An investigation into specialty trainee engagement with e-learning.

AIM:: The objectives of this study were to determine paediatric specialty trainees' engagement with e-learning in Health Education England North West and the characteristics of sites accessed by specialty trainees, and to assess the quality of web interfaces being used and whether this aligns with the best evidence for e-learning provision. METHODS:: A two-phase mixed methods design was used: a scoping exercise to elicit specialty trainees' preferred e-learning tools and a quality assessment of the named sites, and specialty trainee telephone interviews. RESULTS:: A total of 135 respondents identified 86 sites. Quality assessment found considerable variation across sites and a number of barriers to access, one issue being uncertainty about quality and validity of sites. CONCLUSIONS:: E-learning is viewed as an integral part of both mandatory and speciality training but there is considerable variation in access to and quality of sites. Specialty trainees value the convenience and breadth of e-learning available but express concerns about assessing the validity and legitimacy of such sites.

Living and managing with the long-term implications of neonatal chronic lung disease: The experiences and perspectives of children and their parents.

OBJECTIVE: The purpose of the study was to investigate children's perspectives of living with chronic lung disease (CLD) and their parents' long-term experiences of caring for them. BACKGROUND: CLD caused by prematurity of birth is associated with continuing respiratory, neuro-developmental and psychosocial issues. METHODS: 10 children (6-15 years old) with CLD and 12 parents were involved in semi-structured qualitative interviews. Data were analyzed using thematic analysis. RESULTS: CLD was described as 'getting easier over time' and that you 'learnt to live with it.' Expertise was acquired in controlling symptoms and recognizing the onset of illness, despite expressed uncertainty of the nature of the condition. Children experienced difficulties engaging in peer activities and encountered cases of teasing and isolation at school. CONCLUSION: CLD was reported as becoming easier over time to live with. Despite this, children experienced challenges engaging in peer activities and families described difficulties interacting with health and education services.

Two-year outcomes for infants with low cord pH at birth.

OBJECTIVE: To determine the long-term outcome of infants born with cord pH ≤ 7.0 and no clinical evidence of asphyxia at birth. SETTING: Tertiary Referral Centre. A prospective matched cohort study was conducted. 51 term infants were recruited following singleton birth with venous cord pH ≤ 7.0. For each recruited baby a healthy baby with normal cord pH ≥ 7.20 was recruited matched for gestation, gender and mode of delivery. Ages and Stages Questionnaires (ASQ)(TM) and Health Screening Questionnaires (HSQ) were sent out at 24 months of age. Two independent assessors, blinded to the case assignment, reviewed intrapartum and neonatal events to look for clinical evidence of birth asphyxia among the cases. RESULT: From 102 infants recruited, 62 questionnaires (24 cases, 38 controls) were returned. 20 matched pairs with no clinical evidence of birth asphyxia were available for analysis. The groups were similar except in terms of birth weight; the pH ≥ 7.0 group had mean birth weight 584 g lower than controls (p = 0.005). The ASQ motor scores were lower in children born with low cord pH (p = 0.019); however, once adjusted for birth weight, the difference was not significant (p = 0.289). CONCLUSION: It is unlikely that abnormal cord pH in otherwise healthy neonates leads to a substantially increased risk of abnormal neurodevelopmental outcome or severe health problems by 2 years of age.

The first five years: a mixed methods study investigating reflections on working as a hospital consultant.

OBJECTIVES: This paper revisits the same cohort of hospital consultants approximately five years after they were first appointed to investigate their reflections on establishing themselves in their role. DESIGN: Mixed methods using a short survey and in-depth semistructured interviews. SETTING: The study was conducted within one Deanery in the North of England. PARTICIPANTS: The same 45 hospital consultants who were invited to participate in the study in 2007 were asked to take part in the second stage of the project in February 2011. These 45 consultants started their appointments no earlier than May 2006 within 12 National Health Service (NHS) Trusts in one Deanery. A total of 16 consultants participated. Six consultants who took part in semistructured interviews in 2007-2008 were invited to be interviewed again. Four consented and participated in a further interview in 2011. MAIN OUTCOME MEASURES: Do consultants feel they have completed their transition into their senior clinical posts? Yes, although the ever changing nature of the consultant role means new challenges are always having to be being addressed. What support mechanisms are valued by consultants? Informal support mechanisms are greatly valued by consultants and these are built up over time. Are consultants satisfied that they made the correct specialty choice? Yes, all respondents reported satisfaction in their specialty choice. RESULTS: After reflecting on five years in post, all agreed that Specialist training prepared them well for the clinical aspects of their role. Ten (62%) felt they were not prepared for dealing with Trust Management issues and 13 (81%) felt unprepared for financial management. CONCLUSIONS: consultants learn on the job and eventually fulfil their potential in the role over time. However, the role is regularly changing so informal support mechanisms are valued to help deal with a highly complex role.

Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22.

BACKGROUND: In the United Kingdom, there are approximately 300,000 healthcare-associated infections (HCAI) annually, costing an estimated £1 billion. Up to 30% of all HCAI are potentially preventable by better application of knowledge and adherence to infection prevention procedures. Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained improvements in hand hygiene compliance and reductions in HCAI. AIM: To determine the features of structured educational interventions that impact on compliance with hand hygiene in healthcare professionals within a hospital care setting. METHODS: Sixteen electronic databases were searched. Outcomes were assessed using Kirkpatrick's hierarchy and included changes in hand hygiene compliance of healthcare professionals, in service delivery and in the clinical welfare of patients involved. RESULTS: A total of 8845 articles were reviewed, of which 30 articles met the inclusion criteria. Delivery of education was separated into six groups. CONCLUSIONS: It was not possible to identify individual features of educational interventions due to each study reporting multicomponent interventions. However, multiple, continuous interventions were better than single interventions in terms of eliciting and sustaining behaviour change. Data were not available to determine the time, nature and type of booster sessions with feedback needed for a permanent change in compliance.

Respiratory morbidity, healthcare utilisation and cost of care at school age related to home oxygen status.

UNLABELLED: The aim of the study was to determine whether respiratory morbidity, lung function, healthcare utilisation and cost of care at school age in prematurely born children who had bronchopulmonary dysplasia (BPD) were influenced by use of supplementary oxygen at home after neonatal intensive care unit discharge. Healthcare utilisation and cost of care in years 5 to 7 and respiratory morbidity (parent-completed respiratory questionnaire) and lung function measurements at least at age 8 years were assessed in 160 children. Their median gestational age was 27 (range 22-31) weeks and 65 of them had received supplementary oxygen when discharged home (home oxygen group). The home oxygen group had more outpatient attendances (p = 0.0168) and respiratory-related outpatient attendances (p = 0.0032) with greater related cost of care (p = 0.0186 and p = 0.0030, respectively), their cost of care for prescriptions (p = 0.0409) and total respiratory related cost of care (p = 0.0354) were significantly greater. There were, however, no significant differences in cough, wheeze or lung function results between the two groups. CONCLUSION: Prematurely born children who had BPD and supplementary oxygen at home after discharge had increased healthcare utilisation at school age. Whether such children require greater follow, in the absence of excess respiratory morbidity, merits investigation.

First year specialist trainees' engagement with reflective practice in the e-portfolio.

Doctors in specialist training posts in the Mersey Deanery are expected to reflect on their clinical practice and to document their learning experiences in an e-portfolio. This study aims specifically to explore how they have engaged in reflection on their practice and how they utilise their learning portfolio to document evidence of this. A modified Delphi technique was used to develop a grading system to identify the level of reflection recorded by participants in the e-portfolio. Transcripts of the reflective accounts were then analysed using a qualitative approach which involved coding and categorising the data. This study demonstrated a wide variation in both the quantity and quality of reflection. Of particular note in the qualitative data analysis were themes relating to clinical knowledge and skills, learning in practice, communication, feelings, types of learning experience reflected on and wider aspects of medical practice. Findings indicate there is variation is the extent to which doctors both engage in and document evidence of reflection. Further research is needed to explore factors that enable or inhibit the use of the e-portfolio for reflection and whether recorded reflection is a true picture of the cognitive process involved.

A reference interval for sweat chloride in infants aged between five and six weeks of age.

