Patient, caregiver and other knowledge user engagement in consensus-building healthcare initiatives: a scoping review protocol

INTRODUCTION

Patient engagement and integrated knowledge translation (iKT) processes improve health outcomes and care experiences through meaningful partnerships in consensus-building initiatives and research. Consensus-building is essential for engaging a diverse group of experienced knowledge users in co-developing and supporting a solution where none readily exists or is less optimal. Patients and caregivers provide invaluable insights for building consensus in decision-making around healthcare, policy and research. However, despite emerging evidence, patient engagement remains sparse within consensus-building initiatives. Specifically, our research has identified a lack of opportunity for youth living with chronic health conditions and their caregivers to participate in developing consensus on indicators/benchmarks for transition into adult care. To bridge this gap and inform our consensus-building approach with youth/caregivers, this scoping review will synthesise the extent of the literature on patient and other knowledge user engagement in consensus-building healthcare initiatives.

METHODS AND ANALYSIS

Following the scoping review methodology from Joanna Briggs Institute, published literature will be searched in MEDLINE, EMBASE, CINAHL and PsycINFO databases from inception to July 2023. Grey literature will be hand-searched. Two independent reviewers will determine the eligibility of articles in a two-stage process, with disagreements resolved by a third reviewer. Included studies must be consensus-building studies within the healthcare context that involve patient engagement strategies. Data from eligible studies will be extracted and charted on a standardised form. Abstracted data will be analysed quantitatively and descriptively, according to specific consensus methodologies, and patient engagement models and/or strategies.

ETHICS AND DISSEMINATION

Ethics approval is not required for this scoping review protocol. The review process and findings will be shared with and informed by relevant knowledge users. Dissemination of findings will also include peer-reviewed publications and conference presentations. The results will offer new insights for supporting patient engagement in consensus-building healthcare initiatives.

PROTOCOL REGISTRATION

https://osf.io/beqjr.

Pediatric anesthesia in North America

BACKGROUND AND OBJECTIVES

This educational review outlines the current landscape of pediatric anesthesia training, care delivery, and challenges across Canada, Barbados, and the United States.

DESCRIPTIONS AND CONCLUSIONS

Approximately 5% of Canadian children undergo general anesthesia annually, administered by fellowship-trained pediatric anesthesiologists in children's hospitals, general anesthesiologists in community hospitals, or family practice anesthesiologists in underserved regions. In Canada, the focus is on national-level evaluation and accreditation of pediatric anesthesia fellowship training, addressing challenges arising from workforce shortages, particularly in remote areas. Barbados, a Caribbean nation, lacks dedicated pediatric hospitals but has provided pediatric anesthesia since 1972 through anesthetists with additional training. Challenges in its development, common to low-middle-income countries, include inadequate infrastructure and workforce shortages. Increased awareness of pediatric anesthesia as a sub-specialty could enhance perioperative care for Barbadian children. Pediatric anesthesia encompasses various specialties in the United States, with pediatric anesthesiologists playing a foundational role. Challenges faced include recruitment and retention difficulties, supply-chain shortages, and the proliferation of anesthesia sites, all impacting the delivery of modern, high-quality, and cost-effective patient care. Collaborative efforts at national and organizational levels strive to improve the quality and safety of pediatric anesthesia care in the United States.

Social and Structural Drivers of Health and Transition to Adult Care

CONTEXT

Youth with chronic health conditions experience challenges during their transition to adult care. Those with marginalized identities likely experience further disparities in care as they navigate structural barriers throughout transition.

OBJECTIVES

This scoping review aims to identify the social and structural drivers of health (SSDOH) associated with outcomes for youth transitioning to adult care, particularly those who experience structural marginalization, including Black, Indigenous, and 2-spirit, lesbian, gay, bisexual, transgender, queer or questioning, and others youth.

DATA SOURCES

Medline, Embase, CINAHL, and PsycINFO were searched from earliest available date to May 2022.

STUDY SELECTION

Two reviewers screened titles and abstracts, followed by full-text. Disagreements were resolved by a third reviewer. Primary research studying the association between SSDOH and transition outcomes were included.

DATA EXTRACTION

SSDOH were subcategorized as social drivers, structural drivers, and demographic characteristics. Transition outcomes were classified into themes. Associations between SSDOH and outcomes were assessed according to their statistical significance and were categorized into significant (P < .05), nonsignificant (P > .05), and unclear significance.

RESULTS

101 studies were included, identifying 12 social drivers (childhood environment, income, education, employment, health literacy, insurance, geographic location, language, immigration, food security, psychosocial stressors, and stigma) and 5 demographic characteristics (race and ethnicity, gender, illness type, illness severity, and comorbidity). No structural drivers were studied. Gender was significantly associated with communication, quality of life, transfer satisfaction, transfer completion, and transfer timing, and race and ethnicity with appointment keeping and transfer completion.

LIMITATIONS

Studies were heterogeneous and a meta-analysis was not possible.

CONCLUSIONS

Gender and race and ethnicity are associated with inequities in transition outcomes. Understanding these associations is crucial in informing transition interventions and mitigating health inequities.

Using a Quality Improvement Approach to Implement Measurement-Based Care (MBC) in Outpatient General Psychiatry

BACKGROUND

Measurement-based care (MBC) is the clinical practice of using patient-reported symptom measurement to inform treatment decisions. MBC has been shown to improve patient outcomes and quality of care in outpatient psychiatry. Despite these benefits, MBC is not routinely used in most psychiatric outpatient settings. This quality improvement (QI) project aimed to achieve 75% completion of symptom scales using an online MBC platform in a general psychiatry clinic in Toronto, Canada, by June 2022.

