An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm

Essentials Ignorance of direct oral anticoagulants' effects on coagulation tests may be a safety issue. An electronic questionnaire was sent to prescribers in NHS Grampian with 143 respondents. We found widespread evidence of inappropriate interpretation of the clinical scenarios given. The study suggests potential for patient harm due to lack of knowledge and education is required.

SUMMARY

Background Lack of awareness of the nature of the direct oral anticoagulants (DOACs) combined with the poor correlation between routine coagulation test prolongation and the activity of these drugs represents a potential for patient harm. Objectives To establish the level of awareness of the different DOACs, and to assess whether prescribers were able to recognize the state of anticoagulation in a hypothetical patient. Methods and results An electronic questionnaire was sent by email to prescribers in our health board. Among 143 respondents, we found significant differences in awareness of the currently licensed drugs. Of the respondents, 88%, 80% and 50%, respectively, recognized rivaroxaban, dabigatran, and apixaban. When provided with a routine clinical situation, only 13.5%, 17.5% and 16.8%, respectively, recognized that the hypothetical patient was anticoagulated, and only 55-58% recognized that it was unsafe to proceed with an invasive procedure. Conclusion These results indicate a significant risk for patient harm related to lack of knowledge about this new group of frequently used drugs, and indicate that additional education and training on this subject are required.

Sleep and nighttime energy consumption in early childhood: a population-based cohort study

BACKGROUND

Shorter sleep is a risk factor for weight gain in young children. Experimental studies show that sleep deprivation is associated with higher nighttime energy intake, but no studies have examined the patterning of energy intake in relation to nighttime sleep duration in young children.

OBJECTIVES

The objectives of the study were to test the hypothesis that shorter-sleeping children would show higher nighttime energy intake and to examine whether the additional calories were from drinks, snacks or meals.

METHODS

Participants were 1278 families from the Gemini twin cohort, using data from one child per family selected at random to avoid clustering effects. Nighttime sleep duration was measured at 16 months of age using the Brief Infant Sleep Questionnaire. Energy intake by time of day and eating episode (meal, snack, drink) were derived from 3-day diet diaries completed when children were 21 months.

RESULTS

Consistent with our hypothesis, shorter-sleeping children consumed more calories at night only (linear trend P < 0.001), with those sleeping <10 h consuming on average 120 calories (15.2% of daily intake) more at night than those sleeping ≥13 h. The majority of nighttime intake was from milk drinks. Associations remained after adjusting for age, sex, birth weight, gestational age, maternal education, weight and daytime sleep.

CONCLUSIONS

Shorter-sleeping, young children consume more calories, predominantly at night, and from milk drinks. Parents should be aware that providing milk drinks at night may contribute to excess intake. This provides a clear target for intervention that may help address associations between sleep and weight observed in later childhood.

Nighttime sleep duration and hedonic eating in childhood

Background:

Higher food intake is implicated in the elevated risk of obesity associated with shorter sleep in children, but the mechanisms driving higher intake are uncertain. Research in adults suggests that acute sleep deprivation affects brain reward systems, which increases responsiveness to palatable foods. However, there have been few studies addressing habitual sleep duration, and few in children, among whom the strongest associations with body mass index (BMI) are seen.

Objective:

The objective of this study is to test the hypothesis that shorter-sleeping children are more food responsive and explore the mediation of the relationship between sleep and weight by food responsiveness (FR).

Methods:

Participants were families from Gemini, a UK twin birth cohort, who had provided complete information on their children's sleep and appetite at age 5 years (n=1008). One child from each twin pair was randomly selected for analyses. Nighttime sleep duration was calculated from parent-reported bedtime and wake time, and categorised as shorter, adequate or longer according to age-specific reference values. FR was assessed with the Child Eating Behaviour Questionnaire. BMI s.d. scores (BMI-SDS) were calculated from parent-measured heights and weights using the UK 1990 reference data and were available for 494 children.

Results:

There was a significant linear association between shorter sleep and higher FR at age 5 years (P for linear trend=0.032), which was maintained after adjusting for age, sex, birth weight, maternal education and BMI-SDS. In the subset with BMI data at age 5 years, shorter sleep was associated with higher BMI-SDS (P=0.026) as expected. Testing for mediation by adding FR to the model attenuated the linear relationship to borderline significance (P=0.049), suggesting partial mediation.

