Antibiotic use in intensive care units (ICUs) can promote antimicrobial resistance. Outbreaks of multi-resistant bacteria significantly affect patient outcomes and delivery of care. Antibiotic stewardship programmes (ASPs), combining root-cause analyses and multi-faceted prevention strategies, are necessary, often at significant cost and time. Which elements of such strategies have the largest impact on antibiotic usage following an outbreak is unclear. The aim of this study was to investigate how antibiotic usage in a university hospital ICU changed with a non-protocolised ASP following a disruptive outbreak of multi-resistant Acinetobacter baumannii (MRAB). This was a three time-period observational cohort study. The primary endpoint was the change in overall antibiotic usage (daily defined dose, DDD, antibiotic-days, antibiotic-courses) for consecutive ICU patients staying >48 h, over three 6-month study time periods pre-MRAB (2008, n = 84) and post-MRAB (2010, n = 88; 2012, n = 122). Secondary endpoints were changes in antibiotic usage and patient demographics, in predefined admission categories (Medical Emergency, ME; Surgical Elective, SEL; and Surgical Emergency, SE). The mean age (54.6 ± 17.7, 58.1 ± 17.9, 62.8 ± 19.1 years*) and severity of illness (APACHE 14.8 ± 8.0, 16.7 ± 6.8, 18.3 ± 6.1*) increased, particularly medical admissions. There was a sustained reduction in DDD antibiotic usage [1895.1 (2008), 1224.2 (2010), 1236.6 (2012) per 1000 patient-days] but no overall change in antibiotic-days or antibiotic-courses. Antibiotic usage (antibiotic-days) fell significantly in surgical emergency admissions [20.2 ± 32.1, 4.6 ± 7.4*, 5.9 ± 7.3]. There was a sustained drop in beta-lactam, quinolone, glycopeptide and macrolide usage. Following an MRAB outbreak, and subsequent operational changes including enhanced ASPs (non-protocolised), there was a sustained overall fall in antibiotic usage in spite of an increase in disease severity over 5 years.

Objectives This study aims to identify patient and treatment factors that affect clinical outcomes of community psychological therapy through the development of a predictive model using historic data from 2 services in London. In addition, the study aims to assess the completeness of data collection, explore how treatment outcomes are discriminated using current criteria for classifying recovery, and assess the feasibility and need for undertaking a future larger population analysis. Design Observational, retrospective discriminant analysis. Setting 2 London community mental health services that provide psychological therapies for common mental disorders including anxiety and depression. Participants A total of 7388 patients attended the services between February 2009 and May 2012, of which 4393 (59%) completed therapy, or there was an agreement to end therapy, and were included in the study. Primary and secondary outcome measures Different combinations of the clinical outcome scores for anxiety Generalised Anxiety Disorder-7 and depression Patient Health Questionnaire-9 were used to construct different treatment outcomes. Results The predictive models were able to assign a positive or negative clinical outcome to each patient based on 5 independent pre-treatment variables, with an accuracy of 69.4% and 79.3%, respectively: initial severity of anxiety and depression, ethnicity, deprivation and gender. The number of sessions attended/missed were also important factors identified in recovery. Conclusions Predicting whether patients are likely to have a positive outcome following treatment at entry might allow suitable modification of scheduled treatment, possibly resulting in improvements in outcomes. The model also highlights factors not only associated with poorer outcomes but inextricably linked to prevalence of common mental disorders, emphasising the importance of social determinants not only in poor health but also poor recovery.

Quality improvement collaboratives seek to address the mandate to improve healthcare quality and reduce inappropriate variations in care through the use of defined methods and change concepts. There are indications of positive effects, but less evidence of the effectiveness of the methods—the ‘black box’ of the intervention—and how to effectively implement a collaborative. This study uses an assessment framework to quantify engagement with and uptake of collaborative methodology in 17 projects in a quality improvement collaborative in North West London. The framework developed by the NIHR CLAHRC for Northwest London showed variation in uptake and use of methods within and across projects. For example, most projects involved patients and the public and disseminated learning. There was more limited engagement with the NHS Institute for Innovation and Improvement Sustainability Model. The framework provides detailed methods-related information that collaborative leaders could use for generative learning to meet participants’ needs, and identify peer exemplars. This study raises important questions about implementation fidelity and highlights the need to open the ‘black box’ both while the work is in progress to allow generative learning, and for the purposes of evaluation.

