Clinical stakeholders' opinions on the use of selective decontamination of the digestive tract in critically ill patients in intensive care units : an international Delphi study

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“Captain of All These Men of Death”: An Integrated Case Study of Tuberculosis in Nineteenth-Century Otago, New Zealand

The South Island of New Zealand saw several major waves of migration in the mid-nineteenth century, predominantly from Europe but also with an ethnically distinct Chinese presence. The rural community of Milton, Otago, was a settler community established primarily by immigrants from the United Kingdom in search of a better quality of life. However, these settlers faced unique challenges related to surviving in an isolated location with very little infrastructure compared to their origin populations. In 2016, excavation was undertaken at St. John’s burial ground, Milton, with the object of using bioarchaeological methods to elucidate the lived experience of the first organized European settlement of this region, particularly in terms of health and disease. Here we present a case study of Burial 21 (B21), a male individual of known identity and a documented cause of death. We use biochemical and paleopathological methods to ground-truth his written history, which includes a period of invalidism due to tuberculosis, and discuss the implications of our findings for the community, provision of care, and quality of life in rural colonial New Zealand. He maha tonu ngā hekenga tāngata ki Te Waka a Māui i ngā tau kei waenga pū o te rau tau 1800, ko te nuinga nō Ūropi, heoi he tokomaha tonu nō Haina. Nā ngā manene nō Peretānia te hapori o Milton i whakatū ki Tokomairaro, i Ōtākou, i tō rātou hiahia ki tētehi oranga kounga ake i tō rātou oranga i Peretānia. Heoi, ko ētehi o ngā wero nui i tau ki ngā manene nei i ahu mai i te noho pūreirei ki tētehi wāhi kāore rawa ngā ratonga i rite ki ngā wāhi i ahu mai ai rātou. I te tau 2016, i hahu kōiwi i te urupā o Hato Hone, i Milton, hei whakamātau i te kaha o te ora me ngā momo mate i pā atu ki ngā tāngata whai i noho i te rohe nei. Nei rā he ripoata mō tētehi kua hahua, kua tapaina ko B21, he tāne ia, ko tōna ingoa kua mōhiotia, ko tōna mate kua āta tuhia. Kua āta whakamātauria ōna kōiwi me ōna toenga kiko mō ngā tohu ora me ngā tohu mate, kia mārama ai mena rānei e hāngai ana ngā tuhinga rongoā mōna, ngā mea i tuhia nōna e takatū ana, tae atu ki te wā i tūroro ia i te mate kohi, ki ngā tohu e puta ana i te mātauranga Rongoā-Koiora ō nāianei. Ka matapakina ngā hīrautanga o ngā kitenga me te māramatanga kua puta i tēnei rangahau e pā ana ki te hapori, ki ngā ratonga hauora, me te kounga o te oranga mō te hunga noho tuawhenua i tērā wā i Aotearoa

Clinical components and associated behavioural aspects of a complex healthcare intervention : Multi-methods study of selective decontamination of the digestive tract in critical care

Copyright © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.Peer reviewedPostprin

Simulation of metallic nanostructures for emission of THz radiation using the lateral photo-Dember effect

A 2D simulation for the lateral photo-Dember effect is used to calculate the THz emission of metallic nanostructures due to ultrafast diffusion of carriers in order to realize a series of THz emitters.Comment: Corrected version of a paper given at 2011 36th International Conference on Infrared, Millimeter and Terahertz Waves (IRMMW-THz

Selective decontamination of the digestive tract in critically ill patients treated in intensive care units: a mixed-methods feasibility study (the SuDDICU study)

