Bench-to-bedside review: Dealing with increased intensive care unit staff turnover: a leadership challenge

Critical care leaders frequently must face challenging situations requiring specific leadership and management skills for which they are, not uncommonly, poorly prepared. Such a fictitious scenario was discussed at a Canadian interdisciplinary critical care leadership meeting, whereby increasing intensive care unit (ICU) staff turnover had led to problems with staff recruitment. Participants discussed and proposed solutions to the scenario in a structured format. The results of the discussion are presented. In situations such as this, the ICU leader should first define the core problem, its complexity, its duration and its potential for reversibility. These factors often reside within workload and staff support issues. Some examples of core problems discussed that are frequently associated with poor retention and recruitment are a lack of a positive team culture, a lack of a favorable ICU image, a lack of good working relationships between staff and disciplines, and a lack of specific supportive resources. Several tools or individuals (typically outside the ICU environment) are available to help determine the core problem. Once the core problem is identified, specific solutions can be developed. Such solutions often require originality and flexibility, and must be planned, with specific short-term, medium-term and long-term goals. The ICU leader will need to develop an implementation strategy for these solutions, in which partners who can assist are identified from within the ICU and from outside the ICU. It is important that the leader communicates to all stakeholders frequently as the process moves forward

Rates of referable eye disease in the Scottish National Diabetic Retinopathy Screening Programme

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.Peer reviewedPublisher PD

Thalamic inputs to dorsomedial striatum are involved in inhibitory control: evidence from the five-choice serial reaction time task in rats

Rationale Corticostriatal circuits are widely implicated in the top-down control of attention including inhibitory control and behavioural flexibility. However, recent neurophysiological evidence also suggests a role for thalamic inputs to striatum in behaviours related to salient, reward-paired cues. Objectives Here, we used designer receptors exclusively activated by designer drugs (DREADDs) to investigate the role of parafascicular (Pf) thalamic inputs to the dorsomedial striatum (DMS) using the five-choice serial reaction time task (5CSRTT) in rats. Methods The 5CSRTT requires sustained attention in order to detect spatially and temporally distributed visual cues and provides measures of inhibitory control related to impulsivity (premature responses) and compulsivity (perseverative responses). Rats underwent bilateral Pf injections of the DREADD vector, AAV2-CaMKIIa-HA-hM4D(Gi)-IRES-mCitrine. The DREADD agonist, clozapine N-oxide (CNO; 1 μl bilateral; 3 μM) or vehicle, was injected into DMS 1 h before behavioural testing. Task parameters were manipulated to increase attention load or reduce stimulus predictability respectively. Results We found that inhibition of the Pf-DMS projection significantly increased perseverative responses when stimulus predictability was reduced but had no effect on premature responses or response accuracy, even under increased attentional load. Control experiments showed no effects on locomotor activity in an open field. Conclusions These results complement previous lesion work in which the DMS and orbitofrontal cortex were similarly implicated in perseverative responses and suggest a specific role for thalamostriatal inputs in inhibitory control

Determinants of response to a parent questionnaire about development and behaviour in 3 year olds: European multicentre study of congenital toxoplasmosis.

Background: We aimed to determine how response to a parent-completed postal questionnaire measuring development, behaviour, impairment, and parental concerns and anxiety, varies in different European centres. Methods: Prospective cohort study of 3 year old children, with and without congenital toxoplasmosis, who were identified by prenatal or neonatal screening for toxoplasmosis in 11 centres in 7 countries. Parents were mailed a questionnaire that comprised all or part of existing validated tools. We determined the effect of characteristics of the centre and child on response, age at questionnaire completion, and response to child drawing tasks. Results: The questionnaire took 21 minutes to complete on average. 67% (714/1058) of parents responded. Few parents (60/1058) refused to participate. The strongest determinants of response were the score for organisational attributes of the study centre (such as direct involvement in follow up and access to an address register), and infection with congenital toxoplasmosis. Age at completion was associated with study centre, presence of neurological abnormalities in early infancy, and duration of prenatal treatment. Completion rates for individual questions exceeded 92% except for child completed drawings of a man (70%), which were completed more by girls, older children, and in certain centres. Conclusion: Differences in response across European centres were predominantly related to the organisation of follow up and access to correct addresses. The questionnaire was acceptable in all six countries and offers a low cost tool for assessing development, behaviour, and parental concerns and anxiety, in multinational studies

Metabolic and nutritional support of critically ill patients: consensus and controversies.

