Factors that influence the quality of the clinical supervision experience in a first contact physiotherapy (FCP) role - The perspectives of supervisors and supervisees - A qualitative analysis

PURPOSE

First contact practitioner (FCP) roles have been developed to supplement the primary care workforce in managing the burden of musculoskeletal conditions. In order to quality assure and standardise capability of these clinicians an educational framework was developed by NHS England. The Roadmap to Practice (2020) was the curriculum designed to support and develop capability for FCP roles. This secondary analysis of a broader research project aimed to understand the factors affecting the supervisory experience from both a supervisor and supervisee perspective.

METHODS

A qualitative design using group interviews and an online survey was utilised to examine the experiences of these clinicians on their journey navigating and supporting the Roadmap to Practice portfolio process.

FINDINGS

Three principal themes were identified that affected the supervisory process; preparation of both supervisors and supervisee; the person (supervisor) and the practicalities associated with supervision.

CONCLUSION

There were numerous factors influencing the quality of clinical supervision. Adequate preparation of the supervisor and supervisee is critical to success. The attributes of the supervisor were important in the enhancing the quality of supervisory process. Time afforded to undertake supervision and access to appropriate supervisors need to be adequate and accounted for in workforce planning. A paradigm shift in workplace culture is required so clinical supervision is seen as an integral component in maintaining quality and assuring patient safety.

Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence

Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

AIMS AND METHOD

Serious incident management and organisational learning are international patient safety priorities. Little is known about the quality of suicide investigations and, in turn, the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time.

RESULTS

Recent literature proposes a safety-II approach in response to the limitations of RCA. The importance of applying these approaches within a mental healthcare system that advocates a zero suicide framework, grounded in a restorative just culture, is highlighted.

CLINICAL IMPLICATIONS

Although integrative reviews and syntheses have clear methodological limitations, this approach facilitates the management of a disparate body of work to advance a critical understanding of patient safety in adult community mental healthcare.

Retrospective evaluation of acute kidney injury in horses treated with nonnitrogenous bisphosphonates (2013-2020): 8 cases

OBJECTIVE

To describe a population of horses with acute kidney injury (AKI) following administration of bisphosphonates including clinical signs, clinicopathologic data, treatment, and outcome.

DESIGN

Retrospective study from August 2013 to July 2020.

SETTING

Veterinary university teaching hospital.

ANIMALS

Eight adult horses with AKI following administration of nonnitrogenous bisphosphonates.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Five horses received intramuscular clodronate (5/8; 62.5%) and 3 horses received intravenous tiludronate (3/8; 37.5%). Six horses (6/8; 75%) received concurrent nonsteroidal anti-inflammatory drugs. The most common initial presenting complaint was poor appetite (6/8; 75%), followed by abnormal urination (2/8; 25%). At the time of initial evaluation, the mean serum or plasma creatinine was 451.72 ± 190.06 μmol/L (5.11 ± 2.15 mg/dL) and BUN was 18.84 ± 8.85 mmol/L (52.75 ± 24.77 mg/dL). Five horses (5/6; 83.3%) had either an increased number of red blood cells (n = 4) or hemoprotein (n = 1) in the urine. All horses were treated with IV isotonic, balanced crystalloids either as a bolus, continuous rate infusion, or a combination of the 2. Seven horses (7/8; 87.5%) survived the initial episode of AKI and 1 horse (1/8; 12.5%) was euthanized. Of the 7 surviving horses, 2 horses (2/7; 28.5%) went on to develop chronic renal dysfunction. Warmblood breeds were overrepresented in the AKI group (P = 0.008; odds ratio: 11.5, 95% confidence interval: 1.8-72.1), when compared to horses that received bisphosphonates during the study period and did not develop AKI.

CONCLUSIONS

Bisphosphonate administration, with or without concurrent nonsteroidal anti-inflammatory drugs, can be associated with AKI in horses. Serum creatinine should be monitored prior to and following bisphosphonate treatment to minimize this risk. Further evaluation of renal function is warranted in horses that develop clinical signs of poor appetite, lethargy, or altered urination in the days following bisphosphonate treatment.

Mental health trajectories in university students across the COVID-19 pandemic: findings from the Student Wellbeing at Northern England Universities prospective cohort study

Introduction

Psychological wellbeing in university students is receiving increased focus. However, to date, few longitudinal studies in this population have been conducted. As such, in 2019, we established the Student Wellbeing At Northern England Universities (SWANS) cohort at the University of York, United Kingdom aiming to measure student mental health and wellbeing every six months. Furthermore, the study period included the COVID-19 pandemic, giving an opportunity to track student wellbeing over time, including over the pandemic.

Methods

Eligible participants were invited to participate via email. Data were collected, using Qualtrics, from September 2019 to April 2021, across five waves (W1 to W5). In total, n = 4,622 students participated in at least one wave of the survey. Data collection included sociodemographic, educational, personality measures, and mental health and wellbeing. Latent profile analyses were performed, exploring trajectories of student wellbeing over the study period for those who had completed at least three of the five waves of the survey (n = 765), as measured by the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS).

Results

Five latent profile trajectories of student wellbeing were identified. Of these, the two latent classes with initially higher wellbeing scores had broadly stable wellbeing across time (total n = 505, 66%). Two classes had lower initial scores, which lowered further across time (total n = 227, 30%). Additionally, a fifth class of students was identified who improved substantially over the study period, from a mean WEMWBS of 30.4 at W1, to 49.4 at W5 (n = 33, 4%). Risk factors for having less favourable wellbeing trajectories generally included identifying as LGBT+, self-declaring a disability, or previously being diagnosed with a mental health condition.

