bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparative effectiveness and safety of edoxaban versus warfarin in patients with atrial fibrillation: A nationwide cohort study
Authors: Nielsen Peter B , Søgaard Mette , Jensen Martin , Ording Anne G , Lip Gregory YH
Published: June 2021

Background and purpose

The effectiveness and safety of edoxaban 60 mg and 30 mg for stroke prevention compared with warfarin in patients with atrial fibrillation have not been well-described in a nationwide cohort of Caucasian patients treated in standard clinical practice.

Methods

We used Danish nationwide registries to identify patients with atrial fibrillation during June 2016 and November 2018 who were treated with edoxaban or warfarin and computed rates per 100 person-years of thromboembolic, all-cause mortality, and bleeding events using an inverse probability of treatment weighting approach to account for baseline confounding. We used weighted pooled logistic regression to compute hazard ratios with 95% confidence intervals comparing events between edoxaban 60 mg and warfarin users; edoxaban 30 mg was not included in formal comparisons.

Results

We identified 6451 atrial fibrillation patients, mean age was 72 years and 40% were females. A total of 1772 patients were treated with edoxaban 60 mg, 537 with edoxaban 30 mg, and 4142 with warfarin. The median CHA2DS2-VASc score was similar between warfarin and edoxaban 60 mg with a score of 3 (interquartile range (IQR) 2–4). In the inverse probability of treatment-weighted pseudo-population, the thromboembolic event rate for edoxaban 60 mg was 0.95 and 1.0 for warfarin, corresponding weighted hazard ratio of 1.00 (95% confidence intervals (CI) 0.59, 1.71). Edoxaban 60 mg users were associated with lower rates of all-cause mortality (3.93) compared to warfarin (6.04), with a hazard ratio of 0.64 (95% CI 0.47 to 0.88). The event rates for bleeding were 3.36 and 3.14, respectively; hazard ratio 1.09 (95% CI 0.77, 1.57).

Conclusion

Edoxaban 60 mg is a safe and effective treatment compared with warfarin for stroke prevention in routine clinical care for Danish (mainly Caucasian) patients with AF, with non-significantly different risks for stroke and clinically relevant bleeding, but lower all-cause mortality.
Biomarkers for interstitial lung disease and acute-onset diffuse interstitial lung disease in rheumatoid arthritis
Authors: Furukawa Hiroshi , Oka Shomi , Higuchi Takashi , Shimada Kota , Hashimoto Atsushi , Matsui Toshihiro , Tohma Shigeto
Published: June 2021

Interstitial lung disease (ILD) is frequently a complication of rheumatoid arthritis (RA) as an extra-articular manifestation which has a poor prognosis. Acute-onset diffuse ILD (AoDILD) occasionally occurs in RA and includes acute exacerbation of ILD, drug-induced ILD, and Pneumocystis pneumonia. AoDILD also confers a poor prognosis in RA. Previously-established biomarkers for ILD include Krebs von den lungen-6 and surfactant protein-D originally defined in patients with idiopathic pulmonary fibrosis; the sensitivity of these markers for RA-associated ILD (RA-ILD) is low. Although many studies on ILD markers have been performed in idiopathic pulmonary fibrosis, only a few validation studies in RA-ILD or AoDILD have been reported. Biomarkers for RA-ILD and AoDILD are thus still required. Recently, genomic, cytokine, antibody, and metabolomic profiles of RA-ILD or AoDILD have been investigated with the aim of improving biomarkers. In this review, we summarize current preliminary data on these potential biomarkers for RA-ILD or AoDILD. The development of biomarkers on RA-ILD has only just begun. When validated, such candidate biomarkers will provide valuable information on pathogenesis, prognosis, and drug responses in RA-ILD in future.
Diaphyseal Proximal Phalangeal Shortening Osteotomy for Correction of Hammertoe Deformity: Operative Technique and Radiological Outcomes
Authors: Bastías Gonzalo F. , Sage Katherine , Orapin Jakrapong , Schon Lew
Published: June 2021

Background

Correction of hammertoe deformities at the proximal interphalangeal (PIP) joint results in an inherent loss of motion that can be a concern for active patients who want to maintain toe function and grip strength. Diaphyseal proximal phalangeal shortening osteotomy (DPPSO) is a joint-sparing procedure resecting a cylindrical portion of the proximal phalanx on the middiaphysis.

