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Healthcare use attributable to COVID-19: a propensity-matched national electronic health records cohort study of 249,390 people in Wales, UK. BMC Med 2023; 21:259. [PMID: 37468884 PMCID: PMC10354936 DOI: 10.1186/s12916-023-02897-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 05/10/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND To determine the extent and nature of changes associated with COVID-19 infection in terms of healthcare utilisation, this study observed healthcare contact 1 to 4 and 5 to 24 weeks following a COVID-19 diagnosis compared to propensity-matched controls. METHODS Two hundred forty nine thousand three hundred ninety Welsh individuals with a positive reverse transcription-polymerase chain reaction (RT-PCR) test were identified from data from national PCR test results. After elimination criteria, 98,600 positive individuals were matched to test negative and never tested controls using propensity matching. Cohorts were split on test location. Tests could be taken in either the hospital or community. Controls were those who had tested negative in their respective environments. Survival analysis was utilised for first clinical outcomes which are grouped into primary and secondary. Primary outcomes include post-viral-illness and fatigue as an indication of long-COVID. Secondary outcomes include clinical terminology concepts for embolism, respiratory conditions, mental health conditions, fit notes, or hospital attendance. Increased instantaneous risk for positive individuals was quantified using hazard ratios (HR) from Cox regression, while absolute risk (AR) and relative risk were quantified using life table analysis. RESULTS Analysis was conducted using all individuals and stratified by test location. Cases are compared to controls from the same test location. Fatigue (HR: 1.77, 95% CI: 1.34-2.25, p = < 0.001) and embolism (HR: 1.50, 95% CI: 1.15-1.97, p = 0.003) were more likely to occur in all positive individuals in the first 4 weeks; however, anxiety and depression (HR: 0.83, 95% CI: 0.73-0.95, p = 0.007) were less likely. Positive individuals continued to be more at risk of fatigue (HR: 1.47, 95% CI: 1.24-1.75, p = < 0.001) and embolism (HR: 1.51, 95% CI: 1.13-2.02, p = 0.005) after 4 weeks. All positive individuals are also at greater risk of post-viral illness (HR: 4.57, 95% CI: 1.77-11.80, p = 0.002). Despite statistical association between testing positive and several conditions, life table analysis shows that only a small minority of the study population were affected. CONCLUSIONS Community COVID-19 disease is associated with increased risks of post-viral-illness, fatigue, embolism, and respiratory conditions. Despite elevated risks, the absolute healthcare burden is low. Subsequently, either very small proportions of people experience adverse outcomes following COVID-19 or they are not presenting to healthcare.
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Abstract No. 525 Investigation of an Ex Vivo Perfusion Model for Teaching Angiographic Procedures to Novice Trainees. J Vasc Interv Radiol 2023. [DOI: 10.1016/j.jvir.2022.12.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
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Emergency pacemaker implantation in nonagenarians with complete heart block: is single chamber pacing sufficient? Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In ambulatory patients with complete heart block and preserved sinus node activity (CHBs), dual chamber pacing confers well-established physiological benefits versus single chamber pacing. There is limited evidence as to whether these benefits extend to very frail patients, especially those over 90 years of age.
Purpose
In nonagenarians presenting with emergent CHBs from 2016–2019, we compared the clinical characteristics of patients selected for single versus dual chamber pacemakers (PPM), and evaluated the symptomatic and prognostic implications of these devices.
Methods
Baseline characteristics were discerned from electronic records, and physiological data extracted from serial PPM interrogations. Frailty was quantified according to the Rockwood clinical frailty scale (1–9). Cause of death was provided by the patients' General Practitioner. Cox proportional hazards analysis (HR, 95% CI) examined associations with all-cause mortality and death from congestive cardiac failure (CCF).
Results
168 consecutive patients were included (44.3% Male, Median age: 91 (2) years) and followed-up for 26.9±14.6 months. 22 patients (13.1%) were implanted with single chamber pacemakers (all programmed VVIR); when compared with patients receiving dual chamber devices, these patients had similar median age (93 (3) versus 91 (2) years, p=0.15) and LV systolic function (LVEF: 49.2% ±9.7 versus 50.7% ±10.1, p=0.71), but were more frail (Rockwood scale: 5.2±1.8 versus 4.3±1.1, p=0.004) and more likely to have severe cognitive impairment (27.3% versus 9.2%, p=0.018). Post implant, patients who received single chamber devices had higher average respiratory rates (21.3±2.4 breaths per minute versus 17.5±2.6 breaths per minute, p=0.002), lower average heart rates (65.5±10.1 bpm versus 71.9±8.6 bpm, p=0.002), and lower daily activity levels (0.57±0.3 hours of activity versus 1.5±1.1 hours of activity, p=0.016) than those with dual chamber devices. Death from CCF was more common in patients receiving single chamber devices (40.9% versus 6.2%, log rank p<0.0001); this association persisted when adjusting for age, frailty and cognitive impairment (adjusted HR: 6.2 (2.2–17.3, p=0.0005). However, in this age group, single chamber pacing was not independently associated with all-cause mortality when compared with dual chamber pacing (adjusted HR: 1.9 (0.95–3.6, p=0.07).
Conclusions
In nonagenarians with CHBs, dual chamber pacing was associated with improved symptomatic outcomes and a reduced risk of death from CCF, but did not affect all-cause mortality when compared with single chamber pacing.
Funding Acknowledgement
Type of funding sources: None.