Conclusions:

Shorter sleep in childhood is associated with higher FR, which may partly explain the association between shorter sleep and adiposity in childhood.

Outbreak of E. coli O157:H7 associated with lettuce served at fast food chains in the Maritimes and Ontario, Canada, Dec 2012

BACKGROUND

Identification and control of multi-jurisdictional foodborne illness outbreaks can be complex because of their multidisciplinary nature and the number of investigative partners involved.

OBJECTIVE

To describe the multi-jurisdictional outbreak response to an E. coli O157:H7 outbreak in Canada that highlights the importance of early notification and collaboration and the value of centralized interviewing.

METHODS

Investigators from local, provincial and federal jurisdictions, using a national outbreak response protocol to clarify roles and responsibilities and facilitate collaboration, conducted a rapid investigation that included centralized re-interview of cases, descriptive methods, binomial probability, and traceback findings to identify the source of the outbreak.

RESULTS

There were 31 laboratory confirmed cases identified in New Brunswick, Nova Scotia, and Ontario. Thirteen cases (42%) were hospitalized and one case (3%) developed hemolytic uremic syndrome; there were no deaths. Due to early notification a coordinated investigation was initiated before laboratory subtyping was available. Re-interview of cases identified 10 cases who had not initially reported exposure to the source of the outbreak. Less than one week after the Outbreak Investigation Coordinating Committee was formed, consumption of shredded lettuce from a fast food chain was identified as the likely source of the illnesses and the implicated importer/processor initiated a precautionary recall the same day.

CONCLUSION

This outbreak investigation highlights the importance of early notification, prompt re-interviewing and collaboration to rapidly identify the source of an outbreak.

Sleep and energy intake in early childhood

Background And Objectives:

Shorter sleep is associated with higher weight in children, but little is known about the mechanisms. The aim of this study was to test the hypothesis that shorter sleep was associated with higher energy intake in early childhood.

Methods:

Participants were 1303 families from the Gemini twin birth cohort. Sleep duration was measured using the Brief Infant Sleep Questionnaire when the children were 16 months old. Total energy intake (kcal per day) and grams per day of fat, carbohydrate and protein were derived from 3-day diet diaries completed by parents when children were 21 months old.

Results:

Shorter nighttime sleep was associated with higher total energy intake (P for linear trend=0.005). Children sleeping <10 h consumed around 50 kcal per day more than those sleeping 11–<12 h a night (the optimal sleep duration for children of this age). Differences in energy intake were maintained after adjustment for confounders. As a percentage of total energy intake, there were no significant differences in macronutrient intake by sleep duration. The association between sleep and weight was not significant at this age (P=0.13).

Conclusions:

This study provides the first evidence that shorter nighttime sleep duration has a linear association with higher energy intake early in life. That the effect is observed before emergence of associations between sleep and weight indicates that differences in energy intake may be a mechanism through which sleep influences weight gain.

Florence Nightingale and Mary Seacole: Which is the forgotten hero of health care and why?

Background and aims

This paper aims at correcting misinformation in circulation portraying Mary Seacole as a nurse, Crimean War heroine, and health care pioneer, even, for some, a replacement for Florence Nightingale, who really was a health care pioneer as well as being the major founder of the modern profession of nursing.

Methods and results

The article focuses on the claims for Seacole made by C. Short in Scottish Medical Journal, 2011. It reports, using primary sources, on what Seacole actually did – running a business for officers, with kind acts on the side – short of constituting heroism, pioneering health care or nursing.

Conclusion

The article concludes with remarks on how Nightingale came to be forgotten as a health care pioneer, with comments on the two major sources that attacked her reputation, F.B. Smith in 1982, and Hugh Small in 1998. Detailed refutations in peer-reviewed sources are referenced. Finally, it is suggested that recent scandals in English hospital care, documented in the Francis Report, may provoke a revival of interest in Nightingale’s principles and methods.

