Multiple sclerosis or neuromyelitis optica? Re-evaluating an 18th-century illness using 21st-century software

Nurse-led sustainable plastic surgery trauma service transformation: a positive COVID-19 legacy

The aim of this quality improvement was to develop a sustainable nurse-led 'See and Treat' service in a regional plastic surgery unit in England for patients requiring plastic surgery under local anaesthetic following traumatic injury.Trauma-related injuries are a substantial part of the workload in the plastic surgery department in question; with people with the most minor injuries requiring surgery under local anaesthetic accounting for 17%. COVID-19 threatened the continuation of any minor surgery service, but the initial crisis-driven response to the pandemic provided the opportunity to develop a new, more effective, nurse-led service for this patient group.The Model for Improvement was used and four 'Plan, Do, Study, Act' cycles deployed over an 8-week period, involving 102 patients. Routine quantitative and qualitative data in the form of a semistructured patient feedback proforma were used to guide the improvement process, optimising the new service design and delivery.The results demonstrated that 98% (n=100) of patients received same-day surgery via the new 'See and Treat' service. Staff and patient satisfaction remained high throughout; all patients preferred same-day surgery. No negative unintended consequences, for example, postoperative infections, were identified. One positive unintended consequence was the reduction in carbon footprint achieved by decreasing clinical waste and patient travel.Improvement methodology was successfully used by a nurse-led team to enable the continuation and enhancement of surgical services for trauma patients during COVID-19-driven service disruption. This service transformation has resulted in the retention of the revised service delivery model as the 'new normal' approximately 2 years later. The COVID-19 pandemic challenged the resilience of the trauma surgery service but led to a positive long-term legacy that sustainably improved waiting times and patient experience while maintaining safety.

Pretreatment of choriocarcinoma syndrome: a rare complication of metastatic germ cell tumours

A 27-year-old man newly diagnosed with metastatic testicular choriocarcinoma developed a large right perinephric haematoma secondary to a metastatic deposit in his right kidney. His presentation was also complicated by bilateral iliac venous thrombosis and pulmonary embolism identified prior to initiation of chemotherapy. He underwent multiple attempts at angioembolisation of the bleeding vessels and ultimately angioembolisation of the main renal artery had to be performed to control the bleeding. Following resolution and commencement of chemotherapy, the patient also developed spontaneous intracranial haemorrhage requiring craniotomy.

A questionnaire study of the negative outcomes for UK health professional volunteers in low and middle income countries

INTRODUCTION

Past research has reported considerable benefits of international health professional volunteering for British healthcare professionals; however, there are also some negative outcomes reported. Negative outcomes reportedly happen on a personal, professional and organisational level. However, there is little evidence of the frequency they might occur.

METHODS

We aimed to understand what the negative outcomes of health professional volunteering in low-income and middle-income countries were, and how frequently they occurred, in an opportunistic sample of UK health professionals. We used a questionnaire developed using potential negative outcomes reported in the peer-reviewed papers. We conducted secondary analysis on cross-sectional questionnaire data from 222 healthcare professionals.

RESULTS

This research provides an indication of the frequency that negative outcomes might occur. Post hoc analyses revealed that some outcomes were experienced by the majority of health professional volunteers, for example, lack of formal recognition (131/169, 78%) and financial cost (92/169, 68%). While others happened less, for example, a reliance on agency or locum work (12/169, 7%) and loss of pension (31/169, 18%).

CONCLUSION

The outcomes reported in this research quantify some of the concerns that have been raised in previous literature. Negative outcomes might be associated with certain features of volunteering and further research is needed to prospectively compare different features. Organisers of volunteering opportunities should be aware of the potential negative outcomes and engage with the research into negative outcomes to generate and apply findings about minimising potential negative outcomes, carefully balancing these against the needs of the host country.

Lower limb venous and arterial peripheral diseases and work conditions: systematic review

OBJECTIVES

The individual peripheral vascular disease risk factors are well documented, but the role of work conditions remains equivocal. This systematic review aims to assess relationships between lower limb peripheral venous diseases (lower limb varicose veins (LLVV), venous thromboembolism (VTE) comprising deep vein thrombosis and pulmonary embolism), peripheral arterial disease (intermittent claudication, aortic dissection, aortic aneurysm) and occupational constraints among working adults.

