Probiotics for the Treatment of Peanut Allergies

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Probiotics for the treatment of peanut allergy

The original study paper by Tang et al 2015 examines probiotic with peanut oral immunotherapy (PPOIT) for management of peanut allergy and was carried out in Australia.  The results from this can potentially be used to apply to the UK population.  The allocation of 62 patients is randomised and they were blinded to either receive the treatment or placebo.  Interestingly some of the patients underwent an open peanut challenge at entry to the study and it would have been helpful to compare if at the end of the treatment weather these patients were tolerating more, less or equal amount of peanut protein than at the beginning.  Authors have accounted for all participants and used sample power calculations to detect a difference.  The outcome assessors were also blinded.  The problem with this study design is it compares PPOIT against placebo whereas ideally, they should also be comparing PPOIT against peanut oral immunotherapy separately and even probiotic as another treatment arm to detect if combining therapies provides additional benefit.  I think it is not possible to conclude PPOIT is effective at inducing sustained unresponsiveness in 82.1% as it could have been achieved by the therapies separately.  Although the results were statistically significant, they are not precise given the wide confidence intervals for relative risk ratio.  In addition, sustained unresponsiveness which is the body’s ability to tolerate an allergen after treatment has stopped needs to be assessed at longer intervals and not just 2 weeks.  Conflicts of interest in this trial include involvement with the companies Danone and Nestle of which the latter company actually supplied the probiotic in the trial.

The second study by the same group (Hsiao et al 2017) attempts to address the longer-term outcomes at 4 years from the original study by Tang et al 2015.   They managed to enrol 86% of eligible participants but this results in an even smaller sample size.  They have detailed reasons into what happened to the other 14%.  However, the authors have not justified the timings as to why outcomes were measured after 4 years and why the food challenge was performed after 8-week elimination.  It could be argued that a longer period of elimination is needed to assess true sustained unresponsiveness.  The peanut intake and quality of life questionnaires were conducted by allergy nurses and unblinded potentially introducing bias.  The results are not reported in this paper.  There was a difference in skin prick test wheal size between the PPOIT treated and placebo group but it is difficult to translate this to clinical significance (Allergic Living 2017).  More importantly Hsiao et al 2017 report similar number of patients having allergic reactions between the placebo and treatment groups (6 vs 4 respectively).  In addition, it would have been useful to include details of the 2 patients in the PPOIT group and the 4 patients in the placebo group who experienced anaphylaxis during the food challenge requiring intramuscular adrenaline.  Anaphylaxis can be life-threatening and it is important to detail the reasons as to why these patients have experienced this as this can be deemed an unacceptable risk of treatment.   It would be interesting to look into more detail at the patients in the placebo group that had anaphylaxis.  Did they experience a true anaphylactic reaction and were most of the symptoms experienced subjective rather than objective?  I think it is also difficult to conclude that PPOIT induces long term sustained unresponsiveness after 4 years as although these patients were advised to have peanut in their diet freely, of the PPOIT group that were eating peanut 75% were eating more than 2g of peanut protein.  This could be continued desensitisation as they are having regular exposure to the allergen.  I would argue that data for sustained unresponsiveness can only be analysed after the 8-week elimination of peanut followed by food challenge.  If we look at this data only 50% took part and of those only 7 patients achieved sustained unresponsiveness.  This is a low number and difficult to extrapolate to a larger population.  It is clear that further larger multicentre studies with multiple treatment arms are needed before we can apply this to clinical practice.  Also, longer term sustained unresponsiveness needs to be assessed and not just at 8 weeks.


Other literature regarding probiotics in allergy

Currently, the mainstay of treatment for food allergy involves dietary avoidance and symptomatic treatment.  Apart from immunotherapy, other new treatment directions for allergy include biologicals like Omalizumab and probiotics.  The food and agriculture organisation (FAO) and world health organisation (WHO) 2002 p.8 define probiotics as ‘live microorganisms which when administered in adequate amounts confer a health benefit on the host’.  The theory is that by restoring the gut microbiome which has a complex role in the immune system, the allergic response is redirected towards sustained unresponsiveness and eventually tolerance (Castellazi 2013).

Probiotics have been studied for the prevention of allergy as well as treatment.  The EAACI (European Academy of Allergy and Clinical Immunology) guidelines by Muraro et al 2014 found insufficient evidence to recommend probiotics antenatally, postnatally while breastfeeding or as a supplement in infancy.   A more recent systematic review and meta-analysis by Zhang et al 2016 p.1 reported ‘probiotics administered prenatally and postnatally could reduce the risk of food hypersensitivity’.  Looking at the forest plot of the 9 trials that looked at food sensitisation, they all have confidence intervals crossing 1 for risk ratio which would mean no significant effect.  However once pooled together a difference is detected.  Evaluating the different food allergens that were skin prick tested or had specific IgE would have provided interesting results.  This was a secondary outcome measure in this review and as food sensitisation does not always mean food allergy more studies are needed in this field looking at the use of blinded food challenges as an outcome measure of confirming food allergy.

Looking at the research on probiotics in allergy treatment besides the studies discussed, there are no other trials looking at peanut allergy and probiotics as a treatment.  Cow’s milk allergy and probiotics has been researched more extensively.   A meta-analysis by Tan-Lim et al 2018 found probiotics could improve symptoms in cow’s milk allergy but only a scoring index for eczema was used rather than a validated food allergy questionnaire.  Other allergic symptoms were not pooled so again enough robust evidence is not provided for effect.  The secondary outcome measure was tolerance but there was no adjustment for the natural resolution of this type of allergy so may not be the acquisition of tolerance.  In clinical practice we do on occasion recommend probiotics to parents whose infants have cow’s milk allergy and eczema and are struggling with eczema control despite good cream management or as a preventative measure antenatally/postnatally to mothers in infants with a high risk of eczema.  The safety profile of probiotics is good and is one of its main attractions for its use clinically.  However, there are a wide variety of commercially available products not subject to the same regulations as medicinal products and reports of bacteraemia in susceptible populations (Wang et al 2019).  Therefore without further evidence they should be used cautiously and not routinely.


