Patient, caregiver and other knowledge user engagement in consensus-building healthcare initiatives: a scoping review protocol

INTRODUCTION

Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives.

METHODS AND ANALYSIS

Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives.

PROTOCOL REGISTRATION

https://osf.io/beqjr.

Private groundwater contamination and risk management: A comparative scoping review of similarities, drivers and challenges across two socio-economically developed regions

Consolidation of multi-domain risk management research is essential for strategies facilitating the concerted government (educational) and population-level (behavioural) actions required to reduce microbial private groundwater contamination. However, few studies to date have synthesised this literature or sought to ascertain the causal generality and extent of supply contamination and preventive responses. In light of the Republic of Ireland (ROI) and Ontario's high reliance and research focus on private wells and consequent utility for empirical comparison, a scoping review of pertinent literature (1990-2022) from both regions was undertaken. The SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) method was employed to inform literature searches, with Scopus and Web of Science selected as primary databases for article identification. The review identified 65 relevant articles (Ontario = 34, ROI = 31), with those investigating well user actions (n = 22) and groundwater quality (n = 28) the most frequent. A markedly higher pooled proportion of private supplies in the ROI exhibited microbial contamination (38.3 % vs. 4.1 %), despite interregional similarities in contamination drivers (e.g., weather, physical supply characteristics). While Ontarian well users demonstrated higher rates of historical (≥ 1) and annual well testing (90.6 % vs. 71.1 %; 39.1 % vs. 8.6 %) and higher rates of historical well treatment (42.3 % vs. 24.3 %), interregional levels of general supply knowledge were analogous (70.7 % vs. 71.0 %). Financial cost, organoleptic properties and residence on property during supply construction emerged as predictors of cognition and behaviour in both regions. Review findings suggest broad interregional similarities in drivers of supply contamination and individual-level risk mitigation, indicating that divergence in contamination rates may be attributable to policy discrepancies - particularly well testing incentivisation. The paucity of identified intervention-oriented studies further highlights the importance of renewed research and policy agendas for improved, targeted well user outreach and incentivised, convenience-based services promoting routine supply maintenance.

Inappropriate Use of Peripherally Inserted Central Catheters in Pediatrics: A Multisite Study

OBJECTIVES

This study aimed to describe how the current practice of peripherally inserted central catheter (PICC) use in hospitalized children aligns with the Michigan Appropriateness Guide for Intravenous Catheters (miniMAGIC) in Children recommendations, explore variation across sites, and describe the population of children who do not receive appropriate PICCs.

METHODS

A retrospective study was conducted at 4 children's hospitals in the United States. Children with PICCs placed January 2019 to December 2021 were included. Patients in the NICU were excluded. PICCs were categorized using the miniMAGIC in Children classification as inappropriate, uncertain appropriateness and appropriate.

RESULTS

Of the 6051 PICCs identified, 9% (n = 550) were categorized as inappropriate, 9% (n = 550) as uncertain appropriateness, and 82% (n = 4951) as appropriate. The number of PICCs trended down over time, but up to 20% of PICCs each year were not appropriate, with significant variation between sites. Within inappropriate or uncertain appropriateness PICCs (n = 1100 PICC in 1079 children), median (interquartile range) patient age was 4 (0-11) years, 54% were male, and the main reason for PICC placement was prolonged antibiotic course (56%, n = 611). The most common admitting services requesting the inappropriate/uncertain appropriateness PICCs were critical care 24%, general pediatrics 22%, and pulmonary 20%. Complications resulting in PICC removal were identified in 6% (n = 70) of inappropriate/uncertain PICCs. The most common complications were dislodgement (3%) and occlusion (2%), with infection and thrombosis rates of 1% (n = 10 and n = 13, respectively).

CONCLUSIONS

Although the majority of PICCs met appropriateness criteria, a substantial proportion of PICCs were deemed inappropriate or of uncertain appropriateness, illustrating an opportunity for quality improvement.

Social and Structural Drivers of Health and Transition to Adult Care

CONTEXT

Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition.

OBJECTIVES

This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth.

DATA SOURCES

Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022.

STUDY SELECTION

Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included.

DATA EXTRACTION

SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance.

RESULTS

101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion.

LIMITATIONS

Studies were heterogeneous and a meta-analysis was not possible.

