Looking back to look forward: Surviving COVID-19 and the future of the NHS.

The COVID-19 pandemic affected healthcare systems worldwide, including the National Health Service (NHS). It drastically changed the practice and delivery of healthcare and laid bare longstanding structural flaws. It also brought a time of innovation and digitalisation and renewed appreciation of the role of public health. This paper offers a thematic summary of a debate held in December 2021 by the University of Edinburgh School of Medicine. It featured a multi-specialty panel of doctors and patient representative discussing the likely impact of the pandemic on the future of NHS. It serves as a reflection point on the pressures the NHS has faced since and their likely genesis at a time when the impact of the pandemic on staff risks being forgotten.

Is selective digestive decontamination useful in controlling aerobic gram-negative bacilli producing extended spectrum beta-lactamases?

AIMS: To identify outbreak episodes of either carriage or infection due to extended spectrum beta-lactamases producing aerobic Gram-negative bacilli (AGNB-ESBL); to establish whether AGNB-ESBL, sensitive to tobramycin, become resistant over time; and to evaluate the impact of selective decontamination of the digestive tract (SDD) on abnormal carriage of AGNB-ESBL. DESIGN AND SETTING: All children admitted to the pediatric intensive care unit (PICU) over a 12-month period had biweekly surveillance cultures of throat and rectum and diagnostic cultures when clinically indicated. All AGNB were tested for ESBL, and the positive isolates were sent for molecular typing. The PICU uses SDD (parenteral cefotaxime and enteral polymyxin E/tobramycin) to control abnormal carriage. Patients who had at least one AGNB-ESBL were included in the study. RESULTS: During the study period, 1,101 children were admitted to the PICU. There were 39 patients (3.5%) with a total of 236 cultures positive for AGNB-ESBL. Twenty-eight patients (2.5%) were carriers, and 11 (1%) had proven infections. Organisms isolated from the first culture were 14 patients with Klebsiella pneumoniae, 8 with Enterobacter cloacae, 7 with Citrobacter freundii, 5 with Klebsiella oxytoca, and 5 with Escherichia coli. In the first sample, 59% of isolates showed tobramycin resistance. Molecular typing confirmed that there were five different strains of K. pneumoniae and that similar strains were not isolated in the same period. CONCLUSIONS: SDD is an effective measure to control AGNB-ESBL and to avoid outbreak episodes of either carriage or infection. When tobramycin resistance is found, replacing it with another aminoglycoside based on antibiogram may be more effective in achieving AGNB clearance.

Hidden pathologies associated with (and concealed by) early gestational isolated fetal hydrothorax.

Isolated fetal hydrothorax is an uncommon finding on routine prenatal ultrasound and is associated with a variable prognosis. We believe this is the first report of a patient whose antenatal hydrothorax was associated with both congenital diaphragmatic hernia and congenital pulmonary lymphangiectasia. This rare combination caused significant problems in diagnosis and subsequent treatment.

The potential impact of prophylaxis against bronchiolitis due to the respiratory syncytial virus in children with congenital cardiac malformations.

AIMS: To determine the number of infants in the Mersey and North West regions with congenital cardiac disease for whom palivizumab may be appropriate, and to examine the potential impact of introducing prophylaxis with palivizumab on these patients and their economic management. METHODS: We identified those infants deemed to be at high risk, matching the population recently studied by the Cardiac Synagis Group, from the database of the cardiology department of the hospital. The number of patients under the care of the paediatric cardiologists admitted to Alder Hey Hospital with respiratory syncytial viral bronchiolitis over the last three seasons was identified from hospital coding records, and the database of the cardiology department. RESULTS: There are 131 patients at high risk each year. Of these, over the last three "bronchiolitis seasons", 39 infants have been admitted to the hospital with bronchiolitis due to the respiratory syncytial virus. This represents a hospitalisation rate of 10 per cent, as was seen in the study of the Cardiac Synagis Group. Using a monthly dose of 15 milligrams per kilogram for five doses, the cost per patient is 2,650 pounds sterling for the season. To treat the 131 patients seen at Alder Hey, therefore, would cost 346,800 pounds each year. Applying the reductions in hospitalisation identified in the study by the Cardiac Synagis Group to our population would produce an expected reduction in patients hospitalised from 13 to 7 per year, reducing the total length of stay in our hospital wards from 169 to 76 days, and in the paediatric intensive care unit from 93 to 21 days. This amounts to a potential saving of 190,800 pounds per year. Reducing transfers to more distant paediatric intensive care units for referrals refused because of lack of beds could save an additional 50,000 pounds. DISCUSSION: We estimate the net cost of introducing palivizumab for this population to be 106,000 pounds per year. There would, of course, be additional costs involved in setting up this service, as well as additional savings and benefits. This cost is comparable with other new biologic therapies now routinely used in the United Kingdom, such as etanercept for juvenile arthritis. There are, currently, no other obvious therapies that have the potential to reduce admissions to hospital and intensive care during the winter months, when beds are at their most scarce.