Application in clinical practice

The first essential part of deciding whether an allergy to a particular food has occurred is to take a good history.  Amelie has not been seen in clinic for several years and it would be worth going through the symptoms she developed following ingestion of peanut.  Specifically, we need to look at time of onset, symptoms, duration and treatment given.  The circumstances surrounding the event for example season, location or was she unwell at the time.  We need to clarify previous history of food allergy or atopy.  Is her asthma well controlled on her current medication? It would be worth looking at a dietary history from birth and family history.  Is she ingesting other nuts with no reaction?  Once a thorough history is taken we can decide whether this is likely IgE mediated or non IgE mediated allergy.  Certainly, from the limited history this could be IgE mediated.  However, as there are only respiratory symptoms mentioned its worth thinking about whether this could have been an asthma exacerbation rather than peanut allergy.  The two conditions can co-exist and it would be important to ensure good asthma control as uncontrolled asthma and food allergy lead to a higher risk of fatal anaphylaxis (Wang 2011).

Secondly if IgE mediated peanut allergy is suspected we need to look at Amelie’s previous investigations if any.  Skin prick tests or specific IgE component testing to peanut can help guide management.  If results were negative then it would be worth considering a hospital challenge to peanut as she may have outgrown her allergy although it is known that this is less likely with peanut allergy.  If investigations confirmed ongoing allergy the advice would be continual avoidance along with an allergy action plan and adrenaline autoinjector training.  Once this has been done, we can start to address the question Amelie’s mother is posing about probiotics.

There is no data looking at probiotics alone as a treatment for food allergy.  Rather, it is used in conjunction with immunotherapy to help desensitise children.  This would involve the child taking regular amounts of the allergen to maintain desensitisation.  There is not enough long-term data looking at sustained unresponsiveness where children would be safe to consume peanuts on an adhoc basis without reaction.  I would advise that currently oral immunotherapy for peanut allergy is not available on the NHS and the benefits of probiotics in allergy is still being investigated.  Certainly there are trials which show benefits of peanut immunotherapy in reducing symptom severity (PALISADE 2018).  I would explain the results of the PPOIT trial show promise but that the added benefit of probiotics is still unknown as this was not investigated in the study.  Possibly the effect could have been attributed to oral immunotherapy alone.  It is possible these therapies will be recommended in the future following more research.


References

  • Allergic Living (2017) Reality Check: The facts beyond the hype over peanut allergy and probiotics.  Available at:

    Reality Check: The Facts Beyond the Hype over Peanut Allergy and Probiotics

    (Accessed 23

    rd

    August 2019).

  • Castellazi AM, Valsecchi C, Caimmi S, Licari A, Marseglia A, Leoni MC, Caimmi D, Giudice MMD, Leonardi S, Rosa ML, Marseglia DL. (2013) ‘Probiotics and food allergy’,

    Ital J pediatr

    , 39, pp.47.

    https://doi.org/10.1186/1824-7288-39-47

    .
  • Critical Appraisal Skills Programme (2018).  CASP Randomised Controlled Trial Checklist.  Available at:

    http://casp-uk.net/wp-content/uploads/2018/01/CASP-Randomised-Controlled-Trial-Checklist-2018.pdf

    (Accessed 23rd August 2019).
  • Food and Agriculture Organisation, World Health Organisation (2002).  Guidelines for the evaluation of probiotics in food.  In: Report of a joint FAO/WHO working group on drafting guidelines for the evaluation of probiotics in food.  Available at:

    http://www.who.int/foodsafety/fs_management/en/probiotic_guidelines.pdf

    (Accessed 23rd August 2019).
  • Hsiao K-C, Ponsonby A-L, Axelrad C, Pitkin S, Tang MLK. (2017) ‘Long-term clinical and immunological effects of probiotic and peanut oral immunotherapy after treatment cessation: 4-year follow-up of a randomised, double-blind, placebo-controlled trial’,

    The Lancet Child & Adolescent Health

    , 1(2), pp. 97-105.
  • Muraro A, Halken S, Arshad SH, Beyer K, Dubois AE, Du Toit G, Eigenmann PA, Grimshaw KE, Hoest A, Lack G, O’Mahony L, Papadopoulos NG, Panesar S, Prescott S, Roberts G, De Silva D, Venter C, Verhasselt V, Akdis AC, Sheikh A. (2014) ‘EAACI Food Allergy and Anaphylaxis Guidelines. Primary prevention of food allergy’,

    Allergy

    , 69, pp.590-601.
  • PALISADE Group of Clinical Investigators.  (2018) ‘AR101 oral immunotherapy for peanut allergy’, N

    Engl J Med

    , 379(21), pp.1991-2001.
  • Tang ML, Ponsonby AL, Orsini F, Tey D, Robinson M, Su EL, Licciardi P, Burks W, Donath S. (2015) ‘Administration of a probiotic with peanut oral immunotherapy: a randomized trial’,

    J Allergy Clin Immunol

    , 135, pp. 737-744.
  • Tan-Lim CSC, Esteban-Ipac NAR. (2018) ‘Probiotics as treatment for food allergies among pediatric patients: a meta-analysis’,

    World Allergy Organization Journal

    , 11, 25.

    https://doi.org/10.1186/s40413-018-0204-5

    .
  • Wang HT, Anvari S, Anagnostou K. (2019) ‘The role of probiotics in preventing allergic disease’,

    Children

    , 6, 24.

    https://doi.org/10.3390/children6020024

    .
  • Wang J, Liu AH.  (2011) ‘Food allergies and asthma’,

    Curr Opin Allergy Clin Immunol

    , 11(3), pp.249-254.
  • Zhang GQ, Hu HJ, Liu CY, Zhang Q, Shakya S, Li ZY. (2016) ‘Probiotics for prevention of atopy and food hypersensitivity in early childhood’,

    Medicine

    , 95(8), pp.1-10. doi:

    10.1097/MD.0000000000002562

    .

Immunisation Infection Disease

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Immunisation has been continually confirmed in both research trials and in the field to be one of the most successful medical interventions we have to avert disease. As Mims et al (2004: 513) outlines, the rationale of immunisation is simple: to provoke a primed status so that on initial contact with the applicable infection a quick and successful secondary immune response will be induced, leading to the avoidance of disease. A vital part of immunisation programs is the production of ‘herd immunity’-that is an increase in the populations overall immunity status to the point that successful transmission cannot occur due to a lack of susceptible individuals. According to Rogers et al (1995), opposition in this field arose as early as the 19

th

century when vaccination was first introduced in Europe. There were instant objections on religious grounds and doubts about the effectiveness of vaccines were also articulated along with the rights of the individual to refuse immunisation. Present-day objections to mass child immunisation reverberate these early apprehensions. Below an overview is given of the sociological factors associated with non or under immunised children in developed countries. How these factors combine to explain this immunisation status is additionally discussed along with suggestions of potential efforts to increase immunisation uptake rates.

