Process, structural, and outcome quality indicators to support perioperative opioid stewardship: a rapid review.

Opioids are effective analgesics but can cause harm. Opioid stewardship is key to ensuring that opioids are used effectively and safely. There is no agreed set of quality indicators relating to the use of opioids perioperatively. This work is part of the Yorkshire Cancer Research Bowel Cancer Quality Improvement programme and aims to develop useful quality indicators for the improvement of care and patient outcomes at all stages of the perioperative journey.A rapid review was performed to identify original research and reviews in which quality indicators for perioperative opioid use are described. A data tool was developed to enable reliable and reproducible extraction of opioid quality indicators.A review of 628 abstracts and 118 full-text publications was undertaken. Opioid quality indicators were identified from 47 full-text publications. In total, 128 structure, process and outcome quality indicators were extracted. Duplicates were merged, with the final extraction of 24 discrete indicators. These indicators are based on five topics: patient education, clinician education, pre-operative optimization, procedure, and patient-specific prescribing and de-prescribing and opioid-related adverse drug events.The quality indicators are presented as a toolkit to contribute to practical opioid stewardship. Process indicators were most commonly identified and contribute most to quality improvement. Fewer quality indicators relating to intraoperative and immediate recovery stages of the patient journey were identified. An expert clinician panel will be convened to agree which of the quality indicators identified will be most valuable in our region for the management of patients undergoing surgery for bowel cancer.

The lived experience of severe mental illness and long-term conditions: a qualitative exploration of service user, carer, and healthcare professional perspectives on self-managing co-existing mental and physical conditions.

BACKGROUND: People with severe mental illness (SMI), such as schizophrenia, have higher rates of physical long-term conditions (LTCs), poorer health outcomes, and shorter life expectancy compared with the general population. Previous research exploring SMI and diabetes highlights that people with SMI experience barriers to self-management, a key component of care in long-term conditions; however, this has not been investigated in the context of other LTCs. The aim of this study was to explore the lived experience of co-existing SMI and LTCs for service users, carers, and healthcare professionals. METHODS: A qualitative study with people with SMI and LTCs, their carers, and healthcare professionals, using semi-structured interviews, focused observations, and focus groups across the UK. Forty-one interviews and five focus groups were conducted between December 2018 and April 2019. Transcripts were coded by two authors and analysed thematically. RESULTS: Three themes were identified, 1) the precarious nature of living with SMI, 2) the circularity of life with SMI and LTCs, and 3) the constellation of support for self-management. People with co-existing SMI and LTCs often experience substantial difficulties with self-management of their health due to the competing demands of their psychiatric symptoms and treatment, social circumstances, and access to support. Multiple long-term conditions add to the burden of self-management. Social support, alongside person-centred professional care, is a key facilitator for managing health. An integrated approach to both mental and physical healthcare was suggested to meet service user and carer needs. CONCLUSION: The demands of living with SMI present a substantial barrier to self-management for multiple co-existing LTCs. It is important that people with SMI can access person-centred, tailored support for their LTCs that takes into consideration individual circumstances and priorities.

Interpret with caution: An evaluation of the commercial AusDiagnostics versus in-house developed assays for the detection of SARS-CoV-2 virus.

