Use of selective gut decontamination in critically ill children: protocol for the Paediatric Intensive Care and Infection Control (PICnIC) pilot study

INTRODUCTION

Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. In critically ill adults, there are data that suggest the use of Selective Decontamination of the Digestive tract (SDD), alongside standard infection control measures reduce mortality and the incidence of HCAIs. SDD-enhanced infection control has not been compared directly with standard infection prevention strategies in the Paediatric Intensive Care Unit (PICU) population. The aim of this pilot study is to determine the feasibility of conducting a multicentre cluster randomised controlled trial (cRCT) in critically ill children comparing SDD with standard infection control.

METHODS AND ANALYSIS

Paediatric Intensive Care and Infection Control is a parallel group pilot cRCT, with integrated mixed-methods study, comparing incorporation of SDD into infection control procedures to standard care. After a 1-week pretrial ecology surveillance period, recruitment to the cRCT will run for a period of 18 weeks, comprising: (1) baseline control period (2) pre, mid and post-trial ecology surveillance periods and (3) intervention period. Six PICUs (in England, UK) will begin with usual care in period 1, then will be randomised 1:1 by the trial statistician using computer-based randomisation, to either continue to deliver usual care or commence delivery of the intervention (SDD) in period 2. Outcomes measures include parent and healthcare professionals' views on trial feasibility, adherence to the SDD intervention, estimation of recruitment rate and understanding of potential patient-centred primary and secondary outcome measures for the definitive trial. The planned recruitment for the cRCT is 324 participants.

ETHICS AND DISSEMINATION

The trial received favourable ethical opinion from West Midlands-Black Country Research Ethics Committee (reference: 20/WM/0061) and approval from the Health Research Authority (IRAS number: 239324). Informed consent is not required for SDD intervention or anonymised data collection but is sought for investigations as part of the study, any identifiable data collected and monitoring of medical records. Results will be disseminated via publications in peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

ISRCTN40310490.

Family satisfaction with critical care in the UK: a multicentre cohort study

OBJECTIVE

To assess family satisfaction with intensive care units (ICUs) in the UK using the Family Satisfaction in the Intensive Care Unit 24-item (FS-ICU-24) questionnaire, and to investigate how characteristics of patients and their family members impact on family satisfaction.

DESIGN

Prospective cohort study nested within a national clinical audit database.

SETTING

Stratified, random sample of 20 adult general ICUs participating in the Intensive Care National Audit & Research Centre Case Mix Programme.

PARTICIPANTS

Family members of patients staying at least 24 hours in ICU were recruited between May 2013 and June 2014.

INTERVENTIONS

Consenting family members were sent a postal questionnaire 3 weeks after the patient died or was discharged from ICU. Up to four family members were recruited per patient.

MAIN OUTCOME MEASURES

Family satisfaction was measured using the FS-ICU-24 questionnaire.

MAIN RESULTS

A total of 12 346 family members of 6380 patients were recruited and 7173 (58%) family members of 4615 patients returned a completed questionnaire. Overall and domain-specific family satisfaction scores were high (mean overall family satisfaction 80, satisfaction with care 83, satisfaction with information 76 and satisfaction with decision-making 73 out of 100) but varied significantly across adult general ICUs studied and by whether the patient survived ICU. For family members of ICU survivors, characteristics of both the family member (age, ethnicity, relationship to patient (next-of-kin and/or lived with patient) and visit frequency) and the patient (acute severity of illness and receipt of invasive mechanical ventilation) were significant determinants of family satisfaction, whereas, for family members of ICU non-survivors, only patient characteristics (age, acute severity of illness and duration of stay) were significant.

CONCLUSIONS

Overall family satisfaction in UK adult general ICUs was high but varied significantly. Adjustment for differences in family member/patient characteristics is important to avoid falsely identifying ICUs as statistical outliers.

TRIAL REGISTRATION NUMBER

ISRCTN47363549.

