Comparison of the efficacy and safety of cuffed versus uncuffed endotracheal tubes for infants in the intensive care setting: a pilot, unblinded RCT.

OBJECTIVE: To study effectiveness and safety of cuffed versus uncuffed endotracheal tubes (ETTs) in small infants in the intensive care unit (ICU). DESIGN: Pilot RCT. SETTING: Neonatal and paediatric ICUs of children's hospital in Western Australia. PARTICIPANTS: Seventy-six infants ≥35 weeks gestation and infants <3 months of age, ≥3 kg. INTERVENTIONS: Patients randomly assigned to Microcuff cuffed or Portex uncuffed ETT. MAIN OUTCOMES MEASURES: Primary outcome was achievement of optimal ETT leak in target range (10%-20%). Secondary outcomes included: reintubations, ventilatory parameters, ventilatory complications, postextubation complications and long-term follow-up. RESULTS: Success rate (achievement of mean leak in the range 10%-20%) was 13/42 (30.9%) in the cuffed ETT group and 6/34 (17.6%) in uncuffed ETT group (OR=2.09; 95% CI (0.71 to 6.08); p=0.28). Mean percentage time within target leak range in cuffed ETT group 28% (IQR: 9-42) versus 15% (IQR: 0-28) in uncuffed ETT group (p=0.01). There were less reintubations to optimise size in cuffed ETT group 0/40 versus 10/36 (p<0.001). No differences were found in gaseous exchange, ventilator parameters or postextubation complications. There were fewer episodes of atelectasis in cuffed ETT group 0/42 versus 4/34 (p=0.03). No patient had been diagnosed with subglottic stenosis at long-term follow-up. CONCLUSIONS: There was no difference in the primary outcome, though percentage time spent in optimal leak range was significantly higher in cuffed ETT group. Cuffed ETTs reduced reintubations to optimise ETT size and episodes of atelectasis. Cuffed ETTs may be a feasible alternative to uncuffed ETTs in this group of patients. TRIAL REGISTRATION NUMBER: ACTRN12615000081516.

Cuffed endotracheal tubes in infants less than 3 kg: A retrospective cohort study.

BACKGROUND: Cuffed endotracheal tubes are being increasingly used in infants; however, current evidence in the literature mostly includes infants ≥ 3-kg weight. AIMS: The aim of this observational study was to compare the short-term outcomes with the use of Microcuff® cuffed vs uncuffed endotracheal tubes in neonates < 3 kg. METHODS: We performed a retrospective cohort study in a single-centre, tertiary children's hospital neonatal intensive care unit. The study included all infants < 3 kg receiving Microcuff® cuffed endotracheal tubes over the period January 2015 to January 2016. Controls were all infants 2000-2999 g receiving an uncuffed endotracheal tube over the period September 2015 to January 2016. RESULTS: Twenty-three patients < 3 kg were intubated with cuffed endotracheal tubes. All were inserted in the operating room. Of 23 patients, 14 (60.9%) patients had the cuff inflated in the operating room and none subsequently in the neonatal intensive care unit. The group receiving cuffed endotracheal tubes was compared with 23 patients with uncuffed endotracheal tubes. There was no difference in weight (median 2620 g vs 2590 g, diff in median = 10, 95% CI -120, 130) or duration of intubation (median 27 vs 44 hours, diff in median = 17, 95% CI -5, 46). However, there was a significant difference in gestational age (median 37 vs 35 weeks, diff in median = -1, 95% CI -2, 0) and age at intubation (median 6 vs 0 days, diff in median = -4, 95% CI -10, -1). There were no significant differences in the rates of: change of endotracheal tube to find correct size (0/23 vs 4/23, P = .109, OR = 0.13, 95% CI 0.01, 1.41); median ventilator leak reading (0% [IQR 0%-12%] vs 0% [IQR 0%-5.5%], P = .201, diff in median = 0, 95% CI -5.5, 0); unplanned extubations (0/23 vs 2/23; atelectasis (4/23 vs 0/23; endotracheal tube blockage (0/23 vs 0/23; pneumonia (0/23 vs 0/23; or postextubation stridor (1/23 vs 2/23). CONCLUSION: This retrospective study with a small sample size found that Microcuff® cuffed endotracheal tubes may be safe in neonates < 3 kg. Well-designed randomized controlled trials are needed to address this issue definitively.

