Randomised controlled trial of an intervention to improve parental knowledge and management practices of fever

BACKGROUND

We know that parents require resources which can assist them to improve fever knowledge and management practices. The purpose of this study, using an RCT, was to examine the effectiveness of an information leaflet at increasing parental knowledge of fever, specifically temperature definition.

METHODS

A prospective, multi-centre, randomised, two-parallel arm, controlled trial with blinded outcome ascertainment was conducted. Parents presenting at purposively selected healthcare facilities who had a child aged ≤5 years of age were invited to participate. An information leaflet for use in the trial was designed based on previous studies with parents. Parents in the intervention arm read an information leaflet on fever and management of fever in children, completed a short questionnaire at Time 1 (T1) and again 2 weeks after randomisation at Time 2 (T2). Parents in the control arm did not receive the fever information leaflet but completed the same questionnaire as the intervention arm at T1 and againat T2. The primary outcome was the correct definition of fever (higher than ≥38 °C).

RESULTS

A total of 100 parents participated in the study at T1. A greater proportion of the intervention group (76%) than the control group (28%) selected the correct temperature (≥38 °C) at T1. 76% of the intervention arm correctly identified "higher than ≥38°C" as the temperature at which a fever is said to be present compared to 28% of the control arm. After 2 weeks, there was an increase of 6% of parents in the intervention arm (increase to 82.4%) who gave the correct temperature compared to just a 2.8% increase in the control arm (increase to 30.8%). Univariate logistic regression showed that parents in the intervention arm were significantly more likely to give the correct answer at both time-points (T1: OR 8.1; CI 95% 3.3-19.9: p < 0.01; T2: OR 10.5; CI 95% 3.4-32.0: p < 0.01).

CONCLUSIONS

Our RCT of this simple educational intervention has been shown to improve parental understanding of fever knowledge and correct management strategies. Education interventions providing simple, clear information is a key step to decreasing parental mismanagement of fever and febrile illness in children.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02903342, September 16, 2016, Retrospectively registered.

Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments: the Bristol experience 2014 to 2018

AIMS

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

PATIENT AND METHODS

This was a consecutive cohort study of 113 patients, who had sustained type IIIB fractures of the tibia following blunt trauma, over a four-year period in a level 1 trauma centre. The median age was 44.3 years (interquartile range (IQR) 28.1 to 65.9) with a median follow-up of 1.7 years (IQR 1.2 to 2.1). There were 73 male patients and 40 female patients. The primary outcome measures were deep infection rate and number of operations. The secondary outcomes were nonunion and flap failure.

RESULTS

In all, 44 patients had ORDB as part of their reconstruction, with the remaining 69 not requiring it. Eight out of 113 patients (7.1%) developed a deep infection (ORDB 1/44, non-ORDB 7/69). The median number of operations was two. A total of 16/242 complication-related reoperations were undertaken (6.6%), with 2/16 (12.5%) occurring in the ORDB group.

CONCLUSION

In the setting of an effective orthoplastic approach to type IIIB open diaphyseal tibial fractures, using mechanically relevant debrided devitalized bone fragments in the definitive reconstruction appears to be safe. Cite this article: Bone Joint J 2019;101-B:1002-1008.

Systematic review: What works to address obesity in nurses?

Background

There is evidence that the prevalence of overweight and obesity among nurses is increasing. As well as the impact on health, the costs associated with obesity include workplace injury, lost productivity and sickness absence. Finding ways to address obesity in nurses may be a challenge because of the barriers they face in leading a healthy lifestyle.

Aims

To identify the available evidence for interventions to address obesity in nurses.

Methods

Databases searched included CINAHL, SCOPUS (which encompasses the Cochrane Database of Systematic Reviews), PsycINFO, MEDLINE and British Nursing Index. Ancillary searching of the grey literature was conducted for case studies of weight management interventions in National Health Service (NHS) settings. Inclusion criteria were studies involving nurses that reported on interventions addressing health behaviours that contribute to obesity and included at least one obesity-related outcome measure.

