Exploring factors influencing quality of life variability among individuals with coeliac disease: an online survey

OBJECTIVE

Patients with coeliac disease (CD) need to follow a strict gluten-free diet to manage symptoms and prevent complications. Restrictions imposed by the diet can be challenging and affect quality of life (QoL). We explored sources of variation in QoL among patients with CD.

DESIGN

We conducted an online survey of coeliac patients in the UK, including a CD-specific QoL tool (CD-QOL V.1.0), questions on diet adherence and an optional comment box at the end. The survey was disseminated via social media and went live between January and March 2021. We performed multiple linear regression and free text analysis.

RESULTS

We found a median CD-QOL score of 61 (IQR 44-76, range 4-100, n=215) suggesting good QoL (Good >59); however, the individual QoL scores varied significantly. Regression analyses showed that people who found diet adherence difficult and people adhering very strictly had a lower QoL. Free text comments suggested that people who adhered very strictly may do so because they have symptoms with minimal gluten exposure. People who found diet adherence difficult may be people who only recently started the diet and were still adjusting to its impact. Comments also highlighted that individuals with CD often perceive a lack of adequate follow-up care and support after diagnosis.

CONCLUSION

Better support and follow-up care is needed for people with CD to help them adjust to a gluten-free diet and minimise the impact on their QoL. Better education and increased awareness are needed among food businesses regarding cross-contamination to reduce anxiety and accidental gluten exposure.

Education to improve timeliness of shingles diagnosis: Cluster RCT and qualitative study

BACKGROUND

Herpes zoster (shingles) is normally diagnosed clinically. Timely diagnosis is important so antiviral treatment can be started soon after rash onset.

AIM

To assess whether a practice-level educational intervention, aimed at non-clinical patient-facing staff, improves the timely assessment of patients with shingles.

DESIGN AND SETTING

Cluster randomised Study Within A Trial (SWAT) with nested qualitative study in General Practices in England.

METHODS

Practices were cluster randomised 1:1, stratified by centre and minimised by practice list size and index of multiple deprivation score. Intervention practices were sent educational materials, highlighting the common presenting features of shingles and what action to take if suspected. The primary and secondary outcomes were the mean proportion of patients per practice seen within 72 hours and 144 of rash onset, respectively. Comparison between groups was conducted using linear regression, adjusting for randomisation variables. Semi-structured interviews with practice staff in intervention practices explored views and opinions of the intervention.

RESULTS

67 practices were enrolled; 34 randomised to intervention, 33 to control. The mean difference in proportion of patients seen within 72 and 144 hours was -0.132 (95% CI -0.308, 0.043) and -0.039 (95% CI -0.158, 0.080), respectively. In intervention practices, 90.5% reported distributing the educational materials, however engagement with these was suboptimal. 12 participants were interviewed, and the poster component of the intervention was said to be easiest to implement.

CONCLUSION

Our educational intervention did not improve the timely assessment of patients with shingles. This may be the result of poor intervention engagement.

Co-designing adult weight management services: a qualitative study exploring barriers, facilitators, and considerations for future commissioning

BACKGROUND

Weight management services have not always benefitted everyone equally. People who live in more deprived areas, racially minoritised communities, those with complex additional needs (e.g., a physical or mental disability), and men are less likely to take part in weight management services. This can subsequently widen health inequalities. One way to counter this is to co-design services with under-served groups to better meet their needs. Using a case study approach, we explored how co-designed adult weight management services were developed, the barriers and facilitators to co-design, and the implications for future commissioning.

METHODS

We selected four case studies of adult weight management services in Southwest England where co-design had been planned, representing a range of populations and settings. In each case, we recruited commissioners and providers of the services, and where possible, community members involved in co-design activities. Interviews were conducted online, audio-recorded, transcribed verbatim, and analysed using thematic analysis.

RESULTS

We interviewed 18 participants (8 female; 10 male): seven commissioners, eight providers, and three community members involved in co-designing the services. The case studies used a range of co-design activities (planned and actualised), from light-touch to more in-depth approaches. In two case studies, co-design activities were planned but were not fully implemented due to organisational time or funding constraints. Co-design was viewed positively by participants as a way of creating more appropriate services and better engagement, thus potentially leading to reduced inequalities. Building relationships- with communities, individual community members, and with partner organisations- was critical for successful co-design and took time and effort. Short-term and unpredictable funding often hindered co-design efforts and could damage relationships with communities. Some commissioners raised concerns over the limited evidence for co-design, while others described having to embrace "a different way of thinking" when commissioning for co-design.

