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Objectives To determine the need for recovery (NFR) among emergency physicians and to identify demographic and occupational characteristics associated with higher NFR scores.Design Cross-sectional electronic survey.Setting Emergency departments (EDs) (n=112) in the UK and Ireland.Participants Emergency physicians, defined as any registered physician working principally within the ED, responding between June and July 2019.Main outcome measure NFR Scale, an 11-item self-administered questionnaire that assesses how work demands affect intershift recovery.Results The median NFR Score for all 4247 eligible, consented participants with a valid NFR Score was 70.0 (95% CI: 65.5 to 74.5), with an IQR of 45.5–90.0. A linear regression model indicated statistically significant associations between gender, health conditions, type of ED, clinical grade, access to annual and study leave, and time spent working out-of-hours. Groups including male physicians, consultants, general practitioners (GPs) within the ED, those working in paediatric EDs and those with no long-term health condition or disability had a lower NFR Score. After adjusting for these characteristics, the NFR Score increased by 3.7 (95% CI: 0.3 to 7.1) and 6.43 (95% CI: 2.0 to 10.8) for those with difficulty accessing annual and study leave, respectively. Increased percentage of out-of-hours work increased NFR Score almost linearly: 26%–50% out-of-hours work=5.7 (95% CI: 3.1 to 8.4); 51%–75% out-of-hours work=10.3 (95% CI: 7.6 to 13.0); 76%–100% out-of-hours work=14.5 (95% CI: 11.0 to 17.9).Conclusion Higher NFR scores were observed among emergency physicians than reported in any other profession or population to date. While out-of-hours working is unavoidable, the linear relationship observed suggests that any reduction may result in NFR improvement. Evidence-based strategies to improve well-being such as proportional out-of-hours working and improved access to annual and study leave should be carefully considered and implemented where feasible.

Objectives: External ventricular drain (EVD) insertion is a common neurosurgical procedure. EVD-related infection (ERI) is a major complication that can lead to morbidity and mortality. In this study, we aimed to establish a national ERI rate in the UK and Ireland and determine key factors influencing the infection risk.Methods: A prospective multicentre cohort study of EVD insertions in 21 neurosurgical units was performed over 6 months. The primary outcome measure was 30-day ERI. A Cox regression model was used for multivariate analysis to calculate HR.Results: A total of 495 EVD catheters were inserted into 452 patients with EVDs remaining in situ for 4700 days (median 8 days; IQR 4-13). Of the catheters inserted, 188 (38%) were antibiotic-impregnated, 161 (32.5%) were plain and 146 (29.5%) were silver-bearing. A total of 46 ERIs occurred giving an infection risk of 9.3%. Cox regression analysis demonstrated that factors independently associated with increased infection risk included duration of EVD placement for ≥8 days (HR=2.47 (1.12-5.45); p=0.03), regular sampling (daily sampling (HR=4.73 (1.28-17.42), p=0.02) and alternate day sampling (HR=5.28 (2.25-12.38); p<0.01). There was no association between catheter type or tunnelling distance and ERI.Conclusions: In the UK and Ireland, the ERI rate was 9.3% during the study period. The study demonstrated that EVDs left in situ for ≥8 days and those sampled more frequently were associated with a higher risk of infection. Importantly, the study showed no significant difference in ERI risk between different catheter types. [ABSTRACT FROM AUTHOR]

Objective: To assess the quantity and nature of the proteins that adsorb to hydrocephalus shunt catheters after implantation, and to determine whether sufficient could accumulate to obstruct the catheter.Design: Elution of proteins from 102 explanted shunt catheters, with protein assay and electrophoresis of the eluate, and scanning electron microscopy (SEM) of the catheters.Results: The amount of protein elutable was extremely low, and significant protein, apart from a thin film, was not found on SEM. Qualitative analysis disclosed that most of the adsorbed protein was albumin.Conclusions: Protein deposition on hydrocephalus catheters does not occur in sufficient quantities to cause catheter obstruction. [ABSTRACT FROM AUTHOR]

The role of Clostridium difficile in the aetiology of diarrhoea in children with Hirschsprung's disease was investigated in a prospective longitudinal study. In 64 children with Hirschsprung's disease no significant difference was found in the isolation rate of C difficile in patients with diarrhoea (32%) and without diarrhoea (26%). Comparable isolation rates were found in 47 control children with and without diarrhoea (27% and 16% respectively). The number of strains producing toxin B was similar in the four groups of children. In contrast to the disappearance of C difficile by 12 months of age in the control groups of children, C difficile could be repeatedly isolated from a proportion of children with Hirschsprung's disease over 12 months of age. These findings help to reconcile the existing contradictory reports on the incidence of C difficile in Hirschsprung's disease associated enterocolitis. [ABSTRACT FROM AUTHOR]

