The protected antimicrobial process in a University Teaching Hospital: a qualitative interview study exploring the knowledge, attitudes, and experiences of healthcare professionals.

Background The protected or restricted supply of certain antimicrobials such as linezolid, caspofungin, aztreonam, in the acute hospital setting is an important element of Antimicrobial Stewardship (AMS) programmes to address the growing problem of antimicrobial resistance. This process involves submitting an application for use to be reviewed typically by a Consultant Microbiologist, Infectious Disease Consultant or Antimicrobial Pharmacist. Aim To investigate healthcare professionals' knowledge, experiences, and attitudes towards the protected/restricted antimicrobials process in order to identify possible methods of optimisation and improvement. Method Semi-structured interviews with stakeholders involved in the protected/restricted antimicrobial prescribing, dispensing and administration process were conducted in September-October 2019 in a 350-bed voluntary, general, acute hospital in Ireland. Interviews were analysed by the Framework method and mapped to the Theoretical Domains Framework (TDF). Results Interviews were conducted with 8 Doctors, 4 Pharmacists and 3 Nurses. TDF domains identified included: 'Knowledge'; 'Social/professional role and identity'; 'Social influences'; 'Memory, attention and decision processes'; 'Beliefs about consequences'; 'Environmental contexts and resources'. The relationship between prescribers and the AMS Team was reported as a facilitator of the process, whereas the inconsistency of the filing and versions of forms on the wards were seen as challenges. Conclusion The results of this study have shown that the existing protected/restricted antimicrobial process is a multi-disciplinary effort with barriers that require attention in order to make future improvements. Standardization of the form across all wards, an electronic version of the form, and structured education around AMS were suggested to optimize the process.

Impact on patients of the coronovirus disease 2019 pandemic and postponement of cochlear implant surgery: a qualitative study.

OBJECTIVE: This study aimed to explore the impact of the coronavirus disease 2019 pandemic and postponement of elective surgical procedures for profoundly deaf patients awaiting cochlear implantation. METHOD: Open-ended questionnaires were sent to all adult patients awaiting cochlear implantation surgery. Qualitative analysis was performed using a grounded theory approach. RESULTS: Participants described a primarily negative impact on wellbeing from the surgery delay, expressing feelings of isolation or loneliness. Low mood, depression or hopelessness were commonly expressed by elderly participants; frustration and anxiety were described by young adults. Participants described a negative impact on their general daily life, describing difficulties communicating with facemasks and struggles with reliance on telephone communication because of social distancing. Despite these significant psychosocial challenges, only a minority described adaptive coping strategies. DISCUSSION: Profoundly deaf patients may be at greater psychosocial risk because of unique challenges from their hearing disability. Our findings can be used to develop evidence-driven strategies to improve communication, wellbeing and quality of life.

Exploring factors having an impact on attitudes and motivations towards volunteering in the undergraduate nursing student population - A comparative study of the UK and Ghana.

This study explores attitudes and motivations towards volunteering in nursing students in Ghana compared with nursing students in the United Kingdom (UK). Ghana traditionally follows a western model of nurse education, with students studying programmes commensurate in theory and practice, making Ghana a suitable location for a comparative study. We explored similarities and differences in attitudes and motivation towards volunteering to challenge and inform our common place practice towards nursing pedagogy. Ghanaian students displayed positive attitudes towards volunteering, although these did not translate into increased motivation to volunteer while at university. Students reported financial constraints as reasons for not volunteering as did UK students, although Ghanaian students used available resources for daily living expenses, whereas UK students prioritised available resources to pay down student debt. Structured volunteering was absent from both Ghanaian and UK nursing programmes, despite its potential to increase the variety of social groups or situations to which students are exposed, to increase self-confidence and to encourage greater reflection on practice through doing. Structural challenges within countries may provide a better explanation of variation in student motivation towards volunteering, than cross-cultural variation in attitudes towards volunteering between countries.

Differences in nasal immunoglobulin A responses to influenza vaccine strains after live attenuated influenza vaccine (LAIV) immunization in children.

