Category: Free Essays

This work was produced by one of our professional writers as a learning aid to help you with your studies

Discuss how MRSA became resistant to antibiotics and became such a prevalent organism associated with British hospitals. Explain how MRSA is treated and touch upon the wider implications for antibiotics and the future of healthcare.

Introduction

It may be argued that micro-organisms are the most successful life form on the planet partly due to their pervasive presence and their utilisation of any available food source, including humans. The ubiquitous presence of micro-organisms and their astronomic numbers give rise to many mutations that account for rapid evolutionary adaptation and in part for emerging antibiotic resistance (Evans and Brachman 1998). Bacteria have evolved numerous structural and metabolic virulence factors that enhance their survival rate in the host. Once such bacteria is Meticillin Resistant Staphylococcus aureus (MRSA).

What is MRSA and why did resistance occur?

The genus Staphylococcus are non-motile, Gram-positive cocci, measuring 0.5-1.5µm in diameter and are commonly found in the nose and on skin. They can occur singly, in pairs, short chains or in grape like clusters. There are several species but Staphylococcus aureus has been a significant pathogen for humans for many years. It is different from other Staphylococci because it produces the enzyme coagulase. Potential virulence factors include surface proteins, which promote colonisation and membrane damaging toxins that can either damage tissue or invoke other disease symptoms. Before the emergence of antibiotics, the mortality rate for Staphylococcus aureus infections was 80% (Fedtke et al 2004). The versatile organism has developed a resistance to Meticillin due to its mobile genetic element the mecA gene, which is found in the Staphylococcal cassette chromosome mec (SCCmec) and this mediates the resistance to ?-lactam antibiotics such as Meticillin (Greenwood 2000).

Of the current antimicrobial resistant organisms, Meticillin-resistant Staphylococcus aureus (MRSA) is probably the most challenging in a hospital setting. MRSA first came to the public’s attention, here in the UK, in the 1980’s when the first epidemic strain, Epidemic Meticillin-resistant Staphylococcus aureus (EMRSA was identified. Subsequently a further sixteen epidemic strains have been recognised. Each strain has its own genetic makeup and display resistance to different antibiotics. EMRSA -15 and EMRSA -16 are the most common strains found in the UK, accounting for 96% of all MRSA bacteraemia. Worryingly, a new strain, EMRSA – 17 was identified in 2000. Not only did it display resistance to the previously recognised antibiotics but also Fusidic acid, Rifampicin, Tetracycline and sometimes Mupirocin.

Evolution and natural selection have produced the mechanism through which micro-organisms can adapt to their ever changing environment, including resistance to natural and man made antibiotics. Bacteria including Staphylococcus aureus are adept at infecting and colonising humans and also aid other microbes to cause infection by producing anti-inflammatory molecules, which allow microbes to evade the body’s immune system (Fedtke et al 2004). They are also able to hide in biofilms and proteins called defensins.Therefore bacteria successful in these evasive strategies are able to pass these strategies down the generations in a process called horizontal gene transfer (Bush 2004). However, this is not a new phenomenon. As far back as 1940, the journal Nature published an article describing the discovery of an enzyme that destroyed Penicillin called Beta-lactamase.

Two mechanisms are used by Staphylococcus aureus to cause infection (Roghmann et al 2005). These are toxin production and tissue invasion. Toxin production is exemplified in gastroenteritis resulting from consuming Staphylococcal enterotoxins in food and tissue invasion is demonstrated in the classical abscess comprised of pus contained in a fibrin wall and surrounded by inflamed tissues.

Why a hospital problem?

Staphylococci are the classic hospital acquired bacteria and Staphylococcus aureus is the commonest cause of surgical site infection. For years, glycopeptides, such as Vancomycin have been the first choice for serious Staphylococcus aureus infections. Now clinicians are facing strains with reduced susceptibility to glycopeptides, with no decline in virulence (Dancer 2003).

Within the hospital environment there are recognised high risk areas/departments where patients are at greater risk of infection. Two such areas are intensive care units and burns units. Examples of factors associated with higher risk MRSA acquisition are previous antibiotic therapy and frequent admissions. The more often a patient is admitted to hospital the greater the chance of exposure to MRSA and being prescribed antibiotics. Patients and their pre-disposing factors,,for example, being immunocompromised,and having wounds make them more susceptible to acquiring MRSA, In addition the healthcare workers and the environment are also potential reservoirs of MRSA. The environment as a reservoir has been more difficult to assess (Dancer 2004), although work done by Rayner 2003 confirmed that MRSA has been isolated on patient equipment.

The term risk factors, which are often used in relation to MRSA, apply to the strength of association between the organism and the odds of going onto develop an infection.

The factors responsible for increasing resistance are complex and varied as are the potential strategies for overcoming the problem. Inappropriate prescribing and overuse of antimicrobials by clinicians may be driven by lack of understanding of the problem and inadequate surveillance for resistance.

Poor prescribing and increasing resistance however not the only issue in the management of Staphylococcus aureus. This is where medical microbiologists are pivotal in the appropriate use of antimicrobials. They can provide clinicians with laboratory reports that contain a restricted number of antimicrobial sensitivities, as well as advising on the correct method and appropriate specimen to obtain. This saves time and resources. Therefore the patient should receive the appropriate antimicrobial treatment at an earlier stage.

However, it needs to be acknowledged that prescribers prefer and adhere more closely to policies that take an educational rather than a restrictive approach. Some view policies as rigorous and fixed and relate better to guidelines, that are seen as more flexible and acknowledge that some patients will fall outside of the recommendations (Binyon 2000). There are also legal aspects to consider, as it is more difficult to justify action taken outside a policy than a guideline.

Ideally a guideline will limit antimicrobial prescribing to situations where there is a clear indication for their use and that they should be administered for the shortest effective duration. The drug of choice should be appropriate, narrowest in spectrum and correct in dose and duration (SIGN 2000). Prophylactic antimicrobials should be only given for the recommended period. Emmerson (2000) argued that perhaps a guideline’s most important function is that of a vehicle for ensuring regular discussion amongst those concerned.

A study by Harrison (1998) found that approximately 20% of all prescribed antimicrobials relate to hospitalised patients. Of this 20%, 20-50% was unnecessary. His study also revealed that 25-50% of all hospital admissions receive an antimicrobial at some point during their stay. The study also made the point that even if numerous bacteria are killed during a single course of antimicrobials, if one mutant microbe remains in that patient; the possibility exists for the rapid establishment of a resistant population.

Current problems within the National Health Service exacerbate the issue. These problems include ‘hot’ bedding, overcrowding of wards, understaffing, inadequate cleaning, poor laundry services, patient relocation and poor isolation facilities. Dancer and Gemmill (2003) argue that erosion of hygiene standards emanated from the ready provision of antimicrobials.

Numerous guidelines have been written in order to attempt to control these problems. However sometimes what is good in theory is not so good in practice and there may be various explanations for this failure. Regardless of how sound the principles are, there may be insufficient resources to implement them. A prime example here is lack of isolation facilities in hospitals (Cooper 1999). There is a wide variance in which resistance is handled in different hospitals. Some hospitals isolate and treat the patient regardless as to whether or not the patient is colonised or infected. Therefore risk assessment in conjunction with the infection control team on a case-to-case basis is vital when resources are scarce.

Presently Vancomycin and Teicoplanin are used to treat MRSA infections. The majority of patients are colonised and are asymptomatic. They carry MRSA on skin or in the naso-pharynx. Patients who are found to be colonised in hospital settings are actively treated or decolonised. This is done by prescribing five days of a body wash used either in the bath or shower. The wash is also used to cleanse the hair. The wash includes chlorhexidine gluconate and is effective but known to dry out the skin with prolonged use. In conjunction with the body wash the patient is also prescribed a nasal cream which is applied 3 times a day for 5 days to both nares. The cream usually used is Bactroban which contains Mupirocin. For MRSA cases displaying intermediate or total resistance to Mupirocin, the cream of choice is Naseptin (BNF 2015).

Discussion

Antibiotic resistance may lead to routine infections being fatal. Antibiotics are losing their effectiveness at a rate that is both alarming and irreversible. The media talks of a post antibiotic era or antibiotic Armageddon.

So what of the future? Researchers are developing a vaccine. In order to achieve herd immunity, 85% of the population would require to be vaccinated and the vaccine would also have to provide protection against all the strains to which someone is likely to be exposed. However, limited vaccination of at risk groups may be possible (Farr 2004). Work is also ongoing in regard to lysostaphin, which is an enzyme that causes the cell wall in Staphylococcus aureus to rupture. It was first described 40 years ago. As it is specific to Staphylococcus aureus, it would not interfere with normal commensal flora. It could be used to reduce nasal carriage and subsequently reduce infection rates. Early clinical trials have been positive.

Assuming all the issues above were overcome, resistance still would not disappear. Thus there remains a need to continue with research into how and why bacterial mutations occur and into the development of new innovative drugs, vaccines and diagnostics. More resources need to be channelled into education of health care professionals, allied with effective infection control measures.

Every healthcare worker has a duty of care to comply with infection control policies. As long as infection control procedures are adhered to, hygiene improves and antibiotics are used prudently, there is the prospect of bringing MRSA under control in the hospital setting. However, we have to be aware that emphasising the importance of MRSA colonisation via policies and guidelines may result in accidental neglect of the factors that cause infection.

As MRSA will continue to spread in the wider community, via both humans and animals, some of the strains spread may be highly toxic and with an ageing population and increasing numbers of immuno-compromised patients, the danger will only increase. As more advances are made in medicine, these vulnerable populations will also increase. Those at most risk are those in long-term care homes, of which there is an ever-increasing number. While cross infection routes are relatively easily defined in a hospital setting, the situation in the community is not and because care homes are major feeders when it comes to hospital admissions, the impact on the crisis stricken NHS will continue.

Therefore MRSA screening was welcomed when introduced in 2013 across the UK following a nationwide study of the efficacy of screening patients on admission to hospital (HPS 2009). The aim of screening patients for MRSA is to identify patients that are colonised or infected with the organism. These patients can then be managed appropriately to reduce the risk of self-infection and of transmitting the organism to other patients.

As for MRSA rates being indicators of quality healthcare, they should be considered as tools that prompt further inquiry, rather than permitting judgements on quality of care.

Conclusion

MRSA has the capability to cause misery, morbidity and even fatalities under certain circumstances. The body is an incredibly complex machine; scientists are making striking advances in elucidating the precise molecular basis for the interaction between adherence surface structures of an organism and corresponding specific surface receptors on a host cell. Much more has still to be learned and microbiology will continue to play a huge part in research in order to understand the mechanisms of pathogenicity and the development of antibiotic resistance. This is essential for future treatment and prevention of infections allowing humans and micro-organisms to continue to co-exist.

Prevention and control of healthcare acquired infection demands the continual development of intervention strategies aimed at curtailing further antimicrobial resistance and reducing the spread of existing infection. Success however will only be achieved with a multi disciplinary approach at individual and organisational level. Infection prevention has to become an integral part of everyday healthcare practice (Fairclough 2006).

Bibliography

Binyon D. (2000) Restrictive antibiotic policies – how effective are they? Hospital Pharmacist, Vol. 7(7), pp183-187.

British National Formulary (BNF) 69 (March 2015) Joint Formulary Committee. BMJ Publishing Group Ltd. And Royal Pharmaceutical Society.

Bush K. (2004) Antibacterial drug discovery in the 21st century. Clinical Microbiology and Infection, Vol. 10 (Supplement 4), pp 10-17.

Cooper B. S., Medley G. F. and Scott G. M. (1999) Preliminary analysis of the transmission dynamics of nosocomial infections: stochastic and management effects. Journal of Hospital Infection, Vol.43, pp131-147.

Dancer S. J. (2003) Glycopeptide resistance in Staphylococcus aureus. Journal of Antimicrobial Chemotherapy.

Dancer S. J. (2004) How do we assess hospital cleaning? A proposal for microbiological standards for surface hygiene in hospitals. Journal of Hospital Infection, Vol. 56, pp 10-15.

Dancer S. J. and Gemmell C. G. (2003) Control of MRSA – Can Scotland Win? In SCIEH Weekly Report 2003; 37(01).

Emmerson A. M. (2000) Control of the spread of resistance. Chp. 14 in Greenwood D. (ed)(2000) Antimicrobial Chemotherapy, 4th edition, Oxford University Press.

Evans A. and Brachman P. (1998) Bacterial Infections of Humans: Epidemiology and Control. Rd Edition, Plenum Medical Book Company, New York.

Fairclough S. J. (2006) Why tackling MRSA needs a comprehensive approach. British Journal of Nursing, Vol. 15(2), pp 72-75

Farr B. M. (2004) Prevention and control of methicillin-resistant Staphylococcus aureus infections. Current Opinion in Infectious Diseases, Vol. 17, pp 317-322.

Fedtke I.,Gotz F., and Peschel A. (2004) Bacterial evasion of innate host defences – the Staphylococcus aureus lesson. International Journal of Medical Microbiology, Vol. 294, pp 189-194.

Greenwood D. (2000) Antimicrobial Chemotherapy, 4th edition, Oxford University Press.

Harrison P. f. and Lederburg J. (eds) (1998) Antimicrobial resistance: issues and options. Washington DC: National Academy Press.

Health Protection Scotland on behalf of Pathfinder Health Boards (Dec. 2009)

Final Report Volume 1: An investigation of the clinical effectiveness of MRSA screening. Glasgow: Health Protection Scotland.

Rayner D (2003) MRSA: an infection control overview. Nursing Standard, Vol. 17(45), pp 47-53.

Roghmann M., Taylor K.L., Gupte A., Zhan M., Johnson J. A., Cross A., Edelman R. and Fattom A.I. (2005) Epidemiology of capsular and surface polysaccharide in Staphylococcus aureus infections complicated by bacteraemia. Journal of Hospital Infection, Vol. 59, pp 27-32.

Scottish Intercollegiate Guidelines Network (2000) Antibiotic Prophylaxis in Surgery. SIGN Publication No. 45, July. www.sign.ac.uk

This work was produced by one of our professional writers as a learning aid to help you with your studies

Choose one gender group and critically discuss how their health outcomes can be improved in regards to ageing.

The World Health Organisation’s definition of ‘Health’ emphasizes that the overall health of an individual is determined by not only their physical well-being but also their mental and social well-being. Therefore, NICE has framed its public health outcomes broadly to allow a range of health factors to be addressed. The paper will discuss how the health outcomes of the female gender can be improved in regards to ageing. Hence, due to the limited word count of this discussion, the health initiatives addressed will be physical activity and mental well-being with reference to Menopause, Osteoporosis, Depression and Breast Cancer.

Menopause has not just been chosen because it impacts only women but because in 2007 females expressed the need for more information on menopause and its impacts on their health (BMS, 2015). This has driven the creation of new clinical guidelines to be published in approximately four months time for application in all NHS Healthcare settings (BMS, 2015). The formation of these guidelines in response to the surveyed women may act as a possible improvement in the delivery of the healthcare treatments and advice given by practitioners because a greater focus is hoped to be put on menopause than demonstrated in previous years; this could then improve the quality of health education given to the patient, hence allowing them to understand their condition better. A better personal understanding of a condition can allow a patient to be more active in the decision making processes in partnership with the practitioner (D’Ambrosia, 1999). This could then improve the relationship between the patient and the practitioner; Empowerment via knowledge can also positively impact the confidence of the patient because they may be able to apply principles of self-help in some situations where menopause was affecting them because they would have the knowledge to make changes in their lifestyle choices and routines. For example, exercising regularly is promoted in the menopause period to avoid gaining extra weight or to maintain muscle mass and bone strength (NHS, 2014).

Health Psychologists often unravel menopause as a bio-psychosocial event in which social, cultural and biological factors can impact a woman psychologically. Therefore, weight gain may affect their self-esteem, self-confidence and self-image (Ogden, 2012). Hence, health education is not only a method of improvement for health outcomes related to specific conditions and the associated treatments but it also encourages the individual to self develop.

Interestingly, self-image / self – representation is discussed within all media forms in regards to both men and women, however more so for women. Also, ageing and self-image are often not directly addressed within academic texts that analyse the impacts of ageing, yet the physical symptoms of menopause can psychologically impact a woman as mentioned previously in this discussion. Furthermore, despite surveys and questionnaires forming knowledge in regards to the functional aspects of an elderly woman’s life, we know very little about their own perceptions on being someone who is considered as older by society (Queniart and Charpentier, 2011). The definition of Health by WHO is inclusive of social wellbeing, but we still have very limited specific research on elderly women and self-representations. Therefore, there is a need for both qualitative and quantitative research to be conducted on elderly women to be able to support these women to see ageing as a positive process and not a negative process, as this is still a widely accepted connotation amongst society in general and among women.

Within the NHS outcomes framework, mental illness is addressed to acknowledge the growing recognition of mental disorders both diagnosed and undiagnosed and to improve the quality of care for those suffering from mental health conditions. Mental health conditions are good case studies to analyse to explore the barriers which may prevent individuals from reaching their health outcomes. Generally, statistics show that more women access mental health services in comparison to men, however females from BME communities access mental health services less than females from non BME communities. It is often shown in reports that the relationship between BME individuals and healthcare services differs from the relationship of the native community with the healthcare service (Department of Health, 2011). Furthermore, South East Asian women may be dealt with after a delayed period of time and possibly even with inappropriate mental health services (Department of Health, 2011). This has been shown in some cases even where the female has suffered from severe mental health issues. In this case, the lack of accessibility and engagement will prevent these women achieving better health. Elderly men and women are also victims of mental disorders, with statistics suggesting approximately 15% of adults who are 60 years and older being affected (IHME, 2012). Therefore, barriers to health services will also delay treatments for these individuals. There are a variety of reasons why these barriers exist including; language barriers, cultural reasons, practitioners who do not understand the latter, the location of services and the individual’s own perceptions of the mental health condition. Furthermore, it is extremely difficult for a health service to be specialist and practical for all populations, therefore social inequalities exist as barriers to improving the wider health outcomes for services and governing bodies as well as the personal health outcomes of elderly patients.

Elderly individuals face biological, social and mental changes as part of the ageing process and they have to learn to cope and accept these changes. Many elderly individuals also lack the company of family or friends due to their circumstances. These changes could impact an individual’s everyday activities, which then could negatively impact their mental well-being causing them to suffer from depression because they have become socially excluded. Hence, it is important that elderly individuals know how to access specialist services which may not be necessarily healthcare based but who have personal wellbeing as central to their work.

