Role of the multidisciplinary team in the care of the tracheostomy patient

Barbara Bonvento,1 Sarah Wallace,1,2 James Lynch,1 Barry Coe,1 Brendan A McGrath1 1Acute Intensive Care Unit, University Hospital South Manchester, Manchester, 2Royal College of Speech and Language Therapists, London, UK Abstract: Tracheostomies are used to provide artificial airways for increasingly complex patients for a variety of indications. Patients and their families are dependent on knowledgeable multidisciplinary staff, including medical, nursing, respiratory physiotherapy and speech and language therapy staff, dieticians and psychologists, from a wide range of specialty backgrounds. There is increasing evidence that coordinated tracheostomy multidisciplinary teams can influence the safety and quality of care for patients and their families. This article reviews the roles of these team members and highlights the potential for improvements in care. Keywords: tracheotomy, physiotherapist, Speech & Language, Nursin

Glial glutamate transporters and maturation of the mouse somatosensory cortex

In the adult nervous system, glutamatergic neurotransmission is tightly controlled by neuron-glia interactions through glial glutamate reuptake by the specific transporters GLT-1 and GLAST. Here, we have explored the role of these transporters in the structural and functional maturation of the somatosensory cortex of the mouse. We provide evidence that GLT-1 and GLAST are early and selectively expressed in barrels from P5 to P10. Confocal and electron microscopy confirm that the expression is restricted to the astroglial membrane. By P12, and despite an increased global expression as observed by immunoblotting, the barrel pattern of GLAST and GLT-1 staining is no longer evident. In P10 GLT-1 -/- and GLAST -/- mice, the cytoarchitectural segregation of the barrels is preserved. However, at P9-10, the functional response to whisker stimulation, measured by deoxyglucose uptake, is markedly decreased in GLT-1 -/- and GLAST -/- mice. The role of GLAST is transient since the metabolic response is already restored at P11-12 in GLAST -/- mice and remains unchanged in adulthood. However, deletion of GLT-1 seems to impair the functional metabolic response until adulthood. Our data suggest that astrocyte-neuron interactions via the glial glutamate transporters are involved in the functional maturation of the whisker representation in the somatosensory cortex

A lactate-dependent shift of glycolysis mediates synaptic and cognitive processes in male mice

Astrocytes control brain activity via both metabolic processes and glio- transmission, but the physiological links between these functions are scantly known. Here we show that endogenous activation of astrocyte type-1 canna- binoid (CB1) receptors determines a shift of glycolysis towards the lactate- dependent production of D-serine, thereby gating synaptic and cognitive functions in male mice. Mutant mice lacking the CB1 receptor gene in astro- cytes (GFAP-CB1-KO) are impaired in novel object recognition (NOR) memory. This phenotype is rescued by the gliotransmitter D-serine, by its precursor L- serine, and also by lactate and 3,5-DHBA, an agonist of the lactate receptor HCAR1. Such lactate-dependent effect is abolished when the astrocyte-specific phosphorylated-pathway (PP), which diverts glycolysis towards L-serine synthesis, is blocked. Consistently, lactate and 3,5-DHBA promoted the co- agonist binding site occupancy of CA1 post-synaptic NMDA receptors in hip- pocampal slices in a PP-dependent manner. Thus, a tight cross-talk between astrocytic energy metabolism and gliotransmission determines synaptic and cognitive processes

Reactive astrocyte nomenclature, definitions, and future directions

Reactive astrocytes are astrocytes undergoing morphological, molecular, and functional remodeling in response to injury, disease, or infection of the CNS. Although this remodeling was first described over a century ago, uncertainties and controversies remain regarding the contribution of reactive astrocytes to CNS diseases, repair, and aging. It is also unclear whether fixed categories of reactive astrocytes exist and, if so, how to identify them. We point out the shortcomings of binary divisions of reactive astrocytes into good-vs-bad, neurotoxic-vs-neuroprotective or A1-vs-A2. We advocate, instead, that research on reactive astrocytes include assessment of multiple molecular and functional parameters-preferably in vivo-plus multivariate statistics and determination of impact on pathological hallmarks in relevant models. These guidelines may spur the discovery of astrocyte-based biomarkers as well as astrocyte-targeting therapies that abrogate detrimental actions of reactive astrocytes, potentiate their neuro- and glioprotective actions, and restore or augment their homeostatic, modulatory, and defensive functions