Background: In acute asthma the optimal duration of treatment with combination beta agonist and anticholinergic nebuliser solutions is unknown; most studies have investigated single doses or treatment for up to 12 hours. To determine whether longer treatment with ipratropium bromide might aid recovery a study was undertaken in 106 patients with acute asthma.Methods: A double blind, randomised, placebo controlled, three group study was performed with all patients receiving ipratropium for 12 hours and salbutamol for 60 hours after admission (both nebulised four hourly), systemic steroids and, if necessary, theophylline. At 12 hours ipratropium was stopped in group I (n = 35) but was continued in the other two groups, and at 36 hours ipratropium was also stopped in group II (n = 35) while patients in group III (n = 36) continued with ipratropium for 60 hours. Spirometric tests were performed before and after salbutamol, and again 30 and 60 minutes after ipratropium or placebo at 12, 36 and 60 hours. Peak flow rates (PEFR) were measured before and after each nebulisation.Results: There were no differences between the groups in PEFR on admission (group I: 214 l/min, group II: 198 l/min, group III: 221 l/min), or mean forced expiratory volume in one second (FEV1) at 12 hours (group I: 1.81, group II: 2.01, group III: 2.21), 36 hours (group I: 2.11, group II: 2.31, group III: 2.41), or at 60 hours (group I: 2.21, group II: 2.31, group III 2.51). Despite this, median time to discharge was significantly higher for patients in group I (5.4 days) than for those in groups II (4.1 days) and III (4.0 days).Conclusions: Combination nebulised therapy can be continued beyond 12 hours and up to 36 hours after admission with improved recovery time. Lung function testing may not reflect the full benefit of treatment. [ABSTRACT FROM AUTHOR]

The bacteriological findings of a study of intestinal colonisation in 24 neonates with oesophageal atresia are reported. Only five of the patients received antibiotics. When compared with published findings in healthy neonates, the rate of intestinal colonisation in our series was prolonged, with Staphylococcus albus predominating in the first week. Anaerobic colonisation was delayed and bacteroides spp were present in only five patients by the third week. Bifidobacteria were almost completely absent. The onset of intestinal colonisation seemed to be related temporally to enteral feeding. The use of antibiotics in five patients resulted in colonisation by candida in four and clinical thrush in three. [ABSTRACT FROM AUTHOR]

Serial tests for serum C-reactive protein (CRP) were carried out on 40 children undergoing cerebrospinal fluid shunt surgery, to determine the pattern of appearance and disappearance of CRP in relation to this type of operation, in the absence of postoperative complications. Samples of sera from a further 268 children, 79 of whom presented after shunt surgery with symptoms suggesting infective complications related to the shunt, were examined for CRP. The results showed that, while the test in negative in uncomplicated colonisation of ventriculo-atrial shunts, it is reliably positive in patients with colonised ventriculo-peritoneal shunts, ventriculitis, or shunt nephritis. [ABSTRACT FROM AUTHOR]

The effects of the abnormal innervation in Hirschsprung's disease on colonic ion transport were examined in vitro using Ussing chambers. The response of the mucosal/submucosal preparations to different secretagogues were investigated in aganglionic and ganglionic rectosigmoid and transverse colon from children with Hirschsprung's disease and compared with normally innervated colon from children with anorectal anomalies. Basal values were similar in aganglionic and ganglionic rectosigmoid colon. Neurally mediated secretion with iloprost (10(-6) M) and acetylcholine (900 and 9 microM) was considerably reduced in aganglionic colon compared with normally innervated ganglionic colon. The ganglionic colon proximal to the aganglionic colon also had a reduced response to acetylcholine despite a normal acetylcholinesterase staining pattern. The responses to Escherichia coli STa enterotoxin (50 MU/ml) and isobutylmethylxanthine (10(-3) M) were similar in ganglionic and aganglionic colon. The response to STa enterotoxin was not changed by the nerve blocking agent tetrodotoxin (10(-6) M). The data show that colonocytes from aganglionic colon are capable of a normal secretory response if stimulated directly by cAMP or cGMP acting secretagogues but secretion in response to neurally mediated secretagogues is impaired. The hypertrophied acetylcholinesterase positive nerve fibres that infiltrate the aganglionic colon are likely to contribute to the reduced secretion to acetylcholine. [ABSTRACT FROM PUBLISHER]

Comments on several issues related to medicine as of October 1982. Admission of children in General Practitioner Hospitals in Great Britain; Moral and ethical aspects of in-vitro fertilization; Role of an infective agent in pityriasis rosea clustering.