The results of recent large-scale clinical trials have led us to review our understanding of the metabolic response to stress and the most appropriate means of managing nutrition in critically ill patients. This review presents an update in this field, identifying and discussing a number of areas for which consensus has been reached and others where controversy remains and presenting areas for future research. We discuss optimal calorie and protein intake, the incidence and management of re-feeding syndrome, the role of gastric residual volume monitoring, the place of supplemental parenteral nutrition when enteral feeding is deemed insufficient, the role of indirect calorimetry, and potential indications for several pharmaconutrients

Genetic Diversity of PCR-Positive, Culture-Negative and Culture-Positive Mycobacterium ulcerans Isolated from Buruli Ulcer Patients in Ghana.

Culture of Mycobacterium ulcerans from Buruli ulcer patients has very low sensitivity. Thus confirmation of M. ulcerans infection is primarily based on PCR directed against IS2404. In this study we compare the genotypes obtained by variable number of tandem repeat analysis of DNA from IS2404-PCR positive cultures with that obtained from IS2404 positive, culture-negative tissue. A significantly greater genetic heterogeneity was found among culture-negative samples compared with that found in cultured strains but a single genotype is over-represented in both sample sets. This study provides evidence that both the focal location of bacteria in a lesion as well as differences in the ability to culture a particular genotype may underlie the low sensitivity of culture. Though preliminary, data from this work also suggests that mycobacteria previously associated with fish disease (M. pseudoshottsii) may be pathogenic for humans

Outcomes focused user involvement in social work education: applying knowledge to practice

This paper discusses an innovative approach connecting service user and carer involvement (SUCI) in social work education to social work practice. The research team, comprised service users, carers, social work students and module leader, worked collaboratively democratising the research process. At the University of Dundee, a core social work module facilitates students to spend 15 h with a service user and/or carer (host) gaining a unique insight into their everyday lives. During this time, hosts and students discuss two policy practice questions, responses to these questions are generating annual qualitative data, with study findings being disseminated at local and national level. The experiential learning students acquire from spending time with their host becomes the site of knowledge creation through involvement that is applied to practice. This paper reports on the narratives emerging from the longitudinal data (2012–2015, n = 90) on the changing landscape of social care in Scotland and the dissemination of project findings. We explore the intersection where the voices of service users and carers, student learning and social work practice coalesce. A model of outcomes focused SUCI is introduced as a template for meaningful, sustainable and outcomes-focused SUCI in social work education.<br/

Ferritins: furnishing proteins with iron

Ferritins are a superfamily of iron oxidation, storage and mineralization proteins found throughout the animal, plant, and microbial kingdoms. The majority of ferritins consist of 24 subunits that individually fold into 4-α-helix bundles and assemble in a highly symmetric manner to form an approximately spherical protein coat around a central cavity into which an iron-containing mineral can be formed. Channels through the coat at inter-subunit contact points facilitate passage of iron ions to and from the central cavity, and intrasubunit catalytic sites, called ferroxidase centers, drive Fe2+ oxidation and O2 reduction. Though the different members of the superfamily share a common structure, there is often little amino acid sequence identity between them. Even where there is a high degree of sequence identity between two ferritins there can be major differences in how the proteins handle iron. In this review we describe some of the important structural features of ferritins and their mineralized iron cores and examine in detail how three selected ferritins oxidise Fe2+ in order to explore the mechanistic variations that exist amongst ferritins. We suggest that the mechanistic differences reflect differing evolutionary pressures on amino acid sequences, and that these differing pressures are a consequence of different primary functions for different ferritins

Explosive-driven shock wave and vortex ring interaction with a propane flame

Experiments were performed to analyze the interaction of an explosively driven shock wave and a propane flame. A 30 g explosive charge was detonated at one end of a 3-m-long, 0.6-m-diameter shock tube to produce a shock wave which propagated into the atmosphere. A propane flame source was positioned at various locations outside of the shock tube to investigate the effect of different strength shock waves. High-speed retroreflective shadowgraph imaging visualized the shock wave motion and flame response, while a synchronized color camera imaged the flame directly. The explosively driven shock tube was shown to produce a repeatable shock wave and vortex ring. Digital streak images show the shock wave and vortex ring propagation and expansion. The shadowgrams show that the shock wave extinguishes the propane flame by pushing it off of the fuel source. Even a weak shock wave was found to be capable of extinguishing the flame

Mycobacterium ulcerans disease: experience with primary oral medical therapy in an Australian cohort

Mycobacterium ulcerans (MU) is responsible for disfiguring skin infections which are challenging to treat. The recommended treatment for MU has continued to evolve from surgery to remove all involved tissue, to the use of effective combination oral antibiotics with surgery as required. Our study describes the oral medical treatment utilised for consecutive cases of MU infection over a 15 month period at our institution, in Victoria, Australia. Managing patients primarily with oral antibiotics results in high cure rates and excellent cosmetic outcomes. The success with medical treatment reported in this study will aid those treating cases of MU infection, and will add to the growing body of knowledge about the relative roles of antibiotics and surgery for treating this infection