CONCLUSIONS

Co-design is an increasingly popular approach to designing health in services but can be difficult to achieve within traditional funding and commissioning practices. Drawing on our case studies, we present key considerations for those wanting to co-design health services, noting the importance of building strong relationships, creating supportive organisational cultures, and developing the evidence base.

Understanding the patient's experience of coeliac disease diagnosis: a qualitative interview study

BACKGROUND

Coeliac disease (CD) presents with non-specific symptoms, and delays to diagnosis are common. The traditional diagnostic pathway involves serological testing followed by endoscopic biopsy; however, the evidence is increasing about the effectiveness of a diagnosis without the need for a biopsy.

AIM

To understand the patient's experience of being diagnosed with CD.

DESIGN AND SETTING

A qualitative study was conducted, which involved semi-structured interviews with adults diagnosed with CD living in the UK.

METHOD

Participants (n = 20) were purposefully sampled from 200 adults who had completed a diagnostic confidence survey. Interviews were conducted via video-conferencing software (Zoom), recorded, and transcribed verbatim. Data were analysed using reflexive thematic analysis.

RESULTS

Interviewees faced pre-diagnostic uncertainty, presenting with non-specific symptoms that many experienced for several years and may have normalised. GPs often attributed their symptoms to alternative diagnoses, commonly, irritable bowel syndrome or anaemia. Investigations caused further uncertainty, with half of the interviewees unaware that their initial serology included a test for CD, and reporting long waits for endoscopy and challenges managing their diet around the procedure. Their uncertainty reduced once they received their biopsy results. Endoscopy was presented as the 'gold standard' for diagnosis and most interviewees believed that the procedure was necessary for diagnostic confidence and conviction in a lifelong gluten-free diet.

CONCLUSION

Patients experience uncertainty on the pathway to a diagnosis of CD. GPs could improve their experiences by being mindful of the possibility of CD and sharing information about serological testing. Policy and guidance should address the time to endoscopy and diet during diagnosis. If diagnosis without biopsy is adopted, then consideration should be given to clinical pathway implementation and communication approaches to reduce patient uncertainty.

Providing men at risk of suicide with emotional support and advice with employment, housing and financial difficulties: a qualitative evaluation of the Hope service

BACKGROUND

Men at risk of suicide often face difficulties with finances, employment, or housing, yet support services are usually psychologically based. This study evaluated the Hope service which provides integrated psychosocial support alongside practical, financial and specialist advice.

AIMS

To examine how the Hope service supports men at risk of suicide and factors that influence its impact and usefulness.

METHODS

Twenty-six qualitative interviews with 16 service users, six Hope staff, two specialist money advice workers funded to work for Hope and two NHS referral staff, thematically analysed.

RESULTS

The Hope service provided an essential service for men at risk of suicide, with complex needs including addiction, job loss, homelessness, debt, relationship-breakdown and bereavement who often would otherwise have fallen through service provision gaps. Working in a person-centred, non-judgemental way elicited trust and specialist advice tackled problems such as housing needs, debt, benefit claims and employment, enabling men to regain a sense of control over their lives. Some men shared histories of abuse, for which specialist counselling was hard to access.

CONCLUSIONS

Hope provides an effective integrated support package for suicidal men. Funding for services like Hope are important to tackle structural issues such as homelessness and debt, alongside emotional support.

Multidisciplinary Management of Phyllodes Tumours and Breast Sarcoma: A Cross-sectional Survey of Clinical Practice across the UK and Ireland

AIMS

Phyllodes tumours and breast sarcomas are uncommon tumours and their rarity poses significant challenges in diagnosis and management. This cross-sectional study was conducted to evaluate the multidisciplinary clinical practice for these tumours across the UK and Ireland, with the aim of identifying gaps in knowledge and providing direction for establishing national guidelines.

MATERIALS AND METHODS

An international survey was adapted and circulated to breast and/or sarcoma surgeons and oncologists in the UK and Ireland through national organisations. Multidisciplinary team (MDT) responses were analysed anonymously.

RESULTS

Twenty-eight MDTs participated in this study, predominately from high-volume units (85.5%). Although only 43% of the surveyed units were part of a trust that holds a sarcoma MDT, 68% of units managed malignant phyllodes and angiosarcoma, whereas 64.5% managed soft-tissue sarcoma of the breast. Across all subtypes, axillary surgery was recommended by 14-21% of the MDTs and the most recommended resection margins for breast surgery were 'no tumour on ink' in benign phyllodes (39%) and 10 mm in the remaining subtypes (25-29%). Immediate breast reconstruction was supported by 11-18% of MDTs for breast sarcoma subtypes, whereas 36% and 32% advocated this approach in benign and borderline phyllodes tumours, respectively. Adjuvant radiotherapy and chemotherapy were recommended by up to 29% and 11% of the MDTs, respectively.