Patients/Methods

This was a retrospective review including patients treated using DPPSO with at least a 1-year follow-up. Demographic, comorbidity, and Visual Analogue Scale (VAS) scores and complication data were obtained. Radiological assessment included union status and alignment. Medial frontal anatomical (mFAA), frontal proximal interphalangeal (mFIA), plantar lateral anatomical (pLAA), and medial and plantar lateral interphalangeal angles (pLIA) were measured.

Results

A total of 31 patients (45 toes) were included, with a mean age of 59 years (range: 24-72) and follow-up of 35 months (range: 12-60; mean preoperative VAS score was 4.9 ± 1.72 improving to 1.62 ± 2.28; P < .01). Union occurred in all patients at an average of 11.2 weeks. Complications were present on 4 toes (8.8%), with no recurrences. The pLIA significantly changed from 44.9° to 17.9°. There were no significant differences in the preoperative and postoperative values of the mFAA, pLAA, and mFIA.

Conclusions

DPPSO provides adequate pain relief and corrects the PIP joint in the lateral plane without significantly affecting the coronal plane or the anatomical axis of the phalanx in the frontal and lateral views, nor producing secondary deformities. DPPSO is a safe, effective, and reproducible technique with a low complication rate.

Levels of Evidence:

Level IV: Retrospective case series
Guidelines: Discharge Instructions for Covid-19 Patients
Authors: Baker Terrance L. , Greiner Jack V.
Published: June 2021

Introduction/Objectives:

Clinicians treating COVID-19 patients face a major challenge in providing an effective relationship with patients who are discharged to return to home in order to optimize patient self-management after discharge. The purpose of these discharge instructions is to assist and provide guidance for physicians, nurses, and other health care personnel involved in discharging COVID-19 patients to home after encounters at hospitals, emergency departments, urgent care settings, and medical offices.

Methods:

A systematic literature-search of studies evaluating both symptoms and signs of COVID-19 was performed in order to establish specific optimal performance criteria in monitoring a patient’s status with regard to disease safety. These optimal performance criteria parameters were considered with regard to the severity of morbidity and mortality. Strategies used to develop the discharge instructions included review of a broad spectrum of literature to develop the discharge criteria.

Results:

These guidelines are presented for patient education and should achieve the essential goals including: enabling patients to understand their medical situation, preventing complications, supporting patients by providing instructions, helping patients make more effective use of available health services, and managing patient stress by giving patients comfort through the knowledge of specific recommendations including how to respond to situations.

Conclusion:

The COVID-19 pandemic requires clinicians to efficiently teach their patients self-management strategies and to provide a safe educated response to the patient and the surrounding community environment. The primary goal of the patient education discharge-instructions (PEDI) is to provide self-management strategies for preventing complications and disease transmission.
Tibiotalocalcaneal Intramedullary Nailing for Unstable Geriatric Ankle Fractures
Authors: Kulakli-Inceleme Elif , Tas David B. , Smeeing Diederik P.J. , Houwert Roderick M. , van Veelen Nicole M. , Link Bjoern-Christian , Iselin Lukas D. , Knobe Matthias , Babst Reto , Beeres Frank J.P.
Published: June 2021

Background:

Tibiotalocalcaneal (TTC) intramedullary nailing has been suggested as an alternative to open reduction and internal fixation (ORIF) for the primary treatment of unstable fragility ankle fractures with a poor soft tissue envelope. This study aims to investigate the clinical efficacy of TTC intramedullary nail fixation for the primary treatment of unstable ankle fractures in frail elderly patients with poor soft tissue condition, by assessing the number of postoperative complications and the patient-reported functional outcomes.

Methods:

A retrospective cohort study was performed including patients with an unstable ankle fracture treated between 2015 and 2019 with TTC stabilization using a retrograde intramedullary hindfoot nail that was inserted without joint preparation and allowing immediate weight-bearing postoperatively. The primary outcome was the total number of postoperative complications.

Results:

A total of 10 patients were included out of 365 operatively treated ankle fractures. The mean age was 85.2 years (range 66-92) with a mean follow-up of 11.2 months (range 6-16). Fracture types included AO/OTA 44-B2 (n = 1), 44-B3 (n = 6), 44-C1 (n = 2) and 44-C3 (n = 1). Postoperative complications were observed in 4 patients (40%), including 3 nonunions, 2 implant related complications and 1 wound infection. No wound healing disorder or below-the-knee amputation was observed. Four patients (40%) deceased between post-operative 6 to 16 months due to medical conditions unrelated to surgery. The mean Foot and Ankle Outcome Score was 52.6 (range 44.2-73.8).