Conclusion

Our findings suggest a mixed picture of the effect of the COVID-19 pandemic on student wellbeing, with a majority showing broadly consistent levels of wellbeing across time, a smaller but still substantial group showing a worsening of wellbeing, and a small group that showed a very marked improvement in wellbeing. Those from groups traditionally underrepresented in higher education were most at risk of poorer wellbeing. This raises questions as to whether future support for wellbeing should target specific student subpopulations.

Back Onside protocol: A physical activity intervention to improve health outcomes in people who are unemployed or at risk of unemployment

Given the effects of physical activity on people's mental and physical health, a better understanding is needed of how physical activity interventions may impact the health of people who are unemployed or at risk of unemployment. This has added urgency in the context of rising rates of poverty-related unemployment in the UK in 2022. The current paper details the protocol used in the evaluation of the Back Onside Programme; a community-based programme delivered by the Bradford Bulls Foundation in the Bradford District. The Programme supports people from low socio-economic backgrounds who are unemployed or at risk of unemployment to maintain regular physical activity through a ten-week physical activity intervention. This pilot study evaluates how a physical activity intervention may impact the mental and physical health of people who are unemployed or at risk of unemployment in an uncontrolled pragmatic pilot study. Four cohorts run back-to-back between May 2021 and May 2022, with separate groups for men (N = 100) and women (N = 60). Physical and wellbeing assessment at baseline and post-intervention is conducted. If the intervention works in this context for these individuals, it will be a promising low-cost community-based intervention for people who are unemployed or at risk of unemployment.

Safety and efficacy of tenecteplase in patients with wake-up stroke assessed by non-contrast CT (TWIST): a multicentre, open-label, randomised controlled trial

BACKGROUND

Current evidence supports the use of intravenous thrombolysis with alteplase in patients with wake-up stroke selected with MRI or perfusion imaging and is recommended in clinical guidelines. However, access to advanced imaging techniques is often scarce. We aimed to determine whether thrombolytic treatment with intravenous tenecteplase given within 4·5 h of awakening improves functional outcome in patients with ischaemic wake-up stroke selected using non-contrast CT.

METHODS

TWIST was an investigator-initiated, multicentre, open-label, randomised controlled trial with blinded endpoint assessment, conducted at 77 hospitals in ten countries. We included patients aged 18 years or older with acute ischaemic stroke symptoms upon awakening, limb weakness, a National Institutes of Health Stroke Scale (NIHSS) score of 3 or higher or aphasia, a non-contrast CT examination of the head, and the ability to receive tenecteplase within 4·5 h of awakening. Patients were randomly assigned (1:1) to either a single intravenous bolus of tenecteplase 0·25 mg per kg of bodyweight (maximum 25 mg) or control (no thrombolysis) using a central, web-based, computer-generated randomisation schedule. Trained research personnel, who conducted telephone interviews at 90 days (follow-up), were masked to treatment allocation. Clinical assessments were performed on day 1 (at baseline) and day 7 of hospital admission (or at discharge, whichever occurred first). The primary outcome was functional outcome assessed by the modified Rankin Scale (mRS) at 90 days and analysed using ordinal logistic regression in the intention-to-treat population. This trial is registered with EudraCT (2014-000096-80), ClinicalTrials.gov (NCT03181360), and ISRCTN (10601890).

FINDINGS

From June 12, 2017, to Sept 30, 2021, 578 of the required 600 patients were enrolled (288 randomly assigned to the tenecteplase group and 290 to the control group [intention-to-treat population]). The median age of participants was 73·7 years (IQR 65·9-81·1). 332 (57%) of 578 participants were male and 246 (43%) were female. Treatment with tenecteplase was not associated with better functional outcome, according to mRS score at 90 days (adjusted OR 1·18, 95% CI 0·88-1·58; p=0·27). Mortality at 90 days did not significantly differ between treatment groups (28 [10%] patients in the tenecteplase group and 23 [8%] in the control group; adjusted HR 1·29, 95% CI 0·74-2·26; p=0·37). Symptomatic intracranial haemorrhage occurred in six (2%) patients in the tenecteplase group versus three (1%) in the control group (adjusted OR 2·17, 95% CI 0·53-8·87; p=0·28), whereas any intracranial haemorrhage occurred in 33 (11%) versus 30 (10%) patients (adjusted OR 1·14, 0·67-1·94; p=0·64).

INTERPRETATION

In patients with wake-up stroke selected with non-contrast CT, treatment with tenecteplase was not associated with better functional outcome at 90 days. The number of symptomatic haemorrhages and any intracranial haemorrhages in both treatment groups was similar to findings from previous trials of wake-up stroke patients selected using advanced imaging. Current evidence does not support treatment with tenecteplase in patients selected with non-contrast CT.

FUNDING

Norwegian Clinical Research Therapy in the Specialist Health Services Programme, the Swiss Heart Foundation, the British Heart Foundation, and the Norwegian National Association for Public Health.

Validation of a dedicated positron emission tomography scanner for imaging of the distal limb of standing horses

A positron emission tomography (PET) scanner, with an openable ring of detectors, was specifically designed to image the distal limb of standing horses. The goals of this prospective, preclinical, experimental, methods comparison study were to validate the safety of the scanner, assess image quality, and optimize scanning protocols. Six research horses were imaged three times (twice standing, once anesthetized) and six horses in active race training were imaged once under standing sedation. Multiple scans of both front fetlocks were obtained with different scan durations and axial fields of view. A total of 94 fetlock scans were attempted and 90 provided images of diagnostic value. Radiotracer uptake was the main factor affecting image quality, while motion did not represent a major issue. Scan duration and field of view also affected image quality. Eight specific lesions were identified on PET images from anesthetized horses and were all also independently recognized on the PET images obtained on standing horses. Maximal standardized uptake values (SUVmax) had good repeatability for the assessment of specific lesions among different scans. Three feet and six carpi were also successfully imaged. This study validated the safety and practicality of a PET scanner specifically designed to image the distal limb in standing horses. Proper preparation of horses, similar to bone scintigraphy, is important for image quality. A 4-min scan with 12 cm field of view was considered optimal for clinical fetlock imaging. Evaluation of a larger clinical population is the next step for further assessment of the clinical utility of PET imaging in horses.