Octreotide for treatment of chylothorax after repair of congenital diaphragmatic hernia.

Chylothorax is a recognized cause of morbidity after repair of congenital diaphragmatic hernia (CDH). Management may include prolonged hospitalization with cessation of enteral feedings, repeated aspiration, chest tube drainage, total parenteral nutrition, and introduction of a medium chain triglyceride (MCT) diet as the effusion resolves. The authors report that the successful deployment of octreotide, a somatostatin analogue, hastened resolution of a postoperative chylothorax in a newborn infant with CDH.

The best-laid incentive plans.

Hiram Phillips couldn't have been in better spirits. The CFO and chief administrative officer of Rainbarrel Products, a diversified consumer-durables manufacturer, Phillips felt he'd single-handedly turned the company's performance around. He'd only been at Rainbarrel a year, but the company's numbers had, according to his measures, already improved by leaps and bounds. Now the day had come for Hiram to share the positive results of his new performance management system with his colleagues. The corporate executive council was meeting, and even CEO Keith Randall was applauding the CFO's work: "Hiram's going to give us some very good news about cost reductions and operating efficiencies, all due to the changes he's designed and implemented this year." Everything looked positively rosy--until some questionable information began to trickle in from other meeting participants. It came to light, for instance, that R&D had developed a breakthrough product that was not being brought to market as quickly as it should have been--thanks to Hiram's inflexible budgeting process. Then, too, an employee survey showed that workers were demoralized. And customers were complaining about Rainbarrel's service. The general message? The new performance metrics and incentives had indeed been affecting overall performance--but not for the better. Should Rainbarrel revisit its approach to performance management? Commentators Stephen Kaufman, a senior lecturer at Harvard Business School; compensation consultant Steven Gross; retired U.S. Navy vice admiral and management consultant Diego Hernandez; and Barry Leskin, a consultant and former chief learning officer for Chevron Texaco, offer their advice in this fictional case study.

Early severe neutropenia and thrombocytopenia identifies the highest risk cases of severe meningococcal disease.

OBJECTIVE: To determine the performance of established predictors of mortality in pediatric acute meningococcal disease (MD) in a contemporary population and to develop a simple predictive score that will not vary with observer. DESIGN: Prospective study for development set and mixed retrospective and prospective study for validation set. Setting and PATIENTS: A total of 227 patients with clinical meningococcal disease who were referred to three multidisciplinary pediatric intensive care units from 1993 to 1999. Early deaths before transfer to pediatric intensive care unit and deaths from cerebral herniation were included in the analysis. MEASUREMENTS AND MAIN RESULTS: The product of platelet and neutrophil counts at presentation (PN product) predicts mortality from meningococcal disease better than either count alone and at least as well as established severity scores. The Glasgow Meningococcal Septicaemia Prognostic Score and Malley scores performed poorly in these populations. The positive predictive value (PPV) for a Glasgow meningococcal septicemia prognostic score of >/=8/15 was 17.5% (16 of 91; 95% CI = 9%-25%), significantly lower than published estimates of 30%-74%, (p <.01). The PPV for death (or amputation) with a Malley score of 3/3 was 50% (12 of 24; 29%-71%), significantly lower than the published value of 100% (p <.001). The PN product appears to be a useful predictor. For a PN product of <40, PPV = 82% (9 of 11), specificity = 99% (195 of 197), and sensitivity = 73% (23 of 30). The performance of this score was greatest in younger children <5 yrs of age in whom clinical cerebral herniation was not seen as a cause of death (0 of 21 deaths at <5 yrs of age; 4 of 9 deaths at >/=5 yrs of age). CONCLUSION: Established scores significantly overestimate the occurrence of adverse outcomes in meningococcal disease. This may reflect improved resuscitation and outcome or variability in the application of these scores. The PN product achieves similar prediction to the scores currently in use and is independent of the observer. Factors that reflect the extent of the inflammatory response rather than the care before presentation are becoming increasingly important.