The Resilience Hub approach for addressing mental health of health and social care workers during the COVID-19 pandemic: a mixed-methods evaluation

Background

Resilience Hubs provide mental health screening, facilitation of access and direct provision of psychosocial support for health and social care keyworkers in England affected by the coronavirus disease 2019 pandemic.

Aim

To explore implementation of the Hubs, including characteristics of staff using the services, support accessed, costing data and a range of stakeholder perspectives on the barriers and enablers to Hub use and implementation of staff well-being support within the context of the pandemic.

Design

Mixed-methods evaluation.

Setting

Four Resilience Hubs.

Methods

Findings were integrated via mixed-method case studies, including: analyses of Hub mental health screening (N = 1973); follow-up questionnaire data (N = 299) on service use and health status of Hub clients; economic information provided by the Hubs; 63 interviews with Hub staff, wider stakeholders, Hub clients and keyworkers who did not use the Hubs.

Results

Findings were consistent across Hubs and workstreams. Most Hub clients were NHS staff. Under-represented groups included men, keyworkers from minority ethnic communities, care homes and emergency services staff. Clients reported comorbid mental health needs across multiple domains (anxiety; depression; post-traumatic stress; alcohol use; functioning). Their health status was lower than population norms and relevant pre-pandemic data. Several factors predicted higher needs, but having pre-pandemic emotional well-being concerns was one of the most robust predictors of higher need. Sixty per cent of participants who completed follow-up questionnaires reported receiving mental health support since Hub screening, most of which was directly or indirectly due to Hub support. High levels of satisfaction were reported. As in many services, staffing was the central component of Hub cost. Hubs were predominantly staffed by senior clinicians; this staffing model was consistent with the generally severe difficulties experienced by clients and the need for systemic/team-based working. Costs associated with health and social care use for Hub clients were low, which may be due to barriers to accessing support in general. Enablers to accessing Hubs included: a clear understanding of the Hubs, how to self-refer, and managerial support. Barriers included confusion between Hubs and other support; unhelpful beliefs about job roles, unsupportive managers, negative workplace cultures and difficulties caused by systemic issues. Some keyworkers highlighted a perceived need for further diversity and cultural competency training to improve reach to under-represented communities. Other barriers for these groups included prior negative experiences of services, structural inequalities and stigma. Some wider stakeholders had concerns around growing waiting times for Hub-provided therapy, and insufficient data on Hub usage and outcomes. Feedback was otherwise very positive.

Limitations

Main limitations included lack of comparative and pre-pandemic/baseline data, small numbers from under-represented groups limiting fine-grained analysis, and participant self-selection.

Conclusions

Findings highlighted the value of the Hub model of outreach, screening, support navigation and provision of direct support during the coronavirus disease 2019 pandemic, and as a potential model to respond to future crises. The research provided recommendations to improve Hub promotion, equality/diversity/inclusion access issues, management of specialist resources and collection of relevant data on Hub outcomes and activities. Broader recommendations for the primary prevention of mental health difficulties across the health and care system are made, as individual support offers should be an adjunct to, not a replacement for, resolutions to systemic challenges. Research recommendations are made to conduct more robust evaluations of the clinical and cost-effectiveness of the Hubs, using larger data sets and comparative data.

Study registration

This study is registered as researchregistry6303.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR132269) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 29. See the NIHR Funding and Awards website for further award information.

The roles and responsibilities of advanced practice nurses in intensive care units: A scoping review

INTRODUCTION

Since the intensive care units are one of the most sensitive hospital settings and critically ill patients undergo various stressful factors that put their lives in danger, a more advanced level of nursing practice is imperative to accommodate these issues and provide optimal care of patients.

OBJECTIVES

To review the literature describing the roles and activities performed by advanced practice nurses in intensive care units.

REVIEW METHODS

We conducted a scoping review to search published articles using Scopus, PubMed, CINAHL (EBSCOhost), Science Direct, MEDLINE (EBSCOhost) and Cochrane Library during a 10-year period from 2013 to 2023.