Background Readmission rates for healthy term neonates with severe hyperbilirubinaemia has increased in recent years. In 2011, we implemented a comprehensive risk assessment based integrated care pathway situated in the community to monitor all jaundiced babies. The pathway comprises intensive feeding support; monitoring bilirubin levels at home with transcutaneous bilirubinometers (TcB) and total serum bilirubin (TsB); prompt referral to hospital when thresholds for treatment set at 340µmol/l was reached and a standardised weaning strategy for phototherapy dosage. Aims To evaluate the impact of this pathway on variations in decision to treat, readmission rates for jaundiced babies and length of stay (LoS) before and after implementation. Methods We analysed the case records and compared the outcomes for all healthy term babies who were readmitted to receive phototherapy between 1 June and 30 September 2010 with those of babies admitted during the same period in 2011. We used SPSS software for statistical analysis. Results 2921 term babies were delivered during the two time epochs. 28/1468 (0.02 %) received phototherapy in 2010 compared with 19/1453 (0.013%) in 2011. The mean maximum bilirubin levels in 2010 was significantly lower at 292±64 µmol/l (range: 193–457) compared with 362+26.3 µmol/l (range: 323–433) in 2011. The LoS was significantly reduced at 45.5±26.7hr in 2011 compared with 87.2±53.8 hr in 2010. Conclusions This study showed reduced readmission rate and a statistically significant reduction in the length of stay during readmission in the post intervention group despite a significantly increased maximum bilirubin level. In addition, there was improved consistency amongst professionals on when to refer babies for phototherapy.

Overnight medical cover in hospital is less than during daylight hours. We aimed to quantify the numbers of patients deteriorating overnight and their clinical outcome. Data was collected in real time on use of the Standardised Early Warning Score (SEWS), 'time to doctor', seniority of medical review and clinical outcome. 136 incidents of clinical concern were noted on the general wards with a median response time of 5 minutes for SEWS>4 and 10 minutes if SEWS<4. 159 incidents were recorded in critical care. There was significant inter-speciality variation in median response times and seniority of responding staff, particularly within critical care, which recorded the slowest times across the hospital. This will be reassessed following the establishment of Hospital at Night.

Background: Hospital at Night (H@N) is a Department of Health (England) driven programme being widely implemented across UK. It aims to redefine how medical cover is provided in hospitals during the out-of-hours period. Aim: To investigate whether the implementation of H@N is associated with significant change in system or clinical outcomes. Design: An observational study for 14 consecutive nights before, and 14 consecutive nights after the implementation of H@N. Data were collected from the Combined surgical and medical Assessment Unit (CAU), the 18 medical/surgical wards (The Ward Arc) and the four High Dependency Units (The Critical Care corridor) within the Royal Infirmary of Edinburgh. Methods: Following an overnight episode of clinical concern, data were gathered on response time, seniority of reviewing staff, patient outcome and the use of Standardized Early Warning Score (SEWS). Results: Two hundred and nine episodes of clinical concern were recorded before the implementation of H@N and 216 episodes afterwards. There was no significant change in response time in the CAU, Ward Arc or Critical Care corridor. However, significant inter-speciality differences in response time were eradicated, particularly in the Critical Care corridor. Following the implementation of H@N, patients were reviewed more frequently by senior medical staff in CAU (28% vs. 4%, P < 0.05) and the Critical Care corridor (50% vs. 22%, P < 0.001). Finally there was a reduction in adverse outcome (defined as unplanned transfer to critical care/cardiac arrest) in the Ward Arc and CAU from 17% to 6% of patients reviewed overnight (P < 0.01). SEWS was more frequently and accurately recorded in CAU. Conclusion: This is the first study that we are aware of directly comparing out-of-hours performance before and after the implementation of H@N. Significant improvements in both patient and system outcomes were observed, with no adverse effects noted.

