Educational interventions for imposter phenomenon in healthcare: a scoping review

BACKGROUND

Imposter Phenomenon (IP) is a subjective feeling of intellectual fraudulence and self-doubt experienced by individuals in goal-orientated high-achieving professions. The impact of IP within healthcare has been associated with individual physical and mental health and concerns around training, career progression and DEI at an institutional level. To effectively address IP in healthcare, this scoping review aims to explore educational interventions designed to empower high-achieving individuals with the tools needed to confront and overcome IP.

METHODS

The scoping review adhered to a predetermined protocol informed by the JBI methodology and PRISMA-ScR guidelines in order to identify educational interventions addressing IP in high-achieving industries. Articles were searched across multiple databases, including MEDLINE (Ovid), PsychINFO, SCOPUS, and Web of Science, alongside grey literature, without imposing any time constraints. A systematic approach including a thematic analysis allowed for a nuanced exploration and interpretation of the identified educational interventions and their impact on addressing IP.

RESULTS

Seventeen articles were incorporated into the review, with the majority originating from the USA and majority being published since 2020. Ten studies targeted healthcare professionals, undergraduate and postgraduate healthcare students. Majority of studies aimed at addressing IP, featured a larger number of female participants than males. Workshops with self-reflection and group-guided exercises to overcome IP were the most popular educational interventions. Coaching and structured supervision were also suggested. Across all papers, three themes emerged for coping strategies: individual, peer-to-peer, and institutional.

CONCLUSIONS

This scoping review suggests how group and individual interventions such as workshops, small group discussions and coaching can be used to overcome IP in healthcare. Institutional changes like diversity promotion, supervisor education, and support networks are crucial in addressing IP. Further long term and speciality specific assessments are needed to measure impact. Overall, the review highlights how educational awareness and a variety of strategies can be implemented to create a supportive environment for professionals dealing with IP, promoting their well-being and success.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

PRESS survey: PREvention of surgical site infection-a global pan-specialty survey of practice protocol

Background

Surgical site infections (SSI) complicate up to 40% of surgical procedures, leading to increased patient morbidity and mortality. Previous research identified disparities in SSI prevention guidelines and clinical practices across different institutions. The study aims to identify variations in SSI prevention practices within and between specialties and financial systems and provide a representation of existing SSI preventative measures to help improve the standardization of SSI prevention practices.

Methods

This collaborative cross-sectional survey will be aimed at pan-surgical specialties internationally. The study has been designed and will be reported in line with the CROSS and CHERRIES standards. An international study steering committee will design and internally validate the survey in multiple consensus-based rounds. This will be based on SSI prevention measures outlined in the CDC (2017), WHO (2018), NICE (2019), Wounds UK (2020) and the International Surgical Wound Complications Advisory Panel (ISWCAP) guidelines. The questionnaire will include demographics, SSI surveillance, preoperative, peri-operative and postoperative SSI prevention. Data will be collected on participants' surgical specialty, operative grade, of practice and financial healthcare system of practice. The online survey will be designed and disseminated using QualtricsXM Platform™ through national and international surgical colleges and societies, in addition to social media and snowballing. Data collection will be open for 3 months with reminders, and raking will be used to ascertain the sample. Responses will be analyzed, and the chi-square test used to evaluate the impact of SSI prevention variables on responses.

Discussion

Current SSI prevention practice in UK Vascular surgery varies considerably, with little consensus on many measures. Given the inconsistency in guidelines on how to prevent SSIs, there is a need for standardization. This survey will investigate the disparity in SSI preventative measures between different surgical fields and countries.

Imaging manifestations of IgG4-related disease

IgG4-related disease is a multisystem immune-mediated disorder associated with lesions manifesting an IgG4-rich plasma cell infiltrate and often raised serum IgG4 concentrations. The disease can mimic neoplastic, infective, and inflammatory processes due to features such as development of masses or organ enlargement. Prompt consideration of this diagnosis is essential to avoid unnecessary investigations and offer appropriate treatments, which can include steroids and other immunosuppressive agents. Although histology is typically diagnostic, imaging is critical to assess disease burden, determine biopsy targets, and evaluate response to treatment. Characteristic imaging features can also point towards the diagnosis in the absence of biopsy. This review highlights these features, as well as more atypical findings, grouped by organ or system. Differential diagnoses are emphasised. The full spectrum of imaging methods is discussed. Whole-body imaging with integrated 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET)/computed tomography (CT) has an evolving role in the detection of multi-organ involvement and subsequent follow-up.