CONCLUSION

The results of this study demonstrate a wide variation in clinical practice across the surveyed MDTs. As only 28 MDTs participated in our study, with under-representation from low-volume units, our results might be an underestimation of the variability in practice across the UK and Ireland. This multi-institutional study sheds light on controversial aspects in the management of phyllodes tumours and breast sarcoma, identifies the need for national guidelines to inform best practice, and calls for the centralisation of the management of breast sarcoma within specialist centres.

Protocol for the development and validation of a patient-reported experience measure (PREM) for people with hearing loss: the PREM-HeLP

INTRODUCTION

Hearing loss is a common chronic health condition and adversely affects communication and social function resulting in loneliness, social isolation and depression. We know little about the patient experience of living with hearing loss and their views on the quality of the audiology service. In this study, we will develop and validate the first patient-reported experience measure (PREM) to understand patients' experiences of living with hearing loss and their healthcare interactions with audiology services.

METHODS AND ANALYSIS

We will develop the PREM in three phases: (1) development of PREM prototype (items/statements) derived from previous qualitative work and narrative review, (2) cognitive interview testing of the PREM prototype using a 'think aloud' technique to examine the acceptability and comprehensibility of the tool and refine accordingly and (3) psychometric testing of the modified PREM with 300 participants to assess the reliability and validity of the tool using Rasch analyses with sequential item reduction. Eligible participants will be young people and adults aged 16 years and over who have hearing loss. Participants will be recruited from three clinical sites located in England (Bath, Bristol) and Scotland (Tayside) and non-clinical settings (eg, lip-reading classes, residential care settings, national charity links, social media).

ETHICS AND DISSEMINATION

The study was approved by the West of Scotland Research Ethics Service (approval date: 6 May 2022; ref: 22/WS/0057) and the Health Research Authority and Health and Care Research Wales (HCRW) Approval (approval date: 14 June 2022; IRAS project ID: 308816). Findings will be shared with our patient and public involvement groups, academics, audiology communities and services and local commissioners via publications and presentations. The PREM will be made available to clinicians and researchers without charge.

NG2/CSPG4 attenuates motility in mandibular fibrochondrocytes under serum starvation conditions

The migration of mandibular fibrochondrocytes is important for the development of the mandible, the homeostasis of the mandibular cartilage, and for the capacity of the tissue to respond to injury. Mandibular fibrochondrocytes have to overcome formidable obstacles during migration including a dense and heterogeneous three-dimensional matrix. Guiding the direction of cell migration and commitment to a migratory phenotype in this microenvironment necessitates a multivalent response to chemotactic and extracellular matrix-mediated stimuli. One of the key matrix components in the cartilage of the temporomandibular joint is type VI collagen. Neuron/glial antigen 2 (NG2/CSPG4) is a transmembrane proteoglycan that binds with collagen VI and has been implicated in a wide range of cell behaviors including cell migration, motility, adhesion, and proliferation. While NG2/CSPG4 has been shown to be a key regulator of mandibular cartilage homeostasis, its role in the migration of mandibular fibrochondrocytes during normal and cell stress conditions has yet to be resolved. Here, we address this gap in knowledge by characterizing NG2/CSPG4-dependent migration in mandibular fibrochondrocytes using primary mandibular fibrochondrocytes isolated from control and full length NG2/CSPG4 knockout mice, in primary mandibular fibrochondrocytes isolated from NG2|DsRed reporter mice and in an immortalized mandibular fibrochondrocyte cell line with a mutated NG2/CSPG4 ectodomain. All three cells demonstrate similar results, with loss of the full length or truncated NG2/CSPG4 increasing the rate of cell migration in serum starvation/cell stress conditions. These findings clearly implicate NG2/CSPG4 as a key molecule in the regulation of cell migration in mandibular fibrochondrocytes in normal and cell stress conditions, underscoring the role of NG2/CSPG4 as a mechanosensitive signaling hub in the mandibular cartilage.

Comparison of lotions, creams, gels and ointments for the treatment of childhood eczema: the BEE RCT

Background

Emollients are recommended for children with eczema (atopic eczema/dermatitis). A lack of head-to-head comparisons of the effectiveness and acceptability of the different types of emollients has resulted in a 'trial and error' approach to prescribing.

