The application of a haemorrhage assessment tool in evaluating control of bleeding in a pilot trauma haemorrhage trial.

OBJECTIVES: To determine whether it was feasible to use a haemorrhage assessment tool (HAT) within a trauma trial and whether the data obtained could differentiate patients who had achieved haemostasis. BACKGROUND: Major haemorrhage is one of the leading causes of death worldwide, affecting 40% of trauma patients. Clinical trials evaluating haemostatic interventions often use transfusion outcomes as a primary endpoint. Transfusion is highly dependent on local practice, limiting its reliability as a robust, transferable endpoint. METHODS: A five-point HAT questionnaire was applied to participants enrolled into the EFIT-1 trial. This RCT evaluated the feasibility of administering a 6 g fibrinogen concentrate to patients with severe trauma haemorrhage. RESULTS: Of participants, 98% completed a HAT; 75% participants had 'achieved haemostasis' at the time of tool completion, as determined by clinical acumen alone. HAT scores were able to differentiate which participants required transfusion after 3 h. Of participants, 56% were transfused red blood cells when they scored 0-2, compared to 17% with HAT scores between 3 and 5. CONCLUSION: This study has confirmed the feasibility of using a HAT during the emergency care of patients suffering trauma haemorrhage, and future studies should be conducted to determine its value as an endpoint in haemostasis studies.

Monitoring of home safety issues in children on enteral feeds with inherited metabolic disorders.

OBJECTIVE: To assess the safety aspects of carers' enteral feeding technique when home enteral tube feeding children with inherited metabolic disorders (IMD). METHODS: 40 patients (median age, 5.1 years; range, 0.3-13.6 years) with IMD requiring pump tube feeding were recruited. 12 patients had glycogen storage disease, 11 organic acidemias, 8 fatty acid oxidation disorders, 4 urea cycle disorders, and 5 had other conditions. 50% of the patients were fed by gastrostomy and 50% nasogastric tube. A questionnaire and practical assessment of feeding process was completed with carers by a dietician and nurse in the child's home. Areas investigated included carer hygiene, feed preparation, tube care, tube changing, use of feeding pumps and equipment, and storage of enteral feeding equipment. RESULTS: The main issues identified were poor hygiene practices (78% unclean work surfaces; 25% no hand washing); inaccurate ingredient measuring (40%); irregular checking of tube position (40%); inadequate tube flushing (50%); poor knowledge of how to clear tube blockages (80%); incorrect priming of pump sets (50%); incorrect position of child for night feeding (63%); untrained secondary carers (43%); and poor knowledge of pump alarms, battery life, and charging time. Children commonly slept in parent's room as a safety precaution (58%). CONCLUSIONS: Long term follow-up of children with IMD on home enteral tube feeding suggests that regular updates on knowledge and technique for carers may be necessary to reduce risk.

The impact of visual media to encourage low protein cooking in inherited metabolic disorders.

BACKGROUND: The use of educational visual aids is one way to help children with inherited metabolic disorders (IMD) understand and develop a positive attitude towards their low protein diet. However, it is difficult to establish their effectiveness in the clinical setting. The present study aimed to evaluate the impact of a low protein recipe book and accompanying DVD for children with IMD. METHODS: One hundred and five children (53% female; median age = 6-8 years) with IMD on low protein diets were each given a low protein recipe book and DVD. After 6 months, children and carers were posted a questionnaire asking whether they used these resources; identifying any change in frequency of low protein cooking; and the outcome when preparing recipes. RESULTS: One hundred and two questionnaires were returned, representing 105 patients. Seventy percent (n = 71) of questionnaires were from carers. Ninety-three percent (n = 66) of carers acknowledged receipt of the resource; one-third (n = 22) had not watched the DVD and 23% (n = 15) had not opened the recipe book; 55% (n = 36) had tried the recipes; and 71% (n = 47) said the recipe book and/or DVD motivated them to try new recipes. Children were more likely to have watched the DVD (75%; n = 21/28) and read the recipe book (86%; n = 24/28) than carers. CONCLUSIONS: Although a helpful educational tool, just over one-half of respondents had used the resource. Identifying visual media that, by itself, will motivate most families of children with IMD to prepare low protein recipes may be unrealistic. The combined approach of visual aids and 'hands-on' practical experience, such as low protein cooking workshops and individual counselling, may be more beneficial.