The association between iron deficiency and outcomes: a secondary analysis of the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial

In the intravenous iron therapy to treat iron deficiency anaemia in patients undergoing major abdominal surgery (PREVENTT) trial, the use of intravenous iron did not reduce the need for blood transfusion or reduce patient complications or length of hospital stay. As part of the trial protocol, serum was collected at randomisation and on the day of surgery. These samples were analysed in a central laboratory for markers of iron deficiency. We performed a secondary analysis to explore the potential interactions between pre-operative markers of iron deficiency and intervention status on the trial outcome measures. Absolute iron deficiency was defined as ferritin <30 μg.l^-1 ; functional iron deficiency as ferritin 30-100 μg.l^-1 or transferrin saturation < 20%; and the remainder as non-iron deficient. Interactions were estimated using generalised linear models that included different subgroup indicators of baseline iron status. Co-primary endpoints were blood transfusion or death and number of blood transfusions, from randomisation to 30 days postoperatively. Secondary endpoints included peri-operative change in haemoglobin, postoperative complications and length of hospital stay. Most patients had iron deficiency (369/452 [82%]) at randomisation; one-third had absolute iron deficiency (144/452 [32%]) and half had functional iron deficiency (225/452 [50%]). The change in pre-operative haemoglobin with intravenous iron compared with placebo was greatest in patients with absolute iron deficiency, mean difference 8.9 g.l^-1 , 95%CI 5.3-12.5; moderate in functional iron deficiency, mean difference 2.8 g.l^-1 , 95%CI -0.1 to 5.7; and with little change seen in those patients who were non-iron deficient. Subgroup analyses did not suggest that intravenous iron compared with placebo reduced the likelihood of death or blood transfusion at 30 days differentially across subgroups according to baseline ferritin (p = 0.33 for interaction), transferrin saturation (p = 0.13) or in combination (p = 0.45), or for the number of blood transfusions (p = 0.06, 0.29, and 0.39, respectively). There was no beneficial effect of the use of intravenous iron compared with placebo, regardless of the metrics to diagnose iron deficiency, on postoperative complications or length of hospital stay.

The barriers and facilitators to research in practice: the experiences of a medicines optimisation team within a clinical commissioning group

Introduction

Research active healthcare organisations and staff have been shown to significantly improve performance and patient outcomes1. Undertaking research is a core element of the pharmacist role, however many pharmacists report not having the skills, knowledge and/or resources to take part2. There are many opportunities for the delivery of transformational research within primary care, however pharmacy team engagement is lacking.

Aim

To explore the barriers and facilitators to research engagement within a Clinical Commissioning Group (CCG) Medicines Optimisation team.

Methods

Twelve focus groups, guided by a semi-structured topic guide, were held over MS Teams between October 2021 and February 2022. 37 participants (pharmacists, pharmacy technicians and administrative support roles) attended and discussed topics relating to their experiences of engaging with research, as well as what helped or hindered them. Detailed notes were taken and analysed using Thematic Analysis. Following this inductive analysis, which aimed to capture all themes arising from the data, the Consolidated Framework for Implementation Research (CFIR)3 was applied. This helped to categorise the barriers and facilitators into domains which influence to what extent research is undertaken. The analysis was validated by the CCG team. This study was deemed to be service evaluation and therefore no ethical approval was needed.

Results

Three core themes emerged: People, Place and Practicalities. Individuals felt they had limited knowledge and capabilities in the field of research, despite having an internal motivation to engage in research activity. The perception of research was often linked in peoples’ thoughts to academia or secondary care/ acute Trusts or lab-based, and therefore not really something they would engage with in their current role. A lack of research culture, leadership and visibility of projects were all thought to hinder the team. A clear need for training and education in research (what it is, how it can be done, and available tools) was expressed, as well as appropriate resource allocation. Mapping to the CFIR illustrated that most barriers fell within the inner setting (i.e. the organisation itself) and with the process of conducting research, such as limited time, lack of encouragement from champions and poor feedback from projects. Enablers were also identified which included advice offered by external organisations, dissemination about work conducted in other primary care organisations and beliefs about the benefits of being research active.

Discussion/Conclusion

Participants perceived there to be many more barriers to research engagement than enablers, and these ranged from challenges with the individual projects, the process of conducting research within the organisation, things about the person themselves, their organisation or the wider setting of primary care. Areas for improvement were identified, mainly through increased training, visibility of projects and interested people, development of champions and role models, and stronger links with academia. This study was conducted with only one CCG and therefore further work needs to explore the experience within other integrated care boards and across secondary and community practice.