Conclusion:

Hindfoot nailingis a viable treatment option in selected high-risk patients with an advanced age, unstable ankle fractures with significant bone loss, poor soft tissue condition and/or severely impaired pre-injury mobility. In a frail geriatric population, hindfoot nailing may be a safe alternative fixation method with a low risk of wound complication or major amputation. However, unprepared joint may lead to symptomatic nonunion after TTC intramedullary nailing.
A Game-Theoretic Analytical Approach for Fostering Energy-Saving Innovation in the Electric Vehicle Supply Chain
Authors: Wang Jun-bin , Huang Lufei
Published: June 2021

Motivated by the industrial observation that electric vehicle (EV) manufacturers are often fully or partially outsourcing some specific components, for instance, powertrains and battery systems, and rely on their suppliers’ energy-saving innovation to improve their own EVs’ comprehensive performances, this study builds an analytical framework to investigate how different cooperation modes affect the EV supply chain’s energy-saving performance and firms’ profitability. As a main barrier preventing potential consumers from purchasing EVs, the consumer range anxiety for EVs’ performance was incorporated into the analytical model. Three primary cases and one strategic alliance case are sequentially analyzed. The results show that the supplier always self-motivates to implement energy-saving innovation to improve the performance of the core component, and the EV manufacturer is always willing to participate in its supplier’s energy-saving innovation by sharing a fraction of the investment. Moreover, a strategic alliance between the manufacturer and the supplier can effectively improve the profit of the whole supply chain. This strategic alliance can be coordinated through a generalized Nash-bargaining mechanism.
Suprafascial Free Flaps: Classification and Comprehensive Review of the Literature
Authors: Rios Sebastian , Falguera-Uceda María Isabel , Dean Alicia , Heredero Susana
Published: June 2021

Study Design:

Suprafascial free flaps have become common place in reconstructive surgery units. Nomenclature related to these flaps has not been uniform throughout the scientific literature, especially in regard to planes of dissection. This study is designed as a comprehensive review of the literature.

Objectives:

Our study highlights which flaps are used most frequently, their main indications, their survival rate, and how they have evolved in the last few decades as innovations have been introduced.

Methods:

A review of the literature was performed using keywords and Medical Subject Headings search terms. PubMed, Embase, and Cochrane Library were searched using the appropriate search terms. Data collected from each study included flap type, dissection plane, preoperative planning, area of reconstruction, as well as complications, donor-site morbidity and survival rate.

Results:

Seven hundred and fifty-five studies were found based on the search criteria. After full-text screening for inclusion and exclusion criteria 34 studies were included. A total of 1332 patients were comprised in these studies. The most common types of flaps used were superficial circumflex iliac perforator flap (SCIP), anterolateral thigh flap (ALT), and radial forearm flap. The most common areas of reconstruction were head & neck and limbs. There was no significant difference in survival rates between flaps that were raised in different planes of dissection.

Conclusions:

Based on the author’s review of the literature, suprafascial flaps are reliable, they have low donor site morbidity, and there is a wide selection available for harvest. The use of new technologies for preoperative planning, such as CT-Angiography and UHF ultrasound, have contributed to have more predictable results. We propose a standardized classification for these flaps, in order to create a uniform nomenclature for future reference.
Beware of the Dragon: A Case Report of a Komodo Dragon Attack
Authors: Boyd Brandon S. , Colon Felipe , Doty Jesse F. , Sanders Kristopher C.
Published: June 2021

Komodo dragon attacks are rare occurrences, especially in the United States. Attacks are believed to be highly infectious and venomous, leading to demise of its prey. We present a case of a 43-year-old female zookeeper attacked by an adult dragon leading to tendon and neurovascular injuries.
Nissen
Authors: Worrell Stephanie G.
Published: June 2021