CONCLUSIONS

Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

Thoracic Society of Australia and New Zealand (TSANZ) position statement on chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand

This position statement, updated from the 2015 guidelines for managing Australian and New Zealand children/adolescents and adults with chronic suppurative lung disease (CSLD) and bronchiectasis, resulted from systematic literature searches by a multi-disciplinary team that included consumers. The main statements are: Diagnose CSLD and bronchiectasis early; this requires awareness of bronchiectasis symptoms and its co-existence with other respiratory diseases (e.g., asthma, chronic obstructive pulmonary disease). Confirm bronchiectasis with a chest computed-tomography scan, using age-appropriate protocols and criteria in children. Undertake a baseline panel of investigations. Assess baseline severity, and health impact, and develop individualized management plans that include a multi-disciplinary approach and coordinated care between healthcare providers. Employ intensive treatment to improve symptom control, reduce exacerbation frequency, preserve lung function, optimize quality-of-life and enhance survival. In children, treatment also aims to optimize lung growth and, when possible, reverse bronchiectasis. Individualize airway clearance techniques (ACTs) taught by respiratory physiotherapists, encourage regular exercise, optimize nutrition, avoid air pollutants and administer vaccines following national schedules. Treat exacerbations with 14-day antibiotic courses based upon lower airway culture results, local antibiotic susceptibility patterns, clinical severity and patient tolerance. Patients with severe exacerbations and/or not responding to outpatient therapy are hospitalized for further treatments, including intravenous antibiotics and intensive ACTs. Eradicate Pseudomonas aeruginosa when newly detected in lower airway cultures. Individualize therapy for long-term antibiotics, inhaled corticosteroids, bronchodilators and mucoactive agents. Ensure ongoing care with 6-monthly monitoring for complications and co-morbidities. Undertake optimal care of under-served peoples, and despite its challenges, delivering best-practice treatment remains the overriding aim.

The Utility and Acceptability of a New Noninvasive Ventilatory Assist Device, Rest-Activity Cycler-Positive Airways Pressure, During Exercise in a Population of Healthy Adults: Cohort Study

Background

Noninvasive ventilation has been demonstrated to benefit people who have moderate to severe chronic obstructive pulmonary disease during acute exacerbations. Studies have begun to investigate the effectiveness of noninvasive ventilation during pulmonary rehabilitation to improve outcomes for people with chronic obstructive pulmonary disease; however, the lack of portability and humidification of these devices means their use is limited, especially when performing activities of daily living. A new prototype device, RACer-PAP (rest-activity cycler-positive airways pressure), delivers battery-operated positive airway pressure via a nasal interface while regulating nasal airway apportionment bias, removing the need for supplementary humidification. This device may offer people with chronic obstructive pulmonary disease an improved ability to participate in pulmonary rehabilitation and activities of daily living.

Objective

To assess the feasibility of exercising with the RACer-PAP in situ and the acceptability of the device during exercise in normal, healthy individuals.

Methods

A total of 15 healthy adults were invited to attend 2 exercise sessions, each 1 week apart. Sessions lasted approximately 1 hour and included 2 baseline 6-minute walk distance assessments, once with and once without the RACer-PAP in situ. Vital signs and spirometry results were monitored throughout, and spirometry was performed pre- and posttesting with RACer-PAP. Subjective questionnaires ascertained participant feedback on exercising with the device in situ.

Results

Of the 15 initial participants, 14 (93%) completed both sessions. There were no adverse events associated with exercising with the device in situ. There were no differences in vital signs or 6-minute walk distance whether exercising with or without the device in situ. There were small increases in maximum dyspnea score (on the Borg scale) when exercising with the device in situ (median score 2.0, IQR 0.5-3.0, vs 3.0, IQR 2.0-3.25). There were small increases in forced vital capacity following exercise with the RACer-PAP. None of the participants reported symptoms associated with airway drying. Participant feedback provided recommendations for modifications for the next iteration of the device prior to piloting the device with people with chronic obstructive pulmonary disease.

Conclusions

This study has shown RACer-PAP to be safe and feasible to use during exercise and has provided feedback for modifications to the device to improve its use during exercise. We now propose to consider the application of the device in a small pilot feasibility study to assess the safety, feasibility, and utility of the device in a population of people with moderate to severe chronic obstructive pulmonary disease.

Trial Registration

Australian New Zealand Clinical Trials Registry ACTRN12619000478112; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375477

Advancing leaders and leadership: New Zealand women in respiratory medicine

Special Series: Leading Women in Respiratory Medicine; Series Editors: Natasha Smallwood and Fanny Wai San Ko See related Editorial.