References

1. Hanney, S., Boaz, A., Soper, B. and Jones, T. Engagement in research: an innovative three-stage review of the benefits for health-care performance. Health Services and Delivery Research, 2013;1(8). ISSN (print) 2050-4349

2. Crilly P, Patel N, Ogunrinde A, Berko D, Kayyali R. Community Pharmacists’ Involvement in Research in the United Kingdom. Pharmacy. 2017;5(3):48. https://doi.org/10.3390/pharmacy5030048

3. Damschroder, L.J., Aron, D.C., Keith, R.E. et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci 2009;4:50. https://doi.org/10.1186/1748-5908-4-50

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Chronic kidney disease mediates cardiac dysfunction associated with increased resident cardiac macrophages

BACKGROUND

The leading cause of death in end-stage kidney disease is related to cardiovascular disease. Macrophages are known to be involved in both chronic kidney disease (CKD) and heart failure, however their role in the development of cardiorenal syndrome is less clear. We thus sought to investigate the role of macrophages in uremic cardiac disease.

METHODS

We assessed cardiac response in two experimental models of CKD and tested macrophage and chemokine implication in monocytopenic CCR2-/- and anti-CXCL10 treated mice. We quantified CXCL10 in human CKD plasma and tested the response of human iPSC-derived cardiomyocytes and primary cardiac fibroblasts to serum from CKD donors.

RESULTS

We found that reduced kidney function resulted in the expansion of cardiac macrophages, in particular through local proliferation of resident populations. Influx of circulating monocytes contributed to this increase. We identified CXCL10 as a crucial factor for cardiac macrophage expansion in uremic disease. In humans, we found increased plasma CXCL10 concentrations in advanced CKD, and identified the production of CXCL10 in cardiomyocytes and cardiac fibroblasts.

CONCLUSIONS

This study provides new insight into the role of the innate immune system in uremic cardiomyopathy.

Impact of the SARS-CoV-2 (COVID-19) crisis on surgical training: global survey and a proposed framework for recovery

Background

The SARS-CoV-2 pandemic had a profound impact on surgical services, potentially having a detrimental impact on training opportunities. The aim of this global survey was to assess the impact of the COVID-19 crisis on surgical training and to develop a framework for recovery.

Methods

A cross-sectional, web-based survey was conducted. This was designed by a steering committee of medical educationalists and validated by a group of trainees before dissemination.

Results

A total of 608 responses were obtained from 34 countries and 15 specialties. The results demonstrated major disruption in all aspects of training. The impact was greatest for conferences (525 of 608) and hands-on courses (517 of 608), but less for inpatient care-related training (268 of 608). European trainees were significantly more likely to experience direct training disruption than trainees in Asia (odds ratio 0.15) or Australia (OR 0.10) (χ² = 87.162, P < 0.001). Alternative training resources (webinars, 359 of 608; educational videos, 234 of 608) have emerged, although trainees expressed some dissatisfaction with them. The collective responses generated a four-pillar framework for training recovery that involved: guidance from training stakeholders with the involvement of trainees; prioritization of training, especially the roles of senior surgeons/trainers; provision of access to alternative/new teaching methods; and measures to address trainee anxiety.

Conclusion

Training has been greatly affected by the COVID-19 pandemic. The introduction of new teaching methods and a focus on training after the pandemic are imperative.

Identifying behaviour change techniques to support medicines management for older people at care transitions

Introduction

Older patients are at significant risk of medicines-related harm following a hospital to home transition [1]. Strategies, such as information transfer and medicines reconciliation, have been suggested to promote successful transitions through better medicines management [2]. These interventions, however, are not often underpinned by patient experience or grounded in theory, and therefore have variable effects in real-world contexts.

Aim

To identify which behaviour change techniques (BCTs) could be combined within a complex intervention to support post-discharge medicines management.

Methods

Barriers and facilitators to post-discharge medicines management behaviours were identified from an analysis of interviews with twenty-seven older people (aged 75 years plus) and mapped to the Theoretical Domains Framework (TDF). These participants were recruited during a stay in two large hospitals in the North of England. All potential BCTs targeting the identified TDF domains were found using validated mapping exercises and refined by panel consensus. The panel consisted of two pharmacists, two health services researchers, a social work academic and a patient representative. Next, a convenience sample of key stakeholders (n=40; patients and family carers, healthcare professionals and researchers) were invited to take part in an online survey to prioritise remaining techniques. A total score for each BCT was calculated based on its potential i) effectiveness, ii) acceptability and iii) ability to cause unintended consequences. The BCTs were ranked from lowest to highest scores. As validation, the final selection of BCTs was assessed using the APEASE criteria and mapped back to the behavioural determinants to check the components would enhance facilitators and overcome barriers (Figure 1).

