Araceae root and citrus fibers tend to decrease Escherichia coli adhesion and myeloperoxidase levels in weaned piglets.

Introduction: Weaning is a stressful experience in the piglet's life, and it often coincides with impaired gut health. Post-weaning diarrhea in piglets is frequently caused by enterotoxigenic Escherichia coli (E. coli). The first step of an E. coli infection is the adhesion to host-specific receptors present on enterocytes, leading to pro-inflammatory immune responses. The aim of this study was to examine if specific fiber fractions in the piglet diet can prevent E. coli adhesion and subsequent immune responses. Methods: The trial included 200 piglets (Danbred × Piétrain): 10 piglets/pen × 10 pens/dietary treatment × 2 dietary treatments. From weaning until 14 days (d14) post-weaning, piglets were fed a control diet or test diet with 2 kg/ton of a mixture of specific fiber fractions derived from Araceae root and citrus. Afterwards, 1 piglet per pen was euthanized, a section was taken at 75% of small intestinal length and E. coli colonization on the mucosal epithelium was quantified by scraping and conventional plating. From the same small intestinal section, histo-morphological indices were assessed, and mucosal scrapings were analyzed for gene expression of pro- and anti-inflammatory cytokines, and NF-kB. Analyses of specific intestinal bacteria and SCFA were performed on samples of intestinal content (small intestine, caecum, colon). Fecal samples were taken to measure myeloperoxidase (MPO), calprotectin and PAP/RAG3A as biomarkers for intestinal inflammation. Results and discussion: Piglets fed the fiber mixture tended to have decreased E. coli colonization to the mucosal epithelium (5.65 vs. 4.84 log10 CFU/g; P = 0.07), less E. coli in the caecum (8.91 vs. 7.72 log10 CFU/g; P = 0.03) and more Lachnospiraceae in the colon (11.3 vs. 11.6 log10 CFU/g; P = 0.03). Additionally, the fiber mixture tended to increase cecal butyric acid (10.4 vs. 19.1 mmol/kg; P = 0.07). No significant effect on histo-morphological indices and on gene expression of pro- and anti-inflammatory cytokines and NF-kB was observed. The fecal MPO concentration tended to decrease (20.2 vs. 10.4 ng/g; P = 0.07), indicating less intestinal inflammation. In conclusion, this study showed that specific fiber fractions from Araceae root and citrus in piglet weaner diets may decrease the risk of pathogen overgrowth by reducing E. coli adhesion and intestinal inflammation.

Impact of Citrus Pulp or Inulin on Intestinal Microbiota and Metabolites, Barrier, and Immune Function of Weaned Piglets.

We investigated the use of citrus pulp (CP) as a novel prebiotic capable of exerting microbiota and immunomodulating capacities to alleviate weaning stress. Inulin (IN), a well-known prebiotic, was used for comparison. Hundred and 28 male weaned piglets of 21 days old were assigned to 32 pens of 4 piglets each. Piglets were assigned to one of the four treatments, i.e., control, IN supplemented at 0.2% (IN0.2%), and CP supplemented either at 0.2% (CP0.2%) or at 2% (CP2%). On d10-11 and d31-32 post-weaning, one pig per pen was euthanized for intestinal sampling to evaluate the growth performance, chyme characteristics, small intestinal morphology, colonic inflammatory response and barrier integrity, metabolite profiles [gas chromatography-mass spectrometry (GC-MS), and liquid chromatography-mass spectrometry (LC-MS)], and microbial populations. The IN treatment and the two CP treatments induced higher small intestinal villus height to crypt depth ratios in comparison with the control diet at both sampling times. All treatments decreased acidic goblet cell absolute counts in the crypts in comparison to the control diet of the duodenum on d10-11 and d31-32. The gene expression of ß-defensin 2 was downregulated in colonic tissues following the IN and CP2% inclusion on d31-32. On d31-32, piglets fed with IN and CP0.2% showed lower mRNA levels of occludin and claudin-3, respectively. Not surprisingly, flavonoids were observed in the colon in the CP treatments. Increased colonic acetate proportions on d10-11, at the expense of branched-chain fatty acid (BCFA) levels, were observed following the CP2% supplementation compared to the control diet, inferring a reduction of proteolytic fermentation in the hindgut. The beneficial microbial community Faecalibacterium spp. was promoted in the colon of piglets fed with CP2% on d10-11 (p = 0.04; false discovery rate (FDR) non-significant) and on d31-32 (p = 0.03; FDR non-significant) in comparison with the control diet. Additionally, on d31-32, CP2% increased the relative abundance of Megasphaera spp. compared to control values (p = 0.03; FDR non-significant). In conclusion, CP2% promoted the growth of beneficial bacterial communities in both post-weaning time points, modulating colonic fermentation patterns in the colon. The effects of CP supplementation were similar to those of IN and showed the potential as a beneficial feed supplement to alleviate weaning stress.