Objective

To compare the effectiveness and acceptability of four commonly used types of emollients for the treatment of childhood eczema.

Design

Four group, parallel, individually randomised, superiority randomised clinical trials with a nested qualitative study, completed in 2021. A purposeful sample of parents/children was interviewed at ≈ 4 and ≈ 16 weeks.

Setting

Primary care (78 general practitioner surgeries) in England.

Participants

Children aged between 6 months and 12 years with eczema, of at least mild severity, and with no known sensitivity to the study emollients or their constituents.

Interventions

Study emollients sharing the same characteristics in the four types of lotion, cream, gel or ointment, alongside usual care, and allocated using a web-based randomisation system. Participants were unmasked and the researcher assessing the Eczema Area Severity Index scores was masked.

Main outcome measures

The primary outcome was Patient-Oriented Eczema Measure scores over 16 weeks. The secondary outcomes were Patient-Oriented Eczema Measure scores over 52 weeks, Eczema Area Severity Index score at 16 weeks, quality of life (Atopic Dermatitis Quality of Life, Child Health Utility-9 Dimensions and EuroQol-5 Dimensions, five-level version, scores), Dermatitis Family Impact and satisfaction levels at 16 weeks.

Results

A total of 550 children were randomised to receive lotion (analysed for primary outcome 131/allocated 137), cream (137/140), gel (130/135) or ointment (126/138). At baseline, 86.0% of participants were white and 46.4% were female. The median (interquartile range) age was 4 (2-8) years and the median Patient-Oriented Eczema Measure score was 9.3 (SD 5.5). There was no evidence of a difference in mean Patient-Oriented Eczema Measure scores over the first 16 weeks between emollient types (global p = 0.765): adjusted Patient-Oriented Eczema Measure pairwise differences - cream-lotion 0.42 (95% confidence interval -0.48 to 1.32), gel-lotion 0.17 (95% confidence interval -0.75 to 1.09), ointment-lotion -0.01 (95% confidence interval -0.93 to 0.91), gel-cream -0.25 (95% confidence interval -1.15 to 0.65), ointment-cream -0.43 (95% confidence interval -1.34 to 0.48) and ointment-gel -0.18 (95% confidence interval -1.11 to 0.75). There was no effect modification by parent expectation, age, disease severity or the application of UK diagnostic criteria, and no differences between groups in any of the secondary outcomes. Median weekly use of allocated emollient, non-allocated emollient and topical corticosteroids was similar across groups. Overall satisfaction was highest for lotions and gels. There was no difference in the number of adverse reactions and there were no significant adverse events. In the nested qualitative study (n = 44 parents, n = 25 children), opinions about the acceptability of creams and ointments varied most, yet problems with all types were reported. Effectiveness may be favoured over acceptability. Parents preferred pumps and bottles over tubs and reported improved knowledge about, and use of, emollients as a result of taking part in the trial.

Limitations

Parents and clinicians were unmasked to allocation. The findings may not apply to non-study emollients of the same type or to children from more ethnically diverse backgrounds.

Conclusions

The four emollient types were equally effective. Satisfaction with the same emollient types varies, with different parents/children favouring different ones. Users need to be able to choose from a range of emollient types to find one that suits them.

Future work

Future work could focus on how best to support shared decision-making of different emollient types and evaluations of other paraffin-based, non-paraffin and 'novel' emollients.

Trial registration

This trial is registered as ISRCTN84540529 and EudraCT 2017-000688-34.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (HTA 15/130/07) and will be published in full in Health Technology Assessment; Vol. 27, No. 19. See the NIHR Journals Library website for further project information.

Protocol for a qualitative study exploring the lived experience of hearing loss and patient reported experience in the UK: the HeLP study

INTRODUCTION

Worldwide, hearing loss is a significant public health issue and one of the most common chronic health conditions experienced by older adults. Hearing loss is associated with communication difficulties, social withdrawal, isolation and lower quality of life. Although hearing aid technology has improved significantly, the workload of managing hearing aids has increased. The aim of this qualitative study is to develop a novel theory of people's lived experience of hearing loss across the lifespan.

METHODS

Eligible participants will be young people and adults aged 16 years and above who have a hearing loss and carers/family members of people with a hearing loss. This study will use individual, in-depth face-to-face or online interviews. With participants' permission, interviews will be audio-recorded and transcribed verbatim. A grounded theory approach to concurrent data gathering and analysis will develop grouped codes and categories and link these to provide a novel theory to describe the experience of hearing loss.