Results

Forty-six behavioural determinants were identified within interviews and classified as barriers (n=19), facilitators (n=10), or both (n=17). These were deductively mapped onto 11 domains of the TDF. Following the mapping, 50 discrete BCTs were identified, which were reduced to 35 after subsequent consensus discussions between panel members to remove any deemed inappropriate. The survey resulted in 25 responses (62.5% response rate). Following visual inspection of the ranking, a natural cut-off was identified by panel consensus at 88% of the total score. This, and further assessment using the APEASE criteria, prioritised eight BCTs that were highly rated to be effective in promoting post-discharge medicines management when combined within a complex intervention. These were: practical social support, goal/ target specified, prompts, triggers or cues, social processes of encouragement, motivational interviewing, rehearsal, review goals, and comparative imagining of future outcomes.

Conclusion

This study has identified eight BCTs that could be valuable when combined within a complex intervention to support post-discharge medicines management for older people. Consensus allowed prioritisation of BCTs that were likely to be effective, acceptable to older people, practical and cost-effective to deliver within current healthcare organisations. Limitations included challenges of coding complex behavioural determinants to the TDF, defining the BCTs within the medicines management context and modest survey sample size. To overcome these limitations, input was sought from a health psychologist with expertise and consensus involved all relevant stakeholders.

References

1. Parekh, N., Ali, K., Stevenson, J. M., et al. Incidence and cost of medication harm in older adults following hospital discharge: a multicentre prospective study in the UK. British journal of clinical pharmacology 2018;84(8):1789–1797.

2. Tomlinson, J., Cheong, V., Fylan, B., et al. Successful care transitions for older people: a systematic review and meta-analysis of the effects of interventions that support medication continuity. Age and Ageing 2020;00:1–12.

22 Coping with Medicines After Hospital Discharge; the Invisible Work of Older Patients and Their Care-Givers

Introduction

Older patients often experience medication-related problems following discharge from hospital. These can be categorised as issues with obtaining medication, taking medication, medication effects or problems with communication or care co-ordination (Nicosia et al., Journal of General Internal Medicine, 2019, https://doi.org/10.1007/s11606-019-05463-z). The aim of this study was to explore older adults’ experiences of post-discharge medicines management, including the strategies they use to safely manage their changed medicines.

Methods

Following ethical approval, patients aged 75 and above, with a change in their long term medicines, were recruited during admission to one of two hospitals in Yorkshire. Semi-structured interviews took place with the participants in their own homes, approximately two weeks after discharge. Interviews were audio recorded and transcribed. Data were analysed using the Framework method.

Results

Twenty-seven patients (mean age 85 years; 6 males) consented to be interviewed. They described multiple self-management and safety strategies used to support medicines management in the early post-discharge phase. The work done included adaptations (to routines, the home environment and action plans), scaffolding (where patients and their care-givers support the primary care system by providing additional documentation or prompts to ensure medicines were supplied on time and were correct) and error avoidance (seeking information, performing checks and balances).

Conclusion

Older patients experience gaps in their post-discharge medicines-related care which they had to bridge through implementing their own strategies or by enlisting support from others. This study shines a spotlight on to the invisible work that patients have to do in order to make post-discharge medicines management fit for purpose. Further work should consider those patients who are not able to carry out these tasks or who do not have any care-givers available for support and how this potential gap in care can be addressed.

Retrospective Evaluation of Horses Diagnosed with Neuroborreliosis on Postmortem Examination: 16 Cases (2004-2015)

BACKGROUND

Equine neuroborreliosis (NB), Lyme disease, is difficult to diagnose and has limited description in the literature.

OBJECTIVE

Provide a detailed description of clinical signs, diagnostic, and pathologic findings of horses with NB.

ANIMALS

Sixteen horses with histologically confirmed NB.

METHODS

Retrospective review of medical records at the University of Pennsylvania and via an ACVIM listserv query with inclusion criteria requiring possible exposure to Borrelia burgdorferi and histologic findings consistent with previous reports of NB without evidence of other disease.

