How surgical Trainee Research Collaboratives achieve success: a mixed methods study to develop trainee engagement strategies

OBJECTIVES

This study aimed to understand the role of surgical Trainee Research Collaboratives (TRCs) in conducting randomised controlled trials and identify strategies to enhance trainee engagement in trials.

DESIGN

This is a mixed methods study. We used observation of TRC meetings, semi-structured interviews and an online survey to explore trainees' motivations for engagement in trials and TRCs, including barriers and facilitators. Interviews were analysed thematically, alongside observation field notes. Survey responses were analysed using descriptive statistics. Strategies to enhance TRCs were developed at a workshop by 13 trial methodologists, surgical trainees, consultants and research nurses.

SETTING

This study was conducted within a secondary care setting in the UK.

PARTICIPANTS

The survey was sent to registered UK surgical trainees. TRC members and linked stakeholders across surgical specialties and UK regions were purposefully sampled for interviews.

RESULTS

We observed 5 TRC meetings, conducted 32 semi-structured interviews and analysed 73 survey responses. TRCs can mobilise trainees thus gaining wider access to patients. Trainees engaged with TRCs to improve patient care, surgical evidence and to help progress their careers. Trainees valued the TRC infrastructure, research expertise and mentoring. Challenges for trainees included clinical and other priorities, limited time and confidence, and recognition, especially by authorship. Key TRC strategies were consultant support, initial simple rapid studies, transparency of involvement and recognition for trainees (including authorship policies) and working with Clinical Trials Units and research nurses. A 6 min digital story on YouTube disseminated these strategies.

CONCLUSION

Trainee surgeons are mostly motivated to engage with trials and TRCs. Trainee engagement in TRCs can be enhanced through building relationships with key stakeholders, maximising multi-disciplinary working and offering training and career development opportunities.

Patient-centred outcomes of imaging tests: recommendations for patients, clinicians and researchers

BACKGROUND

Imaging tests are one of the most frequently used diagnostic modalities in healthcare, but the benefits of their direct impacts on clinical decision-making have been countered by concerns that they can be overused. Assessing the relative value of imaging tests has largely focused on measures of test accuracy, which overlooks more comprehensive benefits and risks of imaging tests, particularly their impact on patient-centred outcomes (PCOs). We present the findings of the Patient Reported Outcomes of Diagnostics (PROD) research study in response to a methodological gap in the area of diagnostic test comparative effectiveness research.

METHODS

Over a 3-year period, the PROD Study engaged with multiple stakeholders to identify existing conceptual models related to PCOs for imaging testing, conducted primary research and evidence synthesis, and developed consensus recommendations to describe and categorise PCOs related to imaging testing.

RESULTS

The PROD framework categorises PCOs from imaging studies within four main domains: information or knowledge yielded, physical impact, emotional outcomes and test burden. PCOs interact with each other and influence effects across domains, and can be modified by factors related to the patient, clinical situation, healthcare team and the testing environment.

CONCLUSIONS

Using PCOs to inform healthcare decision-making will require ways of collating and presenting information on PCOs in ways that can inform patient-provider decision-making, and developing methods to determine the relative importance of outcomes (including test accuracy) to one another.

Agreement between patient's description of abdominal symptoms of possible upper gastrointestinal cancer and general practitioner consultation notes: a qualitative analysis of video-recorded UK primary care consultation data

INTRODUCTION

Abdominal symptoms are common in primary care but infrequently might be due to an upper gastrointestinal (UGI) cancer. Patients' descriptions may differ from medical terminology used by general practitioners (GPs). This may affect how information about abdominal symptoms possibly due to an UGI cancer are documented, creating potential missed opportunities for timely investigation.

OBJECTIVES

To explore how abdominal symptoms are communicated during primary care consultations, and identify characteristics of patients' descriptions that underpin variation in the accuracy and completeness with which they are documented in medical records.

METHODS AND ANALYSIS

Primary care consultation video recordings, transcripts and medical records from an existing dataset were screened for adults reporting abdominal symptoms. We conducted a qualitative content analysis to capture alignments (medical record entries matching patient verbal and non-verbal descriptions) and misalignments (symptom information omitted or differing from patient descriptions). Categories were informed by the Calgary-Cambridge guide's 'gathering information' domains and patterns in descriptions explored.

RESULTS

Our sample included 28 consultations (28 patients with 18 GPs): 10 categories of different clinical features of abdominal symptoms were discussed. The information GPs documented about these features commonly did not match what patients described, with misalignments more common than alignments (67 vs 43 instances, respectively). Misalignments often featured patients using vague descriptors, figurative speech, lengthy explanations and broad hand gestures. Alignments were characterised by patients using well-defined terms, succinct descriptions and precise gestures for symptoms with an exact location. Abdominal sensations reported as 'pain' were almost always documented compared with expressions of 'discomfort'.

