Understanding Clinicians’ Perceived Barriers and Facilitators to Optimal Use of Acute Oxygen Therapy in Adults

Background: Supplemental oxygen is commonly administered to patients in acute care. It may cause harm when used inappropriately. Guidelines recommend prescription of acute oxygen, yet adherence is poor. We aimed to identify barriers and facilitators to practicing in accordance with the evidence-based Thoracic Society of Australia and New Zealand (TSANZ) oxygen guideline, and to determine the beliefs and attitudes relating to acute oxygen therapy. Methods: A national cross-sectional survey was conducted. The survey consisted of 3 sections: (1) introduction and participant characteristics; (2) opinion/beliefs, knowledge and actions about oxygen therapy and other drugs; and (3) barriers and facilitators to use of the TSANZ guideline. Convenience sampling was employed. A paper-based survey was distributed at the TSANZ Annual Scientific Meeting. An online survey was emailed to the TSANZ membership and to John Hunter Hospital’s clinical staff. Results: Responses were received from 133 clinicians: 52.6% nurses, 30.1% doctors, and 17.3% other clinicians. Over a third (37.7%) were unaware/unsure of the oxygen guideline’s existence. Most (79.8%) believe that oxygen is a drug and should be treated as one. Most (92.4%) stated they only administered it based on clinical need. For four hypothetical cases, there was only one where the majority of participants identified the optimal oxygen saturation. A number of barriers and facilitators were identified when asked about practicing in accordance with the TSANZ guideline. Lack of oxygen equipment, getting doctors to prescribe oxygen and oxygen being treated differently to other drugs were seen as barriers. The guideline itself and multiple clinician characteristics were considered facilitators. Conclusion: There is discordance between clinicians’ beliefs and actions regarding the administration of oxygen therapy and knowledge gaps about optimal oxygen therapy in acute care. Identified barriers and facilitators should be considered when developing evidence-based guidelines to improve dissemination and knowledge exchange

Complotype affects the extent of down-regulation by Factor I of the C3b feedback cycle in vitro.

Sera from a large panel of normal subjects were typed for three common polymorphisms, one in C3 (R102G) and two in Factor H (V62I and Y402H), that influence predisposition to age-related macular degeneration and to some forms of kidney disease. Three groups of sera were tested; those that were homozygous for the three risk alleles; those that were heterozygous for all three; and those homozygous for the low-risk alleles. These groups vary in their response to the addition of exogenous Factor I when the alternative complement pathway is activated by zymosan. Both the reduction in the maximum amount of iC3b formed and the rate at which the iC3b is converted to C3dg are affected. For both reactions the at-risk complotype requires higher doses of Factor I to produce similar down-regulation. Because iC3b reacting with the complement receptor CR3 is a major mechanism by which complement activation gives rise to inflammation, the breakdown of iC3b to C3dg can be seen to have major significance for reducing complement-induced inflammation. These findings demonstrate for the first time that sera from subjects with different complement alleles behave as predicted in an in-vitro assay of the down-regulation of the alternative complement pathway by increasing the concentration of Factor I. These results support the hypothesis that exogenous Factor I may be a valuable therapeutic aid for down-regulating hyperactivity of the C3b feedback cycle, thereby providing a treatment for age-related macular degeneration and other inflammatory diseases of later life.This is the author's accepted manuscript and will be under embargo until the 13th of August 2015. This final version is available from Wiley in Clinical & Experimental Immunology at http://onlinelibrary.wiley.com/doi/10.1111/cei.12437/abstract

Management of Acute COPD Exacerbations in Australia: Do we Follow the Guidelines?

Objective: We aimed to assess adherence to the Australian national guideline (COPD-X) against audited practice, and to document the outcomes of patients hospitalised with an acute exacerbation of chronic obstructive pulmonary disease (COPD) at discharge and 28 days after. Methods: A prospective clinical audit of COPD hospital admission from five tertiary care hospitals in five states of Australia was conducted. Post-discharge follow-up was conducted via telephone to assess for readmission and health status. Results: There were 207 admissions for acute exacerbation (171 patients; mean 70.2 years old; 50.3%males). Readmission rates at 28 days were 25.4%, with one (0.6%) death during admission and eight(6.1%) post-discharge within 28 days. Concordance to the COPD-X guidance was variable; 22.7% performed spirometry, 81.1% had blood gases collected when forced expiratory volume in 1 s was \u3c1 \u3eL,99.5% had chest radiography performed, 95.1% were prescribed systemic corticosteroids and 95% were prescribed antibiotic therapy. There were 89.1% given oxygen therapy and 92.6% when arterial oxygen tension was \u3c80 \u3emmHg; 65.6% were given ventilatory assistance when pH was Conclusion: When compared against clinical practice guidelines, we found important gaps in management of patients admitted with COPD throughout tertiary care centres in Australia. Strategies to improve guideline uptake are needed to optimise care

Rationale and design of the ADDITION-Leicester study, a systematic screening programme and randomised controlled trial of multi-factorial cardiovascular risk intervention in people with type 2 diabetes mellitus detected by screening.

BACKGROUND: Earlier diagnosis followed by multi-factorial cardiovascular risk intervention may improve outcomes in type 2 diabetes mellitus (T2DM). Latent phase identification through screening requires structured, appropriately targeted population-based approaches. Providers responsible for implementing screening policy await evidence of clinical and cost effectiveness from randomised intervention trials in screen-detected T2DM cases. UK South Asians are at particularly high risk of abnormal glucose tolerance and T2DM. To be effective national screening programmes must achieve good coverage across the population by identifying barriers to the detection of disease and adapting to the delivery of earlier care. Here we describe the rationale and methods of a systematic community screening programme and randomised controlled trial of cardiovascular risk management within a UK multiethnic setting (ADDITION-Leicester). DESIGN: A single-blind cluster randomised, parallel group trial among people with screen-detected T2DM comparing a protocol driven intensive multi-factorial treatment with conventional care. METHODS: ADDITION-Leicester consists of community-based screening and intervention phases within 20 general practices coordinated from a single academic research centre. Screening adopts a universal diagnostic approach via repeated 75g-oral glucose tolerance tests within an eligible non-diabetic population of 66,320 individuals aged 40-75 years (25-75 years South Asian). Volunteers also provide detailed medical and family histories; complete health questionnaires, undergo anthropometric measures, lipid profiling and a proteinuria assessment. Primary outcome is reduction in modelled Coronary Heart Disease (UKPDS CHD) risk at five years. Seven thousand (30% of South Asian ethnic origin) volunteers over three years will be recruited to identify a screen-detected T2DM cohort (n = 285) powered to detected a 6% relative difference (80% power, alpha 0.05) between treatment groups at one year. Randomisation will occur at practice-level with newly diagnosed T2DM cases receiving either conventional (according to current national guidelines) or intensive (algorithmic target-driven multi-factorial cardiovascular risk intervention) treatments. DISCUSSION: ADDITION-Leicester is the largest multiethnic (targeting >30% South Asian recruitment) community T2DM and vascular risk screening programme in the UK. By assessing feasibility and efficacy of T2DM screening, it will inform national disease prevention policy and contribute significantly to our understanding of the health care needs of UK South Asians. TRIAL REGISTRATION: Clinicaltrial.gov (NCT00318032).RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are