Quick links: Apprenticeship project

This project was designed to support people to find information, resources, and evidence independently within Health Education England (now NHS England Workforce Training and Education) and allow the Knowledge Management team more time to focus on other services offered. This project aimed to pull together a number of resources in to one simple 'Quick links' page, with relevant information, resources and further training, providing people with opportunities to build on their own knowledge and skills.

Search Club: Using peer support to develop search skills and share knowledge in a specialist NHS team

The newly-formed Knowledge Management team at Health Education England (HEE) established an internal "Search Club" for their Knowledge Specialists to share good practice, exchange ideas, and discuss approaches to developing search strategies. The article describes how this was initiated and run online. The sessions improved the Knowledge Management team skills, and gave them an opportunity to share and learn from each other. A further benefit has been the creation of resources such as a "synonyms bank", search strategies, and a bank of grey literature sources. These reduce duplication of effort, save time, and improve consistency across the team's output. D.I.

Long-term benefits and adverse effects of intermittent versus daily glucocorticoids in boys with Duchenne muscular dystrophy

OBJECTIVE

To assess the current use of glucocorticoids (GCs) in Duchenne muscular dystrophy in the UK, and compare the benefits and the adverse events of daily versus intermittent prednisolone regimens.

DESIGN

A prospective longitudinal observational study across 17 neuromuscular centres in the UK of 360 boys aged 3-15 years with confirmed Duchenne muscular dystrophy who were treated with daily or intermittent (10 days on/10 days off) prednisolone for a mean duration of treatment of 4 years.

RESULTS

The median loss of ambulation was 12 years in intermittent and 14.5 years in daily treatment; the HR for intermittent treatment was 1.57 (95% CI 0.87 to 2.82). A fitted multilevel model comparing the intermittent and daily regiments for the NorthStar Ambulatory Assessment demonstrated a divergence after 7 years of age, with boys on an intermittent regimen declining faster (p<0.001). Moderate to severe side effects were more commonly reported and observed in the daily regimen, including Cushingoid features, adverse behavioural events and hypertension. Body mass index mean z score was higher in the daily regimen (1.99, 95% CI 1.79 to 2.19) than in the intermittent regimen (1.51, 95% CI 1.27 to 1.75). Height restriction was more severe in the daily regimen (mean z score -1.77, 95% CI -1.79 to -2.19) than in the intermittent regimen (mean z score -0.70, 95% CI -0.90 to -0.49).

CONCLUSIONS

Our study provides a framework for providing information to patients with Duchenne muscular dystrophy and their families when introducing GC therapy. The study also highlights the importance of collecting longitudinal natural history data on patients treated according to standardised protocols, and clearly identifies the benefits and the side-effect profile of two treatment regimens, which will help with informed choices and implementation of targeted surveillance.

Rethinking sedation and agitation management in critical illness

OBJECTIVE

To examine difficulties in sedation management in the critically ill patient and explore how a semi automated sedation controller can improve agitation control. To present recent work on measurements of agitation, dynamic systems modelling and control of patient agitation response.

DATA SOURCES

Articles and peer-reviewed studies identified through a PUBMED search and selected original works from the biomedical engineering literature of relevance to agitation control and management.

SUMMARY OF REVIEW

Over-sedation has an adverse impact on intensive care resources. Interventions to constrain sedation delivery through development of protocols or regular cessation of infusions result in reduction in resource utilisation, but have not significantly addressed existing difficulties in agitation control. We develop a paradigm in which control of agitation in critically ill patients becomes the primary objective of sedation management. This principle is central to the function of a nurse-managed semi-automated sedation delivery device. The clinical application of this device using subjective assessments of agitation is presented. A framework for the development of improved automated sedation delivery systems using objective measurements of agitation and control, based on agitation feedback, is described. Using dynamic systems modelling and a simulated nurse, a bolus-driven approach significantly reduced agitation and minimised drug utilisation. This result challenges the current practice of sedating patients using continuous infusions.

CONCLUSIONS

A simple computerised interface with an algorithm that continually reduces the infusion rate in the absence of agitation has successfully been introduced into clinical practice. Nursing staff reported high levels of satisfaction with this device and it has enabled detailed data on patterns of sedation administration to be extracted for analysis. This data has been used to validate a model of the fundamental agitation-sedation dynamics.

Can exercise therapy improve the outcome of microdiscectomy?

STUDY DESIGN

A prospective randomized controlled trial of exercise therapy in patients who underwent microdiscectomy for prolapsed lumbar intervertebral disc. Results of a pilot study are presented.

OBJECTIVE

To determine the effects of a postoperative exercise program on pain, disability, psychological status, and spinal function.

SUMMARY OF BACKGROUND DATA

Microdiscectomy is often used successfully to treat prolapsed lumbar intervertebral disc. However, some patients do not have a good outcome and many continue to have low back pain. The reasons for this are unclear but impairment of back muscle function due to months of inactivity before surgery may be a contributing factor. A postoperative exercise program may improve outcome in such patients.

METHODS

Twenty patients who underwent lumbar microdiscectomy were randomized into EXERCISE and CONTROL groups. After surgery, all patients received normal postoperative care that included advice from a physiotherapist about exercise and a return to normal activities. Six weeks after surgery, patients in the EXERCISE group undertook a 4-week exercise program that concentrated on improving strength and endurance of the back and abdominal muscles and mobility of the spine and hips. Assessments of spinal function were performed in all patients during the week before surgery and at 6, 10, 26, and 52 weeks after. The assessment included measures of posture, hip and lumbar mobility, back muscle endurance capacity and electromyographic measures of back muscle fatigue. On each occasion, patients completed questionnaires inquiring about pain, disability and psychological status.

RESULTS

Surgery improved pain, disability, back muscle endurance capacity and hip and lumbar mobility in both groups of patients. After the exercise program, the EXERCISE group showed further improvements in these measures and also in electromyographic measures of back muscle fatigability. All these improvements were maintained 12 months after surgery. The only further improvement showed by the CONTROL group between 6 and 52 weeks was an increase in back muscle endurance capacity.

CONCLUSION

A 4-week postoperative exercise program can improve pain, disability, and spinal function inpatients who undergo microdiscectomy. [Key words: electromyogram median frequency, exercise therapy, intervertebral disc prolapse, microdiscectomy, randomized controlled trial, spinal function.