RESULTS

We identified 729 records, from which eleven articles were included in the review. We included six reviews and five original articles or research papers. With regard to the target area of our review, we used the information provided by these studies and categorized the contents related to the roles of advanced practice nurses in intensive care units into five sections, including direct practice, education and counseling, research, collaboration, and leadership.

CONCLUSION

Advanced practice nurses are essential members of critical care team by playing various roles in practice, education, research, collaboration, and leadership, and therefore, they can increase patients' access to critical care and improve healthcare outcomes. The advancement of technology and complexity of care in intensive care units have led to the role expansion of these nurses which results in task-shifting between doctors and nurses. Therefore, it is considered essential for nursing and medical professionals to reach an agreement to establish standardized roles for advanced practice nurses.

Acoustic field visualisation using local absorption of ultrasound and thermochromic liquid crystals

Acoustic field and vibration visualisation is important in a wide range of applications. Laser vibrometry is often used for such visualisation, however, the equipment has a high cost and requires significant user expertise, and the method can be slow, as it requires scanning point by point. Here we suggest a different approach to visualisation of acoustic fields in the kHz - MHz range, using paint-on or removable film sensors, which produce a direct visual map of ultrasound displacement. The sensors are based on a film containing thermochromic liquid crystals (TLC), along with a backing/underlay layer which improves absorption of ultrasound. The absorption generates heat, which can be seen by a change in colour of the TLC film. A removable sensor is used to visualise the resonant modes of an air-coupled flexural transducer operated from 410 kHz to 7.23 MHz, and to visualise 40 kHz standing waves in a Perspex plate. The thermal basis of the visualisation is confirmed using thermal imaging. The speed and cost of visualisation makes the new sensor attractive for use in condition monitoring, for fast assessment of transducer quality, or for analysis of acoustic field distribution in power ultrasonic systems.

A service mapping exercise of four health and social care staff mental health and wellbeing services, Resilience Hubs, to describe health service provision and interventions

BACKGROUND

NHS England funded 40 Mental Health and Wellbeing Hubs to support health and social care staff affected by the COVID-19 pandemic. We aimed to document variations in how national guidance was adapted to the local contexts of four Hubs in the North of England.

METHODS

We used a modified version of Price's (2019) service mapping methodology. Service level data were used to inform the analysis. A mapping template was adapted from a range of tools, including the European Service Mapping Schedule, and reviewed by Hub leads. Key data included service model; staffing; and interventions. Data were collected between March 2021 - March 2022 by site research assistants. Findings were accuracy-checked by Hub leads, and a logic model developed to theorise how the Hubs may effect change.

RESULTS

Hub goals and service models closely reflected guidance; offering: proactive outreach; team-based support; clinical assessment; onward referral, and rapid access to mental health support (in-house and external). Implementation reflected a service context of a client group with high mental health need, and high waiting times at external mental health services. Hubs were predominantly staffed by experienced clinicians, to manage these mental health presentations and organisational working. Formulation-based psychological assessment and the provision of direct therapy were not core functions of the NHS England model, however all Hubs incorporated these adaptations into their service models in response to local contexts, such as extensive waiting lists within external services, and/or client presentations falling between gaps in existing service provision. Finally, a standalone clinical records system was seen as important to reassure Hub users of confidentiality. Other more nuanced variation depended on localised contexts.

CONCLUSION

This study provides a map for setting up services, emphasising early understandings of how new services will integrate within existing systems. Local and regional contexts led to variation in service configuration. Whilst additional Hub functions are supported by available literature, further research is needed to determine whether these functions should comprise essential components of staff wellbeing services moving forward. Future research should also determine the comparative effectiveness of service components, and the limits of permissible variation.

STUDY REGISTRATION

researchregistry6303.

Implementing psychological support for health and social care staff affected by the COVID-19 pandemic: a qualitative exploration of staff well-being hubs ('Resilience Hubs') using normalisation process theory

OBJECTIVES

Evaluate the implementation of Hubs providing access to psychological support for health and social care keyworkers affected by the COVID-19 pandemic.

DESIGN

Qualitative interviews informed by normalisation process theory to understand how the Hub model became embedded into normal practice, and factors that disrupted normalisation of this approach.

SETTING

Three Resilience Hubs in the North of England.

