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This paper draws together two elements of the Photography strand in an extensive interdisciplinary research project looking at memorialisation: (i) a literature review (Hutchinson) that exp...

BackgroundOn our paediatric intensive care unit (PICU), we have historically used heparin in 0.9% sodium chloride as a continuous flush to maintain patency of arterial and central venous pressure (CVP) central lines. Practice varies across the UK, some units use heparin in sodium chloride whilst others use sodium chloride alone to maintain line patency. Currently in paediatrics there is not enough evidence to change local practice by removing heparin from the flushes.1 A cost saving scheme was identified whereby using heparin in sodium chloride 0.45% was cheaper than using heparin in sodium chloride 0.9% (both products from Baxter). A proposal was put together and approved by the PICU quality improvement group, demonstrating that in theory, there should be no significant loss of sodium to patients due to the change in fluids. Although it may seem that flushes would not contribute a large proportion of a patient’s fluid requirement, in a typical 2.5 kg patient post cardiac surgery, 2 ml/hour would actually provide 40% of the patient’s total fluid allowance. This change in practice was implemented in June 2018.AimThe aim of this audit was to establish whether patients receiving heparin in sodium chloride 0.45% had lower sodium blood levels or a greater drop in sodium levels than patients on heparin in sodium chloride 0.9%. We also evaluated whether a higher incidence of line blockage was reported in either group.MethodsData was collected retrospectively using the Phillips ICCA electronic prescribing system, using 25 patients pre (April 2018) and 25 patients post (June and July 2018) implementation of the heparin in sodium chloride 0.45% flushes. Sodium blood gas levels were used as these were more consistently taken than plasma blood samples.ResultsThe data showed that heparin in sodium chloride 0.45% did not reduce sodium levels in patients. In each group 1 patient required additional sodium supplementation and 2 patients’ lines became blocked and therefore were removed. The average sodium on admission in the heparin in sodium chloride 0.9% group was 139.96 mmol/L (CI 95% ±1.17 mmol/L) compared to the heparin in sodium chloride 0.45% group which was 135.68 mmol/L (CI 95% ± 1.91mmol/L). The average sodium level on either line removal or discharge from PICU was 138 mmol/L (CI 95% ± 1.35mmol/L) in the heparin sodium chloride 0.9% group compared to 135.72 mmol/L (CI 95% ± 1.88 mmol/L) in the heparin sodium chloride 0.45% group. The results indicated that patients within the pre-change group lost, on average, 2 mmol/L sodium compared to their admission sodium levels compared to 0.04 mmol/L in the post-change group. The reason for this difference is unclear would warrant further investigation into alternative sources of sodium e.g. drug infusions and additional fluids which were outside of the scope of this audit.ConclusionThe change from using heparin in sodium chloride 0.9% to heparin in sodium chloride 0.45% was not found to lead to a reduction in plasma sodium levels in our patient population. Limitations to the audit include not considering alternative sources of sodium and a small patient population.ReferenceBeswick T, Skipp M. Should heparin based flushing solutions be used in preference to saline to maintain the patency of indwelling intravascular catheters and cannulae? – SPS - Specialist Pharmacy Service [Internet]. Available at www.sps.nhs.uk. 2016 [accessed 3 Aug 2018]. Available from: https://www.sps.nhs.uk/articles/should-heparin-based-flushing-solutions-be-used-in-preference-to- saline-to-maintain-the-patency-of-indwelling-intravascular-catheters-and-cannulae/

AimOur paediatric intensive care unit (PICU) has been using the Phillips ICCA electronic prescribing system since 2016. This system has an ‘order set’ function that allows a pre- populated list of medications to be created for use in certain situations. Potential benefits include reduced time to prescribe medications, reduced medication error rate and improved prescribing efficiency. The PICU quality improvement group and Pharmacy Informatics team created an order set for patients under 1 year of age admitted from theatre following cardiac surgery, which was implemented in June 2017. Our theatres do not use the ICCA system so as the patients are transferred with infusions running, there is a time gap where the patient has infusions running on PICU without a live prescription on ICCA. The aim of this project was to establish a reduction in the time taken for all 13 medications to be prescribed. In turn this would reduce the risk of running infusions without a live prescription.MethodsData was collected retrospectively from the ICCA system on 15 patients pre and 15 patients post the introduction of the order set. Time of admission was set when the patient was allocated a bed on ICCA. The times at which each medication was prescribed were taken directly from ICCA. A user satisfaction survey was also sent out to during the order set implementation phase.ResultsThe time taken to prescribe all 13 medications was reduced on average by 9.4 hours per patient. The average time saved per medication was 43 minutes. Pre implementation, the average time to prescribe the medications was 11.4 hours (95% CI [5.5, 17.3]). Post implementation, the time taken to prescribe the same medications was 2 hours (95% CI [0.5, 3.5]). Pre implementation, prescriptions were started at least 30 minutes (average) after the patient arrived on PICU. Post implementation, prescriptions were started 30 minutes before patient admission and completed within 30 minutes of arrival. 20 staff members completed the user satisfaction survey. The survey had a 13% return rate. 70% of users agreed or strongly agreed that using the order set function improved prescribing efficiency and 55% of users agreed or strongly agreed that the order set helped ensure appropriate doses.ConclusionImplementation of an order set for this patient group removed the risk of running infusions without a live prescription. This project is an example of how prescribing support functions within electronic prescribing packages can reduce time taken to write up medications within our unit, allowing prescribers to spend more time on other duties. Following the success of this intervention, further order sets will be created for use on our unit. A high level of clinical knowledge from the pharmacy support team and strong engagement with the clinical team was essential in creating a product that was fit for purpose. Limitations of this project are that we did not have the capability to assess a reduction in medication error. We now have increased support within the Pharmacy Informatics team to enable this for future projects.

BackgroundHIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care but evidence on implementing testing is lacking.AimWe aimed to determine the effectiveness of post-trial implementation of a cluster randomised controlled trial (RHIVA2) promoting HIV testing in Hackney general practice.MethodThe RHIVA2 intervention (2010–12) comprised initial education and training, nomination of a practice lead nurse, external quality assurance, and referral of newly diagnosed patients to HIV services. Post-trial implementation (2012–2015) included additional intervention training, and audit of antiretroviral co-prescribing and missed HIV diagnoses. Monthly computerised HIV testing data, remotely extracted by the clinical effectiveness group, were analysed using interrupted time series analysis.ResultsFollowing RHIVA2 (20 intervention and 20 control practices), an additional 12 practices (11 former trial control, one former non-participating) received the intervention, and training was reinforced in six former trial intervention practices; a total of 31 practices (13 former trial intervention, 15 former trial control, and three former non-participating) completed the audit. HIV testing rates in intervention practices (trial or post-trial) increased immediately following the intervention by 85% (IRR = 1.85, 95% CI 1.72 to 1.99), and a similar effect (IRR 1.82, 95% CI 1.72 to 1.93) was observed when including comparator practices that didn’t receive the intervention at any point. The change in the effect of the intervention during the three years following the intervention decreased significantly (IRR = 0.99, 95% CI 0.99 to 0.99).ConclusionPost-trial implementation of a research intervention increased testing activity but may require regular support for sustainability.

IntroductionHIV remains underdiagnosed. Guidelines recommend routine HIV testing in primary care, but evidence on implementing testing is lacking. In a previous study, the Rapid HIV Assessment 2 (RHIVA2) cluster randomised controlled trial, we showed that providing training and rapid point-of-care HIV testing at general practice registration (RHIVA2 intervention) in Hackney led to cost-effective, increased and earlier diagnosis of HIV. However, interventions effective in a trial context may be less so when implemented in routine practice. We describe the protocol for an MRC phase IV implementation programme, evaluating the impact of rolling out the RHIVA2 intervention in a post-trial setting. We will use a longitudinal study to examine if the post-trial implementation in Hackney practices is effective and cost-effective, and a cross-sectional study to compare Hackney with two adjacent boroughs providing usual primary care (Newham) and an enhanced service promoting HIV testing in primary care (Tower Hamlets).Methods and analysisService evaluation using interrupted time series and cost-effectiveness analyses. We will include all general practices in three contiguous high HIV prevalence East London boroughs. All adults aged 16 and above registered with the practices will be included. The interventions to be examined are: a post-trial RHIVA2 implementation programme (including practice-based education and training, external quality assurance, incentive payments for rapid HIV testing and incorporation of rapid HIV testing in the sexual health Local Enhanced Service) in Hackney; the general practice sexual health Network Improved Service in Tower Hamlets and usual care in Newham. Coprimary outcomes are rates of HIV testing and new HIV diagnoses.Ethics and disseminationThe chair of the Camden and Islington NHS Research Ethics Committee, London, has endorsed this programme as an evaluation of routine care. Study results will be published in peer-reviewed journals and reported to commissioners.

Speciation in eukaryotes is often accompanied by massive changes in nuclear DNA amount resulting from the accumulation or deletion of DNA base sequences within chromosomes. Our evidence shows that, among related species, the DNA lost or gained during divergence is of a remarkably consistent and restricted composition in respect of the ratio of repetitive to non-repetitive base sequences. It is argued that the restriction may in part at least be imposed by natural selection, in the sense that the only changes tolerable are confined to DNA fractions of particular composition and organisation.

Cet article presente une revue des methodes utilisees pour le clonage de sequences d'ADN dans des vecteurs comme des plasmides, cosmides et le phage lambda, en meme temps que la technique de localisation des sequences clones sur les chromosomes en utilisant l'hybridation in situ. Il donne une description detaillee de l'application de ces techniques a l'etude de la structure, l'organisation et l'identification des chromosomes chez les plantes