Background: Hospital-acquired infections (HAIs) are a major cause of morbidity and mortality. Critically ill patients in intensive care units (ICUs) are particularly susceptible to these infections. One intervention that has gained much attention in reducing HAIs is selective decontamination of the digestive tract (SDD). SDD involves the application of topical non-absorbable antibiotics to the oropharynx and stomach and a short course of intravenous (i.v.) antibiotics. SDD may reduce infections and improve mortality, but has not been widely adopted in the UK or internationally. Hence, there is a need to identify the reasons for low uptake and whether or not further clinical research is needed before wider implementation would be considered appropriate. Objectives: The project objectives were to (1) identify and describe the SDD intervention, (2) identify views about the evidence base, (3) identify acceptability of further research and (4) identify feasibility of further randomised controlled trials (RCTs). Design : A four-stage approach involving (1) case studies of two ICUs in which SDD is delivered including observations, interviews and documentary analysis, (2) a three-round Delphi study for in-depth investigation of clinicians' views, including semi-structured interviews and two iterations of questionnaires with structured feedback, (3) a nationwide online survey of consultants in intensive care medicine and clinical microbiology and (4) semistructured interviews with international clinical triallists to identify the feasibility of further research. Setting : Case studies were set in two UK ICUs. Other stages of this research were conducted by telephone and online with NHS staff working in ICUs. Participants : (1) Staff involved in SDD adoption or delivery in two UK ICUs, (2) ICU experts (intensive care consultants, clinical microbiologists, hospital pharmacists and ICU clinical leads), (3) all intensive care consultants and clinical microbiologists in the UK with responsibility for patients in ICUs were invited and (4) international triallists, selected from their research profiles in intensive care, clinical trials and/or implementation trials. Interventions : SDD involves the application of topical non-absorbable antibiotics to the oropharynx and stomach and a short course of i.v. antibiotics. Main outcome measures: Levels of support for, or opposition to, SDD in UK ICUs; views about the SDD evidence base and about barriers to implementation; and feasibility of further SDD research (e.g. likely participation rates). Results : (1) The two case studies identified complexity in the interplay of clinical and behavioural components of SDD, involving multiple staff. However, from the perspective of individual staff, delivery of SDD was regarded as simple and straightforward. (2) The Delphi study (n = 42) identified (a) specific barriers to SDD implementation, (b) uncertainty about the evidence base and (c) bimodal distributions for key variables, e.g. support for, or opposition to, SDD. (3) The national survey (n = 468) identified uncertainty about the effect of SDD on antimicrobial resistance, infection rates, mortality and cost-effectiveness. Most participants would participate in further SDD research. (4) The triallist interviews (n = 10) focused largely on the substantial challenges of conducting a large, multinational clinical effectiveness trial. Conclusions : There was considerable uncertainty about possible benefits and harms of SDD. Further large-scale clinical effectiveness trials of SDD in ICUs may be required to address these uncertainties, especially relating to antimicrobial resistance. There was a general willingness to participate in a future effectiveness RCT of SDD. However, support was not unanimous. Future research should address the barriers to acceptance and participation in any trial. There was some, but a low level of, interest in adoption of SDD, or studies to encourage implementation of SDD into practice

Quality of intervention delivery in a cluster randomised controlled trial : a qualitative observational study with lessons for implementation fidelity

Abstract Background Understanding intervention fidelity is an essential part of the evaluation of complex interventions because fidelity not only affects the validity of trial findings, but also because studies of fidelity can be used to identify barriers and facilitators to successful implementation, and so provide important information about factors likely to impact the uptake of the intervention into clinical practice. Participant observation methods have been identified as being particularly valuable in studies of fidelity, yet are rarely used. This study aimed to use these methods to explore the quality of implementation of a complex intervention (Safewards) on mental health wards during a cluster randomised controlled trial. Specific aims were firstly to describe the different ways in which the intervention was implemented, and secondly to explore the contextual factors moderating the quality of intervention delivery, in order to inform ‘real world’ implementation of the intervention. Methods Safewards was implemented on 16 mental health wards in England. We used Research Assistants (RAs) trained in participant observation to record qualitative observational data on the quality of intervention delivery (n = 565 observations). At the end of the trial, two focus groups were conducted with RAs, which were used to develop the coding framework. Data were analysed using thematic analysis. Results There was substantial variation in intervention delivery between wards. We observed modifications to the intervention which were both fidelity consistent and inconsistent, and could enhance or dilute the intervention effects. We used these data to develop a typology which describes the different ways in which the intervention was delivered. This typology could be used as a tool to collect qualitative observational data about fidelity during trials. Moderators of Safewards implementation included systemic, interpersonal, and individual factors and patient responses to the intervention. Conclusions Our study demonstrates how, with appropriate training in participant observation, RAs can collect high-quality observational data about the quality of intervention delivery during a trial, giving a more complete picture of ‘fidelity’ than measurements of adherence alone. Trial registration ISRCTN registry; IRSCTN38001825 . Registered 29 August 201

