Using creative co-design to develop a decision support tool for people with malignant pleural effusion

BACKGROUND

Malignant pleural effusion (MPE) is a common, serious problem predominantly seen in metastatic lung and breast cancer and malignant pleural mesothelioma. Recurrence of malignant pleural effusion is common, and symptoms significantly impair people's daily lives. Numerous treatment options exist, yet choosing the most suitable depends on many factors and making decisions can be challenging in pressured, time-sensitive clinical environments. Clinicians identified a need to develop a decision support tool. This paper reports the process of co-producing an initial prototype tool.

METHODS

Creative co-design methods were used. Three pleural teams from three disparate clinical sites in the UK were involved. To overcome the geographical distance between sites and the ill-health of service users, novel distributed methods of creative co-design were used. Local workshops were designed and structured, including video clips of activities. These were run on each site with clinicians, patients and carers. A joint national workshop was then conducted with representatives from all stakeholder groups to consider the findings and outputs from local meetings. The design team worked with participants to develop outputs, including patient timelines and personas. These were used as the basis to develop and test prototype ideas.

RESULTS

Key messages from the workshops informed prototype development. These messages were as follows. Understanding and managing the pleural effusion was the priority for patients, not their overall cancer journey. Preferred methods for receiving information were varied but visual and graphic approaches were favoured. The main influences on people's decisions about their MPE treatment were personal aspects of their lives, for example, how active they are, what support they have at home. The findings informed the development of a first prototype/service visualisation (a video representing a web-based support tool) to help people identify personal priorities and to guide shared treatment decisions.

CONCLUSION

The creative design methods and distributed model used in this project overcame many of the barriers to traditional co-production methods such as power, language and time. They allowed specialist pleural teams and service users to work together to create a patient-facing decision support tool owned by those who will use it and ready for implementation and evaluation.

Thoracic ultrasound experiences among respiratory specialty trainees in the UK

Achieving competence in thoracic ultrasound is a mandatory requirement for the successful completion of respiratory specialty training in the UK. We evaluated trainee competencies, access to training and confidence in thoracic ultrasound by means of a nationally distributed survey with the participation of 202 (of approximately 600) respiratory trainees. 65.8% (131/199) of responders are RCR Level 1 accredited and 20.6% (22/107) of these trainees had performed fewer than 20 ultrasounds in the past year. 29.2% (50/171) of trainees reported that access to an ultrasonographer for advice was either 'not easy' or 'impossible'. 59% (107/171) of all respondents are 'never' or 'rarely' supervised, with 60% (102/169) of queries answered by real-time evaluation or review of stored media. Encouragingly ultrasound training has evolved considerably in recent years, but ongoing work needs to focus on improving supervision and training. There is a case for reviewing current guidance and to consider tailoring training and expectations to align with the specific needs of respiratory registrars. We propose a revision of the current Royal College of Radiologists framework towards a respiratory specialist led accreditation in thoracic ultrasound.

Neural respiratory drive predicts clinical deterioration and safe discharge in exacerbations of COPD

Rationale

Hospitalised patients with acute exacerbation of COPD may deteriorate despite treatment, with early readmission being common.

Objectives

To investigate whether neural respiratory drive, measured using second intercostal space parasternal muscle electromyography (EMG_para), would identify worsening dyspnoea and physician-defined inpatient clinical deterioration, and predict early readmission.

Methods

Patients admitted to a single-site university hospital with exacerbation of COPD were enrolled. Spirometry, inspiratory capacity (IC), EMG_para, routine physiological parameters, modified early warning score (MEWS), modified Borg scale for dyspnoea and physician-defined episodes of deterioration were recorded daily until discharge. Readmissions at 14 and 28 days post discharge were recorded.

Measurements and main results

120 patients were recruited (age 70±9 years, forced expiratory volume in 1 s (FEV₁) of 30.5±11.2%). Worsening dyspnoea, defined as at least one-point increase in Borg scale, was associated with increases in EMG_para%max and MEWS, whereas an increase in EMG_para%max alone was associated with physician-defined inpatient clinical deterioration. Admission-to-discharge change (Δ) in the normalised value of EMG_para (ΔEMG_para%max) was inversely correlated with ΔFEV₁ (r=−0.38, p<0.001) and ΔIC (r=−0.44, p<0.001). ΔEMG_para%max predicted 14-day readmission (OR 1.13, 95% 1.03 to 1.23) in the whole cohort and 28-day readmission in patients under 85 years (OR 1.09, 95% CI 1.01 to 1.18). Age (OR 1.08, 95% CI 1.03 to 1.14) and 12-month admission frequency (OR 1.29, 1.01 to 1.66), also predicted 28-day readmission in the whole cohort.

Conclusions

Measurement of neural respiratory drive by EMG_para represents a novel physiological biomarker that may be helpful in detecting inpatient clinical deterioration and identifying the risk of early readmission among patients with exacerbations of COPD.

Trial registration

NCT01361451.