An example of such services are campaigns which aim to tackle elderly depression by focusing on preventing social isolation amongst this age range though the promotion of social activities within community based environments. It is extremely important to recognise that the older age groups in society desire to have or feel similar positive health and well-being states as the younger age groups. However, the method of achieving these positive health and well-being states will in most cases differ between the age groups and also at what level individuals within these groups will be content with their health outcomes may differ too. For example, the Calderdale Clinical Commissioning Group in West Yorkshire has recently invested approximately one million pounds to improve the health and wellbeing of individuals via inclusion within groups, activities and accessibility to services through ‘The Staying Well Project’ (The Halifax Courier, 2015; James, 2014). Achievement of better physical health is viewed highly in this project so physical activity sessions will be delivered for elderly individuals, however the sessions are most likely not going to be at the pace of what would be delivered for younger individuals, traditional activities may be replaced by walking football, tai chi or salsa (James, 2014; NHS, 2013). Improved fitness is a desired health outcome which can support the improvement or treatment of a variety of conditions both acute and chronic, including the prevention of weight gain due to stress in menopause (The Mayo Clinic, 2013).

Also, recommended guidelines for exercise to prevent the onset of musculoskeletal conditions differ depending on the individual’s age and their present health and well-being. Osteoporosis is more prevalent in elderly women due to hormonal changes in the stages of menopause (NOS, 2010); however this may also be due to a lack of exercise or adopting a sedentary lifestyle in early life (WHO, 2003). Osteoporosis negatively impacts bone density either by reducing bone density or preventing bone from developing hence the individual becomes more at risk of acquiring bone fractures. However, physical activity and healthy eating would still be needed for maintaining overall health and as an attempt to maintain bone density, yet an individual may potentially injure themselves by breaking a bone, which then could directly impact their overall health and wellbeing. Doctors and physiotherapists (and relevant knowledgeable individuals) are advised by NICE to promote sufferers of osteoporosis to exercise safely and gently to avoid injury however most reports highlight patients’ lack knowledge of what is considered safe in accordance to their condition (NICE, 2013; Moore, 2011). Therefore, if more specific knowledge of appropriate exercise was given to the patient in relation to their condition, patients could ensure they are exercising safely; these patients could then become independent exercisers who would be more likely to sustain exercise in their daily habits for a longer period of time are able to feel fuller benefits of exercise.

In addition to this, there is a lack of research into social inequalities due to musculoskeletal conditions associated with ageing. However, a recent paper suggests that some sufferers of musculoskeletal disease are becoming victims of material deprivation because their physical ability is preventing them from using or owning social possessions. For example, the young-old Hertfordshire Cohort Study had 3,225 participants who could not possess a home due to lower grip strength and frailty, of which 23.1% were women (p.54, Sydall, 2011). The health outcomes of these individuals may not be solely related to physical health outcomes in relation to improving their muscular strength but they could also desire better mental and social health outcomes because these women are facing challenging life experiences. These outcomes can be achieved or supported by secure methods such as receiving social care support within their own home, fitting assistive healthcare/Telecare technology, by accessing supported living schemes or by sharing their accommodation. This will allow them to feel at least partially in possession of important materialistic things such as a home. Addressing these wider non physical health implications is important to prevent further health and social care concerns because these elderly women may have lost their residence due to the inability to function within their home due to their condition, and this feeling could lead to a lack of control and autonomy within their life, which could then lead to depression, hence co morbidities. To promote positive thinking and motivation in ageing, alternate therapeutic activities such as life coaching and talking therapies may be more engaging and with little or no side effects in comparison to drug based medication, to tackle what is usually diagnosed as clinical depression or anxiety (NHS, 2014).

Cohort studies suggest that physical activity has a protective role in an individual’s life either to prevent the development of conditions or the deterioration/maintenance of health and wellbeing. A study in the Netherlands has suggested physical activity can protect premenopausal women from breast cancer; this study looked at the recreational activities of women throughout their life (Verloop et al, 2000). This major study suggested that present, past and future studies would struggle in measuring all kinds of physical activity done by women due to the extreme difficulty in classifying all movements and the impact of these movements. This study suggested that the relationship between the initiation of physical activity and the risk of breast cancer needed to be examined further – in order to form more reliable public health recommendations. Also, the public need to understand why physical activity is important for them at a more developed level than it simply being part of a recommended ‘healthy living’ regime or for ‘weight management’ or to ‘prevent arthritis’ or ‘prevent cardiovascular disease’, so that the role of physical activity is of greater importance. This will improve specific health outcomes for individuals suffering from specific disease and a greater need for movements and durations of exercise will be understood by the individual.

To summarise, both physical activity and mental wellbeing health outcomes for women when ageing can be improved via health education because it will motivate individuals to self-help. To improve process this, further research needs to be done on the specific impact of physical activity on conditions and also the psycho-social impact of specific diseases; this will improve public health recommendations. Social inequalities such as accessibility of services and the perceptions of female elderly stereotypes need to be addressed via community engagement work at a local level and via national incentives. Lastly, recognition of the wider implications of poor health outcomes will allow professionals to better support both women and men through the ageing process.

Bibliography

British Menopause Society . (2015) Fact Sheets. [Online] Available from: http://www.thebms.org.uk/. [Accessed: 16th March 2015].

British Menopause Society . (2015) Nice Menopause clinical guideline is on its way. [Online] Available from: http://www.thebms.org.uk/index.php. [Accessed: 23rd March 2015].

D’Ambrosia, R. (1999) Orthopaedics in the New Millennium, a new patient-physician partnership. The Journal of Bone and Joint Surgery. 81. p. 447-451.

Department of Health. (2011) No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages. Mental Health and Disability, Department of Health: London. [Accessed: 19th March 2015].

Institute for Health Metrics and Evaluation. (2012) Global Burden of Disease Study 2010 (GBD 2010) Life Expectancy and Healthy Life Expectancy 1970-2010. [Online] Available from: http://ghdx.healthdata.org/record/global-burden-disease-study-2010-gbd-2010-life-expectancy-and-healthy-life-expectancy-1970. [Accessed: 23rd March 2015].

James, E. (2014) Staying Well in your neighbourhood.[Online] Available from: http://locality.org.uk/wp-content/uploads/Elaine-James-Calderdale-Council-Healthy-Neighbourhoods-workshop.pdf. [Accessed: 18th March 2015].

The Mayo Clinic Staff. (2013) Menopause weight gain: Stop the middle age spread. [Online] Available from: http://www.mayoclinic.org/healthy-living/womens-health/in-depth/menopause-weight-gain/art-20046058. [Accessed: 23rd March 2015].

Moore, G.F, Moore, L, Murphy, S. (2011) Facilitating adherence to physical activity: Exercise professionals experiences of the National Exercise Referral scheme in Wales, a qualitative study. [Online] BioMed Central. 935 (11). Available from: http://www.biomedcentral.com/1471-2458/11/935. [Accessed: 19th March 2015].

National Health Service. (2013) Activities for the elderly. [Online] Available from: http://www.nhs.uk/Livewell/fitness/Pages/activities-for-the-elderly.aspx. [Accessed: 19th March 2015].

National Health Service.(2014)Benefits of Talking Therapy. http://www.nhs.uk/Conditions/stress-anxiety-depression/Pages/benefits-of-talking-therapy.aspx. [Accessed: 19th March 2015].

National Osteoporosis Society. (2010) Hormone Replacement Therapy for the Treatment and Prevention of Osteoporosis. [Online] Available from: https://www.nos.org.uk/document.doc?id=823. [Accessed: 23rd March 2015].

National Institute for Health and Care Excellence. (2013) Osteoporosis – prevention of fragility fractures. [Online] Available from: http://cks.nice.org.uk/osteoporosis-prevention-of-fragility-fractures#!topicsummary. [Accessed: 23rd March 2015].

Ogden, J. (2012) Health Psychology. Open University Press: Oxford.

Queniart, A and Charpentier, M. (2011) Older women and their representations of old age: A qualitative analysis. The International Journal of Ageing and Society. 32 (6). p. 983-1007.

Syddall, H.E. (2012) Social inequalities in musculoskeletal ageing among community dwelling older men and women in the United Kingdom.University of Southampton, Gerontology, Doctoral Thesis. [Online] Available from: http://eprints.soton.ac.uk/354738/.[Accessed: 17th March 2015].

The Halifax Courier. (2015) Centre will play a role in tackling loneliness. [Online] Available from: http://www.halifaxcourier.co.uk/news/centre-will-play-a-role-in-tackling-loneliness-1-7060545 [Accessed: 17th March 2015].

Verloop, J, Rookus, M.A, Koay, K.V.D, Leeuwen, F.E.V. (2000) Physical activity and breast cancer risk in women Aged 20-54 years. Journal of the National Cancer Institute. 92 (2). p. 128-135.

World Health Organisation. (2003) Gender, Health and Ageing. [Online] Available from: http://www.who.int/gender/documents/en/Gender_Ageing.pdf [Accessed: 15th March 2015].

This work was produced by one of our professional writers as a learning aid to help you with your studies

With reference to the UK, discuss the reasons why tuberculosis (TB) is a contemporary public health issue and give examples of relevant public health and health promotion initiatives.

With the exception of HIV/AIDS, infection with the Mycobacterium tuberculosis complex (MTB) causes more human deaths each year than any other infectious agent (World Health Organization, 2014a). The symptoms of tuberculosis (TB) are often non-specific and depend on the site of infection. Patients may present with fever, anorexia, weight loss, night sweats or lassitude, but a persistent productive cough is the hallmark of pulmonary tuberculosis (Department of Health, 2006). MTB bacilli multiply within infected macrophages for long periods of time and may be transported in the lymphatics or bloodstream to any part of the body (Gill and Beeching, 2004).

Humans are the only reservoir of infection and transmission of tuberculosis occurs when infectious respiratory secretions are aerosolized by coughing, sneezing or talking. These may remain suspended in the air for long periods and are small enough to reach terminal air spaces if inhaled (Gill and Beeching, 2004). Patients with lung disease are the main source of infection and 52% of cases notified in the UK in 2013 had pulmonary disease (Public Health England, 2014c). 5 to 10% of people will develop active tuberculosis after primary infection reducing to 3% within one year of exposure; however over 90% of MTB infection is non-pathogenic within a normal human lifespan (Gill and Beeching, 2004).

The incidence of tuberculosis in the UK in 2013 (12.3/100 000) was higher than most other Western European countries (European Centre for Disease Prevention and Control (ECDC)/WHO Regional Office for Europe, 2013) and nearly five times as high as the United States (Centers for Disease Control and Prevention, 2013), having increased steadily since the late 1980’s (Public Health England, 2014a). Rates of infection have declined by 11.6% in the past two years, where 73% of cases occurred among people born outside the UK. Of these, India, Pakistan and Somalia were the most common countries of origin but only 15% were recent migrants indicating a high rate of reactivation of latent tuberculosis (Public Health England, 2014c). The number of migrants from countries with very high TB incidence (>250 per 100,000) decreased by 68% in the last decade and indicators of recent transmission reflect a decline in primary infections. However, the rate of infection among the UK born adult population has remained stable (Public Health England, 2014c) and strain typing suggests that up to 40% of all UK cases may be newly acquired (Public Health England, 2014a). Consequently, Public Health England has identified TB as a major priority (12).

Globally, tuberculosis affects predominately young adults (World Health Organization, 2014b) and the highest rates of infection in the non-UK born population are among 25 to 29 year olds. Of patients born in Britain, TB is most virulent in those aged over 75 years and both sexes are equally at risk (Public Health England, 2014c). The burden of TB in England is concentrated in the most deprived communities of large urban areas and London accounted for 37.8% of patients in 2013 (Public Health England, 2014c). Nearly half of these cases were unemployed and 10% had a history of alcohol or drug misuse, homelessness or imprisonment. 6% were health-care workers (Public Health England, 2014c). Tuberculosis is particularly virulent among the immunosuppressed and people with HIV are 26 to 31 times more likely to contract the disease. Tobacco use has also been associated with 20% of TB cases worldwide (World Health Organization, 2014b).

TB is transmitted most effectively in environments where MTB microbes accumulate in the atmosphere, for example in overcrowded and poorly ventilated living and working conditions (Gill and Beeching, 2004). Individuals with close and/or prolonged contact with a patient with pulmonary tuberculosis or connections to higher-prevalence areas of the world are particularly at risk (Department of Health, 2006). Transmission is also favoured by dark and humid conditions, such as mines and prisons (Gill and Beeching, 2004) and several authors have implicated vitamin D deficiency in the disease pathogenesis, although findings are varied and inconclusive (Kearns et al., 2014). Active TB may be mild or asymptomatic for many months and sufferers may unknowingly infect up to 15 people over the course of a year (World Health Organization, 2014b). Drug-resistant TB is an increasing problem in the UK and multi-drug resistant TB comprised 1.6% of cases in 2012 (Public Health England, 2013a). Although MDR tuberculosis is unlikely to be more contagious, patients are infectious for longer than those with fully sensitive tuberculosis (Borrell and Gagneux, 2009, Anderson et al., 2014).

The features of effective national TB control programmes have been well documented (National Institute for Health and Care Excellence, 2011, Story et al., 2012, Department of Health – TB Action Plan Team, 2007, Public Health England, 2014a) and include transparent systems of accountability, adequate resources, active local implementation and close outcome monitoring (Abubakar et al., 2011). These activities are managed in the UK by Public Health England together with a wide range of stakeholders such as NHS England, and include screening. Screening strategies differ for the detection of early active and latent asymptomatic TB, the latter of which is recommended by NICE for individuals at high risk of infection (National Institute for Health and Care Excellence, 2011) and referred to as active case finding (ACF) (Golub et al., 2005, Zenner et al., 2013). Identifying tuberculosis early allows for prompt treatment and reduces transmission (Public Health England, 2014b).

In the UK, ACF is targeted at healthcare workers involved in exposure prone procedures, close contacts of known or suspected tuberculosis patients, and people with social risk factors such as homelessness, drug or alcohol misuse, imprisonment or migration from high risk countries (National Institute for Health and Care Excellence, 2012). Several local authorities and primary care trusts have successfully piloted such schemes, although weaknesses in coordination and targeting have been identified (Pareek et al., 2011a). London’s UCLH Find and Treat Service, for example, screens almost 10 000 socially vulnerable people at high risk of tuberculosis annually (University College London Hospitals NHS Foundation Trust, 2014). Various UK charities, such as ‘TB Alert’, raise public awareness of tuberculosis and support Primary Care Trusts. They build capacity of third sector organisations and inform and subsidize patients and communities (TB Alert, 2014).

The UK Border Agency, in collaboration with the International Organization for Migration, conducts pre-entry screening for active infection across 15 countries where tuberculosis is common (over 40/100,000) (Home Office UK Border Agency, 2012, Public Health England, 2013b). Visa applicants from these countries wishing to stay in the UK for more than 6 months are screened for pulmonary TB and granted entry only on receipt of a certificate of clearance (Public Health England, 2014b). Funding from the Health Protection Agency (HPA) also supports screening activity at Heathrow and Gatwick airports (Home Office UK Border Agency, 2012). Screening is routinely offered to asylum seekers and refugees accepted for resettlement into the UK through the Gateway Programme (Home Office UK Border Agency, 2012). There is further evidence that screening migrants for latent TB on entry to the UK is cost effective for the NHS (Pareek et al., 2011b).

Internationally, the World Health Organization operates via the Stop TB Partnership to set targets, procure and grant funds and resources, lobby governments, educate and advocate on behalf of TB communities (World Health Organization, 2006, Stop TB Partnership, 2014). Simultaneously, not-for-profit product development partnerships such as the TB Alliance endeavour to develop new TB drug regimens (Horsburgh et al., 2013, Lienhardt et al., 2012a, Lienhardt et al., 2012b, Clinton Health Access Initiative et al., 2010). School vaccination of the indigenous UK population was halted in 2005 following a decline in the incidence of TB and the Bacillus Calmette-Guerin immunisation (BCG) is now targeted at neonates within high risk groups (Department of Health, 2006). These UK endeavours contribute towards the WHO target to eliminate TB as a public health problem by 2050 (World Health Organization, 2006).

References

ABUBAKAR, I., LIPMAN, M., ANDERSON, C., DAVIES, P. & ZUMLA, A. 2011. Tuberculosis in the UK–time to regain control. BMJ, 343, d4281.

ANDERSON, L. F., TAMNE, S., BROWN, T., WATSON, J. P., MULLARKEY, C., ZENNER, D. & ABUBAKAR, I. 2014. Transmission of multidrug-resistant tuberculosis in the UK: a cross-sectional molecular and epidemiological study of clustering and contact tracing. Lancet Infect Dis., 14, 406-15. doi: 10.1016/S1473-3099(14)70022-2. Epub 2014 Mar 4.

BORRELL, S. & GAGNEUX, S. 2009. Infectiousness, reproductive fitness and evolution of drug-resistant Mycobacterium tuberculosis. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 13, 1456-66.

CENTERS FOR DISEASE CONTROL AND PREVENTION 2013. Trends in Tuberculosis – United States, 2012. Morbidity and Mortality Weekly Report, 62, 201-2.

CLINTON HEALTH ACCESS INITIATIVE, BILL & MELINDA GATES FOUNDATION, GLOBAL ALLIANCE FOR TB DRUG DEVELOPMENT, GLOBAL DRUG FACILITY, INTERNATIONAL UNION AGAINST TUBERCULOSIS AND LUNG DISEASE, MANAGEMENT SCIENCES FOR HEALTH & TREATMENT ACTION GROUP 2010. Falling Short. Ensuring Access to Simple, Safe and Effective First-Line Medicines for Tuberculosis. New York: Global Alliance for TB Drug Development.

DEPARTMENT OF HEALTH – TB ACTION PLAN TEAM. 2007. Tuberculosis prevention and treatment: a toolkit for planning, commissioning and delivering high-quality services in England [Online]. London: Department of Health. Available: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_075638.pdf [Accessed 19/12/2014].

DEPARTMENT OF HEALTH 2006. Chapter 32 – Tuberculosis. In: SALISBURY, D., RAMSAY, M. & NOAKES, K. (eds.) Immunisation against infectious disease – ‘The Green Book’. 3rd ed. London: The Stationery Office.

EUROPEAN CENTRE FOR DISEASE PREVENTION AND CONTROL (ECDC)/WHO REGIONAL OFFICE FOR EUROPE. 2013. Tuberculosis surveillance and monitoring in Europe 2013 [Online]. Stockholm: European Centre for Disease Prevention and Control. Available: http://www.ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx?List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=811 [Accessed 19/12/2014].

GILL, G. V. & BEECHING, N. J. 2004. Chapter 12 – Tuberculosis. Tropical Medicine. 5th ed. Oxford: Blackwell Science.