Private groundwater management and risk awareness: A cross-sectional analysis of two age-related subsets in the Republic of Ireland

Risk communication represents the optimal instrument for decreasing the incidence of private groundwater contamination and associated waterborne illnesses. However, despite attempts to promote voluntary well maintenance in high groundwater-reliant regions such as the Republic of Ireland, awareness levels of supply status (e.g. structural integrity) have remained low. As investigations of supply awareness are often thematically narrow and homogeneous with respect to sub-population, revised analyses of awareness among both current and future supply owners (i.e. adults of typical well owner and student age) are necessary. Accordingly, the current study utilised a national survey of well users and an age-based comparison of supply awareness. Awareness was measured among 560 Irish private well users using a multi-domain scoring framework and analysed in conjunction with experiential variables including experience of extreme weather events and previous household infections, and perceived self-efficacy in maintaining supply. Respondents displayed a median overall awareness score of 66.7%, with supply owners (n = 399) and students (n = 161) exhibiting median scores of 75% and 58.3%. Awareness among both combined respondent subsets and well owners was significantly related to gender, well use factors and self-perceived behavioural efficacy while awareness among students was not correlated with any independent variable. Cluster analysis identified three distinct respondent groups characterised by awareness score and gender in both current and future well owner subsets. Male well owners and students displayed higher perceived self-efficacy irrespective of awareness score while female well owners that demonstrated high awareness were significantly more likely to report postgraduate educational (p < 0.001). Findings suggest that recent experience of extreme weather events does not significantly influence supply awareness and mirror previously identified knowledge differences between well owners and young adults. Age, gender, supply use and perceived self-efficacy emerge as recurring focal points and accordingly merit consideration from groundwater and health communication practitioners for future risk interventions.

Sputum procalcitonin: a potential biomarker in stable bronchiectasis

Sputum procalcitonin is elevated in exacerbations of bronchiectasis. The primary aim of this study was to investigate whether sputum procalcitonin levels are higher in patients with stable bronchiectasis than in healthy controls. We also assessed differences in procalcitonin levels in spontaneously expectorated and induced sputum samples and their repeatability 1 week later.

Participants included were aged over 18 years and either had radiologically confirmed bronchiectasis or were healthy controls. Patients with bronchiectasis were clinically stable for at least 6 weeks and had spontaneous and induced sputum collected at visit 1 and again 7 days later. Only induced sputum samples were collected from healthy controls during visit 1. Sputum procalcitonin concentrations in sputum were measured.

In total, 30 patients with bronchiectasis and 15 healthy controls were enrolled in this observational study. In the pooled data from visit 1 and 2, the geometric mean procalcitonin level in induced sputum was significantly higher in the bronchiectasis group than in the healthy control group (1.5 ng·mL⁻¹, 95% CI 1.0–2.1 ng·mL⁻¹versus 0.4 ng·mL⁻¹, 95% CI 0.2–0.9 ng·mL⁻¹; mean ratio 3.6, 95% CI 1.5–8.6; p=0.006). Mean procalcitonin level was higher in spontaneous sputum than in induced sputum at visit 1 (1.8 ng·mL⁻¹, 95% CI 1.2–2.7 ng·mL⁻¹versus 1.1 ng·mL⁻¹, 95% CI 0.7–1.8 ng·mL⁻¹) and visit 2 (1.5 ng·mL⁻¹, 95% CI 1.0–2.5 ng·mL⁻¹versus 1.2 ng·mL⁻¹, 95% CI 0.8–1.6 ng·mL⁻¹; p=0.001). Repeating spontaneous and induced sputum procalcitonin levels 1 week later produced similar concentrations (p=0.29, intraclass correlation coefficient (ICC)=0.76 and p=0.72, ICC=0.70, respectively).

Sputum procalcitonin is increased in patients with stable bronchiectasis and has potential as a biomarker of airway inflammation and infection in bronchiectasis.

Sputum procalcitonin levels are higher in patients with stable bronchiectasis than in healthy controls. Sputum procalcitonin has the potential to be a biomarker of airway inflammation and infection in bronchiectasis.https://bit.ly/3ivn7R9

Private groundwater contamination and extreme weather events: The role of demographics, experience and cognitive factors on risk perceptions of Irish private well users