Different vaccine strains included in the live attenuated influenza vaccine (LAIV) have variable efficacy. The reasons for this are not clear and may include differences in immunogenicity. We report a Phase IV open-label study on the immunogenicity of a single dose of quadrivalent LAIV (Fluenz™ Tetra) in children during the 2015/16 season, to investigate the antibody responses to different strains. Eligible children were enrolled to receive LAIV; nasal samples were collected before and approximately 4 weeks after immunization. There was a significant increase in nasal immunoglobulin (Ig)A to the H3N2, B/Victoria lineage (B/Brisbane) and B/Yamagata lineage (B/Phuket) components, but not to the H1N1 component. The fold change in nasal IgA response was inversely proportional to the baseline nasal IgA titre for H1N1, H3N2 and B/Brisbane. We investigated possible associations that may explain baseline nasal IgA, including age and prior vaccination status, but found different patterns for different antigens, suggesting that the response is multi-factorial. Overall, we observed differences in immune responses to different viral strains included in the vaccine; the reasons for this require further investigation.

Improved speech and language development after unilateral cochlear implantation in children with a potentially useable contralateral ear.

OBJECTIVES: Increasingly, children are considered for a unilateral cochlear implant (CI), even if the contralateral ear falls outside current audiological guidelines, especially if they are not considered to be reaching their educational potential. Here we present the outcomes of CI in children with potentially useable hearing in the contralateral ear. METHODS: A retrospective case note review was performed for a total of 57 patients. Primary outcome was speech and language (SaL) development, as measured by the Manchester Speech and Language Development Scale (MSLDS) and SaL age equivalent. Secondary outcomes were auditory perception, perceived parental benefit and compliance; respectively measured by Categories of Auditory Performance (CAP), Brief Assessment of Parental Perception (BAPP) and reported use. RESULTS: SaL development improved after CI with a mean pre-operative MSLDS score of 5.8 to a postoperative score of 8.0 (n = 57) and a mean SaL age equivalent of 14 months in a one-year period (n = 14). Furthermore, CAP scores improved from 4.9 to 7.0 (n = 57). Analysis of BAPP scores showed improved quality of life in 18/19 patients (94.7%). With regards to compliance, 50/57 (87.7%) are fulltime users of both their CI and their HA. CONCLUSION: The present study indicates that despite one ear having potentially useable hearing outside national audiological criteria, the majority of participants received benefit from a CI in the poorer hearing ear. We suggest that assessment of each ear separately and treatment with the most appropriate amplification device, has given these children a benefit they may not otherwise have acquired if they only had bilateral HA.

The impact of timing of maternal influenza immunization on infant antibody levels at birth.

Pregnant women and infants are at an increased risk of severe disease after influenza infection. Maternal immunization is a potent tool to protect both these at-risk groups. While the primary aim of maternal influenza vaccination is to protect the mother, a secondary benefit is the transfer of protective antibodies to the infant. A recent study using the tetanus, diphtheria and acellular pertussis (Tdap) vaccine indicated that children born to mothers immunized in the second trimester of pregnancy had the highest antibody titres compared to children immunized in the third trimester. The aim of the current study was to investigate how the timing of maternal influenza immunization impacts infant antibody levels at birth. Antibody titres were assessed in maternal and cord blood samples by both immunoglobulin (Ig)G-binding enzyme-linked immunosorbent assay (ELISA) and haemagglutination inhibition assay (HAI). Antibody titres to the H1N1 component were significantly higher in infants born to mothers vaccinated in either the second or third trimesters than infants born to unvaccinated mothers. HAI levels in the infant were significantly lower when maternal immunization was performed less than 4 weeks before birth. These studies confirm that immunization during pregnancy increases the antibody titre in infants. Importantly, antibody levels in cord blood were significantly higher when the mother was vaccinated in either trimesters 2 or 3, although titres were significantly lower if the mother was immunized less than 4 weeks before birth. Based on these data, seasonal influenza vaccination should continue to be given in pregnancy as soon as it becomes available.

Nutrient exports from watersheds with varying septic system densities in the North Carolina Piedmont.