INTRODUCTION: There is limited data on the analytical performance of commercial nucleic acid tests (NATs) for laboratory confirmation of COVID-19 infection. METHODS: Nasopharyngeal, combined nose and throat swabs, nasopharyngeal aspirates and sputum was collected from persons with suspected SARS-CoV-2 infection, serial dilutions of SARS-CoV-2 viral cultures and synthetic positive controls (gBlocks, Integrated DNA Technologies) were tested using i) AusDiagnostics assay (AusDiagnostics Pty Ltd); ii) in-house developed assays targeting the E and RdRp genes; iii) multiplex PCR assay targeting endemic respiratory viruses. Discrepant SARS-CoV-2 results were resolved by testing the N, ORF1b, ORF1ab and M genes. RESULTS: Of 52 clinical samples collected from 50 persons tested, respiratory viruses were detected in 22 samples (42 %), including SARS CoV-2 (n = 5), rhinovirus (n = 7), enterovirus (n = 5), influenza B (n = 4), hMPV (n = 5), influenza A (n = 2), PIV-2 (n = 1), RSV (n = 2), CoV-NL63 (n = 1) and CoV-229E (n = 1). SARS-CoV-2 was detected in four additional samples by the AusDiagnostics assay. Using the in-house assays as the "gold standard", the sensitivity, specificity, positive and negative predictive values of the AusDiagnostics assay was 100 %, 92.16 %, 55.56 % and 100 % respectively. The Ct values of the real-time in-house-developed PCR assay targeting the E gene was significantly lower than the corresponding RdRp gene assay when applied to clinical samples, viral culture and positive controls (mean 21.75 vs 28.1, p = 0.0031). CONCLUSIONS: The AusDiagnostics assay is not specific for the detection SARS-CoV-2. Any positive results should be confirmed using another NAT or sequencing. The case definition used to investigate persons with suspected COVID-19 infection is not specific.

European guideline for the management of genital herpes, 2010.

This is the guideline for genital herpes simplex virus (HSV) management for the IUSTI/WHO Europe, 2010. They describe the epidemiology, diagnosis, clinical features, treatment and prevention of genital HSV infection. They include details on the management of HSV in pregnancy, those who are immunocompromised and the clinical investigation and management of suspected HSV-resistant disease.

Pearly penile papules regress in older patients and with circumcision.

This study assesses the prevalence and correlates of pearly penile papules (PPP) in two non-genitourinary (GU) medicine male cohorts (<25 and >50 years). PPP were categorised in 188 university students (<25 years), based on self-examination, and 70 patients (>50 years), based on clinician examination. PPP were categorised from 1 to 4, based on increasing papule size and distribution. An anonymous questionnaire was used to identify associations with PPP prevalence. The prevalence of PPP was 38.3% in <25 years, and 11.4% in >50 years (P < 0.001). The prevalence of categories 3 and 4 PPP was 8.5% in <25 years, and 1.4% in >50 years (P < 0.05). In the younger age group, the prevalence of PPP was 26.5% in circumcised participants, and 42.4% in uncircumcised participants (P < 0.05), but was unrelated to either frequency of sexual intercourse or time since first sexual intercourse. In conclusion, PPP disappear with age, and any PPP in patients >50 years are less marked than those in patients <25 years. Patients should be advised accordingly. PPP are less prevalent in circumcised men. Patients could be advised to wear the foreskin rolled back - this may maximize exposure of the coronal area to normal abrasion, which may hasten PPP regression.

Physical and biochemical aspects of the flow across the Mascarene Plateau in the Indian Ocean.

This paper presents results from a detailed hydrographic survey of the Mascarene Plateau and surrounding area undertaken by the RRS Charles Darwin in June-July 2002. We examine how the westward-flowing South Equatorial Current (SEC) crosses the plateau, and how the structure of the flow determines the supply of nutrients to the surface waters. We find that the flow of the SEC across the plateau is highly dependent on the complex structure of the banks which make up the plateau, and that a large part of the flow is channelled between the Saya de Malha and Nazareth Banks. Furthermore, the SEC forms a sharp boundary between subtropical water masses from further south, which are low in nutrients, and waters from further north, which are relatively nutrient rich. Overall, the SEC delivers relatively high levels of nutrients to the near-surface waters of the central and northern regions of the plateau, compared with the southern regions of the plateau. This is partly due to uplifting of density surfaces through Ekman suction on the northern side of the SEC, and partly due to the higher levels of nutrients on those density surfaces on the northern side of the SEC. This may drive increased production of phytoplankton in these areas, which would in turn be expected to fuel increased abundances of zooplankton and higher levels of the food chain.

A pulmonary monitoring and treatment plan for children with Duchenne-type muscular dystrophies.