ETHICS AND DISSEMINATION

The study was approved by the West of Scotland Research Ethics Service (approval date: 6 May 2022 ref: 22/WS/0057) and the Health Research Authority and Health and Care Research Wales Approval (approval date: 14 June 2022; IRAS project ID: 308816). The research will inform the development of a Patient Reported Experience Measure to improve the information and support given to patients. Findings will be disseminated through peer-reviewed articles and at academic conferences, as well as to our patient and public involvement groups, healthcare professionals, audiology services and local commissioners.

Small bowel obstruction caused by a fibrotic bow-string appendix: a consequence of non-operative management of acute appendicitis

A 73-year-old woman presented with small bowel obstruction that failed to settle with conservative management. Over the previous 2 years she had presented twice with computed tomography scan-proven acute appendicitis with localised perforation of the appendix tip. In view of medical comorbidities, she was treated non-operatively with clinical and radiological resolution on each occasion, but on the third presentation laparoscopy was undertaken for non-resolving small bowel obstruction and the non-inflamed appendix itself was identified as a fibrous band causing compression of the distal ileum and complete small bowel obstruction. Following division and appendicectomy, the patient made an uneventful recovery. This case illustrates the potential consequence of repeated appendiceal inflammation and non-operative management and may be seen increasingly as this approach is widely adopted during the COVID-19 pandemic.

Effectiveness and safety of lotion, cream, gel, and ointment emollients for childhood eczema: a pragmatic, randomised, phase 4, superiority trial

BACKGROUND

To our knowledge, there are no trials comparing emollients commonly used for childhood eczema. We aimed to compare the clinical effectiveness and safety of the four main emollient types: lotions, creams, gels, and ointments.

METHODS

We did a pragmatic, individually randomised, parallel group, phase 4 superiority trial in 77 general practice surgeries in England. Children aged between 6 months and 12 years with eczema (Patient Orientated Eczema Measure [POEM] score >2) were randomly assigned (1:1:1:1; stratified by centre and minimised by baseline POEM score and age, using a web-based system) to lotions, creams, gels, or ointments. Clinicians and parents were unmasked. The initial emollient prescription was for 500 g or 500 mL, to be applied twice daily and as required. Subsequent prescriptions were determined by the family. The primary outcome was parent-reported eczema severity over 16 weeks (weekly POEM), with analysis as randomly assigned regardless of adherence, adjusting for baseline and stratification variables. Safety was assessed in all randomly assigned participants. This trial was registered with the ISRCTN registry, ISRCTN84540529.

FINDINGS

Between Jan 19, 2018, and Oct 31, 2019, 12 417 children were assessed for eligibility, 550 of whom were randomly assigned to a treatment group (137 to lotion, 140 to cream, 135 to gel, and 138 to ointment). The numbers of participants who contributed at least two POEM scores and were included in the primary analysis were 131 in the lotion group, 137 in the cream group, 130 in the gel group, and 126 in the ointment group. Baseline median age was 4 years (IQR 2-8); 255 (46%) participants were girls, 295 (54%) were boys; 473 (86%) participants were White; and the mean POEM score was 9·3 (SD 5·5). There was no difference in eczema severity between emollient types over 16 weeks (global p value=0·77), with adjusted POEM pairwise differences of: cream versus lotion 0·42 (95% CI -0·48 to 1·32), gel versus lotion 0·17 (-0·75 to 1·09), ointment versus lotion -0·01 (-0·93 to 0·91), gel versus cream -0·25 (-1·15 to 0·65), ointment versus cream -0·43 (-1·34 to 0·48), and ointment versus gel -0·18 (-1·11 to 0·75). This result remained unchanged following multiple imputation, sensitivity, and subgroup analyses. The total number of adverse events did not significantly differ between the treatment groups (lotions 49 [36%], creams 54 [39%], gels 54 [40%], and ointments 48 [35%]; p=0·79), although stinging was less common with ointments (12 [9%] of 138 participants) than lotions (28 [20%] of 137), creams (24 [17%] of 140), or gels (25 [19%] of 135).

INTERPRETATION

We found no difference in effectiveness between the four main types of emollients for childhood eczema. Users need to be able to choose from a range of emollients to find one that they are more likely to use effectively.

FUNDING

National Institute for Health and Care Research.