METHODS

The QI team used the Model for Improvement methodology. The main outcome measure was completion of symptom scales using an online MBC platform. Process measures included counts of invitations to join the MBC platform, counts of online MBC account creation, and counts of symptom scale assignment by clinicians. Balancing measures included administrative task completion and physician workload assessment. Stakeholder interviews explored barriers and facilitators to MBC utilization.

RESULTS

Completion of symptom scales increased from 7/65 (10.8%) preintervention to 40/70 (57.1%) during the 26-week intervention. Clinician reminders and coaching clinicians about how to incorporate MBC into the care process facilitated uptake of MBC. Stakeholders identified several barriers to implementation, particularly physician attitudes toward MBC and perceived administrative burden.

CONCLUSION

Completion of symptom scales increased over the course of this QI initiative. Successful implementation of MBC in general psychiatry outpatient settings requires the availability of a broad range of measurement scales given the diversity of mental health diagnoses. Implementation must also consider health equity, including access to technology and availability of symptom scales in multiple languages.

The value of performing cerebrovascular CT angiography in major trauma patients: a 5-year retrospective review

AIM

To assess whether routine cerebrovascular imaging is required in all major trauma (MT) patients.

MATERIALS AND METHODS

All MT patients with cerebrovascular imaging between January 2015 and December 2020 were included in the study. Data were collated regarding the type of indication for computed tomography (CT) angiography imaging, time interval from the initial trauma, relevant trauma diagnoses on initial trauma imaging, and CT angiography. Findings, such as aneurysms, vascular malformations, luminal thrombus, venous sinus thrombosis, or vascular injury, were collated. Subsequent treatment with anti-coagulants/anti-platelets or surgical/radiological intervention was noted. Follow-up imaging was assessed for residual injury or complications.

RESULTS

Two hundred and fifty of the 6,251 MT patients underwent dedicated cerebrovascular imaging and were included in the study. Of these 41 (16.4%) had cervical artery or venous sinus injury. Further positive vascular findings were identified in 25/250 patients who presented with an incidental stroke or a vascular abnormality and were mislabelled as MT patients at presentation. One patient with a carotid injury subsequently died following a large infarction. Another patient with vertebral artery injury suffered a non-lethal stroke. No patients underwent surgery or intervention.

CONCLUSION

The present study showed that the overall incidence of detected blunt cerebrovascular injuries was very low (0.6%) and even lower for symptomatic vascular injury (0.03%). Routine cerebrovascular imaging is not recommended in all MT trauma patients, but instead, a continued case-by-case basis should be considered.

Quality Indicators for Youth Transitioning to Adult Care: A Systematic Review

BACKGROUND AND OBJECTIVE

Transition from pediatric to adult care is associated with adverse health outcomes for many adolescents with chronic illness. We identified quality indicators for transition to adult care that are broadly applicable across chronic illnesses and health systems.

METHODS

Medline, Embase, and the Cumulative Index to Nursing and Allied Health Literature were searched, covering earliest available date to July 2021. The Gray Matters framework was used to search gray literature. Two independent reviewers screened articles by title and abstract, followed by full-text review. Disagreements were resolved by a third reviewer. Studies were included that identified quality indicators developed via consensus-building methods. Indicators were organized into a framework categorized by illness specificity, level of care, Donabedian model, and Institute of Medicine quality domain. Appraisal of Guidelines for Research and Evaluation tool was used for critical appraisal.

RESULTS

The search identified 4581 articles, of which 321 underwent full-text review. Eight peer-reviewed studies and 1 clinical guideline were included, identifying 169 quality indicators for transition. Of these, 56% were illness specific, 43% were at the patient level of care, 44% related to transition processes, and 51% were patient centered and 0% equity focused. Common indicator themes included education (12%), continuity of care (8%), satisfaction (8%), and self-management/self-efficacy (7%). The study was limited by quality indicators developed through consensus-building methodology.

CONCLUSIONS

Although most quality indicators for transition were patient-centered outcomes, few were informed by youth and parents/caregivers, and none focused on equity. Further work is needed to prioritize quality indicators across chronic illness populations while engaging youth and parents/caregivers in the process.

Competency-Based Medical Education: Are Canadian Pediatric Anesthesiologists Ready?

Background

With the introduction of Competency-Based Medical Education (CBME), the Canadian Pediatric Anesthesia Society (CPAS) surveyed its members to assess their awareness of and prior experience with CBME concepts and evaluation tools, and identify methods for faculty development of CBME teaching strategies for pediatric anesthesia residents and fellows.

Methods

An online survey was sent to CPAS members. Outcomes included respondents’ previous exposure to CBME and the educational support they had received in anticipation of the curriculum. Questions used multi-item Likert scales and a general feedback question. 

Results

The response rate was 39% (60/155). Eighty-eight percent of respondents spent ≥50% of their time practicing pediatric anesthesia; 78% and 45% spent at least a quarter of their time teaching residents and fellows respectively. Eighty-three percent were familiar with CBME concepts, and 58% were familiar with Milestones, Competencies, and Entrustable Professional Activities (EPAs). However, 64% had not received any formal training and 52% had not used any CBME evaluation tools. Learning preferences included small group discussions (72%), lectures with questions and answers (Q&A) (62%), seminars (50%), and workshops (50%).

Conclusions

Despite widespread awareness of CBME concepts, there is a need to educate Canadian pediatric anesthesiologists regarding CBME evaluation tools. Faculty development support will increase the utilization of these tools in teaching practice.