Increasing survival after admission to UK critical care units following cardiopulmonary resuscitation

Background

In recent years there have been many developments in post-resuscitation care. We have investigated trends in patient characteristics and outcome following admission to UK critical care units following cardiopulmonary resuscitation (CPR) for the period 2004–2014. Our hypothesis is that there has been a reduction in risk-adjusted mortality during this period.

Methods

We undertook a prospectively defined, retrospective analysis of the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database (CMPD) for the period 1 January 2004 to 31 December 2014. Admissions, mechanically ventilated in the first 24 hours in the critical care unit and admitted following CPR, defined as the delivery of chest compressions in the 24 hours before admission, were identified. Case mix, withdrawal, outcome and activity were described annually for all admissions identified as post-cardiac arrest admissions, and separately for out-of-hospital cardiac arrest and in-hospital cardiac arrest. To assess whether in-hospital mortality had improved over time, hierarchical multivariate logistic regression models were constructed, with in-hospital mortality as the dependent variable, year of admission as the main exposure variable and intensive care unit (ICU) as a random effect. All analyses were repeated using only the data from those ICUs contributing data throughout the study period.

Results

During the period 2004–2014 survivors of cardiac arrest accounted for an increasing proportion of mechanically ventilated admissions to ICUs in the ICNARC CMPD (9.0 % in 2004 increasing to 12.2 % in 2014). Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during this period (OR 0.96 per year). Over this time, the ICU length of stay and time to treatment withdrawal has increased significantly. Re-analysis including only those 116 ICUs contributing data throughout the study period confirmed all the results of the primary analysis.

Conclusions

Risk-adjusted hospital mortality following admission to ICU after cardiac arrest has decreased significantly during the period 2004–2014. Over the same period the ICU length of stay and time to treatment withdrawal has increased significantly.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1390-6) contains supplementary material, which is available to authorized users.

Heterogeneity of prognostic profiles in non-small cell lung cancer: too many variables but a few relevant

OBJECTIVE

Many prognostic factors, exceeding 150, for non-small cell lung cancer (NSCLC) are mentioned in the literature. The different statistical weight of the some variables at issue, their heterogeneity and their clinical uselessness is reviewed.

STUDY DESIGN AND SETTING

Survival analysis of a cohort of NSCLC operated (n = 1730, 1993-1997) was carried out utilizing different statistical approaches: Cox proportional hazard analysis (CPHA), logistic regression (LRA), and recursive partitioning (CART).

RESULTS

CPHA identified 13 prognostic variables and 11 LRA. Of the 17 possible variables, 10 are coincident. CART provided five different diagnostic groups but only three differentiated survival levels. Parsimonious models were constructed including only T and N cancer staging variables. Areas under the ROC curve of 0.68 and 0.68 were found for CPHA and LGA parsimonious models respectively, and 0.72 and 0.71 for complete models.

CONCLUSION

Variables with a minimal impact on the respective models and thus with little or scarce predictive clinical repercussion were identified. Differences in the prognostic profile of survival can be caused by the different methodological approaches used. No relevant differences were found between the parsimonious and complete models. Although the amount of information managed is considerable, there continues to be a large predictive gap yet to be explained.

Comparison of anthropometric parameters as predictors of serum lipids in premenopausal women

No single anthropometric parameter has yet been generally accepted as being superior to others in assessing the metabolic risk associated with abdominal obesity. To compare waist circumference (WC) with waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR), regarding their association with serum lipids, we studied 166 women aged 20 to 48 yr; 53 were obese [body mass index (BMI) 30-39.9 Kg/m2], 50 were overweight (BMI 25-29.9 Kg/m2) and 63 normal weight (BMI 18.5-24.9 Kg/m2). Height, body weight, waist and hip circumferences, total serum cholesterol (Ch), low (LDL) and high density lipoprotein (HDL)-Ch and triglyceride (TG) concentrations were measured. The correlation coefficients between the concentration of serum lipid fractions and each anthropometric parameter did not differ significantly for any lipid variable when WC, WHR and WHtR were compared in the 166 women. The same applied for the obese and the overweight group, whereas in normal weight women there was significant association only between WC and LDL-Ch and between WHR and Ch/HDL-Ch ratio. Stepwise regression analysis showed that the proportion of variance in serum lipids did not change significantly when WHR or WHR+WHtR were added to WC into the regression model (18%, 18% and 18% for Ch; 13%, 18% and 18% for HDL-Ch; 18%, 18% and 12% for LDL-Ch; 35%, 35% and 37% for TG, respectively). These results indicate that WC is the main parameter associated with serum lipid levels and that the ratios studied do not provide additional substantial information in women who need weight management.