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A cross-sectional study of the first two years of mandatory training for doctors participating in voluntary assisted dying. Palliat Support Care 2022:1-7. [PMID: 35899414 DOI: 10.1017/s1478951522000931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Voluntary assisted dying (VAD) was legalized in Victoria, Australia, in June 2019. Victoria was the first jurisdiction in the world to require doctors to undertake training before providing VAD. This study examines data from doctors who completed the mandatory training in the first 2 years of the VAD system's operation (up to 30 June 2021). It describes the doctors who are undertaking VAD training, their post-training attitudes toward VAD participation, and their experiences of the mandatory training. METHODS Through the online training, doctors completed a short demographic survey and undertook formal assessment of knowledge (90% pass mark). They also were invited to complete an optional survey evaluating the training. RESULTS In total, 289 doctors passed the training, most commonly males (56%) aged 36-65 years (82%) from an urban location (72%). Most were more than 10 years post fellowship (68%) and practising as general practitioners (51%) or medical oncologists (16%). The training most commonly took 6 h (range 2 h to over 9 h). Most doctors passed the assessment at the first (65%) or second (19%) attempt. Almost all participants (97%) found the training helpful or very helpful and most reported being confident or very confident in their knowledge (93%) and application (88%) of the VAD legislation. SIGNIFICANCE OF RESULTS Doctors reported the training was helpful and improved their confidence in knowing the law and applying it in clinical practice. The profile of trained doctors (particularly their location and specialty) suggests continued growth of participating doctors is needed to facilitate patient access to VAD. It is important that this safeguard does not discourage doctors' participation.
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1051 EMERGENCY PACEMAKER IMPLANTATION IN NONAGENARIANS: IMPACT OF FRAILTY ON OPERATOR DECISION-MAKING AND PATIENT OUTCOMES. Age Ageing 2022. [DOI: 10.1093/ageing/afac126.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Complete heart block (CHB) is a time-critical emergency. In frail patients with CHB, the absence of test results or a comprehensive history can challenge operator decision-making; in particular, minimal data exists as to the prognostic impact of single versus dual chamber pacing in this group. In patients over 90 years of age presenting with CHB, we examined the prognostic value of parameters obtained from bedside examination, and analysed the impact of single versus dual chamber pacemakers on mortality.
Method
Data were extracted from 2016–2019. Bedside covariates were age, sex, previous cardiac surgery, atrial rhythm, LV systolic function, syncope at presentation, QRS duration, and Rockwood frailty score. Cox-proportional hazards regression examined associations with all-cause mortality and cardiac death, determined from electronic records and death certificates (adjusted HR, 95% CI).
Results
205 patients were included (age 92.3 ± 2.3 years, 45.4% male). Mortality was 13.8% at 90 days and 27.2% at 27.1 ± 16.7 months. The independent predictors of mortality were pre-procedural QRS duration >130 ms (HR 2.4 (1.4–4.1) p = 0.001), age (HR 1.07 (1.02–1.15) p = 0.004), AF (HR 2.0 (1.1–3.6) p = 0.02), and Rockwood score (HR 1.2 (1.02–2.6), p = 0.043). Sex, syncope at presentation, LV function or previous cardiac surgery did not predict mortality (all p > 0.1). In a subset of 168 patients without AF, 30 (17.8%) received single chamber pacemakers. Whilst these patients were more frail than those receiving dual chamber pacemakers (Rockwood scores: 5.2 ± 1.7 vs 4.3 ± 1.1, p = 0.025), implantation of a single chamber pacemaker was independently associated with cardiac death when adjusting for frailty and co-morbidities (HR 6 (1.4–26.4), p = 0.018).
Conclusion
Nonagenarians undergoing emergency pacemaker implantation have a reasonable prognosis. Data ascertained at the bedside can help predict survival, however—when adjusting for frailty and co-morbidities—dual chamber pacing may confer an independent mortality benefit over single chamber pacing in this group.
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Abstract No. 86 Distal glue splenic artery embolization versus other embolics: a single-center analysis. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Abstract No. 61 Assessing probe orientation and renal collecting system injury during microwave ablation in a perfused ex vivo porcine model. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Electroconvulsive Therapy’s use in Idiopathic Intracranial Hypertension with Mood Disorder: caution, promise, and progress. Eur Psychiatry 2022. [PMCID: PMC9564714 DOI: 10.1192/j.eurpsy.2022.769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction Idiopathic Intracranial Hypertension (IIH) is a condition characterized by an increase of intracranial pressure (ICP) with no identifiable cause to date. One-half of patients who suffer from IIH have co-morbid mood disorders, such as Major Depressive Disorder (MDD), that can be refractory to pharmacologic treatment. Electroconvulsive Therapy (ECT) is a safe and effective treatment for treatment-refractory mood disorder, but possesses a relative contra-indication for IIH due to its theoretical increase in ICP. Can ECT become the gold-standard treatment modality for mood disorder from IIH? Objectives We aim to synthesize and summarize the state of the literature surrounding the intersection of ECT and IIH. We will present notable findings and propose avenues for future investigation. Methods We conducted a literature review using PubMed’s search function. Key terms that were queried are as follows: Idiopathic Intracranial Hypertension, Pseudotumor Cerebri, Benign Intracranial Hypertension, Mood Disorder, Major Depressive Disorder, ECT, Electroconvulsive Therapy. Results The prevailing theory of IIH and mood disorder centers around HPA axis dysfunction, which has been heavily theorized to be positively impacted with ECT. ECT itself may not increase the ICP, but the anesthesia might. The only two case reports in the literature presented safe and successful use of ECT’s in patients with IIH and MDD. Conclusions More data is needed to draw conclusions, as the literature surrounding ECT’s use in patients with IIH remains sparse. Further studies must explore whether ECT’s use in IIH remains effective. Through this, we may understand more about both IIH and ECT itself. Disclosure No significant relationships.
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UK National DCD Heart Transplant Program - First Year Experience. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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564 Freedom from Urethral Catherisation – Using QI Methodology to Improve Patient Outcome and Experiences. Br J Surg 2021. [DOI: 10.1093/bjs/znab258.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Abstract
Aim
To reduce catheter burden on patients who could instead be free of urethral catheter and taught intermittent self-catheterisation (ISC).
Method
2 PDSA (Plan, Do, Study, Act) cycles were performed over a 21-month period from February 2018 to November 2020. Using multiple nurse-led TWOC clinics, data was extracted using nurse-completed proformas and electronic patient records to determine: TWOC rate; urethral catheter-free rate; and ISC rate. Following baseline measurement, interventions were made, such as centralisation of TWOC services, emphasis on ISC teaching and the introduction of industry-nurse led clinics.