A cohort study to identify simple clinical tests for chronic respiratory failure in obese patients with sleep-disordered breathing

BACKGROUND

Chronic respiratory failure complicating sleep-disordered breathing in obese patients has important adverse clinical implications in terms of morbidity, mortality and healthcare utilisation. Screening strategies are essential to identify obese patients with chronic respiratory failure.

METHOD

Prospective data were collected from patients with obesity-related sleep-disordered breathing admitted for respiratory assessment at a UK national sleep and ventilation centre. Hypercapnia was defined as an arterial partial pressure of carbon dioxide of >6kPa.

RESULTS

245 obese patients (56±13 years) with a body mass index of 48±12 kg/m(2), forced vital capacity (FVC) of 2.1±1.1 L, daytime oximetry (SpO2) of 91±6% and abnormal overnight oximetry were included in the analysis. Receiver operator curve analysis for the whole group showed that an FVC ≤3 L had a sensitivity of 90% and a specificity of 41% in predicting hypercapnia, and an SpO2 ≤95% had a sensitivity of 83% and a specificity of 63% in predicting hypercapnia. Gender differences were observed and receiver operator curve analysis demonstrated 'cut-offs' for (1) SpO2 of ≤95% for men and ≤93% for women and (2) FVC of ≤3.5 L for men and ≤2.3 L for women, in predicting hypercapnia.

CONCLUSIONS

The measurement of FVC and clinic SpO2 in obese patients with abnormal overnight limited respiratory studies predicted hypercapnia. This may have clinical utility in stratifying patients attending sleep clinics.

Antibody prevalence of Orientia tsutsugamushi, Rickettsia typhi and TT118 spotted fever group rickettsiae among Malaysian blood donors and febrile patients in the urban areas

The seroprevalence of Orientia tsutsugamushi (OT), Rickettsia typhi (RT) and TT118 spotted fever group rickettsiae (SFGR) among blood donors and febrile Malaysian patients in the urban areas was determined. Of the 240 blood donors, 5.4%, 9.2% and 1.7% had either present or previous exposure to OT, RT and SFG rickettsiae, respectively. Patients admitted to an urban hospital had high seroprevalences of OT (43.5%) and RT (22.9%), as compared to SFGR (11.6%). Antibody levels suggestive of recent infections of scrub typhus, murine typhus and tick typhus were detected in 16.8%, 12.7% and 8.2% of patients respectively. No significant difference was noted in the distribution of rickettsial antibodies among urban patients from 2 geographical locations. However, the serologic patterns of rickettsial infection in the urban areas were different form those of rural areas.

Borrelia burgdorferi (strain B. afzelii) antibodies among Malaysian blood donors and patients

In this study, the presence of IgG and IgM antibodies against Borrelia burgdorferi (strain B. afzelii) among Malaysian blood donors and patients admitted to hospital with various infectious diseases was determined. Sera were screened using enzyme-linked immunosorbent assay (ELISA); positive sera were then subjected to Western blot testing. All but one of the blood donors were negative for borrelial antibodies. Of 121 patients' sera, IgM antibodies were detected in 24 (19.8%) and IgG antibodies were detected in 5 (4.1%) sera. Only one of two patients with skin manifestations suggestive of Lyme disease had IgM antibody against B. afzelii. Of 30 patients with exposure to tick typhus, 4 (13.3%) were IgM positive and 1 (3.3%) was IgG positive. Based on the detection of antigenic bands by Western blot, 6 patients' sera showed positive reactions. Antigenic bands of p39, p41 and p59/62 kDa were the commonest findings of Western blotting. This study provides serological evidence of B. afzelii infections in Malaysia; further investigation is needed to correlate serological and clinical findings.

Seroepidemiologic survey of Orientia tsutsugamushi, Rickettsia typhi, and TT118 spotted fever group rickettsiae in rubber estate workers in Malaysia

The seroprevalence of Orientia tsutsugamushi, Rickettsia typhi, and TT118 spotted fever group (SFG) rickettsiae in 300 rubber estate workers in Slim River, Malaysia was determined in December 1996 and March 1997. In December, which was the wet season, 23.3%, 3.0%, and 57.3% of the population had antibodies detected against the three rickettsiae, respectively. The highest seropositive rate of 40% was detected for single infection with SFG rickettsiae, followed by a rate of 15.3% for both O. tsutsugamushi and SFG rickettsiae among the rubber estate workers. Subjects less than 21 years old had a lower seroprevalence of SFG rickettsiae compared with the other age groups. Indians had a higher seroprevalence of O. tsutsugamushi compared with other ethnic groups. Rubber tappers had a higher seroprevalence of SFG rickettsiae compared with other occupational groups. During the dry season in March 1997, there was a significant increase in the seroprevalence of R. typhi. The seroconversion rates for IgM against O. tsutsugamushi, R. typhi, and SFG rickettsiae were 5.7%, 12.3%, and 15.1%, respectively, during the four-month period. Significant variations of antibody titers towards the three rickettsiae was noted among subjects who were bled twice. This suggests a significant and continual exposure of rubber estate workers to the three rickettsiae.