Septic systems (SSs) have been shown to be a significant source of nitrogen and phosphorus to nutrient-sensitive coastal surface and groundwaters. However, few published studies have quantified the effects of SSs on nutrient inputs to water supply watersheds in the Piedmont region of the USA. This region consists of rolling hills at the surface underlain by clayey soils. There are nearly 1 million SSs in this region, which accounts for approximately 50% of all SSs in North Carolina. The goal of this study was to determine if significant differences in nutrient concentrations and exports exist between Piedmont watersheds with different densities of SSs. Water quality was assessed in watersheds with SSs (n = 11) and a sewer and a forested watershed, which were designated as controls. Stream flow and environmental readings were recorded and water samples were collected from the watersheds from January 2015-December 2016. Additional samples were collected from sand filter watersheds in April 2015-March 2016 to compare to septic and control watersheds. Samples were analyzed for total dissolved nitrogen (TDN) and orthophosphate (PO4-P). Results indicated that watersheds served by a high-density (HD) of SSs (4.9 kg-N yr-1 ha-1; 0.2 kg-P yr-1 ha-1) exported more than double the median masses of TDN and PO4-P, respectively, relative to low-density (1.0 kg-N yr-1 ha-1; <0.1 kg-P yr-1 ha-1) and control watersheds (1.4 kg-N yr-1 ha-1; <0.1 kg-P yr-1 ha-1) during baseflow. Isotopic analysis indicated that wastewater was the most likely source of nitrate-N in HD watersheds. In all other watersheds, isotopic results suggested non-wastewater sources as the dominant nitrate-N provider. These findings indicated that SS density was a significant factor in the delivery of septic-derived nutrients to these nutrient-sensitive, water supply watersheds of the North Carolina Piedmont.

Comprehensive molecular screening strategy of OCLN in band-like calcification with simplified gyration and polymicrogyria.

Occludin (OCLN) is an important component of the tight junction complex, providing apical intercellular connections between adjacent cells in endothelial and epithelial tissue. In 2010 O'Driscoll et al reported mutations in OCLN to cause band-like calcification with simplified gyration and polymicrogyria (BLC-PMG). BLC-PMG is a rare autosomal recessive syndrome, characterized by early onset seizures, progressive microcephaly, severe developmental delay and deep cortical gray matter and basal ganglia calcification with symmetrical, predominantly fronto-parietal, polymicrogyria. Here we report 4 additional cases of BLC-PMG with novel OCLN mutations, and provide a summary of the published mutational spectrum. More generally, we describe a comprehensive molecular screening strategy taking into account the technical challenges associated with the genetic architecture of OCLN, which include the presence of a pseudo-gene and copy number variants.

Use of dispersion modelling for Environmental Impact Assessment of biological air pollution from composting: Progress, problems and prospects.

With the increase in composting asa sustainable waste management option, biological air pollution (bioaerosols) from composting facilities have become a cause of increasing concern due to their potential health impacts. Estimating community exposure to bioaerosols is problematic due to limitations in current monitoring methods. Atmospheric dispersion modelling can be used to estimate exposure concentrations, however several issues arise from the lack of appropriate bioaerosol data to use as inputs into models, and the complexity of the emission sources at composting facilities. This paper analyses current progress in using dispersion models for bioaerosols, examines the remaining problems and provides recommendations for future prospects in this area. A key finding is the urgent need for guidance for model users to ensure consistent bioaerosol modelling practices.

Hearing optimisation in neurofibromatosis type 2: A systematic review.