GOLUB, J. E., MOHAN, C. I., COMSTOCK, G. W. & CHAISSON, R. E. 2005. Active case finding of tuberculosis: historical perspective and future prospects. Int J Tuberc Lung Dis., 9, 1183-203.

HOME OFFICE UK BORDER AGENCY 2012. Screening for Tuberculosis and the Immigration Control. UK Border Agency Review of Current Screening Activity 2011 (Central Policy Unit). London: Home Office.

HORSBURGH, C. R., JR., HAXAIRE-THEEUWES, M., LIENHARDT, C., WINGFIELD, C., MCNEELEY, D., PYNE-MERCIER, L., KESHAVJEE, S. & VARAINE, F. 2013. Compassionate use of and expanded access to new drugs for drug-resistant tuberculosis. The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease, 17, 146-52.

KEARNS, M. D., ALVAREZ, J. A., SEIDEL, N. & TANGPRICHA, V. 2014. Impact of Vitamin D on Infectious Disease: A Systematic Review of Controlled Trials. Am J Med Sci, 20, 20.

LIENHARDT, C., GLAZIOU, P., UPLEKAR, M., LONNROTH, K., GETAHUN, H. & RAVIGLIONE, M. 2012a. Global tuberculosis control: lessons learnt and future prospects. Nature reviews. Microbiology, 10, 407-16.

LIENHARDT, C., RAVIGLIONE, M., SPIGELMAN, M., HAFNER, R., JARAMILLO, E., HOELSCHER, M., ZUMLA, A. & GHEUENS, J. 2012b. New drugs for the treatment of tuberculosis: needs, challenges, promise, and prospects for the future. The Journal of infectious diseases, 205 Suppl 2, S241-9.

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. 2011. Clinical guidance and management of tuberculosis, and measures for its prevention and control. CG117 [Online]. Available: http://www.nice.org.uk/guidance/cg117 [Accessed 19/12/2014].

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE. 2012. Identifying and managing tuberculosis among hard-to-reach groups. PH37 [Online]. Available: http://www.nice.org.uk/guidance/cg117 [Accessed 19/12/2014].

PAREEK, M., ABUBAKAR, I., WHITE, P. J., GARNETT, G. P. & LALVANI, A. 2011a. Tuberculosis screening of migrants to low-burden nations: insights from evaluation of UK practice. Eur Respir J., 37, 1175-82. doi: 10.1183/09031936.00105810. Epub 2010 Nov 11.

PAREEK, M., WATSON, J. P., ORMEROD, L. P., KON, O. M., WOLTMANN, G., WHITE, P. J., ABUBAKAR, I. & LALVANI, A. 2011b. Screening of immigrants in the UK for imported latent tuberculosis: a multicentre cohort study and cost-effectiveness analysis. The Lancet. Infectious diseases, 11, 435-44.

PUBLIC HEALTH ENGLAND 2013a. Tuberculosis in the UK: 2013 report. London.

PUBLIC HEALTH ENGLAND. 2013b. UK pre-entry tuberculosis screening brief report 2013 [Online]. London: Public Health England. Available: https://www.gov.uk/government/publications/tuberculosis-pre-entry-screening-in-the-uk [Accessed 19/12/2014].

PUBLIC HEALTH ENGLAND. 2014a. Collaborative Tuberculosis Strategy for England 2014 to 2019: For consultation [Online]. London. Available: https://www.gov.uk/government/consultations/collaborative-tuberculosis-strategy-for-england-2014-to-2019 [Accessed 19/12/2014].

PUBLIC HEALTH ENGLAND. 2014b. Guidance: Tuberculosis screening. Tuberculosis (TB) screening and early detection methods, for professionals working with at-risk populations in the UK. [Online]. Available: https://www.gov.uk/tuberculosis-screening#pre-entry-tb-screening-for-migrants [Accessed 18/12/2014].

PUBLIC HEALTH ENGLAND 2014c. Tuberculosis in the UK: 2014 report. London.

STOP TB PARTNERSHIP 2014. The Stop TB Partnership. Leading the fight against TB. Geneva: Stop TB Partnership.

STORY, A., COCKSEDGE, M., ANDERTON, A., EDGINTON, M., O’DONOGHUE, M., KON, O. M., TAMNE, S., MAW, J. & POLLINGER, E. 2012. Tuberculosis case management and cohort review guidance for health professionals [Online]. London: Royal College of Nursing. Available: http://www.rcn.org.uk/%5F%5Fdata/assets/pdf%5Ffile/0010/439129/004204.pdf [Accessed 19/12/2014].

TB ALERT. 2014. Our Work in the UK [Online]. Brighton. Available: http://www.tbalert.org/what-we-do/uk/ [Accessed 19/12/2014].

UNIVERSITY COLLEGE LONDON HOSPITALS NHS FOUNDATION TRUST. 2014. Find and Treat Service [Online]. Available: https://www.uclh.nhs.uk/OurServices/ServiceA-Z/HTD/Pages/MXU.aspx [Accessed 19/12/2014].

WORLD HEALTH ORGANIZATION. 2006. The Stop TB Strategy [Online]. World Health Organization. Available: http://whqlibdoc.who.int/hq/2006/WHO_HTM_STB_2006.368_eng.pdf [Accessed 19/12/2014].

WORLD HEALTH ORGANIZATION. 2014a. Global tuberculosis report 2014 [Online]. Geneva: World Health Organization. Available: http://www.who.int/tb/publications/global_report/en/ [Accessed 19/12/2014].

WORLD HEALTH ORGANIZATION. 2014b. Tuberculosis Fact Sheet No. 104 [Online]. Geneva: World Health Organization. Available: http://www.who.int/mediacentre/factsheets/fs104/en/ [Accessed 19/12/2014].

ZENNER, D., SOUTHERN, J., VAN HEST, R., DEVRIES, G., STAGG, H. R., ANTOINE, D. & ABUBAKAR, I. 2013. Active case finding for tuberculosis among high-risk groups in low-incidence countries. Int J Tuberc Lung Dis., 17, 573-82. doi: 10.5588/ijtld.12.0920.

This work was produced by one of our professional writers as a learning aid to help you with your studies

Introduction

Recently, the concept of patient autonomy has become more prevalent within the healthcare field with the government and the NHS promoting patient choice and providing assurance that individuals will have full control over their care and patient journey. However, a recent publication from Macmillan Cancer Care (MCC) (2013a, pp. 1-27), suggests that there is very little choice available for individuals suffering from terminal cancer with regards to where they spend the end of their lives. Figures provided within the MCC (2013a, p. 8) report suggest that 81% of cancer sufferers would prefer to die at home whilst in reality, 48% of these die in a hospital with only 23% of patients dying within the comfort of their own homes.

For individuals who are approaching the end of their lives, the option of being cared for and dying within their own home with the familiarity and comfort that this brings, is often very important. The National Bereavement Survey (NBS) (Office for National Statistics, 2012, np) showed that that the loved ones of those who had died in hospital often considered the standard of care as being poor when compared to those who died at home, in a care home or within a hospice. Indeed, the NBS (ONS, 2012, np) showed that 53% of loved ones whose friend or family member had died at home and 58% of those who had died in a hospice, rated the standard of care as outstanding or excellent compared to just 34% for those who had died within a hospital.

This essay will consider the barriers that cancer patients are presented with when making their end of life choices and will make recommendations for improvement of service to ensure that these individuals are allowed to make and receive their final choice. However, the essay will begin with a brief overview of the benefits that end of life patient choice can bring to both the individual and to the wider society.

The Benefits of End of Life Patient Choice

According to the National End of Life Intelligence Network (2012, p.7) 89% of patients who die in hospital are brought in as emergency admissions. However, a large number of these individuals have already expressed their desire to die at home, therefore representing a poor patient outcome and negative experiences. In addition, these unnecessary emergency admissions place a costly strain on accident and emergency departments and the patients take up hospital beds that could be used for other cases. When one considers that the number of people in this country is increasing with the elderly becoming the most prevalent age group, it is not unfeasible to believe that the number of individuals dying from terminal cancer over the next few decades is also going to increase. This increase in numbers is likely to cause the current model of care to become unsustainable. However, promoting choice and delivering end of life care choices can actually save money by reducing the number of emergency admissions. According to MCC (2013a, p.9), there is a net saving of just under A?1000 for every individual who dies in the community rather than in a hospital bed.

Barriers to End of Life Care Choices

Evidence suggests that there are multiple barriers that prevent individuals from being cared for and ending their lives in their chosen place. The first barrier is the identification of people approaching the end of their lives. According to MCC (2013a, p.10), 38% of cancer patients approaching their end of life were unaware that they were dying, whilst figures from Marie Curie Cancer Care (2013, p.7) show that only 26% of individuals with a palliative care need are placed on the palliative care register. One of the main reasons for this appears to be a lack of confidence in the health professionals over instigating conversations with individuals over their end of life journey. A study carried out by Revill (2010, p.11) found that 60% of GPs were not confident about discussing death or dying with their patients. This lack of identification and lack of professional confidence therefore prevents many people from being able to make their end of life choice in a timely fashion, therefore increasing the number of emergency admissions that have previously been discussed.

However, another issue that has been raised is that of poor planning and coordination between services. When one considers the needs of a terminally ill cancer patient, it is clear that there is a requirement for multiple health and social care providers to work together to provide a joined up service delivery. Unfortunately, the MCC (2013a, p.11) report suggests that this joined up service is not occurring with 45% of respondents thinking that community services worked well together and only 33% stating that GP and other services outside of the hospital worked well together. The reason for this poor service is considered to be a lack of coordination and communication between the different care entities. Indeed, the MCC (2013a, p.11) report suggests that it is often a requirement of the close family and friends of the dying loved one or the actual patient to coordinate care between health and social care departments. The report suggested that information needed to be repeated to the different professionals suggesting that there is a lack of communication between the different departments and that patient information is not being recorded or shared in an appropriate manner.

Nevertheless, there is evidence to suggest that Advance Care Plans (ACP) are a successful way in which a person’s end of life choices can be successfully achieved. Abel et al (2013, pp.168-173) followed 969 terminally ill patients, 550 of whom had made an ACP. 75% of these individuals successfully achieved their dying wishes with regards to the location that they had chosen. In addition, a study published by the NHS (2012, pp.3-4) suggests that the Electronic Palliative Care Coordination Systems (EPaCCS) where patient information, including their end of life choices, can be stored and shared, is an effective way of achieving pro choice for the patient with up to 80% of individuals living in areas where the EPaCCS system is implemented achieving their preferred choice of location to die. In addition, the NHS (2012, p.12) report shows that the implementation of this system has resulted in savings of A?133,200 where it is implemented. Another positive study has been published by Gao et al (2013, np) who found that the number of individuals being able to die either at home or in a hospice has increased since 2005 when the National End of Life Care Programme was first launched. However, the percentage change was only marginal (0.8%) therefore suggesting that more needs to be done to ensure patient autonomy is at the top of the list for terminally ill patients.

Another barrier that is likely to prevent an individual from dying within their own home is lack of skills and resources within the community workforce. In these cases, the role of the community nurse is vital, however, the number of community nurses is steadily declining (Royal College of Nursing, 2013, np). This reduction of the workforce further dilutes the available skill mix, therefore having a detrimental impact on the quality of care provided to those who choose to die at home. According to the MCC (2013a, p.13) report, only 19% of individuals who chose to die at home received adequate pain relief during their last 3 months of life. Indeed, the lack of 24/7 access to community services forced a large number of these individuals to contact emergency services resulting in admittance to hospital. In 2010, nearly half of the UK’s primary care trusts did not provide 24/7 community nursing services for end of life patients with little progress being made following the subsequent change to Clinical Commissioning Groups (MCC, 2013a, p. 13).

Another report published by MCC (2013b, pp. 1-15) suggests that a lack of access to social care services also restricts the ability of an individual to make end of life care choices. Whilst it is obvious that the right amount of social support is needed in order for a terminally ill individual to be able to remain at home during their last stages of life, this support is often not provided. The MCC (2013b, p. 3) report suggests that this is not always due to the service not being available, but more often being the result of the complex assessment process and the lack of coordination between health and social services. Indeed, 97% of healthcare professionals stated that the complexity of the social care needs assessment is a substantial barrier to gaining the right amount of home care for terminally ill patients. As such, the care for these terminally ill individuals is often left to family members as informal carers. However, only 5% of these individuals actually receive a carers allowance despite them taking on the majority of the personal care responsibilities of these terminally ill patients. Thomas et al (2002, p.531) asserted that the needs of cancer patient carers were greatest as the cancer progressed to end stage; however, a distinct lack of support for these informal carers is prevalent throughout the UK (Soothill et al, 2001, p.468). MCC (2013b, p.6) found that 47% of these informal carers felt that they needed support but were unable to get any. Therefore it is not surprising that this lack of carer support is resulting in many cancer patients being admitted to hospital in the days or hours before death despite it being their wish to die at home.

Recommendations for Improvement

As studies have shown that the local implementation of the EPaCCS has been successful, there should be a renewed commitment by the Department of Health and the NHS to ensure the national implementation of this scheme. Indeed the National End of Life Care Strategy (DOH, 2008, np) made a commitment to pilot and establish end of life care registers that would ensure the coordinated care of terminally ill patients and also ensure that every organisation involved in the care of that individual were aware of their end of life choices. As such, it is asserted that NHS England need to prioritise the roll out of these systems. When this system is implemented on a national basis, EPaCCS will not only coordinate care but will also provide considerable data that can be used to compare outcomes for end of life patients throughout the UK. In addition to this system, it is vital that health care professionals involved with terminally ill cancer patients encourage them to fill out an ACP as a routine part of the care package. A randomised control trial carried out by Detering et al (2010, np) followed 309 terminally ill patients for a period of six month, 154 of whom had completed an advanced care plan. Of the 56 patients who died during the study period, 29 of them had made an ACP with 86% of these achieving their end of life choices compared to just 30% of those who had not made an ACP. This shows that it is vital to document end of life choices to ensure that they are followed by all those involved in the final days of the patient’s care.

Another recommendation is to make end of life care training mandatory for all health professionals who are likely to be involved in palliative care. This includes making a timely identification of individuals who are approaching the end of their lives and providing these professionals, including GPs, with the right training to boost their confidence in instigating end of life discussions with terminally ill patients. This will enable these terminally ill individuals and their families to come to terms with their disease progression and make appropriate plans for their end of life care. It is also recommended that all terminally ill individuals have a named professional who is responsible for the coordination of their care and who will ensure that their end of life choices are met whenever possible. This was a key recommendation of the UK Government’s (2013, pp. 1-62) review of the Liverpool care pathway, which stated that a named consultant or GP should take overall responsibility for a patient’s end of life care, whilst a named registered nurse would have day to day responsibility for the care of that individual and for the communication of information between the patient, family members and other members of the care team.

The UK Government’s (2013, p. 57) review also recommends improving access to community services by increasing funding to ensure that there is a consistent 24/7 access to all social care services throughout the UK. This is considered to be a priority, as without access to 24/7 care, a large number of individuals are not having their pain managed adequately, forcing them to take further action by attending an emergency department. In addition, the government needs to commit to implementing free social care to terminally ill patients and to simplifying the social care assessment to ensure that all those who need social support are able to access this service in a timely fashion. Whilst the UK government has recognised that there is much merit in the proposal of free end of life social care (MCC, 2013a, p. 19), they are yet to offer a firm commitment to this proposal. The continued complexity of the social care assessment and the confusion over who is able to receive social care needs to change if patients’ wishes to die at home are to be honoured. Indeed, Taylor (2012, p.1297) asserts that there is a need to change the way in which all health and social care is provided to elderly patients and suggests a combined health and social care assessment to ensure a proper joined up and coordinated service for these vulnerable patients.

It is also recommended that improved support for carers is instigated to ensure that all those who are caring for a terminally ill patient are recognised as informal carers and are in receipt of a carers allowance. In addition, it is vital that these carers a given the right level of support by health professionals; this support should include having 24/7 access to help and advice, being given regular respite and having adequate information with regards to the progression of their loved ones disease to enable them to encourage the patient to make end of life care plans. Joyce et al (2014, p.1150) found that out of 120 caregivers who were responsible for delivery of medications to their terminally ill relative, only 27 (22.5%) of them received any formal support. This often led to confusion over dose rate and fear that the patient was receiving too much or too little of the medication provided. This issue is compounded by the fact that many of these informal carers are elderly themselves and often have their own health problems (Jack et al, 2015, p.131).

Finally, it is considered that delivering choice for end of life care should be focused on giving that patient a good death, regardless of where they chose to die. As such, it seems logical that there is a need to understand the experiences of terminally ill patients towards the end of their lives in order to deliver adequate care. As such, it is considered vital to explore how the experiences, concerns, fears and feelings of people approaching the end of their lives can be recorded and used to improve future patient outcomes. Whilst it is accepted that the National Bereavement Survey (ONS, 2012, np) provided a large volume of useful information, the current lack of nationally collected information from end of life patients’ needs to be addressed. As such, it is recommended that future study be directed in this way.

Conclusion

In conclusion, it is clear that whilst having a genuine choice over where to spend the last few days and hours of your life is hugely important to terminally ill patients, there are significant barriers to achieving these choices. Current figures suggest that nearly three quarters of cancer patients chose to die at home but less than 29% of them actually do so. The MCC (2013a, p. 3) report estimate that this amounts to 36,000 patients dying in hospital when they had chosen to die at home. A number of barriers exist that are currently preventing the individual from achieving personal choice at the end of their lives; these include poor identification of individuals entering the end of life stage, poor communication from health professionals, poor planning and coordination between health and social services, lack of skills and resources in community nursing and lack of universal access to social care resources. Nevertheless, despite these current barriers, none are insurmountable if current services are simplified and organised in a way that sees the needs of the individuals and their families and carers brought to the forefront. Whilst the government has funded reports and strategies to improve end of life care, it is clear that not enough is being done to change the way in which end of life care is provided. Significant change is required in order to move care and resources out of hospitals and into the community so that people’s preferences can be delivered. However, this can only happen if there is a clear commitment given by all the players involved in end of life care to share the same ambition, that being to deliver a coordinated and integrated care package that meets the needs, wishes and preferences of end of life patients and their carers. A number of recommendations on how this can be achieved have been included in this essay. These recommendations include simplify the social care assessment, providing free social care to end of life patients, improving support for informal carers and ensuring that these carers are recognised, improving the training of health professionals in recognising the transition to end of life stages and encouraging them to instigate discussions over end of life choices, improving access to social services by ensuring a 24/7 service across the UK and implementing the roll out of the EPaCCS across the whole of the UK to ensure that end of life choices are recorded and shared between all the relevant care providers. As it stands at present, whilst end of life patients do have a choice over where they die, these preferences are often not honoured. They do not have full control or autonomy over their end of life care. However, the choice of place to die is not a myth as it is a very achievable option that requires coordination between services and a commitment from the government to improve community health services.