RESULTS

Sixteen horses were identified, 12 of which had additional evidence of NB. Clinical signs were variable including muscle atrophy or weight loss (12), cranial nerve deficits (11), ataxia (10), changes in behavior (9), dysphagia (7), fasciculations (6), neck stiffness (6), episodic respiratory distress (5), uveitis (5), fever (2), joint effusion (2), and cardiac arrhythmias (1). Serologic analysis was positive for B. burgdorferi infection in 6/13 cases tested. CSF abnormalities were present in 8/13 cases tested, including xanthochromia (4/13), increased total protein (5/13; median: 91 mg/dL, range: 25-219 mg/dL), and a neutrophilic (6/13) or lymphocytic (2/13) pleocytosis (median: 25 nucleated cells/μL, range: 0-922 nucleated cells/μL). PCR on CSF for B. burgdorferi was negative in the 7 cases that were tested.

CONCLUSION AND CLINICAL IMPORTANCE

Diagnosis of equine NB is challenging due to variable clinical presentation and lack of sensitive and specific diagnostic tests. Negative serology and normal CSF analysis do not exclude the diagnosis of NB.

Hypoxia causes increased monocyte nitric oxide synthesis which is mediated by changes in dimethylarginine dimethylaminohydrolase 2 expression in animal and human models of normobaric hypoxia

BACKGROUND

Tissue hypoxia is a cardinal feature of inflammatory diseases and modulates monocyte function. Nitric oxide is a crucial component of the immune cell response. This study explored the metabolism of the endogenous inhibitor of nitric oxide production asymmetric dimethylarginine(ADMA) by monocyte dimethylarginine dimethylaminohydrolase 2(DDAH2), and the role of this pathway in the regulation of the cellular response and the local environment during hypoxia.

METHODS

Peritoneal macrophages were isolated from a macrophage-specific DDAH2 knockout mouse that we developed and compared with appropriate controls. Cells were exposed to 3% oxygen followed by reoxygenation at 21%. Healthy volunteers underwent an 8 h exposure to normobaric hypoxia with an inspired oxygen percentage of 12%. Peripheral blood mononuclear cells were isolated from blood samples taken before and at the end of this exposure.

RESULTS

Intracellular nitrate plus nitrite(NOx) concentration was higher in wild-type murine monocytes after hypoxia and reoxygenation than in normoxia-treated cells (mean(SD) 13·2(2·4) vs 8·1(1·7) pmols/mg protein, p = 0·009). DDAH2 protein was 4·5-fold (SD 1·3) higher than in control cells (p = 0·03). This increase led to a 24% reduction in ADMA concentration, 0·33(0.04) pmols/mg to 0·24(0·03), p = 0·002). DDAH2-deficient murine monocytes demonstrated no increase in nitric oxide production after hypoxic challenge. These findings were recapitulated in a human observational study. Mean plasma NOx concentration was elevated after hypoxic exposure (3·6(1.8)μM vs 6·4(3·2), p = 0·01), which was associated with a reduction in intracellular ADMA in paired samples from 3·6(0.27) pmols/mg protein to 3·15(0·3) (p < 0·01). This finding was associated with a 1·9-fold(0·6) increase in DDAH2 expression over baseline(p = 0·03).

DISCUSSION

This study shows that in both human and murine models of acute hypoxia, increased DDAH2 expression mediates a reduction in intracellular ADMA concentration which in turn leads to elevated nitric oxide concentrations both within the cell and in the local environment. Cells deficient in DDAH2 were unable to mount this response.

Interventions to reduce or prevent obesity in pregnant women: a systematic review

BACKGROUND

Around 50% of women of childbearing age are either overweight [body mass index (BMI) 25-29.9 kg/m(2)] or obese (BMI ≥ 30 kg/m(2)). The antenatal period provides an opportunity to manage weight in pregnancy. This has the potential to reduce maternal and fetal complications associated with excess weight gain and obesity.

OBJECTIVES

To evaluate the effectiveness of dietary and lifestyle interventions in reducing or preventing obesity in pregnancy and to assess the beneficial and adverse effects of the interventions on obstetric, fetal and neonatal outcomes.

DATA SOURCES

Major electronic databases including MEDLINE, EMBASE, BIOSIS and Science Citation Index were searched (1950 until March 2011) to identify relevant citations. Language restrictions were not applied.

REVIEW METHODS

Systematic reviews of the effectiveness and harm of the interventions were carried out using a methodology in line with current recommendations. Studies that evaluated any dietary, physical activity or mixed approach intervention with the potential to influence weight change in pregnancy were included. The quality of the studies was assessed using accepted contemporary standards. Results were summarised as pooled relative risks (RRs) with 95% confidence intervals (CIs) for dichotomous data. Continuous data were summarised as mean difference (MD) with standard deviation. The quality of the overall evidence synthesised for each outcome was summarised using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology and reported graphically as a two-dimensional chart.

