Paediatric nonbronchoscopic bronchoalveolar lavage: Overview and recommendations for clinical practice

NB-BAL is an effective procedure for the diagnosis of pulmonary disease processes in ventilated infants and children. This procedure is, however, not without risks to both patients and staff. Numerous complications of NB-BAL exist, with hypoxia being the most common. As a result, care should be taken in performing NB-BAL on haemodynamically unstable patients; patients with coagulation defects; and patients with cardiac or brain abnormalities. This paper presents an overview of paediatric nonbronchoscopic bronchoalveolar lavage (NB-BAL) including: the rationale for NB-BAL; the complications associated with the procedure; indications and contraindications. It also recommends an evidence-based clinical guideline for performing the procedure in the paediatric intensive care unit. By following the NB-BAL guidelines presented in this paper, one can ensure that an effective specimen is obtained from the lower respiratory tract, whilst minimising the risk to the patient

User perceptions of multi-source feedback tools for junior doctors

Context:  The effectiveness of multi-source feedback (MSF) tools, which are increasingly important in medical careers, will be influenced by their users’ attitudes. This study compared perceptions of two tools for giving MSF to UK junior doctors, of which one provides mainly textual feedback and one provides mainly numerical feedback. We then compared the perceptions of three groups, including: trainees; raters giving feedback, and supervisors delivering feedback. Methods:  Postal questionnaires about the usability, usefulness and validity of a feedback system were distributed to trainees, raters and supervisors across the north of England. Results:  Questionnaire responses were analysed to compare opinions of the two tools and among the different user groups. Overall there were few differences. Attitudes towards MSF in principle were positive and the tools were felt to be usable, but there was little agreement that they could effectively identify doctors in difficulty or provide developmental feedback. The text-oriented tool was rated as more useful for giving feedback on communication and attitude, and as more useful for identifying a doctor in difficulty. Raters were more positive than other users about the usefulness of numerical feedback, but, overall, text was felt to be more useful. Some trainees expressed concern that feedback was based on insufficient knowledge of their work. This was not supported by raters’ responses, although many did use indirect information. Trainees selected raters mainly for the perceived value of their feedback, but also based on personal relationships and the simple pragmatics of getting a tool completed. Discussion:  Despite positive attitudes to MSF, the perceived effectiveness of the tools was low. There are small but significant preferences for textual feedback, although raters may prefer numerical scales. Concerns about validity imply that greater awareness of contextual and psychological influences on feedback generation is necessary to allow the formative benefits of MSF to be optimised and to negate the risk of misuse in high-stakes contexts

Hypophyseal Growth Hormone II. Interaction with Other Hormones

Growth hormone (GH) synthesis and release is controlled by hypothalamic GH releasing factor. Thyroid hormones, androgens and estrogens in physiologic concentrations enhance GH secretion but a controlling role for glucagon and vasopressin in GH release is not established. Under stress, ACTH directly facilitates GH release while the similar action of the catecholamines is mediated by the a-adrenergic receptors. Though physiologic doses of glucorticoids and progestins do not affect GH liberation, prolonged administration of medroxyprogesterone acetate or of glucocorticoids in high dosage will decrease blood levels or blunt Gti responsiveness. GH enhances the release of insulin. A shift in adrenal steroid biosynthesis from the glucocorticoid to the androgenic pathway may also be an effect of GH administration. Prolonged elevated GH levels decrease serum thyroid binding globulin but increase the turnover of free thyroxine. Decreased thyroidal iodine uptake is probably secondary to these changes in thyroxine metabolism. In hypothyroidism and severe Cushing\u27s syndrome GH release is blunted. In most cases of acromegaly as well as in hyperthyroidism GH is nonsuppressible, while in diabetes its response to stimuli other than hypoglycemia is exaggerated