Severe acquired subglottic stenosis in neonatal intensive care graduates: a case-control study.

OBJECTIVE: To analyse current incidence and risk factors associated with severe acquired subglottic stenosis (SASGS) requiring surgical intervention in neonates. DESIGN: Retrospective case-control study. SETTING: Sole tertiary children's hospital. PARTICIPANTS: Patients who underwent surgical intervention for SASGS from January 2006 to December 2014. For each neonatal intensive care unit (NICU) graduate with acquired SASGS, two controls were selected (matched for gestation and year of birth). MAIN OUTCOMES AND MEASURES: Incidences were calculated and cases and controls compared using conditional logistic regression analysis to identify risk factors for SASGS. RESULTS: Thirty-seven NICU graduates required surgical intervention for SASGS of whom 35 were <30-week gestation at birth. The incidence of SASGS in surviving children who had required ventilation in the neonatal period was 27/2913 (0.93%). Incidence was higher in infants <28-week gestation (24/623=3.8%) compared with infants ≥28-week gestation (3/2290=0.13%; p=0.0001). On univariate analysis, risk factors for SASGS were: higher number of intubations (4 vs 2; p<0.001); longer duration ventilation (16 vs 9.5 days; p<0.001); unplanned extubation (45.7% vs 20.0%; p=0.007); traumatic intubation (34.3% vs 7.1%; p=0.003) and oversized endotracheal tubes (ETTs) (74.3% vs 42.9%; p=0.001). On multivariate analysis, risk factors for SASGS were: Sherman ratio >0.1 (adjusted OR (aOR) 6.40; 95% CI 1.65 to 24.77); more than five previous intubations (aOR 3.74; 95% CI 1.15 to 12.19); traumatic intubation (aOR 3.37; 95% CI 1.01 to 11.26). CONCLUSIONS: SASGS is a serious consequence of intubation for mechanical ventilation in NICU graduates, especially in preterm infants. Minimising trauma during intubations, avoiding recurrent extubation/reintubations and using appropriate sized ETTs may help prevent this serious complication.

Mainstreaming the social sciences in conservation.

Despite broad recognition of the value of social sciences and increasingly vocal calls for better engagement with the human element of conservation, the conservation social sciences remain misunderstood and underutilized in practice. The conservation social sciences can provide unique and important contributions to society's understanding of the relationships between humans and nature and to improving conservation practice and outcomes. There are 4 barriers-ideological, institutional, knowledge, and capacity-to meaningful integration of the social sciences into conservation. We provide practical guidance on overcoming these barriers to mainstream the social sciences in conservation science, practice, and policy. Broadly, we recommend fostering knowledge on the scope and contributions of the social sciences to conservation, including social scientists from the inception of interdisciplinary research projects, incorporating social science research and insights during all stages of conservation planning and implementation, building social science capacity at all scales in conservation organizations and agencies, and promoting engagement with the social sciences in and through global conservation policy-influencing organizations. Conservation social scientists, too, need to be willing to engage with natural science knowledge and to communicate insights and recommendations clearly. We urge the conservation community to move beyond superficial engagement with the conservation social sciences. A more inclusive and integrative conservation science-one that includes the natural and social sciences-will enable more ecologically effective and socially just conservation. Better collaboration among social scientists, natural scientists, practitioners, and policy makers will facilitate a renewed and more robust conservation. Mainstreaming the conservation social sciences will facilitate the uptake of the full range of insights and contributions from these fields into conservation policy and practice.

Codifying knowledge to improve patient safety: a qualitative study of practice-based interventions.