CONCLUSIONS

Abdominal symptoms that are well defined or communicated as 'pain' may be more salient to GPs than those expressed vaguely or as 'discomfort'. Variable documentation of abdominal symptoms in medical records may have implications for the development of clinical decision support systems and decisions to investigate possible UGI cancer.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

Role of primary care physician factors on diagnostic testing and referral decisions for symptoms of possible cancer: a systematic review

BACKGROUND

Missed opportunities for diagnosing cancer cause patients harm and have been attributed to suboptimal use of tests and referral pathways in primary care. Primary care physician (PCP) factors have been suggested to affect decisions to investigate cancer, but their influence is poorly understood.

OBJECTIVE

To synthesise evidence evaluating the influence of PCP factors on decisions to investigate symptoms of possible cancer.

METHODS

We searched MEDLINE, Embase, Scopus, CINAHL and PsycINFO between January 1990 and March 2021 for relevant citations. Studies examining the effect or perceptions and experiences of PCP factors on use of tests and referrals for symptomatic patients with any cancer were included. PCP factors comprised personal characteristics and attributes of physicians in clinical practice.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal and data extraction were undertaken independently by two authors. Due to study heterogeneity, data could not be statistically pooled. We, therefore, performed a narrative synthesis.

RESULTS

29 studies were included. Most studies were conducted in European countries. A total of 11 PCP factors were identified comprising modifiable and non-modifiable factors. Clinical judgement of symptoms as suspicious or 'alarm' prompted more investigations than non-alarm symptoms. 'Gut feeling' predicted a subsequent cancer diagnosis and was perceived to facilitate decisions to investigate non-specific symptoms as PCP experience increased. Female PCPs investigated cancer more than male PCPs. The effect of PCP age and years of experience on testing and referral decisions was inconclusive.

CONCLUSIONS

PCP interpretation of symptoms as higher risk facilitated testing and referral decisions for possible cancer. However, in the absence of 'alarm' symptoms or 'gut feeling', PCPs may not investigate cancer. PCPs require strategies for identifying patients with non-alarm and non-specific symptoms who need testing or referral.

PROSPERO REGISTRATION NUMBER

CRD420191560515.

Effectiveness of Smartphone-Based Community Case Management on the Urgent Referral, Reconsultation, and Hospitalization of Children Aged Under 5 Years in Malawi: Cluster-Randomized, Stepped-Wedge Trial

Background

Integrated community case management (CCM) has led to reductions in child mortality in Malawi resulting from illnesses such as malaria, pneumonia, and diarrhea. However, adherence to CCM guidelines is often poor, potentially leading to inappropriate clinical decisions and poor outcomes. We determined the impact of an e-CCM app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi.

Objective

We determined the impact of an electronic version of a smartphone-based CCM (e-CCM) app on the referral, reconsultation, and hospitalization rates of children presenting to village clinics in Malawi.

Methods

We used a stepped-wedge, cluster-randomized trial to compare paper-based CCM (control) with and without the use of an e-CCM app on smartphones from November 2016 to February 2017. A total of 102 village clinics from 2 districts in northern Malawi were assigned to 1 of 6 clusters, which were randomized on the sequencing of the crossover from the control phase to the intervention phase as well as the duration of exposure in each phase. Children aged ≥2 months to <5 years who presented with acute illness were enrolled consecutively by health surveillance assistants. The primary outcome of urgent referrals to higher-level facilities was evaluated by using multilevel mixed effects models. A logistic regression model with the random effects of the cluster and the fixed effects for each step was fitted. The adjustment for potential confounders included baseline factors, such as patient age, sex, and the geographical location of the village clinics. Calendar time was adjusted for in the analysis.

Results

A total of 6965 children were recruited—49.11% (3421/6965) in the control phase and 50.88% (3544/6965) in the intervention phase. After adjusting for calendar time, children in the intervention phase were more likely to be urgently referred to a higher-level health facility than children in the control phase (odds ratio [OR] 2.02, 95% CI 1.27-3.23; P=.003). Overall, children in the intervention arm had lower odds of attending a repeat health surveillance assistant consultation (OR 0.45, 95% CI 0.34-0.59; P<.001) or being admitted to a hospital (OR 0.75, 95% CI 0.62-0.90; P=.002), but after adjusting for time, these differences were not significant (P=.07 for consultation; P=.30 for hospital admission).