BACKGROUND: It is common for patients with neurofibromatosis type 2 to develop bilateral profound hearing loss hearing loss, and this is one of the main determinants of quality of life in this patient group. OBJECTIVES: The aim of this systematic review was to review the current literature regarding hearing outcomes of treatments for vestibular schwannomas in neurofibromatosis type 2 including conservative and medical management, radiotherapy, hearing preservation surgery and auditory implantation in order to determine the most effective way of preserving or rehabilitating hearing. SEARCH STRATEGY: A MESH search in PubMed using search terms (('Neurofibromatosis 2' [Mesh]) AND 'Neuroma, Acoustic'[Mesh]) AND 'Hearing Loss' [Mesh] was performed. A search using keywords was also performed. Studies with adequate hearing outcome data were included. With the exception of the cochlear implant studies (cohort size was very small), case studies were excluded. EVALUATION METHOD: The GRADE system was used to assess quality of publication. Formal statistical analysis of data was not performed because of very heterogenous data reporting. RESULTS: Conservative management offers the best chance of hearing preservation in stable tumours. The use of bevacizumab probably improves the likelihood of hearing preservation in growing tumours in the short term and is probably more effective than hearing preservation surgery and radiotherapy in preserving hearing. Of the hearing preservation interventions, hearing preservation surgery probably offers better hearing preservation rates than radiotherapy for small tumours but recurrence rates for hearing preservation surgery were high. For patients with profound hearing loss, cochlear implantation provides significantly better auditory outcomes than auditory brainstem implantation. Patients with untreated stable tumours are likely to achieve the best outcomes from cochlear implantation. Those who have had their tumours treated with surgery or radiotherapy do not gain as much benefit from cochlear implantation than those with untreated tumours. CONCLUSIONS: This review summarises the current literature related to hearing preservation/rehabilitation in patients with NF2. Whilst it provides indicative data, the quality of the data was low and should be interpreted with care. It is also important to consider that the management of vestibular schwannomas in NF2 is complex and decision-making is determined by many factors, not just the need to preserve hearing.

Meteorological influences on nitrogen dynamics of a coastal onsite wastewater treatment system.

On-site wastewater treatment systems (OWTS) can contribute nitrogen (N) to coastal waters. In coastal areas with shallow groundwater, OWTS are likely affected by meteorological events. However, the meteorological influences on temporal variability of N exports from OWTS are not well documented. Hydrogeological characterization and seasonal monitoring of wastewater and groundwater quality were conducted at a residence adjacent to the Pamlico River Estuary, North Carolina, during a 2-yr field study (October 2009-2011). Rainfall was elevated during the first study year, relative to the annual mean. In the second year, drought was followed by extreme precipitation from Hurricane Irene. Recent meteorological conditions influenced N speciation and concentrations in groundwater. Groundwater total dissolved nitrogen (TDN) beneath the OWTS drainfield was dominated by nitrate during the drought; during wetter periods, ammonium and organic N were common. Effective precipitation (precipitation [P] minus evapotranspiration [ET]) affected OWTS TDN exports because of its influence on groundwater recharge and discharge. Groundwater nitrate-N concentrations beneath the drainfield were typically higher than 10 mg/L when total biweekly precipitation was less than evapotranspiration (precipitation deficit: P < ET). Overall, groundwater TDN concentrations were elevated above background concentrations at distances >15 m downgradient of the drainfield. Although OWTS nitrate inputs caused elevated groundwater nitrate concentrations between the drainfield and the estuary, the majority of nitrate was attenuated via denitrification between the OWTS and 48 m to the estuary. However, DON originating from the OWTS was mobile and contributed to elevated TDN concentrations along the groundwater flowpath to the estuary.

Towards a consensus on a hearing preservation classification system.

CONCLUSION: The comprehensive Hearing Preservation classification system presented in this paper is suitable for use for all cochlear implant users with measurable pre-operative residual hearing. If adopted as a universal reporting standard, as it was designed to be, it should prove highly beneficial by enabling future studies to quickly and easily compare the results of previous studies and meta-analyze their data. OBJECTIVES: To develop a comprehensive Hearing Preservation classification system suitable for use for all cochlear implant users with measurable pre-operative residual hearing. METHODS: The HEARRING group discussed and reviewed a number of different propositions of a HP classification systems and reviewed critical appraisals to develop a qualitative system in accordance with the prerequisites. RESULTS: The Hearing Preservation Classification System proposed herein fulfills the following necessary criteria: 1) classification is independent from users' initial hearing, 2) it is appropriate for all cochlear implant users with measurable pre-operative residual hearing, 3) it covers the whole range of pure tone average from 0 to 120 dB; 4) it is easy to use and easy to understand.