A method of optimising slime production produced by Staphylococcus epidermis and its quantitative assay was developed, which gave a preliminary indication of its identity and an assessment of the correlation between slime production and adherence of the organism to implants. After inducing vigorous growth in brain heart infusion broth to stationary phase, all nutrients were removed by washing and the organisms resuspended in sterile deionised water with added magnesium. After further incubation the culture was centrifuged and the supernatant reacted with alcian blue in 50 mM magnesium chloride/sodium acetate solution, and the amount of bound dye was measured spectrophotometrically at 620 nm after its resolubilisation using sodium dodecyl sulphate. Large quantities of slime were produced by some, but not all, strains. Preliminary electrophoresis of the slime showed mobility and staining similar to that of the glycosaminoglycans. Adherence was tested by growing strains in wells of tissue culture plates and aspirating the supernatant after incubation. After fixation and staining of adherent growth the amount of bound stain was determined spectrophotometrically after its elution with ethanol. In this series of organisms there was no correlation between the result of tests for adherence or production of extracellular slime, and no correlation between either of these and the clinical source of the organisms. [ABSTRACT FROM PUBLISHER]

Antibiotic resistant coryneforms (group JK) have increasingly been reported as causes of serious sepsis in the immunosuppressed and in patients with implants. Their cultural and biochemical characteristics were examined in an attempt to provide a simple scheme for their recognition in the clinical laboratory. Their susceptibilities to a range of antimicrobials were determined, and an enriched selective medium was developed for their isolation from normally non-sterile sites. The JK coryneforms fell into a fairly homogeneous group, producing colonial morphology and biochemical profiles identical with reference strains, which allowed their recognition and differentiation from other coryneforms. All strains were resistant to penicillin and susceptible to vancomycin, but there was considerable variation with respect to other antimicrobials. There is scope for further rationalisation of biochemical tests for the recognition of these organisms. [ABSTRACT FROM PUBLISHER]

A conventional method of bacteriological examination of removed cerebrospinal fluid shunts was compared with another method which relies on microscopic and cultural examination of intraluminal fluid. Fifty-five shunts were tested. All eight cases of clinical shunt infection gave positive results with the latter method, whereas a further 23 shunts yielded positive cultures by the conventional method in the absence of clinical infection. The consequences of missed infections due to omission of microscopic examination and overdiagnosis using the conventional culture method are discussed. [ABSTRACT FROM PUBLISHER]

Colonisation of cerebrospinal fluid shunts by coagulate-negative staphylococci (Staphylococcus albus) is a serious problem. Because of its possible role in prevention of the condition, the antimicrobial activity of silicone rubber after impregnation with antimicrobial drugs was studied. The method of impregnation used and test methods were found to be important. Formaldehyde-urea condensates gave no activity. Gentamicin sulphate gave activity which was short-lived. Sodium and diethanolamine fusidates and clindamycin hydrochloride gave prolonged activity. A method of impregnation was developed which could be applied to commercially available shunts before use. [ABSTRACT FROM PUBLISHER]

Methicillin-resistant staphylococci were tested for susceptibility to cephradine, cephaloridine, cephalexin, and cefuroxime and 30 degree C and 37 degree C on ordinary media and on media of enhanced osmotic strength. The coagulase-negative strains were divided into Staphylococcus epidermis and Staphylococcus hominis. Generally the number of susceptible strains decreased with low incubation temperature and osmotic support. When Staphylococcus aureus was tested against cephalexin and cefuroxime, most were susceptible at 37 degree C whereas all were resistant at 30 degree C. A similar trend was found in the case of cephradine, where it was accentuated by osmotic support. While almost all strains of Staph. epidermidis were sensitive to all four drugs under all test conditions, the susceptibility of Staph. hominis was generally decreased by either lower incubation temperature or osmotic support or both. [ABSTRACT FROM PUBLISHER]

Background: Prosthetic infections are a major problem, requiring complex and lengthy management. The role of blood proteins in the pathogenesis of implant infection has been investigated, but research into the role of CSF protein in shunt infections has not been undertaken, even though a high CSF protein has been assumed to increase the risk of such infections.Methods: New shunt catheters were exposed to either CSF or individual protein solutions, and the numbers of radiolabelled staphylococci that adhered to them were compared with controls that had been exposed to saline only.Results: A significant reduction in bacteria adhering to the test catheter was found in each instance. Furthermore, the CSF with the highest protein content, from a patient with intraventricular haemorrhage, had the greatest inhibitory effect on bacterial adhesion. The effect of the solutions on the hydrophobicity of the silicone rubber was also investigated. The silicone rubber was more hydrophilic, and bacterial adhesion was less, with solutions containing a higher protein content, and these findings were in keeping with the current theories on the mechanism of bacterial adhesion to polymers.Conclusions: A high CSF protein content does not predispose to the development of shunt infections. [ABSTRACT FROM AUTHOR]

