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Disruptions in Maternal-infant Bonding are shown to be the mediating variable between maternal distress and the subsequent expression of childhood asthma. When the mothers’ bonding is repaired, their children’s asthmatic symptoms diminish or remit. This study evaluated 16 asthmatic children before and after their mothers were treated with Bonding Therapy. Fourteen improved on 11 measures, including reduction in the STEP classification system and medication use. Thirteen children were able to stop all medications. Surprisingly, all mothers scores on the Beck Depression Inventory improved through Bonding Therapy, suggesting that impaired bonding can lead to maternal depression or even Postpartum Depression. The link between bonding disruptions and airway inflammation are discussed. Bonding Therapy is described.

To understand formation structures extending away from the wellbore, azimuthal acoustic waveforms are acquired with longer recording length compared to conventional sonic logging. Advanced acoustic waveform processing algorithms such as 3D slowness time coherence (3D STC) and ray tracing applied to the reflection waveforms allow for quantitatively determining the true dip, azimuth, and position of the reflectors in 3D space, especially for far-field reflectors that can't be detected or located by conventional logging methods. In this paper we discuss two case studies of fracture evaluation. For the first one, experiences indicated that natural fractures bring operation risk for horizontal wells in shale gas play of Middle Yangtze Basin, such as casing deformation or screenout. Therefore, it was of great importance to evaluate natural fractures before completion and fracturing design. The borehole resistivity image log provided fracture assessment at the wellbore but cannot assess far-field fractures. The surface seismic ant track depicted fracture distribution on a large scale, yet with limited resolution. Azimuthal borehole acoustic reflection imaging filled the gap in between by identifying fractures as far as tens of meters from the wellbore. In the cased-hole horizontal well, the natural fracture results from azimuthal borehole acoustic reflection imaging confirmed the mud losses encountered while drilling. The operator used the results to optimize the completion design by placing perforation cluster about 15 m away from the natural fractures, and to change the fracturing design by adjusting slurry rate and fluid volume accordingly. For the second case, azimuthal borehole acoustic waveforms were acquired twice with the first run along an interval of Longmaxi shale gas in the vertical section of a 12.25-in. hole and the second run in a deviated section of an 8.5-in. hole. The result of the first run revealed a layer boundary between shale and carbonate. For the second run, high-dip-angle fractures in carbonate formations were identified with a maximum distance of 32 m from the wellbore. The dip and azimuth agreed with the few conductive fractures identified by the borehole resistivity image, yet the former identified more fractures than the latter. The two case studies clearly illustrate that azimuthal borehole acoustic imaging can quantitatively evaluate far-field fractures away from the wellbore, e.g., the true dip and azimuth, as well as position in 3D space. This helps not only provide a better reservoir characterization, but also allows optimization of the completion and fracturing design.

Few studies have evaluated the use of ceftriaxone (CRO) in the treatment of methicillin-susceptible Staphylococcus aureus (MSSA) infections. The purpose of this study was to compare the safety and efficacy of CRO versus cefazolin (CZO) for patients with MSSA bacteraemia. This was a multicentre, single health-system, retrospective study. Adult inpatients were included if they had a primary episode of MSSA bacteraemia and received CRO or CZO as definitive therapy. The primary endpoint was clinical cure at 28 days or at discharge, whichever came first. Secondary endpoints included treatment failure at 90 days, time to treatment failure, re-admission due to recurrent MSSA bacteraemia, duration of bacteraemia, discontinuation of treatment due to adverse drug events, and Clostridioides difficile infection. A total of 248 patients were included, of which 87 (35.1%) received CRO and 161 (64.9%) received CZO. There was no difference in the primary outcome of clinical cure at 28 days or at discharge between the CRO and CZO groups [75 (86.2%) vs. 145 (90.1%); P = 0.359], even after adjusting for Charlson comorbidity index and Pitt bacteremia score (adjusted OR = 1.35, 95% CI 0.58-3.12; P = 0.49). There were no differences in time to clinical cure, treatment failure at 90 days or safety events between the two groups. In conclusion, our findings suggest no clinical difference between CRO and CZO for the definitive treatment of MSSA bacteraemia. Further prospective studies are needed to confirm these findings.

