Quantifying hospital environmental ventilation using carbon dioxide monitoring - a multicentre study

The COVID-19 pandemic has highlighted the importance of environmental ventilation in reducing airborne pathogen transmission. Carbon dioxide monitoring is recommended in the community to ensure adequate ventilation. Dynamic measurements of ventilation quantifying human exhaled waste gas accumulation are not conducted routinely in hospitals. Instead, environmental ventilation is allocated using static hourly air change rates. These vary according to the degree of perceived hazard, with the highest change rates reserved for locations where aerosol-generating procedures are performed, where medical/anaesthetic gases are used and where a small number of high-risk infective or immunocompromised patients may be isolated to reduce cross-infection. We aimed to quantify the quality and distribution of ventilation in hospital by measuring carbon dioxide levels in a two-phased prospective observational study. First, under controlled conditions, we validated our method and the relationship between human occupancy, ventilation and carbon dioxide levels using non-dispersive infrared carbon dioxide monitors. We then assessed ventilation quality in patient-occupied (clinical) and staff break and office (non-clinical) areas across two hospitals in Scotland. We selected acute medical and respiratory wards in which patients with COVID-19 are cared for routinely, as well as ICUs and operating theatres where aerosol-generating procedures  are performed routinely. Between November and December 2022, 127,680 carbon dioxide measurements were obtained across 32 areas over 8 weeks. Carbon dioxide levels breached the 800 ppm threshold for 14% of the time in non-clinical areas vs. 7% in clinical areas (p < 0.001). In non-clinical areas, carbon dioxide levels were > 800 ppm for 20% of the time in both ICUs and wards, vs. 1% in operating theatres (p < 0.001). In clinical areas, carbon dioxide was > 800 ppm for 16% of the time in wards, vs. 0% in ICUs and operating theatres (p < 0.001). We conclude that staff break, office and clinical areas on acute medical and respiratory wards frequently had inadequate ventilation, potentially increasing the risks of airborne pathogen transmission to staff and patients. Conversely, ventilation was consistently high in the ICU and operating theatre clinical environments. Carbon dioxide monitoring could be used to measure and guide improvements in hospital ventilation.

Palliative Radiation Therapy in Older Adults With Cancer: Age-Related Considerations

There are many additional considerations when treating older adults with cancer, especially in the context of palliative care. Currently, radiation therapy is underutilised in some countries and disease sites, but there is also evidence of unnecessary treatment in other contexts. Making rational treatment decisions for older adults necessitates an underlying appraisal of the person's physiological reserve capacity. This is termed 'frailty', and there is considerable heterogeneity in its clinical presentation, from patients who are relatively robust and suitable for standard treatment, to those who are frail and perhaps require a different approach. Frailty assessment also presents an important opportunity for intervention, when followed by Comprehensive Geriatric Assessment (CGA) in those who require it. Generally, a two-step approach, with a short initial screening, followed by CGA, is advocated in geriatric oncology guidelines. This has the potential to optimise care of the older person, and may also reverse or slow the development of frailty. It therefore has an important impact on the patient's quality of life, which is especially valued in the context of palliative care. Frailty assessment also allows a more informed discussion of treatment outcomes and a shared decision-making approach. With regards to the radiotherapy regimen itself, there are many adaptations that can better facilitate the older person, from positioning and immobilisation, to treatment prescriptions. Treatment courses should be as short as possible and take into account the older person's unique circumstances. The additional burden of travel to treatment for the patient, caregiver or family/support network should also be considered. Reducing treatments to single fractions may be appropriate, or alternatively, hypofractionated regimens. In order to enhance care and meet the demands of a rapidly ageing population, future radiation oncology professionals require education on the basic principles of geriatric medicine, as many aspects remain poorly understood.

