Unwarranted variation and the goal of net zero for the NHS in England: exploring the link between efficiency working, patient outcomes and carbon footprint

In 2020 the NHS in England set a target of reaching net zero carbon emissions by 2040. Progress has already been made towards this goal, with substantial reductions in the use of environmentally harmful anaesthetic gases, such as desflurane, in recent years. Where an effective replacement already exists, changing practice to use low carbon alternatives is relatively easy to achieve, but much greater challenges lie ahead. The Getting It Right First Time (GIRFT) programme is a clinically-led, data-driven clinical improvement initiative with a focus on reducing unwarranted variation in clinical practice and patient outcomes. Reducing unwarranted variation can improve patient care and service efficiency, and can also support the drive to net zero. In this article we set out what the GIRFT programme is doing to support sustainable healthcare in England, why it is uniquely positioned to support this goal and what the future challenges, barriers, enablers and opportunities are likely to be in the drive to net zero.

Effects of an eating club for people with a psychotic disorder on personal recovery: Results of a randomized controlled trial

BACKGROUND AND OBJECTIVES

Many people with a psychotic disorder are coping with severe psychosocial limitations related to their illness. The current randomized controlled trial (RCT) investigates the effects of an eating club intervention (HospitalitY (HY)) aimed to improve personal and societal recovery.

METHODS

In 15 biweekly sessions participants received individual home-based skill training and guided peer support sessions in groups of three participants from a trained nurse. A multi-center RCT was conducted (intended sample size: n = 84; n = 7 per block) in patients with a diagnosis of schizophrenia spectrum receiving community treatment. HospitalitY was compared to a Waiting List Control (WLC) condition at three time points (baseline, end-of-treatment (8 months) and follow-up (12 months)) using personal recovery as primary outcome and loneliness, social support, self-stigma, self-esteem, social skills, (social) functioning, independency competence, and psychopathology as secondary outcomes. Outcomes were evaluated with a mixed modeling statistical procedure.

RESULTS

The HY-intervention had no significant effects on personal recovery or secondary outcomes. More attendance was associated with higher scores on social functioning.

LIMITATIONS

With N = 43 participants included, power was insufficient. Seven HY-groups were started, from which three discontinued before the sixth meeting, one HY group stopped due the start of the COVID-19 pandemic.

CONCLUSIONS

Despite a promising pilot study on feasibility, the current RCT did not show any effects of the HY intervention. A mixed qualitative-quantitative research methods might be more appropriate for researching the HospitalitY-intervention to investigate what social and cognitive processes are at play in this peer guided social intervention.

Development and internal validation of a model for postoperative morbidity in adults undergoing major elective colorectal surgery: the peri-operative quality improvement programme (PQIP) colorectal risk model

Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. In addition, contemporary definitions of some model predictors are markedly different compared with when the tool was developed. A second model used in clinical practice is the American College of Surgeons National Surgical Quality Improvement Programme risk model; this provides a risk estimate for a range of postoperative complications. This model, widely used in North America, is not open source and therefore cannot be applied to patient populations in other settings. Data from a prospective multicentre clinical dataset of 118 NHS hospitals (the peri-operative quality improvement programme) were used to develop a bespoke risk-adjustment model for postoperative morbidity. Patients aged ≥ 18 years who underwent colorectal surgery were eligible for inclusion. Postoperative morbidity was defined using the postoperative morbidity survey at postoperative day 7. Thirty-one candidate variables were considered for inclusion in the model. Death or morbidity occurred by postoperative day 7 in 3098 out of 11,646 patients (26.6%). Twelve variables were incorporated into the final model, including (among others): Rockwood clinical frailty scale; body mass index; and index of multiple deprivation quintile. The C-statistic was 0.672 (95%CI 0.660-0.684), with a bootstrap optimism corrected C-statistic of 0.666 at internal validation. The model demonstrated good calibration across the range of morbidity estimates with a mean slope gradient of predicted risk of 0.959 (95%CI 0.894-1.024) with an index-corrected intercept of -0.038 (95%CI -0.112-0.036) at internal validation. Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of < 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.

Age and the anaesthetist: considerations for the individual anaesthetist and workforce planning: Guidelines about the ageing anaesthetic workforce from the Association of Anaesthetists: Guidelines for the ageing anaesthetic workforce from the Association of Anaesthetists

There is clear evidence of a growing workforce gap and this is compounded by demographic data that show the current workforce is ageing. Within the current workforce, more doctors are taking voluntary early retirement and the loss of these experienced clinicians from departments can have wide-ranging effects. Older doctors are at risk of age-related health problems (e.g. sight, musculoskeletal, menopause) and are more susceptible to the effects of fatigue, which may increase the risk of error and or complaint. The purpose of this working party and advocacy campaign was to address concerns over the number of consultants retiring at the earliest opportunity and whether a different approach could extend the working career of consultant anaesthetists and SAS doctors. This could be viewed as 'pacing your career'. The earlier this is considered in a clinician's career the greater the potential mitigation on individuals.