Conclusions

The addition of e-CCM decision support by using smartphones led to a greater proportion of children being referred to higher-level facilities, with no apparent increase in hospital admissions or repeat consultations in village clinics. Our findings provide support for the implementation of e-CCM tools in Malawi and other low- and middle-income countries with a need for ongoing assessments of effectiveness and integration with national digital health strategies.

Trial Registration

ClinicalTrials.gov NCT02763345; https://clinicaltrials.gov/ct2/show/NCT02763345

Thermodynamic model of the coupled valence and spin state transition in cobaltates

A class of cobalt-based oxides exhibits a peculiar type of transition, entangling valence and spin state degrees of freedom of 4f and 3d elements. It constitutes one of the most spectacular illustrations of the interplay between charge, spin and lattice degrees of freedom in strongly correlated materials. In this work, we present a thermodynamic model capable to reproduce the main features of this transition. Our approach is based on the minimization of a free energy combining the contributions of two sublattices and the interaction between them. The coupling energies introduced in the model are related to well-known chemical pressure effects in the perovskite structure. The results of this model are compared to experimental data derived from x-ray absorption spectroscopy.

Identifying Ovarian Cancer in Symptomatic Women: A Systematic Review of Clinical Tools

Simple Summary

Most women with ovarian cancer are diagnosed after they develop symptoms—identifying symptomatic women earlier has the potential to improve outcomes. Tools, ranging from simple symptom checklists to diagnostic prediction models that incorporate tests and risk factors, have been developed to help identify women at increased risk of undiagnosed ovarian cancer. In this review, we systematically identified studies evaluating these tools and then compared the reported diagnostic performance of tools. All included studies had some quality concerns and most tools had only been evaluated in a single study. However, four tools were evaluated in multiple studies and showed moderate diagnostic performance, with relatively little difference in performance between tools. While encouraging, further large and well-conducted studies are needed to ensure these tools are acceptable to patients and clinicians, are cost-effective and facilitate the early diagnosis of ovarian cancer.

Abstract

In the absence of effective ovarian cancer screening programs, most women are diagnosed following the onset of symptoms. Symptom-based tools, including symptom checklists and risk prediction models, have been developed to aid detection. The aim of this systematic review was to identify and compare the diagnostic performance of these tools. We searched MEDLINE, EMBASE and Cochrane CENTRAL, without language restriction, for relevant studies published between 1 January 2000 and 3 March 2020. We identified 1625 unique records and included 16 studies, evaluating 21 distinct tools in a range of settings. Fourteen tools included only symptoms; seven also included risk factors or blood tests. Four tools were externally validated—the Goff Symptom Index (sensitivity: 56.9–83.3%; specificity: 48.3–98.9%), a modified Goff Symptom Index (sensitivity: 71.6%; specificity: 88.5%), the Society of Gynaecologic Oncologists consensus criteria (sensitivity: 65.3–71.5%; specificity: 82.9–93.9%) and the QCancer Ovarian model (10% risk threshold—sensitivity: 64.1%; specificity: 90.1%). Study heterogeneity precluded meta-analysis. Given the moderate accuracy of several tools on external validation, they could be of use in helping to select women for ovarian cancer investigations. However, further research is needed to assess the impact of these tools on the timely detection of ovarian cancer and on patient survival.

Relationship between microbiology of throat swab and clinical course among primary care patients with acute cough: a prospective cohort study

BACKGROUND

Acute lower respiratory tract infections (ALRTIs) account for most antibiotics prescribed in primary care despite lack of efficacy, partly due to clinician uncertainty about aetiology and patient concerns about illness course. Nucleic acid amplification tests could assist antibiotic targeting.

METHODS

In this prospective cohort study, 645 patients presenting to primary care with acute cough and suspected ALRTI, provided throat swabs at baseline. These were tested for respiratory pathogens by real-time polymerase chain reaction and classified as having a respiratory virus, bacteria, both or neither. Three hundred fifty-four participants scored the symptoms severity daily for 1 week in a diary (0 = absent to 4 = severe problem).

RESULTS

Organisms were identified in 346/645 (53.6%) participants. There were differences in the prevalence of seven symptoms between the organism groups at baseline. Those with a virus alone, and those with both virus and bacteria, had higher average severity scores of all symptoms combined during the week of follow-up than those in whom no organisms were detected [adjusted mean differences 0.204 (95% confidence interval 0.010 to 0.398) and 0.348 (0.098 to 0.598), respectively]. There were no differences in the duration of symptoms rated as moderate or severe between organism groups.

CONCLUSIONS

Differences in presenting symptoms and symptoms severity can be identified between patients with viruses and bacteria identified on throat swabs. The magnitude of these differences is unlikely to influence management. Most patients had mild symptoms at 7 days regardless of aetiology, which could inform patients about likely symptom duration.