Blood tests in primary care: A qualitative study of communication and decision-making between doctors and patients

Objective

Blood tests are commonly used in primary care as a tool to aid diagnosis, and to offer reassurance and validation for patients. If doctors and patients do not have a shared understanding of the reasons for testing and the meaning of results, these aims may not be fulfilled. Shared decision‐making is widely advocated; yet, most research focusses on treatment decisions rather than diagnostic decisions. The aim of this study was to explore communication and decision‐making around diagnostic blood tests in primary care.

Methods

Qualitative interviews were undertaken with patients and clinicians in UK primary care. Patients were interviewed at the time of blood testing, with a follow‐up interview after they received test results. Interviews with clinicians who requested the tests provided paired data to compare clinicians' and patients' expectations, experiences and understandings of tests. Interviews were analysed thematically using inductive and deductive coding.

Results

A total of 80 interviews with 28 patients and 19 doctors were completed. We identified a mismatch in expectations and understanding of tests, which led to downstream consequences including frustration, anxiety and uncertainty for patients. There was no evidence of shared decision‐making in consultations preceding the decision to test. Doctors adopted a paternalistic approach, believing that they were protecting patients from anxiety.

Conclusion

Patients were not able to develop informed preferences and did not perceive that choice is possible in decisions about testing, because they did not have sufficient information and a shared understanding of tests. A lack of shared understanding at the point of decision‐making led to downstream consequences when test results did not fulfil patients' expectations. Although shared decision‐making is recommended as best practice, it does not reflect the reality of doctors' and patients' accounts of testing; a broader model of shared understanding seems to be more relevant to the complexity of primary care diagnosis.

Patient or Public Contribution

A patient and public involvement group comprising five participants with lived experience of blood testing in primary care met regularly during the study. They contributed to the development of the research objectives, planning recruitment methods, reviewing patient information leaflets and topic guides and also contributed to discussion of emerging themes at an early stage in the analysis process.

'I guess I'll wait to hear'- communication of blood test results in primary care a qualitative study

BACKGROUND

Rates of blood testing in primary care are rising. Communicating blood test results generates significant workload for patients, GPs, and practice staff.

AIM

To explore GPs' and patients' experience of systems of blood test communication.

DESIGN AND SETTING

Qualitative interviews with patients and GPs in UK primary care in both urban and rural practices in the West of England.

METHOD

A total of 28 patients and 19 GPs from six practices were recruited, with a range of socioeconomic and demographic characteristics. Patients were interviewed at two time points: a) at or soon after their blood test and b) after they had received their test results. The GPs who requested the tests were also interviewed (they could complete a maximum of two interviews about different patients). Eighty qualitative interviews were undertaken; 54 patient interviews and 26 GP interviews.

RESULTS

Methods of test result communication varied between doctors and were based on habits, unwritten heuristics, and personal preferences rather than protocols. Doctors expected patients to know how to access their test results. In contrast, patients were often uncertain and used guesswork to decide when and how to access their tests. Patients and doctors generally assumed that the other party would make contact, with potential implications for patient safety. Text messaging and online methods of communication have benefits, but were perceived by some patients as 'flippant' or 'confusing'. Delays and difficulties obtaining and interpreting test results can lead to anxiety and frustration for patients.

CONCLUSION

Current systems of test result communication are complex and confusing, and mostly based on habits and routines rather than clear protocols. This has important implications for patient-centred care and patient safety.

How parents and children evaluate emollients for childhood eczema: a qualitative study

BACKGROUND

Eczema affects one in five children in the UK. Regular application of emollients is routinely recommended for children with eczema. There are four main emollient types, but no clear evidence of which is best. The current 'trial and error' approach to find suitable emollients can be frustrating for parents, children, and clinicians.

AIM

To identify how parents and children experience and evaluate emollients.

DESIGN AND SETTING

Qualitative interview study, nested within a primary care trial of emollients (Best Emollients for Eczema [BEE] trial).

METHOD

Semi-structured interviews with children with eczema and their parents were conducted. Participants were purposively sampled on emollient type (lotion, cream, gel, or ointment), age, and eczema severity.

RESULTS

Forty-four parents were interviewed, with children participating in 24 of those interviews. There was no clear preference for any one emollient type. The strongest theme was the variation of experience in each of the four types. Participants focused on thickness and absorbency, both positively and negatively, to frame their evaluations. Effectiveness and acceptability were both considered when evaluating an emollient but effectiveness was the primary driver for continued use. For some, participating in the trial had changed their knowledge and behaviour of emollients, resulting in use that was more regular and for a longer duration.

CONCLUSION

There is no one emollient that is suitable for everyone, and parents/children prioritise different aspects of emollients. Future research could evaluate decision aids and/or tester pots of different types, which could enable clinicians and parents/children to work collaboratively to identify the best emollient for them.