Safety of day-case paediatric tonsillectomy in England: an analysis of administrative data for the Getting It Right First Time programme

We used the Hospital Episodes Statistics database to investigate unwarranted variation in the rates Trusts discharged children the same day after scheduled tonsillectomy and associations with adverse postoperative outcomes. We included children aged 2-18 years who underwent tonsillectomy between 1 April 2014 and 31 March 2019. We stratified analyses by category of Trust, non-specialist or specialist, defined as without or with paediatric critical care facilities, respectively. We adjusted analyses for age, sex, year of surgery and aspects of presentation and procedure type. Of 101,180 children who underwent tonsillectomy at non-specialist Trusts, 62,926 (62%) were discharged the same day, compared with 24,138/48,755 (50%) at specialist Trusts. The adjusted proportion of children discharged the same day as tonsillectomy ranged from 5% to 100% at non-specialist Trusts and 9% to 88% at specialist Trusts. Same-day discharge was not independently associated with an increased rate of 30-day emergency re-admission at non-specialist Trusts but was associated with a modest rate increase at specialist Trusts; adjusted probability 8.0% vs 7.7%, odds ratio (95%CI) 1.14 (1.05-1.24). Rates of adverse postoperative outcomes were similar for Trusts that discharged >70% children the same day as tonsillectomy compared with Trusts that discharged <50% children the same day, for both non-specialist and specialist Trust categories. We found no consistent evidence that day-case tonsillectomy is associated with poorer outcomes. All Trusts, but particularly specialist centres, should explore reasons for low day-case rates and should aim for rates >70%.

Facilitating Recovery of Daily Functioning in People With a Severe Mental Illness Who Need Longer-Term Intensive Psychiatric Services: Results From a Cluster Randomized Controlled Trial on Cognitive Adaptation Training Delivered by Nurses

BACKGROUND

Feasible and effective interventions to improve daily functioning in people with a severe mental illness (SMI), such as schizophrenia, in need of longer-term rehabilitation are scarce.

AIMS

We assessed the effectiveness of Cognitive Adaptation Training (CAT), a compensatory intervention to improve daily functioning, modified into a nursing intervention.

METHOD

In this cluster randomized controlled trial, 12 nursing teams were randomized to CAT in addition to treatment as usual (CAT; n = 42) or TAU (n = 47). Daily functioning (primary outcome) was assessed every 3 months for 1 year. Additional follow-up assessments were performed for the CAT group in the second year. Secondary outcomes were assessed every 6 months. Data were analyzed using multilevel modeling.

RESULTS

CAT participants improved significantly on daily functioning, executive functioning, and visual attention after 12 months compared to TAU. Improvements were maintained after 24 months. Improved executive functioning was related to improved daily functioning. Other secondary outcomes (quality of life, empowerment, negative symptoms) showed no significant effects.

CONCLUSIONS

As a nursing intervention, CAT leads to maintained improvements in daily functioning, and may improve executive functioning and visual attention in people with SMI in need of longer-term intensive psychiatric care. Given the paucity of evidence-based interventions in this population, CAT can become a valuable addition to recovery-oriented care.

Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing

Background

The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET.

Aim

We explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice.

Methods

We performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET.

Results

Fitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male.

Conclusion

To our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.

NWChem: Past, present, and future

Specialized computational chemistry packages have permanently reshaped the landscape of chemical and materials science by providing tools to support and guide experimental efforts and for the prediction of atomistic and electronic properties. In this regard, electronic structure packages have played a special role by using first-principle-driven methodologies to model complex chemical and materials processes. Over the past few decades, the rapid development of computing technologies and the tremendous increase in computational power have offered a unique chance to study complex transformations using sophisticated and predictive many-body techniques that describe correlated behavior of electrons in molecular and condensed phase systems at different levels of theory. In enabling these simulations, novel parallel algorithms have been able to take advantage of computational resources to address the polynomial scaling of electronic structure methods. In this paper, we briefly review the NWChem computational chemistry suite, including its history, design principles, parallel tools, current capabilities, outreach, and outlook.

The emerging specialty of perioperative medicine: a UK survey of the attitudes and behaviours of anaesthetists

Background

In 2014, the Royal College of Anaesthetists (RCoA) launched the Perioperative Medicine Programme to facilitate the delivery of best preoperative, intraoperative and postoperative care through implementation of evidence-based medicine to reduce variation and improve postoperative outcomes. However, variation exists in the establishment of perioperative medicine services in the UK. This survey explored attitudes and behaviours of anaesthetists towards perioperative medicine, described current anaesthetic-led perioperative medicine services across the UK and explored barriers to anaesthetic involvement in perioperative medicine.

Methods

Survey content based on the RCoA vision document was refined and validated using an expert panel. An anonymous electronic survey was then sent by email to the members of the RCoA.

Results

Seven hundred fifty-eight UK anaesthetists (4.5% of the RCoA mailing list) responded to the survey. Of these, 64% considered themselves a perioperative doctor, with 65% having changed local services in response to the RCoA vision. Barriers to developing perioperative medicine included insufficient time (75%) and inadequate training (51%). Three quarters of respondents advocate anaesthetists leading the development of perioperative medicine.

Conclusions

Despite evidence of emerging services, this survey describes barriers to ongoing development of perioperative medicine. Facilitators may include increased clinical exposure, targeted education and training and collaborative working with other specialties.