Overcorrection: Reviewed, revisited and revised

Overcorrection is a widely used behavior management procedure, the success of which has been well documented. However, overcorrection is not a simple, single procedure. Rather, it is a complex combination of procedures that often make it a complicated strategy to understand conceptually and to implement correctly. The complex nature of overcorrection combined with the use of multiple labels has created much confusion and debate among both researchers and practitioners. A number of issues relating to overcorrection are examined and evaluated. A proposal is made for revising the present overcorrection terminology. Finally, directions for future research are suggested.

Maternal and fetal tissue accumulation of selected endocrine disrupting compounds (EDCs) following exposure to sewage sludge-treated pastures before or after conception

Liver concentrations of selected pollutant classes were determined in groups of sheep fetuses and their dams, at 55 (Experiment 1) and 110 (Experiment 2) days of gestation (term = 145 d) following exposure, throughout their breeding lives and after mating, to pasture treated with either inorganic fertiliser (control, CC) or with sewage sludge (treated, TT). In a unique study designed to separate the respective contributions of environmental sources and mobilised tissue to the available EDC burden, in additional groups of animals, pollutant burdens at 110 days gestation were assessed following exposure to the respective treatments, either throughout their breeding lives until mating, but not thereafter (TC), or only between mating and slaughter (CT) (Experiment 3). With very few exceptions, maternal and fetal liver concentrations of diethylhexyl phthalate (DEHP) and selected polychlorinated biphenyls (PCBs), and polybrominated diphenyl ethers (PBDE) and polycyclic aromatic hydrocarbons (PAHs) were not significantly affected by sludge exposure in any group. In some cases, maternal and fetal tissue EDC concentrations were different but the differences were not consistent, and maternal and fetal concentrations of none of the classes of chemical were significantly correlated. It was not possible to identify a single chemical, or class of chemical, that may be responsible for previously observed physiological effects of exposure to sludge-treated pastures. It is concluded that exposure of sheep to pastures fertilised with sewage sludge was not associated with increased liver concentrations of EDCs, irrespective of the stage of development at which they were measured and of maternal tissue mobilisation and EDC release during gestation. Thus, retrospective measurements of EDC tissue burdens could not be used to accurately assess earlier fetal EDC insults.

Accumulation of endocrine disrupting compounds in sheep fetal and maternal liver tissue following exposure to pastures treated with sewage sludge

Fetal tissue concentrations of endocrine disrupting compounds (EDCs), and their relationship to maternal tissue concentrations, are largely unknown, in any species. In particular, the patterns of accumulation in the respective tissues following increased rates of environmental exposure are little known. This study was designed to determine fetal and maternal tissue concentrations of selected EDCs in sheep exposed to background, environmental concentrations of EDCs (pastures treated with inorganic fertiliser; Control; C) or to elevated, environmental concentrations (sludge-treated pastures; Treated; T). Mean log concentrations of diethylhexyl phthalate (DEHP) were similar in adult and fetal livers but there was a significant interaction between stage of development (maternal or fetal) and treatment reflecting the fact that mean concentrations were lower (P < 0.05) in C than T fetuses but not adults. Relative concentrations of polychlorinated biphenyls (PCB) in maternal and fetal tissue differed with congener; concentrations of congener 101 were higher (P < 0.05) in fetal tissue. Neither maternal nor fetal liver concentrations of any of the PCB congeners differed significantly with treatment. Polybrominated diphenyl ethers (PBDE) in the tissue were represented primarily by congeners 47 and 99. PBDE 99 concentrations were higher in maternal than fetal tissue (P = 0.01). None differed with treatment in either maternal or fetal tissues. Concentrations of many polycyclic aromatic hydrocarbons (PAH) were higher in maternal tissue but none differed with treatment in either adult or fetuses. It is concluded that sheep fetal liver EDC concentrations are variably related to those of their dams and in some cases appear to be selectively accumulated in fetuses. Differential accumulation of individual pollutants may have important implications for the assessment of risk from exposure.