Health research priorities for wildland firefighters: a modified Delphi study with stakeholder interviews

OBJECTIVES

The increase in global wildland fire activity has accelerated the urgency to understand health risks associated with wildland fire suppression. The aim of this project was to identify occupational health research priorities for wildland firefighters and related personnel.

DESIGN

In order to identify, rank and rate health research priorities, we followed a modified Delphi approach. Data collection involved a two-stage online survey followed by semi-structured interviews.

SETTING

British Columbia, Canada.

PARTICIPANTS

Participants included any current or past wildland firefighter or individuals engaged in related roles. There were 132 respondents to the first survey. Responses to the first survey were analysed to produce 10 research topics which were ranked by 75 participants in the second survey (response rate: 84%).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the identification, ranking and level of agreement of research priorities through a two-round online survey. We contextualised these findings through deductive and inductive qualitative content analysis of semi-structured interviews.

RESULTS

The most important research priorities identified were (% consensus): effects of smoke inhalation on respiratory health (89%), fatigue and sleep (80%), mental health (78%), stress (76%) and long-term risk of disease (67%). Interviews were completed with 14 individuals. Two main themes were developed from an inductive content analysis of interview transcripts: (1) understanding the dynamic risk environment; and (2) organisational fit of mitigation strategies.

CONCLUSIONS

Participants expressed a general concern with the unknown mental and physical health impacts of their jobs, including the long-term risk of morbidity and mortality. Future research must address knowledge gaps in our understanding of the health impacts of wildland fire and work to develop appropriate mitigation strategies while considering the needs of workers and unpredictable workplace environment.

TRIAL REGISTRATION NUMBER

Open Science Framework, https://osf.io/ugz4s/.

Health risks and mitigation strategies from occupational exposure to wildland fire: a scoping review

OBJECTIVES

Due to accelerating wildland fire activity, there is mounting urgency to understand, prevent, and mitigate the occupational health impacts associated with wildland fire suppression. The objectives of this review of academic and grey literature were to: 1. Identify the impact of occupational exposure to wildland fires on physical, mental, and emotional health; and 2. Examine the characteristics and effectiveness of prevention, mitigation, or management strategies studied to reduce negative health outcomes associated with occupational exposure to wildland fire.

METHODS

Following established scoping review methods, academic literature as well as government and industry reports were identified by searching seven academic databases and through a targeted grey literature search. 4679 articles were screened using pre-determined eligibility criteria. Data on study characteristics, health outcomes assessed, prevention or mitigation strategies studied, and main findings were extracted from each included document. The results of this scoping review are presented using descriptive tables and a narrative summary to organize key findings.

RESULTS

The final sample was comprised of 100 articles: 76 research articles and 24 grey literature reports. Grey literature focused on acute injuries and fatalities. Health outcomes reported in academic studies focused on respiratory health (n = 14), mental health (n = 16), and inflammation and oxidative stress (n = 12). The identified studies evaluated short-term outcomes measuring changes across a single shift or wildland fire season. Most research was conducted with wildland firefighters and excluded personnel such as aviation crews, contract crews, and incident management teams. Five articles reported direct study of mitigation strategies, focusing on the potential usage of masks, advanced hygiene protocols to reduce exposure, fluid intake to manage hydration and core temperature, and glutamine supplementation to reduce fatigue.

CONCLUSIONS

While broad in scope, the evidence base linking wildland fire exposure to any one health outcome is limited. The lack of long-term evidence on changes in health status or morbidity is a clear evidence gap and there is a need to prioritize research on the mental and physical health impact of occupational exposure to wildland fire.

Quality indicators for transition from paediatric to adult care for adolescents with chronic physical and mental illness: protocol for a systematic review

INTRODUCTION

Transition from paediatric to adult care is a complex process, which poses significant challenges for adolescents with chronic physical and mental illnesses. For many, transfer to adult care is associated with poor health and psychosocial outcomes. Quality indicators to evaluate transition to adult care are needed to benchmark and compare performance across conditions and health systems. This systematic review aims to identify quality indicators for successful transition to adult care which can be applied across chronic physical and/or mental illnesses.

METHODS

Published literature will be searched using MEDLINE, Embase and CINHAL from earliest available date to July 2021. Grey literature will be searched using the Grey Matters tool. Using a set of inclusion/exclusion criteria, two independent reviewers will screen titles and abstracts, followed by full-text review. Disagreements will be resolved by a third reviewer. Study selection and data extraction will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols. Study appraisal will be completed using the Appraisal of Guidelines for Research and Evaluation for Quality Indicators instrument. Extracted quality indicators will be categorised into a conceptual framework.

ETHICS AND DISSEMINATION

Results from this review will offer novel insights into quality indicators that may be used to measure and evaluate transition success across conditions, which will be disseminated via a Canadian transition collaborative, workshops and peer-reviewed publication. Extracted quality indicators will be further prioritised in a Delphi study with patients, caregivers and providers. This is a critical step in developing a core set of metrics to evaluate transitions to adult care. Ethics approval is not required as this review will identify and synthesise findings from published literature.

PROSPERO REGISTRATION NUMBER

CRD42020198030.

Comparison of the diagnostic performance and impact on management of 18F-FDG PET/CT and whole-body MRI in multiple myeloma

PURPOSE

Comparative data on the impact of imaging on management is lacking for multiple myeloma. This study compared the diagnostic performance and impact on management of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) and whole-body magnetic resonance imaging (WBMRI) in treatment-naive myeloma.