Results

Eleven primary studies were found concerning lifestyle interventions for nurses. There was no strong evidence for any particular intervention to address obesity, although integrating interventions into nurses' daily working lives may be important. Case studies from the grey literature showcased a range of interventions, but very few studies reported outcomes.

Conclusions

The review demonstrates that there is insufficient good-quality evidence about successful interventions to address obesity in nurses. Evidence does indicate that interventions should be designed around the specific barriers nurses may face in leading a healthy lifestyle.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Reference range of liver corrected T1 values in a population at low risk for fatty liver disease-a UK Biobank sub-study, with an appendix of interesting cases

Purpose

Corrected T1 (cT1) value is a novel MRI-based quantitative metric for assessing a composite of liver inflammation and fibrosis. It has been shown to distinguish between non-alcoholic fatty liver disease (NAFL) and non-alcoholic steatohepatitis. However, these studies were conducted in patients at high risk for liver disease. This study establishes the normal reference range of cT1 values for a large UK population, and assesses interactions of age and gender.

Methods

MR data were acquired on a 1.5 T system as part of the UK Biobank Imaging Enhancement study. Measures for Proton Density Fat Fraction and cT1 were calculated from the MRI data using a multiparametric MRI software application. Data that did not meet quality criteria were excluded from further analysis. Inter and intra-reader variability was estimated in a set of data. A cohort at low risk for NAFL was identified by excluding individuals with BMI ≥ 25 kg/m² and PDFF ≥ 5%. Of the 2816 participants with data of suitable quality, 1037 (37%) were classified as at low risk.

Results

The cT1 values in the low-risk population ranged from 573 to 852 ms with a median of 666 ms and interquartile range from 643 to 694 ms. Iron correction of T1 was necessary in 36.5% of this reference population. Age and gender had minimal effect on cT1 values.

Conclusion

The majority of cT1 values are tightly clustered in a population at low risk for NAFL, suggesting it has the potential to serve as a new quantitative imaging biomarker for studies of liver health and disease.

Offering maternal composite ewes higher levels of nutrition from mid-pregnancy to lambing results in predictable increases in birthweight, survival and weaning weight of their lambs

Management of nutrition during pregnancy for maternal composite ewes has the potential to improve lamb production and survival in prime lamb production systems but existing condition score (CS) guidelines developed for Merinos may not be appropriate for the optimum production of maternal ewes. To address this, three replicated experiments were conducted at two research sites in Victoria and one in Western Australia. Ewes (781–800 per site) were allocated to four CS treatments following pregnancy scanning (~Day 50) and differentially fed to reach approximate targets of CS 2.4, 2.8, 3.2 and 3.6 by lambing. Single and multiple bearing ewes grazed together, and nutritional treatments were applied until the end of lambing after which ewes and lambs were aggregated into management groups containing all treatments. At lambing, maternal ewe liveweight had a range between treatments of 13.7–19.1 kg (average 16.4 kg) and CS varied by 1.1–1.5 of a CS (average 1.24). Across site analysis indicated that lamb birthweight and weaning weight increased with application of higher CS treatments (P &lt; 0.001). There was also an improvement in survival of multiple born lambs with increasing CS at lambing (P &lt; 0.001). Birthweight was significantly related to survival (P &lt; 0.001) at all sites with no significant effect of birth type on lamb survival. Changes in birthweight and weaning weight could be predicted from ewe joining liveweight, ewe liveweight change to Day 90 and ewe liveweight change Day 90 to lambing. The coefficients derived for each of these effects were similar to those found in previous experiments examining Merino and crossbred Border Leicester Merino ewes. The optimum CS targets for multiple bearing maternal composite ewes may be higher than the industry recommended target for Merino ewes based on advantages in lamb survival and weaning weight.

Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.