Validation of a conceptual framework aimed to standardize and compare care integration initiatives: the project INTEGRATE framework.

The development of integrated care initiatives to overcome service delivery fragmentation has become a global concern. Yet, the lack of guidance in their design and delivery has led to a high risk of project failure. Several authors have proposed driving ideas and strategies to foster care integration but a comprehensive conceptual framework building on the evidence and different perspectives of scientific contributions is still needed. The objective of this article is to explain the process of development and validation of a comprehensive framework that could be used either to standardize descriptions of existing care integration initiatives or as a conceptual basis for reflecting on the effective design of new programs or projects. In an initial phase, we used a comprehensive list of 175 items resulting from a literature review in order to identify a 'core set' of relevant framework items. subsequent phases, we validated the newly developed framework. External experts supported the validation phases. The iteration process resulted in a framework of 40 items grouped into seven dimensions: Person-centered care, Clinical integration, Professional integration, Organizational integration, Systemic integration, Functional integration, and Normative integration. The validated framework proved to be understandable and relevant to identify analytical aspects fostering care integration. It could be adapted as a useful tool to inform the design and implementation of new integrated care interventions as well as to generate standardized description of initiatives to perform insightful comparisons.

Retrospective analysis of four-year injury data from the Infantry Training Centre, Catterick.

INTRODUCTION: Musculoskeletal injury (MSKI) represents a considerable threat to the effectiveness and productivity of military organisations globally. The impact on the medical chain, occupational disposal with associated loss of working days and associated financial burden have far-reaching consequence. The moral and legal responsibility to reduce avoidable injuries through risk assessment and prevention strategies is fundamental to governance and a key component of best practice. METHODS: A retrospective observational analysis was performed of 4101 MSKIs presenting from a total inflow of 10 498 British Army Infantry recruits recorded over four consecutive training years between 2012 and 2016. Injury incidence, site, type and week of training were recorded and analysed. RESULTS: The total incidence of all MSKI was observed as 39.1%. Overuse injuries were the most common subclassification of injury type (24.5%), followed by trauma (8.8%) and then stress fractures (5.7%). Causes of medical discharge over a four-year cumulative incidence were from overuse injuries (59.3%), stress fractures (21.5%) and trauma (19.2%). 45.5% of all MSKIs presented within the first eight weeks of training. CONCLUSIONS: MSKI data highlighted the requirement for a comprehensive service evaluation of the Combat Infantryman's Course and subsequent justification for the introduction of an injury prevention intervention - Project OMEGA.

Genetic background influences susceptibility to chemotherapy-induced hematotoxicity.

Hematotoxicity is a life-threatening side effect of many chemotherapy regimens. Although clinical factors influence patient responses, genetic factors may also play an important role. We sought to identify genomic loci that influence chemotherapy-induced hematotoxicity by dosing Diversity Outbred mice with one of three chemotherapy drugs; doxorubicin, cyclophosphamide or docetaxel. We observed that each drug had a distinct effect on both the changes in blood cell subpopulations and the underlying genetic architecture of hematotoxicity. For doxorubicin, we mapped the change in cell counts before and after dosing and found that alleles of ATP-binding cassette B1B (Abcb1b) on chromosome 5 influence all cell populations. For cyclophosphamide and docetaxel, we found that each cell population was influenced by distinct loci, none of which overlapped between drugs. These results suggest that susceptibility to chemotherapy-induced hematotoxicity is influenced by different genes for different chemotherapy drugs.

Laboratory evaluation of a novel anaesthesia delivery device.

Here, we describe proof of concept of a novel method for delivering volatile anaesthetics, where the liquid anaesthetic (sevoflurane or isoflurane) is formulated into an emulsion that is contained in a compact, lightweight device through which carrier gas flows. Release of anaesthetic is achieved by stirring of the formulation, allowing controlled and responsive release of anaesthetic at a variety of fixed flow rates between 0.5 l.min-1 and 5 l.min-1 , with ventilated, non-ventilated and draw-over breathing systems. Anaesthetic release was evaluated using target anaesthetic concentrations ranging from 0.5% v/v to 8% v/v to mimic those typically required for induction and maintenance of anaesthesia, and lower concentrations suitable for sedation. Under all conditions, output could be maintained within 0.1% v/v of the intended setting, and the device could deliver a controlled level of anaesthetic for at least 60 min, with compensation for different ambient temperatures (10-30 °C) and carrier gas flow rates. This device offers a simple, inexpensive method of delivering safe concentrations of volatile anaesthetics for a wide range of applications.