Reductions in circulating B cell subsets and immunoglobulin G levels with long-term belimumab treatment in patients with SLE

Objective

To examine the long-term changes in circulating B cell subsets and IgG levels at 5+ years of continuous belimumab treatment and their correlations with efficacy and safety measures.

Methods

This was a post hoc analysis of a continuation study (BEL112233; NCT00724867) of eligible US patients who completed the 76-week BLISS-76 Study (BEL110751; NCT00410384), with up to eight calendar-years of follow-up and median (IQR) belimumab exposure of 310 (209, 364) weeks. From week 76, patients initially randomised to intravenous belimumab 1 mg/kg or 10 mg/kg every 4 weeks in BLISS-76 continued to receive the same dose in the continuation study, while those initially randomised to placebo received belimumab 10 mg/kg intravenous every 4 weeks during continuation. All patients continued to receive standard SLE therapy. Biomarker data were collected, and the effects on baseline and early changes (weeks 0–24 after starting belimumab) from baseline in biomarkers on SLE Responder Index (SRI-4) and infection rate were evaluated.

Results

Of the 819 patients from BLISS-76, 268 self-selecting patients entered BEL112233. Compared with baseline, B cell subset counts decreased by 40%–99% after 312 weeks (6 years), and serum IgG levels decreased by 28% after 284 weeks. Higher baseline naïve B cell counts were associated with greater SRI-4 response rates (p<0.05), whereas higher baseline SLE subset plasma and short-lived plasma B cell counts were associated with lower SRI-4 response rates (p<0.05). Elevated baseline IgG levels were associated with increased infection rates over the treatment period (p<0.05), and early greater decreases in IgG levels were associated with higher SRI-4 response rates (p<0.05).

Conclusions

Belimumab treatment up to 312 weeks (6 years) resulted in substantial decreases in several circulating B cell subsets and IgG levels. Higher baseline naïve B cell counts and IgG levels were associated with improved SRI-4 response and increased infection rates, respectively.

Healthcare provider characteristics that influence the implementation of individual-level patient-centered outcome measure (PROM) and patient-reported experience measure (PREM) data across practice settings: a protocol for a mixed methods systematic review with a narrative synthesis

BACKGROUND

Substantial literature has highlighted the importance of patient-reported outcome and experience measures (PROMs and PREMs, respectively) to collect clinically relevant information to better understand and address what matters to patients. The purpose of this systematic review is to synthesize the evidence about how healthcare providers implement individual-level PROMs and PREMs data into daily practice.

METHODS

This mixed methods systematic review protocol describes the design of our synthesis of the peer-reviewed research evidence (i.e., qualitative, quantitative, and mixed methods), systematic reviews, organizational implementation projects, expert opinion, and grey literature. Keyword synonyms for "PROMs," PREMs," and "implementation" will be used to search eight databases (i.e., MEDLINE, CINAHL, PsycINFO, Web of Science, Embase, SPORTDiscus, Evidence-based Medicine Reviews, and ProQuest (Dissertation and Theses)) with limiters of English from 2009 onwards. Study selection criteria include implementation at the point-of-care by healthcare providers in any practice setting. Eligible studies will be critically appraised using validated tools (e.g., Joanna Briggs Institute). Guided by the review questions, data extraction and synthesis will occur simultaneously to identify biographical information and methodological characteristics as well as classify study findings related to implementation processes and strategies. As part of the narrative synthesis approach, two frameworks will be utilized: (a) Consolidated Framework for Implementation Research (CFIR) to identify influential factors of PROMs and PREMs implementation and (b) Expert Recommendations for Implementing Change (ERIC) to illicit strategies. Data management will be undertaken using NVivo 12TM.

DISCUSSION

Data from PROMs and PREMs are critical to adopt a person-centered approach to healthcare. Findings from this review will guide subsequent phases of a larger project that includes interviews and a consensus-building forum with end users to create guidelines for implementing PROMs and PREMs at the point of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020182904 .

AB0034 PD-1 AGONISM INHIBITS ACTIVATION OF PLASMACYTOID DENDRITIC CELLS

Background:

T cell function is regulated by complex signaling networks of interconnected activators and inhibitors. Blockade of inhibitory receptors such as programmed death-1 (PD-1) has emerged as a novel treatment for multiple forms of cancer. One of the most common adverse events associated with blockade of the endogenous PD-1/PD-L1 pathway is the induction of autoimmune pathology in multiple tissues, demonstrating that PD-1 activation is necessary for normal immune homeostasis in humans (Kostine, et al., 2018). Given this body of clinical data, we sought to develop a PD-1 agonist antibody as a therapeutic approach to restore immune homeostasis in patients living with autoimmune diseases. PD-1 expression and function has been primarily described on T cells (Ishida, et al., 1992), with additional data available from several other immune cell populations (Ohaegbulam, et al., 2015).

Objectives:

To study the effect of PD-1 agonism on plasmacytoid dendritic cell (pDC) function.

Methods:

Human PBMCs stimulated with or without toll-like receptor (TLR)-9 agonist, CpG were analyzed by flow cytometry for PD-1 expression on immune cell subsets. To assess the impact of PD-1 agonist on pDC function human PBMCs were activated by CpG in the presence or absence of PD-1 agonist. Type-I interferon (IFN) levels were quantified using ELISA from culture supernatants. The expression of interferon stimulated genes was analyzed by qPCR as a measure of type-I IFN activation.