METHODS

Forty-six patients undergoing 18F-FDG PET/CT and WBMRI were reviewed by a nuclear medicine physician and radiologist, respectively, for the presence of myeloma bone disease. Blinded clinical and imaging data were reviewed by two haematologists in consensus and management recorded following clinical data ± 18F-FDG PET/CT or WBMRI. Bone disease was defined using International Myeloma Working Group (IMWG) criteria and a clinical reference standard. Per-patient sensitivity for lesion detection was established. McNemar test compared management based on clinical assessment ± 18F-FDG PET/CT or WBMRI.

RESULTS

Sensitivity for bone lesions was 69.6% (32/46) for 18F-FDG PET/CT (54.3% (25/46) for PET component alone) and 91.3% (42/46) for WBMRI. 27/46 (58.7%) of cases were concordant. In 19/46 patients (41.3%) WBMRI detected more focal bone lesions than 18F-FDG PET/CT. Based on clinical data alone, 32/46 (69.6%) patients would have been treated. Addition of 18F-FDG PET/CT to clinical data increased this to 40/46 (87.0%) patients (p = 0.02); and WBMRI to clinical data to 43/46 (93.5%) patients (p = 0.002). The difference in treatment decisions was not statistically significant between 18F-FDG PET/CT and WBMRI (p = 0.08).

CONCLUSION

Compared to 18F-FDG PET/CT, WBMRI had a higher per patient sensitivity for bone disease. However, treatment decisions were not statistically different and either modality would be appropriate in initial staging, depending on local availability and expertise.

Meta-analysis of the impact of postoperative infective complications on oncological outcomes in colorectal cancer surgery

BACKGROUND

Cancer outcomes are complex, involving prevention, early detection and optimal multidisciplinary care. Postoperative infection and surgical site-infection (SSI) are not only uncomfortable for patients and costly, but may also be associated with poor oncological outcomes. A meta-analysis was undertaken to assess the oncological effects of SSI in patients with colorectal cancer.

METHODS

An ethically approved PROSPERO-registered meta-analysis was conducted following PRISMA guidelines. PubMed and Scopus databases were searched for studies published between 2007 and 2017 reporting the effects of postoperative infective complications on oncological survival in colorectal cancer. Results were separated into those for SSI and those concerning anastomotic leakage. Articles with a Methodological Index for Non-Randomized Studies score of at least 18 were included. Hazard ratios (HRs) with 95 per cent confidence intervals were computed for risk factors using an observed to expected and variance fixed-effect model.

RESULTS

Of 5027 articles were reviewed, 43 met the inclusion criteria, with a total of 154 981 patients. Infective complications had significant negative effects on overall survival (HR 1·37, 95 per cent c.i. 1·28 to 1·46) and cancer-specific survival (HR 2·58, 2·15 to 3·10). Anastomotic leakage occurred in 7·4 per cent and had a significant negative impact on disease-free survival (HR 1·14, 1·09 to 1·20), overall survival (HR 1·34, 1·28 to 1·39), cancer-specific survival (HR 1·43, 1·31 to 1·55), local recurrence (HR 1·18, 1·06 to 1·32) and overall recurrence (HR 1·46, 1·27 to 1·68).

CONCLUSION

This meta-analysis identified a significant negative impact of postoperative infective complications on overall and cancer-specific survival in patients undergoing colorectal surgery.

Clinical and laboratory characteristics in juvenile-onset systemic lupus erythematosus across age groups

Background

Systemic lupus erythematous (SLE) is a systemic autoimmune/inflammatory condition. Approximately 15–20% of patients develop symptoms before their 18th birthday and are diagnosed with juvenile-onset SLE (JSLE). Gender distribution, clinical presentation, disease courses and outcomes vary significantly between JSLE patients and individuals with adult-onset SLE. This study aimed to identify age-specific clinical and/or serological patterns in JSLE patients enrolled to the UK JSLE Cohort Study.

Methods

Patient records were accessed and grouped based on age at disease-onset: pre-pubertal (≤7 years), peri-pubertal (8–13 years) and adolescent (14–18 years). The presence of American College of Rheumatology (ACR) classification criteria, laboratory results, disease activity [British Isles Lupus Assessment Group (BILAG) and Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) scores] and damage [Systemic Lupus International Collaborating Clinics (SLICC) damage index] were evaluated at diagnosis and last follow up.

Results

A total of 418 JSLE patients were included in this study: 43 (10.3%) with pre-pubertal disease onset; 240 (57.4%) with peri-pubertal onset and 135 (32.3%) were diagnosed during adolescence. At diagnosis, adolescent JSLE patients presented with a higher number of ACR criteria when compared with pre-pubertal and peri-pubertal patients [pBILAG2004 scores: 9(4–20] vs. 7(3–13] vs. 7(3–14], respectively, p = 0.015] with increased activity in the following BILAG domains: mucocutaneous (p = 0.025), musculoskeletal (p = 0.029), renal (p = 0.027) and cardiorespiratory (p = 0.001). Furthermore, adolescent JSLE patients were more frequently ANA-positive (p = 0.034) and exhibited higher anti-dsDNA titres (p = 0.001). Pre-pubertal individuals less frequently presented with leukopenia (p = 0.002), thrombocytopenia (p = 0.004) or low complement (p = 0.002) when compared with other age groups. No differences were identified in disease activity (pBILAG2004 score), damage (SLICC damage index) and the number of ACR criteria fulfilled at last follow up.

Conclusions

Disease presentations and laboratory findings vary significantly between age groups within a national cohort of JSLE patients. Patients diagnosed during adolescence exhibit greater disease activity and “classic” autoantibody, immune cell and complement patterns when compared with younger patients. This supports the hypothesis that pathomechanisms may vary between patient age groups.