A number of studies (Brynley et al 2001 & Turner et al 2003) conducted in developed countries have identified many sociological factors that are associated with low immunisation uptake among children. Primarily these factors include unemployment, low or high maternal education, single parent status, overseas birth or late birth order and low socio-economic status. In addition to these primary factors other reasons for reduced immunisation uptake are associated with immunisation myths, inadequate service provision or access, child gender/age, late commencement of immunisation and maternal mental instability. A child’s low immunisation status may be the result of one or a combination of the above interacting factors.

There are a variety of myths circulating in the community with regards to immunisation. Begg and Nicoll(1994) noted some common myths that include: “a child with allergies should not be immunised, children taking antibiotics shouldn’t be vaccinated and immunisation is now unnecessary.” Although most myths have a tangible basis with traceable origins all myths should be disregarded on scientific grounds. According to Begg and Nicoll most immunisation myths emerge due to the ignorance of health professionals compounded by the propagation of conflicting material. The media has been quick to take advantage of the profession’s ignorance, predominantly where there are questionsabout the risks coupled with immunisation. Hall (2001) thus puts forward that parents who are unresolved about child vaccination may receive medical advice which is uncertain, while receiving from those in opposition to immunisation strongly argued and seemingly well researched information. A great deal of the controversy surrounding immunisation appeals to parents’ deep-founded regard for the wellbeing of their children and their trepidation principally of injections. Hall also suggested that parents may have difficulty in conveying their concerns to health professionals, and these concerns may induce parents to lean towards arguments against immunisation. Such arguments endow parents’ who have immunisation reservations with rationale to oppose vaccinating of their children.

Low education can greatly disadvantage a mother making decisions concerning immunisation. Forrest et al (1998) mentioned that such a mother may not be able to read or properly comprehend vaccination information and thus not base decisions regarding their infant’s health on scientific evidence. The parental response therefore to a child’s immediate distress may outweigh their attitude towards future benefits from vaccination. Those struggling due to a language barrier, particularly migrants and those of ethnic origin may also encounter similar difficulties. Conversely Rogers et al (1995) explains that people with high education usually choose to oppose vaccination for other reasons. These parents rational is multifaceted being deduced

from a mixture of world views held about healing, the environment, holism and responsibilities of parenting combined with the reading of scientific and alternative literature which cast doubts on the effectiveness of immunisation. Lack of education may also be a barrier to individuals who are unemployed or of low socio-economic status (SES) due to the above reasons. As evident in a study conducted by Li and Taylor (1993), this may be further compounded by low financial position. With a high proportion of the unemployed or those of low SES living in temporary housing, especially in inner city districts, it may be hard for health professionals to keep track of immunisation records and provide reminders about necessary appointments. Those with low income as described by Hull et al (2001) may also not have use of a vehicle making it difficult to access immunisation services; this is a particular problem for those who live in rural areas and can lead to incomplete immunisation in infants.

Children from large families and of late birth order or those of single parents have also been found by studies conducted by Hull et al (2001) and Li and Taylor (1993), to have lower immunisation uptake. Hull et al noted that single parents may encounter greater difficulties in both organising periods off work and have monetary limitations that increase the difficulty in accessing immunisation services. Likewise as discussed by Li and Taylor, parents with many children may find it hard to access immunisation services due to busy schedules or transportation issues. Moreover parents of large families may have had previous adverse immunisation experiences with elder siblings and thus their caution or opposition to vaccination is reflected in the lack of immunisation among younger siblings. Harrington et al (2000) suggested that adverse immunisation experiences are associated with the combination of crammed clinics, long waiting times, inconvenient hours and trouble acquiring an appointment. Additionally many mothers undergo emotional distress due to the knowledge that they are party to the pain inflicted on their infant as a result of vaccination. This perhaps is integrated in the opinion articulated by some parents that health centre immunisation is intolerably forceful and callous due to the lack of compassion shown by health professionals; with evidence revealed in the study conducted by Harington et al, that mothers prefer to have their infant vaccinated by general practitioner, in a ratio of >4:1, with the pre-existing relationship helpful during immunisation visits.

A study conducted on factors associated with low immunisation uptake (Hull et al 2001) also demonstrated a strong association between late immunisation commencement and low overall immunisation uptake. A late commencement of immunisation may echo a parent’s attitude to vaccination or reflect a lack of knowledge regarding immunisation as a whole or its schedule. Hull et al also noted that illness is the primary cause for late commencement with many parents believing that there is an increased risk coupled to vaccination during this time. The decision to vaccinate may be further confused by dissenting personal attitudes towards vaccination. Similarly a study conducted by Turner et al (2003) found that women suffering from mental health problems including depression and anxiety, several months after birth were between 3 and 5 times more likely to have commenced the immunisation schedule late or not at all. Mothers with mental instability may find the seemingly normal task’s associated with motherhood difficult. With the maintenance of a normal day a challenge the importance of immunisation may be decreased.

Gender can also affect immunisation uptake however as illustrated by Markuzzi et al (1997), this is dependant on the specific disease to which vaccination may confer protection. For example Markuzzi et al noted that in the UK it has until recently been considered that boys do not require vaccination against rubella. Therefore the live attenuated vaccine was only administered to adolescent girls to protect them from developing the disease while pregnant and transmitting it to the foetus resulting in congenital rubella syndrome. Consent is an additional problem which may affect vaccination rates, especially for overseas visitors or those from minority ethnic groups who may not understand the language of the country in which they now reside. Even with parental consent (Forrest et al 1998) a child cannot be vaccinated unless they are willing. Vandermeulen et al 2007 notes that adolescents are particularly hard age group to reach as many have a poor perception of risk leading to a greater fear of the initial pain of immunisation than the associated disease. Deferral of appointments for seemingly inadequate reasons such as social commitments also hinders this age bracket.

