Reflections from the forgotten frontline: ‘The reality for children and staff in residential care’ during COVID‐19

Currently, 78,150 children are in care in England, with 11% of the most vulnerable living in 2,460 residential homes due to multitype traumas. These children require safe and secure trauma-informed therapeutic care. However, the children’s residential care workforce delivering this vital care is an unrepresented, under-researched and largely unsupported professional group. The workforce undertakes physically and emotionally challenging work in difficult conditions, exacerbated by the COVID-19 pandemic. Practitioner wellbeing is directly associated with outcomes for children. Therefore, we sought to understand how experiences within the workforce could improve overall working conditions, and thus outcomes for staff and children. Thirty participants took part in a survey, providing feedback on their experiences and the situations they faced during the English lockdown April-June 2020. Two participants also opted to take part in a teleconference interview, rather than survey, although were asked the same questions. Data was analysed through thematic analysis. A stakeholder advisory board supported the project, including frontline staff, care leavers, service managers and policy researchers. The advisory board assisted in reflecting on the data from the survey and interviews to generate a complete analysis. Overall, staff require facilitated safe spaces for peer-support, reflective and emotionally supportive supervision. An organisational awareness that staff wellbeing is intrinsically connected to the wellbeing and therapeutic outcomes of the children they care for is essential. Further, staff require a sense of belongingness to feel safe and competent in their role due to a lack of external recognition and professional representation or validation. Based on the findings of the study and an iterative process with the stakeholder advisory board, we created a Wellbeing Charter for adoption within organisations to promote and protect the wellbeing of this vital workforce. The COVID-19 pandemic has exposed professional, financial and environmental inequalities that affect these frontline workers. Implementing organisational, statutory and policy-driven initiatives to prioritise their wellbeing are essential for the vulnerable children they care for. What is known about this topic and what this paper adds? Following a literature search and consultations with national bodies, it was concluded that no national professional body or Wellbeing Charter exists for this workforce. Residential children’s care and the workforce are under-represented in research, policy and practice. Added value of this study • The Wellbeing Charter could be transformative in the sector to protect and promote the wellbeing of this workforce, and thus contribute to improved outcomes for our most vulnerable children and young people. • We found important associations between individual, relational and organisational factors that influence the care that this workforce is able to provide. • Implications for the professional accreditation, representation and protection of this workforce are discussed in terms of policy, research and practice

Scratch.

Scratch investigated the use of physical space as a site and representation of narrative and dramatic structure. It was commissioned by and collaboratively developed with BBC Radio Drama. Boyd Davis directed the project and devised and undertook the evaluation with 40 trial listeners. It was unprecedented in being location-sensitive without being tied to any particular place, building on research undertaken for Dragons (Boyd Davis REF Output 4). It used pre-recorded audio on GPS-enabled mobile devices allowing sounds to be virtually attached to locations in an outdoor space. As participants moved, they encountered scenes forming a coherent drama; the same place behaved differently if visited more than once. This translocational approach opened novel artistic possibilities that were exploited through team expertise in narrative, sound design and advanced interaction. It was also significant for the economics of broadcast media, a more viable proposition than the many locative experiences that have been site-specific: a factor of great interest to the BBC. The public performance selected for BBC FreeThinking, September 2008 in Liverpool, that year’s European Capital of Culture, was reported in a co-written 2009 conference presentation at ISEA, Belfast (2009) and in a co-written short chapter in Spierling and Szilas (eds.), Interactive Storytelling (2008). Boyd Davis reported the findings to BBC executives (http://researchonline.rca.ac.uk/1000/), for whom an additional trial was run in London in 2009. He used mixed methods, open but capable of rigorous analysis, to feed back to the makers of the drama and to guide BBC policy. Abigail le Fleming (Producer BBC Radio Drama) confirms that ‘through this collaboration, the Radio Drama department became the first BBC unit to experiment with GPS technologies’. The work ‘brought us to tackle non-linear narratives in ways that we would not have otherwise done… invaluable in terms of the questions that it raised for radio drama.