Extreme weather events (EWEs) may significantly increase pathogenic contamination of private (unregulated) groundwater supplies. However, due to the paucity of protective guidance, private well users may be ill-equipped to undertake adaptive actions. With rising instances of waterborne illness documented in groundwater-dependent, developed regions such as the Republic of Ireland, a better understanding of well user risk perceptions pertaining to EWEs is required to establish appropriate educational interventions. To this end, the current study employed an online and physical questionnaire to identify current risk perceptions and correspondent predictors among Irish private well users concerning extreme weather. Respondents were elicited via purposive sampling, with 515 private well users elucidating perceived supply contamination risk in the wake of five EWEs between the years 2013-2018 including drought and pluvial flooding. A novel scoring protocol was devised to quantify overall risk perception (i.e. perceived likelihood, severity and consequences) of extreme weather impacts. Overall risk perception of EWEs was found to demonstrate a significant relationship with gender (p = 0.017) and event experience (p < 0.001), with female respondents and those reporting prior event experience exhibiting higher median risk perception scores. Risk perception was additionally mediated by perceived self-efficacy in undertaking supply maintenance (p = 0.001), as well users citing confidence in ability scored significantly lower than those citing no confidence. Two-step cluster analysis identified three distinct respondent subsets based on risk perception of EWEs (high, moderate and low perception), with female respondents and those with a third-level education significantly more likely to fall within the high perception cluster. Study findings affirm that certain demographic, experiential and cognitive factors exert a significant influence on private well user risk perceptions of EWE impacts and highlight potential focal points for future educational interventions seeking to reduce the risk of human infection associated with groundwater and extreme weather.

Knowledge and behavioural interventions to reduce human health risk from private groundwater systems: A global review and pooled analysis based on development status

Groundwater contamination constitutes a significant health risk for private well users residing in rural areas. As the responsibility to safeguard rural private domestic groundwater typically rests with non-expert homeowners, interventions promoting risk mitigation and awareness represent the most viable means of preventing supply contamination. However, no global review or pooled analyses of these interventions has been undertaken to date. The current study sought to identify and quantify the performance of private well interventions from 1990 to 2018 via a global systematised review and pooled analysis. The PICO (Population-Intervention-Comparison-Outcome) approach was employed for literature identification. Relevant studies were statistically analysed across two quantitative outcome (performance) types, namely knowledge and behaviour, controlling for intervention characteristics and country development status. Mean behavioural and knowledge attainment across interventions was 53% and 48%, respectively, with interventions in economically developed regions exhibiting higher behavioural outcomes (56% vs. 45%) than those in developing regions. Geographically, interventions were located in southern or southeast Asia (n = 23), North America (n = 15), Central America (n = 1) and Africa (n = 1), with none identified in Australia/Oceania, Europe, or South America. Behavioural outcomes were significantly associated with presence of educational/research coordinator (p = 0.023), with these interventions attaining higher levels of efficacy (+74%) than those implemented by other coordinator types. Findings indicate that instructor-led, practical interventions allied with both large- and local-scale awareness-raising campaigns represent an optimum approach for future private well risk interventions. Subsequent adoption of such interventions may lead to increased levels of private well maintenance and provide a point of reference for myriad water and health communication contexts.

An oxygen-rich atmosphere or systemic fluoxetine extend the time to respiratory arrest in a rat model of obstructive apnea

Audiogenic seizure-prone mice can be protected from seizure-associated death by exposure to an oxygen atmosphere or treatment with selective serotonergic reuptake inhibitors (SSRIs). We have shown previously in a rat model that epileptic seizure activity can spread through brainstem areas to cause sufficient laryngospasm for obstructive apnea and that the period of seizure-associated obstructive apnea can last long enough for respiratory arrest to occur. We hypothesized that both the oxygen-rich atmosphere and SSRIs function by prolonging the time to respiratory arrest, thus ensuring that seizure activity stops before the point of respiratory arrest to allow recovery of respiratory function. To test this hypothesis, we evaluated each preventative treatment in a rat model of controlled airway occlusion where the times to respiratory arrest can be measured. Adult male Sprague Dawley rats (median age = 66 days) were studied in the absence of any seizure activity. By directly studying responses to controlled airway occlusion, rather than airway occlusion secondary to seizure activity, we could isolate the effects of manipulations that might prolong respiratory arrest from the effects of those manipulations on seizure intensity. All group sizes were ≥ 8 animals per group. We found that both oxygen exposure and fluoxetine significantly increased the time to respiratory arrest by up to 65% (p < .0001 for 5 min oxygen exposure; p = .031 for 25 mg/kg fluoxetine tested 60 min after injection) and, given that neither treatment has been shown to significantly alter seizure duration, these increases can account for the protection of either manipulation against death in sudden death models. Importantly, we found that 30 s of exposure to oxygen produced nearly the same protection as 5 min exposure suggesting that oxygen exposure could start after a seizure starts (p = .0012 for 30 s oxygen exposure). Experiments with 50% oxygen/50% air mixtures indicate that the oxygen concentration needs to be above about 60% to ensure that times to respiratory arrest will always be longer than a period of seizure-induced airway occlusion. Selective serotonin reuptake inhibitors, while instructive with regard to mechanism, require impractical dosing and may carry additional risk in the form of greater challenges for resuscitation. We conclude that oxygen exposure or SSRI treatment prevent seizure associated death by sufficiently prolonging the time to respiratory arrest so that respiratory function can recover after the seizure abates and eliminates the stimulus for seizure-induced apnea.

