Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients

AIM OF THE STUDY

The introduction of a paediatric medical emergency team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.

METHODS

Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.

RESULTS

Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p<0.001), more often reviewed by consultants (45%/76%, p=0.004), more often transferred to high dependency care (18%/37%, p=0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p=0.024). These improved responses by ward staff extended beyond direct involvement of pMET. There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p<0.001).

CONCLUSIONS

These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.

Coding characteristics of spiking local interneurons during imposed limb movements in the locust

The performance of adaptive behavior relies on continuous sensory feedback to produce relevant modifications to central motor patterns. The femoral chordotonal organ (FeCO) of the legs of the desert locust monitors the movements of the tibia about the femoro-tibial joint. A ventral midline population of spiking local interneurons in the metathoracic ganglia integrates inputs from the FeCO. We used a Wiener kernel cross-correlation method combined with a Gaussian white noise stimulation of the FeCO to completely characterize and model the output dynamics of the ventral midline population of interneurons. A wide range of responses were observed, and interneurons could be classified into three broad groups that received excitatory and inhibitory or principally inhibitory or excitatory synaptic inputs from the FeCO. Interneurons that received mixed inputs also had the greatest linear responses but primarily responded to extension of the tibia and were mostly sensitive to stimulus velocity. Interneurons that received principally inhibitory inputs were sensitive to extension and to joint position. A small group of interneurons received purely excitatory synaptic inputs and were also sensitive to tibial extension. In addition to capturing the linear and nonlinear dynamics of this population of interneurons, first- and second-order Wiener kernels revealed that the dynamics of the interneurons in the population were graded and formed a spectrum of responses whereby the activity of many cells appeared to be required to adequately describe a particular stimulus characteristic, typical of population coding.

Experience with academic detailing services for quality improvement in primary care practice

BACKGROUND

Despite longstanding experimental evidence about effectiveness of academic detailing, transitioning this research-based concept into acceptable primary care quality improvement services has been slow in the USA. The purpose of this study was to describe primary care uptake, retention and response to an academic-detailing-led service in the USA. Exploration of accessible performance indicators of service acceptance, and feasibility of use of an Australian academic detailing service model were secondary objectives.

METHODS

Over a 29-month period, an academic-detailing-led drug and therapeutics information service was offered to all primary care physicians providing ongoing patient care in Fayette County, Kentucky. Two programmes (on type 2 diabetes management and chronic pain management) incorporating up to four office visits were offered.

RESULTS

102 of 130 (78%) eligible primary care physicians participated in the service, 72% receiving visits for the type 2 diabetes management programme, and 58% the chronic non-malignant pain programme. At all successive encounters, participants expressed a willingness to continue to receive visits. Difficulties were experienced in obtaining appointments for subsequent visits, although on direct enquiry, only one participant explicitly declined further visits. No notable differences existed between physicians accepting visits and those who did not. Across successive visits, passive indicators of satisfaction with the service included: duration of visits, office waiting times, retention of printed materials from one visit to the next, whether physicians wished their extender colleagues to also receive visits, and observed levels of interest and participation within encounters.

CONCLUSIONS

Ongoing primary care quality improvement services spearheaded by academic detailing can be acceptable to US primary care physicians in practice.

TGF-beta induces apoptosis in human B cells by transcriptional regulation of BIK and BCL-XL

TGF-β potently induces apoptosis in Burkitt’s Lymphoma (BL) cell lines and in explanted primary human B lymphocytes. The physiological relevance and mechanism of TGF-β-mediated apoptosis induction in these cells remains to be determined. Here we demonstrate the requirement for TGF-β-mediated regulation of BIK and BCL-X_L to activate an intrinsic apoptotic pathway in centroblastic BL cells. TGF-β directly induced transcription of BIK and a consensus Smad binding element identified in the BIK promoter recruits TGF-β-activated Smad transcription factor complexes in vivo. TGF-β also transcriptionally repressed expression of the apoptosis inhibitor BCL-X_L. Inhibition of BCL-X_L sensitised BL cells to TGF-β-induced apoptosis while overexpression of BCL-X_L or suppression of BIK by shRNA, diminished TGF-β-induced apoptosis. BIK and BCL-X_L were also identified as TGF-β target genes in purified normal human centroblast B cells and immunohistochemical analyses of tonsil tissue revealed widespread TGF-β receptor-regulated Smad activation and a focal pattern of BIK expression. Furthermore, using a selective inhibitor of the TGF-β receptor we provide evidence that autocrine TGF-β signaling through ALK5 contributes to the default apoptotic program in normal human centroblasts undergoing spontaneous apoptosis. Our data suggests that TGF-β may act as a physiological mediator of human germinal centre homeostasis via regulation of BIK and BCL-X_L.

Influence of sinusoidally modulated visual stimuli at extremely low frequency range on the human EEG activity

The purpose of this study was to investigate whether sinusoidally modulated visual stimuli at extremely low frequencies (ELF) of 50, 16.66, 13, 10, 8.33 and 4Hz could influence the changes in EEG activity in 33 human subjects. An improved design of visual stimulator system has addressed an issue of electrical interference from electrical signals driven by LED arrays onto simultaneously recorded EEG. A comparison between 1 and 3-Way ANOVA was performed in order to evaluate whether visual stimuli at ELFs could influence the EEG in humans to compliment the currently active medical research in seasonal affective disorder (SAD) and photic driving. The results revealed that under evaluation of 1 and 3-Way repeated-measures ANOVA tests, the Theta, Alpha2 and Gamma EEG bands exhibited a common significant difference between ELF visual stimuli.

Relationship between the fungal complex causing Fusarium head blight of wheat and environmental conditions

ABSTRACT Over 4 years, the environmental conditions and the causal agents of Fusarium head blight (FHB) disease of wheat were determined in field sites in four European countries: Hungary, Ireland, Italy, and the United Kingdom. Polymerase chain reaction-based methods were used to detect each species causing FHB and quantify its DNA (as a measurement of fungal abundance) in the samples. Canonical correspondence analysis (CCA) was used to determine the relationship of the incidence and abundance of each species with weather variables. CCA indicated that little variability in the species prevalence data was explained by the weather variables. In contrast, a greater proportion of variability in abundance data was accounted for by the weather variables. Most samples contained two or more species and statistical analysis suggested that these species tended to coexist at field sites. CCA also indicated that there were differences in the relationships of the prevalence and abundance of the six FHB species with environmental variables. Fusarium poae was associated with relatively drier and warmer conditions, whereas F. graminearum was associated with warmer/humid conditions. F. avenaceum and F. culmorum were both associated with niches of cooler/wet/humid conditions. Two Microdochium species were associated with regions of relatively cool/moderate temperatures and frequent rainfalls of short duration. The results also suggested that environmental conditions differentially affect the infection and colonization processes, and the comparative abundance of the six species.