The potential anti-African swine fever virus effects of medium chain fatty acids on in vitro feed model: An evaluation study using epidemic ASFV strain circulating in Vietnam.

Background: African swine fever (ASF) is an important disease affecting swine and has a significant economic loss in both the developed and developing world. Aim: In this study, we evaluated the potential effects of medium-chain fatty acids (MCFAs) in individual and synergistic forms to prevent and/or reduce ASF virus (ASFV) infection using in vitro feed model. Methods: The cytotoxicity of MCFAs on porcine alveolar macrophages cells was evaluated by using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. The potential effects of MCFAs, including C8 (caprylic acid), C8-C6-C10 (caprylic acid-caproic acid-capric acid; 1:1:1 ratio) and C8-C10-C12 (caprylic acid-capric acid-lauric acid; 1:1:1 ratio) against a field ASFV strain isolated in the capital Hanoi of Vietnam, were further examined by real-time PCR and haemadsorption assays in in vitro feed model. Results: Our results indicated that all tested products do not induce cytotoxicity at the dose of 100 µg/ml and are suitable for further in vitro examination. These products have shown a strong antiviral effect against ASFV infectivity at doses of 0.375% and 0.5%. Interestingly, the synergistic MCFAs have shown clearly their potential activities against ASFV in which at a lower dose of 0.25%, pre-treatment with product two and three induced significant increases at the level of Cq value when compared to positive control and/or product 1 (p < 0.05). However, the viral titre was not changed after 24 hours post-inoculation when compared to positive control. Our findings suggested that all tested products, both individual and synergistic forms of MCFAs, have possessed a strong anti-ASFV effect, and this effect is dose-dependence in in vitro feed model. Additionally, synergistic effects of MCFAs are more effective against ASFV when compared to individual forms. Conclusion: Together, the findings in this study indicate that MCFAs, both individual and synergistic forms, inhibit against a field ASFV strain in the feed model, which may support minimizing the risk of ASF transmission in the pig population. Further studies focusing on in vivo anti-ASFV effects of MCFAs are important to bring new insight into the mode of ASFV-reduced action by these compounds in swine feed.

Barriers and carriers: a multicenter survey of nurses' barriers and facilitators to monitoring of nurse-sensitive outcomes in intensive care units.

AIM: To identify nurses' barriers and facilitators to monitoring of nurse-sensitive outcomes in intensive care units (ICUs), and to explore influential nurse characteristics and work environment factors. DESIGN: A cross-sectional survey in three Dutch ICUs between October 2013 - June 2014. METHODS: A questionnaire with questions regarding facilitators and three types of barriers: knowledge, attitude and behaviour. The Dutch Essentials of Magnetism II was used to examine work environments. RESULTS: All 126 responding nurses identified pressure ulcers and patient satisfaction as outcomes that are nurse-sensitive and nurses' full responsibility. Lack of time (behaviour) was perceived as the most prominent barrier, followed by unfamiliarity with mandatory indicators (knowledge), and unreliability of indicators as benchmark data (attitude). Education and clear policies were relevant facilitators. Of nurse characteristics, only regularity of shifts was related to perceived attitude related barriers. The work environment factor "clinical autonomy" was potentially associated with behaviour related barriers.