Results:

We have discovered that TLR9 activation can induce PD-1 expression on plasmacytoid dendritic cells, which has not been previously reported. Further, we have demonstrated that PD-1 agonism inhibits TLR9-mediated activation and the effector functions of plasmacytoid dendritic cells.

Conclusion:

These data suggest the potential of PD-1 as a target for regulating diseases with pathology generated by type-I IFN.

References:

[1]Ishida, Y., Agata, Y., Shihibahara, K., & Honjo, T. (1992). Induced expression of PD-1, a novel member of the immunoglobulin gene superfamily, upon programmed cell death. EMBO J., 11(11):3887-95.

[2]Kostine, M., Rouxel, L., Barnetche, T., Veillon, R., Martin, F., Dutriaux, C., . . . Schaeverbeke, T. (2018). Rheumatic disorders associated with immune checkpoint inhibitors in patients with cancer-clinical aspects and relationship with tumour response: a single-centre prospective cohort study. Annual Rheumatic Disease, 77(3):393-398.

[3]Ohaegbulam, K. C., Assal, A., Lazar-Molnar, E., Yao, Y., & Zang, X. (2015). Human cancer immunotherapy with antibodies to the PD-1 and PD-L1 pathway. Trends in Molecular Medicine, 21(1); 24-33.

Disclosure of Interests:

Ishita Banerjee Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Lindsay Edwards Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Patrick Halvey Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Salvatore Alioto Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, David Cluckley Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Caitlin Mitchell Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Christopher Cox Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Emily Lurier Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Michael Cianci Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Soumya Bengeri Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Susmita Borthakur Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Katalin Kis-Toth Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Nathan Higginson-Scott Shareholder of: Pandion Therapeutics, Consultant of: Biotech Companies, Employee of: Pandion Therapeutics, Jo Viney Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics, Kevin L. Otipoby Shareholder of: Pandion Therapeutics, Employee of: Pandion Therapeutics

Acute knee clinics are effective in reducing delay to diagnosis following anterior cruciate ligament injury

BACKGROUND

Delays to diagnosis of anterior cruciate ligament (ACL) injury and specialist consultation continue to place patients at risk of early onset osteoarthritis. Incorporating acute knee clinics within a streamlined accident and emergency (A&E) pathway have shown potential in reducing delay but specific evaluative research is lacking. The aim of this service evaluation was to investigate the effectiveness of an acute knee clinic at one NHS Trust in the United Kingdom (UK), on reducing the delay to diagnosis of ACL injury and specialist consultation compared to a standard A&E pathway.

METHODS

An uncontrolled before and after design was utilised for this service evaluation. Data were collected from historical electronic patient records over a 1-year period with analysed results compared against previously collected data from the same NHS Trust.

RESULTS

81 records met the criteria for the streamlined A&E pathway and were compared against 50 from the standard A&E pathway. For the streamlined A&E pathway median delay to diagnosis reduced from 97 to 14 days and delay to specialist consultation reduced from 158.5 to 45 days and were of statistical significance. The incorporation of an acute knee clinic was identified as the most influential factor on delay in addition to the location of presentation and mechanism of injury.

CONCLUSIONS

Introducing an acute knee clinic within a streamlined A&E pathway has a clinically relevant effect on reducing delay to diagnosis and specialist consultation and allows findings to be extrapolated and implemented to all UK based NHS Trust A&E departments.

Inpatient Telehealth Tools to Enhance Communication and Decrease Personal Protective Equipment Consumption during Disaster Situations: A Case Study during the COVID-19 Pandemic

BACKGROUND

As the coronavirus disease 2019 pandemic exerts unprecedented stress on hospitals, health care systems have quickly deployed innovative technology solutions to decrease personal protective equipment (PPE) use and augment patient care capabilities. Telehealth technology use is established in the ambulatory setting, but not yet widely deployed at scale for inpatient care.

OBJECTIVES

This article presents and describes our experience with evaluating and implementing inpatient telehealth technologies in a large health care system with the goals of reducing use of PPE while enhancing communication for health care workers and patients.

METHODS

We discovered use cases for inpatient telehealth revealed as a result of an immense patient surge requiring large volumes of PPE. In response, we assessed various consumer products to address the use cases for our health system.

RESULTS

We identified 13 use cases and eight device options. During device setup and implementation, challenges and solutions were identified in five areas: security/privacy, device availability and setup, device functionality, physical setup, and workflow and device usage. This enabled deployment of more than 1,800 devices for inpatient telehealth across seven hospitals with positive feedback from health care staff.

CONCLUSION

Large-scale setup and distribution of consumer devices is feasible for inpatient telehealth use cases. Our experience highlights operational barriers and potential solutions for health systems looking to preserve PPE and enhance vital communication.

Genetics of Equine Neurologic Disease

Neurologic disease in horses can be particularly challenging to diagnose and treat. These diseases can result in economic losses, emotional distress to owners, and injury to the horse or handlers. To date, there are 5 neurologic diseases caused by known genetic mutations and several more are suspected to be heritable: lethal white foal syndrome, lavender foal syndrome, cerebellar abiotrophy, occipitoatlantoaxial malformation, and Friesian hydrocephalus. Genetic testing allows owners, breeders, and veterinarians to make informed decisions when selecting dams and sires for breeding or deciding the treatment or prognosis of a neurologic animal.

The design and manufacture of 3D-printed adjuncts for powered air-purifying respirators

Spurred in part by literature published in the immediate aftermath of the severe acute respiratory syndrome epidemic in 2003, powered air‐purifying respirators have seen increased use worldwide during the COVID‐19 pandemic. Whereas these devices provide excellent protection of the user, there is an added element of risk during doffing and cleaning of the device. An additional layer of barrier protection, in the form of a polypropylene gown, to be worn over the hood and motor belt, can be used to minimise this risk. However, the device entrains air perpendicular to the lie of the gown, resulting in the impermeable material being sucked into the air intake, and partial occlusion of flow. In this report, we describe a clinical‐academic partnership whereby a bespoke filter guard was designed to disrupt airflow and prevent gown entrainment, thereby enabling full barrier protection of both the device and user. This intervention was simple, cheap, scalable and able to be mass produced.

