High frequency oscillatory ventilation in children: an overview

AbstractThe last 30 years, high frequency ventilation (HFV) has found its way from the neonatal to the paediatric and adult ICU. With its small tidal volumes, strict intrathoracic pressure variations and disengagement of ventilation from oxygenation, HFV fits in our insights nowadays in lung protective ventilation. This review provides you with an understanding of the different modes of HFV, gas exchange mechanisms during HFV which uses tidal volumes below dead space volume, and some information on nursing and weaning a child on HFV. Focus will be on the clinical use of high frequency oscillatory ventilation with a practical overview of the strategies used: the high-volume strategy designed to rapidly recruit and maintain optimal lung volume in diffuse alveolar disease and lung haemorrhage, the low volume strategy in airleak, and the open airway strategy in small airway disease where the continuous distending pressure is used to recruit and stent the airways

The effectiveness of substitution of hospital ward care from medical doctors to physician assistants: a study protocol

Contains fulltext : 137007.pdf (publisher's version ) (Open Access)BACKGROUND: Because of an expected shrinking supply of medical doctors for hospitalist posts, an increased emphasis on efficiency and continuity of care, and the standardization of many medical procedures, the role of hospitalist is increasingly allocated to physician assistants (PAs). PAs are nonphysician clinicians with medical tasks. This study aims to evaluate the effects of substitution of hospital ward care to PAs. METHODS/DESIGN: In a multicenter matched controlled study, the traditional model in which the role of hospitalist is taken solely by medical doctors (MD model) is compared with a mixed model in which a PA functions as a hospitalist, contingent with MDs (PA/MD model). Twenty intervention and twenty control wards are included across The Netherlands, from a range of medical specialisms. Primary outcome measure is patients' length of hospital stay. Secondary outcomes include indicators for quality of hospital ward care, patients experiences with medical ward care, patients health-related quality of life, and healthcare providers' experiences. An economic evaluation is conducted to assess the cost implications and potential efficiency of the PA/MD model. For most measures, data is collected from medical records or questionnaires in samples of 115 patients per hospital ward. Semi-structured interviews with healthcare professionals are conducted to identify determinants of efficiency, quality and continuity of care and barriers and facilitators for the implementation of PAs in the role of hospitalist. DISCUSSION: Findings from this study will help to further define the role of nonphysician clinicians and provides possible key components for the implementation of PAs in hospital ward care. Like in many studies of organizational change, random allocation to study arms is not feasible, which implies an increased risk for confounding. A major challenge is to deal with the heterogeneity of patients and hospital departments

Changes in infectious disease mortality among children in the Netherlands

In this study we examine the changes in mortality due to infectious diseases in childhood over recent decades. We analysed mortality data among children due to infectious diseases from 1969 until 2006. This study shows a steep decline of infectious disease mortality in the 1970s, followed by a relative stabilisation thereafter. This was caused by an isolated decline in infectious disease mortality in children younger than 5 years. In children over 5 years of age the infectious disease mortality remained stable during the entire study period. Analysis of mortality data of our paediatric intensive care unit (PICU) shows an increasing trend in mortality due to infections in children with underlying illnesses. Infections in childhood have remained a stable burden of mortality over recent decades

Physician Assistants and Nurse Practitioners in Primary Care Plus: A Systematic Review

Contains fulltext : 232486.pdf (Publisher’s version ) (Open Access)INTRODUCTION: Shifting specialist care from the hospital to primary care/community care (also called primary care plus) is proposed as one option to reduce the increasing healthcare costs, improve quality of care and accessibility. The aim of this systematic review was to get insight in primary care plus provided by physician assistants or nurse practitioners. METHODS: Scientific databases and reference list were searched. Hits were screened on title/abstract and full text. Studies published between 1990-2018 with any study design were included. Risk of bias assessment was performed using QualSyst tool. RESULTS: Search resulted in 5.848 hits, 15 studies were included. Studies investigated nurse practitioners only. Primary care plus was at least equally effective as hospital care (patient-related outcomes). The number of admission/referral rates was significantly reduced in favor of primary care plus. Barriers to implement primary care plus included obtaining equipment, structural funding, direct access to patient-data. Facilitators included multidisciplinary collaboration, medical specialist support, protocols. CONCLUSIONS AND DISCUSSION: Quality of care within primary care plus delivered by nurse practitioners appears to be guaranteed, at patient-level and professional-level, with better access to healthcare and fewer referrals to hospital. Most studies were of restricted methodological quality. Findings should be interpreted with caution

Substituting physicians with nurse practitioners, physician assistants or nurses in nursing homes: protocol for a realist evaluation case study

Contains fulltext : 174303.pdf (publisher's version ) (Open Access)INTRODUCTION: In developed countries, substituting physicians with nurse practitioners, physician assistants and nurses (physician substitution) occurs in nursing homes as an answer to the challenges related to the ageing population and the shortage of staff, as well as to guarantee the quality of nursing home care. However, there is great diversity in how physician substitution in nursing homes is modelled and it is unknown how it can best contribute to the quality of healthcare. This study aims to gain insight into how physician substitution is modelled and whether it contributes to perceived quality of healthcare. Second, this study aims to provide insight into the elements of physician substitution that contribute to quality of healthcare. METHODS AND ANALYSIS: This study will use a multiple-case study design that draws upon realist evaluation principles. The realist evaluation is based on four concepts for explaining and understanding interventions: context, mechanism, outcome and context-mechanism-outcome configuration. The following steps will be taken: (1) developing a theory, (2) conducting seven case studies, (3) analysing outcome patterns after each case and a cross-case analysis at the end and (4) revising the initial theory. ETHICS AND DISSEMINATION: The research ethics committee of the region Arnhem Nijmegen in the Netherlands concluded that this study does not fall within the scope of the Dutch Medical Research Involving Human Subjects Act (WMO) (registration number 2015/1914). Before the start of the study, the Board of Directors of the nursing home organisations will be informed verbally and by letter and will also be asked for informed consent. In addition, all participants will be informed verbally and by letter and will be asked for informed consent. Findings will be disseminated by publication in a peer-reviewed journal, international and national conferences, national professional associations and policy partners in national government

Somatotropic responses to soy protein alone and as part of a meal.

