Child Health General Practice Hubs: a service evaluation.

OBJECTIVE: To evaluate the impact of an integrated child health system. DESIGN: Mixed methods service evaluation. SETTING AND PATIENTS: Children, young people and their families registered in Child Health General Practitioner (GP) Hubs where groups of GP practices come together to form 'hubs'. INTERVENTIONS: Hospital paediatricians and GPs participating in joint clinics and multidisciplinary team (MDT) meetings in GP practices, a component of an 'Inside-Out' change known as 'Connecting Care For Children (CC4C)'. MAIN OUTCOME MEASURES: Cases seen in clinic or discussed at MDT meetings and their follow-up needs. Hospital Episode data: outpatient and inpatient activity and A&E attendance. Patient-reported experience measures and professionals' feedback. RESULTS: In one hub, 39% of new patient hospital appointments were avoided altogether and a further 42% of appointments were shifted from hospital to GP practice. In addition, there was a 19% decrease in sub-specialty referrals, a 17% reduction in admissions and a 22% decrease in A&E attenders. Smaller hubs running at lower capacity in early stages of implementation had less impact on hospital activity. Patients preferred appointments at the GP practice, gained increased confidence in taking their child to the GP and all respondents said they would recommend the service to family and friends. Professionals valued the improvement in knowledge and learning and, most significantly, the development of trust and collaboration. CONCLUSIONS: Child Health GP Hubs increase the connections between secondary and primary care, reduce secondary care usage and receive high patient satisfaction ratings while providing learning for professionals.

Management and outcomes of pregnancies among women with HIV in Oxford, UK, in 2008-2012.

OBJECTIVE: To evaluate the management and outcomes of pregnancies among women with HIV infection. METHODS: A retrospective cohort study was undertaken of pregnant women with HIV who delivered at one center in the UK in 2008-2012. Case notes were reviewed and detailed information extracted regarding obstetric and virological management. RESULTS: Overall, 61 pregnancies were included; 43% (26/60) were unplanned and 39% (22/57) booked late. HIV infection was diagnosed during pregnancy for 32% (19/60); 71% (12/17) were diagnosed after the first trimester. At booking, 47% of women (28/60) were not on treatment, all but one of whom commenced treatment, either for maternal reasons (CD4 count <350 cells per mm(3); 48% [13/27]) or prevention of mother-to-child-transmission (52% [14/27]). Viral load was high (>50 copies per mL) at delivery for 13% of women (8/61). Delivery was by cesarean for 74% [45/61]. One neonate was diagnosed with HIV infection. There were 6 (10%) preterm births, 9 (15%) cases of low birth weight, 11 (18%) small-for-gestational-age neonates, and 1 (2%) stillbirth. CONCLUSION: Better pregnancy planning, earlier booking and HIV diagnosis, and optimal antiretroviral treatment should increase the proportion of women with a low viral load (<50 copies per mL) at delivery, lead to more vaginal deliveries, and further reduce mother-to-child transmission of HIV.

Eighteen months of "matching Michigan" at a UK neonatal intensive care unit.

Our "Matching Michigan" program has 3 focuses for identifying and reducing nosocomial infection. First, practical training to optimize infection control; second, root cause analysis of blood-culture positives; and third, feedback and use of results to develop new guidelines. Our infection rates are comparable with adult units. Interventions have reduced coagulase-negative staphylococcal infections whereas other infection rates have reduced relative to increased activity.

Storage of saphenous vein grafts prior to coronary artery bypass grafting: is autologous whole blood more effective than saline in preserving graft function?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: 'Is storage of saphenous vein grafts in autologous whole blood prior to coronary artery bypass grafting (CABG) more effective than storage in saline in preserving graft function?' Altogether more than 580 papers were found using the reported search, of which, 10 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Preservation of the vein graft endothelium during graft preparation is of well-recognized importance in forestalling graft occlusion and saphenous vein graft disease following CABG, however, the different preservation capabilities of saline vs autologous whole blood are not well validated. Although there is a complete lack of randomized clinical trials addressing this issue, some studies using basic in vitro techniques and animal models can be extrapolated to answer the clinical question in hand. All are consistent in demonstrating the detrimental effects of saline on vascular endothelium and therefore graft patency, but there is some disagreement in the literature as to whether autologous whole blood is superior as a storage medium. Though three well-designed studies suggest preserved endothelial function when saphenous vein grafts are stored in saline compared with storage in autologous whole blood, data from other studies are unimpressive, with two studies showing no difference. Furthermore, two elegant experiments that seek to mimic in vivo conditions by comparing outcomes postarterialization show no benefit of prior storage in autologous whole blood, despite the initial better-preserved endothelium. Instead, some notice should be taken of alternative storage solutions such as the University of Wisconsin solution, as some early studies suggest that it may be advantageous over both blood and crystalloid solution.