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Bedford J, Martin P, Crowe S, Wagstaff D, Santos C, Singleton G, Baumber R, Vindrola‐Padros C, Vohra R, Swart M, Oliver CM, Dorey J, Leeman I, Moonesinghe SR. Development and internal validation of a model for postoperative morbidity in adults undergoing major elective colorectal surgery: the peri-operative quality improvement programme (PQIP) colorectal risk model. Anaesthesia 2022; 77:1356-1367. [PMID: 36130834 PMCID: PMC9826419 DOI: 10.1111/anae.15858] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 01/11/2023]
Abstract
Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. In addition, contemporary definitions of some model predictors are markedly different compared with when the tool was developed. A second model used in clinical practice is the American College of Surgeons National Surgical Quality Improvement Programme risk model; this provides a risk estimate for a range of postoperative complications. This model, widely used in North America, is not open source and therefore cannot be applied to patient populations in other settings. Data from a prospective multicentre clinical dataset of 118 NHS hospitals (the peri-operative quality improvement programme) were used to develop a bespoke risk-adjustment model for postoperative morbidity. Patients aged ≥ 18 years who underwent colorectal surgery were eligible for inclusion. Postoperative morbidity was defined using the postoperative morbidity survey at postoperative day 7. Thirty-one candidate variables were considered for inclusion in the model. Death or morbidity occurred by postoperative day 7 in 3098 out of 11,646 patients (26.6%). Twelve variables were incorporated into the final model, including (among others): Rockwood clinical frailty scale; body mass index; and index of multiple deprivation quintile. The C-statistic was 0.672 (95%CI 0.660-0.684), with a bootstrap optimism corrected C-statistic of 0.666 at internal validation. The model demonstrated good calibration across the range of morbidity estimates with a mean slope gradient of predicted risk of 0.959 (95%CI 0.894-1.024) with an index-corrected intercept of -0.038 (95%CI -0.112-0.036) at internal validation. Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of < 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.
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Affiliation(s)
- J. Bedford
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - P. Martin
- Department of Applied Health ResearchUniversity College LondonUK
| | - S. Crowe
- Clinical Operational Research UnitUniversity College LondonUK
| | - D. Wagstaff
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - C. Santos
- Health Services Research Centre, National Institute for Academic AnaesthesiaRoyal College of AnaesthetistsLondonUK
| | - G. Singleton
- Centre for Peri‐operative MedicineResearch Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - R. Baumber
- Department of AnaesthesiaRoyal National Orthopaedic Hospital NHS TrustLondonUK
| | - C. Vindrola‐Padros
- Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - R. Vohra
- Department of SurgeryNottingham University Hospitals NHS TrustNottinghamUK
| | - M. Swart
- Department of AnaesthesiaTorbay and South Devon NHS TrustDevonUK
| | - C. M. Oliver
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative MedicineResearch Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - J. Dorey
- Lay CommitteeRoyal College of Anaesthetists and Lay representatives PQIP Project teamLondonUK
| | - I. Leeman
- Lay CommitteeRoyal College of Anaesthetists and Lay representatives PQIP Project teamLondonUK
| | - S. R. Moonesinghe
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
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2
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Singleton G, Dowrick A, Manby L, Fillmore H, Syverson A, Lewis-Jackson S, Uddin I, Sumray K, Bautista-González E, Johnson G, Vindrola-Padros C. UK Healthcare Workers' Experiences of Major System Change in Elective Surgery During the COVID-19 Pandemic: Reflections on Rapid Service Adaptation. Int J Health Policy Manag 2022; 11:2072-2082. [PMID: 34523860 PMCID: PMC9808275 DOI: 10.34172/ijhpm.2021.101] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/07/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC). METHODS Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings. RESULTS Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started. CONCLUSION Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.