BACKGROUND: This study was designed to establish a reference interval for sweat chloride for infants without evidence of cystic fibrosis (CF), aged between 5 wk and 6 wk, a time when sweat testing is an integral part of newborn screening for CF. In addition, we compared the gold standard method of sweat testing (quantitative pilocarpine iontophoresis [QPIT, coulometry]) with an emerging methodology (Macroduct [ISE]). METHODS: This was a prospective study on healthy infants at 5-6 wk of age. Sweat collection was undertaken at home on both outer thigh areas using two methods (QPIT and Macroduct ). The order of testing was randomly assigned. Filter paper samples (QPIT) were analysed using flame photometry and coulometry. Macroduct samples were analysed using ion-selective electrodes (ISE, Abbott Architect c8000, UK). RESULTS: Insufficient sweat was collected on 28 occasions with the QPIT (coulometry) method and on 31 with the Macroduct (ISE) capillary system. We achieved a 92% success rate in undertaking two sweat collections consecutively (n = 177). Sweat chloride concentrations were normally distributed with excellent limits of agreement between the two methods of sweat collection and analysis (n = 150). Median (IQR) sweat chloride was 11.2 mmol/L (8-13) with QPIT (coulometry) method with a 99.5th centile (n = 165) of 24 mmol/L. CONCLUSION: The Macroduct (ISE) capillary sweat collection system is valid in this age group. Sweat chloride concentrations above 30 mmol/L should prompt assessment in a specialist CF centre.

Electrical potential difference across the nasal epithelium is reduced in premature infants with chronic lung disease but is not associated with lower airway inflammation.

Airway liquid content and insufficient absorptive airway ion transport at birth are potentially important factors in the development and severity of neonatal respiratory disease. The role of deficient absorptive airway ion transport in the development of chronic lung disease of prematurity is unknown. Additionally, lung inflammatory mediators modulate airway ion transport. Their effect on preterm lung ion transport and absorptive capacity is not established. We performed serial nasal potential difference studies and broncho-alveolar lavage in preterm infants born less than 30 wk postmenstrual age over the first four postnatal weeks. Our study aims were to: 1) compare nasal potential difference between preterm infants developing chronic lung disease and babies of similar gestation who do not; and 2) examine for an association between airway inflammation and ion transport parameters. We found that potential difference across the nasal epithelium increased with gestation, remained low and unchanged in infants developing chronic lung disease over the first four postnatal weeks, was significantly lower at four weeks in chronic lung disease infants, and was not associated with lower airway inflammation at any time point. We conclude that infants with chronic lung disease postnatally have a persistently reduced absorptive airway ion transport capacity.

Twelve-month prospective study of oxygen saturation measurements among term and preterm infants.

BACKGROUND: Optimising home oxygen delivery in infants has important logistical and safety implications. This can be aided by having a suitable reference range of normal values for arterial oxygen saturation using pulse oximetry (SpO(2)). OBJECTIVES: To describe oxygenation profiles in healthy preterm and term infants in relation to gestational and postnatal age, to extend reference values to guide home oxygen therapy. STUDY DESIGN: Prospective monitoring of SpO(2) for 4 hours at 3 monthly intervals of 34 term, and 53 preterm healthy infants, took place over a 12-month period using an Ohmeda Biox 3700e pulse oximeter and data logger. RESULTS: Group mean and 5th percentiles were used to construct cumulative frequency curves at each time interval, representing the normal reference range of SpO(2) profiles for term and preterm infants over time. CONCLUSIONS: These data may be used to test the benefits in the home or hospital of having a reference range of normal values for cumulative SpO(2).

High versus restricted use of home oxygen therapy, health care utilisation and the cost of care in chronic lung disease infants.

UNLABELLED: Use of home oxygen therapy for prematurely born infants with chronic lung disease (CLD) can facilitate early discharge, but affected infants might require more readmissions. Our aim was to determine if health care utilisation and associated costs in the first 2 years were greater in centres with a high compared to centres with restricted use of home oxygen therapy. A retrospective review of the hospital and general practitioner (GP) medical records of 235 infants with CLD (median gestational age 27 weeks; range 22-33 weeks) was performed to note their readmissions, outpatient attendances, community service referrals and cost of care in the first 2 years after birth. A total of 76 infants (64%) in the high use centres and 12 (10%) in the restricted use centres were discharged home on oxygen. Infants in the high use centres were discharged home from neonatal care at a younger age (median 37.7 versus 39.9 weeks; P<0.001), but subsequently had similar numbers of inpatient events, and less GP (P =0.012) and community care (P < 0.001) contacts, although their duration of home oxygen use was longer (P < 0.001). The post-discharge costs were similar in the two types of centre, but the neonatal costs (P < 0.0001) and total cost of care per infant over the first 2 years (P < 0.0001) were lower in the high use centres. CONCLUSION: Early discharge and high use of home oxygen therapy was not associated with an increased cost of care or increased morbidity.