PARTICIPANTS

Hub staff, keyworkers who accessed Hub support (Hub clients), keyworkers who had not accessed a Hub, and wider stakeholders involved in the provision of staff support within the health and care system (N=63).

RESULTS

Hubs were generally seen as an effective way of supporting keyworkers, and Hub clients typically described very positive experiences. Flexibility and adaptability to local needs were strongly valued. Keyworkers accessed support when they understood the offer, valuing a confidential service that was separate from their organisation. Confusion about how Hubs differed from other support prevented some from enrolling. Beliefs about job roles, unsupportive managers, negative workplace cultures and systemic issues prevented keyworkers from valuing mental health support. Lack of support from managers discouraged keyworker engagement with Hubs. Black, Asian and minority ethnic keyworkers impacted by racism felt that the Hubs did not always meet their needs.

CONCLUSIONS

Hubs were seen as a valuable, responsive and distinct part of the health and care system. Findings highlight the importance of improving promotion and accessibility of Hubs, and continuation of confidential Hub support. Policy implications for the wider health and care sector include the central importance of genuine promotion of and value placed on mental health support by health and social care management, and the creation of psychologically safe work environments. Diversity and cultural competency training is needed to better reach under-represented communities. Findings are consistent with the international literature, therefore, likely to have applicability outside of the current context.

From CoNFLict to Confidence: Solving a Diagnostic Dilemma Using Neurofilament Light – A Case Report

Distinguishing neurodegenerative from primary psychiatric conditions is often challenging for clinicians, particularly when assessing older people presenting with neuropsychiatric symptoms. Measurement of fluid biomarkers of neurodegeneration is an emerging approach offering improved diagnostic accuracy. This report explores the use of emerging fluid biomarkers to address diagnostic challenges, framed around a case where the diagnosis of delirium with dementia was revised based on biomarker analysis, enabling treatment of a primary mood disorder with disabling psychiatric symptoms.

Introducing the '3 Fs model of complexity' for people with dementia accessing a NHS mental health inpatient dementia assessment ward: An interpretive description study

BACKGROUND

In the United Kingdom, the use of the terms 'complex' and 'complexity' alongside dementia is reflected in a number of policy and practice documents. However, there is a lack of evidence that explores how complexity is perceived, constructed and experienced by people with dementia, family carers and practitioners working in the NHS dementia inpatient assessment wards [dementia assessment wards].

OBJECTIVE

To explore the meaning and concept of complexity in dementia from within the setting of a dementia assessment ward and develop a practice model.

METHODS

The study was conducted over three phases: 1) an online electronic survey of UK national dementia leaders; 2) individual interviews and a focus group with dementia practitioners in two dementia assessment wards; 3) case studies of four patients with dementia resident on a dementia assessment ward which included their identified family carer/consultee, the named clinician on the ward involved in that person's care and a care records review.

RESULTS

The findings highlighted that complexity is constructed through a number of interconnected and interrelated domains that vary in acuity. These findings have been developed into the '3 Fs Model of Complexity' and the 3'Fs' stand for Fixed, Flexible and Fluctuating. The Fixed domain consists of six components which are always present in complexity. The Flexible domain consists of 14 components and a person with dementia may experience any number of Flexible domain components at any one time. The Fluctuating domain highlights that all components have the ability to vary in their acuity.

CONCLUSION

The '3 Fs Model of Complexity' may facilitate a more holistic view of a person with dementia than when 'symptoms' are viewed in isolation. Going forward, and subject to further refinement and testing, the '3 Fs Model of Complexity' could help guide the selection of tailored, personalised interventions for people with dementia, including formulation approaches.

Protocol of a Phase II Randomized, Multi-Center, Double-Blind, Placebo-Controlled Trial of S-Adenosyl Methionine in Participants with Mild Cognitive Impairment or Dementia Due to Alzheimer's Disease

BACKGROUND

S-adenosyl methionine (SAMe) is a pivotal metabolite in multiple pathways required for neuronal homeostasis, several of which are compromised in Alzheimer's disease (AD). Correction of the SAMe deficiency that is characteristic of the AD brain may attenuate or prevent pathological processes driving AD-associated neurodegeneration including aberrant tau hyperphosphorylation and DNA hypomethylation.