References

Abel, J., Pring, A., Rich, A., Malik, T., & Verne, J. (2013). The impact of advance care planning of place of death, a hospice retrospective cohort study. BMJ Supportive & Palliative Care, 3(2), 168-173.

Department of Health. (2008). End of life care strategy. Available online at https://www.gov.uk/government/publications/end-of-life-care-strategy-promoting-high-quality-care-for-adults-at-the-end-of-their-life accessed 21 June 2015.

Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. British Medical Journal, 340. 1345-1353

Gao, W., Ho, Y. K., Verne, J., Glickman, M., Higginson, I. J., & GUIDE_Care Project. (2013). Changing patterns in place of cancer death in England: a population-based study. PLoS Med, 10(3), e1001410.

Jack, B. A., O’Brien, M. R., Scrutton, J., Baldry, C. R., & Groves, K. E. (2015). Supporting family carers providing endaˆ?ofaˆ?life home care: a qualitative study on the impact of a hospice at home service. Journal of Clinical Nursing, 24(1-2), 131-140.

Joyce, B. T., Berman, R., & Lau, D. T. (2014). Formal and informal support of family caregivers managing medications for patients who receive end-of-life care at home: A cross-sectional survey of caregivers. Palliative Medicine, 28(9), 1146-1155.

Macmillan Cancer Care. (2013a). A time to choose. Available online at http://www.macmillan.org.uk/Documents/GetInvolved/Campaigns/Endoflife/TimeToChoose.pdf accessed 21 June 2015.

Macmillan Cancer Care. (2013b), There’s no place like home. Available online at http://www.macmillan.org.uk/Documents/GetInvolved/Campaigns/SocialCare/Making-the-case-for-free-social-care-at-the-end-of-life.pdf accessed 21 June 2015.

Marie Curie Cancer Care. (2013). Death and dying. Available online at https://www.mariecurie.org.uk/globalassets/media/documents/policy/policy-publications/february-2013/death-and-dying-understanding-the-data.pdf accessed 21 June 2015.

National End of Life Intelligence Network. (2012). What do we know now that we didn’t know a year ago? New intelligence on end of life care in England. Available online at http://www.endoflifecare-intelligence.org.uk/view?rid=464 accessed 21 June 2015.

NHS. (2012). Making the case for change: Electronic palliative care coordination systems. Available online at www.nhsiq.nhs.uk/download.ashx?mid=4423&nid=4424 accessed 21 June 2015.

Office for National Statistics. (2012). National Bereavement Survey 2012. Available online at http://www.ons.gov.uk/ons/rel/subnational-health1/national-bereavement-survey–voices-/2012/index.html accessed 21 June 2015.

Revill, S. (2010). GP Pilot Project Evaluation. Available online at http://www.dyingmatters.org/sites/default/files/user/documents/Resources/Dying_Matters_GP_Pilot_Evaluation_-_final.pdf accessed 21 June 2015.

Royal College of Nursing. (2013). Frontline First: Nursing on Red Alert. Available online at https://www.rcn.org.uk/__data/assets/pdf_file/0003/518376/004446.pdf accessed 21 June 2015.

Soothill, K., Morris, S. M., Harman, J. C., Francis, B., Thomas, C., & McIllmurray, M. B. (2001). Informal carers of cancer patients: what are their unmet psychosocial needs? Health & Social Care in the Community, 9(6), 464-475.

Taylor, B. J. (2012). Developing an integrated assessment tool for the health and social care of older people. British Journal of Social Work, 42(7), 1293-1314.

Thomas, C., Morris, S. M., & Harman, J. C. (2002). Companions through cancer: the care given by informal carers in cancer contexts. Social Science & Medicine, 54(4), 529-544.

UK Government (2013). More Care, Less Pathway, A review of the Liverpool Care Pathway. Available online at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/212450/Liverpool_Care_Pathway.pdf accessed 21 June 2015.

This work was produced by one of our professional writers as a learning aid to help you with your studies

Introduction

The oral route is still the most desired route for the administration of medicinal products¹ due to the ease and lack of inconvenience associated with this administration route, in comparison to others such as the pulmonary route or the more invasive intravenous route.

The pharmaceutical industry has developed considerably over the past 40 years with respect to the rate at which new chemical entities are being discovered. This increased rate is primarily due to the invention of high throughput screening, but there is no correlation between the rate of synthesis of these novel compounds and the release of new drugs on the market due to the high failure rate during the development process¹.

In order to minimise cost and resources associated with this loss, effective screening methods for both pharmacological action and bioavailability have to be used.

The most important process that influences bioavailability of the drug is absorption and the necessity of creating and using suitable models that can predict the in vivo absorption profile of a drug is absolutely critical in achieving the desired reduction in cost associated with the pharmaceutical development process.

There are two primary phases of absorption for orally administered drugs; the first is dissolution of the drug in the aqueous media present at the site or sites of absorption¹ the second is permeation of the drug particles in solution through predominantly the small intestinal membrane into the hepatic portal vein¹.

The main factors affecting dissolution of a drug in the gastrointestinal (GI) system are the pH of the environment, volume of dissolution media and the presence of food by either encouraging or delaying the passage of the dosage form into the small intestine where many drugs are absorbed.

Permutation of the drug through the small intestinal membrane is influenced by several variables. The presence of influx and efflux pumps on the apical surface is a main consideration². There are three main routes of absorption that drugs can take; transcellular absorption through the cells, paracellular absorption by passing thorough the tight junctions between cells or by using influx transporters present on the apical surface³. Efflux transporters are also present which act to eject the drug molecule out of the cell and limit bioavailability¹.

All of these processes and scenarios need to be considered in developing an in vitro model to accurately predict gastrointestinal drug absorption. The extent to which a particular model represents the results seen in vivo can be conveyed through a mathematical relationship known as the in vitro- in vivo correlation (IVIVC)^2,4. The predictive power of this correlation ultimately depends upon the capacity of the in vitro method used to simulate and reflect what occurred in vivo. The fact that different models are able to do this to different degrees has been appreciated as different levels of IVIVC have been defined; levels A, B, C, multiple C and D with A being the highest level⁵.

There are many factors to consider and appreciate when looking at IVIVC made from drugs absorbed from the gastrointestinal tract, as models are either based on the dissolution of the drug within the GI media at the absorption site or permeability of the drug across the intestinal membrane.

This review primarily considers models used to simulate and predict drug permeability, with a discussion of the ability of each technique to reflect and predict the in vivo environment and response; which would allow a representative IVIVC to be formed.

In silico permeability models

These models are computer programs that aim to predict the absorption and permeability of a drug. One review⁶ gave a very good summary of the programming process and highlighted the specifications against which the physicochemical properties of drugs are judged.

An advantage of using such a model is that a high turnover of compounds can be tested within a short period of time⁶, a property that makes it very practical in industry.

But in terms of developing an IVIVC, this model has limited use⁷. One major argument against the use of this model highlighted by another review ¹ is that absorption predictions are based only on the physicochemical properties of the drug. This assumption is false as there are other factors to consider such as drug – membrane interactions through active transporters and efflux pumps¹

Parallel Artificial membrane permeability assay (PAMPA)

This technique is based on the formation of an artificial membrane by using a hydrophobic filter material as support upon which lecithin and organic solvents are placed upon to produce an artificial lipid¹.

One recent review⁸ greatly criticised the use of this technique in the drug discovery process. It was stated that there was no real benefit in using this technique over the cell culture methods such as caco-2 and MKCD cell lines because it was just as time consuming with less informative data being obtained⁸.

One of the main advantages of using this technique was that it was less labour intensive and quicker to do⁹, but this was a main focus of the argument against use of the technique by this review. Due to the different manipulations such as testing in various pH that need to be carried out, the process was deemed just as labour intensive as the caco-2 or Ussing chamber method.

An attempt to debate against the points raised by this review was done by another⁹ which highlighted the ability to use this technique to obtain various information such as the partition coefficient and apparent permeability (Papp) of a drug.

Nevertheless, both reviews failed to specifically highlight the strengths or weaknesses of the technique in creating IVIVC. It appeared that the capacity of this technique to do so is limited as there is a gross underestimation of active transport of hydrophilic compounds with low molecular weights ¹.

Ussing Chambers

This cell technique involves the isolation of intestinal membrane and cutting the tissue into strips. These strips are clamped onto a suitable clamping device to produce a flat sheet between two chambers, the donor and receiver chamber¹. The measurement is taken as the amount of drug that appears in the receiver chamber¹. To monitor the viability of the intestinal tissue, electrical resistance is measured by placing a current across the membrane¹.

Only few studies have used this technique to reflect its capability but this has only been used to show a level D IVIVC, where drug candidates during the development process are placed in rank order. One such study¹⁰ presented this technique as being equally capable of ranking drug candidates when compared to caco-2 cells and the in situ technique of a perfused jejunum loop.

One article¹¹ opposes the use of this technique and presents the counter argument to the method being used to create such a correlation. The paper identified the ability of this model to be biologically representative but clearly stated that the technique is not robust enough to incorporate as a method which is routinely used in early development, due to the complexity associated with setting up the instrument. This is a good observation and highlights an impracticality of the method.

Caco-2 cell lines and separated clones

The method that has been supported in recent studies is the Caco-2-cell culture model that has been shown to effectively mimic intestinal absorption. These cells are human colon adenocarcinoma cells that undergo proliferation when in culture¹ which are grown on small porous membranes that fit in the wells of welled plates. The sample of the drug being tested is placed on top of the membrane with the amount of drug that passes through being calculated and the Papp is determined.

Arguments in favour of this method state that the ability of this model to reflect in vivo conditions is very good as not only can transcellular and paracellular diffusion occur, both influx and efflux transporters are present, allowing active transport processes to be considered^1,12. Such transport systems are those for sugars, bile acids, the efflux transporter P-glycoprotein¹¹ and the more recently discovered multiple drug resistance protein (MDRP)¹¹.

This view is supported by many whom consider this model to be very representative of the prediction of intestinal absorption. A study by Yee¹³ analysed 36 drugs and observed the correlation between the apparent absorption (Papp) obtained from the cells and the percentage absorbed determined from in vivo testing.

A correlation coefficient of 0.90 between percentage absorbed in vitro and in vivo was obtained, showing that the technique is capable of reliably predicting in vivo results¹³. Another study¹⁴ confirmed the predictive ability of this model using 20 compounds and also established a correlation coefficient of 0.92 between Papp and the percentage of dose absorbed

To further support the use of caco-2 cells, some studies^10,11 have highlighted the ability of this method to be used in early stages of development in order to produce level D IVIVC where drug candidates are placed in rank order.

But despite all these positive aspects some^13,15-16 remain critical of this technique because of an associated low level of reproducibility with gross variability in results from different labs¹⁵. This has been attribute to differing culture conditions within each lab^13,16. For example one study highlighted the importance of culture nutrients and duration of cell feeding as more L-methyldopa was absorbed as the feeding time increased¹³.

Another important limitation of the model that has been recognised is that as the number of cells within a cell line increases, the Trans epithelial electrical resistance (TEER), mannitol flux and cell growth changes¹. The TEER is a validation tool used to quantitatively reflect the integrity of the monolayer as the viability of this cell culture diminishes¹⁷.

The cell line is unable to express mucus¹⁷ which has been shown to act as a barrier to drug permutation in retarding drug contact with the apical membrane of the small intestine and a fixed pH is used in the model¹⁷. This is not reflective of in vivo as the mucus layer has been shown to retard permutation and the pH of the small intestine changes.

A strong counter argument against the use of caco-2 cells is that the predictive power of the method differs depending upon the main absorption route that the drug uses. Two studies^14,15 have indicated variability in the Papp for mannitol, polyethylene glycol (PEG) 4000 and fluorescein that have low paracellular permeability in various batches of caco-2 cells from different origins. Another study¹⁷ clearly showed that caco-2 cells underestimated the absorption of amoxicillin – a passively absorbed drug and was not able to truly model the absorption of drugs that are absorbed using a carrier-mediated process due to the saturation or under-expression of these influx carriers and the over-expression of the efflux transporter P-glycoprotein.

This limitation of the caco-2 cell line is where the calu-2 cell line proves to be superior. This is a sub-clone of the caco-2 cell line that is isolated at a late passage number and has been shown to express different levels of sucrase isomaltase and glucose transporters¹⁷.

Arguments in favour of this model claim that it is more representative of the in vivo situation¹⁷ as it expresses levels of sucrase isomaltase similar to that seen in the human jejunum¹⁷. UDP-transglucoronyltransferase, an enzyme involved in conjugation metabolic reaction is also seen at a level that is more representative of that in vivo and also an IVIVC has been formed using the in-vitro data obtained from this model¹⁷.

Another sub-clone of the caco-2 cell line is the HT29-18-C1. A study¹⁸ used this cell line and the information obtained was used to calculate a permeability coefficient (PC) for a particular compound. A relationship between the percentage absorbed and the PC was formed much in the same manner as that created using Papp and was shown to be a good model to use in the early development process.

Although this method possesses a significant flaw which is that the tight junctions established in this cell line were not as tight as those seen in vivo ¹⁸, therefore allowing passive diffusion to occur to a greater extent than would normally occur. This was shown in the same study¹⁸ where the Pc of mannitol was ten times less than that seen in caco-2 cells, which is not reflective of in vivo conditions.

Madlin Derby Canine Kidney (MDCK) cells

The progressive changes in TEER seen in caco-2 cells have led to the use of Madlin Derby Canine Kidney (MDCK) cells as a model to predict intestinal absorption¹⁴. These are differentiated epithelial cells that form tight junctions when cultured in semi-permeable membranes¹⁴ that also possess transporters, but not as many as seen in the caco-2 cell line¹⁴.

One study¹⁹ highlighted both opposing arguments and those in favour of the technique by comparing the ability of the model with not only in vivo data but also with the caco-2 cell line. The predictive power of the model was similar to that of the caco-2 cells for passively absorbed compounds that showed good permeability¹⁹. For those that were poorly permeable or were actively transported, the model was unable to accurately present the degree of absorption; for the latter this is due to the minimal transporters expressed by the MDCK cells¹⁹, resulting in a poor IVIVC

2/4/A1 cell line

This cell line which originated from fetal rat intestine was reported to mimic the permeability of the small intestine to drugs absorbed via the paracellular route to a greater extent than the caco-2 cell line¹.

One paper²⁰ clearly advocates the use of this cell line because of this point as the tight junctions seen are more representative with the extent of passive absorption being similar to that in vivo. In this study this cell line was transformed in order to improve viability and a sigmoid relationship between fraction of drug absorbed in vivo and permeability coefficient obtained in vitro was obtained.

The predominant argument against the use of this model also presented by the same study²⁰, was that the shape properties of the cell line were not similar to that of the small intestine. The cells are cuboidal as oppose to columnar and there was a lower number of villi present on the apical surface. This limits the model’s capability of reflecting transcellular or carrier mediated absorption, which are major routes for many drugs which negatively impacts the IVIVC created.

Conclusion and the Future

In examining the arguments for and against the different cell culture techniques, the caco-2 cell line appears to be the most reflective of in vivo absorption. This is because the cell line can express transporters, allow all routes of absorption, has an associated low operating cost, high reliability and throughput capacity. All these advantages make it a very practical and useful model to routinely use in industry.

Nevertheless, there is still room for improvement as the in vivo environment is not completely shown with this cell line. One significant aspect omitted is the dissolution of the drug and the impact that this process has on amount of the dose of drug available for permutation.

Therefore the next step in producing a completely reflective model that can be used to form a good IVIVC is the combination of methods to take into account the many aspects influencing bioavailability¹ with an ultimate goal of creating an in vitro gastrointestinal system model.

Incorporation of a modified caco-2 cell line that has been co-cultured with other cells such as MDCK cells with an artificial digestive system model such as the TIM-1 model is an example of such steps that can be investigated into attaining the ultimate goal. Within the TIM-1 model there is still room for improvement but it does provide a foundation to build and develop upon. The incorporation of the newly created PBL dynamic gastric model to replace the gastric compartment of the TIM-1 would be a combination that would shed more insight into actual food effects on drug absorption and permutation. Developments similar to this would eventually lead to the creation of a very reliable and reflective in vitro model.

Bibliography

(1) Balimane PV, Chong S, Morrison RA. Current methodologies used for evaluation of intestinal permeability and absorption. J.Pharmacol.Toxicol.Methods 2000;44(1):301-312.

(2) Emami J. In vitro – In vivo relationships: Concepts, regulatory perspectives, advances and attempts. J.Pharm.Pharm.Sci. 2006 27 Feb;9(1):82-100.

(3) Hu M, Borchardt RT. Mechanism of L-alpha-methyldopa transport through a monolayer of polarized human intestinal epithelial cells (Caco-2). Pharm.Res. 1990;7(12):1313-1319.

(4) Emami J. In vitro-in vivo correlation: From theory to applications. J.Pharm.Pharm.Sci. 2006 16 Jun;9(2):31-51.

(5) Yu LX, Amidon GL, Polli JE, Zhao H, Mehta MU, Conner DP, et al. Biopharmaceutics classification system: The scientific basis for biowaiver extensions. Pharm.Res. 2002;19(7):921-925.

(6) Bergstrom CAS. In silico predictions of drug solubility and permeability: Two rate-limiting barriers to oral drug absorption. Basic Clin.Pharmacol.Toxicol. 2005 Mar;96(3):156-161.

(7) Barr WH, Riegelman S. Intestinal drug absorption and metabolism. I. Comparison of methods and models to study physiological factors of in vitro and in vivo intestinal absorption. J.Pharm.Sci. 1970;59(Feb):154-163.

(8) Galinis-Luciani D, Nguyen L, Yazdanian M. Is PAMPA a useful tool for discovery?. J.Pharm.Sci. 2007 Nov;96(11):2886-2892.

(9) Avdeef A, Bendels S, Di L, Faller B, Kansy M, Sugano K, et al. PAMPA – Critical factors for better predictions of absorption. J.Pharm.Sci. 2007 Nov;96(11):2893-2909.

(10) Boisset M, Botham RP, Haegele KD, Lenfant B, Pachot JI. Absorption of angiotensin II antagonists in Ussing chambers, Caco-2, perfused jejunum loop and in vivo:: Importance of drug ionisation in the in vitro prediction of in vivo absorption. European Journal of Pharmaceutical Sciences, 2000 5;10(3):215-224.

(11) Fearn RA, Hirst BH. Predicting oral drug absorption and hepatobiliary clearance: Human intestinal and hepatic in vitro cell models. Environ.Toxicol.Pharmacol. 2006 Feb;21(2 SPEC. ISS):168-178.