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Affiliation(s)
- Georgina Singleton
- Department of Targeted Intervention, University College London, London, UK
- Rapid Research Evaluation and Appraisal Lab (RREAL), University College London, London, UK
| | - Anna Dowrick
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louisa Manby
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | | | - Aron Syverson
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Sasha Lewis-Jackson
- Department of Targeted Intervention, University College London, London, UK
- Rapid Research Evaluation and Appraisal Lab (RREAL), University College London, London, UK
| | - Inayah Uddin
- Department of Targeted Intervention, University College London, London, UK
- Rapid Research Evaluation and Appraisal Lab (RREAL), University College London, London, UK
| | - Kirsi Sumray
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Elysse Bautista-González
- Rapid Research Evaluation and Appraisal Lab (RREAL), University College London, London, UK
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Ginger Johnson
- Department of Targeted Intervention, University College London, London, UK
- Rapid Research Evaluation and Appraisal Lab (RREAL), University College London, London, UK
| | - Cecilia Vindrola-Padros
- Department of Targeted Intervention, University College London, London, UK
- Rapid Research Evaluation and Appraisal Lab (RREAL), University College London, London, UK
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3
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Wagstaff D, Warnakulasuriya S, Singleton G, Moonesinghe SR, Fulop N, Vindrola-Padros C. A scoping review of local quality improvement using data from UK perioperative National Clinical Audits. Perioper Med (Lond) 2022; 11:43. [PMID: 36031654 PMCID: PMC9422140 DOI: 10.1186/s13741-022-00273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 06/22/2022] [Indexed: 11/28/2022] Open
Abstract
Background Significant resources are invested in the UK to collect data for National Clinical Audits (NCAs), but it is unclear whether and how they facilitate local quality improvement (QI). The perioperative setting is a unique context for QI due to its multidisciplinary nature and history of measurement. It is unclear which NCAs evaluate perioperative care, to what extent their data have been used for QI, and which factors influence this usage. Methods NCAs were identified from the directories held by Healthcare Quality Improvement Partnership (HQIP), Scottish Healthcare Audits and the Welsh National Clinical Audit and Outcome Review Advisory Committee. QI reports were identified by the following: systematically searching MEDLINE, CINAHL Plus, Web of Science, Embase, Google Scholar and HMIC up to December 2019, hand-searching grey literature and consulting relevant stakeholders. We charted features describing both the NCAs and the QI reports and summarised quantitative data using descriptive statistics and qualitative themes using framework analysis. Results We identified 36 perioperative NCAs in the UK and 209 reports of local QI which used data from 19 (73%) of these NCAs. Six (17%) NCAs contributed 185 (89%) of these reports. Only one NCA had a registry of local QI projects. The QI reports were mostly brief, unstructured, often published by NCAs themselves and likely subject to significant reporting bias. Factors reported to influence local QI included the following: perceived data validity, measurement of clinical processes as well as outcomes, timely feedback, financial incentives, sharing of best practice, local improvement capabilities and time constraints of clinicians. Conclusions There is limited public reporting of UK perioperative NCA data for local QI, despite evidence of improvement of most NCA metrics at the national level. It is therefore unclear how these improvements are being made, and it is likely that opportunities are being missed to share learning between local sites. We make recommendations for how NCAs could better support the conduct, evaluation and reporting of local QI and suggest topics which future research should investigate. Trial registration The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42018092993). Supplementary Information The online version contains supplementary material available at 10.1186/s13741-022-00273-0.
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Moonesinghe SR, McGuckin D, Martin P, Bedford J, Wagstaff D, Gilhooly D, Santos C, Wilson J, Dorey J, Leeman I, Smith H, Vindrola-Padros C, Edwards K, Singleton G, Swart M, Baumber R, Sahni A, Warnakulasuriya S, Vohra R, Ellicott H, Bougeard AM, Chazapis M, Ignacka A, Cripps M, Brent A, Drake S, Goodwin J, Martinez D, Williams K, Singh P, Bedford M, Vallance AE, Samuel K, Lourtie J, Olive D, Taylor C, Tucker O, Aresu G, Swift A, Fulop N, Grocott M. The Perioperative Quality Improvement Programme (PQIP patient study): protocol for a UK multicentre, prospective cohort study to measure quality of care and outcomes after major surgery. Perioper Med (Lond) 2022; 11:37. [PMID: 35941603 PMCID: PMC9361526 DOI: 10.1186/s13741-022-00262-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 04/28/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Major surgery accounts for a substantial proportion of health service activity, due not only to the primary procedure, but the longer-term health implications of poor short-term outcome. Data from small studies or from outside the UK indicate that rates of complications and failure to rescue vary between hospitals, as does compliance with best practice processes. Within the UK, there is currently no system for monitoring postoperative complications (other than short-term mortality) in major non-cardiac surgery. Further, there is variation between national audit programmes, in the emphasis placed on quality assurance versus quality improvement, and therefore the principles of measurement and reporting which are used to design such programmes. Methods and analysis The PQIP patient study is a multi-centre prospective cohort study which recruits patients undergoing major surgery. Patient provide informed consent and contribute baseline and outcome data from their perspective using a suite of patient-reported outcome tools. Research and clinical staff complete data on patient risk factors and outcomes in-hospital, including two measures of complications. Longer-term outcome data are collected through patient feedback and linkage to national administrative datasets (mortality and readmissions). As well as providing a uniquely granular dataset for research, PQIP provides feedback to participating sites on their compliance with evidence-based processes and their patients’ outcomes, with the aim of supporting local quality improvement. Ethics and dissemination Ethical approval has been granted by the Health Research Authority in the UK. Dissemination of interim findings (non-inferential) will form a part of the improvement methodology and will be provided to participating centres at regular intervals, including near-real time feedback of key process measures. Inferential analyses will be published in the peer-reviewed literature, supported by a comprehensive multi-modal communications strategy including to patients, policy makers and academic audiences as well as clinicians.