Although it is well established that health care professionals use tacit and codified knowledge to provide front-line care, less is known about how these two forms of knowledge can be combined to support improvement related to patient safety. Patient safety interventions involving the codification of knowledge were co-designed by university and hospital-based staff in two English National Health Service (NHS) hospitals to support the governance of medication safety and mortality and morbidity (M&M) meetings. At hospital A, a structured mortality review process was introduced into three clinical specialities from January to December 2010. A qualitative approach of observing M&M meetings (n = 30) and conducting interviews (n = 40) was used to examine the impact on meetings and on front-line clinicians and hospital managers. At hospital B, a medication safety 'scorecard' was administered on a general medicine and elderly care ward from September to November 2011. Weekly feedback meetings were observed (n = 18) and interviews with front-line staff conducted (n = 10) to examine how knowledge codification influenced behaviour. Codification was shown to support learning related to patient safety at the micro (front-line service) level by structuring the sharing of tacit knowledge, but the presence of professional and managerial boundaries at the organisational level affected the codification initiatives' implementation. The findings suggest that codifying knowledge to support improvement presents distinct challenges at the group and organisational level; translating knowledge across these levels is contingent on the presence of enabling organisational factors, including the alignment of learning from clinical practice with its governance.

Governing patient safety: lessons learned from a mixed methods evaluation of implementing a ward-level medication safety scorecard in two English NHS hospitals.

BACKGROUND: Relatively little is known about how scorecards presenting performance indicators influence medication safety. We evaluated the effects of implementing a ward-level medication safety scorecard piloted in two English NHS hospitals and factors influencing these. METHODS: We used a mixed methods, controlled before and after design. At baseline, wards were audited on medication safety indicators; during the 'feedback' phase scorecard results were presented to intervention wards on a weekly basis over 7 weeks. We interviewed 49 staff, including clinicians and managers, about scorecard implementation. RESULTS: At baseline, 18.7% of patients (total n=630) had incomplete allergy documentation; 53.4% of patients (n=574) experienced a drug omission in the preceding 24 h; 22.5% of omitted doses were classified as 'critical'; 22.1% of patients (n=482) either had ID wristbands not reflecting their allergy status or no ID wristband; and 45.3% of patients (n=237) had drugs that were either unlabelled or labelled for another patient in their drug lockers. The quantitative analysis found no significant improvement in intervention wards following scorecard feedback. Interviews suggested staff were interested in scorecard feedback and described process and culture changes. Factors influencing scorecard implementation included 'normalisation' of errors, study duration, ward leadership, capacity to engage and learning preferences. DISCUSSION: Presenting evidence-based performance indicators may potentially influence staff behaviour. Several practical and cultural factors may limit feedback effectiveness and should be considered when developing improvement interventions. Quality scorecards should be designed with care, attending to evidence of indicators' effectiveness and how indicators and overall scorecard composition fit the intended audience.

Bovine cumulus cell-oocyte gap junctional communication during in vitro maturation in response to manipulation of cell-specific cyclic adenosine 3',5'-monophosophate levels.

In the growing follicle, communication between the oocyte and its surrounding follicular cells is essential for normal oocyte and follicular development. Maturation of the fully grown oocyte in vivo is associated with the loss of cumulus cell-oocyte gap junctional communication, preventing entry of meiotic-modulating factors such as cAMP into the oocyte. We have previously shown that oocyte and cumulus cell cAMP levels can be independently regulated using inhibitors of cell-specific phosphodiesterase (PDE) isoenzymes. The objectives of this study were to examine the effects of cell type-specific PDE inhibitors on the maintenance of cumulus cell-oocyte gap junction communication (GJC) and oocyte meiotic progression. Cumulus-oocyte complexes (COCs) were aspirated from antral follicles of abattoir-derived ovaries. Cumulus cell-oocyte GJC during oocyte maturation was quantified using the fluorescent dye, calcein-AM. COCs were cultured in the presence of specific PDE inhibitors, milrinone (an oocyte PDE3 inhibitor) or rolipram (a cumulus cell PDE4 inhibitor), and were pulsed with calcein-AM to allow dye transfer between the two cell types. Following cumulus cell removal, fluorescence in denuded oocytes was measured by microphotometry, and meiotic progression was assessed. In control COCs, dye transfer from cumulus cells to the oocyte fell progressively from 0 to 9 h, after which oocyte-cumulus cell GJC was completely lost. Loss of GJC was significantly attenuated (P < 0.05) during this time in response to treatment with milrinone and rolipram. Forskolin maintained GJC at the initial 0 h level until 3-4 h of culture, whereas treatment with milrinone and forskolin together actually increased the level of dye transfer above that in COCs treated with forskolin alone. Importantly, all treatments that prolonged GJC also delayed meiotic resumption, with meiosis generally resuming when fluorescence had fallen to approximately 40% of initial levels. These results, together with our previous studies, demonstrate that treatments that maintain or elevate cAMP levels in cumulus cells, oocytes, or both result in prolonged oocyte-cumulus cell communication and delayed meiotic resumption.