Introduction: Erythrocyte sodium–lithium countertransporter (SLC) has traditionally been characterised as the sodium-stimulated lithium efflux from lithium-loaded erythrocytes. Concurrent activity of the sodium–potassium cotransporter (NKCC) can be expected to lead to imprecise estimates of the activity of the SLC. In the present study, we have characterised this methodological problem and have shown that it can be corrected with the inclusion of bumetanide in the physiological salt solution. Methods: Lithium efflux was studied in lithium-loaded erythrocytes from 35 healthy, normotensive subjects. Erythrocytes were divided into two identical samples (A and B) and lithium efflux characteristics in both samples studied simultaneously by incubating aliquots from each in 10 media of differing external sodium concentrations. Efflux media employed for A and B were the same except for 0.02 mM bumetanide in the media used in B. Results: Increased external sodium was associated with increasing lithium efflux both in the absence and presence of bumetanide; efflux rates were consistently lower in media containing bumetanide (P<.05 in all cases). As external sodium increased, bumetanide-sensitive lithium efflux decreased in a manner that correlated inversely with external sodium concentration (r=−.77, P<.01). A small, nonsignificant increase in SLC activity was observed between measurements made under control conditions (median [range] in mmol Li/l RBC h; 0.272 [0.098–0.491]) and those made in the presence of bumetanide (0.286 [0.135–0.650]; P=.064). Bumetanide did not influence maximal rate of turnover or the affinity constant for external sodium. In contrast, the ratio of these variables was lower when determined in the absence than in the presence of bumetanide (5.5 [1.5–14.6] vs. 6.9 [2.8–24.2], respectively; P<.05). Discussion: This work shows that a component of lithium efflux mediated by the NKCC changes substantially with alterations in external sodium, resulting in a variable contribution of this second transport pathway to apparent SLC activity. To eliminate this variability, bumetanide should be included in all media when studying SLC, and the relationship to external sodium concentration determined.

Conference Abstract| August 01 1998 Erythrocyte Sodium-Lithium Countertransport (SLC) Activity and Retinol Binding Protein (Rbp) Excretion in Healthy Normotensive Subjects TC Hardman; TC Hardman 1Dept of Cardiovascular Medicine, Charing Cross Hospital, London W6 8RF Search for other works by this author on: This Site PubMed Google Scholar SW Dub Rey; SW Dub Rey 1Dept of Cardiovascular Medicine, Charing Cross Hospital, London W6 8RF Search for other works by this author on: This Site PubMed Google Scholar S Soni; S Soni 1Dept of Cardiovascular Medicine, Charing Cross Hospital, London W6 8RF Search for other works by this author on: This Site PubMed Google Scholar S Chalkley S Chalkley 2Dept of Child Health, Imperial College School of Medicine, Charing Cross Hospital, London W6 8RF Search for other works by this author on: This Site PubMed Google Scholar Clin Sci (Lond) (1998) 95 (s39): 5P. https://doi.org/10.1042/cs095005pa Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Citation TC Hardman, SW Dub Rey, S Soni, S Chalkley; Erythrocyte Sodium-Lithium Countertransport (SLC) Activity and Retinol Binding Protein (Rbp) Excretion in Healthy Normotensive Subjects. Clin Sci (Lond) 1 August 1998; 95 (s39): 5P. doi: https://doi.org/10.1042/cs095005pa Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsClinical Science Search Advanced Search This content is only available as a PDF. © 1988 The Biochemical Society and the Medical Research Society1988 Article PDF first page preview Close Modal You do not currently have access to this content.

Conference Abstract| February 01 1998 Effects of Exposure to Lead and Cadmium on Metabolism of Vitamin D3 in Smelter Workers S Chalkley; S Chalkley 1 Department of Child Health, Charing Cross & Westminster Medical School, London Search for other works by this author on: This Site PubMed Google Scholar TC Hardman; TC Hardman 2 Department of Cardio-pulmonary Medicine, Charing Cross & Westminster Medical School, London Search for other works by this author on: This Site PubMed Google Scholar J Richmond; J Richmond 1 Department of Child Health, Charing Cross & Westminster Medical School, London Search for other works by this author on: This Site PubMed Google Scholar D Barltrop D Barltrop 1 Department of Child Health, Charing Cross & Westminster Medical School, London Search for other works by this author on: This Site PubMed Google Scholar Clin Sci (Lond) (1998) 94 (s38): 11P–12P. https://doi.org/10.1042/cs094011Pb Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Citation S Chalkley, TC Hardman, J Richmond, D Barltrop; Effects of Exposure to Lead and Cadmium on Metabolism of Vitamin D3 in Smelter Workers. Clin Sci (Lond) 1 February 1998; 94 (s38): 11P–12P. doi: https://doi.org/10.1042/cs094011Pb Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsClinical Science Search Advanced Search This content is only available as a PDF. © 1998 The Biochemical Society and the Medical Research Society1998 Article PDF first page preview Close Modal You do not currently have access to this content.