OBJECTIVES

The primary aim is to test the hypothesis that daily treatment with 400 mg oral SAMe for 180 days will lead to a greater reduction from baseline in plasma levels of p-tau181 compared to placebo in patients with mild cognitive impairment or dementia due to AD.

DESIGN, SETTING, PARTICIPANTS

This is a phase II, randomized, multi-center, double-blind, placebo-controlled trial among 60 participants with mild cognitive impairment or dementia due to AD. Participants will be randomized in a 1:1 ratio to receive either SAMe or matching placebo, to be taken as an adjunct to their AD standard of care.

MEASUREMENTS AND RESULTS

The primary outcome is change in plasma p-tau181 concentration between baseline and following 180 days of treatment, which will be compared between the active and placebo group. Secondary outcomes are the safety of SAMe administration (incidence of serious adverse events), change from baseline in cognitive performance (as measured by the Repeatable Battery for the Assessment of Neuropsychological Status), and epigenetic changes in DNA methylation.

CONCLUSION

Demonstration of effective and safe lowering of plasma p-tau181 with SAMe in this phase II trial would pave the way for an exciting field of translational research and a larger phase III trial.

POS0478 TOPICAL CALCIUM CHELATORS FOR TARGETING CUTANEOUS CALCIFICATION: PRECLINICAL EVIDENCE OF EFFICACY

Background

Cutis calcinosis, defined as sub-epidermal deposition of calcium salts, is a painful, disabling, disfiguring, problem in 20-40% of patients with systemic sclerosis. Its pathogenesis remains poorly understood and currently there is no effective disease-modifying pharmacotherapy. One potential strategy is topical application of calcium chelating agents, able to penetrate the epidermal barrier and dissolve subcutaneous calcinotic deposits in situ. To date, the only compound reported for this application has been sodium thiosulfate (STS), with often-contradictory results.

Objectives

To test the hypothesis, in pre-clinical studies, that polycarboxylic acids can induce calcium dissolution without skin toxicity, with the long-term aim of developing an effective topical treatment for cutis calcinosis.

Methods

We compared the metal ion-chelating agents citric acid (CA) and ethylenediaminetetraacetic acid (EDTA) - polycarboxylic acids with well-characterised chelation profiles – to STS for their ability to chelate calcium, without inducing cytotoxicity or inflammation (pro-inflammatory cytokine expression and release), using in vitro 2D (keratinocyte [HaCaT]; fibroblast ([HCA2]) and recombinant human epidermal (RHE) models. The resultant data was subsequently used to predict therapeutic concentrations for assessment in a validated skin irritation model (SkinEthicTM; Episkin SA) and to assay maximal percutaneous absorption. At relative dermal concentrations, the dissolution performance of each chelator was further assessed using two different models of calcinosis: 1) pharmaceutical dissolution of a hydroxyapatite (HAp) tablet (1) and; 2) dissolution of a calcified extracellular matrix laid down by mineralising SaOS2 in vitro monolayer culture (2).

Results

Incubation with CA, EDTA and STS induced cytotoxicity in both in vitro cell lines studied at concentrations of >10 mM; only EDTA (10 mM) resulted in inflammatory cytokine release (IL8) from cells at these higher concentrations (cf positive control, Lipopolysaccharide 10 mg/mL). When applied topically to RHE models as near-saturated solutions, none of the chelators were categorised as skin irritants. Due to differences in their relative aqueous solubility, higher concentrations of CA (1600 mM) and STS (1200 mM) could be delivered through the RHE model than EDTA (200 mM). Using a simple linear regression model, the rate of compound absorption was: CA, 0.43 ± 0.05; STS, 0.26 ± 0.03 and; EDTA, 0.05 ± 0.01 g/L/hr. At each time-point, the cumulative concentration of compound in the receptor media was CA > STS > EDTA. Incubation with chelators had no effect on the integrity of the RHE by standard histology. Based on the rate of percutaneous absorption, the dissolution performance of each chelator was tested at relative dermal concentrations for phosphate dissolution (nmoles) of HAp (CA, 9.61 ±0.97; EDTA, 5.38 ± 0.28; 3.78 ± 0.58) and in the calcified in vitro model (Figure 1; CA, 3285 ± 105, STS, 947 ± 95, EDTA, 1174 ± 89), showing the superiority of CA in both model systems.