Qualitative study to explore radiologist and radiologic technologist perceptions of outcomes patients experience during imaging in the USA

OBJECTIVE

We aimed to explore the patient-centred outcomes (PCOs) radiologists and radiologic technologists perceive to be important to patients undergoing imaging procedures.

DESIGN

We conducted a qualitative study of individual semi-structured interviews.

PARTICIPANTS

We recruited multiple types of radiologists including general, musculoskeletal neuroradiology, body and breast imagers as well as X-ray, ultrasound, CT or MRI radiologic technologists from Washington and Idaho.

OUTCOME

Thematic analysis was conducted to identify themes and subthemes related to PCOs of imaging procedures.

RESULTS

Ten radiologists and six radiology technologists participated. Four main domains of PCOs were identified: emotions, physical factors, knowledge and patient burden. In addition to these outcomes, we also identified patient and provider factors that can potentially moderate these outcomes.

CONCLUSIONS

Radiologists and technologists perceived outcomes related to the effect of imaging procedures on patients' emotions, physical well-being, knowledge and burden from financial and opportunity costs to be important to patients undergoing imaging procedures. There are opportunities for the radiology community to measure and use these PCOs in comparisons of imaging procedures and potentially identify areas where these outcomes can be leveraged to drive a more patient-centred approach to radiology.

Sustainability of 'mHealth' interventions in sub- Saharan Africa: a stakeholder analysis of an electronic community case management project in Malawi

Background

The global health community and funding agencies are currently engaged in ensuring that worthwhile research-based programmes are sustainable. Despite its importance, few studies have analysed the sustainability of global health interventions. In this paper, we aim to explore barriers and facilitators for the wider implementation and sustainability of a mobile health (mHealth) intervention (Supporting LIFE Community Case Management programme) in Malawi, Africa.

Methods

Between January and March 2017, a qualitative approach was used to carry out and analyse 13 in-depth semi-structured interviews with key stakeholders across all levels of healthcare provision in Malawi to explore their perceptions with regards to the implementation and sustainability of the mHealth programme. Data were analysed thematically by two reviewers.

Results

Overall, our analysis found that the programme was successful in achieving its goals. However, there are many challenges to the wider implementation and sustainability of this programme, including the absence of monetary resources, limited visibility outside the healthcare sector, the lack of integration with community-based and nationwide programmes, services and information and communication technologies, and the limited local capacity in relation to the maintenance, further development, and management.

Conclusions

Future developments should be aligned with the strategic goals and interests of the Ministry of Health and engage with national and international stakeholders to develop shared goals and strategies for nationwide scale-up. These developments should also focus on building local capacity by educating trainers and ensuring that training methods and guidelines are appropriately accredited based on national policies. Our findings provide a framework for a variety of stakeholders who are engaged in sustaining mHealth programmes in resource-poor settings and can be used to develop an evidence-based policy for the utilization of technology for healthcare delivery across developing countries.

Considerations for Improved Mobile Health Evaluation: Retrospective Qualitative Investigation

BACKGROUND

Mobile phone use and, consequently, mobile health (mHealth) interventions have seen an exponential increase in the last decade. There is an excess of 318,000 health-related apps available free of cost for consumers to download. However, many of these interventions are not evaluated and are lacking appropriate regulations. Randomized controlled trials are often considered the gold standard study design in determining the effectiveness of interventions, but recent literature has identified limitations in the methodology when used to evaluate mHealth.

OBJECTIVE

The objective of this study was to investigate the system developers' experiences of evaluating mHealth interventions in the context of a developing country.

METHODS

We employed a qualitative exploratory approach, conducting semistructured interviews with multidisciplinary members of an mHealth project consortium. A conventional content analysis approach was used to allow codes and themes to be identified directly from the data.

RESULTS

The findings from this study identified the system developers' perceptions of mHealth evaluation, providing an insight into the requirements of an effective mHealth evaluation. This study identified social and technical factors which should be taken into account when evaluating an mHealth intervention.

CONCLUSIONS

Contextual issues represented one of the most recurrent challenges of mHealth evaluation in the context of a developing country, highlighting the importance of a mixed method evaluation. There is a myriad of social, technical, and regulatory variables, which may impact the effectiveness of an mHealth intervention. Failure to account for these variables in an evaluation may limit the ability of the intervention to achieve long-term implementation and scale.

Patient-Centered Outcomes From Multiparametric MRI and MRI-Guided Biopsy for Prostate Cancer: A Systematic Review

Objective

To identify and characterize patient-centered outcomes (PCOs) relating to multiparametric MRI (mpMRI) and MRI-guided biopsy as diagnostic tests for possible prostate cancer.