Results
At baseline, TWOC rate, urethral catheter-free rate and ISC rate were 55.7%, 68% and 28.2%, respectively. Following centralisation of TWOC services and emphasis on ISC teaching in Cycle 1, urethral catheter-free rate rose to 77.8% whilst ISC rate fell to 25%. Cycle 2 followed the introduction of industry-nurse led clinics. Following this, urethral catheter-free rate rose further to 81.6%, with ISC rate rising dramatically to 56.3%
Conclusions
To those capable, ISC frees patients of catheter burden and its sequalae. Evidently, a greater onus on ISC training will increase the number of patients left catheter-free.
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018 Cutaneous kinase activity correlates with treatment outcomes following PI3K delta inhibition in mice with experimental pemphigoid diseases. J Invest Dermatol 2021. [DOI: 10.1016/j.jid.2021.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Abstract No. 171 Validating an ex-vivo bovine kidney pulsatile perfusion model with micro-CT evaluation of distal angioembolization. J Vasc Interv Radiol 2021. [DOI: 10.1016/j.jvir.2021.03.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract No. 224 Evaluation of integrated interventional radiology residency websites: comparative cross-sectional analysis from 2017 to 2020. J Vasc Interv Radiol 2021. [DOI: 10.1016/j.jvir.2021.03.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract No. 36 A novel method for loading Tc-99m and R-186 into alginate microspheres for radioembolization. J Vasc Interv Radiol 2021. [DOI: 10.1016/j.jvir.2021.03.452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract No. 154 Medical crowdfunding for interventional oncology treatments. J Vasc Interv Radiol 2021. [DOI: 10.1016/j.jvir.2021.03.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Clinical supervision in general practice training: the interweaving of supervisor, trainee and patient entrustment with clinical oversight, patient safety and trainee learning. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2021; 26:297-311. [PMID: 32833138 DOI: 10.1007/s10459-020-09986-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/17/2020] [Indexed: 06/11/2023]
Abstract
Australian general practice trainees typically consult with patients from their first week of training, seeking in-consultation supervisory assistance only when not sufficiently confident to complete patient consultations independently. Trainee help-seeking plays a key role in supervisor oversight of trainee consultations. This study used focus groups and interviews with general practice supervisors to explore their approaches to trainee help-seeking and in-consultation supervision. Supervisor approaches are discussed under three themes: establishing a help-seeking culture; perceptions of in-consultation assistance required; and scripts for help provision. Within these themes, three interwoven entrustment processes were identified: supervisor entrustment; trainee self-entrustment; and 'patient entrustment' (patient confidence in the trainee's clinical management). Entrustment appears to develop rapidly, holistically and informally in general practice training, partly in response to workflow pressure and time constraints. Typical supervisor scripts and etiquette for help-provision involve indirect, soft correction strategies to build trainee self-entrustment. These scripts appear to be difficult to adapt appropriately to under-performing trainees. Importantly, supervisor scripts also promote patient entrustment, increasing the likelihood of patients returning to the trainee and training practice for subsequent review, which is a major mechanism for ensuring patient safety in general practice. Theories of entrustment in general practice training must account for the interplay between supervisor, trainee and patient entrustment processes, and work-related constraints. Gaps between entrustment as espoused in theory, and entrustment as enacted, may suggest limitations of entrustment theory when extended to the general practice context, and/or room for improvement in the oversight of trainee consultations in general practice training.
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CTRIAL-IE (ICORG) 07-11: Phase II Trial Evaluating Radiobiological Based Reirradiation Strategy for Patients with Malignant Spinal Cord Compression. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.2133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Localising evidence for decision-making: participatory approach to inform schistosomiasis control. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The linear theories of change which ground many interventions do not account for the complex processes and systems in which they are implemented. This reductionist approach prioritises statistical methods which do not accommodate the stochastic, non-linear, dynamic interactions between humans and their environment. The inclusion of practitioners in the process of evidence development and utilisation of complex systems methods mitigates these issues and results in locally relevant, timely evidence for decision-making.
Methods
The aim of this work was to develop localised evidence for decision-making for schistosomiasis control in Uganda, Malawi, and Tanzania. Workshops were conducted with practitioners from the Ministries of Health at various levels and partner organisations to identify evidence needs for their decision-making processes and perceptions of disease transmission and control activities. Participatory systems mapping was used to identify factors directly and indirectly related to transmission. The maps were synthesised to a master complex systems map, which served as the blueprint for a generalised spatial agent-based model and specific ABMs tailored to the evidence needs of decision-makers.
Results
There was a gap in available evidence for practitioners to advocate for resources within the MoH and government budgets, as well as intervention efficacy and resource allocation. The adaptable and data-inclusive characteristics of the AMBs made them well-suited to produce localised outputs. Converted to NetLogo with a tailored user interface, these models were appropriate and responsive to the needs of decision-makers from village to national levels and across country contexts.
Conclusions
Used together, participatory and agent-based modelling resulted in the development of responsive and relevant evidence for practitioner decision-making. This process is generalisable and transferable to other diseases and locations outside of those in this study.
Key messages
The use of participatory systems mapping to develop agent-based models resulted in relevant and timely evidence for practitioner decision-making. The approach used here is transferable and generalisable outside schistosomiasis control and the contexts in this study.
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Participatory systems mapping for localised evidence and decision-making: helminth control, SSA. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.1277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Evidence-informed decision-making to assist public health practitioners in local-level programme implementation requires adaptive approaches to research, policy and practice. To address these needs there is focus on using participatory methods. Adopting such methods, this research asks: what are the evidence needs of local public health practitioners? How do evidence and decision-making processes interact? We reflect on the process of using Participatory Systems Mapping (PSM) and implications for localising evidence-informed decision-making.
Methods
We conducted workshops with district and national-level MoH personnel in Uganda and Malawi using PSM to elicit insights into local modes of schistosomiasis transmission and control, and group discussions on evidence needs and use in implementing control programmes. PSM maps are analysed, triangulated with thematic analysis of group discussion transcripts.
Results
Analysing PSM outputs alongside discussions on evidence provides critical methodological and policy insights with implications for localised evidence and decision-making. Further insights into the local dynamics of public health decision-making are gained by triangulating PSM with discussions on the meanings and importance of 'factors' identified. Information which is accessible and useful for local practitioner's decision-making in implementing disease control measures does not always align with academic production and dissemination of evidence, nor across levels where policy is produced or implemented.