Although in Australia national immunisation coverage levels may surpass 90 percent (

Childhood Immunisation Coverage

2007), there is a considerably lower level of protection among certain subgroups of the population. These pockets of under vaccinated individuals make the population susceptible to major outbreaks. As further suggested by

Childhood Immunisation Coverage

, monitoring the coverage at smaller geographic levels helps ensure that these impending pockets of children are recognised by target interventions and decrease the threat of potential disease outbreaks. Additional efforts to boost immunisation rates in the community should thus focus on increasing service accessibility. As recommended by Forrest et al (1998) and Li and Taylor (1993) this could be achieved via facilitating immunisation session times that parents find easy to attend, the use of mobile vans or other home vaccination methods and the provision of opportunistic immunisations when children appear at hospitals, general practices or health clinics for different reasons. Moreover Li and Taylor also note that attempts should be made to enhance the services provided by health care clinics by the extension of crèche facilities for siblings and the continual education of health providers. This education should focus upon details concerning new vaccinations and current circulatory immunization myths, including there rebuttal. As advised by Harrington et al 2000, health practitioners should also be further encouraged to listen and treat parents concerns seriously . In addition to the education of health practitioners, efforts to increase immunisation uptake should include community education. Enhanced community immunisation education could be achieved, as suggested by Harrington et al, by the increased provision of information packages that are culturally appropriate in a variety of languages to expectant mothers.Furthermore television campaigns depicting children with various diseases could counteract various immunisation myths by forcing parents to understand to painful reality of potential outbreaks as a result of vaccination opposition. In addition to the above, Turner et al (2003) notes that postnatal strategies aimed at increasing mother psychosocial health should better their immunisation patterns for their infants.

As a public health measure, immunisation has had a significant role in decreasing the burden of disease. It is of public health concern to increase immunisation uptake rates, as this decreases the possibility of disease transmission, and hence complications arising from infectious disease outbreaks. It is therefore vital that equity is aspired to via efforts to increase vaccination rates among target subgroups that are affected by the sociological factors discussed above.

Bibliography (1-11)

1.A Markuzzi US, R Weitkunat and G Meyer Measles, mumps and rubella (MMR) vaccination rates in Munich school-beginners. Sozial-und Praventivmedizin. 1997;42(3):1.

2.A Rogers DP, I Guest, D Stone and P Menzel. The Pros and Cons of Immunisation. Health Care Analysis. 1995;3:100-4.

3.B Hull PMaGS. Factors associated with low uptake of measles and pertussis vaccines- an ecologic study based on the Australian Childhood Immunisation Register Australian and New Zealand Journal of Public Health. 2001;25(5):405-10.

4.C Mims HD, R Goering, I Roitt, D Wakelin and M Zuckerman. Medical Microbiology. Mosby, editor.: Mosby-Year Book Europe; 2004.

5.C Turner FBaPOR. Mothers’ health post-partum and their patterns of seeking vaccination for their infants. International Journal of Nursing Practice. 2003;9(2):120.

6.C Vandermeulen MR, H Theeten, P Van Damme and K Hoppenbrouwers. Vaccination coverage and sociodemographic determinants of measles-mumps-rubella vaccination in three different age groups. European Journal of Pediatrics. 2007:103-8.

7.Hall R. Myths and Realities: Responding to arguments against immunisation. In: Care CDHA, editor. third ed; 2001. p. 1-3.

8.Hull B. Childhood Immunisation Coverage. 2007 [updated 2007; cited]; Available from: http://www.ncirs.usyd.edu.au/research/r-acir-3rdquart.html.

9.J Forrest MBaPM. Factors influencing vaccination uptake. Current Australian research on the behavioural, social and demographic factors influencing immunisation; 1998; Royal Alexandra Hospital for Children. 1998. p. 1-2.

10.Nicoll NBaA. Myths in Medicine: Immunisation. Journal [serial on the Internet]. Date.

11.P Harrington CWaFS. Low immunisation uptake: Is the process the problem? J Epidemial Community Health. 2000(54):394 – 400.

Pros and cons of not reimbursing hospitals

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Pros and cons of not reimbursing hospitals

Pros and cons of not reimbursing hospitals

I have to agree with my peer discussions no more than 150 words each

2a. There are many pros and cons of not reimbursing hospitals for never events. Never events are described as “foreign object retained after surgery, air embolism, blood incompatibility, stage III and IV pressure ulcers, falls and trauma, catheter-associated urinary tract infection, vascular catheter-associated infection, surgical site infection (mediastinitis) after coronary artery bypass graft, surgical site infections following certain elective procedures (certain orthopedic surgeries and bariatric surgery), certain manifestations of poor control of blood sugar levels, deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement” (slide 54). “To be included on NQF’s list of “never events”, an event had to have been characterized as: Unambiguous—clearly identifiable and measurable, and thus feasible to include in a reporting system; Usually preventable—recognizing that some events are not always avoidable, given the complexity of health care; Serious—resulting in death or loss of a body part, disability, or more than transient loss of a body function; and Any of the following: Adverse and/or, Indicative of a problem in a health care facility’s safety systems and/or,Important for public credibility or public accountability” (slide 55). “An infection that occurs after a coronary artery bypass graft can cost as much as $30,000 to treat. Similarly, the 257,412 cases of Stage III and IV pressure ulcers in 2007 (not present on admission) cost a non-reimbursable average of $43,180 per stay.  And 193,566 cases of falls and trauma cases in 2007 cost an average of $33,894 per patient” (slide 56). The example given in slide 56 demonstrates both the pros and cons of not reimbursing hospitals for never events. The con of  not of reimbursing hospitals for never events is that they are not getting the money they need to treat their mistakes on patients. However, I believe this is more of a pro than a con for hospitals, insurance companies and patients. I believe that not reimbursing hospitals for never events will help physicians and other medical professionals be more mindful and cautious of their treatments. “It also raises the possibility of changes in medical practice as doctors focus more closely to clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission. Hospital executives worry that they will have to absorb the costs of these extra tests because Medicare generally pays a flat amount for each case. While hospital executives said the policy would require them to collect large amounts of data they did not now have” (slide 60). Slide 60 discusses both the pros and cons. The pros are that hopefully physicians and other medical professionals will adhere more closely to guidelines and protocols. The cons are that hospitals will have to run more tests in the beginning of admission and throughout hospital visits to back themselves up. However, this is coming out of their pocket so they can be more accurate, it is not coming out of the pockets of insurance companies. I believe this is a good strategy to reduce medical errors because I can see physicians and medical professionals making careless mistakes because they know hospitals will receive the money for their mistakes from insurance companies. I think this will enforce physicians to be more mindful and accurate with their decisions and advice towards patients. I think this will also bring more awareness to medical errors that are not always spoken about. I believe this will bring change for the better in Health Care.  Pros and cons of not reimbursing hospitals




ORDER NOW FOR ORIGINAL, PLAGIARISM-FREE PAPERS



References:

Powerpoint #6: “ Introduction to Medical Errors

2b.One of the pros of not reimbursing hospitals for never events is that it will save Medicare $20 million a year.