Common variants in the region around Osterix are associated with bone mineral density and growth in childhood

Peak bone mass achieved in adolescence is a determinant of bone mass in later life. In order to identify genetic variants affecting bone mineral density (BMD), we performed a genome-wide association study of BMD and related traits in 1518 children from the Avon Longitudinal Study of Parents and Children (ALSPAC). We compared results with a scan of 134 adults with high or low hip BMD. We identified associations with BMD in an area of chromosome 12 containing the Osterix (SP7) locus, a transcription factor responsible for regulating osteoblast differentiation (ALSPAC: P = 5.8 × 10−4; Australia: P = 3.7 × 10−4). This region has previously shown evidence of association with adult hip and lumbar spine BMD in an Icelandic population, as well as nominal association in a UK population. A meta-analysis of these existing studies revealed strong association between SNPs in the Osterix region and adult lumbar spine BMD (P = 9.9 × 10−11). In light of these findings, we genotyped a further 3692 individuals from ALSPAC who had whole body BMD and confirmed the association in children as well (P = 5.4 × 10−5). Moreover, all SNPs were related to height in ALSPAC children, but not weight or body mass index, and when height was included as a covariate in the regression equation, the association with total body BMD was attenuated. We conclude that genetic variants in the region of Osterix are associated with BMD in children and adults probably through primary effects on growth

How do they measure up? Differences in stakeholder perceptions of quality measures used in English community nursing

© The Author(s) 2019. Objectives: To establish how quality indicators used in English community nursing are selected and applied, and their perceived usefulness to service users, commissioners and service providers. Methods: A qualitative multi-site case study was conducted with five commissioning organizations and their service providers. Participants included commissioners, provider organization managers, nurses and service users. Results: Indicator selection and application often entail complex processes influenced by wider health system and cross-organizational factors. All participants felt that current indicators, while useful for accountability and management purposes, fail to reflect the true quality of community nursing care and may sometimes indirectly compromise care. Conclusions: Valuable resources may be better used for comprehensive system redesign, to ensure that patient, carer and nurse priorities are given equivalence with those of other stakeholders

The views of health care professionals about selective decontamination of the digestive tract: An international, theoretically informed interview study

Purpose: Selective Decontamination of the Digestive tract (SDD) as a prophylactic intervention improves hospital-acquired infection and survival rates. Uptake of SDD is low and remains controversial. This study applied the Theoretical Domains Framework (TDF) to assess ICU clinicians’ views about SDD in regions with limited or no adoption of SDD. Materials and Methods: Participants were health professionals with ‘decisional authority’ for the adoption of SDD. Semistructured interviews were conducted as the first round of a Delphi study. Views about SDDadoption, delivery and further SDD research were explored. Directed content analysis of interview data identified sub-themes which informed item development for subsequent Delphi rounds. Linguistic features of interview data were also explored. Results: 141 participants provided interview data. Fifty-six sub-themes were identified; 46 were common across regions. Beliefs about consequences was the most widely elaborated theme. Linguistic features of how participants discussed SDD included caution expressed when discussing the risks and benefits and words such as worry, anxiety and fear when discussing potential antibiotic resistance associated with SDD. Conclusions: We identified salient beliefs, barriers and facilitators to SDD adoption and delivery. What participants said about SDD and the way in which they said it demonstrated the degree of clinical caution, uncertainty and concern that SDD evokes