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Affiliation(s)
- S Ramani Moonesinghe
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL, London, UK. .,Health Services Research Centre, Royal College of Anaesthetists, London, UK. .,Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK.
| | - Dermot McGuckin
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL, London, UK
| | - Peter Martin
- Department for Applied Health Research, UCL, London, UK
| | - James Bedford
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL, London, UK.,Health Services Research Centre, Royal College of Anaesthetists, London, UK.,Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Duncan Wagstaff
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL, London, UK.,Health Services Research Centre, Royal College of Anaesthetists, London, UK.,Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - David Gilhooly
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL, London, UK.,Health Services Research Centre, Royal College of Anaesthetists, London, UK.,Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Cristel Santos
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Jonathan Wilson
- Department of Anaesthesia, York Teaching Hospitals NHS Foundation Trust, York, UK
| | | | | | - Helena Smith
- Department of Anaesthesia, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Cecilia Vindrola-Padros
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL, London, UK.,Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Kylie Edwards
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Georgina Singleton
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Michael Swart
- Department of Anaesthesia, Torbay Hospital, Torquay, UK
| | - Rachel Baumber
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL, London, UK.,Department of Anaesthesia, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Arun Sahni
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Samantha Warnakulasuriya
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ravi Vohra
- Department of Upper GI Surgery, Nottingham University Hospitals, Nottingham, UK
| | - Helen Ellicott
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | | | - Maria Chazapis
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Aleksandra Ignacka
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Alexandra Brent
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | | | | | - Dorian Martinez
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Karen Williams
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Pritam Singh
- Trent Oesophago-Gastric Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Matthew Bedford
- Department of Colorectal Surgery, Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Katie Samuel
- Department of Anaesthesia, North Bristol NHS Foundation Trust , Bristol, UK
| | - Jose Lourtie
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Dominic Olive
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Christine Taylor
- Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Olga Tucker
- Department of Upper Gastrointestinal Surgery, Heartlands Hospital, Birmingham, UK
| | - Giuseppe Aresu
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | | | - Naomi Fulop
- Department for Applied Health Research, UCL, London, UK
| | - Mike Grocott
- Division of Critical Care, University of Southampton, Southampton, UK
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Manby L, Dowrick A, Karia A, Maio L, Buck C, Singleton G, Lewis-Jackson S, Uddin I, Vanderslott S, Martin S, Vindrola-Padros C. Healthcare workers' perceptions and attitudes towards the UK's COVID-19 vaccination programme: a rapid qualitative appraisal. BMJ Open 2022; 12:e051775. [PMID: 35168970 DOI: 10.1101/2021.03.30.21254459] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
OBJECTIVES While there is research relating to perceptions of vaccines among healthcare workers (HCWs), the evidence base in relation to COVID-19 remains limited. The aim of this study was to explore HCWs' perceptions and attitudes towards vaccines and the COVID-19 vaccination programme in the UK, including their expectations and views on promoting vaccination to others. DESIGN This study was designed as a rapid qualitative appraisal, integrating data from a review of UK policies and guidance on COVID-19 vaccination with data from in-depth semistructured telephone interviews with frontline HCWs in the UK. Data were analysed using framework analysis. PARTICIPANTS Interviews were carried out with a purposive sample of HCWs from two large London-based hospital Trusts (n=24) and 24 government policies, and guidelines on the vaccination programme were reviewed. RESULTS The level of uncertainty about the long-term safety of vaccines and efficacy against mutant strains made it difficult for HCWs to balance the benefits against the risks of vaccination. HCWs felt that government decisions on vaccine rollout had not been supported by evidence-based science, and this impacted their level of trust and confidence in the programme. The spread of misinformation online also impacted HCWs' attitudes towards vaccination, particularly among junior level and black, Asian and minority ethnic (BAME) HCWs. Most HCWs felt encouraged to promote vaccination to their patients, and the majority said they would advocate vaccination or engage in conversations about vaccination with others when relevant. CONCLUSION In order to improve HCWs' trust and confidence in the UK's COVID-19 vaccination programme, there needs to be clarity about what is known and not known about the vaccines and transparency around the evidence-base supporting government decisions on vaccine rollout. Effort is also needed to dispel the spread of vaccine-related misinformation online and to address specific concerns, particularly among BAME and junior-level HCWs.