The Nissen fundoplication remains the most durable and effective anti-reflux operation. There have been many modifications since it was first introduced. The most notable modifications include a minimally invasive approach, which significantly decreases the morbidity of the operation and technical changes which decrease the risk of potential side effects. The Nissen fundoplication is still associated with the side effects of gas bloat, the inability to belch and vomit, and the occurrence of persistent dysphagia. However, identifying the correct surgical patient, meticulous technique and post-operative care help improved outcomes and the success of the operation.
Cisplatin-based chemoradiation decreases telomerase-specific CD4 TH1 response but increases immune suppressive cells in peripheral blood
Authors: Boustani Jihane , Joseph Elodie Lauret Marie , Martin Etienne , Benhmida Salim , Lecoester Benoit , Tochet Florent , Mirjolet Céline , Chevalier Cédric , Thibouw David , Vulquin Noémie , Servagi Stéphanie , Sun Xushan , Adotévi Olivier
Published: June 2021

Background

The synergistic effect of chemoradiation (CRT) has been previously demonstrated in several cancer types. Here, we investigated the systemic immune effects of CRT in patients with lung or head and neck cancer.

Materials and methods

Peripheral blood mononuclear cells were collected at baseline and 1 month after treatment from blood samples of 29 patients treated with cisplatin-based chemoradiotherapy for lung or head and neck cancer. Circulating anti-tumor Th1 response was assessed by the ELISpot assay using a mixture of human leucocyte antigen (HLA) class II restricted peptides derived from telomerase (TERT). Phenotyping of circulating immunosuppressive cells (Treg and MDSC) was performed by flow cytometry.

Results

A significant increase of circulating Treg was observed in 60% of patients after CRT The mean rate of Treg was 3.1% versus 4.9% at baseline and after CRT respectively, p = 0.0015). However, there was a no significant increase of MDSC rate after CRT. In contrast, a decrease of tumor-specific Th1 response was documented in 7 out of 10 evaluated patients. We found high frequency of pre-existing tumor-specific Th1 response among patients with objective response after CRT compared to non-responders.

Conclusion

Cisplatin-based CRT promotes expansion of Treg and decrease of circulating anti-tumor Th1 response in peripheral blood. The balance towards a sustained specific anti-tumor T-cell response appears to be associated with response to CRT.
The potential renal toxicity of silver nanoparticles after repeated oral exposure and its underlying mechanisms
Authors: Nosrati Hamed , Hamzepoor Manijeh , Sohrabi Maryam , Saidijam Massoud , Assari Mohammad Javad , Shabab Nooshin , Gholami Mahmoudian Zahra , Alizadeh Zohreh
Published: June 2021

Background

Silver nanoparticles (AgNPs) can accumulate in various organs after oral exposure. The main objective of the current study is to evaluate the renal toxicity induced by AgNPs after repeated oral exposure and to determine the relevant molecular mechanisms.

Methods

In this study, 40 male Wistar rats were treated with solutions containing 30, 125, 300, and 700 mg/kg of AgNPs. After 28 days of exposure, histopathological changes were assessed using hematoxylin-eosin (H&E), Masson’s trichrome, and periodic acid-Schiff (PAS) staining. Apoptosis was quantified by TUNEL and immunohistochemistry of caspase-3, and the level of expression of the mRNAs of growth factors was determined using RT-PCR.

Results

Histopathologic examination revealed degenerative changes in the glomeruli, loss of tubular architecture, loss of brush border, and interrupted tubular basal laminae. These changes were more noticeable in groups treated with 30 and 125 mg/kg. The collagen intensity increased in the group treated with 30 mg/kg in both the cortex and the medulla. Apoptosis was much more evident in middle-dose groups (i.e., 125 and 300 mg/kg). The results of RT-PCR indicated that Bcl-2 and Bax mRNAs upregulated in the treated groups (p < 0.05). Moreover, the data related to EGF, TNF-α, and TGF-β1 revealed that AgNPs induced significant changes in gene expression in the groups treated with 30 and 700 mg/kg compared to the control group.

Conclusion

Our observations showed that AgNPs played a critical role in in vivo renal toxicity.
Perceived sustainability of the school-based social and behavior change communication (SBCC) approach on malaria prevention in rural Ethiopia: stakeholders’ perspectives
Authors: Abamecha Fira , Midaksa Gachena , Sudhakar Morankar , Abebe Lakew , Kebede Yohannes , Alemayehu Guda , Birhanu Zewdie
Published: June 2021

Background

Evidence on what makes the school-engaged social and behavior change communication (SBCC) interventions on malaria prevention more sustainable are limited in literature partly due to its recent emergence. Enrolling the key stakeholders, this study explored the perceived sustainability of the SBCC interventions on malaria prevention through primary school communities in rural Ethiopia.