(12) Stewart BH, Chan OH, Lu RH, Reyner EL, Schmid HL, Hamilton HW, et al. Comparison of Intestinal Permeabilities Determined in Multiple in Vitro and in Situ Models: Relationship to Absorption in Humans. Pharm.Res. 1995 May;12(5):693-699.

(13) Yee S. In vitro permeability across Caco-2 cells (colonic) can predict in vivo (small intestinal) absorption in man – Fact or myth. Pharm.Res. 1997;14(6):763-766.

(14) Volpe DA. Variability in Caco-2 and MDCK cell-based intestinal permeability assays. J.Pharm.Sci. 2008 Feb;97(2):712-725.

(15) Walter E, Kissel T. Heterogeneity in the human intestinal cell line Caco-2 leads to differences in transepithelial transport. Eur.J.Pharm.Sci. 1995;3(4):215-230.

(16) Tsuji A, Takanaga H, Tamai I, Terasaki T. Transcellular transport of benzoic acid across Caco-2 cells by a pH-dependent and carrier-mediated transport mechanism. Pharm.Res. 1994;11(1):30-37.

(17) Gres M, Julian B, Bourrie M, Meunier V, Roques C, Berger M, et al. Correlation Between Oral Drug Absorption in Humans, and Apparent Drug Permeability in TC-7 Cells, A Human Epithelial Intestinal Cell Line: Comparison with the Parental Caco-2 Cell Line. Pharm.Res. 1998 May;15(5):726-733.

(18) Wils P, Warnery A, Phung-Ba V, Scherman D. Differentiated intestinal epithelial cell lines as in vitro models for predicting the intestinal absorption of drugs. Cell Biol.Toxicol. 1994 Dec;10(5-6):393-397.

(19) Irvine JD, Takahashi L, Lockhart K, Cheong J, Tolan JW, Selick HE, et al. MDCK (Madin-Darby canine kidney) cells: A tool for membrane permeability screening. J.Pharm.Sci. 1999 Jan;88(1):28-33.

(20) Tavelin S, Milovic V, Ocklind G, Olsson S, Artursson P. A conditionally immortalized epithelial cell line for studies of intestinal drug transport. J.Pharmacol.Exp.Ther. 1999 Sep;290(3):1212-1221.

This work was produced by one of our professional writers as a learning aid to help you with your studies

Can breastfeeding in the first six months prevent childhood obesity?

Childhood obesity is becoming a worldwide concern given the potential health implications in the future. Obese children are more likely to suffer physical and mental health problems and are likely to develop into obese adults (Labayen, Ruiz et al. 2012), thereby increasing the long term risk of developing chronic conditions such as diabetes, cardiovascular diseases and stroke.

The cause of childhood obesity is multifactorial, including hereditary factors, comorbidities, dietary habits and physical activity. There is much debate as to the impact of breastfeeding during the early stages of life and how it correlates with childhood obesity compared with formula-fed newborns.

Breast milk is nutritionally balanced to provide infants with all dietary requirements during the early stages of life. It also provides antibodies to reduce infection risks in newborns. Breast milk constitutes the appropriate amounts of protein, water, fat and sugar for a newborn and changes composition over time to adapt to a growing child’s needs. Formula tends to be higher in protein and fat than the baby actually requires and this excessive intake has been linked with adiposity (Hernell 2011). Marseglia et al have reviewed the potential impact of key breast milk constituents thought to play a role in reducing obesity risk (Marseglia, Manti et al. 2015).

There have been a number of recent reviews discussing the association between breastfeeding and childhood obesity, all of which have concluded that breastfeeding confers a protective effect against childhood obesity and being overweight (Horta and Victora 2013, Aguilar Cordero, Sanchez Lopez et al. 2014, Lefebvre and John 2014, Yan, Liu et al. 2014). The largest reduction in obesity risk was 81%, reported in a study of females aged 11 years of who had been breastfed for more than three months compared with controls who had never been breastfed (Panagiotakos, Papadimitriou et al. 2008). The males in the same study had a reduced risk of 72% and both results were statistically significant. However, other literature reports either no association between breastfeeding and childhood obesity (Burdette, Whitaker et al. 2006, Huus, Ludvigsson et al. 2008, Jing, Xu et al. 2014), or an increased risk of obesity following breastfeeding of 9% (Kwok, Schooling et al. 2010), 10% (Novaes, Lamounier et al. 2012), 11% (Buyken, Karaolis-Danckert et al. 2008), 14% (Sabanayagam, Shankar et al. 2009), 18% He (2000), 29% (Al-Qaoud and Prakash 2009), 34% (Neutzling, Hallal et al. 2009), 40% (Toschke, Martin et al. 2007) and 83% (Araujo, Victora et al. 2006), although none of which were statistically significant.

Some studies suggest that there is a dose-response relationship, with increased duration of breastfeeding resulting in a decreased prevalence of being obese in childhood (von Kries, Koletzko et al. 2000, Fallahzadeh, Golestan et al. 2009, Griffiths, Smeeth et al. 2009, Yan, Liu et al. 2014). In contrast, other studies have reported no significant association between breastfeeding and its duration and obesity prevention (Burke, Beilin et al. 2005, Al-Qaoud and Prakash 2009, Sabanayagam, Shankar et al. 2009, Vehapoglu, YazA±cA± et al. 2014).

One meta-analysis analysed the association between breastfeeding duration and obesity (Yan, Liu et al. 2014). As eligible studies reported different durations, the review categorised breastfeeding duration into less than three months, 3-4.9 months, 5-6.9 months and seven or more months. Those exclusively breastfed for at least seven months had a 21% decrease in the risk of childhood obesity, whilst those fed for less than three months only showed a 10% decrease. They concluded that the duration of breastfeeding was associated with a decreased likelihood of childhood obesity and reported a stepwise gradient of decreasing risk with increasing duration of breastfeeding.

Single studies report a significant protective effect against childhood obesity when breastfeeding is done for at least one to three months (Goldfield, Paluch et al. 2006), three months (Twells and Newhook 2010), 13-25 weeks (McCrory and Layte 2012), four months (Scholtens, Gehring et al. 2007, Griffiths, Smeeth et al. 2009, Chivers, Hands et al. 2010), nine months (Nelson and Sethi 2005), 12 months (Burke, Beilin et al. 2005) and two or more years (Rathnayake, Satchithananthan et al. 2013). However, the differences in study design make it difficult to directly compare findings as the comparator groups can be formula-fed babies or babies’ breastfed for short durations.

For studies investigating the impact of breastfeeding for at least six months on childhood obesity, the comparator group can be either newborns breastfed for less than six months (i.e. mixed feeding of variable durations) or newborns exclusively formula-fed. Additionally, the age of the children being assessed also differs in studies. When comparing those breastfed for at least six months with those breastfed less than six months, studies report a reduction in obesity risk of 60% when assessing two year olds (Weyermann, Rothenbacher et al. 2006), 54% and 43% in four year olds (Komatsu, Yorifuji et al. 2009, Simon, Souza et al. 2009), and 67% in six year olds (Thorsdottir, Gunnarsdottir et al. 2003). This suggests that the age of assessment affects the degree of risk reduction observed. However, when comparing against formula-fed newborns there are studies reporting reductions of 14%, 28% and 67% for three year olds (Poulton and Williams 2001, Armstrong, Reilly et al. 2002, Taveras, Rifas-Shiman et al. 2006), 6% for four year olds (Moschonis, Grammatikaki et al. 2008), 45% for seven year olds (Yamakawa, Yorifuji et al. 2013), 60% for nine year olds (Toschke, Martin et al. 2007), 64% for 11 year olds (Poulton and Williams 2001), 21% for 21 year olds (Poulton and Williams 2001) and 6% for 45 year olds (Michels, Willett et al. 2007). This data suggests that observing adults to determine the impact of breastfeeding on obesity is not advisable.

Only one study reported an increased risk of obesity for newborns breastfed more than six months compared with formula-fed newborns, reporting a non-significant 40% increased risk of obesity in nine year olds (Toschke, Martin et al. 2007).

Interestingly, very few detailed, for those breastfeeding for at least six months, whether the feeding duration was exclusively breastfeeding or mixed. Only two studies (Simon, Souza et al. 2009, Yamakawa, Yorifuji et al. 2013) reported on exclusive breastfeeding. There is evidence that exclusive breastfeeding also results in a decreased prevalence of being obese in childhood (Fallahzadeh, Golestan et al. 2009, Simon, Souza et al. 2009, Lefebvre and John 2014). Mayer-Davis et al (2006) compared exclusively breastfed newborns with exclusively formula-fed newborns and found that the breastfed children were significantly less likely to be overweight (34%) and that the results were not affected by maternal weight or diabetes status (Mayer-Davis, Rifas-Shiman et al. 2006).

When exploring the differences between studies who defined breastfeeding as “Never – ever” and those reporting “exposure” to breastfeeding (implying mixed feeding practices of different types), a systematic review found a reduced likelihood of obesity in the exclusive feeding group of 20% and in the mixed group of 27% (Yan, Liu et al. 2014). This was supported by another review comparing “ever” breastfed with “exclusively breastfed for a specific number of months”, the latter showing a 27% decreased risk compared with the former at 21% (Horta and Victora 2013). That review postulated that if there is no critical window effect, but rather a cumulative effect of breastfeeding, studies that compared ever vs. never breastfed subjects will tend to underestimate any association.

Any observed association between breastfeeding and later obesity does not prove causality (Butte 2001). There may be any number of potential confounders impacting on the relationship including geography, social deprivation status, parental weight status, smoking, marital status and education, ethnicity, gender, number of hospital admissions during the early stages of life, diet, sleep duration and physical activity. Whilst a number of studies discuss their impact, very few studies actually provide control for these factors in their analysis.

The issue of geography is a potential confounder of any association between breastfeeding and obesity. In high-income countries, the babies usually receive formula, whereas many

non-breastfed infants in low and middle income countries receive whole or diluted animal milk (Horta and Victora 2013). However, Hancox et al have reported that whilst breastfeeding reduced the risk of obesity slightly, there was no evidence that an association between breastfeeding and body mass index (BMI) was different in lower income countries compared with higher income countries (Hancox, Stewart et al. 2014).

The socio-economic status of the mother may also contribute to the child’s weight status in childhood. The World Health Organisation (WHO) review analysed obesity risk in studies also controlling for social deprivation and found a further 3% decrease in the risk of obesity to 37% compared with studies which did not (34%) (Horta and Victora 2013). Armstrong et al reported that the reduced prevalence in obesity for breastfed children also persisted after adjustment for socio-economic status, birth weight and gender (30% reduction) (Armstrong, Reilly et al. 2002).

The impact of gender was prominent as Nelson et al reported that breastfeeding for at least nine months reduced the risk of being overweight more in girls than in boys (Nelson and Sethi 2005). A similar gender inequality was reported by Panagiotakos et al with girls breastfed for more than three months having a larger reduced risk of obesity than the boys (Panagiotakos, Papadimitriou et al. 2008).

Sibling studies have been unable to rule out the impact of confounders on childhood obesity. One study which controlled for this as part of a sibling study reported the adolescent BMIs were 0.39 standard deviations lower in the breastfed sibling than the non-breastfed sibling (Metzger and McDade 2010). However, another study of sibling pairs was unable to prove a protective effect for breastfeeding (Nelson and Sethi 2005).

As well as the lack of control for confounders, other study limitations may affect the results reported. Definitions of obesity vary from a BMI of ?90th to ?97th, making any direct comparison of the outcome problematic. During their meta-analysis Yan et al investigated the association of breastfeeding and obesity, stratifying by the definitions of obesity and found a lower adjusted odds ratio for the BMI ? 97th group (25%) than the BMI ? 95th group (22%) (Yan, Liu et al. 2014).

Most studies varied in the time when obesity was measured. As the definition of childhood can extend from one year olds to adolescents, there is an increasing influence of external and genetic factors on a child’s weight as potential confounders for any weight gain. When Scholtens et al looked at children breastfed for at least four months they reported a significantly lower BMI at age 1 compared to children not breastfed, but at age 7 this difference was no longer significant (Scholtens, Gehring et al. 2007). The WHO review reported a 38% decreased risk of obesity when assessing 10-19 year olds compared with 23% for 1-9 year olds and 11% for adults aged 20 and over, suggesting that endpoint for analysis is critical in determining the impact of breastfeed on obesity at various stages in childhood (Horta and Victora 2013).

Finally, study design and follow up can affect the findings as high dropout rates affect long term follow ups, and the methodology used to analyse the results can produce unreliable results. Beyerlein et al investigated the impact of breastfeeding on children’s BMI in Germany but was unable to make any firm conclusions as the results differed according to whether they used linear or logistic regression (Beyerlein, Toschke et al. 2008).

To summarise, there is a wealth of literature reporting the decreased risk of childhood obesity for newborns who are breastfed, although there was limited literature exploring those breastfed for at least six months. However, most studies cannot completely control for confounding maternal, child, cultural, genetic and environmental factors. The WHO recommend that infants should be exclusively breastfed for the first six months and that it should be supplemented with additional foods for the first two years (World Health Organisation 2015). Following close examination of the literature, we would conclude that breastfeeding for at least six months should reduce the risk of obesity in early childhood, although the protective effect may be lost in latter childhood depending upon the child’s upbringing.

References?

Aguilar Cordero, M. J., A. M. Sanchez Lopez, N. Madrid Banos, N. Mur Villar, M. Exposito Ruiz and E. Hermoso Rodriguez (2014). “[Breastfeeding for the prevention of overweight and obesity in children and teenagers; systematic review].” Nutr Hosp 31(2): 606-620.

Al-Qaoud, N. and P. Prakash (2009). “Breastfeeding and obesity among Kuwaiti preschool children.” Med Princ Pract 18(2): 111-117.

Araujo, C. L., C. G. Victora, P. C. Hallal and D. P. Gigante (2006). “Breastfeeding and overweight in childhood: evidence from the Pelotas 1993 birth cohort study.” Int J Obes (Lond) 30(3): 500-506.

Armstrong, J., J. J. Reilly and C. H. I. Team (2002). “Breastfeeding and lowering the risk of childhood obesity.” Lancet 359(9322): 2003-2004.

Beyerlein, A., A. M. Toschke and R. von Kries (2008). “Breastfeeding and childhood obesity: shift of the entire BMI distribution or only the upper parts?” Obesity (Silver Spring) 16(12): 2730-2733.

Burdette, H. L., R. C. Whitaker, W. C. Hall and S. R. Daniels (2006). “Breastfeeding, introduction of complementary foods, and adiposity at 5 y of age.” Am J Clin Nutr 83(3): 550-558.

Burke, V., L. J. Beilin, K. Simmer, W. H. Oddy, K. V. Blake, D. Doherty, G. E. Kendall, J. P. Newnham, L. I. Landau and F. J. Stanley (2005). “Breastfeeding and overweight: longitudinal analysis in an Australian birth cohort.” J Pediatr 147(1): 56-61.

Butte, N. F. (2001). “The role of breastfeeding in obesity.” Pediatr Clin North Am 48(1): 189-198.

Buyken, A. E., N. Karaolis-Danckert, A. Gunther and M. Kersting (2008). “Effects of breastfeeding on health outcomes in childhood: beyond dose-response relations.” Am J Clin Nutr 87(6): 1964-1965; author reply 1965-1966.

Chivers, P., B. Hands, H. Parker, M. Bulsara, L. J. Beilin, G. E. Kendall and W. H. Oddy (2010). “Body mass index, adiposity rebound and early feeding in a longitudinal cohort (Raine Study).” Int J Obes (Lond) 34(7): 1169-1176.

Fallahzadeh, H., M. Golestan, T. Rezvanian and Z. Ghasemian (2009). “Breast-feeding history and overweight in 11 to 13-year-old children in Iran.” World J Pediatr 5(1): 36-41.

Goldfield, G. S., R. Paluch, K. Keniray, S. Hadjiyannakis, A. B. Lumb and K. Adamo (2006). “Effects of breastfeeding on weight changes in family-based pediatric obesity treatment.” J Dev Behav Pediatr 27(2): 93-97.

Griffiths, L. J., L. Smeeth, S. S. Hawkins, T. J. Cole and C. Dezateux (2009). “Effects of infant feeding practice on weight gain from birth to 3 years.” Arch Dis Child 94(8): 577-582.

Hancox, R. J., A. W. Stewart, I. Braithwaite, R. Beasley, R. Murphy, E. A. Mitchell and I. P. T. S. Group (2014). “Association between breastfeeding and body mass index at age 6-7 years in an international survey.” Pediatr Obes.

Hernell, O. (2011). “Human milk vs. cow’s milk and the evolution of infant formulas.” Nestle Nutr Workshop Ser Pediatr Program 67: 17-28.

Horta, B. L. and C. G. Victora (2013). Long-term effects of breastfeeding: a systematic review, World Health Organisation: 74.

Huus, K., J. F. Ludvigsson, K. Enskar and J. Ludvigsson (2008). “Exclusive breastfeeding of Swedish children and its possible influence on the development of obesity: a prospective cohort study.” BMC Pediatr 8: 42.

Jing, H., H. Xu, J. Wan, Y. Yang, H. Ding, M. Chen, L. Li, P. Lv, J. Hu and J. Yang (2014). “Effect of breastfeeding on childhood BMI and obesity: the China Family Panel Studies.” Medicine (Baltimore) 93(10): e55.

Komatsu, H., T. Yorifuji, T. Iwase, A. Sasaki, S. Takao and H. Doi (2009). “Impact of breastfeeding on body weight of preschool children in a rural area of Japan: population-based cross-sectional study.” Acta Med Okayama 63(1): 49-55.

Kwok, M. K., C. M. Schooling, T. H. Lam and G. M. Leung (2010). “Does breastfeeding protect against childhood overweight? Hong Kong’s ‘Children of 1997’ birth cohort.” Int J Epidemiol 39(1): 297-305.

Labayen, I., J. R. Ruiz, F. B. Ortega, H. M. Loit, J. Harro, I. Villa, T. Veidebaum and M. Sjostrom (2012). “Exclusive breastfeeding duration and cardiorespiratory fitness in children and adolescents.” Am J Clin Nutr 95(2): 498-505.

Lefebvre, C. M. and R. M. John (2014). “The effect of breastfeeding on childhood overweight and obesity: a systematic review of the literature.” J Am Assoc Nurse Pract 26(7): 386-401.

Marseglia, L., S. Manti, G. D’Angelo, C. Cuppari, V. Salpietro, M. Filippelli, A. Trovato, E. Gitto, C. Salpietro and T. Arrigo (2015). “Obesity and breastfeeding: The strength of association.” Women Birth.