METHODS

Several databases were systematically searched until February 2019 for observational studies and clinical trials. Preferred Reporting Items for Systematic Reviews and Meta-Analyses method was used for article selection. Quality assessment and risk of bias were evaluated using Strengthening the Reporting of Observational Studies in Epidemiology and Newcastle-Ottawa scales.

RESULTS

Among the 720 screened articles, 37 remained after full-text evaluation. Among the 21 studies on LLVV, prolonged standing was significantly associated to a higher risk of varicose veins with a threshold probably around >3 to 4 hours/day but exposure duration in years was not sufficiently considered. Seated immobility was often observed in workers, with no sufficient evidence to prove that prolonged sitting at work is related to VTE. Carrying heavy loads, stress at work and exposure to high temperatures have emerged more recently notably in relation to varicose veins but need to be better explored. Only three studies discussed the potential role of work on peripheral arterial disease development.

CONCLUSIONS

Although some observational studies showed that prolonged standing can be related to varicose veins and that seated immobility at work could be linked to VTE, very little is known about peripheral arterial disease and occupational constraints. Clinical trials to determine preventive strategies at work are needed.

PROSPERO REGISTRATION NUMBER

CRD42019127652.

Measuring the outcomes of volunteering for education: development and pilot of a tool to assess healthcare professionals' personal and professional development from international volunteering

OBJECTIVE

The development and pilot of a self-report questionnaire, to assess personal and professional development of healthcare professionals gained through experiences in low-income and middle-income countries.

DESIGN

The instrument was developed from a core set of the outcomes of international placements for UK healthcare professionals. Principal component analysis and multidimensional item response theory were conducted using results of a cross-sectional pilot study to highlight items with the best psychometric properties.

SETTING

Questionnaires were completed both online and in multiple UK healthcare professional events face-to-face.

PARTICIPANTS

436 healthcare professional participants from the UK (with and without international experience) completed a 110-item questionnaire in which they assessed their knowledge, skills and attitudes.

MEASURES

The 110-item questionnaire included self-report questions on a 7-point Likert scale of agreement, developed from the core outcome set, including items on satisfaction, clinical skills, communication and other important healthcare professional knowledge, skills, attitudes and behaviours. Item reduction led to development of the 40-item Measuring the Outcomes of Volunteering for Education-Tool. Internal consistency was evaluated by the Cronbach's α coefficient. Exploratory analysis investigated the structure of the data using principal component analysis and multivariate item response theory.

RESULTS

Exploratory analysis found 10 principal components that explained 71.80% of the variance. Components were labelled 'attitude to work, adaptability, adapting communication, cultural sensitivity, difficult communication, confidence, teaching, management, behaviour change and life satisfaction'. Internal consistency was acceptable for the identified components (α=0.72-0.86).

CONCLUSIONS

A 40-item self-report questionnaire developed from a core outcome set for personal and professional development from international placements was developed, with evidence of good reliability and validity. This questionnaire will increase understanding of impact of international placements, facilitating comparisons of different types of experience. This will aid decision making about whether UK healthcare professionals should be encouraged to volunteer internationally and in what capacity.

Clinical and genetic associations of renal function and diabetic kidney disease in the United Arab Emirates: a cross-sectional study

OBJECTIVES

Within the Emirati population, risk factors and genetic predisposition to diabetic kidney disease (DKD) have not yet been investigated. The aim of this research was to determine potential clinical, laboratory and reported genetic loci as risk factors for DKD.

RESEARCH DESIGN AND METHODS

Four hundred and ninety unrelated Emirati nationals with type 2 diabetes mellitus (T2DM) were recruited with and without DKD, and clinical and laboratory data were obtained. Following adjustments for possible confounders, a logistic regression model was developed to test the associations of 63 single nucleotide polymorphisms (SNPs) in 43 genetic loci with DKD (145 patients with DKD and 265 without DKD). Linear regression models, adjusted for age and gender, were then used to study the genetic associations of five renal function traits, including 83 SNPs with albumin-to-creatinine ratio, 92 SNPs with vitamin D (25-OH cholecalciferol), 288 SNPs with estimated glomerular filtration rate (eGFR), 363 SNPs with serum creatinine and 73 SNPs with blood urea.