Conclusions
An array of factors influence local decision-making with implications for global health policies and practices such as for schistosomiasis control. Processes of decision-making and evidence needs of local practitioners need to be better understood within broader context. Evidence and knowledge production on health interventions rarely feedback or respond to local implementation needs, decision-making practices and public health practitioners.
Key messages
Processes of decision-making and evidence needs of local practitioners need to be better understood within broader context. Evidence and knowledge production on health interventions rarely feedback or respond to local implementation needs, decision-making practices and public health practitioners.
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Investigating physiotherapy stakeholders' preferences for the development of performance-based assessment in practice education. Physiotherapy 2020; 108:46-54. [PMID: 32711227 DOI: 10.1016/j.physio.2020.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Discrete choice experiments (DCEs) are used in healthcare to measure the relative importance that stakeholders give to different features (or attributes) of medical treatments or services. They may also help to address research questions in health professional education. Several challenges exist regarding the performance-based assessment process (PBA) employed in physiotherapy practice-based education, a process which determines students' readiness for independent practice. Evidence highlights many commonalities among these challenges, but it is unknown which factors are the most important to stakeholders. The use of DCE methodology may provide answers and help to prioritise areas for development. Thus, this study employed DCE to identify clinical educators', practice tutors and physiotherapy students' preferences for developing the PBA process in physiotherapy. DESIGN Attributes (aspects of the PBA process known to be important to stakeholders) were derived from focus group interviews conducted with three groups; physiotherapy students, clinical educators (practising clinicians) and practice tutors (dedicated educational roles in the workplace). These attributes included the PBA tool, grading mechanisms, assessors involved, and, feedback mechanisms. Preferences for each group were calculated using a logistic regression model. RESULTS Seventy-two students, 124 clinical educators and 49 practice tutors (n=245) participated. Priorities identified centred primarily on the mandatory inclusion of two assessors in the PBA process and on refinement of the PBA tool. CONCLUSION Employment of DCE enabled the prioritisation of stakeholder-informed challenges related to PBA in physiotherapy practice-based education. This corroborates findings from previous qualitative work and facilitates a prioritised pathway for development of this process.
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With a grain of salt? Supervisor credibility and other factors influencing trainee decisions to seek in-consultation assistance: a focus group study of Australian general practice trainees. BMC FAMILY PRACTICE 2020; 21:28. [PMID: 32033540 PMCID: PMC7007682 DOI: 10.1186/s12875-020-1084-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 01/10/2020] [Indexed: 11/22/2022]
Abstract
Background ‘Ad hoc’ help-seeking by trainees from their supervisors during trainee consultations is important for patient safety, and trainee professional development. We explored trainee objectives and activities in seeking supervisor assistance, and trainee perceptions of the outcomes of this help-seeking (including the utility of supervisor responses). Methods Focus groups with Australian general practice trainees were undertaken. All data was audio-recorded and transcribed, coded using in-vivo and descriptive codes, and analysed by the constant comparison of provisional interpretations and themes with the data. Findings are reported under the over-arching categories of help-seeking objectives, activities and outcomes. Results Early in their general practice placements trainees needed information about practice facilities, and the “complex maze” of local patient resources and referral preferences: some clinical presentations were also unfamiliar, and many trainees were unaccustomed to making patient management decisions. Subsequent help-seeking was often characterised informally as “having a chat” or “getting a second opinion” so as not to “miss anything” when trainees were “not 100% sure”. Trainees emphasised the importance of being (and demonstrating that they were) clinically safe. Workflow constraints, and supervisory and doctor-patient relationships, had a powerful influence on trainee help-seeking activities. An etiquette for providing help in front of patients was described. Trainees assessed the credibility of supervisors based on their approach to risk and their clinical expertise in the relevant area. Several trainees reported reservations about their supervisor’s advice on occasions. Conclusion A trainee’s subsequent help-seeking is strongly influenced by how their supervisor responds when their help is sought. Trainees prefer to seek help from credible supervisors who respond promptly and maintain trainee ‘face’ in front of patients. Trainees learn through help-seeking to make their own clinical decisions but may remain uncertain about professional and societal expectations, and curious about how other general practitioners practise. Trainees value opportunities throughout their training to observe expert general practice.
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Australian Policies on "Futile" or "Non-beneficial" Treatment at the End of Life: A Qualitative Content Analysis. JOURNAL OF LAW AND MEDICINE 2019; 27:415-439. [PMID: 32129045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A challenge in end-of-life care is requests by patients or their substitute decision-makers for treatment that doctors consider is "futile" or "non-beneficial". Concerns that these concepts are uncertain and subjective have led to calls for medical policies to clarify terminology and to provide procedural solutions to prevent and address disputes. This article provides a comprehensive analysis of how Australian medical guidelines and policies on withholding or withdrawing potentially life-sustaining treatment address futility. It demonstrates that while the concept is found throughout medical policies and guidelines, the terminology employed is inconsistent. There is also variability in the extent of guidance given about unilateral decision-making and mechanisms for dispute resolution. This is problematic, given that the question of further treatment can often only be determined in relation to the individual patient's goals and values. We conclude by advocating for the development of a unified policy approach to futile or non-beneficial treatment in Australia.
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Factors associated with non-beneficial treatments in end of life hospital admissions: a multicentre retrospective cohort study in Australia. BMJ Open 2019; 9:e030955. [PMID: 31690607 PMCID: PMC6858125 DOI: 10.1136/bmjopen-2019-030955] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To quantitatively assess the factors associated with non-beneficial treatments (NBTs) in hospital admissions at the end of life. DESIGN Retrospective multicentre cohort study. SETTING Three large, metropolitan tertiary hospitals in Australia. PARTICIPANTS 831 adult patients who died as inpatients following admission to the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES Odds ratios (ORs) of NBT derived from logistic regression models. RESULTS Overall, 103 (12.4%) admissions involved NBTs. Admissions that involved conflict within a patient's family (OR 8.9, 95% CI 4.1 to 18.9) or conflict within the medical team (OR 6.5, 95% CI 2.4 to 17.8) had the strongest associations with NBTs in the all subsets regression model. A positive association was observed in older patients, with each 10-year increment in age increasing the likelihood of NBT by approximately 50% (OR 1.5, 95% CI 1.2 to 1.9). There was also a statistically significant hospital effect. CONCLUSIONS This paper presents the first statistical modelling results to assess the factors associated with NBT in hospital, beyond an intensive care setting. Our findings highlight potential areas for intervention to reduce the likelihood of NBTs.