Preventing male suicide through a psychosocial intervention that provides psychological support and tackles financial difficulties: a mixed method evaluation

BACKGROUND

To help resolve high suicide rates in Bristol, North Somerset and South Gloucestershire, the charity Second Step was commissioned to roll-out the Hope service offering a psychosocial intervention for men, supporting them through acute distress and addressing financial difficulties. This study evaluated the impact of the Hope service on men at risk of suicide experiencing financial and other difficulties.

METHODS

Mixed methods study using: (i) a prospective cohort study design to compare depression, suicidal ideation and financial self-efficacy scores of men aged 30-64, referred to the service between October 2018 and July 2020, at baseline and 6 months follow-up and between low and moderate to high-intensity service users; and (ii) a qualitative interview study to evaluate the acceptability and impact of the Hope service to Hope service users.

RESULTS

There was a 49% reduction in depression score (mean reduction - 10.0, 95% CI - 11.7 to - 8.3) and in the proportion of service users with suicidal ideation (percent reduction - 52.5, 95% CI - 64.1% to - 40.9%) at 6 months follow-up compared to baseline. Financial self-efficacy scores increased by 26% (mean increase 2.9, 95% CI 1.8 to 3.9). Qualitative accounts illustrated how 'Hope saved my life' for several men interviewed; most respondents described being able to move forward and tackle challenges with more confidence following the Hope intervention. Professional advice to tackle financial and other difficulties such as housing helped to relieve anxiety and stress and enable practical issues to be resolved.

CONCLUSIONS

The Hope service offered practical and emotional support to men who have experienced suicidal feelings, redundancy, homelessness and poverty and occupies an important space between mental health and social care provision. Hope demonstrates the value of an intervention which cuts across traditional boundaries between psychiatric care and social advice agencies to provide, what is, in effect, an integrated care service.

127 Optimum Treatment for Sigmoid Volvulus Remains Elusive but Surgery May Provide Considerable Benefit: Results of a 5-Year Audit

Background

Sigmoid volvulus is a surgical emergency and patients are often elderly with significant comorbidities. Whilst endoscopic decompression is easy and effective in the short-term, recurrence and repeated admissions are common with surgery generally being reserved for non-resolution or complications. Consensus an optimum management is lacking.

Method

A retrospective audit of all patients admitted with sigmoid volvulus to a DGH General Surgery service between 01/01/2015-20/10/2020 was undertaken. Patient demographics, comorbidities, clinical findings, investigations, and treatment were recorded.

Results

Sixty-three patients were identified (median age 71.5 years; 58.7% male]. Some 50.8% had more than one previous presentation (range 1–6), 19% presented after 3 days of symptoms and 3.2% presented with perforation. Plain radiography and CT scanning was undertaken in 90.5% and 54%, respectively.

Endoscopic detorsion was performed in 77.77% and repeated in the same admission for 33.3% of cases. Flatus tubes and rigid sigmoidoscopy was used in 47.6% with a 59.6% success rate. Seventeen patients (27%) underwent sigmoid resection, 14 having open surgery and 3 laparoscopic. Primary anastomosis was undertaken in 64.7% (11 patients), with only one anastomotic leak; the remaining 6 patients had a colostomy. The re-admission rate was 30.1% (19% non-operated patients, 11.1% operated patients).

Conclusions

Most patients with sigmoid volvulus are managed non-operatively with endoscopic detorsion which may be associated with a considerable healthcare burden and high readmission rates. Selective resection can be associated with low morbidity and good outcomes. Clinicians could reasonably adopt a lower threshold for surgical intervention, particularly for recurrent volvulus.

Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall

BACKGROUND

Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort.

METHODS

Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres.

RESULTS

The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort.

CONCLUSION

A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

Integrating care between an NHS hospital, a community provider and the role of commissioning: the experience of developing an integrated respiratory service

OBJECTIVES

An integrated respiratory service was commissioned in 2016 in a UK region to support patients with chronic obstructive pulmonary disease. The service brought together the respiratory department of a National Health Service hospital and a not-for-profit community provider. This paper evaluates: (1) the perceived efficacy of integrated working between the organisations from the perspective of staff and (2) the relationship between commissioning and integration of the services.

DESIGN

Semistructured interviews with staff from the three organisations involved in the integrated respiratory service. Staff were purposefully sampled. The interviews were audio recorded, transcribed and analysed thematically.

SETTING

Secondary care respiratory unit; community provider of respiratory care; and a clinical commissioning group.