Investigation of phthalate release from tracheal tubes.

Phthalates are chemicals used extensively in the manufacture of plastics for their desirable physical characteristics. In addition to enhancing the performance of plastics, phthalates have a number of undesirable effects, principally endocrine disruptor effects, that may have adverse effects on reproductive development and functioning. As a result, they have been banned from the manufacture of children's toys. Despite this, they continue to be used in the manufacture of medical devices, including anaesthetic equipment. This study aimed to assess phthalate release from five brands of tracheal tube. Using gas chromatography-mass spectrometry, we analysed phthalate concentrations from samples of ultra pure water in which tracheal tubes had been submerged. Phthalate concentration increased from 6.7 to 149 µg.l(-1) over a period of 4.8 days. Phthalate release from anaesthetic equipment has not previously been documented over short time periods and raises the possibility of iatrogenic endocrine disruption with routine anaesthesia.

A randomised crossover trial comparing a single-use polyvinyl chloride laryngeal mask airway with a single-use silicone laryngeal mask airway.

We compared insertion rates of single-use polyvinyl chloride laryngeal mask airways (LMAs) vs single-use silicone LMAs in 72 anaesthetised patients. Both airways were produced by Flexicare Medical. Laryngeal mask airway insertion was successful on the first attempt in 68/72 (94%) polyvinyl chloride LMAs vs 64/72 (89%) silicone LMAs (p = 0.39). Overall insertion rates were 72/72 (100%) for the polyvinyl chloride LMAs and 71/72 (99%) for the silicone LMAs (p = 1.0). Mean (SD) insertion times were similar for polyvinyl chloride and silicone LMAs: 24.3 (5.1)s vs 24.8 (7.8)s (p = 0.64). Laryngeal mask airway position, as assessed using a fibrescope, was not different (p = 0.077). The median (IQR [range]) leak pressure was 16 (12-20 [6-30]) cmH(2) O for the polyvinyl LMA and 18 (13-22 [6-30]) cmH(2) O or the silicone LMA (p = 0.037). In conclusion, we did not find any important differences between polyvinyl chloride and silicone laryngeal mask airways.

LX4211, a dual SGLT1/SGLT2 inhibitor, improved glycemic control in patients with type 2 diabetes in a randomized, placebo-controlled trial.

Thirty-six patients with type 2 diabetes mellitus (T2DM) were randomized 1:1:1 to receive a once-daily oral dose of placebo or 150 or 300 mg of the dual SGLT1/SGLT2 inhibitor LX4211 for 28 days. Relative to placebo, LX4211 enhanced urinary glucose excretion by inhibiting SGLT2-mediated renal glucose reabsorption; markedly and significantly improved multiple measures of glycemic control, including fasting plasma glucose, oral glucose tolerance, and HbA(1c); and significantly lowered serum triglycerides. LX4211 also mediated trends for lower weight, lower blood pressure, and higher glucagon-like peptide-1 levels. In a follow-up single-dose study in 12 patients with T2DM, LX4211 (300 mg) significantly increased glucagon-like peptide-1 and peptide YY levels relative to pretreatment values, probably by delaying SGLT1-mediated intestinal glucose absorption. In both studies, LX4211 was well tolerated without evidence of increased gastrointestinal side effects. These data support further study of LX4211-mediated dual SGLT1/SGLT2 inhibition as a novel mechanism of action in the treatment of T2DM.

Comparison of the manoeuvrability and ease of use of the Ambu aScope and Olympus re-usable fibrescope in a manikin.

In this study, we compared the manoeuvrability and ease of use of the single-use Ambu aScope and Olympus re-usable fibrescope in a manikin set to simulate difficult fibrescope placement. A total of 75 anaesthetists took part in this randomised crossover non-inferiority study. We recorded the time to task completion, tip surface collision count and participants' impression of ease of use. For the Ambu aScope and Olympus fibrescope, the mean (SD) first attempt time to task completion was 63 (31) s and 53 (23) s, respectively (95% CI of the difference 3-17 s), p = 0.008. This rejected the null hypothesis of a difference of > 30 s. The mean (SD) number of tip surface collisions was 2.7 (1.9) and 2.5 (1.8), respectively, (95% CI of the difference -0.4 to 0.7) p = 0.56. However, the participants found the Olympus easier to use (p < 0.001). Mean (SD) visual analogue scores for the perceived ease of use (0 mm = extremely difficult and 100 mm = extremely easy) were 65 (18) mm and 77 (14) mm for the Ambu aScope and Olympus scopes, respectively. This study found that the single-use Ambu aScope is as easy to manoeuvre as the Olympus re-usable fibrescope. This single-use device appears to be an acceptable alternative to the re-usable fibrescope.

