Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: A systematic review

BackgroundThe one way speaking valve was first engineered in 1985 to allow patients with tracheostomies to communicate. The research has indicated alternative physiological benefits of using a speaking valve, however this literature has not yet been evaluated. The purpose of this systematic review was to evaluate the evidence for one-way speaking valve in a range of physiological domains, including vital signs, aspiration, olfaction, ventilation and tracheostomy weaning, length of stay, and quality of life.MethodsA literature search was conducted in September 2017. Studies were eligible if they compared the use of a one-way speaking valve against no speaking valve, across any physiological or clinical parameter.Results16 eligible studies were included in this review. A meta-analysis random-effect model (I² = 71.96, p = 0.006) found reduced instances of aspiration with a speaking valve in situ, compared to without a speaking valve in situ (OR 0.122; 95% confidence interval, 0.031–0.479; p = 0.003). Statically significant results were also found across the domains of olfaction, secretion management and ventilation.ConclusionThere is emerging evidence of additional benefits for using speaking valves. Further studies should focus on clinical outcomes that have the potential to reduce healthcare costs as well as patient outcomes.     

Handover from operating theatre to the intensive care unit: A quality improvement study

BackgroundTransitioning a patient from the operating theatre (OT) to the intensive care unit (ICU) is a dynamic and complex process. Handover of the critically ill postoperative patient can contribute to procedural and communication errors. Standardised protocols are means for structuring and improving handover content. Both have been shown to be effective in reducing information omission and improve communication during this transition period.ObjectivesThe aim of this uncontrolled before and after study was to improve handover processes and communication about the care for critically ill patients transferred from OT to ICU.MethodsThirty-two OT to ICU handovers (16 before and 16 after implementation) were observed. Using a structured tool, we documented who was present, participated in, and initiated handover during ICU admission. Where and when handover was performed, information provided, distractions and interruptions, and handover duration were also recorded. Unstructured field notes and diagrams provided information on staff interaction. Following implementation, semistructured interviews with 27 participants were conducted to understand participants' perceptions of intervention acceptability and to determine factors influencing intervention implementation and spread.FindingsFollowing implementation, a “hands-off” approach was observed with fewer technical tasks completed during handover (43.8% before implementation vs 12.5% after implementation) without an increase in handover time. A single, multidisciplinary handover most often led by the anaesthetist was observed after implementation. Despite these improvements, the use of the physical checklist was not observed in practice, and an situation, background, assessment, recommendation (SBAR) format was not followed. Anaesthetists leading the handover did not view the handover checklist as being beneficial to their practice although some nurses were observed to use the checklist as a prompt for additional information.ConclusionsA single, multidisciplinary handover demonstrated improvement in handover practice despite low uptake of the protocol checklist. Further information is required to inform targeted strategies to improve uptake and sustainability although broader interdisciplinary engagement and commitment may be helpful.     

An Invasive vs a Conservative Approach in Elderly Patients with Non–ST-Segment Elevation Myocardial Infarction: Systematic Review and Meta-Analysis

Background

Elderly (≥ 75 years) patients form a large sub-group of non–ST-segment elevation myocardial infarction (NSTEMI) population but are vastly under-represented in trials. Thus, the benefits of an early angiography in the elderly remain unclear. In this systematic review, we compared outcomes of “invasive” and “conservative” strategies of NSTEMI management in elderly patients.

Increased insulin requirement may contribute to risk of obesity in children and young people with Type 1 Diabetes Mellitus

IntroductionType 1 diabetes mellitus (T1DM) is an autoimmune disorder that interferes with the function of the beta cells in the pancreas. Reports show that the incidence of T1DM is increasing throughout England and Wales, along with the Body Mass Index (BMI) of this patient group. The association between type 2 diabetes mellitus (T2DM) and obesity is recognised, but literature describing the association between T1DM and high BMI is more limited.The aim of this paper is to identify factors affecting BMI and the impact that this increasing trend has on children and young people with T1DM.MethodsInformation was obtained from the medical records of patients with T1DM at the local paediatric centre. BMI standard deviation scores (SDS) were calculated and compared to other factors, which include insulin requirement, HbA1c, pubertal status and age at diagnosis.ResultsThis study involved 102 patients (43 male and 59 female). The mean age at diagnosis was 7.79 years (range from 0.16 to 16.91 years). Our results showed a significant association between insulin requirement and BMI SDS (r = 0.23, p = 0.02) and a significant association between insulin requirement and mean HbA1c (r = 0.59, p=<0.01). A multivariable regression analysis of factors affecting BMI SDS showed that insulin requirement was an independent factor affecting BMI SDS.ConclusionThere were significant associations between increased insulin requirement, high BMI SDS and poorer glycaemic control. Further research is required to fully understand the risk factors that may contribute to obesity in T1DM.