Methods

Medline via OVID, EMBASE, PsycInfo, and the Cochrane Central register of Controlled Trials (CENTRAL) were searched for relevant articles. Hand searching of reference lists and snowballing techniques were performed. Studies of mpMRI and MRI-guided biopsy that measured any PCO were included. There were no restrictions placed on year of publication, language, or country for study inclusion. All database search hits were screened independently by two reviewers, and data were extracted using a standardized form.

Results

Overall, 2,762 database search hits were screened based on title and abstract. Of these, 222 full-text articles were assessed, and 10 studies met the inclusion criteria. There were 2,192 participants featured in the included studies, all of which were conducted in high-income countries. Nineteen different PCOs were measured, with a median of four PCOs per study (range 1-11). Urethral bleeding, pain, and urinary tract infection were the most common outcomes measured. In the four studies that compared mpMRI or MRI-guided biopsy to transrectal ultrasound biopsy, most adverse outcomes occurred less frequently in MRI-related tests. These four studies were assessed as having a low risk of bias.

Discussion

PCOs measured in studies of mpMRI or MRI-guided biopsy thus far have mostly been physical outcomes, with some evidence that MRI tests are associated with less frequent adverse outcomes compared with transrectal ultrasound biopsy. There was very little evidence for the effect of mpMRI and MRI-guided biopsy on emotional, cognitive, social, or behavioral outcomes.

Fermi- to non-Fermi-liquid crossover and Kondo behavior in two-dimensional (Cu2/3V1/3)V2S4

By means of a specific heat (C) and electrical resistivity ([Formula: see text]) study, we give evidence of a pronounced Fermi liquid (FL) behavior with sizable mass renormalization, [Formula: see text], up to unusually high temperatures  ∼70 K in the layered system (Cu_2/3V_1/3)V₂S₄. At low temperature, a marked upturn of both C and [Formula: see text] is suppressed by magnetic field, which suggests a picture of Kondo coupling between conduction electrons in the VS₂ layers and impurity spins of the V³⁺ ions located between layers. This picture opens the possibility of controlling electronic correlations and the FL to non-FL crossover in simple layered materials. For instance, we envisage that the coupling between layers provided by the impurity spins may realize a two-channel Kondo state.

Patient-Centered Outcomes Related to Imaging Testing in US Primary Care

BACKGROUND

Imaging tests are one of the most sophisticated types of diagnostic tools used in health care, yet there are concerns that imaging is overused. Currently, tests are typically evaluated and implemented based on their accuracy, and there is limited knowledge about the range of patient-centered outcomes (PCOs) that imaging tests may lead to. This study explores patients' experiences and subsequent outcomes of imaging tests most notable to patients.

METHODS

Adult patients from four primary care clinics who had an x-ray, CT, MRI, or ultrasound in the 12 months before recruitment participated in a single semistructured interview to recount their imaging experience. Interview transcripts were analyzed thematically.

RESULTS

Four themes related to PCOs were identified from 45 interviews. Participants' mean age was 53 years (25-83 years), 30 had undergone a diagnostic imaging test, and 15 underwent imaging for screening or monitoring. Themes included knowledge gained from the imaging test, its contribution to their overall health care journey, physical experiences during the test procedure, and impacts of the testing process on emotions.

CONCLUSIONS

Patients identified various imaging test outcomes that were important to them. Measurement and reporting these outcomes should be considered more often in diagnostic research. Tools for providers and patients to discuss and utilize these outcomes may help promote shared decision making around the use and impact of imaging tests.

Training community healthcare workers on the use of information and communication technologies: a randomised controlled trial of traditional versus blended learning in Malawi, Africa

BACKGROUND

Despite the increasing uptake of information and communication technologies (ICT) within healthcare services across developing countries, community healthcare workers (CHWs) have limited knowledge to fully utilise computerised clinical systems and mobile apps. The 'Introduction to Information and Communication Technology and eHealth' course was developed with the aim to provide CHWs in Malawi, Africa, with basic knowledge and computer skills to use digital solutions in healthcare delivery. The course was delivered using a traditional and a blended learning approach.

METHODS

Two questionnaires were developed and tested for face validity and reliability in a pilot course with 20 CHWs. Those were designed to measure CHWs' knowledge of and attitudes towards the use of ICT, before and after each course, as well as their satisfaction with each learning approach. Following validation, a randomised controlled trial was conducted to assess the effectiveness of the two learning approaches. A total of 40 CHWs were recruited, stratified by position, gender and computer experience, and allocated to the traditional or blended learning group using block randomisation. Participants completed the baseline and follow-up questionnaires before and after each course to assess the impact of each learning approach on their knowledge, attitudes, and satisfaction. Per-item, pre-post and between-group, mean differences for each approach were calculated using paired and unpaired t-tests, respectively. Per-item, between-group, satisfaction scores were compared using unpaired t-tests.

