Seizure first aid training for people with epilepsy attending emergency departments and their significant others: the SAFE intervention and feasibility RCT

Developing feasible person-centred care alternatives to emergency department responses for adults with epilepsy: a discrete choice analysis mixed-methods study

Background

Calls have been made for paramedics to have some form of care pathway that they could use to safely divert adults with epilepsy away from emergency departments and instigate ambulatory care improvements. Different configurations are possible. To know which to prioritise for implementation/evaluation, there is a need to determine which are acceptable to service users and likely National Health Service-feasible.

Objective(s)

(1) Identify configurations being considered, (2) understand service users' views of them and current provision, (3) identify what sort of care service users want and (4) determine which configuration(s) is considered to achieve optimal balance in meeting users' preference and being National Health Service-feasible.

Design

Service providers were surveyed to address objective 1. Interviews with service users addressed objective 2. Objective 3 was addressed by completing discrete choice experiments. These determined users' care preferences for different seizure scenarios. Objective 4 was addressed by completing 'knowledge exchange' workshops. At these, stakeholders considered the findings on users' stated preferences and judged different pathway configurations against Michie's 'acceptability, practicability, effectiveness, affordability, side-effects and equity' feasibility criteria.

Setting

This project took place in England. The survey recruited representatives from neurology and neuroscience centres and from urgent and emergency care providers. For the interviews, recruitment occurred via third-sector support groups. Recruitment for discrete choice experiments occurred via the North West Ambulance Service NHS Trust and public advert. Workshop participants were recruited from neurology and neuroscience centres, urgent and emergency care providers, support groups and commissioning networks.

Participants

Seventy-two services completed the survey. Interviews were conducted with 25 adults with epilepsy (and 5 relatives) who had emergency service contact in the prior 12 months. Discrete choice experiments were completed by 427 adults with epilepsy (and 167 relatives) who had ambulance service contact in the prior 12 months. Workshops were completed with 27 stakeholders.

Results

The survey identified a range of pathway configurations. They differed in where they would take the patient and their potential to instigate ambulatory care improvements. Users had been rarely consulted in designing them. The discrete choice experiments found that users want a configuration of care markedly different to that offered. Across the seizure scenarios, users wanted their paramedic to have access to their medical records; for an epilepsy specialist (e.g. an epilepsy nurse, neurologist) to be available to advise; for their general practitioner to receive a report; for the incident to generate an appointment with an epilepsy specialist; for the care episode to last < 6 hours; and there was a pattern of preference to avoid conveyance to emergency departments and stay where they were. Stakeholders judged this configuration to be National Health Service-feasible within 5-10 years, with some elements being immediately deployable.

Limitations

The discrete choice experiment sample was broadly representative, but those reporting recent contact with an epilepsy specialist were over-represented.

Conclusions

Users state they want a configuration of care that is markedly different to current provision. The configuration they prefer was, with support and investment, judged to likely be National Health Service-feasible. The preferred configuration should now be developed and evaluated to determine its actual deliverability and efficacy.

Study registration

The study is registered as researchregistry4723.

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: 17/05/62) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 24. See the NIHR Funding and Awards website for further award information.

Susceptibility of All Nymphal Stages of Bemisia tabaci Biotype B (Hemiptera: Aleyrodidae) to Three Brazilian Isolates of Cordyceps sp. (Hypocreales: Cordycipitaceae) in a Screenhouse Under Variable Temperature and Moisture Conditions

The susceptibility of 1st to 4th instars of Bemisia tabaci (Gennadius, 1989) (Hemiptera: Aleyrodidae) to three isolates of Cordyceps sp. (Hypocreales: Cordycipitaceae) was evaluated in screenhouse experiments under variable temperatures and moisture conditions. No differences in susceptibility to the Cordyceps sp. isolates were observed among 1st, 2nd, and 3rd instar nymphs with respect to median lethal time (LT₅₀) values. Confirmed mortalities ranged from 63.7 to 87.8% when the isolates were tested at 5 × 10⁷ conidia mL^-1. The 4th instar was the least susceptible to the fungal isolates (≤ 36.6% mortality). However, 60.0 to 99.5% of the adults that emerged from 4th instar nymphs previously treated with the fungus succumbed to the infection. Temperature was more detrimental to Cordyceps sp. virulence towards B. tabaci nymphs than relative humidity (RH). At similar RH, median LT₅₀ for 1st instar (9.4 days) was higher than for 3rd instar (5.3 days) when the fungus was tested at 5 × 10⁷ conidia mL^-1; minimal temperatures of ≥ 12.6°C compared to ≥ 17.0°C were registered for experiments with 1st and 3rd instars, respectively. However, temperatures ≥ 35°C for 4 to 6 h daily did not affect the efficacy of the fungus against nymphs. Cordyceps sp. showed high virulence to all life stages of B. tabaci at relatively low RH, and an ability to grow extensively over the leaf surface and to produce high amounts of conidia on infected hosts. These attributes certainly boost its potential as an important pest control component of B. tabaci biotype B, especially for management of populations resistant to synthetic insecticides.