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Affiliation(s)
- Louisa Manby
- Department of Targeted Intervention, University College London, London, UK
| | - Anna Dowrick
- Medical Sociology and Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amelia Karia
- Department of Targeted Intervention, University College London, London, UK
| | - Laura Maio
- Department of Targeted Intervention, University College London, London, UK
- Dementia UK, London, UK
| | - Caroline Buck
- Department of Behavioural Science & Health, University College London, London, UK
| | - Georgina Singleton
- Department of Targeted Intervention, University College London, London, UK
- National Institute for Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Sasha Lewis-Jackson
- Medical Sociology and Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Inayah Uddin
- Department of Targeted Intervention, University College London, London, UK
| | | | - Sam Martin
- Department of Targeted Intervention, University College London, London, UK
- Oxford Vaccine Group, Department of Paediatrics, Oxford University, Oxford, UK
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6
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Manby L, Dowrick A, Karia A, Maio L, Buck C, Singleton G, Lewis-Jackson S, Uddin I, Vanderslott S, Martin S, Vindrola-Padros C. Healthcare workers' perceptions and attitudes towards the UK's COVID-19 vaccination programme: a rapid qualitative appraisal. BMJ Open 2022; 12:e051775. [PMID: 35168970 PMCID: PMC8852238 DOI: 10.1136/bmjopen-2021-051775] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES While there is research relating to perceptions of vaccines among healthcare workers (HCWs), the evidence base in relation to COVID-19 remains limited. The aim of this study was to explore HCWs' perceptions and attitudes towards vaccines and the COVID-19 vaccination programme in the UK, including their expectations and views on promoting vaccination to others. DESIGN This study was designed as a rapid qualitative appraisal, integrating data from a review of UK policies and guidance on COVID-19 vaccination with data from in-depth semistructured telephone interviews with frontline HCWs in the UK. Data were analysed using framework analysis. PARTICIPANTS Interviews were carried out with a purposive sample of HCWs from two large London-based hospital Trusts (n=24) and 24 government policies, and guidelines on the vaccination programme were reviewed. RESULTS The level of uncertainty about the long-term safety of vaccines and efficacy against mutant strains made it difficult for HCWs to balance the benefits against the risks of vaccination. HCWs felt that government decisions on vaccine rollout had not been supported by evidence-based science, and this impacted their level of trust and confidence in the programme. The spread of misinformation online also impacted HCWs' attitudes towards vaccination, particularly among junior level and black, Asian and minority ethnic (BAME) HCWs. Most HCWs felt encouraged to promote vaccination to their patients, and the majority said they would advocate vaccination or engage in conversations about vaccination with others when relevant. CONCLUSION In order to improve HCWs' trust and confidence in the UK's COVID-19 vaccination programme, there needs to be clarity about what is known and not known about the vaccines and transparency around the evidence-base supporting government decisions on vaccine rollout. Effort is also needed to dispel the spread of vaccine-related misinformation online and to address specific concerns, particularly among BAME and junior-level HCWs.