Mayer-Davis, E. J., S. L. Rifas-Shiman, L. Zhou, F. B. Hu, G. A. Colditz and M. W. Gillman (2006). “Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter?” Diabetes Care 29(10): 2231-2237.

McCrory, C. and R. Layte (2012). “Breastfeeding and risk of overweight and obesity at nine-years of age.” Soc Sci Med 75(2): 323-330.

Metzger, M. W. and T. W. McDade (2010). “Breastfeeding as obesity prevention in the United States: a sibling difference model.” Am J Hum Biol 22(3): 291-296.

Michels, K. B., W. C. Willett, B. I. Graubard, R. L. Vaidya, M. M. Cantwell, L. B. Sansbury and M. R. Forman (2007). “A longitudinal study of infant feeding and obesity throughout life course.” Int J Obes (Lond) 31(7): 1078-1085.

Moschonis, G., E. Grammatikaki and Y. Manios (2008). “Perinatal predictors of overweight at infancy and preschool childhood: the GENESIS study.” Int J Obes (Lond) 32(1): 39-47.

Nelson, A. and S. Sethi (2005). “The breastfeeding experiences of Canadian teenage mothers.” J Obstet Gynecol Neonatal Nurs 34(5): 615-624.

Neutzling, M. B., P. R. Hallal, C. L. Araujo, B. L. Horta, M. e. F. Vieira, A. M. Menezes and C. G. Victora (2009). “Infant feeding and obesity at 11 years: prospective birth cohort study.” Int J Pediatr Obes 4(3): 143-149.

Novaes, J. F., J. A. Lamounier, E. A. Colosimo, S. C. Franceschini and S. E. Priore (2012). “Breastfeeding and obesity in Brazilian children.” Eur J Public Health 22(3): 383-389.

World Health Organisation. (2015). “Breastfeeding.” Retrieved March 2015 from http://www.who.int/topics/breastfeeding/en/.

Panagiotakos, D. B., A. Papadimitriou, M. B. Anthracopoulos, M. Konstantinidou, G. Antonogeorgos, A. Fretzayas and K. N. Priftis (2008). “Birthweight, breast-feeding, parental weight and prevalence of obesity in schoolchildren aged 10-12 years, in Greece; the Physical Activity, Nutrition and Allergies in Children Examined in Athens (PANACEA) study.” Pediatr Int 50(4): 563-568.

Poulton, R. and S. Williams (2001). “Breastfeeding and risk of overweight.” JAMA 286(12): 1449-1450.

Rathnayake, K. M., A. Satchithananthan, S. Mahamithawa and R. Jayawardena (2013). “Early life predictors of preschool overweight and obesity: a case-control study in Sri Lanka.” BMC Public Health 13: 994.

Sabanayagam, C., A. Shankar, Y. S. Chong, T. Y. Wong and S. M. Saw (2009). “Breast-feeding and overweight in Singapore school children.” Pediatr Int 51(5): 650-656.

Scholtens, S., U. Gehring, B. Brunekreef, H. A. Smit, J. C. de Jongste, M. Kerkhof, J. Gerritsen and A. H. Wijga (2007). “Breastfeeding, weight gain in infancy, and overweight at seven years of age: the prevention and incidence of asthma and mite allergy birth cohort study.” Am J Epidemiol 165(8): 919-926.

Simon, V. G., J. M. Souza and S. B. Souza (2009). “Breastfeeding, complementary feeding, overweight and obesity in pre-school children.” Rev Saude Publica 43(1): 60-69.

Taveras, E. M., S. L. Rifas-Shiman, K. S. Scanlon, L. M. Grummer-Strawn, B. Sherry and M. W. Gillman (2006). “To what extent is the protective effect of breastfeeding on future overweight explained by decreased maternal feeding restriction?” Pediatrics 118(6): 2341-2348.

Thorsdottir, I., I. Gunnarsdottir and G. I. Palsson (2003). “Birth weight, growth and feeding in infancy: relation to serum lipid concentration in 12-month-old infants.” Eur J Clin Nutr 57(11): 1479-1485.

Toschke, A. M., R. M. Martin, R. von Kries, J. Wells, G. D. Smith and A. R. Ness (2007). “Infant feeding method and obesity: body mass index and dual-energy X-ray absorptiometry measurements at 9-10 y of age from the Avon Longitudinal Study of Parents and Children (ALSPAC).” Am J Clin Nutr 85(6): 1578-1585.

Twells, L. and L. A. Newhook (2010). “Can exclusive breastfeeding reduce the likelihood of childhood obesity in some regions of Canada?” Can J Public Health 101(1): 36-39.

Vehapoglu, A., M. YazA±cA±, A. D. Demir, S. Turkmen, M. Nursoy and E. Ozkaya (2014). “Early infant feeding practice and childhood obesity: the relation of breast-feeding and timing of solid food introduction with childhood obesity.” J Pediatr Endocrinol Metab 27(11-12): 1181-1187.

von Kries, R., B. Koletzko, T. Sauerwald and E. von Mutius (2000). “Does breast-feeding protect against childhood obesity?” Adv Exp Med Biol 478: 29-39.

Weyermann, M., D. Rothenbacher and H. Brenner (2006). “Duration of breastfeeding and risk of overweight in childhood: a prospective birth cohort study from Germany.” Int J Obes (Lond) 30(8): 1281-1287.

Yamakawa, M., T. Yorifuji, S. Inoue, T. Kato and H. Doi (2013). “Breastfeeding and obesity among schoolchildren: a nationwide longitudinal survey in Japan.” JAMA Pediatr 167(10): 919-925.

Yan, J., L. Liu, Y. Zhu, G. Huang and P. P. Wang (2014). “The association between breastfeeding and childhood obesity: a meta-analysis.” BMC Public Health 14: 1267.

This work was produced by one of our professional writers as a learning aid to help you with your studies

When I was five, my grandmother passed away in hospital just before Christmas. She had been in the hospital for some time and was very elderly. As my sisters and I were at school, we could only visit the hospital at the weekend, whereas my mother and father would visit during the week. At weekends my sisters and I would be given the choice about going to the hospital with our father to visit, or to stay at home. I often chose to stay at home. I understood that my grandmother was old, however I did not understand how ill she was.

When my grandmother passed away, I felt guilty that I had not chosen to visit her. Although I knew that my grandmother had been ill for some time, I had not understood that she was coming to the end of her life, and it had also not been explained to me by the adults. I knew that death was irreversible, however because her death did not impact on my daily routine as my parents sought to maintain normality as far as possible. I found that my life continued as usual, without any major interruptions.

In the week leading up to my grandmother’s funeral I saw my father crying and remember that seeing my father cry made me feel both frightened and upset. I felt upset because I had never seen my father cry before, and I realised that he was suffering greatly. As a result of this, I tried to behave well at all times as I was worried that my actions would cause my father to cry again. I felt frightened because although my grandmother’s death had not had a large impact on myself, I could see that it was having a profound effect on those that I cared about. As I was only a small child, this was the first time that I had seen such a depth of emotion in those close to me, and I was not sure how to react to this.

Research has demonstrated that children, even very young children, are capable of grieving (Melhern et al, 2011). It is important to note that there are differences in the way that adults and children grieve. In particular, children are likely to show their grief in less direct ways than adults, and can move in and out of grief, almost grieving in bursts (Melhern et al, 2011). It is also important to realise that the child’s age, emotional maturity, circumstances of loss, and the level of relationship between the child and the person who has died are all important factors (Dowdney, 2008).

Piaget’s research demonstrated that toddlers and infants understand events in terms of direct experience, and that the dependable presence and emotional expression of loved people are more important than the language used (Piaget, 2013). Studies which have applied Piaget’s work have demonstrated that even children who cannot yet communicate verbally are aware of the distress of adults around them and are aware of the absence of a loved person (Himebauch et al, 2008). It can therefore be thought that not telling young children about the death of a family member will not protect them from the loss as intended, and will only prevent discussion.

This fits with Piaget’s work, who found that young children (between the ages of 3 – 6) do not think in logical sequences, and therefore have illogical explanations for events (Piaget, 2013). This is reflected in the difficulty they may have grasping that death is not reversible (Brown et al, 2008). Families often find it easier to help children after the loss of a grandparent, as they are often in an age group where death is more common (Brown et al, 2008). In my case, I did not have daily interaction with my grandmother due to geographical distance, however we did have regular contact at weekends. This may have meant that there were fewer obvious changes and reminders of the absence.

This is clearly not applicable to all children and cultures, where the grandparents may play a central role in the child’s life and in the family (Salloum, 2008). In these cases, the effect of the loss may be apparent as regression or behavioural problems in the child (Salloum, 2008). Ongoing discussion of the loss can provide the opportunity for children to reinterpret the death over the years as their cognitive comprehension grows (Salloum, 2008). Research has clearly demonstrated that the lack of a well-structured support system during the mourning period can lead to severe disruption of childhood development (Bonanno, 2004).

One study conducted in the United States found that out of 270 children taken to counselling after the death of a loved one and who lacked a well-structured support system, 66% demonstrated aggressive behaviour, 44% lacked social skills, and 18% had delayed cognitive, fine and gross motor development (McClatchy et al, 2009). However, it is not possible to determine from the study whether these children had developmental difficulties before counselling. If this is true, the quoted percentages may not be a true reflection of the impact of a lack of a well-structured support system.

There is also a clear impact on the academic abilities of children who have suffered loss Shear & Shair, 2005). In addition to this, children often have higher levels of absenteeism from school when a close relative is ill, which could have an impact on their academic performance. This impact on academic performance is often seen in children who have witnessed a traumatic death and subsequently develop post-traumatic stress disorder (Shear & Shair, 2005). I believe that my parents made considerable efforts not to disrupt the daily routines of my sisters and I, particularly around school. I think that this ensured that our academic performance did not suffer as much as it may otherwise have.

It is clear that children’s understanding of death develops in parallel with cognitive maturing throughout childhood (Cohen, 2011). The concept of death may develop at different rates in different children, but the developmental sequence seems to be the same (Cohen, 2011). For example, children below the age of five do not understand that death is irreversible, and will demonstrate this by asking when the person is coming back (Salloum, 2008). As a result of this, children at this age will have difficulty understanding abstract explanations of death, and such explanations such as saying the person has gone to sleep may result in fear of sleep (Cohen, 2011). It is therefore clear that although the concept of death is not fully developed in small children, there is little doubt that they still react strongly to loss at this age (Cohen, 2011).

This does not apply to my experience of loss, as I was slightly older; however it is clear that loss at even a very young age can have a lasting impression on children. Between the ages of four and six, it is thought that children begin to develop a biological understanding of life (Crenshaw, 2005). An example of this is knowing that parts of the body work to sustain life. I feel that this is true of my experience – I knew my grandmother was in hospital because she was ill; however I did not understand the seriousness of her illness, or that she had been in hospital for a considerable length.

Children from five to ten years of age develop an understanding of death as an irreversible process (Currier et al, 2008). Concrete thinking is seen in children until the age of 10, and need concrete expressions such as pictures or visiting graves or memorials as support for their grief (Currier et al, 2008). When my grandmother died, I knew that it was an irreversible event. My parents chose not to take me to the funeral, which I feel was a wise decision. I believe that although I knew my grandmother had died and that this was not a reversible event, I would have found it distressing to see my parents and other adults so openly upset. Research has also found that if children do attend funerals, it should be with someone who can provide emotional support (Currier et al, 2008), and I feel that this would have been an unfair demand on my parents at the funeral, particularly as I was so young.

As I grew older I found that accompanying my parents to the graves of my grandparents, particularly my grandmother, helped me to express my feelings and to ask questions. This is supported by literature which states that visiting graves or memorials can offer children or young adolescents a channel for communicating about the deceased person, which can help them to understand the circumstances of the loss and can also act as an opportunity to express their feelings (Paris et al, 2009). I found that as I matured, I could talk about my grandparents away from their graves, as I came to realise that this would not upset my parents. As a result of this, we were able to talk much more freely and openly about their lives.

My grandmother was the only grandparent that I had known, as my other grandparents had died before I was born. As my grandmother had died when I was relatively young, I have no substantial memories of her. Throughout my childhood this did not have a large impact on my beliefs and attitudes, as I believe that I did not possess the emotional maturity to reflect on the changes this had made to my life, and the impact that her death may have had on those around me. As I grew older, I became aware of the effects of loss on those around me, and in turn this altered my beliefs about life. For example, as I matured I became aware that death can happen at any age and so I was more appreciative of the roles that relatives and friends played in my life, and did not take their presence for granted.

This changed when I was at secondary school and I came to appreciate the roles and relationships that grandparents had in the lives of my peers. I felt, and still feel, that I have missed out on these key relationships, particularly as my parents often comment on how similar I am in both personality and appearance to my grandmother on my mother’s side. As I grew older, particularly in adolescence, I came to value relationships with relatives and friends in a different way from childhood, and I think that experiencing loss early in life was a large part of this. I believe that it is important to work hard to overcome obstacles to maintaining relationships, such as geographical distance and cultural differences, particularly as there is now greater mobility for employment.

In conclusion, although the death of my grandmother was perhaps not a shock to the adults in my life, I had not grasped how ill she was, nor had it been explained to me by adults close to me. As a result of this, I felt guilty because I had not chosen to visit her in the hospital when offered the opportunity. However as we had always lived quite far apart, there was no real impact on my daily life, which research has shown to be particularly disruptive for children going through grief (Bonanno, 2004).

There is clear evidence that experiencing death, particularly a traumatic death, can have a profound effect on childhood, and that a well-established support system is key (Brown et al, 2008). I believe that I had a well-established support system, and this allowed me to adapt to life without my grandmother without great levels of difficulty. Whilst I wish I could have had a longer relationship with my grandmother and have known my other grandparents, I believe it is important not to dwell on things that cannot be changed. Instead I invest my energy in building and maintaining relationships with friends and family. I believe that this attitude comes with maturity and experience of loss, and that small children may not have the emotional capacity to understand this.

References

Bonanno, G. (2004). Loss, trauma, and human resilience: have we underestimated the human capacity to thrive after extremely aversive events? American Psychologist, 59(1), pp.20-28.

Brown, E., Amaya-Jackson, L., Cohen, J., Handel, S., Zatta, E. (2008). Childhood traumatic grief: a multi-empirical examination of the construct and its correlates. Death Studies, 32(10), pp.323-326.

Cohen, J. 2011. Supporting children with traumatic grief: what educators need to know. Developmental and Educational Psychology, 32(2), pp. 117 – 131.

Crenshaw, D. 2005. Clinical tools to facilitate treatment of childhood traumatic grief. Journal of Death and Dying, 51(3), pp.239-255.

Currier, J., Neimeyer, R., Berman, J. (2008). The effectiveness of psychotherapeutic interventions for bereaved persons: A comprehensive quantitative review. Psychological Bulletin, 134(5), pp. 648-661.

Dowdney, L. (2008). Children bereaved by parent or sibling death. Psychiatry, 7(6), pp.270-275.

Himebauch, A., Arnold, R., May, C. (2008). Grief in children and developmental concepts of death. Journal of Palliative Medicine, 11(2), pp.242-244.

McClatchy, I., Vonk, E., Palardy, G. (2009). The prevalence of childhood traumatic grief – a comparison of violent/sudden and expected loss. Journal of Death and Dying, 59(4), pp.305-323.

Melhern, N., Porta, G., Shamseddeen, W., Walker, M., Brent, D. (2011). Grief in children and adolescents bereaved by sudden parental death. Archives of General Psychiatry, 68(9), pp.911-919.

Paris, M., Carter, B., Day, S., Armsworth, M. (2009). Greif and trauma in children after the death of a sibling. Journal of Child and Adolescent Trauma, 2(2), pp.71-80.

Piaget, J. (2013). The Construction of Reality in the Child. 3rd ed. London: Routledge.

Salloum, A. (2008). Evaluation of individual and group grief and trauma interventions for children post-disaster. Journal of Clinical Child and Adolescent Psychology, 37(3), pp. 495-507.

Shear, K., and Shair, H. (2005). Attachment, loss, and complicated grief. Developmental Psychobiology, 47(3), pp.253-267.

This work was produced by one of our professional writers as a learning aid to help you with your studies

In the context of maternity care, ‘collaboration’ is defined as a shared partnership between a birthing woman, midwives, doctors and other members of a multidisciplinary team (National Health & Medical Research Council, 2010). Collaborative practice is based on the philosophy that multidisciplinary teams can deliver care superior to that which could be provided by any one profession alone (National Health & Medical Research Council, 2010). Indeed, there is evidence to suggest that collaborative maternity practice does improve outcomes for women, including both clinical outcomes and consumer satisfaction with care (Hastie & Fahy, 2011). Collaborative practice is particularly important in Australian rural and remote maternity settings, which are characterised by fragmented, discontinuous care provision (Downe et al., 2010). As such, both the Code of Ethics for Midwives in Australia (for midwives and obstetric nurses) and the Collaborative Maternity Care Statement (for obstetricians and other doctors) require that a collaborative model of care be adopted in Australian maternity settings. However, inconsistencies between and among midwives and doctors about the definition of ‘collaboration’, and subsequent ineffective collaborative practice, remain key causes of adverse outcomes in maternity settings in Australia (Hastie & Fahy, 2011; Heatley & Kruske, 2011). This paper provides a critical analysis of collaborative practice in Australian rural and remote maternity settings.

Rural and remote maternity care in Australia

It is estimated that one-third of birthing women in Australia live outside of major metropolitan centres – defined for the purpose of this paper as ‘rural and remote regions’ (National Health & Medical Research Council, 2010). However, the number of facilities offering maternity care to women in these regions is just 156 and declining (2007 estimate) (Australian Government Department of Health, 2011). Australian research suggests that the decreasing number of rural and remote maternity services is resulting in more women having high-risk, unplanned and unassisted births outside of medicalised maternity services (Francis et al., 2012; McLelland et al., 2013); indeed, one recent study drew a direct correlation between these two factors (Kildea et al., 2015). Additionally, statistics suggest that both maternal and neonatal perinatal mortality rates in Australia are highest in rural and remote regions (Australian Government Department of Health, 2011).

High perinatal mortality rates and lack of services in rural and remote communities mean that many rural and remote women are transferred to metropolitan centres, often mandatorily, for birth (Josif et al., 2014). This system has resulted in fragmented, discontinuous care for many rural and remote women – which is itself a poor outcome (National Health & Medical Research Council, 2010; Sandall et al., 2015). Many women find such models of care to be significantly disempowering, which again may result in poorer outcomes (Josif et al., 2014). Indeed, many women, and particularly Aboriginal women, may resist engaging with medicalised maternity services to avoid being transferred ‘off-country’ for birth (Josif et al., 2014). Furthermore, those women who are transferred ‘off-country’ for birth bear a significant financial, social and cultural burden (Dunbar, 2011; Evans et al., 2011; Hoang & Le, 2013).