An Open Randomized Comparison of Gatifloxacin versus Cefixime for the Treatment of Uncomplicated Enteric Fever

OBJECTIVE: To assess the efficacy of gatifloxacin versus cefixime in the treatment of uncomplicated culture positive enteric fever. DESIGN: A randomized, open-label, active control trial with two parallel arms. SETTING: Emergency Room and Outpatient Clinics in Patan Hospital, Lagankhel, Lalitpur, Nepal. PARTICIPANTS: Patients with clinically diagnosed uncomplicated enteric fever meeting the inclusion criteria. INTERVENTIONS: Patients were allocated to receive one of two drugs, Gatifloxacin or Cefixime. The dosages used were Gatifloxacin 10 mg/kg, given once daily for 7 days, or Cefixime 20 mg/kg/day given in two divided doses for 7 days. OUTCOME MEASURES: The primary outcome measure was fever clearance time. The secondary outcome measure was overall treatment failure (acute treatment failure and relapse). RESULTS: Randomization was carried out in 390 patients before enrollment was suspended on the advice of the independent data safety monitoring board due to significant differences in both primary and secondary outcome measures in the two arms and the attainment of a priori defined endpoints. Median (95% confidence interval) fever clearance times were 92 hours (84-114 hours) for gatifloxacin recipients and 138 hours (105-164 hours) for cefixime-treated patients (Hazard Ratio[95%CI] = 2.171 [1.545-3.051], p<0.0001). 19 out of 70 (27%) patients who completed the 7 day trial had acute clinical failure in the cefixime group as compared to 1 out of 88 patients (1%) in gatifloxacin group(Odds Ratio [95%CI] = 0.031 [0.004 - 0.237], p<0.001). Overall treatment failure patients (relapsed patients plus acute treatment failure patients plus death) numbered 29. They were determined to be (95% confidence interval) 37.6 % (27.14%-50.2%) in the cefixime group and 3.5% (2.2%-11.5%) in the gatifloxacin group (HR[95%CI] = 0.084 [0.025-0.280], p<0.0001). There was one death in the cefixime group. CONCLUSIONS: Based on this study, gatifloxacin is a better treatment for uncomplicated enteric fever as compared to cefixime. TRIAL REGISTRATION: Current Controlled Trials ISRCTN75784880

He Rourou Whai Painga, an Aotearoa New Zealand dietary pattern for metabolic health and whānau wellbeing: protocol for a randomized controlled trial

BackgroundCardiometabolic diseases are highly prevalent in Aotearoa New Zealand. Dietary intake is a modifiable risk factor for such diseases and certain dietary patterns, specifically the Mediterranean diet (MedDiet), are associated with improved metabolic health. This study aims to test whether an intervention including a Mediterranean dietary pattern incorporating high quality New Zealand foods (NZMedDiet pattern) and behavior change science can improve the metabolic health of participants and their household/whānau.Methods and analysisThis is a multi-center, three-stage trial with two parallel group superiority randomized controlled trials (RCTs), and a longitudinal cohort study embedded within the trial design. The first RCT (RCT 1) is a comparison of the NZMedDiet pattern compared to usual diet for 12 weeks. The Behavior Change Wheel was used to select and implement strategies to support participant adherence to the NZMedDiet, such as web-based nutrition education on healthy shopping and cooking. The second (RCT 2) compares online social support to no online social support for 12 weeks, administered to participants immediately following RCT 1. The third stage is a longitudinal cohort study where all participants are followed from the beginning of their start of the active intervention for 12 months in total. The primary outcome measure for each stage is the metabolic syndrome severity score (MetSSS). The duration of enrolment is 12–15 months. The total recruitment target is 200 index participants and their household/whānau members who participate with them, and the primary analyses will be intention to treat on index participants.DiscussionThe trial will test whether the NZMedDiet pattern and behavior change support improves the cardiometabolic health of people in Aotearoa New Zealand.Clinical trial registrationhttps://www.anzctr.org.au/Default.aspx, identifier ACTRN12622000906752 and https://www.isrctn.com/, identifier ISRCTN89011056 (Spirit 2)