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385 Ruxolitinib cream ameliorates a preclinical model of skin dermatitis via modulation of inflammatory T-cell subsets. J Invest Dermatol 2019. [DOI: 10.1016/j.jid.2019.07.387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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372 Inhibition of phosphatidylinositol-3-kinase δ improves tissue destruction in pemphigoid diseases by impairing neutrophil function. J Invest Dermatol 2019. [DOI: 10.1016/j.jid.2019.07.374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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391 Ruxolitinib cream is highly effective at modulating a humanised rodent model of psoriasis vulgaris. J Invest Dermatol 2019. [DOI: 10.1016/j.jid.2019.07.393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Simple and Rapid Creation of Customized 3D Printed Bolus Utilizing iPhone X True Depth Camera. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.1012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Misconceiving "Neutrality" in Bioethics: Rejoinder to "Bioethics and the Myth of Neutrality". JOURNAL OF BIOETHICAL INQUIRY 2019; 16:147-151. [PMID: 30887185 DOI: 10.1007/s11673-019-09907-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/05/2019] [Indexed: 06/09/2023]
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Doctors' perceptions of how resource limitations relate to futility in end-of-life decision making: a qualitative analysis. JOURNAL OF MEDICAL ETHICS 2019; 45:373-379. [PMID: 31092631 DOI: 10.1136/medethics-2018-105199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 02/07/2019] [Accepted: 03/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility. SETTING Three tertiary hospitals in metropolitan Brisbane, Australia. DESIGN Qualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic analysis. RESULTS Doctors' perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing. CONCLUSIONS Doctors' ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors' role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making.
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Lymph node harvest in breast cancer patients with and without preoperative scintigraphy. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2018/v56n3a2737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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When genomic medicine reveals misattributed genetic relationships-the debate about disclosure revisited. Genet Med 2019; 21:97-101. [PMID: 29904162 PMCID: PMC6169736 DOI: 10.1038/s41436-018-0023-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/20/2018] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Accidental discovery of misattributed parentage is an age-old problem in clinical medicine, but the ability to detect it routinely has increased recently as a result of high-throughput DNA sequencing technologies coupled with family sequencing studies. Problems arise at the clinical-research boundary, where policies and consent forms guaranteeing nondisclosure may conflict with standard clinical care. METHODS To examine the challenges of managing misattributed parentage within hybrid translational research studies, we used a case study of a developmentally delayed child with a candidate variant found through a large-scale trio genome sequencing study in which data from unrelated samples were routinely excluded. RESULTS We discuss whether genetic parentage should be explicitly confirmed during clinical validation, thus giving greater weight to the diagnosis according to American College of Medical Genetics and Genomics variant interpretation guidelines, and what tensions this approach would create. CONCLUSION We recommend that the possibility of finding and disclosing misattributed parentage should be addressed during the consent or pretest counseling process, and that clinical relevance should determine whether or not to disclose results in the clinic. This proposition has implications for research governance, and implies that it may not always be possible to uphold nondisclosure commitments as investigations move from research to clinical care.
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Nodal disease predicts recurrence whereas other traditional factors affect survival in a cohort of South African patients with differentiated thyroid carcinoma. CANCERS OF THE HEAD & NECK 2018; 3:10. [PMID: 31093363 PMCID: PMC6460678 DOI: 10.1186/s41199-018-0037-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/31/2018] [Indexed: 11/21/2022]
Abstract
Background and aim Information on patients with differentiated thyroid carcinoma in South Africa is limited. The objective of this study was to review demographics and tumour characteristics in a cohort of patients with differentiated thyroid carcinoma, presenting to Groote Schuur Hospital and evaluate risk factors for recurrence and survival. Patients and methodology Retrospective demographic and clinical data were collected on all patients referred between January 2003 and December 2013. Prognostic factors for recurrence free survival and cancer specific survival were assessed using univariate and multivariate analyses. Results The total number of patients was 231.The median age at presentation was 44 years and 82% were female patients. The pathological sub-types were papillary (60.6%), follicular (38.9%) and poorly differentiated (0.5%). Total thyroidectomy was performed in 191 patients and 30 patients required neck dissections. A total of 171 (74%) patients received 131Iodine. The recurrence free and cause specific survival rates at 10 years were 83 and 91%, respectively. Nodal disease at presentation was the only significant risk factor for recurrence (p < 0.001) on multivariate analysis. Significant risk factors for cause specific mortality were age ≥ 45 years (p = 0.006), follicular pathology (p = 0.004), extra-thyroid extension (p = 0.013) and residual tumour (p = 0.004). Conclusions Consistent with international trends, patients with differentiated thyroid carcinoma treated at Groote Schuur Hospital had a favourable prognosis. The known risk factors associated with recurrence and survival in this South African cohort were consistent with those reported in developed countries.
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Juggling roles and generating solutions; practice-based educators' perceptions of performance-based assessment of physiotherapy students. Physiotherapy 2018; 105:446-452. [PMID: 30871892 DOI: 10.1016/j.physio.2018.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/04/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Physiotherapy lacks the significant body of evidence that underpins performance-based assessments in disciplines such as medicine and nursing. In particular, very few studies have examined stakeholder perspectives of the process. This study set out to explore the perceptions of clinicians who undertake student assessment in the workplace in order to inform further development of performance-based assessment in physiotherapy. DESIGN A qualitative, descriptive design was employed where focus group interviews were utilised for data collection. Inductive thematic analysis was used to analyse the data. PARTICIPANTS Clinical educator and practice tutor volunteers affiliated with three Irish universities participated in one of seven focus groups (n=46). RESULTS Two themes were identified; 1) Tensions in the clinical learning environment, 2) An optimal PBA process. The first theme describes clinical educators' struggle with juggling multiple roles and highlights the challenges of sustaining a balance between student mentoring and patient care. The second theme outlines factors perceived to contribute to an optimal performance-based assessment process; these include maintaining aspects of the current process and expanding the employment of dedicated educational roles in the workplace. CONCLUSION Our findings illustrate a complex working environment for clinicians involved in student supervision and assessment. A dedicated educational role was perceived to provide a more standardised and rigorous approach to performance-based assessment. These findings provide critical stakeholder-centred insights, which may inform development of this process by addressing critical aspects deemed to facilitate and challenge clinical educator's roles as assessors.