The Pulmonary Medicine Section of the Department of Pediatrics of the University of Arkansas for Medical Sciences has recently developed an association with the Muscular Dystrophy Association Clinic held at Arkansas Children's Hospital. The slowly progressive, insidious onset of pulmonary problems associated with Duchenne-type muscular dystrophies and other degenerative muscle disorders indicated a need for a aggressive monitoring and treatment plan for these children and their caregivers. We have developed a Respiratory Care Handbook for families with information on the pulmonary consequences of these diseases including pathophysiology, pulmonary function tests, respiratory treatments including mechanical ventilatory support, and anticipation and prevention of pulmonary crises. In addition, we have introduced for the physician a formal monitoring and treatment regimen driven by changes in the vital capacity lung volume. The substance of this plan is presented in this manuscript.

The determination of low levels of radiocaesium and radioruthenium in foodstuffs.

The Ministry of Agriculture, Fisheries and Food (MAFF) has the responsibility for safeguarding the food supply from authorised and accidental releases of radioactivity to the environment. MAFF funds a radiological research programme to assist in the achievement of its objectives and has recognised that there is a continuing requirement to develop cost effective and sensitive analytical methods for the detection of very low levels of radioactivity in foodstuffs. High resolution gamma spectrometry is often the most appropriate analytical method for the determination of 103Ru, 106Ru, 134Cs and 137Cs but the detection limits for these radionuclides in bulk foodstuffs do not permit the acquisition of accurate data at very low levels. Beta counting techniques offer inherently higher sensitivities but the development of radiochemical separation techniques is essential to provide appropriate counting sources. A radiochemical separation method has been developed for the determination of radiocaesium and radioruthenium in 0.5 kg fresh wt samples of a variety of foodstuffs. The method was shown to be robust and specific and mean method recoveries of 75% were obtained for both radiocaesium and radioruthenium. MDA's for the 1000 min counts on a gas-flow proportional counter were determined to be 0.015 Bq/kg fresh wt for both 137Cs and 106Ru.

Chest wall motion in neonates utilizing respiratory inductive plethysmography.

After calibration, respiratory inductive plethysmography can accurately measure breathing patterns noninvasively by transmitting ribcage and abdomen compartment changes caused by ventilation through oscillator circuitry. We measured the breathing pattern of nine quietly awake healthy newborn infants and assessed components reflecting asynchrony, paradoxic motion, and overall phasic relations between ribcage and abdomen compartments. Breathing pattern data (mean +/- SD) on 136 total tidal volume (Vt) breaths revealed: Vt, 14.4 +/- 3.40 ml; frequency, 52.1 +/- 11.5 beats/min; ribcage contribution to Vt, 32.2% +/- 13.4%; maximum compartmental amplitude/Vt, 1.01 +/- 0.01; phase angle, 13.2 +/- 9.50 degrees; inspiratory asynchrony index, 0.26 +/- 0.20 ml2/ml; expiratory asynchrony index, 0.42 +/- 0.3 ml2/ml; and average asynchrony index, 0.34 +/- 0.20 ml2/ml. Results demonstrated a high degree of synchrony between ribcage and abdomen movement during quietly awake breathing. Outward motion of the abdomen preceded that of the ribcage for almost every measured breath.

Breathing patterns in lambs after oleic acid lung injury utilizing respiratory inductive plethysmography.

We measured breathing patterns utilizing a respiratory inductive plethysmograph (RIP) in seven healthy nonsedated lambs after an iv infusion of oleic acid (50 mg/kg) to induce acute pulmonary edema. Our single position graphic (SPG) calibration technique was employed for gain factor calculation. Accuracy was validated by the simultaneous volume measurement of RIP and integrated pneumotachography (PNT). Of a total 840 validation breaths, 467 (56%) were within 5% of PNT, 734 (87%) were within 10%, and 834 (99.9%) were within 20%. In each study baseline physiologic and breathing pattern data were collected and also at 15, 30, 60, 90, 150, and 210 min postoleic acid infusion. Validation of RIP accuracy before each data collection revealed 29% required new gain factor calculation. Recalibration was done within 5 min. Excluding respiratory frequency, which remained at 30% above baseline, variables were not significantly different than baseline measurements at the 210-min interval. Results suggest that calibration of RIP using our SPG technique is a time-efficient method and that RIP can accurately measure breathing patterns, providing an additional tool for assessment of experimental lung injury in lambs.