Optimal management of patients with combined immunodeficiency, especially pertaining to hematopoietic stem cell transplantation (HSCT), remains unclear.To identify factors influencing HSCT and mortality in the population with combined immunodeficiency in North America.We identified 337 participants in the United States Immunodeficiency Network database with diverse forms of combined immunodeficiency and their characteristics, including demographic characteristics, laboratory values, infectious history, comorbidities, and treatment strategies. Univariate analysis was performed using logistic regression, whereas multivariate analysis was performed using multiple Cox proportional hazards.On univariate analysis, disseminated invasive viral infections and variants in STAT3, GATA2, and, DOCK8 were associated with increased odds of HSCT. Mucocutaneous fungal infections and variants in STAT3 were associated with increased odds of survival, whereas disseminated/invasive fungal infections, disseminated/invasive viral infections, and parasitic infections were associated with decreased odds of survival. On multiple variable Cox proportional hazards analysis, variants in ZAP70, nonspecific bacterial, and disseminated/invasive viral infections were associated with increased hazards of transplantation, whereas variants in multiple genes (RMRP, NEMO, DOCK8, CD40L, and CARD9), disseminated/invasive viral infections, autoimmune disease, and higher absolute lymphocyte count were associated with increased hazards of death. Importantly, demographic characteristics, basic lymphocyte subset counts, and absence of genetic diagnosis were not associated with HSCT or mortality.We determined that specific genetic diagnoses and infection burden impacts the decision to undergo HSCT in this cohort. In addition, certain genetic diagnoses and invasive viral infections carry an increased risk of mortality.

ObjectivesPaediatric intubation is a high-risk procedure for ground emergency medical services (GEMS). Physician-staffed helicopter EMS (PS-HEMS) may bring additional skills, drugs and equipment to the scene including advanced airway management beyond the scope of GEMS even in urban areas with short transport times. This study aimed to evaluate prehospital paediatric intubation performed by a PS-HEMS when dispatched to assist GEMS in a large urban area and examine how often PS-HEMS provided airway intervention that was not or could not be provided by GEMS.MethodsWe performed a retrospective observational study from July 2011 to December 2016 of a PS-HEMS in a large urban area (Sydney, Australia), which responds in parallel to GEMS. GEMS intubate without adjuvant neuromuscular blockade, whereas the PS-HEMS use neuromuscular blockade and anaesthetic agents. We examined endotracheal intubation success rate, first-look success rate and complications for the PS-HEMS and contrasted this with the advanced airway interventions provided by GEMS prior to PS-HEMS arrival.ResultsOverall intubation success rate was 62/62 (100%) and first-look success was 59/62 (95%) in the PS-HEMS-treated group, whereas the overall success rate was 2/7 (29%) for the GEMS group. Peri-intubation hypoxia was documented in 5/65 (8%) of the PS-HEMS intubation attempts but no other complications were reported. However, 3/7 (43%) of the attempted intubations by GEMS were oesophageal intubations, two of which were unrecognised.ConclusionsPS-HEMS have high success with low complication rates in paediatric prehospital intubation. Even in urban areas with rapid GEMS response, PS-HEMS activated in parallel can provide safe and timely advanced prehospital airway management for seriously ill and injured children beyond the scope of GEMS practice. Review of GEMS airway management protocols and the PS-HEMS case identification and dispatch system in Sydney is warranted.