Peer support and skills training through an eating club for people with psychotic disorders: A feasibility study

OBJECTIVE

The HospitalitY (HY) intervention is a novel recovery oriented intervention for people with psychotic disorders in which peer support and home-based skill training are combined in an eating club. A feasibility study was conducted to inform a subsequent randomised trial.

METHODS

This study evaluated three eating clubs consisting of nine participants and three nurses. Semi-structured interviews and pre- and post-intervention measures (18 weeks) of personal recovery, quality of life and functioning were used to evaluate the intervention. Participants received individual skills training, guided by self-identified goals, while organising a dinner at their home. During each dinner, participants engaged in peer support, led by a nurse.

RESULTS

In personal interviews participants reported positive effects on social support, loneliness, and self-esteem. Nurses reported that participants became more independent during the intervention. Participants were satisfied with the HY-intervention (attendance rate = 93%). All were able to organise a dinner for their peers with practical support from a nurse. Pre- and post -intervention measures did not show important improvements.

LIMITATIONS

Outcome measures were not sensitive to change, likely due to a short intervention period (5 months) and a limited number of participants (N = 9). Using Goal Attainment Scaling to evaluate personal goals turned out to be unfeasible.

CONCLUSIONS

The HY-intervention is feasible for participants with psychotic disorders. This study refined intervention and research design for the upcoming multicentre randomised controlled trial. We expect that the Experience Sampling Method will be more sensitive to changes in recovery outcomes than regular pre-post intervention measures.

[Aggression regulation in eating disorders: evidence for a brief body and movement oriented intervention]

Individuals with eating disorders tend to internalise their anger and aggression excessively. However, an evidence-based intervention, targeted on this persistent issue, was missing until now. Therefore, a body and movement oriented intervention was developed, which supports patients to reframe and redirect anger and aggression against the destructive influence of the eating disorder.<br/> AIM: To study the effectiveness of the aggression regulation intervention.<br/> METHOD: The intervention was tested in a first randomised controlled trial (RCT) in an outpatient setting and in a two-center RCT in a multidisciplinary day hospital setting. Coping with anger was measured by the Self-Expression and Control Scale (SECS). Eating disorder pathology was measured by the Eating Disorder Examination Questionnaire (EDE-Q).<br/> RESULTS: Both RCTs delivered first evidence for the brief body and movement oriented intervention to reduce excessive anger internalisation in individuals with eating disorders. Moreover, in the outpatient trial the eating disorder pathology was significantly more reduced in the intervention group compared to the control group.<br/> CONCLUSION: There is first evidence for the effectiveness of a body and movement oriented approach of reducing excessive anger internalisation in individuals with eating disorders.

Using predicted 30 day mortality to plan postoperative colorectal surgery care: a cohort study

BACKGROUND

Preoperative identification of high-risk surgical patients might help to reduce postoperative morbidity and mortality. Using a patient's predicted 30 day mortality to plan postoperative high-dependency unit (HDU) care after elective colorectal surgery might be associated with reduced postoperative morbidity.

METHODS

The 30 day postoperative mortality was predicted for 504 elective colorectal surgical patients in a preoperative clinic. The prediction was used to determine postoperative surgical ward or HDU care. Those with a predicted 30 day mortality of 1-3% mortality, and thus deemed at intermediate risk, had either planned HDU care (n=68) or planned ward care (n=139). The main outcome measures were emergency laparotomy and unplanned critical care admission.

RESULTS

There were more emergency laparotomies and unplanned critical care admissions in patients with a predicted 30 day mortality of 1-3% who went to an HDU after surgery compared with patients who went to a ward: 0 vs 14 (10%), P=0.0056 and 0 vs 22 (16%), P=0.0002, respectively.

CONCLUSIONS

Planned postoperative critical care was associated with a lower rate of complications after elective colorectal surgery.

The development and evaluation of a computerized decision aid for the treatment of psychotic disorders

BACKGROUND

Routinely monitoring of symptoms and medical needs can improve the diagnostics and treatment of medical problems, including psychiatric. However, several studies show that few clinicians use Routine Outcome Monitoring (ROM) in their daily work. We describe the development and first evaluation of a ROM based computerized clinical decision aid, Treatment-E-Assist (TREAT) for the treatment of psychotic disorders. The goal is to generate personalized treatment recommendations, based on international guidelines combined with outcomes of mental and physical health acquired through ROM. We present a pilot study aimed to assess the feasibility of this computerized clinical decision aid in daily clinical practice by evaluating clinicians' experiences with the system.

METHODS

Clinical decision algorithms were developed based on international schizophrenia treatment guidelines and the input of multidisciplinary expert panels from multiple psychiatric institutes. Yearly obtained diagnostic (ROM) information of patients was presented to treating clinicians combined with treatment suggestions generated by the algorithms of TREAT. In this pilot study 6 clinicians and 16 patients of Lentis Psychiatric Institute used the application. Clinicians were interviewed and asked to fill out self-report questionnaires evaluating their opinions about ROM and the effectiveness of TREAT.

RESULTS

Six clinicians and 16 patients with psychotic disorders participated in the pilot study. The clinicians were psychiatrists, physicians and nurse-practitioners which all worked at least 8 years in mental health care of which at least 3 years treating patients with psychotic illnesses. All Clinicians found TREAT easy to use and would like to continue using the application. They reported that TREAT offered support in using diagnostic ROM information when drafting the treatment plans, by creating more awareness of current treatment options.

CONCLUSION

This article presents a pilot study on the implementation of a computerized clinical decision aid linking routine outcome monitoring to clinical guidelines in order to generate personalized treatment advice. TREAT was found to be feasible for daily clinical practice and effective based on this first evaluation by clinicians. However, adjustments have to be made to the system and algorithms of the application. The ultimate goal is to provide appropriate evidence based care for patients with severe mental illnesses.

The role of spin states in the catalytic mechanism of the intra- and extradiol cleavage of catechols by O2

Iron-dependent enzymes and biomimetic iron complexes can catalyze the ring cleavage of very inert, aromatic compounds. The mechanisms of these transformations and the factors that lead either to extradiol cleavage or intradiol cleavage have not been fully understood. By using density functional theory we have elucidated the mechanism of the catalytic cycle for two biomimetic complexes, and explained the difference in the experimentally obtained products.

Cardiopulmonary exercise testing (CPET) in the United Kingdom-a national survey of the structure, conduct, interpretation and funding

Background

Cardiopulmonary exercise testing (CPET) is an exercise stress test with concomitant expired gas analysis that provides an objective, non-invasive measure of functional capacity under stress. CPET-derived variables predict postoperative morbidity and mortality after major abdominal and thoracic surgery. Two previous surveys have reported increasing utilisation of CPET preoperatively in England. We aimed to evaluate current CPET practice in the UK, to identify who performs CPET, how it is performed, how the data generated are used and the funding models.

Methods

All anaesthetic departments in trusts with adult elective surgery in the UK were contacted by telephone to obtain contacts for their pre-assessment and CPET service leads. An online survey was sent to all leads between November 2016 and March 2017.

Results

The response rate to the online survey was 73.1% (144/197) with 68.1% (98/144) reporting an established clinical service and 3.5% (5/144) setting up a service. Approximately 30,000 tests are performed a year with 93.0% (80/86) using cycle ergometry. Colorectal surgical patients are the most frequently tested (89.5%, 77/86). The majority of tests are performed and interpreted by anaesthetists. There is variability in the methods of interpretation and reporting of CPET and limited external validation of results.

Conclusions

This survey has identified the continued expansion of perioperative CPET services in the UK which have doubled since 2011. The vast majority of CPET tests are performed and reported by anaesthetists. It has highlighted variation in practice and a lack of standardised reporting implying a need for practice guidelines and standardised training to ensure high-quality data to inform perioperative decision making.

Inter-observer reliability of preoperative cardiopulmonary exercise test interpretation: a cross-sectional study

BACKGROUND

Despite the increasing importance of cardiopulmonary exercise testing (CPET) for preoperative risk assessment, the reliability of CPET interpretation is unclear. We aimed to assess inter-observer reliability of preoperative CPET.

METHODS

We conducted a prospective, multi-centre, observational study of preoperative CPET interpretation. Participants were professionals with previous experience or training in CPET, assessed by a standardized questionnaire. Each participant interpreted 100 tests using standardized software. The CPET variables of interest were oxygen consumption at the anaerobic threshold (AT) and peak oxygen consumption (VO₂ peak). Inter-observer reliability was measured using intra-class correlation coefficient (ICC) with a random effects model. Results are presented as ICC with 95% confidence interval, where ICC of 1 represents perfect agreement and ICC of 0 represents no agreement.

RESULTS

Participants included 8/28 (28.6%) clinical physiologists, 10 (35.7%) junior doctors, and 10 (35.7%) consultant doctors. The median previous experience was 140 (inter-quartile range 55-700) CPETs. After excluding the first 10 tests (acclimatization) for each participant and missing data, the primary analysis of AT and VO₂ peak included 2125 and 2414 tests, respectively. Inter-observer agreement for numerical values of AT [ICC 0.83 (0.75-0.90)] and VO₂ peak [ICC 0.88 (0.84-0.92)] was good. In a post hoc analysis, inter-observer agreement for identification of the presence of a reportable AT was excellent [ICC 0.93 (0.91-0.95)] and a reportable VO₂ peak was moderate [0.73 (0.64-0.80)].

CONCLUSIONS

Inter-observer reliability of interpretation of numerical values of two commonly used CPET variables was good (>80%). However, inter-observer agreement regarding the presence of a reportable value was less consistent.

[Clinical application of ROM in psychosis]

AIM

The use of 'routine outcome monitoring' (ROM) in mental health care has increased widely during the past decade. However, little is known about the use of ROM outcome in daily clinical practice. We investigated to what extent ROM results were reflected in psychotic patients' treatment plans.

DESIGN

Cross-sectional study.

METHOD

The ROM-Phamous, a ROM-protocol for patients with psychotic disorders in which data is collected on the basis of interviews, questionnaires and physical examination was implemented in the northern Netherlands. A random sample of 100 patients was extracted from the 2010 ROM database (n = 1040), from which we determined the prevalence of a number of problem areas. We then investigated whether these problems were reflected in patients' treatment plans.

RESULTS

The sample consisted of 63 men and 37 women, with a mean age of 44 years and a mean duration of illness of 18 years. The prevalence of symptoms and psychosocial problems was 13-37%; the prevalence of cardiovascular risk factors was 11-86%. The majority of problems identified with ROM were not reflected in patients' treatment plans; the opposite also occurred: psychosocial problems, in particular, mentioned in the treatment plans were not always identified with ROM.

CONCLUSION

ROM and treatment should ideally be integrated in mental-health services, but currently appear to be separate processes. If improvement of integration of ROM and clinical practice succeeds it could lead to improvement of care for psychiatric patients. Further investigation is warranted. Conflict of interest and financial support: ICMJE forms provided by the authors are available online along with the full text of this article.

Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery

BACKGROUND

In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery.

METHODS

Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity.

RESULTS

Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o₂ at θ^_L ) and at peak exercise (V˙o_2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o₂ at θ^_L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o_2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙_E /V˙co₂ at θ^_L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m² : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres.

CONCLUSION

These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.

Do routine outcome monitoring results translate to clinical practice? A cross-sectional study in patients with a psychotic disorder

BACKGROUND

The use of Routine Outcome Monitoring (ROM) in mental health care has increased widely during the past decade. Little is known, however, on the implementation and applicability of ROM outcome in daily clinical practice. In the Netherlands, an extensive ROM-protocol for patients with psychotic disorders has been implemented over the last years (ROM-Phamous). The current study investigated to what extent ROM results translate to daily clinical practice. Therefore, we investigated whether clinical problems as identified with ROM were detected and used in the treatment of patients with psychotic disorders.

METHODS

Out of the ROM database of 2010 (n = 1040), a random sample of 100 patients diagnosed with a psychotic disorder was drawn. ROM-data used in this study included a physical examination, laboratory tests, interviews and self-report questionnaires. Based on these data, the prevalence of positive and negative symptoms, psychosocial problems and cardiovascular risk factors was determined. Next, we investigated whether these problems, as identified with ROM, were reflected in the treatment plans of patients, as an indication of the use of ROM in clinical practice.

RESULTS

The sample consisted of 63 males and 37 females. The mean age was 44 and the mean duration of illness was 17.7 years. The prevalence of positive and negative symptoms, psychosocial problems and cardiovascular risk factors ranged from 11 to 86 %. In the majority of cases, problems as identified with ROM were not reflected in the treatment plans of patients.

CONCLUSIONS

We found a substantial discrepancy between the ROM measurements and the treatment plans, i.e. low rates of detection of symptoms, psychosocial problems and cardiovascular risk factors in the treatment plans, even though these problems were identified with ROM. The opposite occurred as well, where problems were reflected in the treatment plans but not identified with ROM. Thus, ROM and daily clinical practice appear to be two separate processes, whereas ideally they should be integrated. Strong efforts should be made to integrate ROM and consequent treatment activities. Such integration may help to provide patients with adequate and customized care and simultaneously minimize under- and over-treatment.

Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery

BACKGROUND

In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery.

METHODS

Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity.

RESULTS

Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o₂ at θ^_L ) and at peak exercise (V˙o_2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o₂ at θ^_L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o_2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙_E /V˙co₂ at θ^_L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m² : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres.

CONCLUSION

These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.

Cognitive alexithymia is associated with the degree of risk for psychosis

Alexithymia is a personality construct denoting emotion processing problems. It has been suggested to encompass two dimensions: a cognitive and affective dimension. The cognitive dimension is characterized by difficulties in identifying, verbalizing and analyzing emotions, while the affective dimension reflects the level of emotional arousal and imagination. Alexithymia has been previously proposed as a risk factor for developing psychosis. More specifically, the two alexithymia dimensions might be differentially related to the vulnerability for psychosis. Therefore, we examined the two dimensions of alexithymia, measured with the BVAQ in 94 siblings of patients with schizophrenia, 52 subjects at ultra-high risk (UHR) for developing psychosis, 38 patients with schizophrenia and 109 healthy controls. The results revealed that siblings and patients had higher levels of cognitive alexithymia compared to controls. In addition, subjects at UHR for psychosis had even higher levels of cognitive alexithymia compared to the siblings. The levels of affective alexithymia in siblings and patients were equal to controls. However, UHR individuals had significantly lower levels of affective alexithymia (i.e. higher levels of emotional arousal and fantasizing) compared to controls. Alexithymia was further related to subclinical levels of negative and depressive symptoms. These findings indicate that alexithymia varies parametrically with the degree of risk for psychosis. More specifically, a type-II alexithymia pattern, with high levels of cognitive alexithymia and normal or low levels of affective alexithymia, might be a vulnerability factor for psychosis.

Grey matter, an endophenotype for schizophrenia? A voxel-based morphometry study in siblings of patients with schizophrenia

BACKGROUND

Grey matter, both volume and concentration, has been proposed as an endophenotype for schizophrenia given a number of reports of grey matter abnormalities in relatives of patients with schizophrenia. However, previous studies on grey matter abnormalities in relatives have produced inconsistent results. The aim of the present study was to examine grey matter differences between controls and siblings of patients with schizophrenia and to examine whether the age, genetic loading or subclinical psychotic symptoms of selected individuals could explain the previously reported inconsistencies.