Pulsed Doppler lidar airborne scanner

This report covers the work accomplished during the reporting period on Pulsed Doppler Lidar Airborne Scanner and describes plans for the next reporting period. The objectives during the current phase of the contract are divided into four phases. Phase 1 includes ground testing of the system and analysis of data from the 1981 Severe Storms Test Flights. Phase 2 consists of preflight preparation and planning for the 1983 flight series. The flight test itself will be performed during Phase 3, and Phase 4 consists of post-flight analysis and operation of the system after that flight test. The range profile from five samples taken during Flight 10, around 1700 Z is given. The lowest curve is taken from data collected upwind of Mt. Shasta at about 10,000 feet of altitude, in a clear atmosphere, where no signals were observed. It thus is a good representation of the noise level as a function of range. The next curve was taken downwind of the mountain, and shows evidence of atmospheric returns. There is some question as to whether the data are valid at all ranges, or some ranges are contaminated by the others

The Effectiveness of Oxandrolone in Promoting Linear Growth in Growth Hormone Deficient Children

This two-year study consisted of a comparison of oxandrolone and growth hormone for the treatment of five children with documented growth hormone deficiency. Previously, androgens have been reported to be relatively ineffective in accelerating linear growth In growth hormone deficient children. Oxandrolone was administered for one year. Growth hormone was added in the second six months and then was given as a single agent in the third six months. Growth accelerated markedly in all patients. Only one child showed more rapid growth with the addition of growth hormone while two children actually grew more rapidly under the Influence of oxandrolone alone. Growth was poor and diminished when growth hormone was given as a single agent in the third six-month period for three children but improved when oxandrolone was re-instituted in a fourth six-month treatment period. These results suggest that oxandrolone may prove to be an effective and safe substitute for growth hormone in the management of selected cases of hypopituitarism

Identification of a novel retroviral gene unique to human immunodeficiency virus type 2 and simian immunodeficiency virus SIVMAC

Human and simian immunodeficiency-associated retroviruses are extraordinarily complex, containing at least five genes, tat, art, sor, R, and 3' orf, in addition to the structural genes gag, pol, and env. Recently, nucleotide sequence analysis of human immunodeficiency virus type 2 (HIV-2) and simian immunodeficiency virus SIVMAC revealed the existence of still another open reading frame, termed X, which is highly conserved between these two viruses but absent from HIV-1. In this report, we demonstrate for the first time that the X open reading frame represents a functional retroviral gene in both HIV-2 and SIVMAC and that it encodes a virion-associated protein of 14 and 12 kilodaltons, respectively. We also describe the production of recombinant TrpE/X fusion proteins in Escherichia coli and show that sera from some HIV-2-infected individuals specifically recognize these proteins

Parental satisfaction with the quality of care in a South African paediatric intensive care unit

Background. The quality of family-centred care in the paediatric intensive care unit (PICU) has been poorly studied in South Africa (SA). Objective. To explore parents’ satisfaction with care in a PICU in SA. Methods. A prospective descriptive survey study was conducted among a convenience sample of 100 parents of children admitted to the PICU for ≥48 hours. Participants completed the EMpowerment of PArents in THe Intensive Care (EMPATHIC-30) questionnaire, which includes 30 closed questions rating satisfaction in different domains and four open-ended questions to qualitatively describe PICU experiences. Results. Of the 100 admissions included in the study, 35% were unplanned and 88% were mechanically ventilated. Parents were very satisfied with the quality of PICU care, with mean scores in all domains reaching ≥5.5 on a 6-point Likert scale. Parents were most satisfied with the professional attitude of PICU staff, whereas the lowest scores were seen in the ‘Information’ and ‘Parental participation’ domains. The internal consistency (Cronbach’s α) associated with the different domains ranged between 0.25 (Parental participation) and 0.59 (Care and cure). The need for communication and support during the admission period, and the importance of environmental factors, proximity to the child, the attitude of medical staff and social support during the PICU stay emerged as common themes from the responses to the open-ended questions. Conclusion. Although parents were generally well satisfied with the quality of care, improving family involvement and providing adequate information in the PICU can contribute to quality family-centred care. Keywords. Family- centered care; patient- centered care; paediatric intensive care unit; quality of car