Figure 1.

Dissolution of a calcified extracellular matrix by citric acid

Conclusion

Overall, this study highlights the promise of polycarboxylic acids, particularly CA, to target subcutaneous calcification, which are neither toxic nor inflammatory to the skin. Specifically, we have identified CA as a potentially more efficacious alternative to STS for the topical treatment of cutis calcinosis.

References

[1]Fei F, Gallas A, Chang YC, Rao Y, Hunter AC, Winpenny REP, Herrick AL, Lockyer NP, Blanford CF. 2017. Quartz crystal microbalance assay of clinical calcinosis samples and their synthetic models differentiates the efficacy of chelation-based treatments. ACS Appl Mater Interfaces, 9(33):27544-27552

[2]Wang QG, Wimpenny I, Dey RE, Zhong X, Youle PJ, Downes S, Watts DC, Budd PM, Hoyland JA, Gough JE. 2018. The unique calcium chelation property of poly(vinyl phosphonic acid-co-acrylic acid) and effects on osteogenesis in vitro. J Biomed Mater Res Part A 2018:106A:168–179

Disclosure of Interests

Kyle Burgess: None declared, Richard Winpenny: None declared, Alberto Saiani: None declared, Ariane Herrick Speakers bureau: Janssen, Consultant of: Arena, Boehringer-Ingelheim, Camurus, CSL-Behring, Gesynta, Grant/research support from: Gesynta, Rachel Watson Consultant of: NAOS, AbbVie, Grant/research support from: Walgreens Alliance Boots.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Internal jugular vein ultrasound in patients with chronic congestive heart failure

Background

Bedside assessment of intravascular volume in patients with chronic congestive heart failure (CHF) is often difficult. Under- and over-diuresis are common causes of morbidity and readmissions in these patients.

Purpose

We hypothesized that ultrasound assessment of the internal jugular vein would be easier and more reproducible than clinically assessing jugular venous pressure (JVP). Our goal was to create a bedside test that would be simpler to learn than inferior vena cava (IVC) assessment and easier to perform in obese patients.

Methods

Adults with HF (n=53, 52% men, mean age 65 years, mean BMI 29.6 kg/m2, mean LVEF 44%) scheduled for right heart catheterization (RHC) had an ultrasound of their right internal jugular (RIJ) vein performed immediately prior. Cross-sectional area of RIJ was measured during normal breathing with patients at 90 and 45 degrees recumbency and was indexed by height (RIJI). JVP was also assessed clinically. Results were compared to right atrial pressure (RAP) measured by RHC. Operators were blinded to RHC results and vice versa.

Results

JVP was correctly assessed clinically in only 43%. RIJI at 90 and 45 degrees were significantly larger in patients with elevated RAP compared to euvolemic patients (Table). At 90 degrees, RIJI of >15 predicted a RAP of >10 mmHg with 68% sensitivity and 72% specificity. At 45 degrees, RIJI of >10 predicted a RAP of >10 mmHg with 94% sensitivity and a negative predictive value of 80% (Table). Simply being able to see the RIJ at 90 degrees (n=34) had an 82.4% positive predictive value for elevated RAP. IVC data could not be obtained on 23% of patients due to body habitus or inability to lay flat.

Conclusion

Ultrasonographic RIJI is more accurate than clinical assessment in patients with CHF and can be accurately performed even in obese patients. It requires only a basic linear ultrasound probe and was easily performed by clinicians at various stages of training with reproducible results. With the increased availability of bedside ultrasound in clinical practice, it is a feasible method of evaluating chronic CHF patients.

Funding Acknowledgement

Type of funding sources: None.

P14.29 The treatment of melanoma brain metastases with stereotactic radiosurgery concurrently with immune checkpoint inhibition is associated with improved extracranial disease control and overall survival compared to the overall metastatic melanoma cohort - a synergistic effect reaching beyond local control?