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Affiliation(s)
- Louisa Manby
- Department of Targeted Intervention, University College London, London, UK
| | - Anna Dowrick
- Medical Sociology and Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Amelia Karia
- Department of Targeted Intervention, University College London, London, UK
| | - Laura Maio
- Department of Targeted Intervention, University College London, London, UK
- Dementia UK, London, UK
| | - Caroline Buck
- Department of Behavioural Science & Health, University College London, London, UK
| | - Georgina Singleton
- Department of Targeted Intervention, University College London, London, UK
- National Institute for Academic Anaesthesia Health Services Research Centre, Royal College of Anaesthetists, London, UK
| | - Sasha Lewis-Jackson
- Medical Sociology and Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Inayah Uddin
- Department of Targeted Intervention, University College London, London, UK
| | | | - Sam Martin
- Department of Targeted Intervention, University College London, London, UK
- Oxford Vaccine Group, Department of Paediatrics, Oxford University, Oxford, UK
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7
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Sogbodjor LA, Singleton G, Davenport M, Walker S, Moonesinghe SR. Quality metrics for emergency abdominal surgery in children: a systematic review. Br J Anaesth 2021; 128:522-534. [PMID: 34895715 DOI: 10.1016/j.bja.2021.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children. METHODS We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications. RESULTS We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways. CONCLUSIONS This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis. CLINICAL TRIAL REGISTRATION PROSPERO CRD42017055285.
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Affiliation(s)
- Lisa A Sogbodjor
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Georgina Singleton
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Suellen Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond St Institute of Child Health, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
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8
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Chow MC, Chambers P, Singleton G, Patel J, Cooper S, Mythen C, Bautista-González E, Chisnall G, Djellouli N, Thwaites B, Wong ICK, Vindrola-Padros C. Global changes to the chemotherapy service during the covid-19 pandemic. J Oncol Pharm Pract 2021; 27:1073-1079. [PMID: 33983080 PMCID: PMC8367193 DOI: 10.1177/10781552211015767] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE In response to the COVID-19 pandemic, changes to chemotherapy services were implemented as a means of managing imposed workload strains within health services and protecting patients from contracting COVID-19. Given the rapidly evolving nature of the pandemic many changes were rapidly adopted and were not substantiated by robust evidence. This study aimed to describe the changes adopted internationally to chemotherapy services, which may be used to guide future changes to treatment delivery. METHODS A survey was developed to understand the impact of COVID-19 on the delivery of systemic anti-cancer therapies (SACT). It comprised 22 questions and examined the strategies implemented during the pandemic to prioritise and protect patients receiving SACT and the participants' professional opinion of the strategies employed. The survey was available in English, Spanish and French and was distributed via professional bodies. RESULTS 129 responses were obtained from healthcare professionals working across 17 different countries. 45% of institutions had to implement treatment prioritisation strategies and all hospitals implemented changes in the delivery of treatment, including: reduction in treatments (69%), using less immunosuppressive agents (50%), allowing treatment breaks (14%) and switching to oral therapies (45%). Virtual clinic visits were perceived by participants as the most effective strategy to protect patients. CONCLUSIONS The pandemic has forced chemotherapy healthcare professionals to adopt new ways of working by reducing health interactions. Many areas of research are needed following this period, including understanding patients' perceptions of risks to treatment, utilisation of oral treatments and the impact of treatment breaks on cancer outcomes.
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Affiliation(s)
- Man-Chie Chow
- Pharmacy Department, University College London Hospitals NHS Foundation Trust, UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK,Man-Chie Chow, Pharmacy Department, University College London Hospitals NHS Foundation Trust, UCLH-UCL Centre for Medicines Optimisation Research and Education, 235 Euston Road, London NW1 2BU, UK.
