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.

Total HDL cholesterol efflux capacity in healthy children - Associations with adiposity and dietary intakes of mother and child

BACKGROUND AND AIMS

High-density lipoprotein (HDL) cholesterol efflux capacity in adults may be a measure of the atheroprotective property of HDL. Little however, is known about HDL cholesterol efflux capacity in childhood. We aimed to investigate the relationship between HDL cholesterol efflux capacity and childhood anthropometrics in a longitudinal study.

METHODS AND RESULTS

Seventy-five children (mean age = 9.4 ± 0.4 years) were followed from birth until the age of 9 years. HDL cholesterol efflux capacity was determined at age 9 by incubating serum-derived HDL-supernatants with ³H-cholesterol labeled J774 macrophages and percentage efflux determined. Mothers provided dietary information by completing food frequency questionnaires in early pregnancy and then 5 years later on behalf of themselves and their children. Pearson's correlations and multiple regression analyses were conducted to confirm independent associations with HDL efflux. There was a negative correlation between HDL cholesterol efflux capacity and waist circumference at age 5 (r = -0.3, p = 0.01) and age 9 (r = -0.24, p = 0.04) and BMI at age 5 (r = -0.45, p = 0.01) and age 9 (r = -0.19, p = 0.1). Multiple regression analysis showed that BMI at age 5 remained significantly associated with reduced HDL cholesterol efflux capacity (r = -0.45, p < 0.001). HDL-C was negatively correlated with energy-adjusted fat intake (r = -0.24, p = 0.04) and positively correlated with energy-adjusted protein (r = 0.24, p = 0.04) and starch (r = 0.29, p = 0.01) intakes during pregnancy. HDL-C was not significantly correlated with children dietary intake at age 5. There were no significant correlations between maternal or children dietary intake and HDL cholesterol efflux capacity.

CONCLUSIONS

This novel analysis shows that efflux capacity is negatively associated with adiposity in early childhood independent of HDL-C.

"This is a question we have to ask everyone": asking young people about self-harm and suicide

WHAT IS KNOWN ON THE SUBJECT?: An essential part of the mental health assessment is to evaluate the risk of harm to self. Fundamentally this involves asking directly about self-harming behaviour and suicidal thoughts or urges, but practitioners often find it difficult to open up these conversations. This evaluation of risk is particularly important as self-harm and suicidal thoughts are frequently found in young people who attend mental health services. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Young people are not always routinely asked directly about self-harm or suicidal thoughts when they are assessed. There are two ways that mental health practitioners introduce this topic: first, by building up to it by initially asking about general feelings, and second by stating that it is a requirement to ask everyone. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These questions should not be avoided by mental health practitioners just because they are difficult. We offer suggestions as to how to ask questions about self-harm and suicide based on real-world practice.

ABSTRACT

Introduction Questions about self-harm and suicide are essential in risk assessments with children and young people, yet little is known about how mental health practitioners do this. Aim The core aim was to examine how questions about self-harm and suicidal ideation are asked in real-world practice. Method A qualitative design was employed to analyse 28 video-recorded naturally occurring mental health assessments in a child and adolescent mental health service. Data were analysed using conversation analysis (CA). Results In 13 cases young people were asked about self-harm and suicide, but 15 were not. Analysis revealed how practitioners asked these questions. Two main styles were revealed. First was an incremental approach, beginning with inquiries about emotions and behaviours, building to asking about self-harm and suicidal intent. Second was to externalize the question as being required by outside agencies. Discussion The study concluded that the design of risk questions to young people had implications for how open they were to engaging with the practitioner. Implications for practice The study has implications for training and practice for psychiatric nurses and other mental health practitioners in feeling more confident in communicating with young people about self-harm and suicidal ideation.

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

Background

Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional “waitlist and triage” model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction.

Methods/design

A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12 weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial.

Discussion

This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12615001016527. Approved 15/9/2015.

Disseminated Mycobacterium haemophilum skeletal disease in a patient with interferon-gamma deficiency

Disseminated non-tuberculous mycobacterial (NTM) infection is rare in immunocompetent adults. Anti-interferon-gamma (IFN-γ) autoantibodies have recently been associated with NTM infections, particularly in patients of Asian ethnicity. We describe a case of disseminated Mycobacterium haemophilum skeletal infection due to anti IFN-γ autoantibodies in a 71-year-old Cambodian man. He responded to a combination of anti-mycobacterial antibiotics without requirement for immunomodulator therapy. Testing for acquired IFN-γ deficiency due to IFN-γ autoantibodies should be considered when standard tests for immunodeficiency are negative in patients with unusual or severe opportunistic infections, including NTM.