Economic and organizational impact of a clinical decision support system on laboratory test ordering

Background:: We studied the impact of a clinical decision support system (CDSS) implemented in a few wards of two Italian health care organizations on the ordering of redundant laboratory tests under dierent perspectives: (1) analysis of the number of tests, (2) cost analysis, (3) end-user satisfaction before and after the installation of the CDSS. Methods:: (1) and (2) were performed by comparing the ordering of laboratory tests between an intervention group of wards where a CDSS was in use and a control group where a CDSS was not in use; data were compared during a 3-month period before (2014) and a 3-month period after (2015) CDSS installation. To measure end-user satisfaction, a questionnaire based on POESUS was administered to the medical sta. Results:: After the introduction of the CDSS, the number of laboratory tests requested decreased by 16.44% and costs decreased by 16.53% in the intervention group, versus an increase (+3.75%) in the number of tests and of costs (+1.78%) in the control group. Feedback from practice showed that the medical sta was generally satised with the CDSS and perceived its benets, but they were less satised with its technical performance in terms of slow response time. Conclusions:: The implementation of CDSSs can have a positive impact on both the eciency of care provision and health care costs. The experience of using a CDSS can also result in good practice to be implemented by other health care organizations, considering the positive result from the rst attempt to gather the point of view of end-users in Italy

La valutazione di impatto di un sistema order entry sull’appropriatezza degli esami di laboratorio. Approccio metodologico e prime evidenze

L’incidenza del numero di esami di laboratorio è aumentata negli ultimi anni e si ritiene che l’inappropriatezza ne rappresenti una delle cause principali. Vari contributi tendenti a valutare i costi derivanti dall’inappropriatezza e l’efficacia di azioni volte a ridurne l’incidenza hanno prodotto, ad oggi, risultati contrastanti. Alla luce dell’analisi della letteratura e dei primi risultati di uno studio realizzato in un contesto ospedaliero, tale lavoro intende proporre un’analisi metodologica degli aspetti essenziali da includere nella valutazione di impatto relativa all’introduzione di un sistema informatico prototipale (SIP) del tipo order entry nelle Aziende sanitarie. Il lavoro intende anche presentare le prime evidenze relative agli effetti derivanti dall’utilizzo del SIP sul numero e sui costi degli esami di laboratorio eseguiti.The incidence of the number of laboratory tests has been increasing in recent years, and many authors find that their inappropriateness represents one of the main causes of the rising demand for laboratory tests. Some literature evaluates the costs of inappropriateness and the effectiveness of actions aiming at reducing the incidence of laboratory tests; however, it has produced conflicting results so far. This paper aims at analyzing the essential aspects to be included in the evaluation of the impact on the introduction of a computer system prototype (SIP) within a hospital department. SIP is able to detect if a laboratory test has already been performed on the same patient, when a new laboratory test is requested; thus the SIP allows the clinicians to assess the opportunity to repeat it. Considering costs and outcomes, measured before and after the implementation of the new technology (SIP), a model for the evaluation of its impact is proposed

Valutazione dell’intensità assistenziale nell’analisi costo-efficacia di due protocolli chirurgici alternativi per l’intervento di resezione colo-rettale per cancro del colon

Increasingly, the cost effectiveness assessment requires careful evaluation of nursing care, particularly when that assessment is applied to alternative therapeutic pathways in hospitals. The main objective of the study is to evaluate the intensity of care in the two protocols for surgical resection of the colon - recto: the traditional protocol and the fast-track protocol and the possible correlation between the complexity of care and the cost of hospitalization for the purpose an assessment of the cost-effectiveness of the two alternative protocols. All this can lead, in our view, a reinterpretation of the traditional cost-effectiveness as a function of intensive care

Valutazione dell’intensità assistenziale nell’analisi costo-efficacia di due protocolli chirurgici alternativi per l’ intervento di resezione colo-rettale per cancro del colon

Increasingly, the cost effectiveness assessment requires careful evaluation of nursing care, particularly when that assessment is applied to alternative therapeutic pathways in hospitals. The main objective of the study is to evaluate the intensity of care in the two protocols for surgical resection of the colon - recto: the traditional protocol and the fast-track protocol and the possible correlation between the complexity of care and the cost of hospitalization for the purpose an assessment of the cost-effectiveness of the two alternative protocols. All this can lead, in our view, a reinterpretation of the traditional cost-effectiveness as a function of intensive care