Fibreoptic intubation through the laryngeal mask airway: effect of operator experience*.

SUMMARY: In a randomised crossover study, we compared times and success rates for tracheal placement of a fibrescope and railroading of a tracheal tube through the classic laryngeal mask airway by anaesthetists with limited experience in fibreoptic intubation (trainees) and those who were experts. Thirty-two patients, 32 trainees and three experts took part. The median (IQR [range]) times to fibrescope placement for trainees and experts were 21 (18-30 [12-58]) s and 17 (14-24 [9-55]) s, respectively (95% CI for the difference 2-8 s; p = 0.023). There were no significant differences between trainees and experts in the times to placement of the laryngeal mask airway (41 (33-47 [31-105]) s and 36 (33-43 [30-52]) s, respectively; p = 0.24), railroading times (43 (40-58 [33-87]) s and 44 (38-57 [31-83]) s, respectively; p = 0.96) and total intubation time (114 (97-127 [80-213]) s and 95 (89-116 [74-139]) s, respectively; p = 0.13). There was no significant difference in the number of attempts needed for successful placement of the fibrescope (p = 0.12) and railroading the tracheal tube (p = 0.22). The differences between experts and trainees when using fibrescope assisted intubation via the classic laryngeal mask airway were not clinically important.

A randomised crossover trial comparing the i-gel supraglottic airway and classic laryngeal mask airway.

In a randomised cross-over study, we compared the performance of the single use i-gel supraglottic airway and reusable classic laryngeal mask airway (cLMA) in 50 healthy anaesthetised patients who were breathing spontaneously. Primary outcome was successful insertion at first attempt. Secondary outcomes included overall insertion success rate, ease of insertion, leak pressure and fibreoptic position. Success rate for insertion at the first attempt was significantly different (54% with i-gel vs 86% with cLMA; p = 0.001). Overall success after two attempts (when the anaesthetist was allowed to change the size of the device) improved to 84% with i-gel vs 92% with cLMA; p = 0.22. In 14 patients, the i-gel when used first needed to be replaced with a larger size. Leak pressure was higher for the i-gel (median [IQR] 20 [14-24] cm H(2)O than the cLMA 17 [12-22] cm H(2)O; p = 0.023). The fibreoptic view through the device was significantly better with the i-gel than the cLMA, which was statistically significant (p = 0.03). We conclude that, with its current sizing recommendations, the i-gel is not an acceptable alternative to cLMA. However because of the significantly improved success rate after a larger sized i-gel was used, we recommend the manufacturer to review the sizing guidelines to improve the success rate.

Bispectral Index asymmetry and COMFORT score in paediatric intensive care patients.

BACKGROUND: The Bispectral Index (BIS) monitor has been suggested as a potential tool to measure depth of sedation in paediatric intensive care unit (PICU) patients. The primary aim of our observational study was to assess the difference in BIS values between the left and right sides of the brain. Secondary aims were to compare BIS and COMFORT score and to assess change in BIS with tracheal suctioning. METHODS: Nineteen ventilated and sedated PICU patients had paediatric BIS sensors applied to either side of their forehead. Each patient underwent physiotherapy involving tracheal suctioning. Their BIS data and corresponding COMFORT score, assessment as by their respective nurses, were recorded before, during, and after physiotherapy. RESULTS: Seven patients underwent more than one physiotherapy session; therefore, 28 sets of data were collected. The mean BIS difference values (and 95% CI) between left BIS and right BIS for pre-, during, and post-physiotherapy periods were 9.2 (5.9-12.5), 15.8 (11.9-19.7), and 7.5 (5.2-9.7), respectively. Correlation between mean BIS, left brain BIS, and right brain BIS to COMFORT score was highly significant (P<0.001 for all three) during the pre- and post-physiotherapy period, but less so during the stimulated physiotherapy period (P=0.044, P=0.014, and P=0.253, respectively). CONCLUSIONS: A discrepancy between left and right brain BIS exists, especially when the patient is stimulated. COMFORT score and BIS correlate well between light and moderate sedation.

Policy brief: How can the settings used to provide care to older people be balanced?

