Estimating insertion length of umbilical arterial and venous catheters in newborn infants: time for change.

BACKGROUND: Umbilical catheters are inserted through the umbilical artery or vein at birth and are crucial in neonatal care. There are several different methods of estimating adequate insertion length of umbilical catheters based on one of two hypotheses; that the insertion length of the UC is correlated to either the infant's birth weight or an external length measurement. AIM: To review the published literature on methods of estimating insertion lengths of umbilical arterial catheters (UACs) and umbilical venous catheters (UVCs) in newborn infants. METHODS: Systematic search on Medline was undertaken using keywords for relevant papers up to March 2019. Papers were selected by manual search of titles and abstracts. RESULTS: Formulae for predicting umbilical catheter insertion length are unreliable, particularly for UVCs. There is also conflicting evidence around whether birth weight-based formulae are more reliable than external length-based formulae. Studies comparing various methods to determine their efficacy to show that current formulae have a low accuracy for determining both UVC and UAC positioning. CONCLUSIONS: Current formulae for estimating insertion length of umbilical catheters are not fit for purpose. We propose a new observational study which uses a new external length measurement, the sternal notch to umbilicus length, to develop a more reliable formula for the insertion of UVC and UAC to an adequate length.

Early Secretory Antigenic Target-6 Drives Matrix Metalloproteinase-10 Gene Expression and Secretion in Tuberculosis.

Tuberculosis (TB) causes disease worldwide, and multidrug resistance is an increasing problem. Matrix metalloproteinases (MMPs), particularly the collagenase MMP-1, cause lung extracellular matrix destruction, which drives disease transmission and morbidity. The role in such tissue damage of the stromelysin MMP-10, a key activator of the collagenase MMP-1, was investigated in direct Mycobacterium tuberculosis (Mtb)-infected macrophages and in conditioned medium from Mtb-infected monocyte-stimulated cells. Mtb infection increased MMP-10 secretion from primary human macrophages 29-fold, whereas Mtb-infected monocytes increased secretion by 4.5-fold from pulmonary epithelial cells and 10.5-fold from fibroblasts. Inhibition of MMP-10 activity decreased collagen breakdown. In two independent cohorts of patients with TB from different continents, MMP-10 was increased in both induced sputum and bronchoalveolar lavage fluid compared with control subjects and patients with other respiratory diseases (both P < 0.05). Mtb drove 3.5-fold greater MMP-10 secretion from human macrophages than the vaccine strain bacillus Calmette-Guerin (P < 0.001), whereas both mycobacteria up-regulated TNF-α secretion equally. Using overlapping, short, linear peptides covering the sequence of early secretory antigenic target-6, a virulence factor secreted by Mtb, but not bacillus Calmette-Guerin, we found that stimulation of human macrophages with a single specific 15-amino acid peptide sequence drove threefold greater MMP-10 secretion than any other peptide (P < 0.001). Mtb-driven MMP-10 secretion was inhibited in a dose-dependent manner by p38 and extracellular signal-related kinase mitogen-activated protein kinase blockade (P < 0.001 and P < 0.01 respectively), but it was not affected by inhibition of NF-κB. In summary, Mtb activates inflammatory and stromal cells to secrete MMP-10, and this is partly driven by the virulence factor early secretory antigenic target-6, implicating it in TB-associated tissue destruction.

A qualitative study of the allergy testing experiences, views and preferences of adult patients.

BACKGROUND: Patients can be tested for IgE sensitivities with in vivo or in vitro testing, but patients' experiences of different allergy test modalities have not been studied. The objective of this study was to investigate adult patients' experiences, views and preferences for allergy testing, exploring skin prick testing and allergen-specific IgE testing. METHODS: A qualitative study of adults attending out-patients for investigation of a suspected allergy. A purposive, convenience sample identified participants and semi-structured interviews were conducted, face to face or by telephone. Interviews were recorded and transcribed verbatim. Thematic content analysis was used to explore patients' experiences. RESULTS: 23 patients were interviewed. The characteristics of skin prick tests particularly valued were the immediacy and visibility of results, which enabled testing and interpretation to be achieved within a single clinic appointment. In vitro testing offered patients simplicity and procedural speed, necessitating only a single puncture site, and was perceived to be a superior test as it was conducted in a laboratory. CONCLUSIONS: The patient preferred method of allergy testing was skin prick testing rather than in vitro allergen specific IgE testing. However, most patients were accepting of either testing modality because their desire to confirm or exclude an allergic trigger overrode any perceived disadvantages of the test method. TRIAL REGISTRATION: Not applicable as study descriptive and qualitative.

Improving the percentage of electronic discharge summaries completed within 24 hours of discharge.

EDSs are an important part of patient care and medical communication. The GWH has a financially motivated target stating that 95% of EDS are to be completed within 24 hours of patient discharge. On review of a six-week pre-intervention period, the medical ward mean weekly EDS completion rate within 24 hours was 74.3%. EDSs form a significant part of junior doctor workload. We found that on a medical ward the mean completion time for one EDS was 18.25 minutes. In January 2014, 387 EDSs were written between four medical wards. This equates to 29.25 hours per week of junior doctor time spent completing EDSs on the four main medical wards. Our aim was to improve the percentage of EDSs completed within 24 hours of discharge from medical wards in the GWH. We proposed and implemented two interventions: 1) Five day EDS summary 2) Protected EDS hour. The five day EDS summary was implemented on wards 1 and 2. The protected EDS hour on ward 3. Ward 1: mean pre-intervention EDS completion rate: 81.1% (six months pre-intervention). This increased by 7.9% to 89% (four week mean EDS completion rate post-intervention) Ward 2: mean pre-intervention EDS completion rate: 75.2%. This increased by 11.6% to 86.8% Ward 3: mean pre-intervention EDS completion rate: 71%. This increased by 4.5% to 75.5% Control ward: mean pre-intervention EDS completion rate: 85.1%. This increased by 5.1% to 90.2% Our results show the five day EDS summary led to a mean 9.75% improvement and the protected EDS hour a mean 4.5% improvement in EDS completion rates. A 5.1% increase was seen on the control ward suggesting confounding factors in this data which are most likely the trust EDS working group, junior doctor experience and EDS project publicity.

Severe antiretroviral therapy-induced toxic epidermal necrolysis in a child.

Toxic epidermal necrolysis (TEN) is a rare and life-threatening condition characterised by extensive epidermal detachment and mucosal erosion. Adverse drug reaction is a strongly correlated causative factor and TEN is currently considered the most severe end of a spectrum of drug-induced mucocutaneous diseases, including Stevens-Johnson syndrome. Attaining an accurate and detailed patient history is critical for identifying potential causative agents, which can prove challenging; particularly in cultures such as that of Malawi. TEN lacks definitive management and the use of immunomodulation, such as with corticosteroids and intravenous immunoglobulin, remains controversial. We report a fascinating case of TEN associated with antiretroviral therapy. A 10-year-old female was given a combination of antiretroviral drugs (lamivudine, nevirapine and stavudine) as postexposure prophylaxis, having been raped. The child subsequently developed TEN and presented to our remote hospital in Malawi, where she was treated entirely with supportive therapy. This is an excellent example of difficult disease management in a limited-resource setting and provides reassuring evidence to clinicians of similar circumstance. To our knowledge, this is the first case report of antiretroviral therapy-induced TEN in a child.