I think it is a good strategy to reduce medical errors because it “raises the possibility of changes in medical practice as doctors focus more closely on clinical guidelines and hospitals perform more tests to assess the condition of patients at the time of admission” (Introduction to Medical Errors, 60). Hospitals will try to prevent the occurrence of never events from happening. They will improve the quality of care and services and be more careful. However, because of these new tests and guidelines, hospitals will have to worry about absorbing the costs of these extra tests. Medicare would usually pay a flat amount for each case (Introduction to Medical Errors, 60).Pros and cons of not reimbursing hospitals

Reference

(PowerPoint: “Introduction to Medical Errors”)

3a.Based on material in the PowerPoint: “Tort Reform” the types of reforms that are more likely to succeed would be limited attorney contingency and the abolition of collateral source rule. Limited attorney contingency fees would be a great reform where the lawyer receives a percentage of the damage award.  This enables victims of negligence of “all economic levels to bring suit from injuries resulting from negligence” (Foote, 2015, slide 16). It will also ensure that lawyers will not take advantage of people and bring on unnecessary suits since they will only receive payment if there is a win (Foote,2015).  The abolition of collateral source rule is another reform that would likely succeed.  It is a rule that prohibits juries from hearing evidence that claimants have been fully or partially compensated from other sources for their injuries”(Foote, 2015, slide 15). Many states have already set this in place.  This is helpful because evidence regarding a person receiving compensation from their insurance company, etc can involve decisional bias and change a juror’s mind in their final decision.While reading we learn that the Safe Harbor Rules shield physicians from lawsuits where they are known to be following accepted guidelines. Safe harbor rules are set in place to protect doctors from getting sued for unnecessary charges.  There guidelines are set in place for physicians to follow and if they followed the steps necessary to properly care for their patient and an unfortunate occurrence happened they cannot and should not be held accountable (Foote, 2015). In the long run, the safe harbor rule will not drastically decrease the malpractice suits but may initiated but rather make physicians more aware of the clinical guidelines set in place to ensure patient safety and improve patient care.Reference:Foote, S. (2015) “Tort Reform”[PowerPoint slides]. Retrieved fromTORT REFORM REVISEDD 4-1-15.pptx

3b I believe increase rate of litigation is likely to succeed. This reform offers, “periodic payment of damages, mandatory pretrial screening panels, optional arbitration of malpractice cases” (slide 27). Periodic payment allows a defendant to pay over time instead of a lump sum, this prevents them from going bankrupt. “Arbitration is permitted in some states, often as a prerequisite to litigation, and may address liability and amount of damages” (slide 21). “Review/Screening panels are used as a pre-trial screening mechanism. Finding may or may not be submitted as evidence” (slide 22). “There is mixed evidence on screening panels, with one research team finding that the panels reduce obstetricians’ and gynecologists’ premiums by 20% and others finding that the panels may increase claim frequency by making expert evaluations more accessible” (slide 23).  “Experts have been promoting a type of reform known as “safe harbor rules,” which would shield physicians from lawsuits in cases where they were known to be following accepted clinical guidelines. For example, a patient who develops metastatic prostate cancer could not sue his physician for failing to screen him for that cancer if safe harbor rules include recent guidelines concluding the prostate screening is not routinely indicated. The goal of safe harbor rules is to protect doctors from frivolous lawsuits” (slide 32). “In short, safe harbor legislation will not necessarily reduce the number of medical malpractice suits in the U.S. But it might improve patient care, by focusing physicians on the importance of following carefully crafted clinical guidelines” (slide 34). I believe in what is stated in the power points. I do not think that malpractice will go away, however, I believe these reforms will bring some sort of awareness to medical professionals and their decisions will change for the better. I think patient care will increase and that there will be better quality of care. Physicians will be more cautious and accurate with their advice and decisions.

References:

Powerpoint #5: “Tort Reform”

Describe how you plan to utilize and implement evidence-based practice protocols found from the Agency for Healthcare Research and Quality to ensure competent and safe care for your patients.

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Describe how you plan to utilize and implement evidence-based practice protocols found from the Agency for Healthcare Research and Quality to ensure competent and safe care for your patients.

Answer the following questions in a 2-pages document as two separate discussion topics:
• The Centers for Medicare and Medicaid Services and MACRA Legislation require provider transparency in quality and value care. As an Advanced Practice Nurse enrolled in the Medicare reimbursement program, you will be expected to demonstrate competent, patient-centered outcomes. Describe how you plan to utilize and implement evidence-based practice protocols found from the Agency for Healthcare Research and Quality to ensure competent and safe care for your patients.
• Review the Team STEPPS initiative from the Agency for Healthcare Research and Quality (AHRQ). Describe the specific objectives of this national initiative and how you can implement this into your clinical setting as an APN to reduce patient errors and improve teamwork and communication.

Do nurses need to be graduates?

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Do nurses need to be graduates?

Paper instructions:
UNIVERSITY OF SALFORD
COLLEGE OF HEALTH & SOCIAL CARE
SCHOOL OF NURSING, MIDWIFERY & SOCIAL WORK

PRE-REGISTRATION BSC (HONS) NURSING SEPTEMBER 2011 INTAKE

YEAR 3 SEMESTER 1/2 – SUMMATIVE ASSESSMENT
DEVELOPING THE EVIDENCE BASE FOR PRACTICE MODULE
40 CREDITS – LEVEL 6

SUBMISSION date: Tuesday 08.04.14
FEEDBACK date: Wednesday 30.04.14
RESUBMISSION date: Tuesday 24.06.14
FEEDBACK date: Tuesday 15.07.13