Introduction The COVID-19 pandemic has placed considerable demands on global healthcare. Where patients are admitted to hospital, they may require escalating levels of care across different departments. Healthcare staff needed to be able to manage these patients effectively, and simulation-based-training (SBT) can be used to prepare staff and organisations to review their systems for advanced planning.1 2 Methods A multi-professional simulation was implemented to replicate a patient transfer from ambulance, emergency department, ward area, intensive care and theatres. The simulation was led by experienced facilitators in early March 2020 prior to the UK endemic, and included practical elements of patient care including use of personal protective equipment (PPE) and intubation. Scenario participants were staff on shift at the time and included clerical, nursing, medical, anaesthetists and theatre staff, cleaners, porters, infection control and microbiologists. A live actor and SimMan 3G was used throughout the scenario which lasted for approximately six hours including a multi-professional debrief. Workflows were observed throughout and clinical leads asked to reflect on the event. The aim was to review systems and processes to support action plans for advance planning of Covid-19 patient workflow. Results Three key areas for action were identified: Staff capability, communication, and systems and processes. For staff capability, knowledge of latest public health advice, use of PPE and donning and doffing techniques were incorrect. Communication and handover issues were identified across teams and difficulties in staff communication between isolation and non-isolation areas highlighted. Systems and process issues included difficulty in locating lift keys, incorrect sample bottles for blood gases, incorrect transfer of samples, lack of equipment for intubation, decontamination of lift areas and anaesthetic airway equipment. Other system issues included non-availability of security staff to clear transfer areas and design and capacity of emergency department covid-19 areas. Actions and outcomes following this event have included updated guidance and policies, intubation checklists, education and training of staff, departmental and equipment redesign, and cascade of updated information to support both patient and staff safety. Discussion and Conclusion SBT can test response to situations in a safe environment before they occur.1 By simulating a COVID-19 patient journey, SBT can identify performance gaps and latent safety threats to inform practice. This COVID-19 simulation demonstrates the value of SBT to test hospital systems for advance planning of and preparation for emergencies and critical incidents to support both patient and staff safety. References Lloyd M, Watmough S, Bennett, N. Simulation-based training: applications in clinical pharmacy. Clinical Pharmacist 2018;10(9): 3–10. LeBlanc VR, Manser T, Weinger MB, Musson D, Kutzin J, Howard SK. The study of factors affecting human and systems performance in healthcare using simulation. Simul Healthc 2011;6:S24e9.

Background Clinical team composition for prehospital paediatric intubation may affect success and complication rates. We performed a systematic review and meta-analysis to determine the success and complication rates by type of clinical team. Methods We searched MEDLINE, EMBASE, and CINAHL for interventional and observational studies describing prehospital intubation attempts in children with overall success, first-pass success, and complication rates. Eligible studies, data extraction, and assessment of risk of bias were assessed independently by two reviewers. We performed a random-effects meta-analysis of proportions. Results Forty studies (1989 to 2019) described three types of clinical teams: non-physician teams with no relaxants (22 studies, n = 7602), non-physician teams with relaxants (12 studies, n = 2185), and physician teams with relaxants (12 studies, n = 1780). Twenty-two (n = 3747) and 18 (n = 7820) studies were at low and moderate risk of bias, respectively. Non-physician teams without relaxants had lower overall intubation success rate (72%, 95% CI 67–76%) than non-physician teams with relaxants (95%, 95% CI 93–98%) and physician teams (99%, 95% CI 97–100%). Physician teams had higher first-pass success rate (91%, 95% CI 86–95%) than non-physicians with (75%, 95% CI 69–81%) and without (55%, 95% CI 48–63%) relaxants. Overall airway complication rate was lower in physician teams (10%, 95% CI 3–22%) than non-physicians with (30%, 95% CI 23–38%) and without (39%, 95% CI 28–51%) relaxants. Conclusion Physician teams had higher rates of intubation success and lower rates of overall airway complications than other team types. Physician prehospital teams should be utilised wherever practicable for critically ill children requiring prehospital intubation.

Background Few studies have evaluated the use of ceftriaxone (CRO) in the treatment of Methicillin-sensitive Staphylococcus aureus (MSSA) infections. Available studies include a small number of patients with MSSA bacteremia, with conflicting results and several limitations. The purpose of this study was to compare the safety and efficacy of CRO versus cefazolin (CFZ) for patients with MSSA bacteremia. Methods This was a multi-center, single health-system retrospective cohort study. Patients were included if they were at least 18 years old, had a primary episode of MSSA bacteremia within Saint Luke’s Health System and received CRO or CEFZ as definitive therapy for MSSA bacteremia. Patients were excluded if they had a previous MSSA bacteremia within 6 months, a polymicrobial infection, received combination antimicrobial therapy as definitive therapy, started treatment at outside hospital, treated for less than 72 hours, or deemed palliative or comfort care. The primary endpoint was clinical cure at 7, 10, 14, and 28 days, or discharge, whichever came first. Secondary endpoints included time to clinical cure or discharge, treatment failure at 90 days, time to treatment failure, readmission due to recurrent MSSA bacteremia at 30 and 90 days, duration of bacteremia, discontinuation of definitive treatment due to adverse drug events, incidence of Clostridiodes difficile infection, and hospital length of stay. Results A total of 248 patients met inclusion criteria. Among these, 87 (35.1%) received CRO and 161 (64.9%) received CFZ as definitive therapy. Patient baseline and treatment characteristics are shown in Table 1. The primary outcome occurred in 75 (86.2%) patients in the CRO group vs 145 (90.1%) patients in the CFZ group (P= 0.359), even after adjusting for Charlson Comorbidity Index, Pitt bacteremia score and serum creatinine, (aOR=0.74, 95% CI 0.32 – 1.72; p=0.473). There were no differences in time to clinical cure or discharge, treatment failure at 90 days, or safety events between the two groups. Primary and secondary endpoints are included in Table 2. Table 1 Table 2 Conclusion Our study suggests that there is no clinical difference between CRO and CFZ for the treatment of MSSA bacteremia. Further studies are needed to confirm these findings. Disclosures All Authors: No reported disclosures