A multifaceted feedback strategy alone does not improve the adherence to organizational guideline-based standards: a cluster randomized trial in intensive care.

BACKGROUND: Organizational data such as bed occupancy rate and nurse-to-patient ratio are related to clinical outcomes and to the efficient use of intensive care unit (ICU) resources. Standards for these performance indicators are provided in guidelines. We studied the effects of a multifaceted feedback strategy to improve the adherence to these standards. METHODS: In a cluster randomized controlled study design the intervention ICUs received extensive monthly feedback reports, they received outreach visits and initiated a quality improvement team. The control ICUs received limited quarterly feedback reports only. We collected primary data prospectively within the setting of a Dutch national ICU registry over a 14-month study period. The target indicators were bed occupancy rate (aiming at 80 % or below) and nurse-to-patient ratio (aiming at 0.5 or higher). Data were collected per 8-h nursing shift. Logistic regression analysis was performed. For both study end points, the odds ratios (OR) for improvements at follow-up versus at baseline were calculated separately for control and intervention ICUs. RESULTS: We analyzed data on 67,237 nursing shifts. The bed occupancy rate did not improve in the intervention group compared to baseline (adjusted OR 0.88; 95 % confidence interval (CI), 0.62-1.27) or compared to control group (OR 0.67; 95 % CI 0.39-1.15). The nurse-to-patient ratio did not improve (OR 0.72; 95 % CI 0.41-1.26 compared to baseline and OR 0.65; 95 % CI 0.35-1.19 compared to control group). CONCLUSIONS: A multifaceted feedback intervention did not improve the adherence to guideline-based standards on the organizational issues bed occupancy rate and nurse-to-patient ratio in the ICU. The reasons may be a limited confidence in data quality, the lack of practical tools for improvement, and the relatively short follow-up. ISRCTN: ISRCTN50542146.

Are all tissue donors recognised? A cohort study in three Dutch hospitals.

Nowadays, the demand for tissue transplantation has significantly increased. To optimize donor recruitment, the potential availability of tissue donors has to be evaluated. In 2011 we conducted a cohort study in three Dutch hospitals in the Netherlands. The potential amount of eligible tissue donors found, based on medical records in these hospitals is compared to the physician's donation form report. In total 1,342 patient records were analysed. From these records, the donation officers considered 484 patients as a potential tissue donor (36.1 %). Despite the absence of contra-indication, the physician did not recognise 25 % (n = 123/484) of potential tissue donors. Physicians' lack of sufficient knowledge of tissue donation was the main cause of adequately identifying tissue donors. A higher percentage of tissue donors in these Dutch hospitals should be feasible through creating awareness and education regarding tissue donation.

Effect of a multifaceted performance feedback strategy on length of stay compared with benchmark reports alone: a cluster randomized trial in intensive care*.

OBJECTIVE: To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports. DESIGN: The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011. SETTING: Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months. PATIENTS: We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded. INTERVENTION: The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports. MEASUREMENTS AND RESULTS: The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD, 2.3; range, 0.6-8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0-12). ICU length of stay did not significantly reduce after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92-1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality). CONCLUSIONS: In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.

Process evaluation of a tailored multifaceted feedback program to improve the quality of intensive care by using quality indicators.

