Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol

<b>Background</b> Understanding implementation processes is key to ensuring that complex interventions in healthcare are taken up in practice and thus maximize intended benefits for service provision and (ultimately) care to patients. Normalization Process Theory (NPT) provides a framework for understanding how a new intervention becomes part of normal practice. This study aims to develop and validate simple generic tools derived from NPT, to be used to improve the implementation of complex healthcare interventions.<p></p> <b>Objectives</b> The objectives of this study are to: develop a set of NPT-based measures and formatively evaluate their use for identifying implementation problems and monitoring progress; conduct preliminary evaluation of these measures across a range of interventions and contexts, and identify factors that affect this process; explore the utility of these measures for predicting outcomes; and develop an online users’ manual for the measures.<p></p> <b>Methods</b> A combination of qualitative (workshops, item development, user feedback, cognitive interviews) and quantitative (survey) methods will be used to develop NPT measures, and test the utility of the measures in six healthcare intervention settings.<p></p> <b>Discussion</b> The measures developed in the study will be available for use by those involved in planning, implementing, and evaluating complex interventions in healthcare and have the potential to enhance the chances of their implementation, leading to sustained changes in working practices

Modelling Eurasian beaver foraging habitat and dam suitability, for predicting the location and number of dams throughout catchments in Great Britain

This is the final version. Available from Springer via the DOI in this record.Eurasian beaver (Castor fiber) populations are expanding across Europe. Depending on location, beaver dams bring multiple benefits and/or require management. Using nationally available data, we developed: a Beaver Forage Index (BFI), identifying beaver foraging habitat, and a Beaver Dam Capacity (BDC) model, classifying suitability of river reaches for dam construction, to estimate location and number of dams at catchment scales. Models were executed across three catchments, in Great Britain (GB), containing beaver. An area of 6747 km2 was analysed for BFI and 16,739 km of stream for BDC. Field surveys identified 258 km of channel containing beaver activity and 89 dams, providing data to test predictions. Models were evaluated using a categorical binomial Bayesian framework to calculate probability of foraging and dam construction. BFI and BDC models successfully categorised the use of reaches for foraging and damming, with higher scoring reaches being preferred. Highest scoring categories were ca. 31 and 79 times more likely to be used than the lowest for foraging and damming respectively. Zero-inflated negative binomial regression showed that modelled dam capacity was significantly related (p = 0.01) to observed damming and was used to predict numbers of dams that may occur. Estimated densities of dams, averaged across each catchment, ranged from 0.4 to 1.6 dams/km, though local densities may be up to 30 dams/km. These models provide fundamental information describing the distribution of beaver foraging habitat, where dams may be constructed and how many may occur. This supports the development of policy and management concerning the reintroduction and recolonisation of beaver.Wellcome TrustUniversity of ExeterDWTNERCScottish Natural Heritag

Efficacy and safety of a two-step method of skin preparation for peripheral intravenous catheter insertion: a prospective multi-centre randomised trial

We have developed a two-step procedure for preparing the skin before peripheral venous catheter (PVC) insertions. This procedure involves two successive swabbings with wipes soaked in alcoholic antiseptic. We investigated whether this two-step procedure was as effective and safe as the standard four-step procedure – washing with detergent, rinsing, drying, applying antiseptic – by carrying out a multicentre randomised equivalence study comparing the frequency of precursor signs of infection at the site of insertion for the two skin preparation procedures. The study was carried out over an eight-month period, and 248 PVC insertion sites were evaluated. The two-step procedure was used for 130 subjects and the standard procedure for 118. Taking into account all the confounding factors predisposing patients to the complications studied, the characteristics of the two groups of patients were found to be similar, with no significant differences noted. The incidence of precursor signs of infection was 11 % 24 hours after PVC insertion (27/248), 25 % at 48 hours (50/203) and at 29 % at 72 hours (34/119). Eleven patients had complications necessitating the withdrawal of the PVC: sensitivity of the insertion site, with redness and/or slight swelling and/or a palpable venous cord. No major complications were observed in this study. The frequency of local complications associated with PVCs reported in this study, whether simple or severe, was not affected by the skin preparation procedure used for PVC insertion (two-step or four-step procedure)

Chronic Granulomatous Disease; fundamental stages in our understanding of CGD

It has been 50 years since chronic granulomatous disease was first reported as a disease which fatally affected the ability of children to survive infections. Various milestone discoveries from the insufficient ability of patients' leucocytes to destroy microbial particles to the underlying genetic predispositions through which the disease is inherited have had important consequences. Longterm antibiotic prophylaxis has helped to fight infections associated with chronic granulomatous disease while the steady progress in bone marrow transplantation and the prospect of gene therapy are hailed as long awaited permanent treatment options. This review unearths the important findings by scientists that have led to our current understanding of the disease