Background Respiratory tract infections are often viral and but are frequently treated with antibiotics, providing a significant opportunity for antibiotic de-escalation in patients. We sought to determine whether an automated electronic medical record best practice alert (BPA) based on procalcitonin and respiratory polymerase chain reaction (PCR) results could help reduce inappropriate antibiotic use in patients with likely viral respiratory illness. Methods This multisite, pre–post, quasi-experimental study included patients 18 years and older with a procalcitonin level, In patients with a procalcitonin level

Objective This study aimed to determine if integrating antimicrobial stewardship program (ASP) personnel with rapid diagnostic testing resulted in improved outcomes for patients with positive blood cultures. Method Beginning in 2016, Saint Luke’s Health System (SLHS) implemented a new process where all positive blood cultures were communicated to ASP personnel or SLHS pharmacy staff. Pharmacists then became responsible for interpreting results, assessing patient specific information, and subsequently relaying culture and treatment information to providers. This was a multisite, pre-post, quasi-experimental study (Pre: August to December 2014; Post: August to December 2016). Patients 18 years of age and older with a positive blood culture during admission were included (2014, n = 218; 2016, n = 286). Coprimary outcomes of time to optimal and appropriate therapy were determined from time of culture positivity via gram stain. Secondary outcomes focused on clinical, process, and fiscal endpoints. A pre-post intervention physician survey was conducted to assess the impact on antimicrobial decision making and perceived effect on patient outcomes. Results There was no difference in time to appropriate therapy groups (P = .079). Time to optimal therapy was 9.2 hours shorter in 2016 (P = .004). Provider surveys indicated the process improved communication among clinicians and facilitated a shared decision-making process with a perceived improvement in patient care. Conclusions An ASP-led blood culture communication process for patients with positive blood cultures was shown to improve time to optimal therapy, support physicians in their decision making on critical lab data, and improve the care for hospitalized patients., Integration of antimicrobial stewardship personnel plus rapid identification testing was associated with reduced time to optimal therapy, increased collaboration between clinical staff, and improved care for hospitalized patients with positive blood cultures.

Antimicrobial resistance is recognized as a global health crisis.[1][1] In the United States alone, more than 2 million patients contract antibiotic-resistant infections that result in 23,000 deaths annually.[2][2] One factor contributing to antimicrobial resistance is antimicrobial misuse or

The role of pharmacists in the UK has evolved substantially over recent years. Simulation-based training (SBT) is a widely used educational technique that could support the development of the clinical skills and competencies required of pharmacists. However, while SBT is widely adopted in other healthcare areas, evidence supporting its use in pharmacy is limited in the UK. This article discusses how SBT can be applied to clinical pharmacy and describes the educational benefits of developing pharmacists’ technical and non-technical skills. The application of SBT in other industries and healthcare areas is discussed, with consideration of the types of simulation techniques used and design of the simulation sessions. Evidence supporting the use of high-fidelity SBT for pharmacists is reviewed for both individual skill acquisition and development of multiprofessional team performance. Applications of SBT to support both patient safety and development of the skills required for pharmacists are described with consideration of the challenges and barriers to its implementation.