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PRESSURE-TARGETED PERFUSION IS THE OPTIMAL STRATEGY OF THE PEDIATRIC EX-VIVO HEART PERFUSION FOR DONATION AFTER CARDIAC DEATH IN PORCINE MODEL. Can J Cardiol 2018. [DOI: 10.1016/j.cjca.2018.07.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Australian doctors' knowledge of and compliance with the law relating to end-of-life decisions: implications for LGBTI patients. CULTURE, HEALTH & SEXUALITY 2018; 20:845-857. [PMID: 29067876 DOI: 10.1080/13691058.2017.1385854] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In most developed countries, competent patients have the legal right to refuse any medical treatment; Advance Care Planning mechanisms extend this right to non-competent patients. However, some groups, including lesbian, gay, bisexual, transgender and intersex (LGBTI) people, risk their wishes not being respected if they lose capacity, more than others. Little is known about medical practitioners' knowledge of, or attitudes to, the law in this area, especially in relation to LGBTI people, or how the law influences their decision-making. An Australian postal survey explored knowledge and attitudes of medical specialists to legal issues relating to withdrawing/ withholding life-sustaining treatment from adults without capacity. One scenario (the focus of this paper) asked which of four plausible substitute decision-makers, including a same-sex partner, had the legal authority to make such decisions. The overall response rate was 32% (867/2702). Less than one-third of respondents correctly identified the same-sex partner as the legally authorised decision-maker. LGBTI people face multiple obstacles to having their end-of-life wishes respected. Where healthcare providers are also ignorant of the partner's legal right to make such decisions, the problem is compounded. Improved legal education for clinicians and promotion of educational resources for members of the LGBTI community is needed.
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The need to exercise caution in accepting addiction as a reason for performing euthanasia. Addiction 2018; 113:1178-1180. [PMID: 29024121 DOI: 10.1111/add.14025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 05/02/2017] [Accepted: 08/24/2017] [Indexed: 01/01/2023]
Abstract
The recent practice in Belgium and the Netherlands of accepting addiction as a reason for performing euthanasia raises important issues for the field of addiction and the practice of euthanasia. In this paper we outline some of these issues. We also argue that physicians making decisions about whether to accept requests for euthanasia from people with an allegedly untreatable addiction should consider two issues carefully. They should ensure that: (1) the person has the capacity to give free and informed consent to undergo euthanasia; and (2) their request is the outcome of a deliberative process in which all reasonable treatment options and harm reduction measures have been offered to and considered by the person.
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Reasons for ambivalence about accepting addiction as a reason for performing euthanasia. Addiction 2018; 113:1186-1187. [PMID: 29752754 DOI: 10.1111/add.14246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/11/2018] [Indexed: 11/27/2022]
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Diagnostic accuracy of a prototype rapid chlamydia and gonorrhoea recombinase polymerase amplification assay: a multicentre cross-sectional preclinical evaluation. Clin Microbiol Infect 2018; 25:380.e1-380.e7. [PMID: 29906594 PMCID: PMC6420679 DOI: 10.1016/j.cmi.2018.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 11/27/2022]
Abstract
Objectives Rapid and accurate sexually transmitted infection diagnosis can reduce onward transmission and improve treatment efficacy. We evaluated the accuracy of a 15-minute run-time recombinase polymerase amplification–based prototype point-of-care test (TwistDx) for Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG). Methods Prospective, multicentre study of symptomatic and asymptomatic patients attending three English sexual health clinics. Research samples provided were additional self-collected vulvovaginal swab (SCVS) (female participants) and first-catch urine (FCU) aliquot (female and male participants). Samples were processed blind to the comparator (routine clinic CT/NG nucleic acid amplification test (NAAT)) results. Discrepancies were resolved using Cepheid CT/NG GeneXpert. Results Both recombinase polymerase amplification and routine clinic NAAT results were available for 392 male and 395 female participants. CT positivity was 8.9% (35/392) (male FCU), 7.3% (29/395) (female FCU) and 7.1% (28/395) (SCVS). Corresponding NG positivity was 3.1% (12/392), 0.8% (3/395) and 0.8% (3/395). Specificity and positive predictive values were 100% for all sample types and both organisms, except male CT FCU (99.7% specificity (95% confidence interval (CI) 98.4–100.0; 356/357), 97.1% positive predictive value (95% CI 84.7–99.9; 33/34)). For CT, sensitivity was ≥94.3% for FCU and SCVS. CT sensitivity for female FCU was higher (100%; 95% CI, 88.1–100; 29/29) than for SCVS (96.4%; 95% CI, 81.7–99.9; 27/28). NG sensitivity and negative predictive values were 100% in FCU (male and female). Conclusions This prototype test has excellent performance characteristics, comparable to currently used NAATs, and fulfils several World Health Organization ASSURED criteria. Its rapidity without loss of performance suggests that once further developed and commercialized, this test could positively affect clinical practice and public health.