RESULTS

A total of 88 studies (40 randomised and 48 non-randomised and observational studies, involving 182,139 women) evaluated the effect of weight management interventions in pregnancy on maternal and fetal outcomes. Twenty-six studies involving 468,858 women reported the adverse effect of the interventions. Meta-analysis of 30 RCTs (4503 women) showed a reduction in weight gain in the intervention group of 0.97 kg compared with the control group (95% CI -1.60 kg to -0.34 kg; p = 0.003). Weight management interventions overall in pregnancy resulted in a significant reduction in the incidence of pre-eclampsia (RR 0.74, 95% CI 0.59 to 0.92; p = 0.008) and shoulder dystocia (RR 0.39, 95% CI 0.22 to 0.70; p = 0.02). Dietary interventions in pregnancy resulted in a significant decrease in the risk of pre-eclampsia (RR 0.67, 95% CI 0.53 to 0.85; p = 0.0009), gestational hypertension (RR 0.30, 95% CI 0.10 to 0.88; p = 0.03) and preterm birth (RR 0.68, 95% CI 0.48 to 0.96; p = 0.03) and showed a trend in reducing the incidence of gestational diabetes (RR 0.52, 95% CI 0.27 to 1.03). There were no differences in the incidence of small-for-gestational-age infants between the groups (RR 0.99, 95% CI 0.76 to 1.29). There were no significant maternal or fetal adverse effects observed for the interventions in the included trials. The overall strength of evidence for weight gain in pregnancy and birthweight was moderate for all interventions considered together. There was high-quality evidence for small-for-gestational-age infants as an outcome. The quality of evidence for all interventions on pregnancy outcomes was very low to moderate. The quality of evidence for all adverse outcomes was very low.

LIMITATIONS

The included studies varied in the reporting of population, intensity, type and frequency of intervention and patient complience, limiting the interpretation of the findings. There was significant heterogeneity for the beneficial effect of diet on gestational weight gain.

CONCLUSIONS

Interventions in pregnancy to manage weight result in a significant reduction in weight gain in pregnancy (evidence quality was moderate). Dietary interventions are the most effective type of intervention in pregnancy in reducing gestational weight gain and the risks of pre-eclampsia, gestational hypertension and shoulder dystocia. There is no evidence of harm as a result of the dietary and physical activity-based interventions in pregnancy. Individual patient data meta-analysis is needed to provide robust evidence on the differential effect of intervention in various groups based on BMI, age, parity, socioeconomic status and medical conditions in pregnancy.

Type 2 diabetes and cardiovascular disease in polycystic ovary syndrome: what are the risks and can they be reduced?

Polycystic ovary syndrome (PCOS) is a risk factor for Type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), but these risks are poorly defined. This study aimed to evaluate the evidence for these risks and whether screening and risk reduction are feasible. Medline reviews and data quality analysis were used using standard tools. Results showed that (i) polycystic ovary syndrome is a risk factor forT2DM but the magnitude of risk is uncertain, (ii) fasting plasma glucose is an inadequate screening test forT2DM in this population and the oral glucose tolerance test is superior, (iii) the identification of women with PCOS for diabetes screening is constrained by current diagnostic criteria for PCOS; however, women with oligomenorrhoea and those with diagnosed PCOS and obesity or a family history of T2DM are at highest risk, (iv) risk factors for T2DM are improved by weight loss interventions and by metformin. However, no studies have determined whether T2DM incidence is reduced, (v) polycystic ovary syndrome is associated with cardiovascular disease (CVD) risk factors but data on CVD incidence are weak, (vi) risk factors for CVD are improved by the same interventions and statins and (vi) no studies have evaluated whether CVD incidence is reduced. While PCOS has important metabolic associations, and short-term interventions reduce risk factors for T2DM and CVD, data on prevalence and incidence of T2DM and particularly CVD are poor. There is a need for a clear definition of PCOS, for diabetes screening protocols and for long-term studies to determine whether risks can be reduced.

Potential of LAMP for detection of plant pathogens

Abstract

Accurate detection of plant pathogens is a crucial step in the process of disease management. Methods based on polymerase chain reaction (PCR) have advantages of sensitivity and specificity that make them valuable tools for pathogen detection, but a number of drawbacks to these methods prevent their use in some circumstances. In particular, the cost and complexity of the thermal cycling equipment required for PCR restricts the use of these methods mainly to centralized facilities. Loop-mediated isothermal amplification (LAMP) is a method for the detection of specific nucleic acid sequences and has the potential to overcome many of the limitations of PCR-based methods. The ability of LAMP to amplify a target nucleic acid sequence under isothermal conditions eliminates the need for thermal cycling equipment, allowing testing to be carried out with minimal equipment (a water bath or heated block). Furthermore, simplified methods for the detection of amplification products facilitate the use of LAMP-based methods in the field or in less well-resourced settings. This paper reviews the reports to date of plant pathogen detection using LAMP; highlights the features that make LAMP well suited to applications such as field testing; and explores some recent advances that point to the broader potential for LAMP-based methods to be used in novel phytodiagnostic solutions.