In this article, we argue for the usefulness of relational event network analysis to study online communication networks. Unlike other network analytic techniques that require online communication data to be summarized prior to analysis, relational event network analysis uses un-summarized time-stamped data to track the dynamic evolution of communication networks. To illustrate, we use relational event network analysis to analyze the evolution of a communication network within the virtual world Second Life. Results suggest that there are different patterns of communication among nonfriends and friends within the network. Nonfriends tend to communicate with those they have communicated with in the past, reciprocate communication, and close communication triads. Friends tend not to communicate with those they have communicated with in the past, instead preferring to reciprocate communication and close triads. We discuss implications for the study of online communication and identify directions for future re...

To determine if children with congenital heart disease (CHD) have lower newborn T-cell receptor excision circles (TREC) levels than the general population and to evaluate if low TREC levels in newborns with CHD are associated with clinical complications such as hospitalization for infection.The Connecticut Newborn Screening Program reported TREC levels for newborns with CHD delivered between October 2011 and September 2016 at 2 major Connecticut children's hospitals. TREC levels for children with CHD were compared with the general population. TREC levels and outcome measures, including hospitalization for infection, were compared.We enrolled 575 participants with CHD in the study. The median TREC level for newborns with CHD was lower than the general population (180.1 copies/μL vs 312.5 copies/μL; P .01). patients with CHD requiring hospitalization for infection had lower median TREC levels than their counterparts (143.0 copies/μL vs 186.7 copies/μL; P .01). The combination of prematurity and low TREC level had a strong relationship to hospitalization for infection (area under the receiver operative characteristic curve of 0.89). There was no association between TREC level and CHD severity.Newborns with CHD demonstrated lower TREC levels than the general population. Low TREC levels were associated with hospitalization for infection in preterm children with CHD. Study limitations include that this was a retrospective chart review. These findings may help to identify newborns with CHD at highest risk for infection, allowing for potential opportunities for intervention.

Background Preparing medical students with the skills necessary to deal with emergency situations as junior doctors can be challenging due to the complexities of creating authentic ‘real life’ experiences in artificial environments. The following paper is an evaluation of the UMUST (Unexpected Medical Undergraduate Simulation Training) project; a high-fidelity simulation based training programme designed to emulate the experience of dealing with medical emergencies for final year medical students preparing for practice as Foundation Year trainees. Methods Final year medical students from Liverpool University who undertake their clinical placements at Blackpool Teaching Hospitals NHS Foundation Trust and St. Helens & Knowsley Teaching Hospitals NHS Trust were randomly allocated into groups and took part in a series of four unexpected simulation based scenarios. At the beginning of the week in which the scenarios ran, participants were issued with a hospital bleep which they carried with them during their placement. At an unknown time to them, the participants were bleeped to attend a simulated emergency scenario, and on arrival to the Clinical Skills and Simulation facility, members of the education team undertook a standardised simulation scenario. Each session was recorded on video which the participants subsequently watched as part of a debriefing process. An assessment tool was developed to gauge whether the participants made progress in their learning over the course of the four sessions. Focus groups were held with the participants in order to evaluate their experience of the programme, and questionnaires were later distributed to all participants once they had begun working as a Foundation Year trainee. The questionnaires asked them how relevant UMUST was in preparing them for dealing with medical emergencies. Results The questionnaires and the focus groups clearly showed that the doctors felt like UMUST was very valuable in preparing them to work as junior doctors. They had enjoyed taking part in UMUST and thought was a realistic and useful part of their undergraduate training. Conclusions The feedback from the focus groups and the subsequent questionnaires clearly demonstrate that participants felt the UMUST programme helped to prepare them as junior doctors in terms of dealing with emergency situations.