Methods

The SBCC interventions were implemented from 2017 to 2019 in 75 primary schools and villages in rural Jimma to promote malaria preventive practices. As a part of program evaluation, this study employed a mixed-method to collect qualitative and quantitative data from 205 stakeholders following the end of the program. Data were collected using interview guides and structured questionnaires. The SPSS version 26 and Atlas ti7.1 software were used to analyze the data. Multivariable linear regression modeling was used to identify predictors of the perceived sustainability of the program (SOP).

Results

The mean score of SOP was 25.93 (SD = 4.32; range 6–30). Multivariable linear regression modeling showed that the perceived risk to malaria (β = 0.150; P = 0.029), self-efficacy (β = 0.192; P = 0.003), and perceived fidelity of implementation (β = 0.292; P = 0.000) and degree of adoption (β = 0.286; P = 0.000) were positively predicted the perceived SOP. The qualitative result identified various barriers and opportunities to sustaining the program that summarized under three themes which include perceptions about the quality of program delivery (e.g inadequate involvement of stakeholders and staffs, concerns over short project life, immature sustainability efforts), school settings (e.g schools’ malaria priority, schools’ climate and quality of coaching) and the outer settings (e.g existing structures in the health and education systems).

Conclusion

The study identified key predictive variables such as stakeholders’ perceived risk to malaria, self-efficacy, perceived fidelity of implementation and degree of adoption that could help to improve the sustainment of the school-based SBCC approach on malaria prevention and control. Further longitudinal study should be conducted to examine the rate of decline in program components over time and how improved sustainability would contribute to the effectiveness on malaria preventive behaviors among students.
Identifying relevant factors for successful implementation into routine practice: expert interviews to inform a heart failure self-care intervention (ACHIEVE study)
Authors: Herber Oliver Rudolf , Ehringfeld Isabell , Steinhoff Paula , Whittal Amanda
Published: June 2021

Background

Adherence to heart failure (HF) self-care behaviours has been found to be effective for alleviating illness symptoms, increasing quality of life and reducing hospital re-admissions and mortality. However, many patients fail to implement on-going self-care into their daily lives. It is therefore crucial to improve the behaviour of HF patients to increase self-care adherence. The aim of this study is to identify relevant factors to successfully implement a complex, theory-based HF self-care intervention into routine practice.

Methods

We conducted semi-structured interviews to obtain key stakeholders’ opinions on previously developed behaviour change techniques for enhancing HF patients’ self-care behaviours, in order to optimise implementation of these techniques in an intervention. The interview topic guide was developed based on the Normalisation Process Theory (NPT), a tool that takes into account the feasibility of implementation and the acceptability to stakeholders. Interviews were analysed using thematic analysis and supported by MAXQDA 2020, a software for qualitative research.

Results

Interview participants included 18 key stakeholders consisting of three crucial groups: clinical experts (n = 7), patients (n = 3) and high calibre policy makers/potential funders (n = 8). The interviews revealed numerous factors to consider for successful implementation of an intervention into routine practice. The findings are presented according to two major categories: (1) themes within the NPT framework and (2) themes beyond the NPT framework. Themes within the NPT component ‘Coherence’ include three sub-themes: ‘understandability’, ‘value beyond existing interventions’ and ‘perceived benefits’. The NPT component ‘Cognitive participation’ revealed two sub-themes: ‘time resources’ and ‘financial sustainability’. Finally, the NPT component ‘Collective action’ uncovered three sub-themes: ‘need for training’, ‘compatibility with existing practice’ and ‘influence on roles’. A further two themes were identified beyond the NPT framework, namely: ‘structural challenges’ and (2) ‘role of carers’.