Prevalence and impact of alcohol and other drug use disorders on sedation and mechanical ventilation: a retrospective study

Background

Experience suggests that patients with alcohol and other drug use disorders (AOD) are commonly cared for in our intensive care units (ICU's) and require more sedation. We sought to determine the impact of AOD on sedation requirement and mechanical ventilation (MV) duration.

Methods

Retrospective review of randomly selected records of adult patients undergoing MV in the medical ICU. Diagnoses of AOD were identified using strict criteria in Diagnostic and Statistical Manual of Mental Disorders, and through review of medical records and toxicology results.

Results

Of the 70 MV patients reviewed, 27 had AOD (39%). Implicated substances were alcohol in 22 patients, cocaine in 5, heroin in 2, opioids in 2, marijuana in 2. There was no difference between AOD and non-AOD patients in age, race, or reason for MV, but patients with AOD were more likely to be male (21 versus 15, p < 0.0001) and had a lower mean Acute Physiology and Chronic Health Evaluation II (22 versus 26, p = 0.048). While AOD patients received more lorazepam equivalents (0.5 versus 0.2 mg/kg.day, p = 0.004), morphine equivalents (0.5 versus 0.1 mg/kg.day, p = 0.03) and longer duration of infusions (16 versus 10 hours/day. medication, p = 0.002), they had similar sedation levels (Richmond Agitation-Sedation Scale (RASS) -2 versus -2, p = 0.83), incidence of agitation (RASS ≥ 3: 3.0% versus 2.4% of observations, p = 0.33), and duration of MV (3.6 versus 3.9 days, p = 0.89) as those without AOD.

Conclusion

The prevalence of AOD among medical ICU patients undergoing MV is high. Patients with AOD receive higher doses of sedation than their non-AOD counterparts to achieve similar RASS scores but do not undergo longer duration of MV.

An assessment of mother-to-child HIV transmission prevention in 16 pilot antenatal clinics in Jamaica

OBJECTIVES

This study aims to determine the number and age distribution of pregnant women testing positive for HIV at 16 selected clinics in Jamaica between 2001 and 2002; the utilization of therapeutic interventions to minimize the risk of mother-to-child transmission (MTCT) and the current status of the HIV-exposed infants and, finally, the number of children who received testing for detection of HIV and to calculate the incidence of MTCT in these children.

METHODS

A retrospective study was carried out at sixteen pilot clinic sites by examining the patient records for all confirmed HIV-positive pregnant mothers and the resultant infants at these facilities for the period January 2001 to December 2002.

RESULTS

One hundred and twenty-three of 8116 pregnant women newly tested positive during the period January 2001 to December 2002; however, 176 HIV+ women delivered. Fifty-three (30%) knew their HIV status prior to participating in the programme. Sixty-two (1.4%) and 61 (1.6%) tested positive in 2001 and 2002, respectively. One hundred and ten (77%) and 113 (83%) mothers and infants, respectively, received ARV therapy, (92% - nevirapine, 8% - zidovudine). Twenty-three per cent of pregnant women received no ARV Forty-four (25.0%) of the 176 infants had a documented ELISA HIV test before eighteen months of age, none had a PCR test. The health status of 40 (23%) of these children was known: 30 (75%) were alive and well, five of whom did not receive any ARV, one (2.5%) was alive and ill and nine (22.5%) were reported dead, five of whom received ARV; 28.6% of infants who did not receive ARV were reported as either dead or ill compared to 13.8% of those receiving ARV CONCLUSION: Though the majority of pregnant women discovered their HIV status during pregnancy, a significant number got pregnant knowing that they were HIV+. The majority of mothers and infants received ARV but the follow-up and testing of infants was limited. Nevirapine is clearly protective in the prevention of MTCT of HIV and should be made universally accessible. All infants delivered to HIV+ mothers should be identified and tested for HIV.

Efficacy of IV tissue plasminogen activator in acute stroke: does stroke subtype really matter?