Health care experiences of mothers of children with bronchiectasis in Counties Manukau, Auckland, New Zealand

BACKGROUND

Bronchiectasis is a worsening public health problem in New Zealand. This study aimed to explore the health care experiences of mothers of children with bronchiectasis in the Counties Manukau District Health Board area of Auckland, New Zealand.

METHODS

Semi-structured interviews were undertaken with ten mothers of children with bronchiectasis. Data were analysed using thematic analysis.

RESULTS

Five themes emerged: 1) Searching for answers, describing mothers' search for a diagnosis; 2) (Dis)empowerment, describing mothers' acquisition of knowledge, leading to empowerment; 3) Health care and relationships, describing the impact of relationships on the mother's health care experiences; 4) A juggling act, describing the challenges of juggling health care with school, work and family; 5) Making it work, describing how mothers overcome barriers to access health care for their child.

CONCLUSIONS

The health provider-parent relationship was crucial for fostering positive health care experiences. Mothers' acquisition of knowledge facilitated empowerment within those relationships. Additionally, mothers' perceptions of the quality and benefit of health services motivated them to overcome barriers to accessing care. Study findings may help to improve health care experiences for parents of children with bronchiectasis if identified issues are addressed.

Molecular testing of 163 patients with Morquio A (Mucopolysaccharidosis IVA) identifies 39 novel GALNS mutations

Morquio A (Mucopolysaccharidosis IVA; MPS IVA) is an autosomal recessive lysosomal storage disorder caused by partial or total deficiency of the enzyme galactosamine-6-sulfate sulfatase (GALNS; also known as N-acetylgalactosamine-6-sulfate sulfatase) encoded by the GALNS gene. Patients who inherit two mutated GALNS gene alleles have a decreased ability to degrade the glycosaminoglycans (GAGs) keratan sulfate and chondroitin 6-sulfate, thereby causing GAG accumulation within lysosomes and consequently pleiotropic disease. GALNS mutations occur throughout the gene and many mutations are identified only in single patients or families, causing difficulties both in mutation detection and interpretation. In this study, molecular analysis of 163 patients with Morquio A identified 99 unique mutations in the GALNS gene believed to negatively impact GALNS protein function, of which 39 are previously unpublished, together with 26 single-nucleotide polymorphisms. Recommendations for the molecular testing of patients, clear reporting of sequence findings, and interpretation of sequencing data are provided.

The prevalence of aortic calcification on vertebral fracture assessment imaging among patients with rheumatoid arthritis

Patients with rheumatoid arthritis (RA) are at increased risk of osteoporosis (OP) and cardiovascular disease (CVD). Dual-energy X-ray absorptiometry scans have been validated for identifying patients with RA at risk for fracture. Reliable CVD risk stratification remains an unmet need in this population. Vertebral fracture assessment (VFA)-detected abdominal aortic calcification (AAC) has been validated as a marker of CVD in other populations, but the prevalence among patients with RA is unknown. In this study, we determined the prevalence and severity of AAC on VFA scans in a cohort of patients with RA. AAC was detected in 211 of the 603 (35%) eligible subjects; 24% were graded as severe. In multivariable analyses, the presence of AAC was significantly associated with longer disease duration and higher disease activity (p<0.05). Further studies are needed on the relationship between AAC and CVD in patients with RA.

The impact of meeting donor management goals on the development of delayed graft function in kidney transplant recipients

Many organ procurement organizations (OPOs) utilize preset critical care endpoints as donor management goals (DMGs) in order to standardize care and improve outcomes. The objective of this study was to determine the impact of meeting DMGs on delayed graft function (DGF) in renal transplant recipients. All eight OPOs of the United Network for Organ Sharing Region 5 prospectively implemented nine DMGs in every donor after neurologic determination of death (DNDD). "DMGs met" was defined a priori as achieving any seven of the nine DMGs and this was recorded at the time of consent for donation to reflect donor hospital ICU management, 12-18 h later, and prior to organ recovery. Multivariable analyses were performed to identify independent predictors of DGF (dialysis in the first week after transplantation) with a p<0.05. A total of 722 transplanted kidneys from 492 DNDDs were included. A total of 28% developed DGF. DMGs were met at consent in 14%, 12-18 h in 32% and prior to recovery in 38%. DGF was less common when DMGs were met at consent (17% vs. 30%, p=0.007). Independent predictors of DGF were age, Cr and cold ischemia time, while meeting DMGs at consent was significantly protective. The management of potential organ donors prior to consent affects outcomes and should remain a priority in the intensive care unit.