Neural systems include interactions that occur across many scales. Two divergent methods for characterizing such interactions have drawn on the physical analysis of critical phenomena and the mathematical study of information. Inferring criticality in neural systems has traditionally rested on fitting power laws to the property distributions of ''neural avalanches'' (contiguous bursts of activity), but the fractal nature of avalanche shapes has recently emerged as another signature of criticality. On the other hand, neural complexity, an information theoretic measure, has been used to capture the interplay between the functional localization of brain regions and their integration for higher cognitive functions. Unfortunately, treatments of all three methods - power-law fitting, avalanche shape collapse, and neural complexity – have suffered from shortcomings. Empirical data often contain biases that introduce deviations from true power law in the tail and head of the distribution, but deviations in the tail have often been unconsidered; avalanche shape collapse has required manual parameter tuning; and the estimation of neural complexity has relied on small data sets or statistical assumptions for the sake of computational efficiency. In this paper we present technical advancements in the analysis of criticality and complexity in neural systems. We use maximum-likelihood estimation to automatically fit power laws with left and right cutoffs, present the first automated shape collapse algorithm, and describe new techniques to account for large numbers of neural variables and small data sets in the calculation of neural complexity. In order to facilitate future research in criticality and complexity, we have made the software utilized in this analysis freely available online in the MATLAB NCC (Neural Complexity and Criticality) Toolbox.

Routine childhood infections in patients with congenital heart disease (CHD) are a risk factor for morbidity and death. T-cell Receptor Excision Circles (TRECs) are an established biomarker of T-cell lymphopoiesis and low TREC levels are a marker for Severe Combined Immunodeficiency (SCID). False

The data delivered by a new reservoir mapping while drilling (RMWD) tool provides more geological information than that from any other logging-while-drilling (LWD) technology previously available in the oil field. Its answer product images the surrounding formation structure, and the resulting maps can be used by the geoscientists to improve their understanding of the subsurface, the well placement and the reservoir. To take advantage of the richness of the measurements and deep depth of investigation across multiple formation boundaries, an automatic stochastic inversion has been developed that combines approximately a hundred phase and attenuation measurements at various frequencies and transmitter-to-receiver distances. This efficient Bayesian model-based stochastic inversion runs in parallel with multiple independent search instances that randomly sample hundreds of thousands of formation models using a Markov chain Monte Carlo method. All samples above a quality threshold over the solution space are used to generate the distribution of formation models that intrinsically contain the information for model uncertainties. RMWD is a highly nonlinear problem; inverting for a unique solution is analytically difficult due to the well-known local minima issue. The stochastic method addresses that by sampling thousands of possible formation models and outputting a distribution of layered models that are consistent with the measurements. Statistical distributions are displayed for formation resistivity, anisotropy and dip at each logging point. Additionally, the median formation models for resistivity are shown along the well trajectory as a curtain section plot. This provides an intuitive interpretation for the entire reservoir formation around the tool. The inversion curtain section plot can be overlaid with the seismic formation model for combined interpretation. Furthermore, the curtain plot provides graphical information for dip and distance to boundary, which are critical for field applications such as landing, geosteering, remote fluid contact identification, etc. The stochastic-sampling-based answer product has been intensively field tested and has proven to provide reliable estimation of the formation geometries and fluid distributions in many locations and geological environments worldwide. Field applications and simulated examples of the stochastic inversion include remote detection of the reservoir to enable accurate landing, navigating multilayered reservoirs, remote identification of fluid contacts and reservoir characterization in the presence of faults. The stochastic inversion samples the formation properties randomly and provides the distribution of formation properties based on a large number of samples, instead of providing only the most likely solution as is typical for deterministic inversions. A statistical method of presenting inversion results in formation space provides an instant and intuitive understanding of the formation surrounding the tool. Quantifying the non-uniqueness of the inverted formation models gives geologists a more robust insight into what the formation scenarios may be, and helps with the steering decision-making and reservoir mapping interpretation.

Introduction Chronic microtraumatic digital pulpitis is a painful, fissuring dermatitis of the dominant finger pulps associated with repetitive traumatic injury to the hands. It is regarded as an occupational hazard and has been reported in chefs, postal workers and dental technicians.

Team collaboration in multi-player online games provides opportunities for players to interact with each other. Facilitating teams has become one of the main design principles to increase social activities. However, there is no research evidence that collaborating on tasks in game teams can produce the desired relational outcome. This paper examines more than half a million solo and team activities during a week in Dragon Nest, an MMO game. We measure the degree of team engagement using the percentage of time played in teams and the percentage of play with repeated teammates, and we then identify different types of players using this. The results show that solo players and team players are two distinct populations and they are highly predictable based on players' in-game status. Moreover, we find that spending more time in teams does not always lead to more social interactions. The interviews with players are conducted to validate the findings.