RESULTS

Scores across all scales improved after attending the traditional and blended learning courses. Self-rated ICT knowledge was significantly improved in both groups with significant differences between groups in seven domains. However, actual ICT knowledge scores were similar across groups. There were no significant differences between groups in attitudinal gains. Satisfaction with the course was generally high in both groups. However, participants in the blended learning group found it more difficult to follow the content of the course.

CONCLUSIONS

This study shows that there is no difference between blended and traditional learning in the acquisition of actual ICT knowledge among community healthcare workers in developing countries. Given the human resource constraints in remote resource-poor areas, the blended learning approach may present an advantageous alternative to traditional learning.

The added value of a mobile application of Community Case Management on referral, re-consultation and hospitalization rates of children aged under 5 years in two districts in Northern Malawi: study protocol for a pragmatic, stepped-wedge cluster-randomized controlled trial

Background

There is evidence to suggest that frontline community health workers in Malawi are under-referring children to higher-level facilities. Integrating a digitized version of paper-based methods of Community Case Management (CCM) could strengthen delivery, increasing urgent referral rates and preventing unnecessary re-consultations and hospital admissions. This trial aims to evaluate the added value of the Supporting LIFE electronic Community Case Management Application (SL eCCM App) compared to paper-based CCM on urgent referral, re-consultation and hospitalization rates, in two districts in Northern Malawi.

Methods/design

This is a pragmatic, stepped-wedge cluster-randomized trial assessing the added value of the SL eCCM App on urgent referral, re-consultation and hospitalization rates of children aged 2 months and older to up to 5 years, within 7 days of the index visit. One hundred and two health surveillance assistants (HSAs) were stratified into six clusters based on geographical location, and clusters randomized to the timing of crossover to the intervention using simple, computer-generated randomization. Training workshops were conducted prior to the control (paper-CCM) and intervention (paper-CCM + SL eCCM App) in assigned clusters. Neither participants nor study personnel were blinded to allocation. Outcome measures were determined by abstraction of clinical data from patient records 2 weeks after recruitment. A nested qualitative study explored perceptions of adherence to urgent referral recommendations and a cost evaluation determined the financial and time-related costs to caregivers of subsequent health care utilization. The trial was conducted between July 2016 and February 2017.

Discussion

This is the first large-scale trial evaluating the value of adding a mobile application of CCM to the assessment of children aged under 5 years. The trial will generate evidence on the potential use of mobile health for CCM in Malawi, and more widely in other low- and middle-income countries.

Trial registration

ClinicalTrials.gov, ID: NCT02763345. Registered on 3 May 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2213-z) contains supplementary material, which is available to authorized users.

Qualitative study of primary care clinicians' views on point-of-care testing for C-reactive protein for acute respiratory tract infections in family medicine

OBJECTIVE

To explore clinicians views of the barriers and facilitators to use of C-reactive protein (CRP) point-of-care tests (POCT) in US family medicine clinics for the management of acute respiratory tract infections (ARTIs) in adults.

SETTING

Five family medicine clinics across two US states.

PARTICIPANTS

30 clinicians including 18 physicians, 9 physician residents, 2 physician assistants and 1 nurse practitioner, took part in the study.

DESIGN

A qualitative study using a grounded theory approach to thematically analyse focus group interviews.

RESULTS

These clinicians had limited access to diagnostic tests for patients with ARTI, and very little knowledge of CRP POCT. Three major themes were identified and included the potential clinical role of CRP POCT, concerns related to implementing CRP POCT and evidence needed prior to wider adoption in family medicine. Clinicians believed CRP POCT could support decision-making for some presentations of ARTIs and patient populations when used in conjunction with clinical criteria. Clinicians had concerns about possible overuse and inaccuracy of CRP POCT which they believed might increase antibiotic prescribing rates. Other concerns identified included integration of the test with clinic workflows and cost-effectiveness.

CONCLUSIONS

Clinicians stand at the forefront of antibiotic stewardship efforts, but have few diagnostic tests to help them confidently manage ARTIs. CRP POCT may facilitate some aspects of clinical practice. Incorporating CRP POCT with clinical guidelines may strengthen utility of this test, when there is diagnostic uncertainty.

Exploring the barriers and facilitators to use of point of care tests in family medicine clinics in the United States

Background

Point-of-care tests (POCTs) are increasingly used in family medicine clinics in the United States. While the diagnostics industry predicts significant growth in the number and scope of POCTs deployed, little is known about clinic-level attitudes towards implementation of these tests. We aimed to explore attitudes of primary care providers, laboratory and clinic administrative/support staff to identify barriers and facilitators to use of POCTs in family medicine.