A-37 Effects of Atypical Language Representation in Populations Suffering From Intractable Epilepsy

Objective

Atypical language laterality, secondary to refractory epilepsy, presents complications to surgical planning/cognitive outcomes. Extant research shows the non-dominant hemisphere reallocates neural resources for language compensation in response to left-sided lesions (resulting in decreased visuoperceptual/visual memory). The present study examined relationships between 1) lesion location and atypical language organization and 2) lesion location/language laterality on performance on memory (California Verbal Memory Test 2nd-edition (CVLT; Delayed Recall), and visuoperceptual (Rey-Osterrieth Complex Figure Test, ROCFT; Copy) tests in relation to lesion location in a sample of patients with intractable epilepsy.

Method

Retrospective data was compiled on patients with refractory epilepsy undergoing interdisciplinary pre-surgical workup (N = 101), mean age of 37.2 (SD = 11.9) and mean education of 12.3 (SD = 3.7). The sample was then stratified by non-lesional (n = 48), left (n = 26), right (n = 21) or bilateral (n = 6) mesial temporal sclerosis (MTL); and, language laterality was confirmed by neuroradiologists via functional Magnetic Resonance Imaging (fMRI) scans.

Results

Analyses showed patients with left MTS were more likely to have atypical language organization, X2 (1, N = 47) = 6.6, p = .01. Moreover, significant differences on T-scores for CVLT, F (3,15) = 3.81, p = .04, 95% Cl [-1.73, -.08] and ROCFT, F(4,28) = 2.85, p = .046 95% Cl [31.62, 46.17] were found between groups stratified by lesion location/language laterality, respectively.

Conclusions

Organization of language in epileptic populations presents atypically in conjunction with left-sided lesions. Additionally, cognitive processes such as verbal memory and visuoperceptual abilities suffer based on lesion presence/location and language laterality in this fMRI confirmed sample.

One In Five Fewer Heart Attacks: Impact, Savings, And Sustainability In San Diego County Collaborative

Before 2011 rates of hospitalization for heart attacks were about the same in San Diego County as they were in the rest of California. In 2011 a multistakeholder population health collaborative consisting of partners at the federal, state, and local levels launched Be There San Diego. The collaborative's goal was to reduce cardiovascular events through the spread of best practices aimed at improving control of hypertension, lipid levels, and blood sugar and through patient and medical community activation. Using hospital discharge data for the period 2007-16, we compared acute myocardial infarction (AMI) hospitalization rates in San Diego County and the rest of the state before and after the demonstration project started. AMI hospitalization rates decreased by 22 percent in San Diego County versus 8 percent in the rest of the state, with an estimated 3,826 AMI hospitalizations avoided and $86 million in savings in San Diego. Results show that a science-based health collaborative can improve outcomes while lowering costs, and efforts are under way to ensure the collaborative's sustainability.

Anomalous neutron scattering `halo' observed in highly oriented pyrolytic graphite

Highly oriented pyrolytic graphite (HOPG) has been used as monochromators, analyzers and filters at neutron and X-ray scattering facilities for more than half a century. Interesting questions remain. In this work, the first observation of anomalous neutron `halo' scattering of HOPG is reported. The scattering projects a ring onto the detector with a half-cone angle of 12.4°, which surprisingly persists to incident neutron wavelengths far beyond the Bragg cutoff for graphite (6.71 Å). At longer wavelengths the ring is clearly a doublet with a splitting roughly proportional to wavelength. Sample tilting leads to the shift of the ring, which is wavelength dependent with longer wavelengths providing a smaller difference between the ring shift and the sample tilting. The ring broadens and weakens with decreasing HOPG quality. The lattice dynamics of graphite play a role in causing the scattering ring, as shown by the fact that the ring vanishes once the sample is cooled to 30 K. A possible interpretation by multiple scattering including elastic and inelastic processes is proposed.

Outcomes following mycophenolate mofetil versus cyclophosphamide induction treatment for proliferative juvenile-onset lupus nephritis

Background

Juvenile-onset systemic lupus erythematosus (JSLE) is more severe than adult-onset disease, including more lupus nephritis (LN). Despite differences in phenotype/pathogenesis, treatment is based upon adult trials. This study aimed to compare treatment response, damage accrual, time to inactive LN and subsequent flare, in JSLE LN patients treated with mycophenolate mofetil (MMF) versus intravenous cyclophosphamide (IVCYC).

Methods

UK JSLE Cohort Study participants, ≤16 years at diagnosis, with ≥4 American College of Rheumatology criteria for SLE, with class III or IV LN, were eligible. Mann–Whitney U tests, Fisher's exact test and Chi-squared tests were utilized for statistical analysis.

Results

Of the patients, 34/51 (67%) received MMF, and 17/51 (33%) received IVCYC. No significant differences were identified at 4–8 and 10–14 months post-renal biopsy and last follow-up, in terms of renal British Isles Lupus Assessment Grade scores, urine albumin/creatinine ratio, serum creatinine, ESR, anti-dsDNA antibody, C3 levels and patient/physician global scores. Standardized Damage Index scores did not differ between groups at 13 months or at last follow-up. Inactive LN was attained 262 (141–390) days after MMF treatment, and 151 (117–305) days following IVCYC ( p = 0.17). Time to renal flare was 451 (157–1266) days for MMF, and 343 (198–635) days for IVCYC ( p = 0.47).

Conclusion

This is the largest study to date investigating induction treatments for proliferative LN in children, demonstrating comparability of MMF and IVCYC.