Prior outpatient antibiotic use as predictor for microbial aetiology of community-acquired pneumonia: hospital-based study

Objective: The causative micro-organism in community-acquired pneumonia (CAP) is often difficult to predict. Different studies have examined chronic morbidity and clinical symptoms as predictors for microbial aetiology of pneumonia. The aim of our study was to assess whether prior outpatient antimicrobial treatment is predictive for determining the microbial aetiology of CAP. Methods: This was a hospital-based prospective observational study including all patients admitted with CAP between 1 October 2004 and 1 August 2006. Microbial investigations included sputum, blood culture, sputum PCR, antigen testing and serology. Exposure to antimicrobial drugs prior to hospital admission was ascertained through community pharmacy dispensing records. Multivariate logistic regression analysis was conducted to assess whether prior outpatient antimicrobial treatment is a predictor of microbial aetiology. Patient demographics, co-morbidities and pneumonia severity were considered to be other potential predictors. Results: Overall, 201 patients were included in the study. The microbial aetiology was determined in 64% of the patients. The five most prevalent pathogens were Streptococcus pneumoniae, Heamophilus influenzae, Legionella spp., Mycoplasma pneumoniae and Influenza virus A+B. Forty-seven of the patients (23%) had received initial antimicrobial treatment as outpatients. Multivariate analyses revealed that initial outpatient beta-lactam treatment was associated with a threefold increased chance of finding atypical pathogens and a threefold decreased probability of pneumococcal infection; the corresponding odds ratios were 3.51 (95% CI 1.25-9.99) and 0.30 (95% CI 0.10-0.90), respectively. Patients who received macrolides prior to hospitalisation had an increased probability of viral pneumonia. Conclusion: Prior outpatient antimicrobial therapy has a predictive value in the diagnostic workup aimed at identifying the causative pathogen and planning corresponding antimicrobial treatment in patients hospitalised for pneumonia

X-Ray Spectroscopy of Stars

(abridged) Non-degenerate stars of essentially all spectral classes are soft X-ray sources. Low-mass stars on the cooler part of the main sequence and their pre-main sequence predecessors define the dominant stellar population in the galaxy by number. Their X-ray spectra are reminiscent, in the broadest sense, of X-ray spectra from the solar corona. X-ray emission from cool stars is indeed ascribed to magnetically trapped hot gas analogous to the solar coronal plasma. Coronal structure, its thermal stratification and geometric extent can be interpreted based on various spectral diagnostics. New features have been identified in pre-main sequence stars; some of these may be related to accretion shocks on the stellar surface, fluorescence on circumstellar disks due to X-ray irradiation, or shock heating in stellar outflows. Massive, hot stars clearly dominate the interaction with the galactic interstellar medium: they are the main sources of ionizing radiation, mechanical energy and chemical enrichment in galaxies. High-energy emission permits to probe some of the most important processes at work in these stars, and put constraints on their most peculiar feature: the stellar wind. Here, we review recent advances in our understanding of cool and hot stars through the study of X-ray spectra, in particular high-resolution spectra now available from XMM-Newton and Chandra. We address issues related to coronal structure, flares, the composition of coronal plasma, X-ray production in accretion streams and outflows, X-rays from single OB-type stars, massive binaries, magnetic hot objects and evolved WR stars.Comment: accepted for Astron. Astrophys. Rev., 98 journal pages, 30 figures (partly multiple); some corrections made after proof stag

Digital clubbing in tuberculosis – relationship to HIV infection, extent of disease and hypoalbuminemia

BACKGROUND: Digital clubbing is a sign of chest disease known since the time of Hippocrates. Its association with tuberculosis (TB) has not been well studied, particularly in Africa where TB is common. The prevalence of clubbing in patients with pulmonary TB and its association with Human Immunodeficiency Virus (HIV), severity of disease, and nutritional status was assessed. METHODS: A cross-sectional study was carried out among patients with smear-positive TB recruited consecutively from the medical and TB wards and outpatient clinics at a public hospital in Uganda. The presence of clubbing was assessed by clinical signs and measurement of the ratio of the distal and inter-phalangeal diameters (DPD/IPD) of both index fingers. Clubbing was defined as a ratio > 1.0. Chest radiograph, serum albumin and HIV testing were done. RESULTS: Two hundred patients (82% HIV-infected) participated; 34% had clubbing by clinical criteria whilst 30% had clubbing based on DPD/IPD ratio. Smear grade, extensive or cavitary disease, early versus late HIV disease, and hypoalbuminemia were not associated with clubbing. Clubbing was more common among patients with a lower Karnofsky performance scale score or with prior TB. CONCLUSION: Clubbing occurs in up to one-third of Ugandan patients with pulmonary TB. Clubbing was not associated with stage of HIV infection, extensive disease or hypoalbuminemia

Are there independent predisposing factors for postoperative infections following open heart surgery?