BACKGROUND

Melanoma brain metastases (MBM) are an increasingly common referral to the neuro-oncology MDT in the context of lengthening survivorship of metastatic melanoma (MM) patients in the immunotherapy era. Stereotactic radiosurgery (SRS) and immune checkpoint inhibition (ICI) are both effective in the management of MBM and, when combined, 12-month local control rates of >85% and overall survival (OS) >80% have been reported.[4,5] Recent local analysis of patients treated at our tertiary SRS referral centre has revealed even greater outcomes in this patient cohort. This study aimed to compare the outcomes of patients with MBM treated with concurrent SRS and ICI compared to the overall metastatic melanoma cohort, to elucidate whether the addition of SRS to ICI may improve disease control outside of the brain as well as within.

MATERIAL AND METHODS

A retrospective analysis of our local SRS database and an ARIA ePrescribing database search was performed to identify a cohort of patients treated with concurrent SRS and ICI for MBM, as well as a control cohort of MM patients who received ICI alone, over a 4 year period until February 2020. The primary endpoints were the extracranial progression free survival (PFS) and overall survival (OS) at 12 months. Secondary endpoints were the median PFS (mPFS) and OS (mOS). Kaplan-Meier curves and survival statistics were generated using SPSS v26.

RESULTS

A total of 34 MBM from 19 patients were identified in the SRS+ICI group and there were 200 patients in the control group. The minimum follow up was 12 months. The median patient age, duration of ICI and use of combination ICI favoured the SRS+ICI group. The number of sites of extracranial disease pre-ICI and overall anti-PD-1 usage was well matched. In the SRS+ICI group, there were no cases of extracranial progression and no deaths within 12 months. In the control group, the 12-month PFS and OS rates were 50.5% and 77.5% respectively. In terms of mPFS, this was not reached (estimated 37.6 months) in the SRS+ICI group, versus 13.4 months in the control group (log rank test, p=0.001). In terms of mOS, this was not reached in the SRS+ICI group, versus 55.8 months in the control group (log rank test, p=0.016).

CONCLUSION

We demonstrate improved extracranial disease control and survivorship amongst metastatic melanoma patients who develop brain metastases and are treated with concurrent SRS and ICI compared to those who do not. The outcomes of our control cohort are comparable to the 4-year follow up of the CheckMate 067 trial (n=945),[6] which strengthens the validity of the statistical comparisons made in this study. The improved extracranial disease control seen when SRS and ICI are combined in the treatment of MBM questions whether an abscopal effect may be at play, and therefore further accents the utility of SRS in MBM beyond that of local control alone. This could influence management in cases of borderline decisions for SRS.

P14.85 Impact of the neuro-radiologist and neuro-surgeon in contouring with the neuro-oncologist on local relapse rates for brain metastases treated with stereotactic radiosurgery

BACKGROUND

The audit evaluates the value of MDT, including neuro-radiologist and neuro-surgeon, review of contouring carried out by a clinical oncologist in stereotactic radiosurgery (SRS).

MATERIAL AND METHODS

A sequential audit was conducted of all patients receiving intracranial SRS at our local institution for the first 22 months of a new SRS service. Lesions were contoured first by clinical oncologist then reviewed/edited by the MDT. The initial contour was compared with final contour using Jaccard conformity and geographical miss indices. The dosimetric impact of a contouring change was assessed using plan metrics to both original and final contour. The impact of the contouring review on local relapse, overall survival and radio necrosis rate was evaluated with at least 24 months follow up (24–46 months).

RESULTS

113 patients and 142 lesions treated over 22 months were identified. Mean JCI was 0.92 (0.32–1.00) and 38% needed significant editing (JCI<0.95). Mean GMI was 0.03 (0.0–0.65) and 17% showed significant miss (GMI>0.05). Resection cavities showed more changes, with lower JCI and higher GMI (p<0.05). There was no significant improvement on JCI or GMI shown over time. Dosimetric analysis indicated a strong association of conformity metrics with PTV dose metrics; a 0.1 change in GTV conformity metric association with 6–17% change in dose to 95% of resulting PTV. Greater association was seen in resection cavity suggesting the geographical nature of a typical contouring error gives rise to greater potential change in dose. Clinical outcomes compared well with published series. Median survival was 20 months and local relapse free rate in the treated areas of 0.89 (0.8–0.94) at 40 months, and 0.9 (0.83–0.95) radio-necrosis free rate at 40 months with a median 17 months to developing radio-necrosis for those that did.

