Development of an international standard set of outcome measures for patients with venous thromboembolism: an International Consortium for Health Outcomes Measurement consensus recommendation

The International Consortium for Health Outcomes Measurement assembled an international working group of venous thromboembolism experts and patient representatives to develop a standardised minimum set of outcomes and outcome measurements for integration into clinical practice and potentially research to support clinical decision making and benchmarking of quality of care. 15 core outcomes important to patients and health-care professionals were selected and categorised into four domains: patient-reported outcomes, long term consequences of the disease, disease-specific complications, and treatment-related complications. The outcomes and outcome measures were designed to apply to all patients with venous thromboembolism aged 16 years or older. A measurement tool package was selected for inclusion in the core standard set, with a minimum number of items to be measured at predefined timepoints, which capture all core outcomes. Additional measures can be introduced to the user by a cascade opt-in system that allows for further assessment if required. This set of outcomes and measurement tools will facilitate the implementation of the use of patient-centred outcomes in daily practice.

The Corona-Eye: Exploring the risks of COVID-19 on fair assessments of impact for REF2021

This paper assesses the risk of two COVID-19 related changes necessary for the expert-review of the REF2021’s Impact criterion: the move from F2F to virtual deliberation; and the changing research landscape caused by the COVID-19 crisis requiring an extension of deadlines, and accommodation of COVID-19 related mitigation. Peer review in its basic form requires expert debate, where dissenting opinions and non-verbal cues are absorbed into a groups deliberative practice and therefore inform outcomes. With a move to deliberations in virtual settings, the most likely current outcome for REF2021 evaluations, the extent that negotiation dynamics necessary in F2F evaluations are diminished and how this limits panelists’ ability to sensitively assess COVID-19 mitigation statements is questioned. This article explores the nature of, and associated capabilities to undertake, complex decision making in virtual settings around the Impact criterion as well the consequences of COVID-19 on normal Impact trajectories. It examines the risks these changes present for evaluation of the Impact criterion and provides recommendations to offset these risks to enhance discussion and safeguard the legitimacy of evaluation outcomes. This paper is also relevant for evaluation processes of academic criteria that require both a shift to virtual, and/or guidance of how to sensitively assess the effect of COVID-19 on narratives of individual, group or organisational performance.

A structural equation model to predict pre-exposure prophylaxis acceptability in men who have sex with men in Leicester, UK

OBJECTIVES

Pre-exposure prophylaxis (PrEP) is an effective HIV prevention tool for high-risk men who have sex with men (MSM). However, acceptability and uptake have been variable. This study explored the factors that predict PrEP acceptability in MSM in Leicester, where HIV prevalence is double the national average.

METHODS

A total of 191 HIV-negative MSM completed a cross-sectional survey. Participants provided demographic information, and completed measures of HIV knowledge, perceived HIV risk, engagement in sexual risk behaviour, acquisition of a sexually transmitted infection (STI) in the last 12 months, frequency of HIV testing and PrEP acceptability.

RESULTS

Kruskal-Wallis tests showed statistically significant effects of sexual orientation, education level and income, respectively, on HIV knowledge. Gay-identified individuals possessed greater HIV knowledge than bisexuals. Respondents with General Certificate of Secondary Education (GCSE)-level education had significantly less HIV knowledge than those educated to postgraduate level. Respondents with income of < £10 000 possessed significantly less HIV knowledge than higher income groups. Structural equation modelling showed that the relationship between HIV knowledge and PrEP acceptability was mediated by perceived HIV risk, engagement in sexual risk behaviour, acquisition of an STI in the past 12 months and frequency of HIV testing.

CONCLUSIONS

The results reveal socio-economic inequalities in HIV knowledge and HIV testing, and suggest that MSM who have high levels of HIV knowledge and perceived HIV risk and who regularly test for HIV are most likely to endorse PrEP as personally beneficial. HIV knowledge and accurate risk appraisal should be promoted in MSM. The HIV testing context constitutes an ideal context for promoting PrEP to high-risk MSM.