Predictors of depressive symptoms in primary caregivers of young children with or at risk for developmental delay

BACKGROUND

Despite extensive research with families raising children with or at risk for developmental delay (DD), it is not clear whether primary caregivers of these children are at increased risk for depressive symptoms. Discrepant findings in the literature may be owing to heterogeneity of child problems. More research is needed on child, parent and family variables that may increase risk for, or resilience to, caregiver depressive symptoms. Some studies have found that parental resources (e.g. social support and coping strategies) may buffer the effects of parental distress, while other studies have highlighted the role of parental self-efficacy.

METHODS

We examined Beck Depression Inventory (BDI) scores in 178 primary caregivers (mainly biological mothers) who had 2-year-old children with or at risk for DD owing to: (a) low birthweight, prematurity or multiple birth (n = 58), (b) other known reasons (e.g. Down syndrome, spina bifida) (n = 67), or (c) unknown reasons (n = 69).

RESULTS

We found that 20% (n = 35) of the caregivers scored above the BDI clinical cut-off for depression. Analysis of variance revealed that caregivers with elevated BDI scores had higher child behaviour problem and escape-avoidance coping scores, and lower social support and parent self-efficacy, compared with caregivers without depressive symptoms. Caregivers with children who had DD for unknown reasons had higher BDI scores than caregivers of the other two groups of children. Regression analyses showed that child behaviour problems, escape-avoidance coping strategies and social support predicted caregiver BDI scores, but caregiver self-efficacy only did so when entered independently of social support. Only social support mediated and (marginally) moderated the relationship between child behaviour problems and caregiver depressive symptoms.

CONCLUSIONS

These findings suggest that early intervention programmes should carefully consider the interaction of child characteristics (e.g. Diagnosis and behaviour problems), caregiver resources (e.g. coping strategies and social support), and parental mental health and mood when planning and tailoring services for families of children with or at risk for DD.

Chemical ripeners increase early season sugar content in a range of sugarcane varieties

Ripening in sugarcane refers to an increase in sugar content on a fresh weight basis before commercial harvest. Certain chemicals are applied to cane in commercial fields in some countries to accelerate ripening and improve profitability of sugar production. However, responses have usually been reported to be variety and environment specific. We examined changes in the sucrose content in the juice extracted from 43 Australian sugarcane (Saccharum spp. hybrid) varieties in response to 4 ripener treatments in the Burdekin region in northern Queensland over 2 years. The 4 treatments applied were ethephon (as Ethrel®) + fluazifop-P butyl (as Fusilade®), Fusilade® alone, glyphosate (as Weedmaster® Duo), and haloxyfop-R methyl (as Verdict®). These treatments were applied in March–April each year and compared with an untreated control. Of particular interest was whether economic responses are possible for Australian varieties harvested in the May and June period when sugar content in cane is usually low. Increases in sucrose (measured by pol) levels in cane juice were observed after combined application of Ethrel + Fusilade (E+F) and after application of glyphosate, although the result for the latter varied between years. These results suggest that opportunities exist in the Australian industry to improve the profitability of early-harvested sugarcane crops, but further research is required to quantify effects on cane yield and responses in diverse environments.

Patient satisfaction in radiation oncology

As part of a quality improvement exercise at the Perth Radiation Oncology Centre, a survey was undertaken to ascertain the current level of patient satisfaction with the information they were receiving from their treating radiation oncologist. In addition, the effect of radiation on patients' anxiety levels was investigated. Two questionnaires were given to patients having radical radiotherapy for malignancy. The first questionnaire consisted of the Information Satisfaction Questionnaire and the State Trait Anxiety Index. It was given to patients before the commencement of their course of radiotherapy. The second questionnaire consisted of the State Trait Anxiety Index and was given at the completion of their radiotherapy. A total of 120 patients completed both the questionnaires. The majority of patients were satisfied/very satisfied with the explanation of their illness and radiation toxicities. Fewer patients were satisfied with the explanation of lifestyle (e.g. diet, exercise, smoking) and practical issues such as parking and treatment costs. The patients showed a statistically significant reduction in both their State and Trait Anxiety scores following radiotherapy. Following this study, we have developed new information booklets addressing lifestyle and practical issues, which were not being adequately addressed as shown in this study. Our next study will assess the effect of these new information booklets.