Calibration of respiratory inductive plethysmography during quiet and active sleep in lambs.

Respiratory inductive plethysmography provides a noninvasive method of measuring breathing patterns. Calibration of respiratory inductive plethysmography requires calculation of gain factors for ribcage and abdomen transducers utilizing 2 breathing patterns with different ribcage and abdomen contributions and tidal volume measured by either spirometry or integrated pneumotachography. The purpose of this study was to determine if respiratory inductive plethysmography can be calibrated to provide accurate measurements during quiet and active sleep in lambs. We used a least squares linear regression calibration technique with breaths selected from quiet sleep and active sleep to calculate gain factors in 6 tracheostomized lambs. Validation of gain factors was performed by comparing tidal volumes obtained simultaneously by respiratory inductive plethysmography and pneumotachography during quiet sleep and active sleep. Tidal volume differences between respiratory inductive plethysmography and pneumotachography on validation runs of 15 consecutive breaths each revealed 90% of validation breaths within +/- 20% during quiet sleep and 82% of validation breaths within +/- 20% during active sleep. These data provide evidence that respiratory inductive plethysmography can be calibrated to allow breathing pattern measurement during sleep.

Calibration of the respiratory inductive plethysmograph with the single position graphic technique. Accuracy in different behavior states in lambs.

Respiratory inductive plethysmography (RIP) can measure breathing patterns noninvasively. Calibration is required for rib cage and abdomen transducers utilizing breaths with different compartment contribution correlated with tidal volume measured by integrated pneumotachography (PNT). This study was performed to determine if RIP remains accurate during sleep states following calibration in the quietly awake state. We used our single position graphic calibration technique (SPG) to calculate gain factors in seven tracheostomized lambs. Validation of gain factors was accomplished by comparing tidal volume obtained simultaneously by RIP and PNT during quiet wakefulness (QW), quiet sleep (QS) and active sleep (AS). Results of the study showed that RIP was accurately calibrated during QW. Accuracy was decreased during QS and AS.

Face mask application for calibration of respiratory inductive plethysmography in lambs.

Respiratory inductive plethysmography is a non-invasive method of assessing breathing patterns that requires an airway connection for calibration. In previous studies an endotracheal tube was used to establish this connection. We employed a single position graphic calibration technique for gain calculation using a conical face mask in place of the endotracheal tube, thus eliminating the need for sedation and topical anaesthesia. Thirteen studies were completed on seven lambs. Validation of gains was performed by comparing volumes obtained simultaneously by respiratory inductive plethysmography and integrated pneumotachography. Total study time ranged between 5 and 10 min for each calibration procedure. Our results suggest that the conical mask can be used to perform accurate and time-efficient calibration of the respiratory inductive plethysmograph in the spontaneously breathing non-sedated lamb and eliminates the need for endotracheal intubation.

Calibration of respiratory inductive plethysmography in lambs receiving intermittent mandatory mechanical ventilation.

Respiratory inductive plethysmography (RIP) is a noninvasive method of assessing breathing pattern. We employed a single-position graphic (SPG) calibration technique for gain factor calculation in 38 studies on five sedated lambs who were receiving intermittent mandatory mechanical ventilation (IMV). The SPG technique uses selection of two breaths from a 20-sec run of breaths with different ribcage/pneumotachograph (PNT) and abdomen/PNT ratios for gain calculation. Validation of gains was performed by comparing volumes obtained simultaneously by RIP and PNT. The mean tidal volume (VT) measured by RIP corresponded well with mean VT measured by PNT with animals receiving 42.2 +/- 13.2 (SD) % of breaths over 1 min by IMV. Time for calibration and validation ranged between 15 and 30 min. The results of this study suggest that the SPG calibration technique provides an accurate method of calibration of RIP in sedated lambs receiving IMV.

Calibration of respiratory inductive plethysmography in spontaneously breathing lambs and piglets.