| | - Pinkie Chambers
- Pharmacy Department, University College London Hospitals NHS Foundation Trust, UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
| | - Georgina Singleton
- Department for Targeted Intervention, UCL/UCLH Surgical Outcomes Research Centre, Centre for Perioperative Medicine, University College London, London, UK,Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Jignesh Patel
- Rapid Research Evaluation and Appraisal Lab (RREAL), London, UK,Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK
| | - Silvie Cooper
- Department of Applied Health Research, University College London, London, UK
| | - Charlotte Mythen
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Elysse Bautista-González
- Rapid Research Evaluation and Appraisal Lab (RREAL), London, UK,Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Georgia Chisnall
- Rapid Research Evaluation and Appraisal Lab (RREAL), London, UK,Institute of Epidemiology and Healthcare, University College London, London, UK
| | | | - Benjamin Thwaites
- Pharmacy Department, University College London Hospitals NHS Foundation Trust, UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
| | - Ian CK Wong
- Pharmacy Department, University College London Hospitals NHS Foundation Trust, UCLH-UCL Centre for Medicines Optimisation Research and Education, London, UK
| | - Cecilia Vindrola-Padros
- Department for Targeted Intervention, UCL/UCLH Surgical Outcomes Research Centre, Centre for Perioperative Medicine, University College London, London, UK,Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
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Vera San Juan N, Aceituno D, Djellouli N, Sumray K, Regenold N, Syversen A, Mulcahy Symmons S, Dowrick A, Mitchinson L, Singleton G, Vindrola-Padros C. Mental health and well-being of healthcare workers during the COVID-19 pandemic in the UK: contrasting guidelines with experiences in practice. BJPsych Open 2020; 7:e15. [PMID: 33298229 PMCID: PMC7844154 DOI: 10.1192/bjo.2020.148] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Substantial evidence has highlighted the importance of considering the mental health of healthcare workers during the COVID-19 pandemic, and several organisations have issued guidelines with recommendations. However, the definition of well-being and the evidence base behind such guidelines remain unclear. AIMS The aims of the study are to assess the applicability of well-being guidelines in practice, identify unaddressed healthcare workers' needs and provide recommendations for supporting front-line staff during the current and future pandemics. METHOD This paper discusses the findings of a qualitative study based on interviews with front-line healthcare workers in the UK (n = 33), and examines them in relation to a rapid review of well-being guidelines developed in response to the COVID-19 pandemic (n = 14). RESULTS The guidelines placed greater emphasis on individual mental health and psychological support, whereas healthcare workers placed greater emphasis on structural conditions at work, responsibilities outside the hospital and the invaluable support of the community. The well-being support interventions proposed in the guidelines did not always respond to the lived experiences of staff, as some reported not being able to participate in these interventions because of understaffing, exhaustion or clashing schedules. CONCLUSIONS Healthcare workers expressed well-being needs that aligned with socio-ecological conceptualisations of well-being related to quality of life. This approach to well-being has been highlighted in literature on support of healthcare workers in previous health emergencies, but it has not been monitored during this pandemic. Well-being guidelines should explore the needs of healthcare workers, and contextual characteristics affecting the implementation of recommendations.
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Affiliation(s)
- Norha Vera San Juan
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; and Rapid Research Evaluation and Appraisal Lab, University College London, UK
| | - David Aceituno
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; and Department of Psychiatry, School of Medicine, Pontifical Catholic University of Chile, Chile
| | - Nehla Djellouli
- Institute for Global Health, University College London, UK; and Rapid Research Evaluation and Appraisal Lab, University College London, UK
| | - Kirsi Sumray
- Institute of Epidemiology and Health Care, University College London, UK
| | - Nina Regenold
- Department of Anthropology, University College London, UK
| | - Aron Syversen
- Institute of Epidemiology and Health Care, University College London, UK
| | | | - Anna Dowrick
- Institute of Population Health Science, Queen Mary University of London, UK
| | - Lucy Mitchinson
- Marie Curie Palliative Care Research Department, University College London, UK
| | - Georgina Singleton
- Health Services Research Centre, National Institute of Academic Anaesthesia, London, UK; and Rapid Research Evaluation and Appraisal Lab, University College London, UK
| | - Cecilia Vindrola-Padros
- Department of Targeted Intervention, University College London, UK; and Rapid Research Evaluation and Appraisal Lab, University College London, UK
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Vindrola-Padros C, Chisnall G, Cooper S, Dowrick A, Djellouli N, Symmons SM, Martin S, Singleton G, Vanderslott S, Vera N, Johnson GA. Carrying Out Rapid Qualitative Research During a Pandemic: Emerging Lessons From COVID-19. Qual Health Res 2020; 30:2192-2204. [PMID: 32865149 PMCID: PMC7649912 DOI: 10.1177/1049732320951526] [Citation(s) in RCA: 197] [Impact Index Per Article: 49.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Social scientists have a robust history of contributing to better understandings of and responses to disease outbreaks. The implementation of qualitative research in the context of infectious epidemics, however, continues to lag behind in the delivery, credibility, and timeliness of findings when compared with other research designs. The purpose of this article is to reflect on our experience of carrying out three research studies (a rapid appraisal, a qualitative study based on interviews, and a mixed-methods survey) aimed at exploring health care delivery in the context of COVID-19. We highlight the importance of qualitative data to inform evidence-based public health responses and provide a way forward to global research teams who wish to implement similar rapid qualitative studies. We reflect on the challenges of setting up research teams, obtaining ethical approval, collecting and analyzing data in real-time and sharing actionable findings.