Readmissions after Ileostomy Creation Using a Nationwide Database

Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to more than 30 per cent. The objective of this study was to compare the reasons for early versus intermediate readmissions after surgical procedures involving formation of ileostomies at a national level. Patients receiving a new ileostomy were identified in the 2010 to 2014 Nationwide Readmission Database. Patients were categorized into Early, Intermediate, and Late cohorts (0–7, 8–30, 31–90 days, respectively), based on discharge-to-readmission interval. Of the 76,590 patients undergoing ileostomy creation, 28 per cent were nonelectively rehospitalized within 90 days after discharge: 10 per cent Early, 12 per cent Intermediate, and 7 per cent Late. Compared with the Intermediate cohort, the Early readmissions were more frequently because of anastomotic complications (20% vs 12%, P < 0.001) and gastrointestinal obstruction (10% vs 5%, P < 0.001), whereas Intermediate readmissions were because of renal failure (17% vs 9%, P < 0.001). In the Late group, the most common reason for readmission was renal failure (14%), followed by anastomotic complications (11%), and stoma reversal (8%). In this nationwide study, all-cause 90-day non-elective readmissions after ileostomy procedures occurred in nearly 30 per cent of patients. Although early rehospitalizations were mainly because of surgical complications and gastrointestinal complications, late readmissions were because of ileostomy reversal.

Readmissions after Ileostomy Creation Using a Nationwide Database

Readmissions occur frequently in patients undergoing ostomy creation, ranging from 12 per cent to more than 30 per cent. The objective of this study was to compare the reasons for early versus intermediate readmissions after surgical procedures involving formation of ileostomies at a national level. Patients receiving a new ileostomy were identified in the 2010 to 2014 Nationwide Readmission Database. Patients were categorized into Early, Intermediate, and Late cohorts (0-7, 8-30, 31-90 days, respectively), based on discharge-to-readmission interval. Of the 76,590 patients undergoing ileostomy creation, 28 per cent were nonelectively rehospitalized within 90 days after discharge: 10 per cent Early, 12 per cent Intermediate, and 7 per cent Late. Compared with the Intermediate cohort, the Early readmissions were more frequently because of anastomotic complications (20% vs 12%, P < 0.001) and gastrointestinal obstruction (10% vs 5%, P < 0.001), whereas Intermediate readmissions were because of renal failure (17% vs 9%, P < 0.001). In the Late group, the most common reason for readmission was renal failure (14%), followed by anastomotic complications (11%), and stoma reversal (8%). In this nationwide study, all-cause 90-day nonelective readmissions after ileostomy procedures occurred in nearly 30 per cent of patients. Although early rehospitalizations were mainly because of surgical complications and gastrointestinal complications, late readmissions were because of ileostomy reversal.

Prevalence and predictors of complementary and alternative medicine/non-pharmacological interventions use for menopausal symptoms within the UK Collaborative Trial of Ovarian Cancer Screening

OBJECTIVES

The negative publicity about menopausal hormone therapy (MHT) has led to increased use of complementary and alternative medicines (CAM) and non-pharmacological interventions (NPI) for menopausal symptom relief. We report on the prevalence and predictors of CAM/NPI among UK postmenopausal women.

METHOD

Postmenopausal women aged 50-74 years were invited to participate in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). A total of 202 638 women were recruited and completed a baseline questionnaire. Of these, 136 020 were sent a postal follow-up-questionnaire between September 2006 and May 2009 which included ever-use of CAM/NPI for menopausal symptom relief. Both questionnaires included MHT use.

RESULTS

A total of 88 430 (65.0%) women returned a completed follow-up-questionnaire; 22 206 (25.1%) reported ever-use of one or more CAM/NPI. Highest use was reported for herbal therapies (43.8%; 9725/22 206), vitamins (42.6%; 9458/22 206), lifestyle approaches (32.1%; 7137/22 206) and phytoestrogens (21.6%; 4802/22 206). Older women reported less ever-use of herbal therapies, vitamins and phytoestrogens. Lifestyle approaches, aromatherapy/reflexology/acupuncture and homeopathy were similar across age groups. Higher education, Black ethnicity, MHT or previous oral contraceptive pill use were associated with higher CAM/NPI use. Women assessed as being less hopeful about their future were less likely to use CAM/NPI.

CONCLUSION

One in four postmenopausal women reported ever-use of CAM therapies/NPI for menopausal symptom relief, with lower use reported by older women. Higher levels of education and previous MHT use were positive predictors of CAM/NPI use. UKCTOCS Trial registration: ISRCTN22488978.

Evaluation of the ACR and SLICC classification criteria in juvenile-onset systemic lupus erythematosus: a longitudinal analysis

Objectives The Systemic Lupus International Collaborating Clinics (SLICC) group proposed revised classification criteria for systemic lupus erythematosus (SLICC-2012 criteria). This study aimed to compare these criteria with the well-established American College of Rheumatology classification criteria (ACR-1997 criteria) in a national cohort of juvenile-onset systemic lupus erythematosus (JSLE) patients and evaluate how patients' classification criteria evolved over time. Methods Data from patients in the UK JSLE Cohort Study with a senior clinician diagnosis of probable evolving, or definite JSLE, were analyzed. Patients were assessed using both classification criteria within 1 year of diagnosis and at latest follow up (following a minimum 12-month follow-up period). Results A total of 226 patients were included. The SLICC-2012 was more sensitive than ACR-1997 at diagnosis (92.9% versus 84.1% p < 0.001) and after follow up (100% versus 92.0% p < 0.001). Most patients meeting the SLICC-2012 criteria and not the ACR-1997 met more than one additional criterion on the SLICC-2012. Conclusions The SLICC-2012 was better able to classify patients with JSLE than the ACR-1997 and did so at an earlier stage in their disease course. SLICC-2012 should be considered for classification of JSLE patients in observational studies and clinical trial eligibility.