BACKGROUND: In multisite trials evaluating a complex quality improvement (QI) strategy the 'same' intervention may be implemented and adopted in different ways. Therefore, in this study we investigated the exposure to and experiences with a multifaceted intervention aimed at improving the quality of intensive care, and explore potential explanations for why the intervention was effective or not. METHODS: We conducted a process evaluation investigating the effect of a multifaceted improvement intervention including establishment of a local multidisciplinary QI team, educational outreach visits and periodical indicator feedback on performance measures such as intensive care unit length of stay, mechanical ventilation duration and glucose regulation. Data were collected among participants receiving the intervention. We used standardised forms to record time investment and a questionnaire and focus group to collect data on perceived barriers and satisfaction. RESULTS: The monthly time invested per QI team member ranged from 0.6 to 8.1 h. Persistent problems were: not sharing feedback with other staff; lack of normative standards and benchmarks; inadequate case-mix adjustment; lack of knowledge on how to apply the intervention for QI; and insufficient allocated time and staff. The intervention effectively targeted the lack of trust in data quality, and was reported to motivate participants to use indicators for QI activities. CONCLUSIONS: Time and resource constraints, difficulties to translate feedback into effective actions and insufficient involvement of other staff members hampered the impact of the intervention. However, our study suggests that a multifaceted feedback program stimulates clinicians to use indicators as input for QI, and is a promising first step to integrating systematic QI in daily care.

Maturation of digestive function is retarded and plasma antioxidant capacity lowered in fully weaned low birth weight piglets.

The digestive function of low birth weight (LBW) pigs post-weaning has been poorly studied. Therefore, newborns from eleven hyperprolific sows were weighed, weaned at 27·2 d and fed a starter diet until sampling. Sampling was done between 18 and 28 d post-weaning. An LBW piglet (n 19) was defined as a piglet having a birth weight less than 1 kg and less than the lower quartile of litter birth weights. Normal birth weight (NBW) piglets (n 13) were having a birth weight close to the mean litter birth weight. For each piglet, eighty-eight variables were determined. Data were analysed with linear models with type of piglet and litter as predictors. A principal component analysis was performed to determine the most important discriminating variables. In the LBW pig, the development of the digestive tract post-weaning was delayed: lower small-intestinal weight:length ratio due to a thinner tela submucosa and tunica muscularis and a higher secretory capacity, both in the distal jejunum. These observations might be a consequence of lower circulating insulin-like growth factor-1 (IGF-1) concentrations (126 (se 10·0) v. 158 (se 12·0) ng/ml for LBW and NBW, respectively) and a lower density of IGF-1 receptors in the proximal small intestine. Additionally, the plasma antioxidant capacity was lower for the LBW pig. Taken together, in the LBW piglet, the normal gut maturation post-weaning was retarded and this did not seem to be related to the weaning transition as such.

[Possibly fewer donors due to decreasing hospital mortality rates]. / Mogelijk minder donoren door daling ziekenhuissterfte.

Over the past ten years, the mortality rate at the Amphia Hospital in the Netherlands has decreased and the average age at death has increased significantly. This downward trend in hospital mortality rates is a national trend in the Netherlands. In addition, in recent years road traffic fatalities have steadily decreased. Both trends have had a significant impact on the availability of potential organ and tissue donors. Currently the main barriers to donation are the limited number of registrations in the donor registry and obtaining permission from relatives. To achieve the maximum number of donors, several initiatives must be undertaken. These include hospitals encouraging registration in the donor registry, training of professionals in communication skills concerning donation, increasing opportunities for organ donations in the emergency department and recruiting donors extramurally. If no measures are taken, a decreasing number of patients with end-stage organ failure will be able to profit from organ transplantation.

Evaluating the effectiveness of a tailored multifaceted performance feedback intervention to improve the quality of care: protocol for a cluster randomized trial in intensive care.