Assessment
You are required to write a 6000 word report that critically evaluates the evidence underpinning an area of clinical practice and explore the usefulness of this evidence for practice and your client group. You are expected to develop a clear search strategy and critically appraise the quality of the evidence identified. You need to identify the implications for clinical practice and include ways to disseminate your findings. The work will be marked using Level 6 Grade descriptors. You must support your work with appropriate evidence and adhere to the university guide to referencing which can be found by clicking on the following link https://www.informationliteracy.salford.ac.uk/resources/?resources=ref
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Student Guidelines
Produce a robust report that summarises and critically evaluates relevant current evidence in relation to a clearly identified field-specific nursing topic. You will use the report findings to provide a rationale to support practice or to suggest practice changes. You are expected to include ways to disseminate your findings. You will use clear headings to structure your report (for example background and context, aim of report, search strategy, summary of evidence, quality appraisal, discussion, implications for practice and dissemination plan). The module e-workbook provides additional information about how to structure your report.
Your report should include the following:
• Background and context – identify a field-specific nursing topic and outline the rationale for the choice of topic, highlighting key issues;
• Aim of report – develop a robust and clear question that will help you address the topic;
• Search strategy – outline the search strategy that you used to explore research, and how you will identify user and carer perspectives and clinical experiences relating to your question. Include an example of one of your database searches in an appendix;
• Summary of the evidence – describe the evidence that you have identified and discuss its relevance to your topic;
• Quality appraisal – critically appraise the quality of the identified evidence and any identified ethical issues;
• Discussion – critically evaluate the key findings and outline the implications of the evidence for your chosen client group. Present this section using themed sub-headings.
• Implications from practice – identify gaps in the evidence and suggest ways in which these may be addressed in clinical practice;
• Dissemination plan – formulate a plan to disseminate your findings and consider the effectiveness of your chosen dissemination strategies.

You are advised to refer to the module learning outcomes when considering the direction and scope of your report and to discuss this with your academic supervisor.

The work will be marked using Level 6 Grade descriptors. You must support your work with appropriate evidence and adhere to the university guide to referencing which can be found here https://www.informationliteracy.salford.ac.uk/resources/?resources=ref

Word Count
You must adhere to the word count which is 6 000 words.

Confidentiality Statement
All references to patients, clients, health care organisations, medical / nursing documentation should be anonymised in the work you present for assessment. You should make this clear in the introduction of your work.
Under no circumstances must you identify;
• Patient / client / relative / carer / staff names,
• Name of hospital / PCT / clinical area
• Diagnostic information that has identifiable patient data visible
• Documentation where the patient’s / client’s ID, name, address, etc is clearly visible or can be identified.
• Any documents must be photocopied with the names, addresses, Trust and clinical staff names omitted. DO NOT photocopy documents and then try to omit names etc using corrector or black indelible markers as these can show confidential information once the fluid has dried.
This is in line with NMC (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives

Referencing: Information that is only available via the organisation’s INTRANET must be anonymised and referenced as ‘Local Trust’ e.g. local and unpublished clinical guidelines.
Where the healthcare organisation’s information is in the in the public domain i.e. available via the INTERNET then cite these using the normal conventions.

Contracting and negotiating final project | MKTG410 | American Military University

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Final project

Start working on the final project this week.

The final project is due by the end of week 8 and will analyze a case study.

Read How to Ask Your Boss for an Unpaid Leave to Travel, Study, or Spend Time with Family and Select one of the case studies at the end.

In 4 body page essay, complete an analysis of the case in APA format.

1) What is the issue?

2)Identify the parties involved, the negotiation strategies, cultural and ethical issues, etc.

3) What next steps would you recommend and why?

Make sure to support your essay with 5 – 7 outside sources.

How to Ask Your Boss for an Unpaid Leave to Travel, Study, or Spend Time with Family (hbr.org)

Discuss the three (3) types of nursing interventions (nurse-initiated, dependent, and interdependent) that applies to the patient care situation. Provide an example of each (refer to your textbook).

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Discuss the three (3) types of nursing interventions (nurse-initiated, dependent, and interdependent) that applies to the patient care situation. Provide an example of each (refer to your textbook).

 

 

Here is the information i need. Please i have had a bad experience with my last 2 papers. Both grades were 69. I hope that i wont be disapointed.

Using APA format, the information from this course, and your assigned readings write a six (6) to ten (10) page paper (excludes cover and reference page) addressing the application of the nursing process to a patient care scenario. Use these directions and the scoring rubric as you develop the paper. Outlines and abstracts are NOT required with this paper. Do not include the scenario in the paper

A minimum of three (3) current professional references must be provided excluding a nursing diagnosis book. Current references include professional publications or valid and current websites dated within five (5) years. Additionally, a textbook that is no more than one (1) edition old may be used. Do not use abbreviations…write out everything.

The paper consists of three (3) parts:

The meaning and use of the nursing process in making good nursing judgments that effect patient care
The development of a plan of care using the nursing process for a specific patient situation
The preparation stage for a teaching plan to prevent a recurrence of a similar situation

The following sheet will assist you when composing the plan of care for the paper: Overview of the Nursing Process.

Part 1 (3-4 pages)

Review the required readings about the nursing process. In your own words, define each step of the process and provide an example for each step.

In the implementation step, what is meant by direct and indirect care as described by the Nursing Intervention Classification (NIC) project?

Discuss the three (3) types of nursing interventions (nurse-initiated, dependent, and interdependent) that applies to the patient care situation. Provide an example of each (refer to your textbook).

Explain how the nursing process provides the basis for the registered nurse to make a nursing judgment that results in safe patient care with good outcomes.

Discuss how the registered nurse evaluates the overall use of the nursing process. Identify three (3) variables that may influence the ability to achieve the desired outcomes for the patient.

How is the plan of care modified when the outcomes are not met?

How does the RN use the nursing process to make decisions about the priority of care?

Part 2 (3 pages)

Patient scenario

A 78-year-old man is living in an assisted living facility. He is able to walk very short distances and uses a wheelchair to transport himself to the communal dining room. He administers his own medications independently and bathes himself. Over the last year he prefers to remain in the wheelchair even when in his room. He has a history of CHF, hypertension, hyperlipidemia and lower extremity weakness. He is able to state his current medications include metoprolol (Lopressor) 50 mg once daily by mouth, furosemide (Lasix) 20 mg once daily by mouth, Quinapril (Acupril) 20 mg once daily by mouth, atorvastatin (Lipitor) 20 mg once daily by mouth. During a routine examination, his physician noted a pressure ulcer over the ischium on the right buttocks. The wound is oval about 10mm x 8 mm, with red and yellow areas in the middle and black areas on some surrounding tissue. It has a foul odor. The patient had been padding the area so “it doesn’t get my pants wet”. The physician arranged for him to be admitted to the hospital in order for intravenous antibiotic therapy and wound care to be initiated. After being admitted to the hospital his medications are: metoprolol (Lopressor )50 mg orally every 12 hours, furosemide (Lasix ) 40mg once daily by mouth, quinapril HCl (Accupril) 40 mg once daily by mouth, cefazolin (Ancef)1.5 Grams in 50 mL 0.9 % Normal Saline intravenously three times a day. The result of the wound culture identified Methicilin-resistant staphylococcus aureus. After a surgical debridement of the black tissue a SilvaSorb® (antimicrobial gel) dressing was ordered daily.