A275 REVISITING THE DIAGNOSTIC YIELD OF ERCP BRUSH CYTOLOGY FOR INDETERMINATE BILIARY STRICTURES

Background

Endoscopic Retrograde Cholangiopancreatography (ERCP) brush cytology is the most frequently used tool for sampling indeterminate biliary strictures. Previous studies have demonstrated that the diagnostic yield of brush cytology for malignant biliary strictures is 60%. With improved diagnostic tools, sampling techniques and specimen processing, the yield of ERCP brush cytology may be higher.

Aims

To assess the diagnostic yield of ERCP brush cytology in patients with indeterminate biliary strictures and to determine factors associated with positive diagnosis.

Methods

This is a retrospective study of all patients who underwent ERCP with brush cytology at University Health Network (UHN) from October 2016 to September 2019. The cytological samples were taken as follows: the cytology brush is introduced into the stricture ten times under direct fluoroscopy guidance. The brush was cut and placed into a methanol based buffered solution (CytoLyt®). Residual sample was then flushed out of the catheter with the solution and into the sample container. Patient demographic, clinical, procedural and pathological data was collected by chart review. All patients were followed for a minimum of three months after their index ERCP. Post-ERCP sampling via repeat ERCP brushings, endoscopic ultrasound fine needle biopsy, percutaneous biopsy or surgical resection was recorded.

Results

A total of 97 patients underwent ERCP with brush cytology during the study period (43 females, median age 69 years). Fifty-nine patients (84%) were diagnosed with malignancy via ERCP brush cytology. Using follow up sampling, surgical resection and clinical follow up as the gold standard, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were 84%, 100%, 100%, and 71% respectively. Patient demographics, degree of cholestasis or stricture location had no significant impact on these outcomes.

Conclusions

This study shows a high diagnostic yield for ERCP with brush cytology for patients with indeterminate biliary strictures. Large prospective studies using updated tools, techniques and specimen handling processes are needed to confirm our observations.

Funding Agencies

None

Research priorities of women at risk for preterm birth: findings and a call to action

BACKGROUND

Traditional hierarchical approaches to research give privilege to small groups with decision-making power, without direct input from those with lived experience of illness who bear the burden of disease. A Research Justice framework values the expertise of patients and communities as well as their power in creating knowledge and in decisions about what research is conducted. Preterm birth has persisted at epidemic levels in the United States for decades and disproportionately affects women of color, especially Black women. Women of color have not been included in setting the agenda regarding preterm birth research.

METHODS

We used the Research Priorities of Affected Communities protocol to elicit and prioritize potential research questions and topics directly from women of color living in three communities that experience disproportionately high rates of preterm birth. Women participated in two focus group sessions, first describing their healthcare experiences and generating lists of uncertainties about their health and/or healthcare during pregnancy. Women then participated in consensus activities to achieve 'top-priority' research questions and topic lists. The priority research questions and topics produced by each group were examined within and across the three regions for similarities and differences.

RESULTS

Fifty-four women participated in seven groups (14 sessions) and generated 375 researchable questions, clustered within 22 topics and four overarching themes: Maternal Health and Care Before, During, and After Pregnancy; Newborn Health and Care of the Preterm Baby; Understanding Stress and Interventions to Prevent or Reduce Stress; and Interpersonal and Structural Health Inequities. The questions and topics represent a wide range of research domains, from basic science, translational, clinical, health and social care delivery to policy and economic research. There were many similarities and some unique differences in the questions, topics and priorities across the regions.

CONCLUSIONS

These findings can be used to design and fund research addressing unanswered questions that matter most to women at high risk for preterm birth. Investigators and funders are strongly encouraged to incorporate women at the front lines of the preterm birth epidemic in research design and funding decisions, and more broadly, to advance methods to deepen healthcare research partnerships with affected communities.

Research priorities of women at risk for preterm birth: findings and a call to action

Background

Traditional hierarchical approaches to research give privilege to small groups with decision-making power, without direct input from those with lived experience of illness who bear the burden of disease. A Research Justice framework values the expertise of patients and communities as well as their power in creating knowledge and in decisions about what research is conducted. Preterm birth has persisted at epidemic levels in the United States for decades and disproportionately affects women of color, especially Black women. Women of color have not been included in setting the agenda regarding preterm birth research.

Methods

We used the Research Priorities of Affected Communities protocol to elicit and prioritize potential research questions and topics directly from women of color living in three communities that experience disproportionately high rates of preterm birth. Women participated in two focus group sessions, first describing their healthcare experiences and generating lists of uncertainties about their health and/or healthcare during pregnancy. Women then participated in consensus activities to achieve ‘top-priority’ research questions and topic lists. The priority research questions and topics produced by each group were examined within and across the three regions for similarities and differences.

Results

Fifty-four women participated in seven groups (14 sessions) and generated 375 researchable questions, clustered within 22 topics and four overarching themes: Maternal Health and Care Before, During, and After Pregnancy; Newborn Health and Care of the Preterm Baby; Understanding Stress and Interventions to Prevent or Reduce Stress; and Interpersonal and Structural Health Inequities. The questions and topics represent a wide range of research domains, from basic science, translational, clinical, health and social care delivery to policy and economic research. There were many similarities and some unique differences in the questions, topics and priorities across the regions.