AB - CONTEXT: Growth hormone (GH) is an important regulator of growth and body composition. We previously showed that GH release can be promoted by oral ingestion of soyprotein, it is not known however whether these somatotropic effects of soy protein are also present when soy protein is ingested as part of a complete meal. OBJECTIVE/DESIGN: We compared effects of oral ingestion of soyprotein alone with effects of a meal containing the same amount of soyprotein on GH secretion in six healthy women (BMI=19-26kg/m2; 19-36years), in a randomized crossover design. During the complete experiment serum GH, insulin and glucose were determined every 20 minutes. RESULTS: GH responses as determined by area under the curve (AUC) and peak values were lower after ingestion of the meal, in comparison with after the soy protein consumption alone (p<0.05), and did not differ from the placebo condition. Glucose-responses and insulin-responses, both determined as area under the curve (AUC) and peak values, were higher after ingestion of the meal, compared with these after ingestion of the protein-drink or the placebo (p<0.05). CONCLUSION: The somatotropic effect of soy protein is reduced and delayed when soy protein is ingested as part of a complete meal. Dietary carbohydrates, by increasing serum levels of glucose and insulin concentration, as well as dietary fat, may have interfered with the somatotropic effects of soy protein

The cost-effectiveness of physician assistants/associates: A systematic review of international evidence

BACKGROUND: The global utilization of the physician assistant/associate (PA) is growing. Their increasing presence is in response to the rising demands of demographic changes, new developments in healthcare, and physician shortages. While PAs are present on four continents, the evidence of whether their employment contributes to more efficient healthcare has not been assessed in the aggregate. We undertook a systematic review of the literature on PA cost-effectiveness as compared to physicians. Cost-effectiveness was operationalized as quality, accessibility, and the cost of care. METHODS AND FINDINGS: Literature to June 2021 was searched across five biomedical databases and filtered for eligibility. Publications that met the inclusion criteria were categorized by date, country, design, and results by three researchers independently. All studies were screened with the Risk of Bias in Non-randomised Studies-of Interventions (ROBIN-I) tool. The literature search produced 4,855 titles, and after applying criteria, 39 studies met inclusion (34 North America, 4 Europe, 1 Africa). Ten studies had a prospective design, and 29 were retrospective. Four studies were assessed as biased in results reporting. While most studies included a small number of PAs, five studies were national in origin and assessed the employment of a few hundred PAs and their care of thousands of patients. In 34 studies, the PA was employed as a substitute for traditional physician services, and in five studies, the PA was employed in a complementary role. The quality of care delivered by a PA was comparable to a physician's care in 15 studies, and in 18 studies, the quality of care exceeded that of a physician. In total, 29 studies showed that both labor and resource costs were lower when the PA delivered the care than when the physician delivered the care. CONCLUSIONS: Most of the studies were of good methodological quality, and the results point in the same direction; PAs delivered the same or better care outcomes as physicians with the same or less cost of care. Sometimes this efficiency was due to their reduced labor cost and sometimes because they were more effective as producers of care and activity

The effects of dietary protein on the somatotropic axis: a comparison of soy, gelatin, alpha-lactalbumin and milk.

Background/Objectives:Growth hormone (GH) is an important regulator of growth and body composition. It has been shown that GH release can be promoted by administration of various amino acids (AAs), such as arginine and lysine, that are present in soy protein. We previously showed that oral ingestion of soy protein stimulates the GH release, it is not known however to which extent other proteins stimulate the GH secretion.Subjects/Methods:Ingestion of soy protein (soy), gelatin protein (gelatin), alpha-lactalbumin protein (alpha-lactalbumin) and milk protein (milk) were compared on their GH-stimulating capacity. After oral ingestion of protein (0.6 g protein per kg bodyweight), blood was sampled every 20 min for 5 h to analyze GH, AA, insulin and glucose concentrations. The study was performed in eight healthy women (aged 19-26 years; body mass index 19-26 kg/m(2)) in a randomized, single blind, placebo-controlled crossover design.Results:GH responses were more increased after ingestion of gelatine (8.2+/-1.1 mug/l) compared with ingestion of soy, alpha-lactalbumin and milk (5.0+/-0.8, 4.5+/-0.6 and 6.4+/-1.0 mug/l, respectively) (P<0.05). After ingestion of each protein, GH responses were higher compared with placebo ingestion (P<0.05). Simultaneously ingestion of gelatin resulted in the highest serum-arginine concentrations (ARG) compared with after ingestion of the other proteins (P<0.05). Insulin as well as glucose concentrations were not different after ingestion of the various proteins (P<0.05).Conclusions:The GH-promoting activity of protein depends on the protein source, in that, gelatin protein is the most potent GH stimulator. Arginine may be the responsible AA in the GH-promoting effect of gelatin, although each protein may have its own specific AA-spectrum involved in the stimulation of the somatotropic axis.European Journal of Clinical Nutrition advance online publication, 10 March 2010; doi:10.1038/ejcn.2010.21