Postoperative management for neurogenic thoracic outlet syndrome (TOS) begins with preoperative preparation of the patient. Obtaining informed consent includes reviewing with the patient the risks and complications of surgery, how soon symptoms will subside, and expectations for return to work and recreation. Postoperatively, a chest x-ray in the recovery room is obtained to detect pneumothorax, to look for apical fluid collection, and to view position of the hemidiaphragm. Medication for nausea, sleep, and pain should include anticipation of constipation from narcotics. Other postoperative considerations include deep vein thrombosis prophylaxis, diet, ambulation, and instructions for postoperative activity and physical therapy.

Summary Objective The aim of the study is to report a case of multi-focal necrotising fasciitis, review research on this subject to identify common aetiological factors and highlight suggestions to improve management. Context Necrotising fasciitis is a severe, life-threatening soft tissue infection that typically arises from a single area, usually secondary to a minor penetrating injury. Multi-focal necrotising fasciitis, where there is more than one non-contiguous area of necrosis, is much less commonly reported. There are no guidelines specific to the management of multi-focal necrotising fasciitis, and its under-reporting may lead to missed management opportunities. Design A systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Data sources A search of MEDLINE, OLD MEDLINE and the Cochrane Collaboration was performed from 1966 to March 2011 using 16 search terms. Data extraction All articles were screened for genuine non-contiguous multi-focal necrotising fasciitis. Of the papers that met this criterion, data on patient demographics, likely inciting injury, presentation time-line, microbial agents, sites affected, objective assessment scores, treatment and outcome were extracted. Data synthesis A total of 31 studies met our inclusion criteria and 33 individual cases of multi-focal necrotising fasciitis were included in the quantitative analysis. About half (52%) of cases were type II necrotising fasciitis; 42% of cases had identifiable inciting injuries; 21% of cases developed multi-focal lesions non-synchronously, of which 86% were type II. Nearly all (94%) of cases had incomplete objective assessment scores. One case identified inflammatory imaging findings prior to clinical necrosis. Conclusions Multifocality in necrotising fasciitis is likely to be associated with type II disease. We postulate that validated objective tools will aid necrotising fasciitis management pathways that will identify high-risk groups for multifocality and advise early pre-emptive imaging. We recommend the adoption of regional multi-focal necrotising fasciitis registers.

The Golisano Children’s Hospital at Upstate Medical University is a 71 bed children’s hospital within a hospital, serving nearly two million people in Central New York. Minor procedures occur daily in all children9s hospitals, yet team coordination when planning for these procedures is often overlooked. LEAPP™ is a mnemonic for: Listen, Evaluate, Anticipate, Plan, and Proceed. The “Look before You LEAPP™” program was developed by a group of nurses, child life specialists, faculty, a chief resident and a fellow. LEAPP™ is a team-based program providing consistent care to all children undergoing inpatient procedures. It improves patient satisfaction and reduces procedural distress. Through LEAPP™ steps, teams are created at point of care — at the bedside or treatment room of inpatient units. Educational goals are linked to the practical goal of cooperation for good health care. The approach uses an online educational module for residents, students and nurses to introduce an innovative protocol and a planning tool.1 Pocket cards, promotional pens, and logo door-clings, purchased through grant funds (The Foundation for Upstate Medical University) were initially used to encourage participation. Pre/post observations of procedural planning and performance of the nurse, caregiver, physician, child-life specialist and independent observer included patient and family preparation, pain and anxiety, staffing and supplies, and satisfaction. Fifty procedures were assessed pre-implementation and 28 post implementation. Although satisfaction with procedures improved between pre and post LEAPP™ implementation, there were overall differences in satisfaction with procedural management and pain/anxiety control by physicians, caregivers, and staff that remained statistically significant. Interdisciplinary bedside teamwork can be used to support interprofessional education and this education can similarly be used to support improved patient outcomes.

Summary Educational policy is not free from the transference of conventional thinking from one set of social circumstances to another, in which it may be no less inappropriate. One of the many assumptions about educational policy at the primary level and especially for the conditions of low income rural communities concerns the desirability of literacy not necessarily in and for itself but as a means to the achievement of high priority economic development goals for the local community concerned. This paper provocatively challenges arguments for the unquestioning necessity of literacy in these circumstances and points out the poverty of research on the subject that would permit definitive policy decisions.