The optimal balance between institutional, home-based and community care for older adults requires an effective mix of organizational, funding and delivery mechanisms for target populations. This spans health and social care, and the coordination of care must respect older people's care preferences and that of their families and friends as well as limits on the available resources to support and fund service provision. Care settings used to provide long-term care for older people and how they are defined vary greatly across Europe. This policy brief addresses the appropriate balance between three main components of long-term care: home care services; institutional care (formal and informal sectors); and care provided by family and friends (informal care). The dramatic upward trend in the cost and use of long-term care, the projected impact of ageing populations and the prevalence of age-related chronic disease and dependency ratios have catalysed proposals to redesign the funding, organization and delivery of affordable, effective and equitable health and social care for older people.

Flexibility and light emission of disposable paediatric Miller 1 laryngoscope blades*.

With the emergence of Creutzfeldt-Jakob disease and the discovery of prions in tonsillar material, there has been an increase in the number of available disposable laryngoscope blades. This has led to non-conformity over many aspects of blade design. Miller 1 disposable blades have been produced in both metal and plastic and appear to have different properties of rigidity. We examined the rigidity of 11 disposable Miller 1 blades in three different axes of force. There was a significant difference in flexibility between metal and plastic blades in both primary and torsional axis (p = 0.006). We also studied the blades' light intensity and angle of light emission, finding up to an eightfold difference in the level of illumination provided at a distance of 10 mm from the tips of the blades. The area of maximal illumination varied, with some blades providing narrow beams of light, and others provided a more dispersed field of illumination. In addition, the angle of maximal illumination varied between the blade types from a central position to one directed to the right-hand side.

Life history evolution in cichlids 1: revisiting the evolution of life histories in relation to parental care.

Empirical links between egg size and duration of parental care in fishes have generated a considerable amount of theory concerning life history evolution. However, to date, this link has not been investigated in relation to other important life-history traits such as clutch size and body size, or while controlling for shared ancestry between species. We provide the first phylogenetically based tests using a database with information on egg size, clutch size, body size and care duration in cichlid fishes (Cichlidae). Multiple regression analyses, based on independent contrasts on both the species and the genus level, showed that clutch size is the variable most closely related to duration of care. This pattern appeared to be driven by post-hatch care relationships. Our results show that, contrary to expectation, there is no positive link between egg size and care duration in Cichlidae. Instead, greater reproductive output through increased clutch size investment appears to have coevolved with greater care of offspring. We suggest that re-evaluation of the generality of current models of the evolution of egg size under parental care in fishes is needed.

Life history evolution in cichlids 2: directional evolution of the trade-off between egg number and egg size.

The negative relationship between offspring number and offspring size provides a classic example of the role of trade-offs in life history theory. However, the evolutionary transitions in egg size and clutch size that have produced this negative relationship are still largely unknown. Since body size may affect both of these traits, it would be helpful to understand how evolutionary changes in body size may have facilitated or constrained shifts in clutch and egg size. By using comparative methods with a database of life histories and a phylogeny of 222 genera of cichlid fishes, we investigated the order of evolutionary transitions in these traits in relation to each other. We found that the ancestral large-bodied cichlids first increased egg size, followed by a decrease in both body size and clutch size resulting in the common current combination of a small-bodied cichlid with a small clutch of large eggs. Furthermore, lineages that deviated from the negative relationship between clutch and egg size underwent different transitions in these traits according to their body size (large bodied genera have moved towards the large clutch/small egg end of the continuum and small bodied genera towards the small clutch/large egg end of the continuum) to reach the negative relationship between clutch size and egg size. Our results show that body size is highly important in shaping the negative relationship between clutch size and egg size.

Effect of breathing low concentrations of volatile anaesthetic agents on incidence of adverse airway events.

The effect of breathing 0.1 minimum alveolar concentrations (MAC) of desflurane or isoflurane for three minutes on the incidence of adverse airway events on a subsequent breath of 2 MAC was investigated. Twenty-five volunteers known to develop an adverse airway event to desflurane or isoflurane took part in the study. Each volunteer was exposed to isoflurane and desflurane at least 24 h apart. Volunteers were assessed for adverse airway events while breathing 2 MAC inhalational anaesthetic following breathing 100% O(2) for 3 min. This was repeated with 0.1 MAC inhalational anaesthetic in oxygen instead of 100% O(2). Adverse airway events decreased from 88% to 40% when tests were conducted with desflurane (p = 0.002). With isoflurane, the reduction from 60% to 52% was not statistically significant (p = 0.774). Breathing low concentrations of desflurane decreases the incidence of adverse airway events on subsequent inhalation of higher concentration of desflurane.