Onsite wastewater system nitrogen contributions to groundwater in coastal North Carolina.

The objective of the study described in this article was to evaluate the nitrogen contributions from two onsite wastewater systems (sites 1 and 2) to groundwater and adjacent surface waters in coastal Beaufort County, North Carolina. Groundwater levels and water quality parameters including total nitrogen, nitrogen species, temperature, and pH were monitored from October 2009 to May 2010. Nitrogen was also tested in groundwater from deeper irrigation or drinking water wells from the two sites and six additional neighboring residences. Mean total nitrogen concentrations in groundwater beneath onsite wastewater systems 1 and 2 were 34.3 +/- 16.7 mg/L and 12.2 +/- 2.9 mg/L, respectively, and significantly higher than background groundwater concentrations (< 1 mg/L). Groundwater in the deeper wells appeared not to be influenced by the onsite systems. Groundwater nitrogen concentrations typically decreased with distance down-gradient from the systems, but were still elevated relative to background conditions more than 15 m from the systems and near the estuary. This was a pioneering effort to better understand the link of onsite systems, the fate of nitrogen in the environment, and public health.

The management of cochlear nerve deficiency.

The assessment process is critical in deciding whether a profoundly deaf child with cochlear nerve deficiency (CND) will be suitable for a cochlear or auditory brainstem implant (ABI). Magnetic resonance imaging (MRI) using submillimetric T2 weighted gradient echo or turbo spin echo sequences is mandatory for all profoundly deaf children to diagnose CND. Evidence of audition on behavioural or electrophysiological tests following both auditory and electrical stimulation sometimes allows identification of significant auditory tissue not visible on MRI. In particular electric auditory brainstem response (EABR) testing may allow some quantification of auditory tissue and help decide whether a cochlear implant will be beneficial. Age and cognitive development are the most critical factors in determining ABI benefit. Hearing outcomes from both cochlear implants and ABIs are variable and likely to be limited in children with CND. A proportion of children will get no benefit. Usually the implants would be expected to provide recognition of environmental sounds and understanding of simple phonetics. Most children will not develop normal speech and they will often need to learn to communicate with sign language. The ABI involves a major neurosurgical procedure and at present the long term outcomes are unknown. It is therefore essential that parents who are considering this intervention have plenty of time to consider all aspects and the opportunity for in depth discussion.

Overwhelming support among urban Irish COPD patients for lung cancer screening by low-dose CT scan.

PURPOSE: The National Lung Screening Trial (NLST) has renewed interest in low-dose computed tomography (LDCT) screening for lung cancer. Smokers may be less receptive toward LDCT screening, however, compared with never smokers. The views of patients with COPD, a particularly high-risk group, toward LDCT screening for lung cancer are currently unknown. We therefore evaluated attitudes of patients with COPD toward LDCT screening for lung cancer. METHODS: Interviews with Irish patients with COPD who satisfied NLST eligibility criteria were conducted in clinical settings using a questionnaire based on that of a comparable study of U.S. current/former smokers of unspecified disease status. RESULTS: A total of 142 subjects had a mean age of 65.09 ± 6.07 years (46.4 % were male, mean pack years 54.5 ± 33.3, mean FEV1 59.16 ± 23 %); 97.8 % had an identifiable usual source of healthcare. Compared with data from a U.S. cohort of current/former smokers, a higher proportion of Irish COPD smokers: believed that they were at risk for lung cancer (63.6 vs. 15.7 %); believed that early detection improved chances of survival (90 vs. 51.2 ); were willing to consider LDCT screening (97.9 vs. 78.6 %); were willing to pay for a LDCT scan (68.6 vs. 36.2 %); and were willing to accept treatment recommendations arising (95.7 vs. 56.2 %; p < 0.0001 for all comparisons). CONCLUSIONS: Urban Irish smokers with COPD who would be eligible for LDCT screening are almost universally in favor of being screened and treated for screening-detected lung cancers. This readily accessible high-risk population should be actively targeted in future screening programs.