Use of Alkaline Phosphatase Staining to Differentiate Canine Osteosarcoma from Other Vimentin-positive Tumors

Aspiration of lytic bone lesions is an excellent diagnostic test in the initial evaluation of primary bone neoplasia. However, cytologically, it can be difficult to differentiate osteosarcoma (OSA) from other bone neoplasms, including fibrosarcoma, chondrosarcoma, synovial cell sarcoma, and plasma cell myeloma. The purpose of this study is to determine the sensitivity and specificity of alkaline phosphatase (ALP) staining to differentiate OSA from other tumors that express vimentin by immunocytochemistry or immunohistochemistry. ALP is a hydrolytic enzyme present in multiple tissues including liver, kidney, intestine, placenta, and bone. Hypothetically, neoplasms actively producing bone should be specifically positive for ALP staining. Unstained, cytologic specimens were incubated for 8-10 minutes with nitroblue tetrazolium chloride/5-bromo-4-chloro-3-indolyl phosphate toluidine salt-phosphatase substrate. A positive reaction stains the membrane of the cells gray to black. Samples were counterstained with a Romanowsky's stain to determine whether the sample was of representative cellularity. A total of 61 vimentin-positive neoplasms have been evaluated and confirmed histopathologically. Tumors that expressed vimentin and were positive for ALP included 33 OSAs, one multilobular tumor of bone, one amelanotic melanoma, and one chondrosarcoma. Tumors that expressed vimentin and were negative for ALP included chondrosarcomas (three of four), multiple fibrosarcomas, and multiple synovial cell sarcomas. The sensitivity is 100%, and the specificity is 89%. In conclusion, ALP appears to be a highly sensitive and fairly specific marker in the diagnosis of OSA.

Seroprevalence of human toxocariasis, Jamaica

Seroprevalence of human toxocariasis was studied, based on 1544 samples selected from a total of 3524 submitted to the University of the West Indies in Kingston, Jamaica for diagnosis of dengue during an epidemic in 2010. The prevalence of anti-Toxocara IgG using the CELISA® (Cellabs) ELISA was 21.2% and males (24.4%) were significantly more likely to be exposed than females (17.5%) [χ² =10.4; p=0.001]. No association was foundbetween exposure to Toxocara and area of residence (rural vs. urban) [χ² =0.835; p = 0.409]. Prevalence of infection peaked in adolescents (10-19 years-old) and declined thereafter although a rise in prevalence was seen in older age classes. There was a high prevalence of toxocariasis in Jamaica with significant exposure among school age children with no predilection to either sex. The study will inform future work on elucidating the public health and clinical significance of toxocariasis in Jamaica.

Urodynamics for Prostate Surgery Trial; Randomised Evaluation of Assessment Methods (UPSTREAM) for diagnosis and management of bladder outlet obstruction in men: study protocol for a randomised controlled trial

Background

Lower urinary tract symptoms (LUTS) comprise storage symptoms, voiding symptoms and post-voiding symptoms. Prevalence and severity of LUTS increase with age and the progressive increase in the aged population group has emphasised the importance to our society of appropriate and effective management of male LUTS. Identification of causal mechanisms is needed to optimise treatment and uroflowmetry is the simplest non-invasive test of voiding function. Invasive urodynamics can evaluate storage function and voiding function; however, there is currently insufficient evidence to support urodynamics becoming part of routine practice in the clinical evaluation of male LUTS.

Design

A 2-arm trial, set in urology departments of at least 26 National Health Service (NHS) hospitals in the United Kingdom (UK), randomising men with bothersome LUTS for whom surgeons would consider offering surgery, between a care pathway based on urodynamic tests with invasive multichannel cystometry and a care pathway based on non-invasive routine tests. The aim of the trial is to determine whether a care pathway not including invasive urodynamics is no worse for men in terms of symptom outcome than one in which it is included, at 18 months after randomisation. This primary clinical outcome will be measured with the International Prostate Symptom Score (IPSS). We will also establish whether inclusion of invasive urodynamics reduces rates of bladder outlet surgery as a main secondary outcome.

Discussion

The general population has an increased life-expectancy and, as men get older, their prostates enlarge and potentially cause benign prostatic obstruction (BPO) which often requires surgery. Furthermore, voiding symptoms become increasingly prevalent, some of which may not be due to BPO. Therefore, as the population ages, more operations will be considered to relieve BPO, some of which may not actually be appropriate. Hence, there is sustained interest in the diagnostic pathway and this trial could improve the chances of an accurate diagnosis and reduce overall numbers of surgical interventions for BPO in the NHS. The morbidity, and therapy costs, of testing must be weighed against the cost saving of surgery reduction.

Trial registration

Controlled-trials.com - ISRCTN56164274 (confirmed registration: 8 April 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1087-1) contains supplementary material, which is available to authorized users.

Acute chest pain in contingency operations at a Role 1 facility

Acute chest pain is a common medical presenting complaint which can be difficult to diagnose and treat outside of a fully equipped emergency department. In future contingency operations the number of personnel deployed is likely be smaller, with the medical cover appropriate for the population at risk, such that the deployed medical facilities will be smaller than the Role 3 unit with which we have become familiar over the last 10 years of operations in Afghanistan. Physician involvement in these smaller medical facilities is crucial to maintain clinical effect when dealing with patients presenting with disease and non-battle injury, which can often make up the majority of deployed healthcare work. Patients presenting with chest pain require rapid assessment and stabilisation prior to medical evacuation to a suitable definitive care unit. This article focuses on emergency acute chest pain presentations, non-cardiac causes of chest pain, risk reduction and how contingency will affect patient care.