Publication guidelines for quality improvement in health care: evolution of the SQUIRE project

In 2005, draft guidelines were published for reporting studies of quality improvement interventions as the initial step in a consensus process for development of a more definitive version. This article contains the full revised version of the guidelines, which the authors refer to as SQUIRE (Standards for QUality Improvement Reporting Excellence). This paper also describes the consensus process, which included informal feedback from authors, editors and peer reviewers who used the guidelines; formal written commentaries; input from a group of publication guideline developers; ongoing review of the literature on the epistemology of improvement and methods for evaluating complex social programmes; a two-day meeting of stakeholders for critical discussion and debate of the guidelines' content and wording; and commentary on sequential versions of the guidelines from an expert consultant group. Finally, the authors consider the major differences between SQUIRE and the initial draft guidelines; limitations of and unresolved questions about SQUIRE; ancillary supporting documents and alternative versions that are under development; and plans for dissemination, testing and further development of SQUIRE.

Sensitivity of carbon sequestration costs to soil carbon rates

Modifying current agricultural management practices as a means of sequestering carbon has been shown to be a relatively low cost way to offset greenhouse gas emissions. In this paper we examine the sensitivity of the estimates of the amount of soil carbon sequestered and the implied costs of sequestering a tonne of carbon to changes in the rates of soil carbon sequestered for alternative production practices. An application is made to the dryland grain production systems of the US Northern Plains where the marginal costs of soil C range from $20 to $100 per MT. We show that the resulting changes in the marginal costs quantities of C sequestered are not a monotonic transformation of the changes in the soil carbon rates. These results underscore the importance of using a linked economic and biophysical simulation model to assess the economic potential for sequestering carbon in agricultural soils.

Examination performance and graphological analysis of students' handwriting

Research has yielded mixed support for graphological claims. The present study was designed to see whether specific components of students' handwriting were related to personality traits associated with achievement in written examinations. If aspects were identified that could be used to predict future academic performance, the findings would not only be of interest to graphologists but would be invaluable to both student and tutor in a teaching environment. In a blind trial, 100 handwriting samples from first-year scripts were analysed for the presence or absence of 12 graphological characteristics deemed to be relevant for academic performance, and each of these aspects was tested for association with the grade points awarded. Statistically significant differences were found for two of the 12 characteristics: "carefulness" and "constancy." Also, measurements of individual letters indicated that consistent slant was significantly associated with high grade points, whereas upright or mixed writing was not. These attributes appeared to be generally related to readability and aesthetic quality. Although such aspects might influence the grading of scripts by teachers, typed versions received similar grades to those awarded for the handwritten versions.

Heparin versus citrate regional anticoagulation during autotransfusion in a porcine intra-abdominal hemorrhage model

Our objective was to determine the effects of anticoagulants and blood loss on hemodynamic, hematologic, and coagulation parameters following autotransfusion in an animal model of intraabdominal hemorrhage. We performed a prospective, randomized observational animal study at an animal research laboratory at a university medical center. Eight Landrace, domestic pigs, weighing 17-23 kg, each underwent jugular venous and iliac arterial catheterization and laparotomy with retroperitoneal dissection for aortic exposure to simulate an operative environment. Following baseline laboratory and hemodynamic determinations, intra-abdominal hemorrhage was accomplished via aortotomy in three sequential 10 mL/kg blood volumes. After allowing pooling in the exposed retroperitoneum to ensure tissue contact, the shed blood was suctioned, processed, and washed in an autotransfusion device utilizing either heparin (n = 4) or acid-citrate-dextrose (n = 4) as a system anticoagulant. Prior to autologous transfusion, each pig received a 20 mL/kg intravenous bolus of 0.9 per cent saline to treat shock. The processed blood was then infused, and laboratory and hemodynamic measurements were repeated following each cycle of hemorrhage and autotransfusion. Sequential fixed volume hemorrhage resulted in significant reductions in mean arterial pressure. Despite crystalloid infusion and transfusion of processed shed blood, postresuscitation mean arterial pressure did not return to baseline values, with no difference noted between anticoagulant groups. Infusion of increasing volumes of autologous blood resulted in significant reductions in hematocrit, platelet count, fibrinogen, antithrombin III, ionized calcium, and total protein. The decrease in concentration of each variable was independent of the choice of anticoagulant with the exception of antithrombin III, with higher levels noted in animals receiving blood anticoagulated with acid-citrate-dextrose. Prothrombin time and partial thromboplastin time were unaffected by volume of autologous transfusion or choice of anticoagulant. We conclude that changes in hemodynamic, hematologic, and coagulation parameters associated with hemorrhage and autotransfusion appear related more to the volume of blood loss and the cumulative pheresis of plasma than to the choice of anticoagulant.