Expert consensus panel guidelines on geriatric assessment in oncology

Despite consensus guidelines on best practice in the care of older patients with cancer, geriatric assessment (GA) has yet to be optimally integrated into the field of oncology in most countries. There is a relative lack of consensus in the published literature as to the best approach to take, and there is a degree of uncertainty as to how integration of geriatric medicine principles might optimally predict patient outcomes. The aim of the current study was to obtain consensus on GA in oncology to inform the implementation of a geriatric oncology programme. A four-round Delphi process was employed. The Delphi method is a structured group facilitation process, using multiple iterations to gain consensus on a given topic. Consensus was reached on the optimal assessment method and interventions required for the commonly employed domains of GA. Other aspects of GA, such as screening methods and age cut-off for assessment, represented a higher degree of disagreement. The expert panel employed in this study clearly identified the criteria that should be included in a clinical geriatric oncology programme. In the absence of evidence-based guidelines, this may prove useful in the care of older cancer patients.

Looked after children in Dublin and their mental health needs

Children in care in Ireland have increased by 27% in the last decade. This population is recognized to be among the most vulnerable. This study aims to describe their placement histories, service use and mental health needs. Data was obtained on 174 children (56.5% of eligible sample) with a mean age of 10.83 (SD = 5.04). 114 (65.5%) were in care for three years or more. 29 (16.7%) did not have a SW and 49 (37.7%) had no GP 50 (28.7%) were attending CAMHS. Long term care, frequent placement changes and residential setting were significantly related with poorer outcomes and increased MH contact. Given the increase in numbers in care and the overall decrease in resource allocation to health and social care, individual care planning and prioritizing of resources are essential.

A prospective longitudinal study of the prevalence of post-traumatic stress disorder resulting from childbirth events

BACKGROUND

Childbirth has been linked to postpartum impairment. However, controversy exists regarding the onset and prevalence of post-traumatic stress disorder (PTSD) after childbirth, with seminal studies being limited by methodological issues. This longitudinal prospective study examined the prevalence of PTSD following childbirth in a large sample while controlling for pre-existing PTSD and affective symptomatology.

METHOD

Pregnant women in their third trimester were recruited over a 12-month period and interviewed to identify PTSD and anxiety and depressive symptoms during the last trimester of pregnancy, 4-6 weeks postpartum, 12 weeks postpartum and 24 weeks postpartum.

RESULTS

Of the 1067 women approached, 933 were recruited into the study. In total, 866 (93%) were retained to 4-6 weeks, 826 (89%) were retained to 12 weeks and 776 (83%) were retained to 24 weeks. Results indicated that, uncontrolled, 3.6% of women met PTSD criteria at 4-6 weeks postpartum, 6.3% at 12 weeks postpartum and 5.8% at 24 weeks postpartum. When controlling for PTSD and partial PTSD due to previous traumatic events as well as clinically significant anxiety and depression during pregnancy, PTSD rates were less at 1.2% at 4-6 weeks, 3.1% at 12 weeks and 3.1% at 24 weeks postpartum.

CONCLUSIONS

This is the first study to demonstrate the occurrence of full criteria PTSD resulting from childbirth after controlling for pre-existing PTSD and partial PTSD and clinically significant depression and anxiety in pregnancy. The findings indicate that PTSD can result from a traumatic birth experience, though this is not the normative response.

Service users' experiences of a therapeutic group programme in an acute psychiatric inpatient unit

Psychiatric nurses have been facilitating therapeutic groups in acute psychiatric inpatient units for many years; however, there is a lack of nursing research related to this important aspect of care. This paper reports the findings of a study which aimed to gain an understanding of service users' experiences in relation to therapeutic group activities in an acute inpatient unit. A qualitative descriptive study was undertaken with eight service users in one acute psychiatric inpatient unit in Ireland. Data were collected using in-depth semi-structured interviews and analysed using Burnard's method of thematic content analysis. Several themes emerged from the findings which are presented in this paper.

Dietary intervention in chronic fatigue syndrome

BACKGROUND

Anecdotal reports and books have been published linking an over growth of Candida Albicans with chronic fatigue syndrome (CFS), suggesting dietary change as a treatment option. Little scientific data has been published to validate this controversial theory. This study aims to determine the efficacy of dietary intervention on level of fatigue and quality of life (QoL) in individuals with CFS.