Hypertension in the military patient

Hypertension and hypertension-related diseases are a leading cause of morbidity and mortality worldwide. A diagnosis of hypertension can have serious occupational implications for military personnel. This article examines the diagnosis and management of hypertension in military personnel, in the context of current international standards. We consider the consequences of hypertension in the military environment and potential military-specific issues relating to hypertension.

The influence of image valence on visual attention and perception of risk in drivers

Currently there is little research into the relationship between emotion and driving in the context of advertising and distraction. Research that has looked into this also has methodological limitations that could be affecting the results rather than emotional processing (Trick et al., 2012). The current study investigated the relationship between image valence and risk perception, eye movements and physiological reactions. Participants watched hazard perception clips which had emotional images from the international affective picture system overlaid onto them. They rated how hazardous or safe they felt, whilst eye movements, galvanic skin response and heart rate were recorded. Results suggested that participants were more aware of potential hazards when a neutral image had been shown, in comparison to positive and negative valenced images; that is, participants showed higher subjective ratings of risk, larger physiological responses and marginally longer fixation durations when viewing a hazard after a neutral image, but this effect was attenuated after emotional images. It appears that emotional images reduce sensitivity to potential hazards, and we suggest that future studies could apply these findings to higher fidelity paradigms such as driving simulators.

Transethnic meta-analysis suggests genetic variation in the HEME pathway influences potassium response in patients treated with hydrochlorothiazide

Hypokalemia is a recognized adverse effect of thiazide diuretic treatment. This phenomenon, which may impair insulin secretion, has been suggested to be a reason for the adverse effects on glucose metabolism associated with thiazide diuretic treatment of hypertension. However, the mechanisms underlying thiazide diuretic-induced hypokalemia are not well understood. In an effort to identify genes or genomic regions associated with potassium response to hydrochlorothiazide, without a priori knowledge of biologic effects, we performed a genome-wide association study and a multiethnic meta-analysis in 718 European- and African-American hypertensive participants from two different pharmacogenetic studies. Single-nucleotide polymorphisms rs10845697 (Bayes factor=5.560) on chromosome 12, near to the HEME binding protein 1 gene, and rs11135740 (Bayes factor=5.258) on chromosome 8, near to the Mitoferrin-1 gene, reached genome-wide association study significance (Bayes factor >5). These results, if replicated, suggest a novel mechanism involving effects of genes in the HEME pathway influencing hydrochlorothiazide-induced renal potassium loss.

Note: efficient generation of optical sidebands at GHz with a high-power tapered amplifier

Two methods using a laser-diode tapered amplifier to produce high-power, high-efficiency optical frequency sidebands over a wide tunable frequency range are studied and compared. For a total output of 500 mW at 811 nm, 20% of the power can be placed in each of the first-order sidebands. Functionality and characterization are presented within the sideband frequency region of 0.8-2.3 GHz, and it is shown that both methods can be applied beyond this frequency range. These methods provide a versatile and effective tool for atomic physics experiments.

Ion current as a precise measure of the loading rate of a magneto-optical trap

We have demonstrated that the ion current resulting from collisions between metastable krypton atoms in a magneto-optical trap can be used to precisely measure the trap loading rate. We measured both the ion current of the abundant isotope 83Kr (isotopic abundance=11%) and the single-atom counting rate of the rare isotope 85Kr (isotopic abundance∼1×10(-11)), and found the two quantities to be proportional at a precision level of 0.9%. This work results in a significant improvement in using the magneto-optical trap as an analytical tool for noble-gas isotope ratio measurements, and will benefit both atomic physics studies and applications in the earth sciences.

Non-organic hearing loss in United Kingdom military personnel

Non-organic hearing loss (NOHL) is a condition in which there is audiometric discrepancy between the real hearing threshold and the measured threshold of the patient, in the absence of any organic disease. It can, rarely, be the manifestation of a somatoform disorder when it is known as conversion deafness. We present a case of conversion deafness diagnosed following a five-year period of apparent fluctuating unilateral hearing loss, and discuss the diagnosis, clinical and occupational considerations of managing this condition in a military environment.

Genome-wide association analyses suggest NELL1 influences adverse metabolic response to HCTZ in African Americans

Hydrochlorothiazide (HCTZ) is one of the most widely prescribed antihypertensive medications. Although it is well known that HCTZ is associated with hyperglycemia and hypertriglyceridemia, the mechanisms underlying these adverse effects are not well understood. We performed a genome-wide association study and meta-analysis of the change in fasting plasma glucose and triglycerides in response to HCTZ from two different clinical trials: the Pharmacogenomic Evaluation of Antihypertensive Responses and the Genetic Epidemiology of Responses to Antihypertensive studies. Two single-nucleotide polymorphisms (rs12279250 and rs4319515 (r²=0.73)), located at 11p15.1 in the NELL1 gene, achieved genome-wide significance for association with change in fasting plasma triglycerides in African Americans, whereby each variant allele was associated with a 28 mg dl⁻¹ increase in the change in triglycerides. NELL1 encodes a cytoplasmic protein that contains epidermal growth factor-like repeats and has been shown to represses adipogenic differentiation. These findings may represent a novel mechanism underlying HCTZ-induced adverse metabolic effects.