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International Fragility Fracture Network Delphi consensus statement on the principles of anaesthesia for patients with hip fracture. Anaesthesia 2018; 73:863-874. [DOI: 10.1111/anae.14225] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2018] [Indexed: 01/16/2023]
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Law as Clinical Evidence: A New ConstitutiveModel of Medical Education and Decision-Making. JOURNAL OF BIOETHICAL INQUIRY 2018; 15:101-109. [PMID: 29349590 DOI: 10.1007/s11673-017-9836-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 08/29/2017] [Indexed: 06/07/2023]
Abstract
Over several decades, ethics and law have been applied to medical education and practice in a way that reflects the continuation during the twentieth century of the strong distinction between facts and values. We explain the development of applied ethics and applied medical law and report selected results that reflect this applied model from an empirical project examining doctors' decisions on withdrawing/withholding treatment from patients who lack decision-making capacity. The model is critiqued, and an alternative "constitutive" model is supported on the basis that medicine, medical law, and medical ethics exemplify the inevitable entanglement of facts and values. The model requires that ethics and law be taught across the medical education curriculum and integrated with the basic and clinical sciences and that they be perceived as an integral component of medical evidence and practice. Law, in particular, would rank as equal in normative authority to the relevant clinical scientific "facts" of the case, with graduating doctors having as strong a basic command of each category as the other. The normalization of legal knowledge as part of the clinician's evidence base to be utilized in practice may provide adequate consolation for clinicians who may initially resent further perceived incursions on their traditional independence and discretion.
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A culturally tailored research ethics training curriculum for American Indian and Alaska Native communities: a randomized comparison trial. CRITICAL PUBLIC HEALTH 2018; 29:27-39. [PMID: 30613127 PMCID: PMC6320230 DOI: 10.1080/09581596.2018.1434482] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 12/23/2017] [Indexed: 11/20/2022]
Abstract
The primary aim of this study was to develop an American Indian and Alaska Native (AIAN) tailored research with human subjects curriculum that would increase the participation of AIAN members in research affecting their communities. We used a community-engaged research approach to co-design and evaluate a culturally tailored online human subjects curriculum among a national sample of AIAN community members (n = 244) with a standard nationally used online curriculum (n = 246). We evaluated pre-and post-test measures to assess group differences in ethics knowledge, perceived self-efficacy to apply such knowledge to protocol review, and trust in research. Analysis of regional tribal differences assessed curriculum generalizability. Using an 80% correct item cut-off at first attempt as passing criterion, the tailored curriculum achieved a 59.3% passing rate versus 28.1% in the standard curriculum (p < .001). For both arms, participants reported a significant increase in trust in research and in research review efficacy. Participants took less time to complete the training and reported significantly higher acceptability, satisfaction, and understandability of the curriculum for the tailored curriculum. This culturally tailored research ethics curriculum has the potential to increase participation in AIAN communities in research affecting tribal members. The AIAN curriculum achieved significantly higher levels of participants' research ethics knowledge, self-efficacy in reviewing research protocols, trust in research, and completion of the training requirements. Culturally grounded training curricula may help remedy the impact of historical research ethics abuses involving AIAN communities that have contributed to mistrust of research and lack of community engagement in research.
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Engaging 'communities': anthropological insights from the West African Ebola epidemic. Philos Trans R Soc Lond B Biol Sci 2017; 372:rstb.2016.0305. [PMID: 28396476 PMCID: PMC5394643 DOI: 10.1098/rstb.2016.0305] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2016] [Indexed: 11/12/2022] Open
Abstract
The recent Ebola epidemic in West Africa highlights how engaging with the sociocultural dimensions of epidemics is critical to mounting an effective outbreak response. Community engagement was pivotal to ending the epidemic and will be to post-Ebola recovery, health system strengthening and future epidemic preparedness and response. Extensive literatures in the social sciences have emphasized how simple notions of community, which project solidarity onto complex hierarchies and politics, can lead to ineffective policies and unintended consequences at the local level, including doing harm to vulnerable populations. This article reflects on the nature of community engagement during the Ebola epidemic and demonstrates a disjuncture between local realities and what is being imagined in post-Ebola reports about the lessons that need to be learned for the future. We argue that to achieve stated aims of building trust and strengthening outbreak response and health systems, public health institutions need to reorientate their conceptualization of 'the community' and develop ways of working which take complex social and political relationships into account.This article is part of the themed issue 'The 2013-2016 West African Ebola epidemic: data, decision-making and disease control'.
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Comparing doctors' legal compliance across three Australian states for decisions whether to withhold or withdraw life-sustaining medical treatment: does different law lead to different decisions? BMC Palliat Care 2017; 16:63. [PMID: 29179708 PMCID: PMC5704501 DOI: 10.1186/s12904-017-0249-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/16/2017] [Indexed: 11/23/2022] Open
Abstract
Background Law purports to regulate end-of-life care but its role in decision-making by doctors is not clear. This paper, which is part of a three-year study into the role of law in medical practice at the end of life, investigates whether law affects doctors’ decision-making. In particular, it considers whether the fact that the law differs across Australia’s three largest states – New South Wales (NSW), Victoria and Queensland – leads to doctors making different decisions about withholding and withdrawing life-sustaining treatment from adults who lack capacity. Methods A cross-sectional postal survey of the seven specialties most likely to be involved in end-of-life care in the acute setting was conducted between 18 July 2012 and 31 January 2013. The sample comprised all medical specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in those three Australian states. The survey measured medical specialists’ level of legal compliance, and reasons for their decisions, concerning the withholding or withdrawal of life-sustaining treatment. Multivariable logistic regression was used to examine predictors of legal compliance. Linear regression was used to examine associations between the decision about life-sustaining treatment and the relevance of factors involved in making these decisions, as well as state differences in these associations. Results Response rate was 32% (867/2702). A majority of respondents in each state said that they would provide treatment in a hypothetical scenario, despite an advance directive refusing it: 72% in NSW and Queensland; 63% in Victoria. After applying differences in state law, 72% of Queensland doctors answered in accordance with local law, compared with 37% in Victoria and 28% in NSW (p < 0.001). Doctors reported broadly the same decision-making approach despite differences in local law. Conclusions Law appears to play a limited role in medical decision-making at the end of life with doctors prioritising patient-related clinical and ethical considerations. Different legal frameworks in the three states examined did not lead to different decisions about providing treatment. More education is needed about law and its role in this area, particularly where law is inconsistent with traditional practice. Electronic supplementary material The online version of this article (10.1186/s12904-017-0249-1) contains supplementary material, which is available to authorized users.