Respiratory inductive plethysmography is a method of assessing breathing pattern without an airway connection. We employ a single position graphic calibration technique for gain factor calculation. Nineteen studies were completed in piglets and 20 studies were completed in lambs. The single position graphic technique utilizes selection of two breaths from a 20 s run of breaths with different ribcage/pneumotachograph and abdomen/pneumotachograph ratios for gain calculation. Validation of gains was performed by comparing volumes obtained simultaneously by respiratory inductive plethysmography and pneumotachography. Total study time ranged between 15 and 30 min. Results suggest that the single position graphic calibration technique provides time-efficient and accurate calibration of respiratory inductive plethysmography in the spontaneously breathing, sedated lamb and piglet, allowing respiratory inductive plethysmography to become an additional tool for ventilatory parameter measurement.

Breathing patterns in infants utilizing respiratory inductive plethysmography.

Respiratory inductive plethysmography (RIP) is a method that can be used to assess breathing patterns in infants without an airway connection. Ribcage and abdomen transducers are used which require gain factor calculation for calibration. We employed a single position graphic (SPG) calibration technique for gain factor calculation in RIP to obtain breathing pattern data for 70 infants in the quietly awake state. The SPG technique utilizes selection of two breaths from a 20s run of breaths with different ribcage/pneumotachograph (RC/PNT) and abdomen/pneumotachograph (AB/PNT) ratios for the gain factor calculation. Validation of gain factors was performed by comparing volumes obtained simultaneously by RIP and PNT. In 46 of the infants, maintenance of gain factor accuracy was confirmed following position reversal. Revalidation after position change could not be accomplished in 24 infants who were aroused into an agitated state. Breathing patterns were collected by RIP alone on the 46 infants who remained accurately calibrated in the supine and prone positions. No significant correlations were found between breathing pattern data and anthropometric characteristics. When the infants were repositioned, no consistent pattern of change could be identified. This study suggests that the SPG technique provides time-efficient and accurate calibration of RIP in the newborn infant. Furthermore, accuracy is maintained through position change if the infant remains in the same behavioral state. Breathing pattern data presented is representative of normative values in the quietly awake state for our study population.

Calibration of computer-assisted (Respicomp) respiratory inductive plethysmography in newborns.

We investigated the accuracy of a computer-assisted, respiratory inductive plethysmograph (Respicomp) on 50 awake human newborns who were lying supine. Breaths were selected with different rib cage (RC) to pneumotach (PNT) and abdomen (AB) to pneumotach (PNT) values. The equation RC/PNT + AB/PNT = 1 was solved using the least squares method (LSQ) of calculation of calibration factors. Validation of the calibration factors was performed with a range of consecutive breaths between 6 and 22. Of the 1,128 validation or revalidation breaths, 628 (56%) were within 10% of the simultaneously measured PNT volume, 1,024 (91%) were within 20%, and 1,128 (100%) were within 30%. The RC or AB compartment contributions to ventilation changed spontaneously in the awake newborns. This change eliminated the need to wait for varying sleep states to obtain calibration factors and reduced total time required for calibration. (Some loss of accuracy is a compromise with this method; the calibration factors obtained do not remain accurate while the infant is asleep.) This method provided a reliable and rapid calibration and validation technique of the respiratory inductive plethysmograph (Respicomp) on awake newborns.

Pediatric aerosol therapy guidelines. Indications, techniques, and dosages.

Delivery of medication in aerosol form to the pediatric population is an important therapeutic module. Aerosol therapy allows rapid medication effects, reduces systemic side effects, and provides uniform results in comparable clinical presentations if preparation techniques and dosages are appropriate. The effectiveness of aerosol therapy is dependent upon several key factors, and techniques developed to emphasize these factors will maximize aerosol delivery into the tracheobronchial tree. Indications for medical aerosol therapy are specific for children, and individualized treatment can be structured for a wide variety of pulmonary disorders. Proper and successful administration of aerosol therapy to the infant or child requires a comprehensive amount of skill and knowledge on the part of the respiratory therapy practitioner. Guidelines discussed in this paper will assist the respiratory care practitioner in achieving optimal results in treating airway disease in the pediatric patient.