Linking the sounds of dolphins to their locations and behavior using video and multichannel acoustic recordings.

It is difficult to attribute underwater animal sounds to the individuals producing them. This paper presents a system developed to solve this problem for dolphins by linking acoustic locations of the sounds of captive bottlenose dolphins with an overhead video image. A time-delay beamforming algorithm localized dolphin sounds obtained from an array of hydrophones dispersed around a lagoon. The localized positions of vocalizing dolphins were projected onto video images. The performance of the system was measured for artificial calibration signals as well as for dolphin sounds. The performance of the system for calibration signals was analyzed in terms of acoustic localization error, video projection error, and combined acoustic localization and video error. The 95% confidence bounds for these were 1.5, 2.1, and 2.1 m, respectively. Performance of the system was analyzed for three types of dolphin sounds: echolocation clicks, whistles, and burst-pulsed sounds. The mean errors for these were 0.8, 1.3, and 1.3 m, respectively. The 95% confidence bound for all vocalizations was 2.8 m, roughly the length of an adult bottlenose dolphin. This system represents a significant advance for studying the function of vocalizations of marine animals in relation to their context, as the sounds can be identified to the vocalizing dolphin and linked to its concurrent behavior.

Differential effects of specific phosphodiesterase isoenzyme inhibitors on bovine oocyte meiotic maturation.

The differential regulation of cAMP levels within the oocyte and somatic (cumulus) cell compartments of the bovine follicle, and the subsequent regulation of oocyte meiotic maturation was examined through specific cell-type localisation of phosphodiesterases (PDEs). Selective PDE inhibitors were used to modulate cAMP levels in each of the two follicular compartments and to examine their effects on oocyte meiotic maturation. Ovaries were obtained from an abattoir and cumulus-oocyte complexes (COC) were aspirated from antral follicles into culture medium supplemented with 4 mg/ml BSA and 2mM 3-isobutyl-1-methylxanthine (IBMX). COC, denuded oocytes (DO), or mural granulosa cells (MGC) were cultured either with or without forskolin or FSH, in the presence of specific PDE inhibitors; either milrinone (PDE3 inhibitor), cilostamide (PDE3 inhibitor), or rolipram (PDE4 inhibitor). COC/DO cultures were assessed for meiotic progression and cAMP content, and MGC for cAMP production. The type 3 PDE inhibitor, but not the type 4, prevented spontaneous meiotic maturation and elevated intraoocyte cAMP in cultured denuded oocytes. In contrast, the type 4 PDE inhibitor had no effect on the oocyte, but elevated mural granulosa and cumulus cell cAMP production. The results of this study indicate that specific PDE subtypes are differentially localised within the two compartments of the bovine follicle-the type 3 PDE in the oocyte and the type 4 PDE in the granulosa cells. In addition, oocyte cAMP levels are primarily regulated in bovine oocytes by its degradation by PDE, whereas granulosa cell cAMP levels are controlled mainly by active adenylate cyclase, with both sources able to participate in oocyte meiotic regulation.