Methods

Seven focus groups and four semi-structured interviews were conducted with a total of 52 clinic staff from three family medicine clinics in two US states. Qualitative data from this exploratory study was analyzed using the constant comparison method.

Results

Five themes were identified which included the impact of POCTs on clinical decision-making; perceived inaccuracy of POCTs; impact of POCTs on staff and workflow; perceived patient experience and patient-provider relationship, and issues related to cost, regulation and quality control. Overall, there were mixed attitudes towards use of POCTs. Participants believed the added data provided by POCT may facilitate prompt clinical management, diagnostic certainty and patient-provider communication.

Perceived barriers included inaccuracy of POCT, shortage of clinic staff to support more testing, and uncertainty about their cost-effectiveness.

Conclusions

The potential benefits of using POCTs in family medicine clinics are countered by several barriers. Clinical utility of many POCTs will depend on the extent to which these barriers are addressed. Engagement between clinical researchers, industry, health insurers and the primary care community is important to ensure that POCTs align with clinic and patient needs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-016-0549-1) contains supplementary material, which is available to authorized users.

Jumps in entropy and magnetic susceptibility at the valence and spin-state transition in a cobalt oxide

A wide family of cobalt oxides of formulation (Pr(1-y)Ln(y))(1-x)Ca(x)CoO3 (Ln being a lanthanide) exhibits a coupled valence and spin-state transition (VSST) at a temperature T*, which involves two concomitant modifications: (i) a change in the spin state of Co(3+) from low-spin (T < T*) to a higher spin state (T > T*) and (ii) a change in the valence state of Pr, from a mixed Pr(4+)/Pr(3+) state (T < T*) to a purely trivalent state (T > T*), accompanied by an ~ 90 K is investigated by magnetization and heat capacity measurements.First, we quantitatively characterized the jumps in magnetic susceptibility (χ) and entropy (S) around T*. Then, these values were compared to those calculated as a function of the variations in the population of the different cationic species involved in the VSST. X-ray absorption spectroscopy experiments recently showed that the higher spin state above T* should be regarded as an inhomogeneous mixture between low-spin (LS) and high-spin (HS) states. In the frame of this description, we demonstrate that the jumps in both χ and S can be associated with the same change in the Co(3+) HS content around T*. This result lends further support to the relevance of the LS/HS picture for the VSST, challenging the currently dominant interpretation based on the occurrence of an intermediate-spin (IS) state of Co(3+) above T*.

Brief interventions for heavy alcohol users admitted to general hospital wards

BACKGROUND

Brief interventions involve a time-limited intervention focusing on changing behaviour. They are often motivational in nature using counselling skills to encourage a reduction in alcohol consumption.

OBJECTIVES

To determine whether brief interventions reduce alcohol consumption and improve outcomes for heavy alcohol users admitted to general hospital inpatient units.

SEARCH STRATEGY

We searched the Cochrane Drug and Alcohol Group Register of Trials (March 2011) the Cochrane Central Register of Controlled Trials (The Cochrane Library March 2011), MEDLINE January 1966-March 2011, CINAHL 1982-March 2011, EMBASE 1980-March 2011 and www.clinicaltrials.gov to April 2011 and performed some relevant handsearching.

SELECTION CRITERIA

All prospective randomised controlled trials and controlled clinical trials were eligible for inclusion. Participants were adults and adolescents (16 years or older) admitted to general inpatient hospital care for any reason other than specifically for alcohol treatment and received brief interventions (of up to 3 sessions) compared to no or usual care.

DATA COLLECTION AND ANALYSIS

Three reviewers independently selected the studies and extracted data. Where appropriate random effects meta-analysis and sensitivity analysis were performed.

MAIN RESULTS

Forteen studies involving 4041 mainly male participants were included. Our results demonstrate that patients receiving brief interventions have a greater reduction in alcohol consumption compared to those in control groups at six month, MD -69.43 (95% CI -128.14 to -10.72) and nine months follow up, MD -182.88 (95% CI -360.00 to -5.76) but this is not maintained at one year. Self reports of reduction of alcohol consumption at 1 year were found in favour of brief interventions, SMD -0.26 (95% CI -0.50 to -0.03). In addition there were significantly fewer deaths in the groups receiving brief interventions than in control groups at 6 months, RR 0.42 (95% CI 0.19 to 0.94) and one year follow up, RR 0.60 (95% CI 0.40 to 0.91). Furthermore screening, asking participants about their drinking patterns, may also have a positive impact on alcohol consumption levels and changes in drinking behaviour.