The Effects of High Frequency Oscillatory Ventilation (HFOV) with Volume Guarantee (VG) on Left Ventricular Function, Systemic and Regional Oxygenation, and Ventilation When Compared to HFOV and Conventional Mechanical Ventilation (CMV) in A Newborn Piglet Model of Respiratory Distress Syndrome (RDS)

BACKGROUND: RDS due to surfactant deficiency is commonly seen in preterm infants. These infants often require ventilatory support such as CMV and HFOV. HFOV with VG (HFOV+VG) is an alternative mode that delivers a set tidal volume. There is limited data on either HFOV mode regarding the effects on left ventricular (LV) function, systemic and regional oxygenation, and ventilation.

OBJECTIVES: We primarily compared the effects of CMV with VG, HFOV, and HFOV+VG on cardiac index (CI). Secondary parameters included heart rate (HR), mean arterial pressure (MAP), LV ejection fraction (EF), stroke volume (SV), dP/dt max, LV end-systolic volume and pressure (ESV, ESP), end-diastolic volume and pressure (EDV, EDP), and measures of oxygenation and ventilation. Oxygenation parameters included cerebral and renal near-infrared spectroscopy (NIRS), partial pressure of arterial oxygen (PaO2), and carotid artery flow index (CAFI). Ventilation parameters included partial pressure of arterial carbon dioxide (PaCO2) and minute ventilation (MV).

DESIGN/METHODS: Piglets (1.4-2.4 kg; 1-3 days old) were acutely anesthetized and instrumented with the placement of a right femoral arterial catheter for blood gas analysis, NIRS probes (Invos®), Transonic® flow probe on right common carotid artery, and Millar® catheter in the LV. Warm saline lung lavage was performed to achieve an AaDO2 of 300-450 mmHg to simulate moderate to severe RDS. Piglets were then block-randomized to CMV, HFOV or HFOV+VG for 4 hours using a Fabian HFO ventilator (Acutronic Medical Systems AG, Switzerland)(n=8 per group). Sham-operated piglets without RDS were monitored for the same duration under CMV (n=6). Two-way repeated measures ANOVA was used to analyze the data between modes or time points.

RESULTS: Piglets developed moderately severe RDS with comparable AaDO2 and Paw along with stable hemodynamic parameters. Both HFOV and HFOV+VG groups had similar PaCO2 whereas the CMV group had elevated PaCO2 when compared to that of the Sham (p&lt;0.01). Switching to HFOV resulted in a higher MV than its baseline. HFOV+VG but not HFOV or CMV groups had lower regional oxygenation and CAFI than its respective normoxic baseline (all p&lt;0.01). HFOV and HFOV+VG had higher CI, EF, and SV than CMV at 4 hours of recovery (p&lt;0.05) with similar HR, MAP, dP/dt max, ESV, ESP, EDV and EDP.

CONCLUSION: In our piglet model of RDS, HFOV shows benefits to LV function and ventilation when compared to CMV. HFOV+VG does not show benefits compared to HFOV.

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Pre-Hospital Fast Positive Cases Identified by DFB Ambulance Paramedics: Final Clinical Diagnosis

Ischaemic stroke clinical outcomes are improved by earlier treatment with intravenous thrombolysis. An existing pathway at the Mater University Hospital for assessment of suspected acute stroke in the Emergency Department was updated, aiming to shorten door-to-needle time. This study examines the final clinical diagnosis of Dublin Fire Brigade Ambulance Paramedic identified Face-Arm-Speech-Test (FAST) positive patients presenting to the Emergency Department over a 7 month period. A retrospective analysis was carried out of 177 consecutive FAST positive patients presenting between March and November 2014. The final clinical diagnosis was acute stroke in 57.1% (n=101) of patients. Of these, 76 were ischaemic strokes of whom 56.5% (n=43) were thrombolysed. In the pre-hospital setting Ambulance Paramedics can identify, with reasonable accuracy, acute stroke using the FAST test. Over half of the ischaemic stroke patients presenting via this pathway can be treated with intravenous thrombolysis.