CONCLUSION

This work highlights that a MDT contour review adds significant value to SRS and the approach translates into reduced local recurrence rates at our local institution compared with previously published data. Radio-necrosis rates are below 10%. No improvement in clinical oncologist contouring over time was shown indicating a collaborative approach is needed regardless of experience of clinical oncologist. MDT input is recommended in particular in contouring of resection cavities.

Food for all: designing sustainable and secure future seafood systems

Food from the sea can make a larger contribution to healthy and sustainable diets, and to addressing hunger and malnutrition, through improvements in production, distribution and equitable access to wild harvest and mariculture resources and products. The supply and consumption of seafood is influenced by a range of 'drivers' including ecosystem change and ocean regulation, the influence of corporations and evolving consumer demand, as well as the growing focus on the importance of seafood for meeting nutritional needs. These drivers need to be examined in a holistic way to develop an informed understanding of the needs, potential impacts and solutions that align seafood production and consumption with relevant 2030 Sustainable Development Goals (SDGs). This paper uses an evidence-based narrative approach to examine how the anticipated global trends for seafood might be experienced by people in different social, geographical and economic situations over the next ten years. Key drivers influencing seafood within the global food system are identified and used to construct a future scenario based on our current trajectory (Business-as-usual 2030). Descriptive pathways and actions are then presented for a more sustainable future scenario that strives towards achieving the SDGs as far as technically possible (More sustainable 2030). Prioritising actions that not only sustainably produce more seafood, but consider aspects of access and utilisation, particularly for people affected by food insecurity and malnutrition, is an essential part of designing sustainable and secure future seafood systems.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11160-021-09663-x.

Nasal high-flow therapy as an adjunct to exercise in patients with cystic fibrosis: A pilot feasibility trial

BACKGROUND

Exercise tolerance in people with CF and advanced lung disease is often reduced. While supplemental oxygen can improve oxygenation, it does not affect dyspnoea, fatigue or comfort. Nasal high-flow therapy (NHFT), thanks to its pathophysiological mechanisms, could improve exercise tolerance, saturation and dyspnoea. This study explores the feasibility of conducting a clinical trial of using NHFT in patients with CF during exercise.

METHODS

A pilot, open-label, randomized crossover trial was performed, enroling 23 participants with CF and severe lung disease. Participants completed two treadmill walking test (TWT) with and without NHFT at 24-48 h interval. Primary outcome was trial feasibility, and exploratory outcomes were TWT distance (TWTD), SpO₂, transcutaneous CO₂, dyspnoea and comfort.

RESULTS

Recruitment rate was 2.4 subjects/month with 1.3:1 screening-to-randomization ratio. No adverse events caused by NHFT were observed. Tolerability was good and data completion rate was 100%. Twenty subjects (91%) were included in the exploratory study. Mean difference in TWTD on NHFT was 19 m (95% CI [4.8 - 33.1]). S_pO₂ was similar, but respiratory rate and mean tcCO₂ were lower on NHFT (mean difference = -3.9 breaths/min 95% CI [-5.9 - -1.9] and -0.22 kPa 95% CI [-0.4 - 0.04]). NHFT reduced exercise-induced dyspnoea and discomfort.

CONCLUSION

Trials using NHFT in patients with CF during exercise are feasible. NHFT appears to improve walking distance, control respiratory rate, CO₂, dyspnoea and improve comfort. A larger trial with a longer intervention is feasible and warranted to confirm the impact of NHFT in training programmes for patients with CF.

Noninvasive Ventilation in Cystic Fibrosis: Clinical Indications and Outcomes in a Large UK Adult Cystic Fibrosis Center

BACKGROUND

Noninvasive ventilation (NIV) is routinely used to treat patients with cystic fibrosis and respiratory failure. However, evidence on its use is limited, with no data on its role in disease progression and outcomes. The aim of this study was to assess the indications of NIV use and to describe the outcomes associated with NIV in adults with cystic fibrosis in a large adult tertiary center.