Develop a Plan of Nursing Care for this patient that includes all steps of the nursing process:

One (1) actual NANDA-I nursing diagnosis statement addressing the priority problem the patient is experiencing. You need to provide the entire nursing diagnosis statement. For example: Acute pain, related to tissue trauma, as evidenced by patient rating pain at 7 on the 0-10 verbal pain scale. Provide a rationale, with evidence, why this nursing diagnosis is the priority for this patient.
What is the assessment data that supports the use of this nursing diagnosis? These are the assessments you will collect to determine if the patient has this nursing diagnosis. For example: Will assess the patient’s pain using the 0-10 verbal pain scale.
One (1) expected outcome (realistic, measureable and contains a time frame). that addresses the diagnosis and meets the criteria for an expected patient outcome. Discuss whether the outcome is a cognitive, psychomotor, affective or physiologic outcome. Discuss why the time frame selected for the evaluative criteria was selected. Use evidence as the basis for the time frame and criteria. You need to be specific to this particular patient. For example: Patient will rate pain at 3 on the 0-10 verbal pain scale. Of course, you would also need to answer the rest of the items in this section.
Four (4) nursing interventions that includes at least one (1) nurse-initiated, one (1) dependent, one (1) interdependent intervention. Label your interventions as above. Provide a rationale for each intervention that is evidence-based. Lastly, your interventions must be able to move the patient toward the achievement of the outcome. Select interventions, you as the RN can perform, that could reduce the pain and provide the rationale as to why; be sure they are evidence-based. For example: Teach patient guided imagery to distract attention and reduce tension.

Part 3 (1-2 pages)

To assist the patient in preventing a recurrence of a similar incident once he returns to the assisted living environment, the RN needs to develop a teaching plan. Use the nursing process to consider the information the RN would need prior to development of the plan. Respond to the following and be able to support your answers. You will not be developing a teaching-learning plan but demonstrating using the teaching-learning process to prepare for an individualized plan.

How does the RN decide the format of the teaching plan, i.e., written, verbal, or other?
How does the RN know which information needs to be included?
When does the RN determine how and when to evaluate the teaching-learning process?

Environmental- health- and safety (ehs) disciplines powerpoint

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Create a PowerPoint presentation of 15 slides (not counting title and reference slides) that provides an overview of the three major environmental, health, and safety (EHS) disciplines. Include each of the following elements:

summary of the responsibilities for the discipline,

evaluation of types of hazards addressed by the discipline,

description of how industrial hygiene practices relate to safety and environmental programs,

description of how industrial hygiene practices relate to environmental programs,

evaluation of types of control methods commonly used by the discipline,

interactions with the other two disciplines, and major organizations associated with the discipline.

Construct your presentation using a serif type font such as Times New Roman. A serif type font is easier to read than a non-serif type font. For ease of reading, do not use a font smaller than 28 points.

Adolescent Drug Use Exerciseand submit your response in the text box here. MAKE A DECISION: What does George do Frequently uses marijuana Occasionally uses marijuana Never uses marijuanaWhy Give r

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Adolescent Drug Use Exerciseand submit your response in the text box here.

MAKE A DECISION: What does George do?

  1. Frequently uses marijuana
  2. Occasionally uses marijuana
  3. Never uses marijuana

Why? Give reasons for why you assessed George’s marijuana use as you did. Consider the following factors in your reasons:

  • Parental monitoring and attitudes
  • Sibling factors
  • Peer factors


Rubric


PSY 1821 Case Development Rubric 2.1

PSY 1821 Case Development Rubric 2.1CriteriaRatingsPtsThis criterion is linked to a Learning OutcomeContent

20.0


to >15.0


ptsAdvancedAll key components of the Case Development questions are addressed. Proper terminology to describe concepts in the vignette are used (3 or more terms).15.0


to >10.0


ptsProficientMost key components of the Case Development questions are addressed. Proper terminology to describe concepts in the vignette are used (2 terms).10.0


to >5.0


ptsDevelopingSome key components of the Case Development questions are addressed. Proper terminology to describe concepts in the vignette are used (1 term).5.0


to >0.0


ptsPoorFew or no key components of the Case Development questions are addressed. Proper terminology to describe concepts in the vignette are not used.0.0


ptsNot Present

20.0 ptsThis criterion is linked to a Learning OutcomeFocus

10.0


to >9.0


ptsAdvancedWriting remains focused on the topic assigned throughout, bringing each paragraph back to the thesis and making connections to sources. Paper also meets all length requirements (250 words or more).9.0


to >8.0


ptsProficientWriting mostly focuses on the topic assigned but misses some connections between sources and thesis. Paper meets at least 80 percent of the length requirement.8.0


to >7.0


ptsDevelopingWriting focuses on topic throughout but loses focus or digresses in individual paragraphs. Paper meets at least 70 percent of the length requirement.7.0


to >1.0


ptsPoorWriting struggles to focus on the topic in individual paragraphs and in the paper as a whole. Paper meets at least 65 percent of the length requirement.1.0


to >0


ptsNot PresentWriting was not submitted, is about a topic other than the one assigned, or meets less than 65 percent of the length requirement.

10.0 ptsThis criterion is linked to a Learning OutcomeAPA Style

10.0


to >9.0


ptsAdvancedAssignment correctly follows APA formatting, including a title page, abstract, header, page numbers, and reference page. Sources are cited correctly in the document.9.0


to >8.0


ptsProficientAssignment is mostly correctly formatted and/or sources are cited, but there are a few errors in the format.8.0


to >7.0


ptsDevelopingAssignment exhibits many errors in APA formatting and/or sources are cited, but there are several errors in the format.7.0


to >0.0


ptsPoorAPA formatting is attempted, but several elements are missing or incorrect, an/or some of the sources are not cited and/or the format is incorrect.0.0


ptsNot PresentSources are not cited at all/format is not correct and/or APA is not attempted.