Australian maternity services reform

In response to these issues, in 2009 the Australian government commenced a major reform of maternity care. This reform included attempts to shift maternity services provided to rural and remote women to more collaborative, continuous, community-centred models (Francis et al., 2012). These new models of care require midwives to work collaboratively with general practitioners, obstetricians and rural doctors to care for a rural or remote woman in her own community to the greatest extent possible (McIntyre et al., 2012a). Evidence suggests that rural and remote women desire to be cared for in their local communities provided the maternity services offered are safe (Hoang & Le, 2013). Indeed, there is evidence to suggest that women, and particularly Aboriginal women, who birth within their communities have an increased likelihood of positive outcomes (Commonwealth of Australia, 2009). However, the National Guidance on Collaborative Maternity Care, which resulted from the government reforms, notes there are a number of unique and significant challenges to achieving collaborative practice in rural and remote community settings (National Health & Medical Research Council, 2010).

Collaborative care in Australian maternity settings – challenges and complexities

The fundamental aim of collaborative services in Australia is the provision of ‘woman-centred care’, where women are empowered to be active partners in the provision of their care (National Health & Medical Research Council, 2010). It is well-established that the delivery of woman-centred care in a maternity setting produces the best outcomes, in terms of both clinical outcomes and consumer satisfaction with care (Pairman et al., 2006). In a recent Australian study, Jenkins et al. (2015) suggest that collaboration is fundamental in the achievement of woman-centred care in rural and remote settings in terms of continuity of care – including consistency in communication between care providers – across often vast geographical regions. However, conflicting definitions and interpretations of the concept of ‘woman-centred care’ between midwives and doctors are a key barrier to achieving collaborative practice in Australian maternity settings (Lane, 2006). These problems are magnified in rural and remote settings, where transfers of care between midwives and doctors often occur abruptly when women are transported ‘off-country’ to deliver (Lane, 2012).

Differences in understandings of the concept of ‘woman-centred care’ between midwives and doctors – and, therefore, impairments to effective collaboration – are underpinned by midwives’ and doctors’ differing perceptions of ‘risk’ in childbirth. Indeed, a study by Beasley et al. (2012) identified incompatible perceptions of best-practice strategies to mitigate risk as the key factor underpinning the lack of collaborative practice between midwives and doctors in Australian maternity settings. Whilst midwives focus on normalcy, wellness and physiology in birth, doctors place an emphasis on intervention – both valid approaches to risk mitigation in birth, but fundamentally contradictory (Lane, 2006; Beasley et al. 2012; Downe et al., 2010; Lane 2006). These differing philosophies of care have resulted in increasing tensions in maternity settings, and this has been exacerbated by sensationalist media reporting, particularly following the Senate Inquiries into Media Reform of 2008/09 (Beasley et al., 2012). The concept of risk is particularly important in rural and remote settings, given the decision to transfer a woman ‘off-country’ is often made on the basis of risk.

The reforms to the Australian maternity system – including the introduction of the Nurses and Midwives Act 2009 – have resulted in significant increases to midwives’ scope of practice and autonomy (National Health & Medical Research Council, 2010; Beasley et al., 2012). This is particularly important in rural settings, where midwives are often required to be ‘specialist generalists’ with a diverse suite of clinical skills (Gleeson, 2015). However, this expansion in midwives’ scope has further challenged the achievement of collaborative practice in Australian maternity settings. Tensions have occurred because doctors often perceive themselves to be solely accountable for the outcomes of maternity care and, therefore, legally vulnerable when practicing under midwifery-led models of care focusing in risk-mitigation strategies to which they may be unaccustomed or opposed (Lane, 2006; Beasley et al., 2012). These issues are particularly obvious in rural and remote maternity settings, where the referral of the care of birthing women by midwives to doctors may occur primarily during obstetric emergencies. Doctors in Australia have been particularly vocal about the fact that there is poor evidence to support the safety of midwifery-led models of care, including in rural and remote maternity settings (Boxall & Flitcroft, 2007).

The expansion in midwives’ scope of practice has also challenged the achievement of collaborative practice in Australian maternity settings in other ways. Australian research suggests doctors fear the expansion of midwives’ scope will result in them becoming redundant in, and therefore, excluded from maternity settings, and that a decline in clinical outcomes will result (Lane, 2012). As noted by Barclay and Tracy (2010), despite the recent increases to midwives’ scope of practice, both midwives’ and doctors’ continue to have a distinct scope in terms of caring for a birthing woman and both remain legally bound to practice within this scope. However, many doctors continue to oppose the reforms to the maternity system on the basis of changes in midwives’ scope – and also because these reforms may not be evidence based, may fail to meet the needs of women (and particularly the unique needs of rural and remote women), and are driven by service providers rather than consumers (Boxall & Flitcroft, 2007; McIntyre et al., 2012b; Hoang & Le, 2013). Again, doctors’ opposition to changes in midwives’ scope significantly impairs the achievement of collaborative practice in Australian maternity settings.

These issues are further complicated by the fact that Commonwealth law now requires midwives practicing in Australia to have ‘collaborative arrangements’ with a medical practitioner if they are to receive Medicare-provider status (Barclay & Tracy, 2010). This particularly affects private-practice midwives practicing in rural and remote areas of Australia. However, as noted by Lane (2012), such legislation – which effectively forces midwives and doctors into a collaborative relationship – is fundamentally inconsistent with the concept of collaboration as a professional relationship based on equity, trust and respect. Further, these reforms impose collaboration and compel midwives and doctors to form collaborative relationships are unworkable in many rural and remote maternity settings. Often, midwives practicing in these settings work with doctors who are fly-in fly-out locums, who are on temporary placements or who are located in regional centres many hundreds of kilometres away, making the establishment of genuine collaborative relationships a highly complex process (Barclay & Tracy, 2010).

Collaborative care in Australian maternity settings – opportunities and achievement

Despite these significant issues, however, research suggests that collaboration can be achieved in Australian rural and remote maternity settings. The first step in achieving collaboration in this context is for both midwives and doctors to undergo a ‘shift in perception’ with regards to each other’s’ professional roles and boundaries (Lane, 2006; McIntyre et al., 2012a). This will particularly involve doctors’ increasing acceptance of midwives’ expanding role in rural and remote maternity care provision. Rural and remote maternity services in particular provide positive examples of midwifery-led models of maternity care providing maternity services which are both safe and effective (McIntyre et al., 2012a); indeed, one study concludes that shared but midwifery-led models are the best way to achieve continuity of care in rural and remote maternity settings (Francis et al., 2012). Therefore, evidence from these models may be used to bolster doctors’ confidence in the efficacy of midwifery-led approaches to maternity care. However, for this to be achieved, incompatibilities in care philosophies between midwives and doctors must be overcome. This may commence with midwives and doctors recognising that both professions share the same basic goal of achieving the best outcomes for women (Lane, 2006).

Communication is also fundamental to the achievement of collaborative practice in Australian maternity settings (National Health & Medical Research Council, 2010). Indeed, Lane (2012) notes that effective communication between midwives and doctors is one of the ‘minimal conditions’ which must be met if collaborative practice in maternity settings is to be achieved. However, there are a range of barriers to effective communication between midwives and doctors in rural and remote maternity settings, the most significant of which is geographical distance. ‘Telehealth’, which involves the use of telecommunication technologies to facilitate communication between clinicians – and particularly those who care for ‘priority consumers’ such as mothers and babies’ – in geographically diverse regions of Australia may be useful in promoting collaborative practice in rural and remote maternity settings (Australian Nursing Federation 2013). The National Health & Medical Research Council (2010) also identifies written documentation – including pregnancy records, care pathways and a transfer / retrieval plan – to be important in fostering collaborative practice in in rural and remote maternity settings.

Collaboration, or practice based on a shared partnership between a birthing woman, midwives, doctors and other members of a multidisciplinary team, results in improves outcomes for birthing women. As such, codes of practice for both midwives and doctors in Australia require that collaborative practice be utilised in Australian maternity settings. Research evidence suggests that due to the unique challenges posed by rural and remote maternity settings in Australia, collaborative practice is particularly important in this context. However, in Australia in general – and in rural and remote maternity settings in particular – collaborative practice is both lacking and challenging to achieve. This paper has provided a critical analysis of collaborative practice, with a particular focus on Australian rural and remote maternity settings. It has concluded that whilst it may be challenging to achieve, collaboration in Australian rural and remote maternity settings can – and, indeed, should – be achieved in order to promote the best outcomes for birthing women in these regions.

References

Australian Government Department of Health, (2011), Provision of Maternity Care, accessed 02 October 2015, http://www.health.gov.au/internet/publications/publishing.nsf/Content/pacd-maternityservicesplan-toc~pacd-maternityservicesplan-chapter3#Rural%20and%20remote%20services

Australian Nursing Federation, (2013), Telehealth standards: Registered midwives, accessed 02 October 2015, https://crana.org.au/files/pdfs/Telehealth_Standards_Registered_Midwives.pdf

Barclay, L & Tracy, SK, (2010), Legally binding midwives to doctors is not collaboration, Women & Birth, vol. 23, no. 1, pp. 1-2.

Beasley, S, Ford, N, Tracy, SK & Welsh, AW, (2012), Collaboration in maternity care is achievable and practical, Australia & New Zealand Journal of Obstetrics & Gynaecology, vol. 52, no.6, 576-581.

Boxall, AM & Flitcroft, K, (2007), From little things, big things grow: A local approach to system-wide maternity services reform in the absence of definitive evidence, Australia & New Zealand Health Policy, vol. 4, no. 1, p. 18.

Commonwealth of Australia, (2009), Improving Maternity Services in Australia: The Report of the Maternity Services Review, accessed 02 October 2015, https://www.health.gov.au/internet/main/publishing.nsf/content/624EF4BED503DB5BCA257BF0001DC83C/$File/Improving%20Maternity%20Services%20in%20Australia%20-%20The%20Report%20of%20the%20Maternity%20Services%20Review.pdf

Downe, S, Finlayson, K & Fleming, A, (2010), Creating a collaborative culture in maternity care, Journal of Midwifery & Women’s Health, vol. 55, no. 3, pp. 250-254.

Dunbar, T, (2011), Aboriginal people’s experiences of health and family services in the Northern Territory, International Journal of Critical Indigenous Studies, vol. 4, no. 2, pp. 2-16.

Evans, R, Veitch, C, Hays, R, Clark, M & Larkins, S, (2011), Rural maternity care and health policy: Parents’ experiences, Australian Journal of Rural Health, vol. 19, no. 6, pp. 306-311.

Francis, K, McLeod, M, McIntyre, M, Mills, J, Miles, M & Bradley, A (2012), Australian rural maternity services: Creating a future or putting the last nail in the coffin?, Australian Journal of Rural Health, vol. 20, no. 5, pp. 281-284.

Gleeson, G (2015), Contemporary midwifery education focusing on maternal emergency skills in remote and isolated areas, Australian Nursing & Midwifery Journal, vol. 22, no. 11, p. 48.

Hastie, C & Fahy, K (2011), Interprofessional collaboration in delivery suite: A qualitative study, Women & Birth, no. 24, vol. 2, pp. 72-79.

Heatley, M & Kruske, S (2011), Defining collaboration in Australian maternity care, Women & Birth, no. 24, vol. 2, pp. 53-57.

Hoang, H & Le, Q (2013), Comprehensive picture of rural women’s needs in maternity care in Tasmania, Australia, Australian Journal of Rural Health, vol. 21, pp. 197-202.

Jenkins, MG, Ford, JB, Todd, AL, Forsyth, R, Morris, J & Roberts, CL (2015), Women’s views about maternity care: How do women conceptualise the process of continuity?, Midwifery, vol. 31, no. 1, pp. 25-30.

Josif, CM, Barclay, L, Kruske, S & Kildea, S (2014), ‘No more strangers’: Investigating the experience of women, midwives and others during the establishment of a new model of maternity care for remote dwelling Aboriginal women in northern Australia, Midwifery, vol. 30, no. 3, pp. 317-323.

Kildea, S, McGhie, AC, Ghao, Y, Rumbold, A & Rolfe, M (2015), Babies born before arrival to hospital and maternity unit closures in Queensland and Australia, Women & Birth, vol. 28, no. 3, pp. 236-245.

Lane, K (2006), The plasticity of professional boundaries: A case study of collaborative care in maternity services, Health Sociology Review, vol. 15, no. 4, pp. 341-352.

Lane, K (2012), When is collaboration not collaboration? When it’s militarized, Women & Birth, vol. 25, no. 1, pp. 29-38.

McIntyre, M, Francis, K & Champan, Y (2012a), The struggle for contested boundaries in the move to collaborative care teams in Australian maternity care, Midwifery, vol. 28, no. 3, pp. 298-305.

McIntyre, M, Francis, K & Chapman, Y (2012b), Primary maternity care reform: Whose influence is driving the change?, Midwifery, vol. 28, no. 5, pp. 705-711.

McLelland, G, McKenna, L & Archer, F (2013), No fixed place of birth: Unplanned BBAs in Victoria, Australia, Midwifery, vol. 29, no. 1, pp. 19-25.

National Health and Medical Research Council (2010), National Guidance on Collaborative Maternity Care, accessed 02 October 2015, https://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/CP124.pdf

Pairman, S, Pincombe, J, Thorogood, C & Tracy, S (2006), Midwifery: Preparation for Practice, Churchill Livingstone Elsevier, Sydney.

Sandall, J, Soltani, H, Gates, S, Shennan, A & Declan, D (2015), Midwife-led continuity models versus other models of care for childbearing women, Cochrane Database of Systematic Reviews, accessed 02 October 2015, http://onlinelibrary.wiley.com.ezp01.library.qut.edu.au/doi/10.1002/14651858.CD004667.pub4/abstract

This work was produced by one of our professional writers as a learning aid to help you with your studies

Discuss the clients that would use each piece and how it would benefit the client and the staff. Describe each and outline how they are used correctly.

Include two examples in each of the below areas:

Lifts and Hoists
Mobility aids
Incontinence aids
Personal care aids
Communication aids
Introduction

There are a vast number of caring aids available to improve the quality of an individual’s daily living. These aids include lifts, hoists and mobility aids as well as incontinence aids, personal care aids and communication aids (Assist Ireland, no date, a). This report will consider two examples from each of the aforementioned categories and detail the clients that would use such an aid, the benefit of the aid to both patient and carer and how the aid is used.

Lifts and Hoists

There are two types of patient lift or hoist: these can be either a sling lift or a sit-to-stand lift (Thomas & Thomas, 2014). The sling lift is an assistive device that allows immobile patients, either at home or within the care environment, to be transferred between resting places, usually a bed and a chair (Baptiste et al, 2008). They are either mobile (floor based) or fixed (overhead) lifts that are suspended from the ceiling. The sit-to-stand lift is used to help patients who have some mobility but lack the core strength to rise to a standing position from a chair, bed or commode (Radawiec et al, 2009). A number of different slings, straps and belts are available for different uses. For example, a mobile hoist can be used in conjunction with a narrow sling that is positioned under the patient’s arms halfway down their back. The patient must be able to take some of their weight on their legs as the hoist lifts them from sitting to standing position (Assist Ireland, no date, b). An overhead hoist can be used with a divided leg sling. This U shaped sling is positioned with a leg band under each leg then crossed in the middle to provide the patient with some dignity; not crossed in the middle to allow for toileting or with both leg bands under each leg for improved comfort (Assist Ireland, no date, c).

There are multiple benefits of these aids to the patient. These include the prevention of pressure sores, improved quality of life due to enabling an element of mobility and the potential for the individual to remain in their own home rather than in the care environment. However, a study by Bilboe et al (2007) reported some interesting results. A total of 21 normal subjects performed three sit-to-stand transfers from a stool using no device, the Sara 3000 and the Encore hoist. The subjects were filmed with joint line markers on the greater trochanter, the lateral malleolus and the lateral femoral epicondyle. Bilboe et al (2007) found that neither device reproduced normal trunk angles or joint kinematics in the patients they were lifting when compared to the no device test. Nevertheless, it is considered that this study is somewhat limited due to only two devices being trialled and no other therapeutic benefit, such as weight relief or endurance, being measured. However, it does show that the choice of lifting device should be carefully considered for each patient.

The benefits for care workers have been extensively studied, with Chhokar et al (2005) finding that the use of an overhead suspended ceiling lift resulted in a sustained decrease in care worker days off, injury claims and direct costs associated with patient handling injuries over a three year period. These findings were supported by further studies from Engst et al (2005), Miller et al (2006) and Alamgir et al (2008).

Mobility Aids

A mobility aid benefits the patient by allowing them some freedom to either get out and about or move around their home in a safe manner. There are various walking aids, such as canes, crutches and walkers for patients with balance problems or to compensate for weakness or injury, along with wheelchairs and mobility scooters for those with more severe mobility impairments. A walker is used by the patient in a standing position and provides extra stability and confidence by providing additional points of contact with the floor and by the patient’s hands on the frame. It consists of four upright posts and one handgrip for each hand. The walker can reduce the loading on the lower limb by directing some of the load through the upper limbs and the frame of the walker. A wheelchair, can be either manually or battery powered, and allows the patient to travel further distances in a comfortable sitting position. Both of these aids benefit the carer by reducing the amount of intervention the patient requires; for example, with the use of a walker or cane, the patient may be able to access the toilet unaided, therefore reducing the need for carer intervention.

However, there is a considerable body of evidence that indicates that there is a high prevalence of disuse or abandonment of such aids, with between 30% and 50% of patients discontinuing use of their device soon after receiving it (Bateni & Maki, 2005). There is also evidence that the repetitive strains on the joints of the upper extremities can lead to injury and promote the discontinuation of use (Konop et al, 2011).

Incontinence Aids

There are a wide range of incontinence aids available for both bowel and bladder incontinence. These include pads and pull-up pants, protective sheets and pads for chairs and beds, catheters, penile sheaths and specially adapted clothing. The most popular of these are the incontinence pads that are worn inside the patient’s own underwear to mop up small to moderate urine leaks (NHS Choices, 2015). These pads are positioned within the user’s underwear and have a hydrophilic layer which ensures the urine is drawn away from the body, therefore preventing the skin from developing sores associated with wetness (Sugama et al, 2012). Another incontinence aid, used by men, is the penile sheath. These devices resemble a condom with a funnel tipped end and are applied by rolling the silicone sheath down the shaft of the penis (Robinson, 2006). A leg bag connector, or a sheath urinary drainage system, is then attached to the funnel tip (Robinson, 2006). Williams and Moran (2006) detailed the difficulties and benefits of the use of a penile sheath for male incontinence. They reported that this sizing of the sheath was difficult to establish, with even a 1mm error in measurement causing the sheath to become detached during urination or causing penile trauma. However, they do explain that with correct fitment, with the appropriate sized sheath being applied, this system provides significant freedom for the patient and improves their confidence and self-esteem.