METHODS

A retrospective analysis of data captured prospectively on the unit electronic patient records was performed. All patients with cystic fibrosis who received NIV over a 10-y period were included in the study. A priori, 2 groups were identified based on length of follow-up, with 2 subgroups identified based on duration of NIV treatment.

RESULTS

NIV was initiated on 64 occasions. The duration of follow-up was categorized as > 6 months or < 6 months in 31 (48.4%) and 33 (51.6%) occasions, respectively. The most common indications for starting NIV were chronic (48.5%) and acute (32.8%) hypercapnic respiratory failure. Among those with a follow-up > 6 months, subjects who stopped using NIV early showed a steady median (interquartile range) decline in FEV₁ (pre-NIV: -0.04 [-0.35 to 0.03] L/y vs post-NIV: -0.07 [-0.35 to 0.01] L/y, P = .51), while among those who continued using it had an improvement in the rate of decline (pre-NIV: -0.25 [-0.52 to -0.02] L/y vs post-NIV: -0.07 [-0.13 to 0.16] L/y, P = .006). No differences in intravenous antibiotic requirement or pulmonary exacerbations were noted with the use of NIV. Pneumothorax and massive hemoptysis occurred independently in 4 cases.

CONCLUSIONS

NIV is being used in cystic fibrosis as adjunct therapy for the management of advanced lung disease in a similar fashion to other chronic respiratory conditions. Adherence to NIV treatment can stabilize lung function but does not reduce pulmonary exacerbations or intravenous antibiotic requirement.

Evaluating serious stress in military veterans, their carers and families: a protocol

In 2018, the Armed Forces Covenant Fund Trust (ACFT) allocated approximately £4M to seven UK projects to address serious stress in military veterans, their carers and families. These programmes commenced between May and October 2019 and will conclude in August 2021.

This paper outlines the protocol for the evaluation of the Tackling Serious Stress programme and the novel support provided to grant holders. Entry into the programmes was through multiple routes, including self-referrals with an anticipated sample of approximately 2000 participants. A common outcomes framework was designed to measure outcomes. Grant holders accepted ownership for data collection and quality and were supported through accompanying guidance material.

Veterans were often reluctant to seek support, and the anonymous and confidential nature of the evaluation plus the study team’s military background helped address this. Participants’ voices were a key part in developing the protocol, leading to results to inform policy and highlight success, efficiency and cost effectiveness, and providing markers for future development.

The study provided a reservoir of information. Interim reports indicated compliance with performance indicators and provided timely evidence. Shared learning provided grant holders with an indication of what was helping the beneficiaries and what needed to be improved. The combination of all data sets provided the ACFT with a resource to demonstrate success and insight into projects where improvement was required, and indicators of how to redress these problems. The study protocol provided a platform for building lasting partnerships.

Psychosocial burden and out-of-pocket costs in patients with atopic dermatitis in Ireland

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases in the developed world, affecting 1-3% of the adult population in Europe. This inflammatory disease can have a marked impact on affected individuals, leading to significant impairment in physical wellbeing and quality of life (QoL). The aim of this study was to investigate the psychosocial impact and financial burden of AD on patients in Ireland. To increase our understanding of the psychosocial and financial aspects of AD disease burden in the Irish population, an online survey was designed. The survey was launched by the Irish Skin Foundation, and included questions focusing on disease severity, disease control, psychosocial impact, interrupted sleep, missed work and school days, and financial cost. The survey showed that the impact of AD on QoL was profound. The survey demonstrated that 85% of adults described interrupted sleep, 70% reported social anxiety, 65% avoid exercise and sports, 52% avoid social activities, 52% avoid sexual intimacy and 43% feel they are depressed as a result of their AD. Approximately one-quarter of those surveyed can spend up to €2300 annually on over-the-counter, prescription and alternative treatments. This study has shown the significant impact AD has on patients living in Ireland. It also highlights that out-of-pocket costs for patients is higher compared with previous studies across European countries.