AUTHORS' CONCLUSIONS

The main results of this review indicate that there are benefits to delivering brief interventions to heavy alcohol users admitted to general hospital wards in terms of reduction in alcohol consumption and death rates. However, these findings are based on studies involving mainly male participants. Further research is required determine the optimal content and treatment exposure of brief interventions within general hospital settings and whether they are likely to be more successful in patients with certain characteristics.

Magnetocaloric effect and improved relative cooling power in (La(0.7)Sr(0.3)MnO(3)/SrRuO(3)) superlattices

Magnetic properties of a series of (La(0.7)Sr(0.3)MnO(3)/SrRuO(3)) superlattices, where the SrRuO(3) layer thickness is varying, are examined. A room-temperature magnetocaloric effect is obtained owing to the finite size effect which reduces the T(C) of La(0.7)Sr(0.3)MnO(3) layers. While the working temperature ranges are enlarged, - ΔS(M)(max) values remain similar to the values in polycrystalline La(0.7)Sr(0.3)MnO(3). Consequently, the relative cooling powers are significantly improved, the microscopic mechanism of which is related to the effect of the interfaces at La(0.7)Sr(0.3)MnO(3)/SrRuO(3) and higher nanostructural disorder. This study indicates that artificial oxide superlattices/multilayers might provide an alternative pathway in searching for efficient room-temperature magnetic refrigerator for (nano) micro-scale systems.

Emergency preparedness and disaster recovery in the US post 9/11

Purpose

The purpose of this paper is to determine how facility managers currently plan for emergencies and disaster recovery. Although preparation and drills have been demonstrated to improve lifesaving and business recovery capabilities, many organisations still do not have these plans. The scope of unpreparedness and reasons for lack of preparation were key issues, along with preferred methods to gain support for setting up plans.

Design/methodology/approach

Online surveys sent to members of facility management (FM) groups within the USA were utilised. Qualified FM professionals made them relevant survey groups.

Findings

With 78 percent of respondents responsible for their organisation's emergency preparedness planning, only 87 percent in 2007 and 92 percent in 2008 actually have these plans in place. Reasons for lack of plans included “other priorities taking precedence” and “lack of personnel to address the issue”. Provision of sample or boilerplate templates could result in improved performance.

Research limitations/implications

US FM professionals were surveyed. Results in non‐US locations may provide different information; locations with strong mandates for emergency/disaster plans would be expected to have better results. Industry types were not identified in this initial research data; however, future research could help to align specific industries' needs.

Practical implications

Despite 11 September and other tragedies, many organisations are still delaying or not understanding the importance of emergency/disaster recovery plans for their employees and business continuity.

Originality/value

Direct feedback from FM professionals was utilised to understand emergency preparedness/disaster recovery planning. This is the first survey to report details of the many organisations still lacking these critical plans.

Scaling behavior in thermoelectric misfit cobalt oxides

We investigate both thermoelectric and thermodynamic properties of the misfit cobalt oxide [Bi1.7Co0.3Ca2O4]RS0.6CoO2. A large negative magnetothermopower is found to scale with both magnetic field and temperature, revealing a significant spin entropy contribution to thermoelectric properties giving rise to a constant S0 approximately 60 microV K-1. Specific heat measurements allow us to determine an enhanced electronic part with gamma approximately 50 mJ (mol K2)-1 attesting to strong correlations. Thereby, the comparison between cobaltites and other materials reveals a universal behavior of the thermopower slope as a function of gamma, testifying to a purely electronic origin. This potentially generic scaling behavior suggests here that the high room temperature value of the thermopower in misfit cobalt oxides results from the addition of a spin entropy contribution to an enlarged electronic one.

Gingival attachment level measurements with an automated periodontal probe

The accurate and reproducible measurement of gingival attachment level is essential for studying the progression of periodontitis in human populations. An automated periodontal probe has been developed which measures gingival attachment level using the occlusal or incisal surface of the tooth as a fixed landmark and which transfers data directly to a computer. The probing force is adjustable and is regulated by changing the air pressure. A mercury level switch maintains uniform probe angulation during measurements. The reproducibility of measurements obtained with the automated periodontal probe was examined by making duplicate gingival attachment level measurements at 784 sites in 9 patients 1 week apart and comparing the difference between the paired values. A probing force of 0.30 N was used. There was no significant difference in the frequency distributions of measurement differences between either maxillary versus mandibular teeth or anterior versus posterior teeth. The data demonstrate that this device can be used to measure gingival attachment level without the need for stents or estimation of the level of the cementoenamel junction and that reproducible data can be obtained and automatically stored in a computer for subsequent analysis.