Patricia A. Bennett

We prospectively investigated the large-scale implementation of a respiratory-therapist-driven protocol (TDP) that included 117 respiratory care practitioners (RCPs) managing 1,067 patients with respiratory failure over 9,048 patient days of mechanical ventilation. During a 12-mo period, we reintroduced a previously validated protocol that included a daily screen (DS) coupled with spontaneous breathing trials (SBTs) and physician prompt, as a TDP without daily input from a physician or "weaning team." With graded, staged educational interventions at 2-mo intervals, RCPs had a 97% completion rate and a 95% correct interpretation rate for the DS. The frequency with which patients who passed the DS underwent SBTs increased throughout the implementation process (p < 0.001). As the year progressed, RCPs more often considered SBTs once patients had passed a DS (p < 0.001), and physicians ordered more SBTs (46 versus 65%, p = 0.004). Overall, SBTs were ordered more often on the medicine than on the surgical services (81 versus 63%, p = 0.001), likely reflecting medical intensivists' prior use of this protocol. Important barriers to protocol compliance were identified through a questionnaire (89 respondents, 76%), and included: Physician unfamiliarity with the protocol, RCP inconsistency in seeking an order for an SBT from the physician, specific reasons cited by the physician for not advancing the patient to a SBT, and lack of stationary unit assignments by RCPs performing the protocol. We conclude that implementation of a validated weaning strategy is feasible as a TDP without daily supervision from a weaning physician or team. RCPs can appropriately perform and interpret DS data more than 95% of the time, but significant barriers to SBTs exist. Through a staged implementation process, using periodic reinforcement of all participants in ventilator management, improved compliance with this large-scale weaning protocol can be achieved.

AIM: Health literacy is the ability to understand and interpret health information and navigate the health-care system. Low health literacy is associated with poorer health knowledge and disease management, increased chronic illness, underutilisation of preventative health services and increased hospitalisations. The aim of the study is to review the available literature on the relationship between parental health literacy and health outcomes for children with chronic disease in high-income countries (HIC) and low- and middle-income countries (LMIC). METHODS: We systematically searched Medline, EMBASE and Web of Science, and assessed study quality using the Newcastle Ottawa Scale. We reviewed all relevant studies, and identified themes using thematic analysis. RESULTS: Of 1167 studies assessed, 49 were included in the review. All studies were of adequate quality. Twenty-two were from LMIC and 27 from HIC. Six themes were identified: Parental health literacy, parental education, socio-economic conditions, identity and culture, family factors, and health behaviours. In both HIC and LMIC, lower parental health literacy was associated with poorer child health outcomes. Disease-specific knowledge was found in a number of papers to directly impact parent health behaviour and child health outcomes, and may mitigate the effects of low parental health literacy. CONCLUSION: There is a clear link between parental health literacy, health behaviour and health outcomes for children with chronic disease. Disease-specific knowledge as a target for health-care interventions holds promise for application in low-resourced settings with parents (particularly mothers) who have lower health literacy, where disease-specific education may improve child health outcomes, although more research is required to determine how we can best facilitate these programmes.

When isolated aleurone layers of barley are incubated they produce a number of hydrolytic enzymes which can be divided into three groups. The synthesis and the secretion of the hydrolases in the first group is greatly enhanced by gibberellic acid. Using the density labeling technique of Filner and Varner (3) it has been shown that the increase in enzymatic activity of two of the enzymes in this group (a-amylase and protease) is due to de novo synthesis (3, 6). The marked effect of gibberellic acid on the rate of enzyme synthesis makes this an ideal system to study hormonal control of protein synthesis (10). The total enzymatic activity of hydrolases in the second group (e.g., ribonuclease and B-glucanase) does not show the same response to GA. There is a considerable increase in enzymatic activity during imbibition of the seeds, but the addition of GA to the isolated aleurone layers causes only a small increase in the total amount of enzyme activity (2, 7). However, release of these enzymes in the medium is dependent on GA, and this system has been used to study hormonal control of enzyme secretion (2, 7). Whether or not the increase in enzymatic activity which occurs during imbibition of the halfseeds and incubation of the aleurone layers is due to de novo synthesis has never been determined. Finally, the enzymatic activity of at least one hydrolase, /3-amylase, increases in the presence of GA, but this is due to release of preformed enzyme and not to de novo synthesis (5). We now present evidence consistent with the idea that two enzymes in the second group are also synthesized de novo.