BACKGROUND: Feedback is potentially effective in improving the quality of care. However, merely sending reports is no guarantee that performance data are used as input for systematic quality improvement (QI). Therefore, we developed a multifaceted intervention tailored to prospectively analyzed barriers to using indicators: the Information Feedback on Quality Indicators (InFoQI) program. This program aims to promote the use of performance indicator data as input for local systematic QI. We will conduct a study to assess the impact of the InFoQI program on patient outcome and organizational process measures of care, and to gain insight into barriers and success factors that affected the program's impact. The study will be executed in the context of intensive care. This paper presents the study's protocol. METHODS/DESIGN: We will conduct a cluster randomized controlled trial with intensive care units (ICUs) in the Netherlands. We will include ICUs that submit indicator data to the Dutch National Intensive Care Evaluation (NICE) quality registry and that agree to allocate at least one intensivist and one ICU nurse for implementation of the intervention. Eligible ICUs (clusters) will be randomized to receive basic NICE registry feedback (control arm) or to participate in the InFoQI program (intervention arm). The InFoQI program consists of comprehensive feedback, establishing a local, multidisciplinary QI team, and educational outreach visits. The primary outcome measures will be length of ICU stay and the proportion of shifts with a bed occupancy rate above 80%. We will also conduct a process evaluation involving ICUs in the intervention arm to investigate their actual exposure to and experiences with the InFoQI program. DISCUSSION: The results of this study will inform those involved in providing ICU care on the feasibility of a tailored multifaceted performance feedback intervention and its ability to accelerate systematic and local quality improvement. Although our study will be conducted within the domain of intensive care, we believe our conclusions will be generalizable to other settings that have a quality registry including an indicator set available. TRIAL REGISTRATION: Current Controlled Trials ISRCTN50542146.

Parenteral and enteral feeding in preterm piglets differently affects extracellular matrix proteins, enterocyte proliferation and apoptosis in the small intestine.

The preterm intestine is immature and responds differently to total parenteral nutrition (TPN) and enteral nutrition, compared with the term intestine. We hypothesised that in preterms, diet composition and feeding route affect mucosal morphology, enterocyte mitosis and apoptosis, and the distribution of laminin-1, fibronectin and collagen IV (extracellular matrix proteins (ECMP)). Preterm piglets (93.5 % of gestation) were delivered via caesarean section and birth weight-matched allocated to one of the four experimental groups: the piglets were either euthanised immediately after delivery, after 3 d of TPN or after 2 d enteral feeding with colostrum or milk formula, following 3 d of TPN. We combined immunohistochemistry, image analysis and stereological measurements to describe the intestinal mucosal layer. No significant changes occurred after 3 d of TPN. Feeding colostrum or milk replacer for 2 d after TPN was associated with an increased crypt depth. Only enteral feeding with colostrum resulted in an increased villus height and mitotic index. Neither TPN nor enteral feeding changed the distribution pattern of ECMP or the occurrence of bifid crypts. The immature distribution pattern of ECMP in TPN-fed piglets, coupled with unchanged enterocyte mitosis and apoptosis indices, illustrates that feeding preterm pigs 3 d TPN does not lead to mucosal atrophy. Despite the invariable distribution of ECMP, colostrum was associated with crypt hyperplasia resulting in an increased villus height. These data illustrate that some mechanisms regulating cell turnover are immature in preterms and may in part explain the abnormal gut responses to TPN and enteral feeding in prematurely born pigs.

Implementing quality indicators in intensive care units: exploring barriers to and facilitators of behaviour change.

BACKGROUND: Quality indicators are increasingly used in healthcare but there are various barriers hindering their routine use. To promote the use of quality indicators, an exploration of the barriers to and facilitating factors for their implementation among healthcare professionals and managers of intensive care units (ICUs) is advocated. METHODS: All intensivists, ICU nurses, and managers (n = 142) working at 54 Dutch ICUs who participated in training sessions to support future implementation of quality indicators completed a questionnaire on perceived barriers and facilitators. Three types of barriers related to knowledge, attitude, and behaviour were assessed using a five-point Likert scale (1 = strongly disagree to 5 = strongly agree). RESULTS: Behaviour-related barriers such as time constraints were most prominent (Mean Score, MS = 3.21), followed by barriers related to knowledge and attitude (MS = 3.62; MS = 4.12, respectively). Type of profession, age, and type of hospital were related to knowledge and behaviour. The facilitating factor perceived as most important by intensivists was administrative support (MS = 4.3; p = 0.02); for nurses, it was education (MS = 4.0; p = 0.01), and for managers, it was receiving feedback (MS = 4.5; p = 0.001). CONCLUSIONS: Our results demonstrate that healthcare professionals and managers are familiar with using quality indicators to improve care, and that they have positive attitudes towards the implementation of quality indicators. Despite these facts, it is necessary to lower the barriers related to behavioural factors. In addition, as the barriers and facilitating factors differ among professions, age groups, and settings, tailored strategies are needed to implement quality indicators in daily practice.