Conclusions

These findings can be used to design and fund research addressing unanswered questions that matter most to women at high risk for preterm birth. Investigators and funders are strongly encouraged to incorporate women at the front lines of the preterm birth epidemic in research design and funding decisions, and more broadly, to advance methods to deepen healthcare research partnerships with affected communities.

Point-of-care lung ultrasound in the assessment of suspected COVID-19: a retrospective service evaluation with a severity score

INTRODUCTION

Point-of-care lung ultrasound (POCUS) has been advocated as a tool to assess the severity of COVID19 and thereby aid risk stratification.

METHODS

We conducted a retrospective service evaluation between the 3rd March and the 5th May 2020 to describe and characterise the use of POCUS within an acute care pathway designed specifically for the assessment of suspected or confirmed COVID-19. A novel POCUS severity scale was formulated by assessing pleural and interstitial abnormalities within six anatomical zones (three for each lung). An aggregated score was calculated for each patient and evaluated as a marker of disease severity using standard metrics of discriminatory performance.

RESULTS

POCUS was performed in the assessment of 100 patients presenting with suspected COVID-19. POCUS was consistent with COVID-19 infection in 92% (n = 92) of the patients assessed. Severity, as assessed by POCUS, showed good discriminatory performance to predict all-cause inpatient mortality, death or critical care admission, and escalated oxygen requirements (AUC .80, .80, 82). The risk of all-cause mortality in patients with scores in lowest quartile was 2.5% (95%CI 0.12- 12.95) compared with 42.9% (95CI 15.8 - 75.0%) in the highest quartile. POCUS assessed severity correlated with length of stay and duration of supplemental oxygen therapy.

CONCLUSION

A simple aggregated score formed by the summating the degree of pleural and interstitial change within six anatomical lung zones showed good discriminatory performance in predicting a range of adverse outcomes in patients with suspected COVID-19.

Fungal Placentitis Caused by Aspergillus terreus in a Mare: Case Report

Placentitis has been reported as the most important cause of equine abortions, stillbirths, and perinatal deaths in horses. Most cases are caused by bacteria and less commonly by fungal elements. The aim of this report is to describe the clinical presentation of a fungal placentitis caused by Aspergillus terrerus. A 5-year-old thoroughbred maiden mare at the 217th day of gestation presented with some classic signs of placentitis (premature udder development and milk dripping). All ultrasonographic findings were consistent with a live fetus and a severe placentitis. On vaginal examination, purulent discharge was found coming from the external cervical os. Samples sent for culture yielded very small numbers of mixed growth including Enterococcus faecalis (by matrix-assisted laser desorption/ionization time-of-flight mass spectrometer), Streptococcus viridans, and Aspergillus terreus, and polymerase chain reaction was positive for Aspergillus terreus and Pseudomonas. The mare was placed on broad-spectrum antimicrobials, nonsteroidal anti-inflammatories, and hormonal and antifungal treatment. The fetus kept on developing and growing despite the placentitis for 14 days until the demise of the fetus in utero occurred. Aspergillus terreus was isolated from the chorionic surface but not from the fetus. Fungal placentitis is not very commonly found in mares. The extent of the placental lesions and the severity of the placentitis contributed to the death of the fetus. This is one of the few case reports available describing fungal placentitis. Aspergillus terreus has not been previously reported as a cause of placentitis.

Cat-PROM5: a brief psychometrically robust self-report questionnaire instrument for cataract surgery

Purpose

To develop a short, psychometrically robust and responsive cataract patient reported outcome measure suitable for use in high-volume surgical environments.

Methods

A prospective study in which participants completed development versions of questionnaires exploring the quality of their eyesight using items harvested from two existing United Kingdom developed parent questionnaires. Participants were 822 patients awaiting cataract surgery recruited from 4 cataract surgical centres based in the UK. Exclusion criteria were other visually significant comorbidities and age <50 years. An iterative multi-stage process of evaluation using Rasch and factor analyses with sequential item reduction was undertaken.

Results

A definitive item set of just five items delivered performance in accordance with the requirements of the Rasch model: no threshold disordering, no misfitting items, Rasch-based reliability 0.90, person separation 2.98, Cronbach’s α 0.89, good targeting of questions to patients with cataract with pre-operative item mean −0.41 logits and absence of significant floor or ceiling effects, minor deviations of item invariance, and confirmed unidimensionality. The test–re-test repeatability intra-class correlation coefficient was 0.89 with excellent responsiveness to surgery, Cohen’s d −1.45 SD. Rasch calibration values are provided for Cat-PROM5 users.

Conclusions

A psychometrically robust and highly responsive five-item cataract surgery patient reported outcome measure has been developed, which is suitable for use in high-volume cataract surgical services.

Double-ended Pigtail Polyethylene Stents in Management of Benign and Malignant Ureteric Obstruction

Surgical urinary diversion for incurable pelvic malignancy has a high morbidity and mortality, and external drainage provides less than ideal palliation. Six patients with ureteric obstruction caused by cancer have been managed by operative or endoscopic insertion of self-retaining polyethylene tubes. These techniques also have applications in non-malignant disease, and the treatment of two patients with benign ureteric stricture is described.

Cataract surgery patient-reported outcome measures: a head-to-head comparison of the psychometric performance and patient acceptability of the Cat-PROM5 and Catquest-9SF self-report questionnaires

Background Cataract surgery is the most frequently undertaken NHS surgical procedure. Visual acuity (VA) provides a poor indication of visual difficulty in a complex visual world. In the absence of a suitable outcome metric, recent efforts have been directed towards the development of a cataract patient-reported outcome measure (PROM) of sufficient brevity, precision, and responsiveness to be implementable in routine high volume clinical services.

Aim To compare and contrast the two most promising candidate PROMs for routine cataract surgery.