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Affiliation(s)
- Cecilia Vindrola-Padros
- University College London, London, United Kingdom
- Royal College of Anaesthetists, London, United Kingdom
- Cecilia Vindrola-Padros, Department of Targeted Intervention, University College London, 3rd Floor, Charles Bell House, 43-45 Foley Street, London W1W 7TY, UK.
| | | | | | - Anna Dowrick
- Queen Mary University of London, London, United Kingdom
| | | | | | - Sam Martin
- University of Oxford, Oxford, United Kingdom
| | - Georgina Singleton
- University College London, London, United Kingdom
- Royal College of Anaesthetists, London, United Kingdom
| | | | - Norha Vera
- King’s College London, London, United Kingdom
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Vindrola-Padros C, Andrews L, Dowrick A, Djellouli N, Fillmore H, Bautista Gonzalez E, Javadi D, Lewis-Jackson S, Manby L, Mitchinson L, Mulcahy Symmons S, Martin S, Regenold N, Robinson H, Sumray K, Singleton G, Syversen A, Vanderslott S, Johnson G. Perceptions and experiences of healthcare workers during the COVID-19 pandemic in the UK. BMJ Open 2020; 10:e040503. [PMID: 33154060 PMCID: PMC7646318 DOI: 10.1136/bmjopen-2020-040503] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/07/2020] [Accepted: 10/18/2020] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE The COVID-19 pandemic has set unprecedented demand on the healthcare workforce around the world. The UK has been one of the most affected countries in Europe. The aim of this study was to explore the perceptions and experiences of healthcare workers (HCWs) in relation to COVID-19 and care delivery models implemented to deal with the pandemic in the UK. METHODS The study was designed as a rapid appraisal combining: (1) a review of UK healthcare policies (n=35 policies), (2) mass media and social media analysis of front-line staff experiences and perceptions (n=101 newspaper articles, n=1 46 000 posts) and (3) in-depth (telephone) interviews with front-line staff (n=30 interviews). The findings from all streams were analysed using framework analysis. RESULTS Limited personal protective equipment (PPE) and lack of routine testing created anxiety and distress and had a tangible impact on the workforce. When PPE was available, incorrect size and overheating complicated routine work. Lack of training for redeployed staff and the failure to consider the skills of redeployed staff for new areas were identified as problems. Positive aspects of daily work reported by HCWs included solidarity between colleagues, the establishment of well-being support structures and feeling valued by society. CONCLUSION Our study highlighted the importance of taking into consideration the experiences and concerns of front-line staff during a pandemic. Staff working in the UK during the COVID-19 pandemic advocated clear and consistent guidelines, streamlined testing of HCWs, administration of PPE and acknowledgement of the effects of PPE on routine practice.
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Affiliation(s)
| | - Lily Andrews
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Anna Dowrick
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Nehla Djellouli
- Institute of Global Health, University College London, London, UK
| | | | | | - Dena Javadi
- Harvard TH Chan School of Public Health, Department of Social and Behavioral Sciences, Harvard University, Cambridge, Massachusetts, USA
| | | | - Louisa Manby
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Lucy Mitchinson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, United Kingdom
| | | | - Sam Martin
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), Oxford University, Oxford, Oxfordshire, UK
| | - Nina Regenold
- Department of Anthropology, University College London, London, UK
| | - Hannah Robinson
- School for Policy Studies, Bristol University, Bristol, United Kingdom
| | - Kirsi Sumray
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Georgina Singleton
- Department of Targeted Intervention, University College London, London, UK
| | - Aron Syversen
- Institute of Epidemiology and Healthcare, University College London, London, UK
| | - Samantha Vanderslott
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine (CCVTM), Oxford University, Oxford, Oxfordshire, UK
| | - Ginger Johnson
- Department of Targeted Intervention, University College London, London, UK
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12
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Singleton G, Levy N. Age‐adjusted minimum alveolar concentration and standards of monitoring. Anaesthesia 2019; 74:1615-1616. [PMID: 31681996 DOI: 10.1111/anae.14824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - N. Levy
- West Suffolk NHS Foundation Trust Suffolk UK
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13
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Abstract
House mice (Mus domesticus) in the Victorian mallee region of southeastern Australia show irregular outbreaks. Changes in reproductive output that could potentially drive changes in mouse numbers were assessed from 1982 to 2000. Litter size in females is positively correlated with body size. When standardized to an average size female, litter size changes seasonally from highest in spring to lowest in autumn and winter. Litter size is depressed throughout breeding seasons that begin when the abundance of mice is high, but is similar in breeding seasons over which the abundance of mice increases rapidly or remains low. Breeding begins early and is extended on average by about five weeks during seasons when mouse abundance increases rapidly. The size at which females begin to reproduce is larger during breeding seasons that begin when mouse abundance is high. An extended breeding season that begins early in spring is necessary for the generation of a house mouse plague, but it is not in itself sufficient. Reproductive changes in outbreaks of house mice in Australia are similar but not identical to reproductive changes that accompany rodent population increases in the Northern Hemisphere. We conclude that food quality, particularly protein, is a probable mechanism driving these reproductive changes, but experimental evidence for field populations is conflicting.