A case of Evans' syndrome in a patient with ulcerative colitis

The case of a 37-year-old male diagnosed 16 years previously with ulcerative colitis, admitted on account of hemolytic anaemia and thrombocytopaenia that responded to immunosuppressive therapy, is reported. Despite various peculiarities discussed, this may be the first reported case of Evans' syndrome associated with ulcerative colitis.

Staging in lung cancer: is 3 cm a prognostic threshold in pathologic stage I non-small cell lung cancer? A multicenter study of 1,020 patients

INTRODUCTION

Since 1974, a tumor size of 3 cm in diameter has been regarded as the prognostic threshold in the staging of bronchogenic carcinoma.

OBJECTIVE

To study the prognostic behavior of surgical-pathologic tumor size in non-small cell lung cancer (NSCLC) with complete resection.

DESIGN

Four-year multi-institutional prospective study from 1993 to 1997.

PATIENTS

Consecutive cases of NSCLC in pathologic stages IA-IB (pIA-pIB) treated surgically with complete resection in hospitals belonging to the Bronchogenic Carcinoma Co-operative Group of the Spanish Society of Pneumology and Thoracic Surgery (GCCB-S).

METHODS

The Schoenfeld procedure was used to identify different prognostic groups, considering 1 cm as the measurement unit.

RESULTS

Based on the 1,020 cases evaluated, four prognostic groups were identified: 0 to 2 cm (group A; n = 147), 2.1 to 4 cm (group B; n = 448), 4.1 to 7 cm (group C; n = 336), and > 7 cm (group D; n = 89). At 5 years, survival was 0.63 (95% confidence interval [CI], 0.58 to 0.68), 0.56 (95% CI, 0.53 to 0.59), 0.49 (95% CI, 0.46 to 0.52), and 0.38 (95% CI, 0.32 to 0.44) for groups A, B, C, and D, respectively. Differences between paired groups (log-rank) were significant: 0.0074 between groups A and B, 0.0048 between groups B and C, and 0.0034 between groups C and D.

CONCLUSIONS

In initial stages (pIA-pIB) of NSCLC, the 3-cm value was not found to behave as a prognostic threshold; in this study, four surgical-pathologic tumor size groups were identified with strong prognostic differences: from 0 to 2 cm, from 2.1 to 4 cm, from 4.1 to 7 cm, and > 7 cm.

Cosmic Ray and Solar Particle Investigations Over the South Polar Regions of the Sun

Observations of galactic cosmic radiation and anomalous component nuclei with charged particle sensors on the Ulysses spacecraft showed that heliospheric magnetic field structure over the south solar pole does not permit substantially more direct access to the local interstellar cosmic ray spectrum than is possible in the equatorial zone. Fluxes of galactic cosmic rays and the anomalous component increased as a result of latitude gradients by less than 50% from the equator to -80 degrees . Thus, the modulated cosmic ray nucleon, electron, and anomalous component fluxes are nearly spherically symmetric in the inner solar system. The cosmic rays and the anomalous nuclear component underwent a continuous, -26 day recurrent modulation to -80.2 degrees , whereas all recurring magnetic field compressions and recurring streams in the solar wind disappeared above approximately 55 degrees S latitude.