Method The psychometric performance and patient acceptability of the recently UK developed five-item Cat-PROM5 questionnaire was compared with the English translation of the Swedish nine-item Catquest-9SF using Rasch-based performance metrics and qualitative semistructured interviews.

Results Rasch-based performance was assessed in 822 typical NHS cataract surgery patients across four centres in England. Both questionnaires demonstrated good to excellent performance for all metrics assessed, including Person Reliability Indices of 0.90 (Cat-PROM5) and 0.88 (Catquest-9SF), responsiveness to surgery (Cohen’s standardized effect size) of 1.45 SD (Cat-PROM5) and 1.47 SD (Catquest-9SF) and they were highly correlated with each other (R=0.85). Qualitative assessments confirmed that both questionnaires were acceptable to patients, including in the presence of ocular comorbidities. Preferences were expressed for the shorter Cat-PROM5, which allowed patients to map their own issues to the questions as opposed to the more restrictive specific scenarios of Catquest-9SF.

Conclusion The recently UK developed Cat-PROM5 cataract surgery questionnaire is shorter, with performance and patient acceptability at least as good or better than the previous ‘best of class’ Catquest-9SF instrument.

Attention-deficit hyperactivity and developmental coordination disorders: knowledge and practice among child and adolescent psychiatrists and paediatricians

Aims and Method

Despite extensive evidence that attention-deficit hyperactivity disorder (ADHD) and developmental coordination disorder commonly present as overlapping disorders, it is not clear whether clinicians routinely enquire about movement difficulties when assessing children with suspected ADHD. We describe a survey that examines knowledge and practice of child and adolescent psychiatrists (n=107) and paediatricians (n=51) in this area.

Results

Results show that 67.3% of child and adolescent psychiatrists compared with 15.7% of paediatricians claimed to have poor or very poor knowledge of developmental coordination disorder, and 28% compared with 5.9% respectively reported that they never or only occasionally ask about motor difficulties.

Clinical Implications

Child and adolescent psychiatrists should consider routine screening for developmental coordination disorder when assessing for ADHD. Further training in assessment of developmental coordination disorder is recommended to facilitate this.

Equipping providers with principles, knowledge and skills to successfully integrate behaviour change counselling into practice: a primary healthcare framework

OBJECTIVES

There is an urgent need for healthcare providers and healthcare systems to support productive interactions with patients that promote sustained health behaviour change in order to improve patient and population health outcomes. Behaviour change theories and interventions have been developed and evaluated in experimental contexts; however, most healthcare providers have little training, and therefore low confidence in, behaviour change counselling. Particularly important is how to integrate theory and method to support healthcare providers to engage in behaviour change counselling competently. In this article, we describe a general training model developed from theory, evidence, experience and stakeholder engagement. This model will set the stage for future evaluation research on training needed to achieve competency, sustainability of competency, as well as effectiveness/cost-effectiveness of training in supporting behaviour change.

DESIGN AND METHODS

A framework to support competency based training in behaviour change counselling is described in this article. This framework is designed to be integrative, sustainable, scalable and capable of being evaluated in follow-up studies.

RESULTS AND DISCUSSION

Effective training in behaviour change counselling is critical to meet the current and future healthcare needs of patients living with, or at risk of, chronic diseases. Increasing competency in establishing change-based relationships, assessing and promoting readiness to change, implementing behaviour modification and addressing psychosocial issues will be value added to the healthcare system.

Survival from Septic Shock Secondary to Disseminated Group A Streptococcal Infection after Central Extracorporeal Membrane Oxygenation

Objective The objective of this study was to describe a case of severe life-threatening acute respiratory distress syndrome (ARDS) and septic shock in a child who responded to a prolonged extracorporeal membrane oxygenation (ECMO) support course utilizing different cannulation techniques depending on the physiological derangement until he recovered.

Design This is a case report.

Setting This study was done at the medical–surgical pediatric intensive care unit in an academic freestanding children's hospital.

Patient A previously healthy 4-year-old boy was presented with respiratory distress and fever. He was diagnosed with respiratory syncytial viral upper respiratory tract infection and group A β-hemolytic Streptococcus septic shock.

Interventions The patient was referred to peripheral ECMO for hemodynamic, ventilatory, and oxygenation support; conversion to central ECMO to augment blood flow; and transition to extracorporeal carbon dioxide removal before successful wean off extracorporeal support.

Measurements and Main Results Patient experienced severe pediatric ARDS and septic shock that were refractory to maximal medical therapy. Patient was able to be decannulated after 75 days of extracorporeal support. He was weaned completely off of mechanical ventilation and oxygen after 6 months. The only neurological deficit he exhibited was poor fine motor skills of his hands for which he continued to receive physical therapy.

Conclusion Central ECMO may benefit children with pediatric ARDS and septic shock who require higher flows than what can be provided from peripheral ECMO. Extracorporeal membrane carbon dioxide removal may be an effective option in children who do not respond to mechanical ventilation alone.

Adequacy of Online Patient Information Resources on Gout and Potentially Curative Urate-Lowering Treatment

OBJECTIVE

To assess the content and readability of online patient information resources against the current understanding of gout.

METHODS

An online survey was undertaken using Google UK, USA, Australia, and Canada. Information was assessed for content and accuracy on 19 key points regarding core content for gout patient information resources. Readability was assessed using the Flesch-Kincaid Reading Ease score. Fifteen randomly selected websites were reviewed by a blinded second observer.

RESULTS

A total of 85 websites were selected. More than 50% of the websites provided no information or had inaccuracies regarding the pathogenesis of gout. Most websites contained information on dietary and lifestyle modifications for treating gout and did not emphasize urate-lowering therapy (ULT) and its potential for cure. Over 75% of the websites had no/inaccurate information on the role of ULT or prophylaxis for preventing gout attacks on starting ULT. The majority of websites were difficult to read, with information in 68% of the websites rated at least fairly difficult.