Effects of intraluminal and extracorporeal inferior vena caval bypass on canine hemodynamics

OBJECTIVE

To compare inferior vena cava-right atrial extracorporeal bypass with intraluminal atriocaval shunting during hepatic vascular isolation.

DESIGN

Prospective, randomized, controlled animal study.

SETTING

University research laboratory.

SUBJECTS

Adult mongrel dogs (n = 5) weighing 20 to 27 kg.

INTERVENTIONS

Anesthetized dogs underwent laparotomy and sternotomy for vascular isolation. For atriocaval shunting, 20- and 24-Fr intraluminal shunts were inserted into the inferior vena cava via right atriotomy. For extracorporeal bypass, each animal underwent inferior vena cava, portal vein, and right atrial cannulation for venovenous bypass, utilizing a centrifugal pump. Hemodynamic data were recorded at baseline and at intervals after caval occlusion, Pringle maneuver, and caval occlusion with Pringle maneuver.

MEASUREMENTS AND MAIN RESULTS

Isolated Pringle maneuver and caval occlusion with Pringle maneuver produced significant reductions in mean arterial pressure (MAP) and cardiac output, irrespective of pulmonary artery occlusion pressure. Extracorporeal bypass, including both caval and portal venous return, produced significant increases in MAP and cardiac output during caval occlusion with Pringle maneuver, while atriocaval shunting and extracorporeal bypass without portal venous return did not improve MAP or cardiac output.

CONCLUSION

Venovenous extracorporeal bypass with portal return, acting as a right ventricular assist device, is superior to intraluminal atriocaval shunting in maintaining hemodynamic stability during hepatic vascular isolation.

Infant apnea detection after herniorrhaphy

STUDY OBJECTIVE

To elucidate risk factors for apnea in preterm infants discharged from the hospital and in full-term healthy infants. To determine the efficacy of real-time cardiopulmonary monitoring versus computerized storage and retrieval for infants at risk.

STUDY DESIGN

Prospective study.

SETTING

Operating rooms and pediatric patient care units of university medical center.

PATIENTS

27 preterm infants and 20 full-term infants no more than 60 weeks' post-conceptional age, who were admitted for elective herniorrhaphy.

INTERVENTIONS

Infants were monitored before and after herniorrhaphy with general anesthesia using an infant apnea impedance monitor, pulse oximetry, and nursing observation.

MEASUREMENTS AND MAIN RESULTS

Demographic information and medical history were correlated with postoperative apnea. The sensitivity and specificity of nursing observation and oximetry were compared with computerized apnea monitors. Five patients (11%, four preterm, one full-term) were apneic postoperatively as recorded by computerized pneumocardiography. Previous apnea history, gestational age at birth, and postconceptional age at operation positively correlated with postoperative apnea. Nursing observation failed to detect 4 of 5 patients with documented apnea (sensitivity 20%, positive predictive value 50%). Pulse oximetry failed to detect 3 of 5 patients with apnea (sensitivity 40%, positive predictive value 66%).

CONCLUSIONS

Although it is easier to predict postoperative respiratory dysfunction in previously sick or very young infants, absolute predictability for all neonates remains elusive. Clinical monitors with both storage and retrieval capabilities and real-time monitoring increase our ability to detect significant events in children at risk for apnea after herniorrhaphy.

Preparation of blood components

The processing of blood into various components and the knowledge of component usage enables veterinarians to support and beneficially treat more animals. Blood products include packed red blood cells; fresh frozen, fresh, and modified plasma; cryoprecipitate; platelets; and concentrates. Some methods of preparation of blood products and storage are presented.

Cancer of the maxillary sinus treated with surgery and/or radiation therapy

This is an analysis of 37 previously untreated patients with squamous cell carcinoma of the maxillary sinus treated with curative intent at the University of Florida from January 1966 through January 1984. All patients were followed for at least two years and 86 per cent (32/27) were followed for a minimum of five years. Patients were treated for cure with radiation therapy alone (25), surgery alone (1), or surgery and preoperative (6) or postoperative (5) radiation therapy. This study presents the results of treatment and the incidence of treatment-related complications in this group of patients.