Conclusions

Factors identified previously by NPT were validated, but stakeholders further identified relevant aspects beyond NPT. Based on these findings, we suggest the existing NPT framework could be expanded to include a fifth component: questions considering specific environmental factors (contextual considerations). Sensitising researchers to these issues at an early stage when designing an intervention can facilitate its later success.
Pyrroloquinoline quinone regulates the redox status in vitro and in vivo of weaned pigs via the Nrf2/HO-1 pathway
Authors: Huang Caiyun , Fan Zijuan , Han Dandan , Johnston Lee J. , Ma Xi , Wang Fenglai
Published: June 2021

Background

Oxidative stress is a main cause of piglet gut damage and diarrhea. Pyrroloquinoline quinone (PQQ), is a novel redox cofactor with antioxidant properties. However, the effect and mechanism that PQQ supplementation decreases oxidative injury in weaned pigs is not understood. Therefore, the aim of this study is to confirm the effect of PQQ on regulating redox status in weaned pigs and the mechanism for antioxidant function by porcine intestinal epithelial cell line (IPEC-J2) challenged with H2O2.

Results

Experiment 1, 144 Duroc × Landrace × Yorkshire pigs (weaned at 28 d) were allocated to four groups: received a basal diet (control) and diets supplemented with 0.15%, 0.30% and 0.45% PQQ, respectively. On d 28, growth performance, diarrhea incidence and redox factors were measured. Experiment 2, IPEC-J2 were treated with or without PQQ in the presence or absence of H2O2 for indicated time points. Experiment 3, IPEC-J2 were transfected with or without Nrf2 siRNA, then treated according to Experiment 2. The cell viability, redox factors, protein of tight junctions and Nrf2 pathway were determined.

In vivo, PQQ supplementation demonstrated dose-related improvements in average daily gain, and gain to feed ratio (Linear P < 0.05). During d 0–28, compared to controls, 0.45% PQQ supplementation for pigs decreased diarrhea incidence and MDA content in liver and jejunum, and increased concentration of SOD in liver; 0.3% PQQ supplementation decreased ileal and liver MDA concentration; and 0.15% PQQ supplementation decreased ileal MDA concentration (P < 0.05). In vitro, compared to cells cultured with H2O2, pre-treatment with PQQ increased cell viability, tight junction proteins expression including ZO-1, ZO-2, Occludin and Claudin-1; and decreased ROS concentration and level of Caspase-3 (P < 0.05); as well as upregulated the ratio of Bcl-2 to Bax and protein expression of nuclear Nrf2, HO-1. Notably, Nrf2 knockdown by transfection with Nrf2 siRNA largely abrogated the positive effects of PQQ pretreatment on H2O2-induced intracellular changes.

Conclusions

PQQ administration attenuated oxidative stress in weaned pigs which is associated with activation of Nrf2/HO-1 pathway.
Confusion and a cough: an experience of COVID-19 in dementia patients
Authors: Giles Emily
Published: June 2021

Aims

To assess the clinical presentation and outcomes of COVID-19 positive patients with dementia and to evaluate the suitability of the “4C mortality score.” Older adults with dementia are a vulnerable patient group therefore it was predicted that this patient demographic would have poorer outcomes and high mortality rates. Ward 24 is an organic old age psychiatry ward in University Hospital Monklands, Lanarkshire for patients with advanced dementia. Older adults have been found to have atypical presentations and non-specific symptoms in COVID-19, however given COVID is still a new and evolving disease, little is known about the impact on dementia patients. The 4C mortality score was designed to predict in-hospital mortality for hospitalised COVID-19 patients using a number of clinical parameters.

Method

Data were collected retrospectively from all inpatients on ward 24 testing positive for COVID-19 between October and December 2020. Data were collected using online MIDIS entries, paper notes, NEWS charts and Clinical Portal. A 4C mortality score was calculated for each patient using an online calculator based on the data collected.

Result

15 patients tested positive for COVID-19; 47% male and 53% female, age range between 64 and 92 years old. 67% of patients had 3 or more comorbidities and 89% had either a high or very high 4C mortality score. Mortality from COVID-19 was 13% and 20% of patients required oxygen. 27% of patients were asymptomatic, these patients also had the lower risk mortality scores. 67% presented with pyrexia, 33% had a cough and 13% had breathlessness. Non-specific symptoms were also seen; 53% had fatigue, 20% had diarrhoea and 20% had unresponsive episodes. Post COVID delirium was seen in 20% of patients.