BACKGROUND

The National Institute of Neurological Disorders and Stroke (NINDS) trial reported that stroke subtype (e.g., large-artery atherothrombosis, cardioembolism, and lacunae) does not affect response to IV thrombolytic treatment. However, these conclusions were based upon stroke subtypes determined prior to extensive diagnostic evaluation. Because such initial diagnoses are frequently inaccurate, the efficacy of IV recombinant tissue plasminogen activator (rt-PA) based upon verified specific stroke subtypes remains uncertain.

METHODS

The records of consecutive acute stroke patients treated with IV rt-PA at two regional stroke centers were retrospectively reviewed. The final stroke subtype after complete diagnostic evaluation was determined. The relationship between final stroke subtype and response to thrombolytic therapy was then investigated and compared with the results reported in the NINDS trial.

RESULTS

Ninety consecutive patients were studied. After adjusting for baseline NIH Stroke Scale scores, no significant difference in final outcome based on confirmed stroke mechanism was identified.

CONCLUSIONS

These data are consistent with those of the NINDS trial that reported that the efficacy of IV thrombolysis within the 3-hour time window is similar between different stroke subtypes. Based upon these data, allocating treatment of stroke patients with IV rt-PA based upon presumed stroke mechanism may be unnecessary. Such testing may result in time delays that could compromise the efficacy of treatment.

Prognosis for patients newly admitted to hospital with heart failure: survival trends in 12 220 index admissions in Leicestershire 1993-2001

OBJECTIVE

To examine rates of, prognosis following, and the influences on first hospital admission with heart failure in Leicestershire during 1993-2001.

DESIGN

Historical cohort study using record linked discharge and mortality data.

SETTING

Leicestershire, England.

PATIENTS

12 220 individual patients newly hospitalised with heart failure between 1 April 1993 and 31 March 2001.

MAIN OUTCOME MEASURES

30 day and one year survival, temporal trends in survival, and the influence on prognosis of age, sex, comorbidity, social deprivation, and year of hospital admission.

METHODS AND RESULTS

Between 1993/94 and 2000/01, rates of first hospitalisation increased by 62%, from 29 to 47/10 000 population, confined largely to those aged > 65 years. Rates did not increase after 1998. Median age at presentation increased from 74 years in 1993/94 to 77 years in 2000/01 for men but was unchanged (80 years) for women. Overall one and five year survival was 57% and 27%, respectively. There was a 43-45% increase in risk of death for each decade of age at admission and a 14-17% increase associated with male sex. There was a clear influence on outcome of comorbidity but no influence of social deprivation score. Both one month and one year survival were lower for patients whose first heart failure admission was concomitant with acute myocardial infarction. Between 1993/94 and 2000/01 postdischarge cardiovascular survival improved by 50% (p < 0.001).

CONCLUSIONS

Rates of first hospital admission with heart failure reached a plateau in the late 1990s. Case fatality rates remain high and prognosis poor, in particular for those of increasing age, for men, and for patients with concomitant acute myocardial infarction. However, clear trends to improved survival were seen over this time.

Thoracoscopic-assisted diaphragmatic hernia repair using a thoracic rib resection

OBJECTIVE

To describe the surgical treatment of a dorsal diaphragmatic hernia in an adult horse using thoracic rib resection aided by thoracoscopy and a flank incision.

STUDY DESIGN

Case report.

ANIMAL POPULATION

One client-owned horse.

RESULTS

A six-year-old Dutch warmblood gelding was admitted for colic-associated colonic incarceration in a diaphragmatic hernia. Seven weeks after the initial colic surgery, the gelding underwent surgery to repair the defect. Thoracoscopy and a flank incision were used to identify the location of the hernia and the subsequent site of rib resection. The stomach was adhered to the edges of the defect, leaving only a small residual hole. Resection of the 14th rib provided excellent exposure of the defect and closure of the remaining hernia.

CONCLUSION AND CLINICAL RELEVANCE

Thoracic rib resection can provide access to diaphragmatic hernias in adult horses. Thoracoscopy or a flank incision, or both, may aid in determining which rib is best resected.

Solid variant of alveolar rhabdomyosarcoma with unbalanced t(2;13) and hypotetraploidy, without MYCN amplification

The histological subtype of alveolar rhabdomyosarcoma (AR) is characterised by the cytogenetic translocation t(2;13)(q35;q14) in approximately 70% of cases, a rearrangement rarely present in the embryonal rhabdomyosarcoma (ER) subtype. The MYCN gene is amplified in some cases of AR. We present a young man with an unusual pattern, namely solid variant of AR with hypotetraploidy and the t(2;13) in an unbalanced form. The MYCN gene was not amplified on FISH, but showed increased copy number, consistent with ploidy.