CONCLUSION

Only a few web-based patient information resources provide accurate and easy-to-read information on gout. This study will help physicians direct patients to currently reliable resources, but there is a need to improve many web-based patient information resources, which at present act as barriers to care.

Impact of concomitant medication use on belimumab efficacy and safety in patients with systemic lupus erythematosus

Practicing physicians have requested efficacy and safety data for belimumab, when used with specific systemic lupus erythematosus (SLE) medications. This was a post hoc analysis of pooled efficacy and safety data from patients who received belimumab 10 mg/kg plus standard of care (SoC) or placebo (SoC) in two Phase III, randomized trials, BLISS-52 and BLISS-76. Patients were categorized into four groups based on baseline concomitant medication usage: steroids only; antimalarials (AM) only; steroids + AM; or steroids + AM + immunosuppressants (IS). The primary endpoint was the SLE Responder Index (SRI) at Week 52. SRI over time and individual SRI components were secondary endpoints. Time to first flare and changes in concomitant medications were exploratory endpoints. Safety was assessed using adverse event (AE) reporting. Across 834 patients, steroids + AM was the largest group (n = 346, 41.5%) and AM only was the smallest (n = 77, 9.2%). Disease duration was shortest in the steroids + AM group (5.7 years vs 6.4–7.1 years); SELENA-SLEDAI scores were similar across groups. At Week 52, the percentage of SRI responders was greatest in the steroids + AM group for belimumab 10 mg/kg (59%) compared with placebo (44%); treatment response and SRI component improvements were also observed across other groups. The probability of experiencing an SLE flare was reduced in the steroids-only group for patients who received belimumab 10 mg/kg compared with placebo (64.3% vs 78.1%; hazard ratio 0.64; 95% confidence interval: 0.42–0.96). There was little or no change in daily AM or IS dose in any group. For all groups, there was a general decrease in steroid dose over time; a quarter to a third of patients experienced decreased steroid doses at Week 52. The overall safety profile was similar across treatment arms and concomitant medication groups, with the exception of serious AEs in the steroids + AM group (belimumab 10 mg/kg 16%, placebo 8%). The efficacy and safety of belimumab in combination with SoC was demonstrated for various groupings of steroids, AM and IS. These findings may improve the understanding of the safety and efficacy of adding belimumab to different treatments.

Sun Exposure Behavior, Seasonal Vitamin D Deficiency, and Relationship to Bone Health in Adolescents

CONTEXT

Vitamin D is essential for bone health in adolescence, when there is rapid bone mineral content accrual. Because cutaneous sun exposure provides vitamin D, there is no recommended oral intake for UK adolescents.

OBJECTIVE

Our objective was to assess seasonal vitamin D status and its contributors in white Caucasian adolescents and examine bone health in those found deficient.

DESIGN

Prospective cohort study was undertaken.

SETTING

Six schools in Greater Manchester, UK, were included.

PARTICIPANTS

Participants were 131 adolescents between 12 and 15 years of age.

INTERVENTION(S)

Seasonal assessment of circulating 25-hydroxyvitamin D (25OHD), personal sun exposure, and dietary vitamin D. Adolescents deficient (25OHD <10 ng/ml/25 nmol/liter) in at least one season underwent dual-energy X-ray absorptiometry (lumbar spine, femoral neck), with bone mineral apparent density correction for size, and peripheral quantitative computed tomography (distal radius) for volumetric bone mineral density (BMD).

MAIN OUTCOME MEASURE

Serum 25OHD and BMD measurements.

RESULTS

Mean 25OHD was highest in September: 24.1 (SD, 6.9) ng/ml and lowest in January: 15.5 (5.9) ng/ml. Over the year, 16% were deficient in ≥ one season and 79% insufficient (25OHD <20 ng/ml/50 nmol/liter) including 28% in September. Dietary vitamin D was low year-round, whereas personal sun exposure was seasonal and predominantly across the school week. Holidays accounted for 17% variation in peak 25OHD (P < .001). Nineteen adolescents underwent bone assessment, which showed low femoral neck bone mineral apparent density vs matched reference data (P = .0002), three with Z less than or equal to -2.0 distal radius trabecular volumetric BMD.

CONCLUSIONS

Sun exposure levels failed to provide adequate vitamin D, with approximately one-quarter of adolescents insufficient even at summer peak. Seasonal vitamin D deficiency was prevalent and those affected had low BMD. Recommendations on vitamin D acquisition are indicated in this age-group.

Brief Assessment of Parental Perception (BAPP): Development and validation of a new measure for assessing paediatric outcomes after bilateral cochlear implantation

OBJECTIVE

In contrast to previous clinical practice, current guidelines recommend bilateral cochlear implantation in children, resulting in a cohort of children who initially received one implant, but have subsequently had a second, contralateral implant. This study aimed to explore satisfaction and quality of life in children implanted simultaneously or sequentially.

DESIGN

A novel measure of satisfaction and quality of life following paediatric bilateral cochlear implantation (the Brief Assessment of Parental Perception; BAPP) was developed and preliminary validation undertaken as part of a large, national project of bilateral implantation. Children's parents completed the measure yearly for up to three years following implantation.

STUDY SAMPLE

Children from 14 UK implant centres were recruited into the study; data were available for 410 children one year post-implantation.

RESULTS

The BAPP was found to have good face and convergent validity, and internal consistency. Results indicated very high levels of satisfaction with the devices, and improvements in quality of life. However there was evidence that children implanted sequentially were less willing to wear their second implant in the first two years than those children receiving simultaneous implants.

CONCLUSION

Simultaneous and sequential cochlear implants have a positive impact on the quality of life of deaf children.