METHODS

We compared the grey matter volume and grey matter concentration of healthy siblings of patients with schizophrenia and healthy controls matched for age, sex and education using voxel-based morphometry (VBM). Furthermore, we selected subsamples based on age (< 30 yr), genetic loading and subclinical psychotic symptoms to examine whether this would lead to different results.

RESULTS

We included 89 siblings and 69 controls in our study. The results showed that siblings and controls did not differ significantly on grey matter volume or concentration. Furthermore, specifically selecting participants based on age, genetic loading or subclinical psychotic symptoms did not alter these findings.

LIMITATIONS

The main limitation was that subdividing the sample resulted in smaller samples for the subanalyses. Furthermore, we used MRI data from 2 different scanner sites.

CONCLUSION

These results indicate that grey matter measured through VBM might not be a suitable endophenotype for schizophrenia.

Effectiveness and cost-effectiveness of cognitive adaptation training as a nursing intervention in long-term residential patients with severe mental illness: study protocol for a randomized controlled trial

Background

Despite the well-known importance of cognitive deficits for everyday functioning in patients with severe mental illness (SMI), evidence-based interventions directed at these problems are especially scarce for SMI patients in long-term clinical facilities. Cognitive adaptation Training (CAT) is a compensatory approach that aims at creating new routines in patients’ living environments through the use of environmental supports. Previous studies on CAT showed that CAT is effective in improving everyday functioning in outpatients with schizophrenia. The aim of this study is to evaluate the effect of CAT as a nursing intervention in SMI patients who reside in long-term clinical facilities.

Methods/Design

This is a multicenter cluster randomized controlled trial comparing CAT (intervention group) as a nursing intervention to treatment as usual (control group). The primary goal is to evaluate the effectiveness of CAT on everyday functioning. Secondary outcomes are quality of life, empowerment and apathy. Further, an economic evaluation will be performed. The study has a duration of one year, with four follow-up assessments at 15, 18, 21 and 24 months for the intervention group.

Discussion

There is a need for evidence-based interventions that contribute to the improvement of the functional recovery of long-term residential patients. If our hypotheses are confirmed, it may be recommended to include CAT in the guidelines for SMI care and to implement the method in standardized care.

Trial registration

Nederlands Trial Register (identifier: NTR3308). Date registered: 12 February 2012.

Differential stigmatizing attitudes of healthcare professionals towards psychiatry and patients with mental health problems: something to worry about? A pilot study

PURPOSE

This study compares stigmatizing attitudes of different healthcare professionals towards psychiatry and patients with mental health problems.

METHODS

The Mental Illness Clinicians Attitude (MICA) questionnaire is used to assess stigmatizing attitudes in three groups: general practitioners (GPs, n = 55), mental healthcare professionals (MHCs, n = 67) and forensic psychiatric professionals (FPs, n = 53).

RESULTS

A modest positive attitude towards psychiatry was found in the three groups (n = 176). Significant differences were found on the total MICA-score (p < 0.001). GPs scored significantly higher than the FPs and the latter scored significantly higher than the MHCs on all factors of the MICA. Most stigmatizing attitudes were found on professionals' views of health/social care field and mental illness and disclosure. Personal and work experience did not influence stigmatizing attitudes.

CONCLUSIONS

Although all three groups have a relatively positive attitude using the MICA, there is room for improvement. Bias toward socially acceptable answers cannot be ruled out. Patients' view on stigmatizing attitudes of professionals may be a next step in stigma research in professionals.

Use of a pathway quality improvement care bundle to reduce mortality after emergency laparotomy

Background

Emergency laparotomies in the UK, USA and Denmark are known to have a high risk of death, with accompanying evidence of suboptimal care. The emergency laparotomy pathway quality improvement care (ELPQuiC) bundle is an evidence-based care bundle for patients undergoing emergency laparotomy, consisting of: initial assessment with early warning scores, early antibiotics, interval between decision and operation less than 6 h, goal-directed fluid therapy and postoperative intensive care.

Methods

The ELPQuiC bundle was implemented in four hospitals, using locally identified strategies to assess the impact on risk-adjusted mortality. Comparison of case mix-adjusted 30-day mortality rates before and after care-bundle implementation was made using risk-adjusted cumulative sum (CUSUM) plots and a logistic regression model.

Results

Risk-adjusted CUSUM plots showed an increase in the numbers of lives saved per 100 patients treated in all hospitals, from 6·47 in the baseline interval (299 patients included) to 12·44 after implementation (427 patients included) (P < 0·001). The overall case mix-adjusted risk of death decreased from 15·6 to 9·6 per cent (risk ratio 0·614, 95 per cent c.i. 0·451 to 0·836; P = 0·002). There was an increase in the uptake of the ELPQuiC processes but no significant difference in the patient case-mix profile as determined by the mean Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity risk (0·197 and 0·223 before and after implementation respectively; P = 0·395).

Conclusion

Use of the ELPQuiC bundle was associated with a significant reduction in the risk of death following emergency laparotomy.

Neural correlates of emotion regulation in patients with schizophrenia and non-affected siblings

BACKGROUND

Patients with schizophrenia often experience problems regulating their emotions. Non-affected relatives show similar difficulties, although to a lesser extent, and the neural basis of such difficulties remains to be elucidated. In the current paper we investigated whether schizophrenia patients, non-affected siblings and healthy controls (HC) exhibit differences in brain activation during emotion regulation.

METHODS

All subjects (n = 20 per group) performed an emotion regulation task while they were in an fMRI scanner. The task contained two experimental conditions for the down-regulation of emotions (reappraise and suppress), in which IAPS pictures were used to generate a negative affect. We also assessed whether the groups differed in emotion regulation strategies used in daily life by means of the emotion regulation questionnaire (ERQ).

RESULTS

Though the overall negative affect was higher for patients as well as for siblings compared to HC for all conditions, all groups reported decreased negative affect after both regulation conditions. Nonetheless, neuroimaging results showed hypoactivation relative to HC in VLPFC, insula, middle temporal gyrus, caudate and thalamus for patients when reappraising negative pictures. In siblings, the same pattern was evident as in patients, but only in cortical areas.

CONCLUSIONS

Given that all groups performed similarly on the emotion regulation task, but differed in overall negative affect ratings and brain activation, our findings suggest reduced levels of emotion regulation processing in neural circuits in patients with schizophrenia. Notably, this also holds for siblings, albeit to a lesser extent, indicating that it may be part and parcel of a vulnerability for psychosis.

Alexithymia influences brain activation during emotion perception but not regulation

Alexithymia is a psychological construct that can be divided into a cognitive and affective dimension. The cognitive dimension is characterized by difficulties in identifying, verbalizing and analysing feelings. The affective dimension comprises reduced levels of emotional experience and imagination. Alexithymia is widely regarded to arise from an impairment of emotion regulation. This is the first functional magnetic resonance imaging (fMRI) study to critically evaluate this by investigating the neural correlates of emotion regulation as a function of alexithymia levels. The aim of the current study was to investigate the neural correlates underlying the two alexithymia dimensions during emotion perception and emotion regulation. Using fMRI, we scanned 51 healthy subjects while viewing, reappraising or suppressing negative emotional pictures. The results support the idea that cognitive alexithymia, but not affective alexithymia, is associated with lower activation in emotional attention and recognition networks during emotion perception. However, in contrast with several theories, no alexithymia-related differences were found during emotion regulation (neither reappraisal nor suppression). These findings suggest that alexithymia may result from an early emotion processing deficit rather than compromised frontal circuits subserving higher-order emotion regulation processes.

Normal brain activation in schizophrenia patients during associative emotional learning

Emotional deficits are among the core features of schizophrenia and both associative emotional learning and the related ability to verbalize emotions can be reduced. We investigated whether schizophrenia patients demonstrated impaired function of limbic and prefrontal areas during associative emotional learning. Patients and controls filled out an alexithymia questionnaire and performed an associative emotional learning task with positive, negative and neutral picture-word pairs during fMRI scanning. After scanning, they indicated for each pair whether they remembered it. We conducted standard GLM analysis and Independent Component Analysis (ICA). Both the GLM results and task-related ICA components were compared between groups. The alexithymia questionnaire indicated more cognitive-emotional processing difficulties in patients than controls, but equal experienced intensity of affective states. Patients remembered less picture-word pairs, irrespective of valence. GLM analysis showed significant visual, temporal, amygdalar/hippocampal, and prefrontal activation in all subjects. ICA identified a network of brain areas similar to GLM, mainly in response to negative stimuli. Neither analysis showed differences between patients and controls during learning. Although in previous studies schizophrenia patients showed abnormalities in both memory and emotion processing, neural circuits involved in cross-modal associative emotional learning may remain intact to a certain degree, which may have potential consequences for treatment.

When Broca goes uninformed: reduced information flow to Broca's area in schizophrenia patients with auditory hallucinations

Auditory-verbal hallucinations (AVHs) are frequently associated with activation of the left superior temporal gyrus (including Wernicke's area), left inferior frontal gyrus (including Broca's area), and the right hemisphere homologs of both areas. It has been hypothesized that disconnectivity of both interhemispheric transfer and frontal and temporal areas may underlie hallucinations in schizophrenia. We investigated reduced information flow in this circuit for the first time using dynamic causal modeling, which allows for directional inference. A group of healthy subjects and 2 groups of schizophrenia patients-with and without AVH-performed a task requiring inner speech processing during functional brain scanning. We employed connectivity models between left hemispheric speech-processing areas and their right hemispheric homologs. Bayesian model averaging was used to estimate the connectivity strengths and evaluate group differences. Patients with AVH showed significantly reduced connectivity from Wernicke's to Broca's area (97% certainty) and a trend toward a reduction in connectivity from homologs of Broca's and Wernicke's areas to Broca's area (93% and 94% certainty). The connectivity magnitude in patients without hallucinations was found to be intermediate. Our results point toward a reduced input from temporal to frontal language areas in schizophrenia patients with AVH, suggesting that Broca's activity may be less constrained by perceptual information received from the temporal cortex. In addition, a lack of synchronization between Broca and its homolog may lead to the erroneous interpretation of emotional speech activity from the right hemisphere as coming from an external source.