Development of an Intervention to Increase Sexual Health Service Uptake by Young People

This study aimed to develop and implement an intervention, delivered via a website and Web app, to increase the uptake of sexual health services by young people. The intervention was co-designed with a group of 10 young people. Intervention mapping was used to guide development. To identify barriers and facilitators of access to sexual health services, three focus groups with 24 young people aged 13 to 19 years, and interviews with 12 professionals recruited from across a range of health and social services, were conducted. Data were analyzed using content analysis. Evidence was supplemented through a literature review. Barriers and facilitators were categorized as theoretical determinants and then suitable behavior change techniques (BCTs) for targeting them were selected. Targeted determinants were attitude, subjective norm, perceived behavioral control, and knowledge. Selected BCTs included "information about others' approval," "framing/reframing," and "credible source." The website/app enable users to search for services, access key information about them, watch videos about what to expect, and have key concerns removed/addressed. This is the first known digital evidence-based intervention to target this behavior described in the literature. A clear and full description of intervention development and content, including of theorized causal pathways, is provided to aid interpretation of future outcome evaluations.

Tackling sensitive issues using a game-based environment: serious game for relationships and sex education (RSE)

Experiencing sexual coercion during adolescence can lead to adverse psychological and physical health outcomes for those affected. Eliminating such experiences is important for enhancing adolescent wellbeing, and the provision of good quality relationships and sex education (RSE) is needed. Engaging young people in sensitive subject matters in RSE can be challenging, and using Serious Gaming technology may support young people and educators in this process. This paper describes the use of Intervention mapping (IM) in the development of a serious game on the topic of sexual coercion for use in RSE. IM is a process that draws on stakeholder engagement and the theory and evidence base to support health improvement intervention planning. Serious game developers transformed the game concept 'flat plan' into an interactive gameshow. The game is teacher led and aims to engage students in game play and discussion around the issue of sexual coercion. The final product known as PR:EPARe (Positive Relationships: Eliminating Coercion and Pressure in Adolescent Relationships) is the subject of an ongoing cluster Randomised Controlled Trial (RCT) in local schools. Early data analysis shows improvements in psychological preparedness for dealing with sexual coercion against some change objectives. This work represents the first attempt to use IM in the development of a Serious Game and the use of Serious Gaming for RSE delivery. RCT work is ongoing and PR:EPARe will become part of local RSE delivery in the new school year. Plans for ensuring broader impact of the game are in development.

Teenagers uncovered

There is a common belief that peer pressure and alcohol are instrumental in teenagers having sex, but new research reveals a different story.

Survey evaluation of the National Patient Safety Agency's Root Cause Analysis training programme in England and Wales: knowledge, beliefs and reported practices

BACKGROUND

Root Cause Analysis (RCA) is a systematic approach to investigations, and is applied in many healthcare settings within comprehensive patient safety systems. The National Patient Safety Agency (NPSA) in England and Wales commissioned a survey evaluation of its national training programme which consisted of 3-day workshops and internet support materials.

METHODS

Anonymous survey of 374 health professionals immediately after they attended the programme (T1), and a further 350 participants 6 months after the programme (T 2), who had attended courses in England and Wales in 2005.

RESULTS

T1 knowledge tests showed a greater understanding of the frameworks and techniques of RCA but with less accuracy in application to scenarios. Personal beliefs about conducting RCAs were consistently positive at both times, but many participants experienced personal barriers to conducting RCA in their current role and trust context, and some felt low confidence in undertaking cascade training of other staff in their trust. There was also low confidence in implementing RCA as standard practice at both times. At T2, 76.7% were confident the outcomes from their RCA had been implemented, but only 12.1% were aware if improvements had been shared outside the local organisation. Barriers to RCA at both times most often concerned time and resources to apply RCA. At T1, there was particular concern for personal development, at T2 greater concern for organisational impediments.

CONCLUSIONS

The RCA programme enhanced knowledge of RCA, and participants valued the programme, but further personal development and organisational support are required to achieve continued improvement in practice and sustained organisational learning.

"What Should We Tell the Children About Relationships and Sex?"©: development of a program for parents using intervention mapping

This article describes the development of an intervention that aims to increase the quantity and quality of parent-child communication about sex and relationships. The intervention has been designed as part of a local strategic approach to teenage pregnancy and sexual health. The process and findings of Intervention Mapping (IM), a tool for the development of theory-and evidence-based interventions, are presented. The process involves a detailed assessment of the difficulties parents experience in communicating with their children about sex and relationships. The findings are translated into program and change objectives that specify what parents need to do to improve their communication. Theory-based practical strategies most likely to bring about the desired behavioral change are then identified and pretested. The intervention developed consists of a six-session facilitator-led program that targets parents' attitudes, knowledge, communication skills, and self-efficacy. Following on from Bartholomew's seminal work on IM, this article develops and extends the application of this process by presenting explicit detail on the behavioral change techniques used and their theoretical underpinnings. The strengths and weaknesses of IM as a process for the development of health behavior interventions are discussed.