Risk factors for the development of severe typhoid fever in Vietnam

Background Typhoid fever is a systemic infection caused by the bacterium Salmonella enterica serovar Typhi. Age, sex, prolonged duration of illness, and infection with an antimicrobial resistant organism have been proposed risk factors for the development of severe disease or fatality in typhoid fever. Methods We analysed clinical data from 581 patients consecutively admitted with culture confirmed typhoid fever to two hospitals in Vietnam during two periods in 1993–1995 and 1997–1999. These periods spanned a change in the antimicrobial resistance phenotypes of the infecting organisms i.e. fully susceptible to standard antimicrobials, resistance to chloramphenicol, ampicillin and trimethoprim-sulphamethoxazole (multidrug resistant, MDR), and intermediate susceptibility to ciprofloxacin (nalidixic acid resistant). Age, sex, duration of illness prior to admission, hospital location and the presence of MDR or intermediate ciprofloxacin susceptibility in the infecting organism were examined by logistic regression analysis to identify factors independently associated with severe typhoid at the time of hospital admission. Results The prevalence of severe typhoid was 15.5% (90/581) and included: gastrointestinal bleeding (43; 7.4%); hepatitis (29; 5.0%); encephalopathy (16; 2.8%); myocarditis (12; 2.1%); intestinal perforation (6; 1.0%); haemodynamic shock (5; 0.9%), and death (3; 0.5%). Severe disease was more common with increasing age, in those with a longer duration of illness and in patients infected with an organism exhibiting intermediate susceptibility to ciprofloxacin. Notably an MDR phenotype was not associated with severe disease. Severe disease was independently associated with infection with an organism with an intermediate susceptibility to ciprofloxacin (AOR 1.90; 95% CI 1.18-3.07; p = 0.009) and male sex (AOR 1.61 (1.00-2.57; p = 0.035). Conclusions In this group of patients hospitalised with typhoid fever infection with an organism with intermediate susceptibility to ciprofloxacin was independently associated with disease severity. During this period many patients were being treated with fluoroquinolones prior to hospital admission. Ciprofloxacin and ofloxacin should be used with caution in patients infected with S. Typhi that have intermediate susceptibility to ciprofloxacin

The sensitivity of real-time PCR amplification targeting invasive Salmonella serovars in biological specimens

Background: PCR amplification for the detection of pathogens in biological material is generally considered a rapid and informative diagnostic technique. Invasive Salmonella serovars, which cause enteric fever, can be commonly cultured from the blood of infected patients. Yet, the isolation of invasive Salmonella serovars from blood is protracted and potentially insensitive. Methods: We developed and optimised a novel multiplex three colour real-time PCR assay to detect specific target sequences in the genomes of Salmonella serovars Typhi and Paratyphi A. We performed the assay on DNA extracted from blood and bone marrow samples from culture positive and negative enteric fever patients. Results: The assay was validated and demonstrated a high level of specificity and reproducibility under experimental conditions. All bone marrow samples tested positive for Salmonella, however, the sensitivity on blood samples was limited. The assay demonstrated an overall specificity of 100% (75/75) and sensitivity of 53.9% (69/128) on all biological samples. We then tested the PCR detection limit by performing bacterial counts after inoculation into blood culture bottles. Conclusions: Our findings corroborate previous clinical findings, whereby the bacterial load of S. Typhi in peripheral blood is low, often below detection by culture and, consequently, below detection by PCR. Whilst the assay may be utilised for environmental sampling or on differing biological samples, our data suggest that PCR performed directly on blood samples may be an unsuitable methodology and a potentially unachievable target for the routine diagnosis of enteric fever. </p