Airway ion transport on the first postnatal day in infants delivered vaginally or by elective cesarean section.

To determine airway ion transport in term infants on the first day of postnatal life, and to test the hypothesis that infants born without labor have reduced sodium absorption, we measured nasal potential difference using a modified perfusion protocol suitable for newborn infants. We examined maximal stable baseline potential difference, the change after perfusion with 10(-4) M amiloride (Deltaamil), and the change after perfusion with a zero-chloride solution (Deltazero Cl-) in infants born after elective cesarean section (n = 21) or normal labor (n = 20). Maximal stable baseline potential difference was not different in the two cohorts (-24.0 mV, range -9 to -64 mV versus -25.5 mV, range -6 to -44 mV). The majority of infants in both cohorts showed a substantial fall in potential difference after amiloride perfusion, and there was little capacity for chloride secretion. These results demonstrate a fluid absorptive pattern in the airways on the first postnatal day. In these well infants, the ion transport phenotype was not dependent on the presence or absence of labor.

Bronchoalveolar lavage surfactant protein a, B, and d concentrations in preterm infants ventilated for respiratory distress syndrome receiving natural and synthetic surfactants.

Surfactant proteins (SPs) play an important role in surfactant metabolism and function. Understanding their relative contribution to clinical outcome remains incomplete. Exogenous surfactants differ in their SP content and physiologic effects. The aims of this study were to measure bronchoalveolar lavage (BAL) SP concentrations from preterm infants ventilated for respiratory distress syndrome and to assess their association with clinical outcome. Fifty preterm infants randomized to receive a natural or synthetic surfactant were lavaged each day for the first week and twice weekly thereafter using a standardized nonbronchoscopic technique. BAL SP-A, SP-B, and SP-D concentrations were measured using ELISA. Median BAL SP-A, SP-B, and SP-D concentrations for the whole cohort rose significantly during the first postnatal week (p < 0.05). SP-A concentration did not differ between outcome groups. BAL SP-B concentration rose significantly in lungs that were not supplemented with SP-B. Infants dying had significantly lower BAL SP-B concentrations on d 2 and 6 compared with survivors. BAL SP-D concentrations were significantly lower on d 2 and 3 among infants in supplemental oxygen on d 28 compared with those in air. BAL SP-A and SP-D concentrations did not differ significantly between infants randomized to receive a natural or synthetic surfactant. Lower BAL SP-B and SP-D but not SP-A concentrations were associated with worse clinical prognosis.

Detectable IL-8 and IL-10 in bronchoalveolar lavage fluid from preterm infants ventilated for respiratory distress syndrome.

Pro-inflammatory cytokines such as IL-8 play an important role in the inflammatory response to neonatal airway injury. Difficulty in detecting counter-regulatory cytokines such as IL-10 in lavage fluid from preterm infants led to the suggestion that its deficit may be a factor in the etiology of chronic lung disease of prematurity (CLD). The aim of the study was to determine IL-8 and IL-10 concentrations in lavage fluid from preterm infants ventilated for respiratory distress syndrome. Fifty infants <30 wk gestation were studied who had been randomized to receive a natural or synthetic surfactant. Lavage samples were collected daily for the first week and twice weekly thereafter. Samples were immediately centrifuged and stored at -70 degrees C. Cytokine concentrations were quantified in duplicate using commercially available sandwich ELISA kits. Lavage IL-10 concentration, at a minimum initially, rose significant over the first five postnatal days (p = 0.009). In the same samples, lavage IL-8 concentrations rose significantly over the first postnatal week (p < 0.001), the rise preceding that of IL-10. Infants dying or developing CLD had a significant early rise in both cytokine concentrations. Compared with infants developing CLD, lavage IL-10 concentrations were significantly higher on d 1 among those not developing CLD but significantly lower on d 4 (p < 0.05). To conclude, IL-10 is detectable in lavage fluid from ventilated preterm infants and its concentrations rise significantly over the first five postnatal days. In the same samples, IL-8 concentration also rises and this increase precedes the rise in IL-10.