METHODS

A 24-week randomized intervention study was conducted with 52 individuals diagnosed with CFS. Patients were randomized to either a low sugar low yeast (LSLY) or healthy eating (HE) dietary interventions. Primary outcome measures were fatigue as measured by the Chalder Fatigue Score and QoL measured by Medical Outcomes Survey Short Form-36.

RESULTS

A high drop out rate occurred with 13 participants not completing the final evaluation (7HE/6LSLY). Intention to treat analysis showed no statistically significant differences on primary outcome measurements.

CONCLUSION

In this randomized control trial, a LSLY diet appeared to be no more efficacious on levels of fatigue or QoL compared to HE. Given the difficulty with dietary compliance experienced by participants, especially in the LSLY group, it would appear HE guidance is a more pragmatic approach than advocating a complicated dietary regime.

Patient-centred care in acute psychiatric admission units: reality or rhetoric?

It has been suggested that patient-centred care be adopted as the primary method of mental health service delivery. This approach has been widely described in the literature and various frameworks for its delivery have been developed; however, many lack evaluation at present. The primary aim of this study was to gain an understanding of psychiatric nursing practice with people who self-harm using a qualitative descriptive approach. One of its objectives was to explore psychiatric nurses' approach and philosophical underpinnings to care. A sample of eight psychiatric nurses from two acute psychiatric admission units in Ireland was gained through convenience sampling. Data were collected through in-depth semi-structured interviews and analysed using a combination of content and theme analysis. Barker's Tidal Model was being utilized as the basis of nursing practice in both units. This paper presents one of the themes that emerged from the findings on the concept of patient-centred care, and how this translated in the use of the Tidal Model.

Pragmatism rules: the intervention and prevention strategies used by psychiatric nurses working with non-suicidal self-harming individuals

Self harm in the absence of expressed suicidal intent is an under explored area in psychiatric nursing research. This paper reports on findings of a study undertaken in two acute psychiatric inpatient units in Ireland. The purpose of the study was to gain an understanding of the practices of psychiatric nurses in relation to people who self harm, but who are not considered suicidal. Semi structured interviews were held with eight psychiatric nurses. Content analysis revealed several themes. For the purpose of this paper the prevention and intervention strategies psychiatric nurses engage in when working with non-suicidal self harming individuals are presented. Recommendations for further research are offered.

The future of paediatric surgery outside specialist paediatric hospitals

BACKGROUND

In Ireland, general surgeons provide paediatric surgical services to patients remote from specialist paediatric units.

AIM

To review general paediatric surgical services in the Mid-Western Health Board (MWHB) region with a view to informing future policy decisions in Ireland.

METHODS

From 1995 to 2000, the paediatric surgical workload at the Mid-Western Regional Hospital was reviewed. Operations performed, level of operating surgeon, morbidity and mortality were recorded.

RESULTS

There were 3,166 general paediatric surgical patients cared for by three general surgeons and one urologist, all with paediatric surgical training. There was an increase in day cases (55% to 70%) and operations at which the consultant was the main operator (40% to 67%). There was no mortality and the morbidity rate was less than 1%.

CONCLUSIONS

General paediatric surgery and urology is well provided for in the MWHB by appropriately trained surgeons. Lack of opportunity for surgeons in training to obtain general paediatric surgical experience will put this service at risk as the current cohort of surgeons retire. Expansion in specialist paediatric surgical services, changes in general surgical training to include general paediatric surgery or proleptic appointments may be required.

A case-control study of obstetric complications and later autistic disorder

The precise etiology of autism remains unclear. Obstetric adversity has been described as one factor that may increase the risk for the disorder. We examined the contemporaneous birth records of 49 children satisfying DSM-III-R criteria for autistic disorder, at four Dublin maternity hospitals, using the previous same-sex live birth in that hospital as a control. Data were evaluated blind to subject status using two obstetric complication (OC) rating scales. No significant differences in obstetric adversity were found between index and control groups. Autistic individuals did not differ from controls in terms of previously described risk factors for this disorder (maternal age, maternal parity, birth order, and low birth weight) in autism. These data do not support the view that OCs increase the risk for later autism.

