding environment, phage-to-bacteria ratios were increased on all mucosal surfaces sampled ranging from cnidarians to humans. This increased phage abundance protects the underlying epithelium from bacterial infection. Enrichment of phage on mucus occurs via interactions between host mucin glycoproteins and phage immunoglobulin-like protein domains exposed on phage capsids. Metagenomic analysis found these immunoglobulin-like proteins present in many environments, particularly those adjacent to mucosal surfaces. Preliminary glycan microarrays and 2D gel electrophoresis show that phage adherence can rapidly adapt to hosts mucus glycan profiles, and in response, the host may regulate its mucus glycosylation to select for a beneficial phage community. This adaptation between phage and host provide a mechanism for the manipulation and selection of the mucosal microbiota. Based on these observations, we present the Bacteriophage Adherence to Mucus (BAM) model describing a phage-derived mucosal immunity with potential applicability to all mucosal surfaces, thus opening a novel field of immunological study.

Group B streptococcus induces trophoblast death

Group B streptococcus (GBS) is one of the leading causes of neonatal infection; however the molecular mechanisms involved are not clearly known. Here we used high and low hemolytic GBS isolates and mutant GBS that lacks beta-hemolysin expression and showed that GBS infection or exposure to GBS hemolysin extract induces primary human trophoblast, placental fibroblast and JEG3 trophoblast cell line death, and that GBS-induced trophoblast death was beta-hemolysin dependent. The fibroblasts and trophoblasts provide an innate immune barrier between fetal and maternal circulation in the placenta. These data suggest that GBS may disrupt this barrier to invade fetal circulation.

Controlled trial of pharmacist intervention in general practice: the effect on prescribing costs

BACKGROUND

It has been suggested that the employment of pharmacists in general practice might moderate the growth in prescribing costs. However, empirical evidence for this proposition has been lacking. We report the results of a controlled trial of pharmacist intervention in United Kingdom general practice.

AIM

To determine whether intervention practices made savings relative to controls.

METHOD

An evaluation of an initiative set up by Doncaster Health Authority. Eight practices agreed to take part and received intensive input from five pharmacists for one year (September 1996 to August 1997) at a cost of 163,000 Pounds. Changes in prescribing patterns were investigated by comparing these practices with eight individually matched controls for both the year of the intervention and the previous year. Prescribing data (PACTLINE) were used to assess these changes. The measures used to take account of differences in the populations of the practices included the ASTRO-PU for overall prescribing and the STAR-PU for prescribing in specific therapeutic areas. Differences between intervention and control practices were subjected to Wilcoxon matched-pairs, signed-ranks tests.

RESULTS

The median (minimum to maximum) rise in prescribing costs per ASTRO-PU was 0.85 Pound (-1.95 Pounds to 2.05 Pounds) in the intervention practices compared with 2.55 Pounds (1.74 Pounds to 4.65 Pounds) in controls (P = 0.025). Had the cost growth of the intervention group been as high as that of the controls, their total prescribing expenditure would have been around 347,000 Pounds higher.

CONCLUSION

This study suggests that the use of pharmacists did control prescribing expenditure sufficiently to offset their employment costs.