RESULTS

Patients with DKD, as compared with those without the disease, were mostly men (52%vs38% for controls), older (67vs59 years) and had significant rates of hypertension and dyslipidaemia. Furthermore, patients with DKD had T2DM for a longer duration of time (16vs10 years), which in an additive manner was the single factor that significantly contributed to the development of DKD (p=0.02, OR=3.12, 95% CI 1.21 to 8.02). Among the replicated associations of the genetic loci with different renal function traits, the most notable included SHROOM3 with levels of serum creatinine, eGFR and DKD (P_adjusted=0.04, OR=1.46); CASR, GC and CYP2R1 with vitamin D levels; as well as WDR72 with serum creatinine and eGFR levels.

CONCLUSIONS

Associations were found between several genetic loci and risk markers for DKD, which may influence kidney function traits and DKD in a population of Arab ancestry.

Patient-reported experience measure in sickle cell disease

OBJECTIVES

To develop patient-reported experience measure surveys for patients with sickle cell disease (SCD) to understand their healthcare and lived experience in the UK and for their use in future to inform healthcare service development.

DESIGN

Picker methodology was used as follows: (1) qualitative scoping by focus group discussions; (2) questionnaire development through stakeholder consultations; (3) construct validation of questionnaires through cognitive testing; and (4) further assessment of construct validity by a nationwide pilot survey.

SETTING

Patients with SCD and their carers were eligible. Focus group discussions took place in non-hospital settings, arranged out of hours. Cognitive testing took place in specialist sickle cell clinics. The pilot survey was available to UK participants only and was administered through web-based questionnaires, face-to face completion and in sickle cell community events.

PARTICIPANTS

Thirty-three patients and carers took part in the focus groups, 21 participants undertook cognitive testing and 722 respondents completed the pilot survey.

RESULTS

Findings highlighted a widespread prevalence of poor knowledge about SCD among healthcare providers and the public. Poorer experience of care was present in the emergency setting compared with planned care, of which lack of timely provision of pain relief was of concern. Adolescents and young people reported significantly poorer experience of care in several domains compared with children or adults.

CONCLUSIONS

The new surveys functioned well, with good evidence of validity, and were accessible to the SCD patient population, supporting their future use in assessing patient experience to inform service delivery and improvements in care quality.

Neuromyelitis optica: Application of computer diagnostics to historical case reports

The retrospective diagnosis of illnesses by medical historians can often be difficult and prone to bias, although knowledge of the medical disorders of historical figures is key to the understanding of their behavior and reactions. The recent application of computer diagnostics to historical figures allows an objective differential diagnosis to be accomplished. Taking an example from clinical neurology, we analyzed the earliest reported cases of Devic's disease (neuromyelitis optica) that commonly affects the optic nerve and spinal cord and was previously often confused with multiple sclerosis. We conclude that in most identified cases the software concurred with the contemporary physicians' interpretation, but some claimed cases either had insufficient data to provide a diagnosis or other possible diagnoses were suggested that had not been considered. Computational methods may, therefore, help historians to diagnose the ailments of historical figures with greater objectivity.

"The mothers have eaten unripe grapes and the children's teeth are set on edge": the potential inter-generational effects of the Holocaust on chronic morbidity in Holocaust survivors' offspring

Modern epidemiology has evolved in the last decades from the simplified “cause-effect” paradigm to a multi-factorial framework of causality. The concept of “Fetal Origin of Adult Diseases” (FOAD) is a good example: it suggests that preconception circumstances and fetal exposures as well as infancy and early childhood experiences may eventually change an individual’s susceptibility to adult morbidity through fetal programming and epigenetic changes. The FOAD concept was supported, between others, by well-designed cohort studies carried out on non-Jewish World War II (WWII) survivors, exposed to hunger during the War years. However, data on late physical morbidity of Jewish WWII survivors are still scarce.

The current paper presents some cohorts addressing the FOAD hypothesis in relation to the long-term impact of early exposures to hunger and their main results. It stresses the need for the establishing of a similar cohort in Israel, in order to study the long-term effects of the Holocaust on the health of Holocaust child survivors and on that of the “second” and “third” generations. A framework for such a cohort in Israel is also proposed.

Establishing a cohort of this character in Israel should be a national priority and policy. First, taking special care of Holocaust survivors is a somewhat neglected national obligation. Second, if the population of Holocaust survivors and their offspring is indeed a high risk group for late chronic morbidity, higher awareness may lead to better primary prevention and to tailored secondary prevention programs. Third, the population at stack is unique and its contribution to the consolidation of the FOAD theory and its translational applications may be of foremost importance, in the global and national sense.