Viewing distance affects stereoscopic tilt created with spatial frequency disparity

A controversy exists as to whether stereoscopic tilt created with interocular differences in spatial frequency is based on perception of spatial frequency disparity or positional disparity. To determine which hypothesis is correct, we investigated the influence of viewing distance on perceived tilt. Tilt was induced by having observers view, at three viewing distances, dichoptic spatial frequency grating patterns differing in frequency by 25%. By appropriate physical scaling of the size of the patterns, their spatial frequency and angular width remained unchanged as distance varied. Under such conditions, the spatial frequency disparity hypothesis predicts no effect of distance, whereas the positional disparity hypothesis predicts a significant effect of distance (due to stereoscopic depth constancy) on the magnitude of tilt. The results showed that perceived tilt does covary with distance, a result consistent with only the positional disparity hypothesis.

The detection of conventional class I and class II I-E homologue major histocompatibility complex molecules on feline cells

The presence on feline cells of class I and class II I-E type major histocompatibility complex (MHC) homologues was demonstrated using cross-reacting monoclonal antibodies (mAb). The feline class I antigen homologues were detected with both immunofluorescent and biochemical techniques, using the anti-human class I mAb W6/32. The class I antigens were detected on in vitro cultured feline fibroblasts and lymphoid cells, but not on fresh lymphoid cells, apparently as a result of the association of bovine beta-2 microglobulin with feline class I heavy chains which generated the determinant(s) recognized by mAb W6/32. Class II I-E-like molecules could be detected with immunofluorescent techniques using the species cross-reactive anti-mouse I-E antibody 40D only when peripheral blood mononuclear cells were activated, for example, with the mitogens staphylococcus enterotoxin A or lipopolysaccharide. The predominant expression of I-A-like molecules by resting class II-positive feline cells could explain some of the functional difference we have seen in comparison with those of most other mammalian species.

Feline melanoma: a comparative study of ocular, oral, and dermal neoplasms

Melanomas diagnosed in 29 cats over an 11 year period included 19 ocular (16 intraocular, three palpebral), five oral, and five dermal melanomas. Intraocular melanomas involved the ciliary body and iris in 12; the whole eye was involved in four. The average age of cats with intraocular melanomas was 11 years; the female : male ratio was 9 : 7. Histologically, eight intraocular tumors were mixed, six were epithelioid, and two were spindle cell. Ten of 16 cats (62.5%) with intraocular melanomas were killed because of the tumor at a mean of 156 days; four are living with no evidence of disease (average, 255 days). The mean time of death in cats with palpebral melanoma was 409 days. Metastasis occurred in 63% of cats with intraocular melanoma and all cats with palpebral melanoma. Four cats with oral melanoma were killed at a mean of 61 days; all had metastasis. Of five cats with cutaneous melanoma, one was killed with metastasis at 90 days; three cats were alive without evidence of recurrence or metastasis greater than 365 days after surgery. Results of this study indicate that in the cat, ocular melanomas are more common than oral and dermal melanomas, and ocular and oral melanomas are more malignant than dermal melanomas, with higher rates of mortality and metastasis.

Primary pulmonary neoplasia in the dog and cat

This article covers the pertinent clinical, physical, and radiographic findings in dogs and cats with primary pulmonary neoplasia. Diagnostic and treatment recommendations are made. Although primary pulmonary neoplasia is rare in both the dog and cat, it appears to be diagnosed with increasing frequency. Early detection and surgical treatment of carefully selected cases can prolong a good quality of life.

Evaluation of effects of levamisole and surgery on canine mammary cancer

Three hundred and forty-five dogs with mammary tumors were initially evaluated for study. One hundred and forty-four dogs with untreated malignant mammary tumors (136 adenocarcinomas, 5 malignant mixed, 3 sarcomas) were selected for study. All dogs were clinically staged and stratified on the basis of tumor volume and body weight. Dogs were randomized to either a radical mastectomy or simple mastectomy group, and then further randomized to a levamisole or placebo group. There was no significant difference in either survival time or cancer-free survival time between the surgery groups or between the levamisole and placebo groups. The most significant prognostic factor was tumor volume; dogs with tumors less than 41 cc had significantly enhanced survival time (p = 0.0007) and cancer-free survival time (p = 0.0005).

Levamisole as adjuvant to chemotherapy for canine lymphosarcoma

Ninety-eight dogs with previously untreated lymphosarcoma were selected for study. All dogs were clinically staged and stratified on the basis of stage. All dogs were treated with combination chemotherapy (vincristine, L-asparaginase, cyclophosphamide, and methotrexate) and randomized to either a levamisole or placebo group. There was no significant difference in either remission time or survival time between the levamisole and placebo groups. Clinical stage, age, and body weight had no influence on remission or survival time. The most significant prognostic factor was sex: Female dogs had significantly enhanced remission time (p = 0.004) and survival time (p = less than 0.001).