PARTICIPANTS

Nineteen interview participants: nine from the community provider; eight from the hospital and two from the clinical commissioning group.

RESULTS

Staff identified lack of integration between the organisations characterised by: poor communication, lack of trust, absence of shared information technology and ineffective integrative initiatives. The commissioning process created barriers to integration including: contractual limitations which prevented pathway development, absence of agreed clinical governance arrangements and lack of recognition of community work undertaken by hospital staff. Positive working relationships were established over time as staff recognised the skills that each had to offer.

CONCLUSIONS

The commissioning process underpinned the relationship between the organisations and contributed to distrust and negative perceptions of the 'other'. Commissioning an integrated service should incorporate dialogue with stakeholders as early as possible and before the contract is finalised to develop a bedrock of trust.

Raised inflammatory markers as a predictor of one-year mortality: a cohort study in primary care in the UK using electronic health record data

OBJECTIVES

Identification of patients at increased mortality risk is important in the context of increasing multimorbidity and an ageing population, to help facilitate the planning and delivery of services. The aim of this study was to examine 1-year all-cause mortality in a cohort of primary care patients in whom inflammatory markers including C reactive protein (CRP), erythrocyte sedimentation rate (ESR) and plasma viscosity (PV), had been tested.

DESIGN

Observational cohort study using general practitioner Electronic Health Records from the Clinical Practice Research Datalink, with linkage to Office for National Statistics (ONS) Death Registry.

SETTING

UK Primary Care.

PARTICIPANTS

159 325 patients with inflammatory marker tests done in 2014 and 39 928 age, sex and practice-matched controls without inflammatory marker testing. ONS Death registry data were available for 109 966 participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

One-year mortality in those with raised inflammatory markers compared with normal inflammatory markers and untested controls. Subanalyses stratified 1-year mortality by age group, gender and cause of death.

RESULTS

Patients with a raised inflammatory marker (n=47 797) had an overall 1-year all-cause mortality of 6.89%, compared with 1.41% in those with normal inflammatory markers (p<0.001) and 1.62% in untested controls. A raised CRP is associated with the highest mortality rate at 8.76% compared with 4.99% for ESR and 4.66% for PV. One-year mortality is higher in men with a raised inflammatory marker compared with women (9.78% vs 5.29%). The C-statistic of a simple mortality prediction model containing age, sex and CRP test result is 0.89.

CONCLUSIONS

Inflammatory markers are a strong predictor of all-cause mortality in primary care, with a C-statistic comparable to several previously developed frailty indices. Future research should consider the added value of CRP testing, in combination with other risk factors, to improve prediction of mortality in primary care. Evidence- based interventions for frailty are needed alongside predictive tools.

Urine Extracellular Vesicle GATA2 mRNA Discriminates Biopsy Result in Men with Suspicion of Prostate Cancer

PURPOSE

Prostate specific antigen has limited performance in detecting prostate cancer. The transcription factor GATA2 is expressed in aggressive prostate cancer. We analyzed the predictive value of urine extracellular vesicle GATA2 mRNA alone and in combination with a multigene panel to improve detection of prostate cancer and high risk disease.

MATERIALS AND METHODS

GATA2 mRNA was analyzed in matched extracellular vesicles isolated from urines before and after prostatectomy (16) and paired urine and tissue prostatectomy samples (19). Extracellular vesicle GATA2 mRNA performance to distinguish prostate cancer and high grade disease was tested in training (52) and validation (165) cohorts. The predictive value of a multigene score including GATA2, PCA3 and TMPRSS2-ERG (GAPT-E) was tested in both cohorts.

RESULTS

Confirming its prostate origin, urine extracellular vesicle GATA2 mRNA levels decreased significantly after prostatectomy and correlated with prostate cancer tissue GATA2 mRNA levels. In the training and validation cohort GATA2 discriminated prostate cancer (AUC 0.74 and 0.66) and high grade disease (AUC 0.78 and 0.65), respectively. Notably, the GAPT-E score improved discrimination of prostate cancer (AUC 0.84 and 0.72) and high grade cancer (AUC 0.85 and 0.71) in both cohorts when compared with each biomarker alone and PT-E (PCA3 and TMPRSS2-ERG). A GAPT-E score for high grade prostate cancer would avoid 92.1% of unnecessary prostate biopsies, compared to 61.9% when a PT-E score is used.

CONCLUSIONS

Urine extracellular vesicle GATA2 mRNA analysis improves the detection of high risk prostate cancer and may reduce the number of unnecessary biopsies.