Evaluation of on-site wastewater system Escherichia coli contributions to shallow groundwater in coastal North Carolina.

The study goal was to determine if on-site wastewater systems (OSWWS) installed in coastal areas were effective at reducing indicator bacteria densities before discharge to groundwater. Groundwater Escherichia coli (E. coli) densities and groundwater levels adjacent to 16 OSWWS in three different soil groups (sand, sandy loam, and sandy clay loam) were monitored and compared to background groundwater conditions on four occasions between March 2007 and February 2008 in coastal North Carolina. Groundwater beneath OSWWS had significantly (p≤0.05) lower densities of E. coli than septic tank effluent, but significantly higher densities of E. coli than background conditions for each soil type. Twenty three percent of all groundwater samples near OSWWS had E. coli densities that exceeded the EPA freshwater contact standards (single sample 235 cfu/100 mL) for surface waters. Groundwater E. coli densities near OSWWS were highest during shallow water table periods. The results indicate that increasing the required vertical separation distance from drainfield trenches to seasonal high water table could improve shallow groundwater quality.

Controls on groundwater nitrogen contributions from on-site wastewater systems in coastal North Carolina.

The goal of this study was to evaluate the influence of soil type and separation distance to water table on dissolved inorganic nitrogen concentrations in groundwater adjacent to on-site wastewater systems. Groundwater nitrogen species (NO3--N and NH4+-N) and groundwater levels adjacent to 16 on-site systems in three different soil groups (group I- sand, group II- coarse loams and group III -sandy clay loams) were monitored for 15 months (January 2007-March 2008) in coastal North Carolina. On-site systems in soil group I had the highest concentrations of dissolved inorganic nitrogen (median of 18.9 mg/L) in groundwater, and most frequently (mean 61%) exceeded 10 mg/L, followed by systems in soil group II (11.0 mg/L, 50%) and soil group III (2.6 mg/L, 9%), respectively. Groundwater NH4+-N concentrations near on-site systems in soil groups I and II that maintained a 60+cm separation to the seasonal high water table were 4 mg/L lower in relation to systems that had <60 cm separation, but median NO3--N concentrations were 6.5 mg/L higher. On-site systems in group I and II soils are prone to groundwater nitrogen loading with separation distance often controlling the nitrogen speciation in groundwater near on-site systems.

Still looking for leadership--who is responsible for student nurses' learning in practice?

The study on which this paper reports examined how the widespread changes in the NHS workforce and in higher education which have transformed nurse education in recent decades have impacted on responsibility for the leadership of student nurse learning in clinical practice. Findings from this mixed methods case study carried out at four English higher education institutions between 2006 and 2007 suggest that link lecturers' presence in clinical areas is diminishing, and that practice nurses' involvement with pre-registration students' learning may be limited. Ward managers lead learning at ward level but changes to their role limit their presence on the wards, so that mentors lead student learning on a day to day basis, which they must balance with caring for patients. Changes to the nurse's role mean that modelling bedside care often falls to health care assistants. This deficit of leadership for learning may be understood as a manifestation of the 'uncoupling' of education and practice following the move of nurse education into higher education and subsequent changes to nursing roles. Strengthening leadership for learning is likely to be associated with recoupling practice and education and indicators to assess the quality of leadership for learning in clinical practice are suggested.

Sedation with oral chloral hydrate in children undergoing MRI scanning.

In the absence of a general anaesthetic facility for MRI scanning in children, we introduced a sedation protocol using chloral hydrate. Our aim was to evaluate the success and safety of our protocol. This was a retrospective study enrolling 36 children over a 7 month period. The overall success rate was 86% with no child experiencing respiratory complications. In those less than one year, the success rate was 100%, aged 1-5 years 91%, with 50% successful at 80 mg/kg and 50% at 100 mg/kg dose. For children greater than 5 years of age the success rate was 70%. 92% of developmentally normal children and 83% of developmentally delayed children were successfully sedated. Success rates were poorer in children older than 5 years and in those with developmental delay. Our findings suggest that this protocol could be safely used in units where general anaesthetic facilities are unavailable for MRI and for other radiological investigations.