Reduced connectivity in the self-processing network of schizophrenia patients with poor insight

Lack of insight (unawareness of illness) is a common and clinically relevant feature of schizophrenia. Reduced levels of self-referential processing have been proposed as a mechanism underlying poor insight. The default mode network (DMN) has been implicated as a key node in the circuit for self-referential processing. We hypothesized that during resting state the DMN network would show decreased connectivity in schizophrenia patients with poor insight compared to patients with good insight. Patients with schizophrenia were recruited from mental health care centers in the north of the Netherlands and categorized in groups having good insight (n= 25) or poor insight (n = 19). All subjects underwent a resting state fMRI scan. A healthy control group (n = 30) was used as a reference. Functional connectivity of the anterior and posterior part of the DMN, identified using Independent Component Analysis, was compared between groups. Patients with poor insight showed lower connectivity of the ACC within the anterior DMN component and precuneus within the posterior DMN component compared to patients with good insight. Connectivity between the anterior and posterior part of the DMN was lower in patients than controls, and qualitatively different between the good and poor insight patient groups. As predicted, subjects with poor insight in psychosis showed decreased connectivity in DMN regions implicated in self-referential processing, although this concerned only part of the network. This finding is compatible with theories implying a role of reduced self-referential processing as a mechanism contributing to poor insight.

Altered resting state connectivity of the default mode network in alexithymia

Alexithymia is a trait characterized by a diminished capacity to describe and distinguish emotions and to fantasize; it is associated with reduced introspection and problems in emotion processing. The default mode network (DMN) is a network of brain areas that is normally active during rest and involved in emotion processing and self-referential mental activity, including introspection. We hypothesized that connectivity of the DMN might be altered in alexithymia. Twenty alexithymic and 18 non-alexithymic healthy volunteers underwent a resting state fMRI scan. Independent component analysis was used to identify the DMN. Differences in connectivity strength were compared between groups. Within the DMN, alexithymic participants showed lower connectivity within areas of the DMN (medial frontal and temporal areas) as compared to non-alexithymic participants. In contrast, connectivity in the high-alexithymic participants was higher for the sensorimotor cortex, occipital areas and right lateral frontal cortex than in the low-alexithymic participants. These results suggest a diminished connectivity within the DMN of alexithymic participants, in brain areas that may also be involved in emotional awareness and self-referential processing. On the other hand, alexithymia was associated with stronger functional connections of the DMN with brain areas involved in sensory input and control of emotion.

Case-controlled study of critical care or surgical ward care after elective open colorectal surgery

BACKGROUND

Evidence for the benefit of critical care after surgery is limited. This study assessed the value of immediate admission to the critical care unit (CCU) after open colorectal surgery.

METHODS

Patients aged over 45 years were screened with a cardiopulmonary exercise test to determine their anaerobic threshold. Less fit patients defined by an anaerobic threshold below 11 ml oxygen per kg per min were assigned to either critical care or surgical ward care. Those with an anaerobic threshold of 11 ml oxygen per kg per min or above were assigned to ward care. The outcome measure was the number of cardiac events.

RESULTS

Of 153 patients who underwent exercise testing, 55 had an anaerobic threshold of at least 11 ml oxygen per kg per min (ward care) and 98 had a threshold of less than 11 ml oxygen per kg per min, of whom 39 were allocated to ward care and 51 to critical care. Median length of CCU stay was 31 (range 5-46) h. More cardiac events occurred in patients allocated to ward care (7 of 39) than in those allocated to critical care (0 of 51): absolute difference 18 (95 per cent confidence interval 10 to 26) per cent (P = 0·002). There were no cardiac events in patients with an anaerobic threshold of 11 ml oxygen per kg per min or higher.

CONCLUSION

Patients with an anaerobic threshold of at least 11 ml oxygen per kg per min and those with a threshold below 11 ml oxygen per kg per min managed in the CCU had fewer cardiac events.

Variation of the gene coding for DARPP-32 (PPP1R1B) and brain connectivity during associative emotional learning

Associative emotional learning, which is important for the social emotional functioning of individuals and is often impaired in psychiatric illnesses, is in part mediated by dopamine and glutamate pathways in the brain. The protein DARPP-32 is involved in the regulation of dopaminergic and glutaminergic signaling. Consequently, it has been suggested that the haplotypic variants of the gene PPP1R1B that encodes DARPP-32 are associated with working memory and emotion processing. We hypothesized that PPP1R1B should have a significant influence on the network of brain regions involved in associative emotional learning that are rich in DARPP-32, namely the striatum, prefrontal cortex (comprising the medial frontal gyrus and inferior frontal gyrus (IFG)), amygdala and parahippocampal gyrus (PHG). Dynamic causal models were applied to functional MRI data to investigate how brain connectivity during an associative emotional learning task is affected by different single-nucleotide polymorphisms (SNPs) of PPP1R1B: rs879606, rs907094 and rs3764352. Compared to heterozygotes, homozygotes with GTA alleles displayed increased intrinsic connectivity between the IFG and PHG, as well as increased excitability of the PHG for negative emotional stimuli. We have also elucidated the directionality of these genetic influences. Our data suggest that homozygotes with GTA alleles involve stronger functional connections between brain areas in order to maintain activation of these regions. Homozygotes might engage a greater degree of motivational learning and integration of information to perform the emotional learning task correctly. We conclude that PPP1R1B is associated with the neural network involved in associative emotional learning.