Personal Care Aids

Personal care aids include long handled nail clippers, lotion applicators, shampooing aids and toileting aids. The extended reach, long handled or pistol grip toenail clipper is used by patients who are unable to bend far enough forwards to clip their toenails using standard clippers (Semple et al, 2009). These patient groups include pregnant women, overweight patients, the elderly and people with back problems. The device extends the length of reach enabling the individual to maintain independence and trim their own nails rather than relying on their carer to carry out this task for them (Semple et al, 2009).

Another personal care aid that benefits both the patient and the carer is that of the shampooing rinse basin. This basin, used for washing the hair of a bed bound, immobile patient, is positioned at the top of the bed and has a comfortable head and neck cradle to support the patient’s head in an appropriate position (Sloan et al, 1995; Eigsti, 2011). The patient’s hair can then be wetted, shampooed and rinsed within the basin without the need for the patient to be moved from the bed. The basin has a side drain and drain hose that can be left open for continuous irrigation or closed to hold water. This aid therefore reduces the risk of handling injury to both patient and carer and allows for a number of personal care routines including shampooing, ear irrigation or scalp treatment.

Communication Aids

Communication aids include aids that improve the hearing, reading and writing of the patient. One example is a magnifier, which can be handheld or attached to a spectacle, headband or neck attachment (Berry & Ignash, 2003). They can also be furniture, floor or wall mounted or can fit over screens. These aids magnify the size of the text on letters, books or other print therefore providing benefit to the patient by enabling them to read their own correspondence, therefore keeping personal information to themselves, or keep themselves entertained or informed by reading newspapers or books (Berry & Ignash, 2003). This also benefits the carer as is frees up their time to carry out other tasks.

Another communication aid is a personal sound amplifier, which amplifies TV and audio equipment. The equipment includes a microphone, which is positioned near to the TV or audio equipment, an amplifier and an earpiece for the patient (Palmer et al, 1995). These devices benefit the patient as they are able to enjoy the benefits of listening to on-screen or audio entertainment and also benefit the carer and other household individuals as the volume of the audio and TV equipment can be maintained at a normal level. The patient is able to increase the volume of the sound through their own earpiece without increasing the overall volume of the sound emitting device.

Conclusion

This report provides two examples of each of a number of care aids and explains the way in which these benefit both the carer and the patient. Examples include mobile hoists to transfer the patient between sitting and standing positions, a walking frame, which gives the patient additional support and confidence when mobilising both inside and outside the home and personal care aids such as the shampooing basin and long reach nail clippers that maintain the hygiene needs of restricted mobility patients.

References

Alamgir, H., Yu, S., Fast, C., Hennessy, S., Kidd, C., & Yassi, A. (2008). Efficiency of overhead ceiling lifts in reducing musculoskeletal injury among carers working in long-term care institutions. Injury, 39(5), 570-577.

Assist Ireland (no date, a). Choosing a product. Available online at http://www.assistireland.ie/eng/Information/Information_Sheets/ accessed 23 October 2015.

Assist Ireland (no date, b). Choosing a mobile hoist. Available online at http://www.assistireland.ie/eng/Information/Information_Sheets/Choosing_a_Mobile_Hoist.html accessed 23 October 2015.

Assist Ireland (no date, c). Choosing an overhead hoist. Available online at http://www.assistireland.ie/eng/Information/Information_Sheets/Choosing_an_Overhead_Hoist.html accessed 23 October 2015.

Baptiste, A., Cleerey, M. M., Matz, M., & Evitt, C. P. (2008). Proper sling selection and application while using patient lifts. Rehabilitation Nursing, 33(1), 22-32.

Bateni, H., & Maki, B. E. (2005). Assistive devices for balance and mobility: benefits, demands, and adverse consequences. Archives of Physical Medicine and Rehabilitation, 86(1), 134-145.

Berry, B. E., & Ignash, S. (2003). Assistive technology: Providing independence for individuals with disabilities. Rehabilitation Nursing, 28(1), 6-14.

Bilboe, J., Healey, K., & Busse, M. E. (2007). Investigating joint kinematics during a hoist-assisted sit-to-stand activity. International Journal of Therapy and Rehabilitation, 14(7), 311-317.

Chhokar, R., Engst, C., Miller, A., Robinson, D., Tate, R. B., & Yassi, A. (2005). The three-year economic benefits of a ceiling lift intervention aimed to reduce healthcare worker injuries. Applied Ergonomics, 36(2), 223-229.

Eigsti, J. E. (2011). Innovative solutions: beds, baths, and bottoms: a quality improvement initiative to standardize use of beds, bathing techniques, and skin care in a general critical-care unit. Dimensions of Critical Care Nursing, 30(3), 169-176.

Engst, C., Chhokar, R., Miller, A., Tate, R. B., & Yassi, A. (2005). Effectiveness of overhead lifting devices in reducing the risk of injury to care staff in extended care facilities. Ergonomics, 48(2), 187-199.

Konop, K. A., Strifling, K. M., Krzak, J., Graf, A., & Harris, G. F. (2011). Upper Extremity Joint Dynamics During Walker Assisted Gait: A Quantitative Approach Towards Rehabilitative Intervention. Journal of Experimental & Clinical Medicine, 3(5), 213-217.

Miller, A., Engst, C., Tate, R. B., & Yassi, A. (2006). Evaluation of the effectiveness of portable ceiling lifts in a new long-term care facility. Applied Ergonomics, 37(3), 377-385.

NHS Choices. (2015). Incontinence Products. Available online at http://www.nhs.uk/Livewell/incontinence/Pages/Incontinenceproducts.aspx accessed 23 October 2015.

Radawiec, S. M., Howe, C., Gonzalez, C. M., Waters, T. R., & Nelson, A. (2009). Safe ambulation of an orthopaedic patient. Orthopaedic Nursing, 28(2S), S24-S27.

Robinson, J. (2006). Continence: sizing and fitting a penile sheath. British Journal of Community Nursing, 11(10), 420-427.

Semple, R., Newcombe, L. W., Finlayson, G. L., Hutchison, C. R., Forlow, J. H., & Woodburn, J. (2009). The FOOTSTEP self management foot care programme: Are rheumatoid arthritis patients physically able to participate? Musculoskeletal Care, 7(1), 57-65.

Sloane, P. D., Rader, J., Barrick, A. L., Hoeffer, B., Dwyer, S., McKenzie, D., & Pruitt, T. (1995). Bathing persons with dementia. The Gerontologist, 35(5), 672-678.

Sugama, J., Sanada, H., Shigeta, Y., Nakagami, G., & Konya, C. (2012). Efficacy of an improved absorbent pad on incontinence-associated dermatitis in older women: cluster randomized controlled trial. BMC Geriatrics, 12(1), 22-24.

Thomas, D. R., & Thomas, Y. L. N. (2014). Interventions to reduce injuries when transferring patients: A critical appraisal of reviews and a realist synthesis. International Journal of Nursing Studies, 51(10), 1381-1394.

Williams, D., & Moran, S. (2005). Use of urinary sheaths in male incontinence. Nursing Times, 102(47), 42-44.

This work was produced by one of our professional writers as a learning aid to help you with your studies

Campylobacter jejuni is one of a family of bacteria known as Campylobacteriaceae that collectively are responsible for a significant number of reported cases of gastroenteritis in the UK. Gastrointestinal infection with Campylobacter spp. can produce significant long term sequelae, such as reactive arthritis and the neurological condition Guillain-Barre Syndrome. This report will give a brief overview of campylobacter jejuni with regard to its microbiology, and the identification and management of campylobacter infection.

Campylobacters were recognised as a cause of human illness in the 1970s, but were probably first identified in humans by Escherich in 1886, who identified spiral shaped bacteria of the colons of children who had died from a condition he called “cholera infantum” (Escherisch 1886). Veterinary research at the beginning of the twentieth century identified similar bacteria in livestock, and the bacteria (termed at the time “vibrio” or “spirillium”) was implicated in a number of reported cases in both animals and humans throughout the mid-twentieth century (Butzler 2004). The key breakthrough was reported in 1972, when Dekeyser and Butzler were able to isolate the bacteria now known as campylobacter jejuni from the stool of an infected patient (Dekeyser 1972).

Campylobacter spp. are classified as part of rRNA superfamily VI, a classification of bacteria that also includes Helicobacter and Arcobacter (Vandamme 1991). Campylobacters, and other members of the classification, are small, gram-negative bacteria that are specially adapted to colonise the surface of the mucous membranes of the digestive tract. This is reflected in the morphology of the bacteria, which has a spiral-shaped body with long unsheathed flagella at each tip. Consequently, Campylobacter are highly motile, and are able to tunnel through the mucous layer and colonise the membrane below, which is a key ability as they are highly susceptible to acidity. They are partially anaerobic, alongside other members of the classification, and undergo transformation to coccoid forms when exposed to adverse conditions (Moran 1987). Presently, 18 subspecies of Campylobacter have been identified and 11 of these are thought to be pathogenic in humans. By far the most common are campylobacter jejuni and campylobacter coli; together, these bacteria are a leading cause of diarrhoeal illness.

Principal risk factors for infection with campylobacter jejuni include the consumption of undercooked meat, especially poultry, inadequately pasteurised milk, contaminated water and pets with diarrhoea (Gillespie 2008). There may be human-human transmission via the faeco-oral route if personal hygiene is unsatisfactory (Wilson 2008).

There is an incubation period of around 3 days, though this can range from 1-7 days. There is occasionally a prodromal illness of fever, myalgia and headache lasting around 24 hours, and patients who present with the prodromal illness often have a more severe infection than those presenting with gastrointestinal symptoms (Minton 2004). The principal illness is characterised by colicky, periumbical abdominal pain, pyrexia (the fever may be as high as 40a?°C) and profuse diarrhoea, often with up to 10 bowel movements each day. The stool may be watery initially, and blood may appear in the stool as the infection progresses. Around 25% of patients will experiences tenesmus (Minton 2004).

Symptoms of diarrhoea generally last for up to 7 days, and abdominal pain may persist a little longer. The illness is generally self-limiting, though the prognosis can be worse in the very young, the elderly, those with comorbid condition and the immunocompromised (Nelson 2004).

It is not possible to differentiate campylobacter infection from other causes of infective gastroenteritis based on history and examination findings alone (Buss 2015). Therefore, detection of campylobacter in a stool sample is the mainstay of diagnosis, though a negative sample cannot exclude the presence of campylobacter. Samples are rarely positive after two weeks. Stool samples should always be collected in patients presenting with these symptoms, as infection with campylobacter is a notifiable disease in England and Wales (NICE 2014).

In a generally fit and well adult, the main risk of acute diarrhoea of any cause, including campylobacter, is dehydration. Therefore, maintaining adequate hydration is the cornerstone of treatment. This can generally be achieved by increasing oral fluid intake, but in vulnerable patients intravenous hydration may be indicated. Rehydration may be encouraged with the administration of Racecadotril. Racecadotril is an intestinal antisecretory enkephalinase inhibitor that inhibits the breakdown of endogenous enkephalins, reducing the hypersecretion of water and electrolytes into the intestine (NICE 2013). Racecadotril is licensed in the United Kingdom for the complimentary treatment of acute diarrhoea in patients aged greater than 3 months, together with oral rehydration.

Though the symptoms of campylobacter infection are unpleasant and inconvenient, there is generally no indication for antimotility medications. In fact, unless the diagnosis is confirmed via the laboratory, these medications are contraindicated as toxic megacolon has been reported as an adverse effect of antimotility medications in patients with pseudomembranous colitis and inflammatory bowel disease (Minton 2004).

Given the short duration and self-limiting nature of the condition, antibiotic therapy is generally not recommended. A Swedish meta-analysis of eleven randomised control trials reported that, versus placebo, antimicrobial therapy reduced the duration of intestinal symptoms by only 1.3 days (95% CI 0.6-2.0 days) (Ternhag 2007). A further review by the National Institute of Health and Care Excellence (NICE) reported that antibiotic treatment with erythromycin cleared the bacteria from stool samples rapidly, but had no effect on the course of the disease (NICE 2009).

Problems exist with antibiotic-resistant species of campylobacter, largely due to antibiotic use in animals (Gallay 2007; Lehtopolko 2010). However, antibiotic therapy should be considered for patients with severe disease or at risk of severe disease. Patients with severe disease include individuals with bloody stools, high fever, extra intestinal infection, worsening or relapsing symptoms, or symptoms lasting longer than one week (Ruiz-Palacios 2007). Patients classified as at risk of severe disease include the immunocompromised, the elderly and pregnant women. NICE supports this, suggesting that antibiotic therapy may be indicated if any of the following occur (NICE 2014):

High fever
Bloody diarrhoea
More than eight stools daily
Worsening clinical condition
Illness for over a week
Pregnancy
Immunocompromise

Should an antibiotic be required, azithromycin and erythromycin are the most effective agents against campylobacter in the UK, with a single 30mg/kg dose of azithromycin early in the disease proving just as effective as a 5 day course of erythromycin (Vukelic 2010). The British National Formulary recommends a combination therapy of clarithromycin with ciprofloxacin as an alternative.

There are a number of complications of campylobacter infection. Acute bacterial gastroenteritis has been linked with the onset of irritable bowel syndrome in around 15% of cases aˆ“ this is termed post-infective IBS (Smith 2007). Further complications include Reiter’s Syndrome (a form of reactive arthritis characterised by urethritis, conjunctivitis and arthritis), and the neurological condition Guillain-Barre Syndrome.

In summary, campylobacter jejuni is a gram negative, spiral shaped bacteria that colonises the mucous membranes of the gut. This colonisation produces a self-limiting illness characterised by fever, cramping abdominal pains and diarrhoea. Infection is diagnosed via detection of the bacteria in a sample of faeces. The mainstay of treatment is rehydration aˆ“ antibiotics are rarely indicated.

References

Buss S, Leber A, Chapin K, Fey P, Bankowski M, Jones M, Rogatcheva M, Kanack K, Bourzac K. (2015). Multicenter Evaluation of the BioFire FilmArray Gastrointestinal Panel for Etiologic Diagnosis of Infectious Gastroenteritis. Journal of Clinical Microbiology. 53(3)

Butzler J-P 2004 Campylobacter, from obscurity to celebrity. Clinical Microbiology and Infection 10(10)

Dekeyser, P, Gossuin-Detrain, M, Butzler, JP, and Sternon, J. 1972 Acute enteritis due to a related vibrio: first positive stool cultures. Journal of Infectious Diseases 125

Escherich, T. 1886 Beitrage zur Kenntniss der Darmbacterien. III. Ueber das Vorkommen von Vibrionen im Darmcanal und den Stuhlgangen der Sauglinge. (Articles adding to the knowledge of intestinal bacteria. III. On the existence of vibrios in the intestines and feces of babies.). MA?nchener Med Wochenschrift. 33

Gallay A, Prouzet-MaulA©on V, Kempf I, Lehours P, Labadi L, Camou C, Denis M, de Valk H, Desenclos JC, MA©graud F. 2007 Campylobacter antimicrobial drug resistance among humans, broiler chickens, and pigs, France. Emerging Infectious Diseases 13(2)

Gillespie L, O’Brien S, Penman C, Tomkins D, Cowden J, Humphrey T. 2008 Demographic determinants for Campylobacter infection in England and Wales: implications for future epidemiological studies. Epidemiology and Infection 136(12)

Lehtopolku M, Nakari UM, Kotilainen P, Huovinen P, Siitonen A, Hakanen AJ. 2010 Antimicrobial susceptibilities of multidrug-resistant Campylobacter jejuni and C. coli strains: in vitro activities of 20 antimicrobial agents. Antimicrobial Agents and Chemotherapy 54(3)

Minton J, Stanley P. 2004 Intra-Abdominal Infections. Clinical Medicine 4(6)

Moran AP, Upton ME 1987 Factors affecting production of coccoid forms by Campylobacter jejuni on solid media during incubation. Journal of Applied Bacteriology 62(6)

Nelson JM, Smith KE, Vugia DJ, Rabatsky-Ehr T, Segler SD, Kassenborg HD, Zansky SM, Joyce K, Marano N, Hoekstra RM, Angulo FJ. 2004 Prolonged diarrhea due to ciprofloxacin-resistant campylobacter infection. Journal of Infectious Diseases 190(6)

NICE. (2013). Acute diarrhoea in children: racecadotril as an adjunct to oral rehydration. Available: https://www.nice.org.uk/advice/esnm12. Last accessed March 23rd 2015.

NICE. (2009). CG84 – Diarrhoea and vomiting in children: Diarrhoea and vomiting caused by gastroenteritis: diagnosis, assessment and management in children younger than 5 years. Available: https://www.nice.org.uk/guidance/cg84. Last accessed March 23rd 2015.

NICE. (2014). Gastroenteritis. Available: http://cks.nice.org.uk/gastroenteritis. Last accessed March 23rd 2015.

Ruiz-Palacios GM 2007. The health burden of Campylobacter infection and the impact of antimicrobial resistance: playing chicken. Clinical Infectious Diseases 44(5)

Smith JL, Bayles D. 2007 Postinfectious irritable bowel syndrome: a long-term consequence of bacterial gastroenteritis. Journal of Food Protection 70(7)

Ternhag A, Asikainen T, Giesecke J, Ekdahl K. 2007 A meta-analysis on the effects of antibiotic treatment on duration of symptoms caused by infection with Campylobacter species. Clinical Infectious Diseases 44(5)

Vandamme P, Falsen E, Rossau R, Hoste B, Segers P, Tytgat R, De Ley J 1991 Revision of Campylobacter, Helicobacter, and Wolinella taxonomy: emendation of generic descriptions and proposal of Arcobacter gen. nov. International Journal of Systematic Bacteriology 41(1)

Vukelic D, Trkulja V, Salkovic-Petrisic M. 2010 Single oral dose of azithromycin versus 5 days of oral erythromycin or no antibiotic in treatment of campylobacter enterocolitis in children: a prospective randomized assessor-blind study. Journal of Pedatric Gastroenterology and Nutrition 50(4)

Wilson D, Gabriel E, Leatherbarrow A, Cheesbrough J, Gee S, Bolton E, Fox A, Fearnhead P, Hart C, Diggle P. 2008 Tracing the Source of Campylobacteriosis. PLoS Genetics 26; 4(9)