10.0 ptsThis criterion is linked to a Learning OutcomeSpelling and Grammar

10.0


to >5.0


ptsAdvancedSpelling and grammar are correct. Sentences are complete, clear, and concise. Paragraphs contain appropriately varied sentence structures.5.0


to >3.0


ptsProficientThere are some spelling and grammar errors. Some sentence level errors are present as well. Paragraphs contain some varied sentence structures.3.0


to >2.0


ptsDevelopingSpelling and grammar errors distract from meaning. Paragraphs are poorly formed.2.0


to >0.0


ptsPoorMultiple spelling and grammar errors. Sentences are incomplete or unclear.0.0


ptsNot Present

10.0 pts

Reason For Aseptic Technique Is To Maintain Asepsis Nursing Essay

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Reflection 2 – Aseptic Non-Touch Technique

This reflective piece will be about a procedure that took place whilst on placement and will look at infection control whilst doing an aseptic non-touch technique (ANTT). Using Atkins and Murphy’s 1993 model of reflection (Rolfe, G et al 2001). I have used this model as it helped me become aware of my actual thoughts and feelings regarding the situation, and more focused when analyzing it.

Description

I visited a lady who had bilateral leg wounds that needed to be dressed daily, the leg dressings that had been put on the day before were heavily exudated, the lady who I am going to call Jane to protect her identity as per NMC 2004 was adamant that she had kept her legs raised. The nurse that I was working with said that she would dress the legs this time and when I visited again I would do the dressings. The nurse opened the sterile packaging of gloves and placed it on the floor, this was to be her sterile field. The dressings and bandages that she required were opened and placed onto the sterile field and the nurse placed an apron over her uniform. The sterile gloves were put on and she proceeded to remove the dressings that were on Jane’s legs, once the dressing had been removed these were placed into the waste bag.

The nurse then proceeded to assess the wound and then redress it without changing her gloves, by not changing her gloves which were originally sterile these will now have become contaminated by handling the soiled dressing and would contaminate the new dressings and the wound.

Stage One

Whilst watching the nurse change the dressing this made me question what I had been taught in University about ANTT. The procedure that we were taught in university is from The Royal Marsden 2008. This made me feel uncomfortable and question that the patient would be at risk from healthcare associated infections (HCAI).

Stage Two

The reason for aseptic technique is to maintain asepsis and helps to protect the patient from HCAI it also protects the nurse from any of the patient’s body fluids and toxic substances (Department of Health (DOH) 2005). Elderly people are more at risk of infection which is caused by organisms that invade the immunological defence mechanisms as there immune systems are less efficient ( Calandra 2000) ANTT is used to ensure that when a healthcare professional handles sterile equipment only the part of the equipment that will not contact the wound is handled (Preston 2005). When doing the ANTT procedure this involves ensuring that consent has been gained from the patient and they are aware of what the procedure will be, the environment and the equipment is prepared, hand-washing takes place, personal protective equipment is used and a sterile field is maintained. In a Primary Care setting one of the biggest problems is infection that enters the body through a tear in the skin, this may be through a leg ulcer. A small number of microbes are sufficient enough for an infection to be caused, this may then be difficult to treat with antibiotics and what may have been a trivial problem may end up becoming a significant problem (DOH 2007). Nurses should assess the risk of transmission of infections from one person to another and plan their nursing care accordingly before they commence any form of action (Chalmers & Straub 2006).

Hand washing prior to ANTT has been found to be the most important procedure for preventing infections, hands can be the biggest route of transmission of infection if not washed correctly (Akyol et al 2006). There have been recent studies that show that hand washing is rarely carried out in a satisfactory manner and 89% of staff misses some part of their hand surface during hand washing (Mcardle et al 2006). Handwashing should be done prior any procedure, this can be achieved by three different methods:-

Soap and water this is effective in removing physical dirt or any soiling and micro-organisms liquid soap is more efficient than a soap bar (Ehrenkrantz, 1992).

Anti-microbial detergent which is effective in removing physical dirt and is more effective than soap in removing micro-organisms (Ehrenkrantz, 1992).

Alcohol based hand rubs, these are not as effective as the above in removing dirt or soil but are more effective in destroying transient bacteria (Storr, J, Clayton-Kent, S, 2004).

An aseptic procedure should be done in a clean environment and any equipment used should be sterile and disposable or decontaminated after each use and the nurse should ensure that the equipment is free from dust and any other soilage (DOH 2003). Whilst the nurse does ANTT procedure it is essential that her hands, even though they have been washed, do not contaminate the sterile field or the patient, this is achieved by the nurse using sterile gloves she needs to be aware however that gloves can be damaged during use and may no longer be sterile (Kelsall et al 2006).

The aim of wearing sterile gloves is to reduce the risk of cross-infection from nursing staff to patients and to also reduce the transient contamination of the hands by micro-organisms from one patient to another (infection control Nurses Association (ICNA) 2002). The ICNA recommend that before a patient is treated a comprehensive risk assessment is taken to determine the most appropriate glove type for the task to be undertaken. Its been suggested that sterile gloves are only necessary if the nurses hands come into contact with the patients sterile body area, they argue that non-sterile gloves provide adequate infection control if hands decontamination has been done effectively (Hollinworth and Kingston 1998). Factors that need to be considered when making the choice between aseptic or clean technique for wound care is the setting where the dressing is to be done, the immune status of the patient, this is influenced by age, medication, type of wound, location and depth of wound and the invasiveness of the procedure (APIC 2001).

Hartley (2005) reports that aseptic technique is not being carried out to a high standard and this could be related to the theory-practice gap or complacency in the professional field. Improving the skill based care needs to be the main focus on post -registration education this includes which gloves to choose, maintaining a sterile field with the risk of non-touch technique and also developing assessment protocols (Preston 2005).

Stage 3

During my time on placement I cleaned and redressed a lot of wounds and I ensured that I used the Aseptic non touch Technique that was taught to me whilst at University. I ensured that I gained the consent of the patient prior to any procedure taking place and also maintained the client’s privacy and dignity whilst carrying out the procedure.

Whilst being on placement I have learnt that staff change the dressing on wounds using the aseptic non-touch technique differently to how I was taught in university but when questioning them why they do something a certain way they have a rationale for it. I will continue to clean and redress wound in the way I have been taught and believe that this is the way forward in fighting wound infections.