A program to measure new energetic particle nuclear interaction cross sections

The Transport Collaboration, consisting of researchers from institutions in France, Germany, Italy and the USA, has established a program to make new measurements of nuclear interaction cross sections for heavy projectiles (Z > or = 2) in targets of liquid H2, He and heavier materials. Such cross sections directly affect calculations of galactic and solar cosmic ray transport through matter and are needed for accurate radiation hazard assessment. To date, the collaboration has obtained data using the LBL Bevalac HISS facility with 20 projectiles from 4He to 58Ni in the energy range 393-910 MeV/nucleon. Preliminary results from the analysis of these data are presented here and compared to other measurements and to cross section prediction formulae.

Energetic Charged-Particle Phenomena in the Jovian Magnetosphere: First Results from the Ulysses COSPIN Collaboration

The Ulysses spacecraft made the first exploration of the region of Jupiter's magnetosphere at high Jovigraphic latitudes ( approximately 37 degrees south) on the dusk side and reached higher magnetic latitudes ( approximately 49 degrees north) on the day side than any previous mission to Jupiter. The cosmic and solar particle investigations (COSPIN) instrumentation achieved a remarkably well integrated set of observations of energetic charged particles in the energy ranges of approximately 1 to 170 megaelectron volts for electrons and 0.3 to 20 megaelectron volts for protons and heavier nuclei. The new findings include (i) an apparent polar cap region in the northern hemisphere in which energetic charged particles following Jovian magnetic field lines may have direct access to the interplanetary medium, (ii) high-energy electron bursts (rise times </= 1 minute and energies extending to > approximately 17 megaelectron volts) on the dusk side that are apparently associated with field-aligned currents and radio burst emissions, (iii) persistence of the global 10-hour relativistic electron "clock" phenomenon throughout Jupiter's magnetosphere, (iv) on the basis of charged-particle measurements, apparent dragging of magnetic field lines at large radii in the dusk sector toward the tail, and (v) consistent outflow of megaelectron volt electrons and large-scale departures from corotation for nucleons.

Mentally retarded siblings with congenital heart defect, peculiar facies and cryptorchidism in the male: possible McDonough syndrome with coincidental (X; 20) translocation

We report on a family in which two of the three children (girl and boy) have a MCA/MR syndrome consisting of peculiar facies, retarded psychomotor development, mental retardation, congenital heart defect, kyphoscoliosis, diastasis recti, and cryptorchidism in the boy. This syndrome is quite similar to that of the only family previously described and which was denominated McDonough Syndrome. The syndrome is delineated and autosomal recessive inheritance is suggested as the most likely etiology. A balanced translocation (X; 20) in the affected boy and in the unaffected mother was a coincidental finding.

Partial trisomy 6p: 46,XX, -10, der(10),t(6;10) (p22;q26)pat and HLA localisation

A child with multiple facial anomalies showed partial trisomy 6p, 46,XX, -10,der(10), t(6;10)(p22;q26)pat. Family studies suggested that the HLA complex is probably between 6p22.4 and 6p21.05. The HLA system had previously been localised between 6p21 and 23(12) and more precisely located by Berger et al3 above 6p21.05. We have studied the clinical presentation and the HLA system of the family of a child with partial trisomy 6p derived from a paternal translocation. Since Breuning et al4 collected and studied the first six known cases of trisomy 6p, 12 cases have been found with similar clinical manifestations, varying in the breakpoint and the part of 6p which was triplicated. Independent of the classification of the clinical manifestations of new syndromes, the importance of duplication-deficiency chromosomal abnormalities is determined by the localised of gene loci. The HLA system was localised by Berger et al3 at above 6p21.05. Our results suggest that the HLA system is below 6p22.4, the breakpoint found in the balanced translocation 6p22;10q26 of the father which produced the partial trisomy 6p22 leads to pter of the proband.

Interstitial deletion in the long arms of chromosome 1: 46,XY,del(1)(pter leads to q22::q25 leads to qter)

A child was brought to us with multiple anomalies. On examination we found an interstitial deletion in the long arms of chromosome 1. We studied genetic and chromosome markers, comparing our clinical and cytogenetic findings with other reported cases of chromosome 1 interstitial deletion.