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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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

Barriers and facilitators of evidence-based management of patients with bacterial infections among general dental practitioners:a theory-informed interview study

Background: General dental practitioners (GDPs) regularly prescribe antibiotics to manage dental infections although most infections can be treated successfully by local measures. Published guidance to support GDPs to make appropriate prescribing decisions exists but there continues to be wide variation in dental antibiotic prescribing. An interview study was conducted as part of the Reducing Antibiotic Prescribing in Dentistry (RAPiD) trial to understand the barriers and facilitators of using local measures instead of prescribing antibiotics to manage bacterial infections. Methods: Thirty semi-structured one-to-one telephone interviews were conducted using the Theoretical Domains Framework (TDF). Responses were coded into domains of the TDF and sub-themes. Priority domains (high frequency: ≥50 % interviewees discussed) relevant to behaviour change were identified as targets for future intervention efforts and mapped onto 'intervention functions' of the Behaviour Change Wheel system. Results: Five domains (behavioural regulation, social influences, reinforcement, environmental context and resources, and beliefs about consequences) with seven sub-themes were identified as targets for future intervention. All participants had knowledge about the evidence-based management of bacterial infections, but they reported difficulties in following this due to patient factors and time management. Lack of time was found to significantly influence their decision processes with regard to performing local measures. Beliefs about their capabilities to overcome patient influence, beliefs that performing local measures would impact on subsequent appointment times as well as there being no incentives for performing local measures were also featured. Though no knowledge or basic skills issues were identified, the participants suggested some continuous professional development programmes (e.g. time management, an overview of published guidance) to address some of the barriers. The domain results suggest a number of intervention functions through which future interventions could change GDPs' antibiotic prescribing for bacterial infections: imparting skills through training, providing an example for GDPs to imitate (i.e. modelling) or creating the expectation of a reward (i.e. incentivisation). Conclusions: This is the first theoretically informed study to identify barriers and facilitators of evidence-based management of patients with bacterial infections among GDPs. A pragmatic approach is needed to address the modifiable barriers in future interventions intended to change dentists' inappropriate prescribing behaviour.</p

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

On the determinants of local government debt: Does one size fit all?

This paper analyzes the factors that directly influence levels of debt in Spanish local governments. Specifically, the main objective is to find out the extent to which indebtedness is originated by controllable factors that public managers can influence, or whether it hinges on other variables beyond managers’ control. The importance of this issue has intensified since the start of the crisis in 2007, due to the abrupt decline of revenues and, simultaneously, to the stagnation (or even increase) in the levels of costs facing these institutions face. Results can be explored from multiple perspectives, given that the set of explanatory factors is also multiple. However, the most interesting result relates to the varying effect of each covariate depending on each municipality’s specific debt level, which suggests that economic policy recommendations should not be homogeneous across local governments

Devolution dynamics of Spanish local government

Over the last few years, ther has been a devolutionary tendency in many developed and developing countries. In this article we propose a methodology to decompose whether the benefits in terms of effciency derived from transfers of powers from higher to municipal levels of government "the "economic dividend" of devolution) might increase over time. This methodology is based on linear programming approaches for effciency measurement. We provide anapplication to Spanish municipalities, which have had to adapt to both the European Stability and Growth Pact as well as to domestic regulation seeking local governments balanced budget. Results indicate that efficiency gains from enhaced decentralization have increased over time. However, the way through which these gains accrue differs across municipalities -in some cases technical change is the main component, whereas in others catching up dominates

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

The global impact of adverse childhood experiences on criminal behavior: A cross-continental study

Background: Adverse Childhood Experiences (ACEs) have been associated with a greater risk of later criminal offending. However, existing research in this area has been primarily conducted in Western developed countries and cross-cultural studies are rare. Objectives: This study examined the relationship between ACEs and criminal behaviors in young adults living in 10 countries located across five continents, after accounting for sex, age, and cross-national differences. Participants and setting: In total, 3797 young adults aged between 18 and 20 years (M = 18.97; DP = 0.81) were assessed locally in community settings within the 10 countries.Method: The ACE Questionnaire was used to assess maltreatment and household dysfunction during childhood and a subset of questions derived from the Deviant Behavior Variety Scale (DBVS) was used to determine past-year criminal variety pertaining to 10 acts considered crime across participating countries. Results: Physical and sexual abuse, physical neglect, and household substance abuse were related to criminal variety, globally, and independently across sexes and countries ranked differently in the United Nations Human Development Index (HDI). In addition, three out of five experiences of household dysfunction were related to criminal variety, but subsequent analyses indicate that some forms of household dysfunction only hold statistical significance among males or females, or in countries ranking lower in the HDI. Conclusions: This research strengthens the finding that there are cross-cultural mechanisms perpetuating the cycle of violence. It also indicates that forms of household dysfunction have an impact on criminal behavior that is shaped by gender and the country's levels of social well-being.info:eu-repo/semantics/publishedVersio

Shell we cook it? An experimental approach to the microarchaeological record of shellfish roasting

In this paper, we investigate the microarchaeological traces and archaeological visibility of shellfish cooking activities through a series of experimental procedures with direct roasting using wood-fueled fires and controlled heating in a muffle furnace. An interdisciplinary geoarchacological approach, combining micromorphology, FTIR (in transmission and ATR collection modes), TGA and XRD, was used to establish a baseline on the mineralogical transformation of heated shells from aragonite to calcite and diagnostic sedimentary traces produced by roasting fire features. Our experimental design focused on three main types of roasting procedures: the construction of shallow depressions with heated rocks (pebble cuvette experiments), placing shellfish on top of hot embers and ashes (fire below experiment), and by kindling short-lived fires on top of shellfish (fire above experiments). Our results suggest that similar shellfish roasting procedures will largely create microstratigraphic signatures of anthropogenically reworked combusted material spatially "disconnected" from the actual combustion locus. The construction of shallow earth ovens might entail an increased archaeological visibility, and some diagnostic signatures of in situ hearths can be obtained by fire below roasting activities. We also show that macroscopic visual modifications and mineralogical characterization of discarded shellfish might be indicative of specific cooking activities versus secondary burning.Max Planck Societyinfo:eu-repo/semantics/publishedVersio