An XPG DNA repair defect causing mutagen hypersensitivity in mouse leukemia L1210 cells

One of the most widely used antitumor drugs is cis-diamminedichloroplatinum(II) (cisplatin), and mechanisms of cisplatin resistance have been investigated in numerous model systems. Many studies have used mouse leukemia L1210/0 as a reference wild-type cell line, and cisplatin-resistant subclones have been derived from it. Increased DNA excision repair capacity is thought to play a key role in the acquired cisplatin resistance, and this has influenced development of drugs for clinical trials. We report here that the L1210/0 line is in fact severely deficient in nucleotide excision repair of damaged DNA in vivo and in vitro. L1210/0 cell extracts could be complemented by extracts from repair-defective human xeroderma pigmentosum (XP) or rodent excision repair cross-complementing (ERCC) mutant cells, except for XPG/ERCC5 mutants. Purified XPG protein could restore repair proficiency to L1210/0 extracts. Expression of mouse XPG mRNA was similar in all L1210 lines studied, suggesting a point mutation or small alteration of XPG in L1210/0 cells. The DNA repair capacity of a cisplatin-resistant subline, L1210/DDP10, is similar to that of type culture collection L1210 cells and to those of other normal mammalian cell lines. Nucleotide excision repair of DNA is thus clearly important in the intrinsic cellular defense against cisplatin. However, in contrast to what is generally believed, enhancement of DNA repair above the normal level in these rodent cells does not appear to be a mechanism of acquired resistance to the drug.

XPG endonuclease makes the 3' incision in human DNA nucleotide excision repair

Humans with a defect in the XPG protein suffer from xeroderma pigmentosum (XP) resulting from an inability to perform DNA nucleotide excision repair properly. Here we show that XPG makes a structure-specific endonucleolytic incision in a synthetic DNA substrate containing a duplex region and single-stranded arms. One strand of the duplex is cleaved at the border with single-stranded DNA. A cut with the same polarity is also made in a bubble structure, at the 3' side of the centrally unpaired region. Normal cell extracts introduce a nick 3' to a platinum-DNA lesion, but an XP-G cell extract is defective in making this incision. These data show that XPG has a direct role in making one of the incisions required to excise a damaged oligonucleotide, by cleaving 3' to DNA damage during nucleotide excision repair.

Isolation of active recombinant XPG protein, a human DNA repair endonuclease

Complementation group G of xeroderma pigmentosum (XP-G) is one of the most rare and phenotypically heterogeneous forms of this inherited disorder. XP-G patients vary from having a very mild defect in DNA repair to being severely affected, and a few cases are also associated with the neurological complications of Cockayne's syndrome. The XPG gene encodes an acidic protein with a predicted molecular mass of 133 kDa that confers normal UV resistance when expressed in XP-G cells. Here we report the isolation of full-length XPG as a soluble protein expressed from a recombinant baculovirus. The purified polypeptide corrects the DNA nucleotide excision repair defect of XP-G cell extracts in vitro, and it acts as a magnesium-dependent single-stranded DNA endonuclease. This is the first direct evidence for a human protein with properties that implicate it in the incision step of nucleotide excision repair.

Identical defects in DNA repair in xeroderma pigmentosum group G and rodent ERCC group 5

Humans with the complementation group G form of the inherited syndrome xeroderma pigmentosum (XP) are hypersensitive to solar ultraviolet light because of a defect in nucleotide-excision repair of DNA. Some individuals are also affected with Cockayne's syndrome, and have neurological abnormalities. Here we report that the DNA repair deficiency of XP-G cell extracts can be corrected by addition of protein fractions from normal cells. Repair proficiency can also be restored by mixing XP-G cell extracts with extracts from different repair-defective cell lines, with one exception. Extracts from cells representing group 5 of a set of ultraviolet-sensitive rodent mutants fail to complement XP-G extracts. XP-G and group 5 correcting activities co-elute after approximately 1,000-fold purification from HeLa cells. An antibody directed against a recombinant fragment of the XP-G complementing protein (XPGC) inhibits excision repair by normal cell extracts, and activity can be restored with an XP-G/group 5 complementing fraction. These data strongly suggest that the XPGC and group 5 correcting (ERCC5) proteins are identical.