Fathers and parenting programmes: barriers and best practice

Fathers are particularly difficult to recruit to voluntary parenting programmes, despite the advantages of such programmes for confidence and skills in parenting and associated improvements in child behaviour. The apparent reluctance of fathers to engage in parenting services is recognised as a problem by health and social care practitioners, and the Department of Health identifies the engagement of fathers as a key service target. This review gathers information on barriers to fathers' engagement with parenting support services and identifies best practice for recruitment. It draws on published academic literature, government and community organisation reports and empirical data collection through interviews with parenting experts (n=9) and focus groups and questionnaires with fathers (n=29). The barriers identified were lack of awareness, work commitments, female-orientated services, lack of organisational support and concerns over programme content. Aspects of best practice included actively promoting services to fathers rather than parents, offering alternative forms of provision, prioritising fathers within organisations and taking different cultural and ethnic perspectives into account. Achieving greater engagement of fathers in parenting support programmes requires a greater understanding of the perspectives of fathers.

Timing of surgical decompression and fixation of acute spinal fractures

A retrospective evaluation of 138 patients requiring operative decompression, reduction and fixation of spinal injuries between January 1986 and April 1989 was conducted. The variables of timing and method of operative intervention, level and classification of fracture, associated injuries, injury severity score (ISS), associated neurologic deficits, length of intensive care unit and hospital stays, and projected costs were analyzed for correlation with postoperative complications (pulmonary, skin, urinary, other). Four subgroups were identified: group IA patients underwent surgery within 72 h of injury and had an ISS of < 18; group IB patients underwent surgery after 72 h and had an ISS of < 18; group IIA patients underwent surgery within 72 h and had an ISS of > or = 18; and group IIB underwent surgery after 72 h and had an ISS of > or = 18. There was no statistically significant difference in the incidence of medical complications in patients comparing groups IA and IB. Group IIB patients had a statistically significant higher rate of morbidity than did group IIA. A separate group of patients with cervical spine injuries with neurologic deficit was analyzed by the same statistical analysis. Irrespective of associated injuries, all had fewer complications if they underwent surgery within 72 h. Morbidity was higher in patients with a neurological deficit compared with neurologically intact patients. Surgical decompression, reduction, and/or fixation of spinal fractures within the first 72 h is indicated in patients with multiple trauma (ISS > or = 18) and cervical injuries with a neurological deficit.

Degenerative lumbar spinal stenosis. Diagnostic value of the history and physical examination

OBJECTIVE

To assess the value of the history and physical examination findings in the diagnosis of symptomatic degenerative lumbar spinal stenosis (LSS).

METHODS

The study was performed in 3 specialty clinics, and included patients with low back pain who were at least age 40. Findings from a standardized history and physical examination were compared with the diagnostic impression of expert attending clinicians. Imaging studies were available in 88% of those with LSS, and the findings further supported the diagnosis of LSS in each case. The sensitivity, specificity, and likelihood ratio associated with each history and physical examination finding were calculated in bivariate analyses, and independent correlates of LSS were identified with multivariate analyses.

RESULTS

Ninety-three patients were evaluated. History findings most strongly associated with the diagnosis of LSS (likelihood ratio > or = 2) were greater age, severe lower-extremity pain, and absence of pain when seated. Physical examination findings most strongly associated with the diagnosis were wide-based gait, abnormal Romberg test result, thigh pain following 30 seconds of lumbar extension, and neuromuscular deficits. Independent correlates of LSS included advanced age (P = 0.0001), absence of pain when seated (P = 0.006), wide-based gait (P = 0.013), and thigh pain following 30 seconds of lumbar extension (P = 0.002).

CONCLUSION

Specific history and physical examination findings are useful in the diagnosis of LSS and should be ascertained routinely in older patients with low back pain.

Mutagenic activity of 3 industrial chemicals in a battery of in vitro and in vivo tests

3 chemicals were selected for mutagenicity testing from a priority list, based on production volume and available mutagenicity data. Propargyl alcohol (PA), 2-nitroaniline (2NA), and 5-methyl-1H-benzo-triazole (MBT) were selected for testing using the approach recommended in the Health Protection Branch Genotoxicity Guidelines. The battery of tests included the Salmonella/mammalian microsome mutation assay, the in vitro chromosomal aberration assay, and the bone-marrow micronucleus assay. The results indicate that 2 of the 3 chemicals, PA and 2NA, were clastogenic in vitro. Both PA and 2NA induced chromosomal aberrations in CHO cells in vitro with and without metabolic activation, while none induced reverse mutations detectable with the Salmonella/mammalian microsome assay. Because PA and 2NA were found to be in vitro clastogens, they also were tested in the mouse bone-marrow micronucleus assay. 2NA induced a small increase in micronuclei in males but not females. PA did not induce an increase in micronuclei.

Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine

A nerve root impingement within a stenotic neuroforamen is a common sequela of cervical degenerative arthritis and herniated nucleus pulposus. Understanding of the effects of cervical position on foraminal size is important in the assessment of pathology and injury, for selection of a provocative maneuver to elicit symptoms and in selecting a position of immobilization for the management of nerve root impingement syndrome. This biomechanical study of human cadaver cervical spines reports the measured variations in the sizes of neuroforamina as a function of cervical positioning. Five fresh frozen adult human cadaver cervical spines (C2-T1) were tested with combinations of flexion-extension and rotational position. Ten pounds of axial load was applied to simulate a normal loading of a cervical spine. The foramina of C5, C6, and C7 were directly measured using a set of finely graded circular probes. Compared to the foraminal diameter at the neutral position, there were statistically significant reductions in the foramen diameter of 10% and 13%, at 20 degrees and 30 degrees of extension respectively (P < 0.01). Conversely, in flexion, there were statistically significant increase of 8% and 10% at 20 degrees and 30 degrees of flexion respectively (P < 0.01). Though there was a reduction in the foraminal size with ipsilateral 20 degrees rotation, and an increase with contralateral 20 degrees rotation, these changes were not significantly different from the mean of the control. Combinations of flexion or extension position with axial rotation did not significantly change the foraminal size compared to the respective sagittal position with no axial rotation.(ABSTRACT TRUNCATED AT 250 WORDS)

The Auger electron dosimetry of indium-111 in mammalian cells in vitro

Most of the radionuclides used in the formulation of radiopharmaceuticals emit Auger electrons when they undergo radioactive decay. The release of these low-energy electrons at extracellular sites produces little direct damage to intracellular structures. However, many radiopharmaceuticals, or their metabolites, can be transported into the cell where the Auger electrons have the potential to damage nearby intracellular macromolecules, including DNA. In this preliminary study, chromosome damage, expressed as 60Co equivalent doses, and the effects on cell division following treatment with intracellular and extracellular 111In were measured in Chinese hamster V79 cells. The chromosome aberration yield in cells irradiated by intracellular 111In indicated that damage was induced at a rate of 7.2 X 10(-4) Gy/decay for levels of activity up to 0.075 Bq/cell and 4.5 X 10(4) and 2.9 X 10(4) Gy/decay for intermediate (0.204 Bq/cell) and high (0.389 Bq/cell) levels, respectively. Extracellular 111In-chloride produced damage at a rate of about 6.1 X 10(-12) Gy/decay. As little as 4.4 mBq/cell (about 4.4 X 10(3) Bq/ml of culture) of intracellular 111In was able to affect cell division, whereas extracellular 111In at 1.150 MBq/ml of culture had little effect. These data indicate that the Medical Internal Radiation Dose and International Committee on Radiation Units methods for organ dosimetry may underestimate the potential of intracellular Auger electron emitters to produce radiation damage.

Avascular necrosis of the proximal carpal row. A case report

Avascular necrosis of bone has been described in many sites, including the carpal bones. The case history of a patient with avascular necrosis of the entire proximal row, previously undescribed, is detailed. Numerous contributing factors, including steroid administration, hyperlipidemia, and systemic lupus erythematosus are noted. Occult wrist pain in any patient with known risk factors for avascular necrosis is a warning sign; early bone scan may help prevent late complications.

Diverticulitis of the cecum

Ten patients with diverticulitis of the cecum are reported upon herein. The disease is difficult to distinguish preoperatively from that of appendicitis and may be difficult to distinguish intraoperatively from carcinoma of the cecum. The diverticula are usually solitary and may be of the true or false variety. A review of the literature is presented, and the difficulties of diagnosis and treatment are discussed. We advocate local resection of the diverticulum, when possible, and a right hemicolectomy when the diagnosis is in doubt or when local resection or invagination would jeopardize the ileocecal valve or the blood supply to the intestine. With more awareness of diverticulitis of the cecum, intraoperative diagnosis may be made easier and the treatment simplified.