Using quality indicators to improve hospital care: a review of the literature.

PURPOSE: To review the literature concerning strategies for implementing quality indicators in hospital care, and their effectiveness in improving the quality of care. DATA SOURCES: A systematic literature study was carried out using MEDLINE and the Cochrane Library (January 1994 to January 2008). STUDY SELECTION: Hospital-based trials studying the effects of using quality indicators as a tool to improve quality of care. DATA EXTRACTION: Two reviewers independently assessed studies for inclusion, and extracted information from the studies included regarding the health care setting, type of implementation strategy and their effectiveness as a tool to improve quality of hospital care. RESULTS: A total of 21 studies were included. The most frequently used implementation strategies were audit and feedback. The majority of these studies focused on care processes rather than patient outcomes. Six studies evaluated the effects of the implementation of quality indicators on patient outcomes. In four studies, quality indicator implementation was found to be ineffective, in one partially effective and in one it was found to be effective. Twenty studies focused on care processes, and most reported significant improvement with respect to part of the measured process indicators. The implementation of quality indicators in hospitals is most effective if feedback reports are given in combination with an educational implementation strategy and/or the development of a quality improvement plan. CONCLUSION: Effective strategies to implement quality indicators in daily practice in order to improve hospital care do exist, but there is considerable variation in the methods used and the level of change achieved. Feedback reports combined with another implementation strategy seem to be most effective.

Quality measurement at intensive care units: which indicators should we use?

OBJECTIVE: This study was conducted to develop a set of indicators that measure the quality of care in intensive care units (ICU) in Dutch hospitals and to evaluate the feasibility of the registration of these indicators. METHODS: To define potential indicators for measuring quality, 3 steps were made. First, a literature search was carried out to obtain peer-reviewed articles from 2000 to 2005, describing process or structure indicators in intensive care, which are associated with patient outcome. Additional indicators were suggested by a panel of experts. Second, a selection of indicators was made by a panel of experts using a questionnaire and ranking in a consensus procedure. Third, a study was done for 6 months in 18 ICUs to evaluate the feasibility of using the identified quality indicators. Site visits, interviews, and written questionnaires were used to evaluate the use of indicators. RESULTS: Sixty-two indicators were initially found, either in the literature or suggested by the members of the expert panel. From these, 12 indicators were selected by the expert panel by consensus. After the feasibility study, 11 indicators were eventually selected. "Interclinical transport," referring to a change of hospital, was dropped because of lack of reliability and support for further implementation by the participating hospitals in the study. The following structure indicators were selected: availability of intensivist (hours per day), patient-to-nurse ratio, strategy to prevent medication errors, measurement of patient/family satisfaction. Four process indicators were selected: length of ICU stay, duration of mechanical ventilation, proportion of days with all ICU beds occupied, and proportion of glucose measurement exceeding 8.0 mmol/L or lower than 2.2 mmol/L. The selected outcome indicators were as follows: standardized mortality (APACHE II), incidence of decubitus, number of unplanned extubations. The time for registration varied from less than 30 minutes to more than 1 hour per day to collect the items. Among other factors, this variation in workload was related to the availability of computerized systems to collect the data. CONCLUSION: In this study, a set of 11 quality indicators for intensive care was defined based on literature research, expert opinion, and testing. The set gives a quick view of the quality of care in individual ICUs. The availability of a computerized data collection system is important for an acceptable workload.