The impact of COVID-19 on Children's Social Care in England.

BACKGROUND: As a response to COVID-19 the population of England was asked to stay at home and work from there wherever possible. This included those working in children's social care (CSC) who have responsibility for child protection and other safeguarding duties. OBJECTIVE: The study was designed to understand how CSC made the transition from being an office-based agency to one where the majority of social workers were based at home and to understand how CSC perceived the impact on children and their families. Participants and setting Senior members of CSC staff in 15 local authorities took part in the research in June 2020. METHODS: Nine interviews were conducted by video call, three by telephone, and three consisted of initial written responses that were then followed by telephone calls. RESULTS: Service delivery had been maintained across all the authorities with most visits being made virtually after assessments of risk had been conducted on all cases. Multiagency working had improved, with greater involvement of general practitioners and paediatricians. Overall activity in CSC had been lower than normal but as lockdown eased this was changing. Concerns were expressed about how to manage the response that would be required to meet the expected level of harm that had occurred but been hidden. CONCLUSIONS: Responses to COVID-19 prompted widespread innovation and it will be an imperative to evaluate which initiatives have worked for children and families, as well as practitioners, and which should be discarded, sustained or reshaped.

Comparison of laparoscopic jejunostomy tube to percutaneous endoscopic gastrostomy tube with jejunal extension: long-term durability and nutritional outcomes.

INTRODUCTION: Enteral access through the jejunum is indicated when patients cannot tolerate oral intake or gastric feeding. While multiple approaches for feeding jejunal access exist, few studies have compared the efficacy of these techniques. The purpose of this study was to investigate the long-term durability, re-intervention rates, and nutritional outcomes following percutaneous endoscopic gastrostomy tubes with jejunal extension tubes (PEG-JET) versus laparoscopic jejunostomy tubes (j-tubes). METHODS: Retrospective chart review was performed on all patients who underwent PEG-JET or laparoscopic jejunostomy tube placement from January 2005 through December 2015 at our institution. Thirty-day and long-term outcomes were compared between the two groups. RESULTS: A total of 105 patients underwent PEG-JET and 307 patients underwent laparoscopic j-tube placement during the defined study period. In terms of 30-day outcomes, patients who underwent PEG-JET placement were significantly more likely to experience a tube dislodgement event (p = 0.005) and undergo a re-intervention (p < 0.001). Patients who had a laparoscopic j-tube placed were significantly more likely to meet their enteral feeding goals (p = 0.002) and less likely to require nutritional supplementation with total parenteral nutrition (TPN) (p < 0.001). With regard to long-term outcomes, patients who underwent PEG-JET placement were significantly more likely to experience tube occlusion (p < 0.001) and require an endoscopic or surgical tube re-intervention (p < 0.001). Patients who underwent laparoscopic j-tube placement were significantly more likely to experience a tube site leak (p = 0.015) but were less likely to require nutritional supplementation with TPN (p = 0.001). CONCLUSION: Laparoscopic jejunostomy tubes provide more durable long-term enteral access compared to PEG-JET. Consideration should be given to laparoscopic jejunostomy tube placement in eligible patients who cannot tolerate oral intake or gastric enteral feeding.

Volume-Based Enteral Nutrition Support Regimen Improves Caloric Delivery but May Not Affect Clinical Outcomes in Critically Ill Patients.

INTRODUCTION: Meeting enteral nutrition goals is an ongoing challenge in the intensive care unit (ICU). Most hospitals use rate-based (RB) protocols for nutrient delivery. Previous studies have found that volume-based (VB) protocols improve delivery of prescribed calories. However, these studies did not assess clinical outcomes. We hypothesize that a VB method will improve the delivery of prescribed calories and lead to improved clinical outcomes. METHODS: A before-and-after study was performed following implementation of a VB feeding protocol in an adult mixed medical-surgical ICU. Formal institutional review board approval was obtained. The effect of RB and VB protocols on percentage of goal calories received, ICU length of stay (LOS), hospital LOS, mortality, days on the ventilator, and rates of infection were investigated using the Kruskal-Wallis test of differences. Multivariate regression was used to identify independent predictors of outcome. Significance was defined as P < .05. RESULTS: A total of 77 patients were included (RB = 39, VB = 38). There were no differences in demographics between the 2 groups with the exception of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, which was significantly higher in the VB group. VB patients received significantly more prescribed calories (74% vs 57%, P < .001). VB patients had significantly longer ICU LOS and duration of mechanical ventilation on univariate analysis. These differences did not persist after controlling for APACHE II score. CONCLUSION: VB enteral feeding allows for a significantly greater provision of prescribed calories but may not affect clinical outcomes. A larger sample size is needed for adequate power to corroborate these findings.

Preoperative hypoalbuminemia is associated with worse outcomes in colon cancer patients.

BACKGROUND & AIMS: The National Veterans' Affairs Surgical Risk Study identified preoperative hypoalbuminemia as an independent risk factor for postoperative morbidity and mortality. Since that time, few studies have investigated the use of preoperative markers as tools to risk stratify colon cancer patients. The purpose of our study is to determine if there is an association between preoperative hypoalbuminemia and 30-day patient morbidity and mortality in colon cancer patients using the Targeted-Colectomy American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP). METHODS: Stage I, II, and III elective colon resections with ileocolostomy or colocolostomy were identified within the ACS-NSQIP targeted colectomy database from 2012 through 2013. Hypoalbuminemia was defined as albumin <3.5 g/dL. Patients with hypoalbuminemia were compared to those with a normal albumin level in terms of 30-day morbidity and mortality. The albumin level at which point 30-day morbidity and mortality increased was identified. RESULTS: A total of 5143 patients met inclusion criteria; 4397 (85.5%) patients had a normal albumin level while 746 (14.5%) had hypoalbuminemia. Preoperative hypoalbuminemia significantly increased the risk of 30-day mortality (p < 0.0001). The association of hypoalbuminemia with 30-day outcomes was more significant in patients who underwent open surgery and had an intra-abdominal anastomosis. The risk of an adverse event was observed to increase at an albumin level ≤3.1 g/dL. CONCLUSIONS: Preoperative hypoalbuminemia is associated with an increased risk of early patient morbidity and mortality in patients undergoing surgery for colon cancer. Preoperative optimization of this patient population warrants further investigation in order to prevent delay from surgical intervention to adjuvant therapy.