Conference Abstract| February 01 1998 Iron Deficiency in a Cohort of School Children Living within the Inner-City London Area S Chalkley; S Chalkley 1 Department of Child Health, Charing Cross & Westminster Medical School, London Search for other works by this author on: This Site PubMed Google Scholar TC Hardman; TC Hardman 2 Department of Cardio-pulmonary Medicine, Charing Cross & Westminster Medical School, London Search for other works by this author on: This Site PubMed Google Scholar D Barltrop D Barltrop 1 Department of Child Health, Charing Cross & Westminster Medical School, London Search for other works by this author on: This Site PubMed Google Scholar Clin Sci (Lond) (1998) 94 (s38): 11P. https://doi.org/10.1042/cs094011P Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Citation S Chalkley, TC Hardman, D Barltrop; Iron Deficiency in a Cohort of School Children Living within the Inner-City London Area. Clin Sci (Lond) 1 February 1998; 94 (s38): 11P. doi: https://doi.org/10.1042/cs094011P Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search Dropdown Menu toolbar search search input Search input auto suggest filter your search All ContentAll JournalsClinical Science Search Advanced Search This content is only available as a PDF. © 1998 The Biochemical Society and the Medical Research Society1998 Article PDF first page preview Close Modal You do not currently have access to this content.

1. Blood lead measurements in samples collected from 660 London schoolchildren during 1991 to 1992 suggest that the blood lead values in children in the U.K. are decreasing. 2. Geometric mean values for blood lead were 0.18 (range 0.05-0.71) micromol/l [3.7 (1. 0-15.0) microgram/dl]. Analysis of variance showed differences between ethnic groups, sex and schools. An age-matched subset of 148 children was compared with 136 children from an earlier study in 1986 and 1987. Trend analysis of the geometric mean lead values showed a negative slope (b=-0.484, P<0.0001), with maximum values of 0.81, 1.00, 0.71 and 0.43 micromol/l (17, 21, 15 and 9 microgram/dl) for the years 1986, 1987, 1991 and 1992 respectively. 3. It is recommended that children in the U.K. being investigated for anaemia, pica, recurrent abdominal pain or a high-risk environment should have blood lead values measured and that the action level for blood lead in children should be decreased from 1.19 micromol/l to 0.48 micromol/l (from 25 microgram/dl to 10 microgram/dl). 4. Guidance is offered to clinicians and other health professionals investigating excessive lead exposure.

The dietary intake of six elements--Al, Ca, Cu, Fe, Pb, and Zn--was measured in 39 normal healthy children aged 17-61 (mean 35.5) weeks. There was a downward trend with age in daily intake of fluid, Pb and Fe, in contrast to an increase in solid intake, Ca and Zn throughout the study. The geometric mean total daily element intake (mg) was: Al 1.12; Ca 446; Cu 0.6; Fe 4.5; Pb 0.020; Zn 2.8. The geometric mean daily element intake (mg) from milks only was as follows: Formula milk (n = 14): Al 0.26; Ca 184; Cu 0.24; Fe 1.85; Pb 0.005; Zn 1.6. Cows' milk (n = 6): Al 0.27; Ca 384; Cu 0.04; Fe 0.21; Pb 0.004; Zn 1.3. Breast milk (n = 12): Al 0.77; Ca 116; Cu 0.15; Fe 0.38; Pb 0.012; Zn 0.4. Additionally, levels of aluminium were investigated in some packaged infant foodstuffs, including four soya milk formulae. The soya-based formulae had a mean concentration of 1.09 +/- 0.37 micrograms/g, which was not significantly different from the mean of 0.83 +/- 0.28 microgram/g for six cows' milk formulae.