Does maternal knowledge and parent education affect blood phenylalanine control in phenylketonuria?

BACKGROUND: Metabolic control in phenylketonuria (PKU) may be influenced by parental ability because dietary treatment involves complex food choices. This is an observational study to compare maternal carer (MC) knowledge and parental education with phenylalanine concentrations in children with PKU. METHODS: Children (n = 46; 26 boys) aged 1-10 years (median age 6 years) on dietary treatment were recruited. Their median lifetime and median phenylalanine concentrations in the year prior to study were estimated. MC completed a questionnaire to assess dietary knowledge. RESULTS: Overall maternal knowledge on most aspects of diet was good and there was a correlation between annual median blood phenylalanine concentrations, but at the age of 5-6 years of age only, and higher maternal carer scores on PKU knowledge (r = -0.646; P < 0.0001). Three of only four children (12%) with median phenylalanine concentrations above 500 micromol L(-1) in the year prior to study had both parents leave school without educational qualifications. Children who had median phenylalanine concentrations (n = 3; 7%) over the recommended ranges at 3 years of age or earlier continued to have poor control. CONCLUSIONS: Blood phenylalanine control within the first 3 years of age, poor parental educational achievement at school level, and unsatisfactory maternal dietary knowledge may all influence longer-term blood phenylalanine control in children.

Home enteral tube feeding in patients with inherited metabolic disorders: safety issues.

BACKGROUND: Many children with inherited metabolic disorders (IMD), at risk of hypoglycaemia and metabolic decompensation, are dependent on long-term home overnight enteral tube feeding but its safety issues have not been evaluated. OBJECTIVE: To identify common safety issues and carer pressures for patients with IMD on home enteral tube feeds (HETF). METHODS: Thirty-four patients (53% male; median age 4.1, range: 1.2-15.8 years), with IMD on home continuous overnight tube feeds were recruited. They were all following specialized feeding regimens. A questionnaire, administered by face-to-face interview with carers identified family members involved in feeding, training they received; child safety issues; equipment reliability and carer night time disturbance. RESULTS: The principal problems were: carer sleep disturbance (100%); tube entanglement (71%); untrained secondary carers (71%); faulty pumps (50%); tube blockages (45%); faulty equipment (32%); and child tampering with pumps and feeding equipment (29%). CONCLUSIONS: Significant risks for children on HETF with IMD were identified, potentially leading to metabolic decompensation and hospitalization. The safety of feeding equipment, lack of training of extended family members and practical support for carers requires urgent attention.

Diagnostic criteria for irritable bowel syndrome: utility and applicability in clinical practice.

BACKGROUND/AIMS: Symptom-based criteria have been introduced to aid the diagnosis of irritable bowel syndrome (IBS). Although they have been widely adopted and have proved useful for research purposes by ensuring homogeneity of study populations, there is little information about their utility in routine clinical practice. It was the aim of this study to assess the applicability of the Manning, Rome I and Rome II criteria in the clinical setting and to ascertain how often hospital specialists and general practitioners (GPs) use them. METHODS: Hundred secondary-care IBS patients were assessed for their conformity to these criteria. Forty-eight hospital specialists and 68 GPs were asked about their knowledge and utilization of these criteria. RESULTS: Seventy-three percent of IBS patients met Rome II diagnostic criteria with 82 and 94% meeting Rome I and Manning, respectively. Approximately 80% of GPs had no knowledge of any of the specific criteria, and only 4% had ever used them. The majority of specialists had knowledge of the criteria, with 70% having used them. CONCLUSION: The Rome II criteria are remarkably insensitive and if rigidly applied in the clinical situation would lead to much diagnostic uncertainty. The current lack of interest in them, especially amongst GPs, is unlikely to change unless they can be considerably improved.

Clinical supervision: making it happen.

When owned and governed by those who implement it, clinical supervision can become a living, breathing part of professional working life, and not just another ritual. A multidisciplinary team from Southampton explains.

Dementia in acute units: communication.

This is the second article in our series which looks in detail at one of the most pressing nursing problems of the age--coping with the behaviours of people with dementia in acute care units. The authors analyse the misunderstandings and misperceptions which conspire to build barriers to communication between nurses and people with dementia, and offer some practical advice on how to overcome them.