<p>Abstract</p> <p>Background</p> <p>Nosocomial infections after cardiac surgery represent serious complications associated with substantial morbidity, mortality and economic burden. This study was undertaken to evaluate the frequency, characteristics, and risk factors of microbiologically documented nosocomial infections after cardiac surgery in a Cardio-Vascular Intensive Care Unit (CVICU).</p> <p>Methods</p> <p>All patients who underwent open heart surgery between May 2006 and March 2008 were enrolled in this prospective study. Pre-, intra- and postoperative variables were collected and examined as possible risk factors for development of nosocomial infections. The diagnosis of infection was always microbiologically confirmed.</p> <p>Results</p> <p>Infection occurred in 24 of 172 patients (13.95%). Out of 172 patients, 8 patients (4.65%) had superficial wound infection at the sternotomy site, 5 patients (2.9%) had central venous catheter infection, 4 patients (2.32%) had pneumonia, 9 patients (5.23%) had bacteremia, one patient (0.58%) had mediastinitis, one (0.58%) had harvest surgical site infection, one (0.58%) had urinary tract infection, and another one patient (0.58%) had other major infection. The mortality rate was 25% among the patients with infection and 3.48% among all patients who underwent cardiac surgery compared with 5.4% of patients who did not develop early postoperative infection after cardiac surgery. Culture results demonstrated equal frequencies of gram-positive cocci and gram-negative bacteria. A backward stepwise multivariable logistic regression model analysis identified diabetes mellitus (OR 5.92, CI 1.56 to 22.42, p = 0.009), duration of mechanical ventilation (OR 1.30, CI 1.005 to 1.69, p = 0.046), development of severe complications in the CICU (OR 18.66, CI 3.36 to 103.61, p = 0.001) and re-admission to the CVICU (OR 8.59, CI 2.02 to 36.45, p = 0.004) as independent risk factors associated with development of nosocomial infection after cardiac surgery.</p> <p>Conclusions</p> <p>We concluded that diabetes mellitus, the duration of mechanical ventilation, the presence of complications irrelevant to the infection during CVICU stay and CVICU re-admission are independent risk factors for the development of postoperative infection in cardiac surgery patients.</p

The effect of using an interactive booklet on childhood respiratory tract infections in consultations: Study protocol for a cluster randomised controlled trial in primary care

Background: Respiratory tract infections in children result in more primary care consultations than any other acute condition, and are the most common reason for prescribing antibiotics (which are largely unnecessary). About a fifth of children consult again for the same illness episode. Providing parents with written information on respiratory tract infections may result in a reduction in re-consultation rates and antibiotic prescribing for these illnesses. Asking clinicians to provide and discuss the information during the consultation may enhance effectiveness. This paper outlines the protocol for a study designed to evaluate the use of a booklet on respiratory tract infections in children within primary care consultations. Methods/Design: This will be a cluster randomised controlled trial. General practices will be randomised to provide parents consulting because their child has an acute respiratory tract infection with either an interactive booklet, or usual care. The booklet provides information on the expected duration of their child's illness, the likely benefits of various treatment options, signs and symptoms that should prompt re-consultation, and symptomatic treatment advice. It has been designed for use within the consultation and aims to enhance communication through the use of specific prompts. Clinicians randomised to using the interactive booklet will receive online training in its use. Outcomes will be assessed via a telephone interview with the parent two weeks after first consulting. The primary outcome will be the proportion of children who re-consult for the same illness episode. Secondary outcomes include: antibiotic use, parental satisfaction and enablement, and illness costs. Consultation rates for respiratory tract infections for the subsequent year will be assessed by a review of practice notes. Discussion: Previous studies in adults and children have shown that educational interventions can result in reductions in re-consultation rates and use of antibiotics for respiratory tract infections. This will be the first study to determine whether providing parents with a booklet on respiratory tract infections in children, and discussing it with them during the consultation, reduces re-consultations and antibiotic use for the same illness without reducing satisfaction with care. Trial registration: Current Controlled Trials ISRCTN46104365 </p