Publisher Summary This chapter discusses the microfiltration as a means of separating free antigen from antigen–antibody complexes in immunoassay. In immunoassay techniques, efficient separation of free antigen from the antigen–antibody complexes is essential for reproducible results and maximum sensitivity. Microfiltration, under suitable conditions, gives efficient separation and ease of handling large or small numbers of samples. The technique of microfiltration is more adaptable to mechanization than centrifugation. Microfiltration, using glass fiber filter disks, is an efficient alternative to centrifugation for the separation of free antigen from antigen–antibody complexes. When small numbers of samples are involved in manual methods or for mechanized apparatus, microfiltration has advantages over centrifugation. For immunoassay techniques, cellulose acetate filters offer no advantage over glass fiber filter paper, and the slow flow rate and the handling problems of cellulose acetate, when compared with glass fiber, make it less suitable for use when large numbers of samples are involved. The retention characteristics of GF/B filter paper are adequate for most immunoassay techniques. However, in receptor assays, TM, the particle sizes are close to the minimum retention size of the GF/B filter paper.

A microfilter was designed, together with a mechanical filtration apparatus for the separation of "antibody-bound" and "free" antigen in radioimmunoassay. A comparison of the results obtained using both filtration and centrifugation was carried out and the optimum incubation times, reaction conditions and washing volume for use with the microfilter were studied. The use of microfilters in radioimmunoassay gave reproducible results and offered a convenient means of automating the separation procedure.

22 patients with Graves' disease were followed up for up to a year after antithyroid drug therapy was discontinued. Clinical assessment and serum T3, T4, and thyroid-stimulating-hormone (T.S.H.) estimations were done serially and simultaneously. Serum T3 or T4 concentrations may be elevated briefly in the first few weeks after antithyroid drugs are stopped, as a rebound effect not necessarily indicative of subsequent relapse. Clinical relapse of hyperthyroidism with subsequent improvement on antithyroid drugs occurred in 13 patients. Of these 13, serum T3 concentrations became elevated before serum T4 concentrations in 5, thus predicting the subsequent development of clinical hyperthyroidism. In the remaining 8 patients who relapsed, serum T3 and T4 rose together in 7 and in 1 patient serum T4 was elevated a month before the serum T3. Hyperthyroidism was diagnosed clinically after elevated serum T3 concentrations in 11 patients and at the same time in 2 patients. The mean period of " biochemical hyperthyroidism" in these 11 patients was 12 weeks, with a range of 1 to 56 weeks. During this period 9 of the 11 had minor clinical changes attributable to hyperthyroidism. It is concluded that serial estimations of serum T3 provide the most reliable method of monitoring relapse in hyperthyroidism.

A solid phase second antibody was prepared by covalent coupling of a mouse monoclonal anti rabbit IgG to monodisperse particles. This preparation was compared with immunosorbent purified sheep anti rabbit IgG antibodies coupled to the same particles. The monoclonal antibody bound rabbit IgG with a dissociation constant of 3 X 10(-11) L/mol, and the binding was Fc specific. The sheep antibodies had a similar Kd and about 75% of the activity was directed against the Fc portion of IgG. The binding capacity per mol of both solid phase antibodies was 0.7 mol of rabbit IgG. Monoclonal and polyclonal solid phase antibodies were equally effective as separating agents in various radioimmunoassays. Direct coupling of the rabbit antibodies to the solid phase resulted in a marked loss of binding capacity for the respective thyroid hormones. However, when rabbit anti-thyroxine or anti-triiodothyronine were preadsorbent to second-antibody-coated particles the binding capacities of the former antibodies were well preserved.

Antibodies to human growth hormone (HGH) have been measured by radioimmunoassay on one or more occasions in 98 children with short stature treated with HGH, and in 51 other children. Positive antibody binding reactions occurred in nearly a third of these 149 children, but the great majority of these showed an assay curve significantly non-parallel to the standard, denoting the presence of only non-specific antibodies. However reactions above 0·1% antibody binding capacity in relation to the M.R.C. standard anti-serum are mostly specific to HGH. Specific reaction over 0·1% occurred in 19 sera taken from 10 children, all of whom were under treatment with HGH. Only 4 of these children showed a slowing down of growth associated with the development of antibodies, 2 children permanently and 2 only for a period of three months with spontaneous recovery of growth rate and drop of antibodies. The level of antibodies which appears to cause growth inhibition is between 0·5% and 1% binding capacity of the M.R.C. standard. In all, 4 out of 42 children with isolated growth hormone deficiency have developed `permanent' growth-retarding antibodies on HGH treatment. No children with other diagnoses have done so. Specific antibodies were not present in any of our patients before treatment.