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Affiliation(s)
- G Singleton
- CSIRO Sustainable Ecosystems, GPO Box 284, Canberra, ACT 2601, Australia.
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14
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Singleton G. Displaced abomasum in dairy cattle. Vet Rec 1999; 144:512. [PMID: 10358894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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15
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Morgan UM, Sturdee AP, Singleton G, Gomez MS, Gracenea M, Torres J, Hamilton SG, Woodside DP, Thompson RC. The Cryptosporidium "mouse" genotype is conserved across geographic areas. J Clin Microbiol 1999; 37:1302-5. [PMID: 10203475 PMCID: PMC84758 DOI: 10.1128/jcm.37.5.1302-1305.1999] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 298-bp region of the Cryptosporidium parvum 18S rRNA gene and a 390-bp region of the acetyl coenzyme A synthetase gene were sequenced for a range of Cryptosporidium isolates from wild house mice (Mus domesticus), a bat (Myotus adversus), and cattle from different geographical areas. Previous research has identified a distinct genotype, referred to as the "mouse"-derived Cryptosporidium genotype, common to isolates from Australian mice. Comparison of a wider range of Australian mouse isolates with United Kingdom and Spanish isolates from mice and cattle and also an Australian bat-derived Cryptosporidium isolate revealed that the "mouse" genotype is conserved across geographic areas. Mice are also susceptible to infection with the "cattle" Cryptosporidium genotype, which has important implications for their role as reservoirs of infection for humans and domestic animals.
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Affiliation(s)
- U M Morgan
- World Health Organisation Collaborating Centre for the Molecular Epidemiology of Parasitic Infections, School of Veterinary and Biomedical Sciences, Murdoch University, Murdoch, Western Australia, Australia.
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16
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Boyer P, Singleton G. Digital dermatitis, superfoul and severe necrotic dermatitis [correction of enteritis] of the udder in dairy cows. Vet Rec 1998; 142:147-8. [PMID: 9507654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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18
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Affiliation(s)
- F Figueroa
- Max-Planck-Institut für Biologie, Abteilung Immungenetik, Tübingen, Federal Republic of Germany
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Singleton G, Weider D, Brackmann D, Black FO, Williams JD, Arenberg IK, Epley J, Pillsbury HC, Gibson WP, Gantz B. Panel discussion: Perilymphatic fistula. Am J Otol 1987; 8:355-63. [PMID: 3631245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
We recently treated two narcotic addicts with bacterial endocarditis who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This prompted a retrospective review of blood chemistry studies in all narcotic addicts admitted to our hospital over a 30-month period because of a clinical suspicion of bacterial endocarditis. Patients with culture-positive endocarditis (group 1) had significantly lower plasma osmolality, sodium, calcium and albumin values (P less than .02, .001, .005, and .005 respectively) than addicts without endocarditis (group 2). More than 90% of those in group 1 had hyponatremia, and 48% had plasma hypoosmolality. These findings may be of value in the initial evaluation of ill narcotic addicts for hospitalization.
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Outhwaite RI, Singleton G, Ross JA. A simple stress relaxometer and its use with vulcanized nitrile rubber/PVC compounds. J Appl Polym Sci 1964. [DOI: 10.1002/app.1964.070080236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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