Conclusion

Mortality rates were lower than expected, indicating that the 4C mortality score might not be appropriate to use in this patient demographic due to confounding factors. Atypical symptoms were common in patients, with a variability of clinical presentations within the patient demographic. These findings suggest the importance of having a low threshold for COVID-19 infection even in the absence of typical symptoms. Development of an alternative risk stratification tool would be beneficial for this patient group, with further studies needed on a larger scale to facilitate this.
An evaluation of barriers to the initiation of clozapine in patients with treatment-resistant schizophrenia
Authors: Hyland Declan , Jamieson Seth
Published: June 2021

Aims

This evaluation aimed to identify patient, practitioner and infrastructural barriers to initiation of clozapine treatment in patients with treatment-resistant schizophrenia (TRS). In response to recent research supporting use of clozapine as the most effective treatment for patients with TRS, concerted efforts have been made to establish why clozapine is underutilised in the NHS. Following a study conducted by South London and Maudsley NHS Foundation Trust, which identified barriers and made recommendations, this evaluation aimed to identify barriers to initiation of clozapine in patients under the care of Mersey Care NHS Foundation Trust.

This evaluation also aimed to make further recommendations to increase use of clozapine in Mersey Care's TRS patients and assess whether there have been any differences to concerns about clozapine initiation compared to previous evaluations.

Method

An online questionnaire containing a series of Likert scales was e-mailed to all Consultant Psychiatrists in Mersey Care NHS Foundation Trust. The questionnaire asked Consultants to rate how often they felt a range of barriers interfered with successful initiation of Clozapine treatment. The barriers chosen were based on the 2019 systematic review “Barriers to using clozapine in treatment-resistant schizophrenia.”

Result

Nineteen consultant psychiatrists completed the online questionnaire. All 19 indicated they either “agreed” (16%) or “strongly agreed” (84%) that they were confident in diagnosing TRS. This was a significant increase compared to the South London and Maudsley evaluation, with only 81% of participants in that study being “fairly familar” or “very familiar” with clozapine guidelines.

Furthermore, concerns about inadequate blood testing facilities appear to have been addressed, with no participants in this evaluation staing there were insufficient blood testing facilities. However, 53% of Consultants who completed this evaluation stated they “often” (37%) or “very often” (16%) have patients who refuse clozapine because of the requirement for regular blood testing. Refusal to agree to required blood testing was the commonest reason identified for failure to initiate clozapine in TRS patients. This was consistent with the results from the South London and Maudsley study.

Conclusion

Those Mersey Care consultants surveyed identified that providing patients with further information about clozapine would be the most valuable intervention to increase likelihood of uptake of clozapine in the treatment of TRS. Significant progress has been made in improving the likelihood that clozapine can be successfully initiated, especially in the removal of practitioner barriers. This evaluation suggests interventions should now be aimed at reducing patient barriers to initiation of treatment.
Using quality improvement to standardise and enhance the use of the national early warning score (NEWS) in an old age psychiatry inpatient setting
Authors: MacNicoll Fraser , Tung Mong Sun , McGowan Brion
Published: June 2021

Aims

Within an inpatient old-age psychiatry setting, there is an increased risk of acute physical deterioration secondary to age, comorbidities and reduced physiological reserve. Numerous recent clinical incidents highlighted late recognition of physical deterioration within this population. We assessed the use of the NEWS, a system for scoring physiological measurements, in an old-age psychiatry ward and subsequently attempted to improve performance of obtaining physical health observations in this cohort of patients.

Method

Retrospective pre- and post- quality improvement study in a twenty bed Old Age Psychiatry Ward in East Lothian Community Hospital, Haddington, Scotland. Data were collected from 12th October – 16th November, 2020 (pre- period) and from 16th November 2020 to 15th February, 2021 (post- period). The primary process measure was ensuring all patients had at least one full set of physical observations at least once a week, or more frequent as deemed clinically appropriate. Secondary measures included ensuring NEWS scores were accurately calculated and improved documentation. This was tracked using a run chart. Improvement activities focused on increased awareness, effective training, key stakeholder buy-in and reviewing trust policy.

Result

The percentage of NEWS documented for all patients at least once a week improved from a mean of 28.7% (31/108) in the 6 weeks prior to intervention, to a mean of 71.4% (125/175) in the following 13 weeks. The minimum required physical observations required to accurately calculate a NEWS improved from 51.6% (16/31) pre-intervention to 95.2% (119/125) post-intervention and NEWS being calculated correctly increased from 80.6% (25/31) to 96% (120/125). