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"Macdonell, Anne"
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Paediatric early warning systems for detecting and responding to clinical deterioration in children: a systematic review
ObjectiveTo systematically review the available evidence on paediatric early warning systems (PEWS) for use in acute paediatric healthcare settings for the detection of, and timely response to, clinical deterioration in children.MethodThe electronic databases PubMed, MEDLINE, CINAHL, EMBASE and Cochrane were searched systematically from inception up to August 2016. Eligible studies had to refer to PEWS, inclusive of rapid response systems and teams. Outcomes had to be specific to the identification of and/or response to clinical deterioration in children (including neonates) in paediatric hospital settings (including emergency departments). 2 review authors independently completed the screening and selection process, the quality appraisal of the retrieved evidence and data extraction; with a third reviewer resolving any discrepancies, as required. Results were narratively synthesised.ResultsFrom a total screening of 2742 papers, 90 papers, of varied designs, were identified as eligible for inclusion in the review. Findings revealed that PEWS are extensively used internationally in paediatric inpatient hospital settings. However, robust empirical evidence on which PEWS is most effective was limited. The studies examined did however highlight some evidence of positive directional trends in improving clinical and process-based outcomes for clinically deteriorating children. Favourable outcomes were also identified for enhanced multidisciplinary team work, communication and confidence in recognising, reporting and making decisions about child clinical deterioration.ConclusionsDespite many studies reporting on the complexity and multifaceted nature of PEWS, no evidence was sourced which examined PEWS as a complex healthcare intervention. Future research needs to investigate PEWS as a complex multifaceted sociotechnical system that is embedded in a wider safety culture influenced by many organisational and human factors. PEWS should be embraced as a part of a larger multifaceted safety framework that will develop and grow over time with strong governance and leadership, targeted training, ongoing support and continuous improvement.
Journal Article
South America is becoming warmer, drier, and more flammable
South America is experiencing severe impacts from climate change. Although the warming of the subcontinent closely follows the global path, the rise of temperatures has been more pronounced in some regions, which have also seen a parallel increment in the occurrence of droughts and weather conditions associated with enhanced fire risk. Here, we use reanalysis datasets to analyze the progression of the concurring warm, dry, and high fire risk conditions (i.e., dry compounds) since 1971. We show that the frequency of these compound extremes has surged in key South American regions including the northern Amazon, which have seen a 3-fold increase in the number of days per year with extreme fire weather conditions (including high temperatures, dryness, and low humidity). Our results also suggest that the surface temperature of the tropical Pacific Ocean modulates the interannual variability of dry compounds in South America. While El Niño enhances the fire risk in the northern Amazon, dry extremes in the Gran Chaco region appear to be more responsive to La Niña.Concurring warm and dry conditions with high fire risk in South America have become more frequent since 1971, with a three-fold increase in high-fire-risk days per year in northern Amazonia, according to an assessment of reanalysis data.
Journal Article
Effectiveness of autologous haematopoietic stem cell transplantation versus natalizumab in progressive multiple sclerosis
BackgroundNatalizumab was not shown to modify disability in progressive multiple sclerosis (MS). This matched observational study compared the effectiveness of autologous haematopoietic stem cell transplantation (AHSCT) with natalizumab in progressive MS.MethodsPatients with primary/secondary progressive MS from seven AHSCT MS centres and the MSBase registry, treated with AHSCT or natalizumab, were matched on a propensity score derived from sex, age, Expanded Disability Status Scale (EDSS), number of relapses 12/24 months before baseline, time from MS onset, the most effective prior therapy and country. The pairwise-censored groups were compared on hazards of 6-month confirmed EDSS worsening and improvement, relapses and annualised relapse rates (ARRs), using Andersen-Gill proportional hazards models and conditional negative binomial model.Results39 patients treated with AHSCT (37 with secondary progressive MS, mean age 37 years, EDSS 5.7, 28% with recent disability progression, ARR 0.54 during the preceding year) were matched with 65 patients treated with natalizumab. The study found no evidence for difference in hazards of confirmed EDSS worsening (HR 1.49, 95% CI 0.70 to 3.14) and improvement (HR 1.50, 95% CI 0.22 to 10.29) between AHSCT and natalizumab over up to 4 years. The relapse activity was also similar while treated with AHSCT and natalizumab (ARR: mean±SD 0.08±0.28 vs 0.08±0.25; HR 1.05, 95% CI 0.39 to 2.82). In the AHSCT group, 3 patients experienced febrile neutropenia during mobilisation, 9 patients experienced serum sickness, 6 patients required intensive care unit admission and 36 patients experienced complications after discharge. No treatment-related deaths were reported.ConclusionThis study does not support the use of AHSCT to control disability in progressive MS with advanced disability and low relapse activity.
Journal Article