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Incidence, duration and cost of futile treatment in end-of-life hospital admissions to three Australian public-sector tertiary hospitals: a retrospective multicentre cohort study. BMJ Open 2017; 7:e017661. [PMID: 29038186 PMCID: PMC5652539 DOI: 10.1136/bmjopen-2017-017661] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To estimate the incidence, duration and cost of futile treatment for end-of-life hospital admissions. DESIGN Retrospective multicentre cohort study involving a clinical audit of hospital admissions. SETTING Three Australian public-sector tertiary hospitals. PARTICIPANTS Adult patients who died while admitted to one of the study hospitals over a 6-month period in 2012. MAIN OUTCOME MEASURES Incidences of futile treatment among end-of-life admissions; length of stay in both ward and intensive care settings for the duration that patients received futile treatments; health system costs associated with futile treatments; monetary valuation of bed days associated with futile treatment. RESULTS The incidence rate of futile treatment in end-of-life admissions was 12.1% across the three study hospitals (range 6.0%-19.6%). For admissions involving futile treatment, the mean length of stay following the onset of futile treatment was 15 days, with 5.25 of these days in the intensive care unit. The cost associated with futile bed days was estimated to be $AA12.4 million for the three study hospitals using health system costs, and $A988 000 when using a decision maker's willingness to pay for bed days. This was extrapolated to an annual national health system cost of $A153.1 million and a decision maker's willingness to pay of $A12.3 million. CONCLUSIONS The incidence rate and cost of futile treatment in end-of-life admissions varied between hospitals. The overall impact was substantial in terms of both the bed days and cost incurred. An increased awareness of these economic costs may generate support for interventions designed to reduce futile treatments. We did not include emotional hardship or pain and suffering, which represent additional costs.
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Changes in LXR signaling influence early-pregnancy lipogenesis and protect against dysregulated fetoplacental lipid homeostasis. Am J Physiol Endocrinol Metab 2017; 313:E463-E472. [PMID: 28420650 PMCID: PMC5689017 DOI: 10.1152/ajpendo.00449.2016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/13/2017] [Accepted: 04/13/2017] [Indexed: 12/13/2022]
Abstract
Human pregnancy is associated with enhanced de novo lipogenesis in the early stages followed by hyperlipidemia during advanced gestation. Liver X receptors (LXRs) are oxysterol-activated nuclear receptors that stimulate de novo lipogenesis and also promote the efflux of cholesterol from extrahepatic tissues followed by its transport back to the liver for biliary excretion. Although LXR is recognized as a master regulator of triglyceride and cholesterol homeostasis, it is unknown whether it facilitates the gestational adaptations in lipid metabolism. To address this question, biochemical profiling, protein quantification, and gene expression studies were used, and gestational metabolic changes in T0901317-treated wild-type mice and Lxrab-/- mutants were investigated. Here, we show that altered LXR signaling contributes to the enhanced lipogenesis in early pregnancy by increasing the expression of hepatic Fas and stearoyl-CoA desaturase 1 (Scd1). Both the pharmacological activation of LXR with T0901317 and the genetic ablation of its two isoforms disrupted the increase in hepatic fatty acid biosynthesis and the development of hypertriglyceridemia during early gestation. We also demonstrate that absence of LXR enhances maternal white adipose tissue lipolysis, causing abnormal accumulation of triglycerides, cholesterol, and free fatty acids in the fetal liver. Together, these data identify LXR as an important factor in early-pregnancy lipogenesis that is also necessary to protect against abnormalities in fetoplacental lipid homeostasis.
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Drivers of choice for fluid milk versus plant-based alternatives: What are consumer perceptions of fluid milk? J Dairy Sci 2017; 100:6125-6138. [DOI: 10.3168/jds.2016-12519] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Accepted: 03/31/2017] [Indexed: 11/19/2022]
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PO-0879: Differences between planned and delivered maximum spinal cord dose in Head &Neck cancer patients. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31316-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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The role of law in decisions to withhold and withdraw life-sustaining treatment from adults who lack capacity: a cross-sectional study. JOURNAL OF MEDICAL ETHICS 2017; 43:327-333. [PMID: 27531924 DOI: 10.1136/medethics-2016-103543] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 06/20/2016] [Accepted: 07/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To determine the role played by law in medical specialists' decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. DESIGN Cross-sectional postal survey of medical specialists. SETTING The two largest Australian states by population. PARTICIPANTS 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. MAIN OUTCOME MEASURES Compliance with law and the impact of legal knowledge on compliance. RESULTS 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. CONCLUSIONS Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care.
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Gestational disruptions in metabolic rhythmicity of the liver, muscle, and placenta affect fetal size. FASEB J 2017; 31:1698-1708. [PMID: 28082353 PMCID: PMC5566176 DOI: 10.1096/fj.201601032r] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 01/03/2017] [Indexed: 11/12/2022]
Abstract
Maternal metabolic adaptations are essential for successful pregnancy outcomes. We investigated how metabolic gestational processes are coordinated, whether there is a functional link with internal clocks, and whether disruptions are related to metabolic abnormalities in pregnancy, by studying day/night metabolic pathways in murine models and samples from pregnant women with normally grown and large-for-gestational age infants. In early mouse pregnancy, expression of hepatic lipogenic genes was up-regulated and uncoupled from the hepatic clock. In late mouse pregnancy, rhythmicity of energy metabolism-related genes in the muscle followed the patterns of internal clock genes in this tissue, and coincided with enhanced lipid transporter expression in the fetoplacental unit. Diurnal triglyceride patterns were disrupted in human placentas from pregnancies with large-for-gestational age infants and this overlapped with an increase in BMAL1 expression. Metabolic adaptations in early pregnancy are uncoupled from the circadian clock, whereas in late pregnancy, energy availability is mediated by coordinated muscle-placenta metabolic adjustments linked to internal clocks. Placental triglyceride oscillations in the third trimester of human pregnancy are lost in large-for-gestational age infants and may be regulated by BMAL1. In summary, disruptions in metabolic and circadian rhythmicity are associated with increased fetal size, with implications for the pathogenesis of macrosomia.-Papacleovoulou, G., Nikolova, V., Oduwole, O., Chambers, J., Vazquez-Lopez, M., Jansen, E., Nicolaides, K., Parker, M., Williamson, C. Gestational disruptions in metabolic rhythmicity of the liver, muscle, and placenta affect fetal size.
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