Complications of Treated Cushing\u27s Syndrome

Fifty-two patients with Cushing\u27s syndrome are reported with emphasis on post treatment complications. Seven patients, cured of their disease following appropriate therapy, had a recurrence of adrenal hypersecretion from one to ten years later. This occurred after all modalities of treatment, but was more common after sub-total adrenalectomy. Pituitary adenomas were found in two cases. Pseudotumor cerebri, psychiatnc complications, hyperthyroidism and hyperpigmentation were observed. One patient developed progressive hyperplgmentation despite pituitary radiation. Thirteen of fifty-two patients had malignant disease including three endometrial carcinomas, one rectal carcinoma and one adenocarcinoma of the mandible. Despite the remarkable improvement In the prognosis for patients with Cushing\u27s syndrome, this population continues to be at high risk for late complications and warrants close follow-up medical care

Understanding implementation success: protocol for an in-depth, mixed-methods process evaluation of a cluster randomised controlled trial testing methods to improve detection of Lynch syndrome in Australian hospitals.

INTRODUCTION:In multisite intervention trials, implementation success often varies widely across settings. Process evaluations are crucial to interpreting trial outcomes and understanding contextual factors and causal chains necessary for successful implementation. Lynch syndrome is a hereditary cancer predisposition conferring an increased risk of colorectal, endometrial and other cancer types. Despite systematic screening protocols to identify Lynch syndrome, the condition remains largely underdiagnosed. The Hide and Seek Project ('HaSP') is a cluster randomised controlled trial determining the effectiveness of two approaches to improving Lynch syndrome detection at eight Australian hospital networks. To enhance widespread implementation of optimal Lynch syndrome identification, there is a need to understand not only what works, but also why, in what contexts, and at what costs. Here we describe an in-depth investigation of factors influencing successful implementation of procedures evaluated in the HaSP trial. METHODS AND ANALYSIS:A mixed-methods, theory-driven process evaluation will be undertaken in parallel to the HaSP trial. Data will include: interviews of Implementation Leads and Lynch syndrome stakeholders, pre-post implementation questionnaires, audio analysis of meetings and focus groups, observation of multidisciplinary team meetings, fidelity checklists and project log analysis. Results will be triangulated and coded, drawing on the Theoretical Domains Framework, Consolidated Framework for Implementation Research and Proctor's implementation outcomes. ETHICS AND DISSEMINATION:Use of a theory-based process evaluation will enhance interpretation and generalisability of HaSP trial findings, and contribute to the implementation research field by furthering understanding of the conditions necessary for implementation success. Ethical approval has been granted and results will be disseminated via publications in peer-reviewed journals and conference presentations. At trial completion, key findings will be fed back to sites to enable refinement of intervention strategies, both in the context of Lynch syndrome and for the possible generalisability of intervention components in other genetic and broader clinical specialties. HASP TRIAL REGISTRATION NUMBER:Australian New Zealand Clinical Trials Registry (Identifier: ACTRN12618001072202). Registered 27 June 2018. http://www.ANZCTR.org.au/ACTRN12618001072202.aspx

The provision of adult intensive care in Northern Ireland with reference to the role of high dependency care.

In 1991 an audit of Intensive Care Services was carried out by the Northern Ireland Intensive Care Group. In conjunction with this regional overview, all patients in the Regional Intensive Care Unit, (RICU) in the Royal Victoria Hospital were assessed daily, over a 10 month period in 1990-91 and classified as conforming to either intensive care or high dependency status. These data were then used to compare adult intensive care service in Northern Ireland with recent national and international recommendations on intensive care. Ten units in Northern Ireland were surveyed. In regard to national or international guidelines, all ten were deficient to some degree. Four units had significant deficiencies; small patient numbers, lack of 'dedicated' 24 hr medical cover and or deficiencies in the provision of appropriate monitoring and or equipment. There was a large diversity in casemix among the ten units surveyed which suggested differing admission criteria. The bed occupancy of RICU was 100%. Refused admissions constituted a further 13% of unresourced workload. The lack of physically separate, dedicated high dependency unit facilities meant that 26% of bed days were devoted to HDU care (usually for "improved" intensive care unit patients not yet ready for discharge to a general ward. Achieving nationally recommended intensive care standards (on a regional basis) is probably only possible if a number of the smaller intensive care units are redesignated as high dependency units, and patients requiring intensive care are concentrated in a smaller number of larger ICUs. This will increase the frequency of interhospital transfer of critically ill patients