A process is described by which hydrocephalus shunt catheters can be impregnated with antimicrobials. The processed catheters showed antimicrobial activity at their surfaces for long periods and could be sterilised by autoclaving. When tested in vitro in a model of catheter colonisation using large challenge doses of Staphylococcus epidermidis and prolonged perfusion, some antimicrobials failed to protect against colonisation whereas others protected against one or two challenges. A combination of rifampicin and clindamycin gave best results, protecting against three successive challenges over a 28 day perfusion period. Resistant organisms did not develop. The process is likely to be useful in prevention of hydrocephalus shunt infection. [ABSTRACT FROM AUTHOR]

The results of treatment of 50 cases of ventriculitis associated with the use of cerebrospinal fluid shunts or external ventricular drains, and treated with intraventricular vancomycin, are reported. While the overall cure rate was 66% with four cases lost to follow-up, in those cases where treatment involved shunt removal, 20 mg vancomycin daily intraventricularly, and another appropriate systemic antibiotic, 22 of 24 cases were cured with two cases lost to follow-up. In those cases where the shunt was left in during treatment, results were poor and revision for blockage of the distal catheter of ventriculoperitoneal shunts was required in 44% of these. All five patients whose ventriculitis followed external ventricular drainage were cured. Despite relatively high trough levels of vancomycin in the cerebrospinal fluid, no evidence of toxicity was seen. [ABSTRACT FROM AUTHOR]

A 38-year-old man with a ventriculoatrial shunt presented with non-specific symptoms (headache, back pain, night sweats) and inconclusive laboratory results. He showed an extremely high titre of antibody to Staphylococcus epidermidis which proved diagnostic of shunt infection. This was confirmed on shunt removal and he was successfully treated. [ABSTRACT FROM AUTHOR]

Clostridium difficile cytopathic toxin was found in the faeces or gut content of five of 39 neonates with necrotising enterocolitis (NEC). Toxin concentrations were uniformly low and did not differ from those found in healthy neonates. C difficile is unlikely to be involved in the pathogenesis of NEC. Stools from 33 babies with NEC were also tested for C perfringens alpha toxin, with negative results. [ABSTRACT FROM AUTHOR]

The use of polyvinylpyrrolidone, an inert polymer resembling plasma proteins in its colligative effects, in the testing of micrococcaceae for sensitivity to methicillin and cephradine is described. Generally results are quite comparable with those of conventional methods. The absence of any inhibitory effect of the polymer compared to sodium chloride, and its physiological inertia compared to sucrose, along with its suitability for sterilisation by autoclaving are seen as advantages. It is suggested that the use of this substance may give results which are more applicable to the in vivo situation. This may apply particularly in the case of cephradine. [ABSTRACT FROM PUBLISHER]

It has been found that children with hydrocephalus, whose Spitz-Holter valves are colonized with , have an antibody to this organism in their serum. Children without colonized shunts have little or no such antibody. A test for this antibody is described, and its use in such cases is discussed. [ABSTRACT FROM PUBLISHER]

The isolation of two coagulase-negative strains of is reported, and their biochemical characteristics are given. The reliability of coagulase tests alone in the identification of is discussed, and the deoxyribonuclease test is recommended as a useful confirmatory test. [ABSTRACT FROM PUBLISHER]

Forty patients undergoing routine bronchoscopy were randomised to receive inhaled micronised gentamicin powder (180 mg) or nebulised gentamicin solution (160 mg) one hour before the procedure. Similar levels of gentamicin were detected in bronchoalveolar lavage fluid in the two groups (micronised powder (n = 20) 9.3 (SD 9.3) mg/l, nebulised solution (n = 20) 8.0 (7.8) mg/l). The micronised gentamicin powder preparation caused cough in half the patients but this did not stop their receiving a full dose. Dry powder gentamicin may be a convenient formulation for long term inhaled treatment if the problem of cough can be overcome. [ABSTRACT FROM PUBLISHER]

Background The first step in bundle design or implementation is to identify the problem being addressed. Several validated approaches are recommended to facilitate this. These include using systematic reviews, adverse event triggers and risk assessment tools. However, these methods do not fully take the local context into account, which will limit the effectiveness of the bundle.Aim This study explores the potential benefit of using a comprehensive audit to identify an organisation’s local context prior to designing and implementing a care bundle.Method A comprehensive audit comprising observations of four patient journeys, interviews with 21 staff and clinical data was carried out at one large National Health Service trust in England. A patient warming care bundle was used as the exemplar.Findings Each of the three data collection methods identified specific local practices which would be addressed within the planning and implementation stages of a care bundle. These practices would not have been identified through other recommended methods.Conclusion A comprehensive audit, comprising observations, interviews and clinical data is a successful method to identify local contextual issues prior to care bundle implementation.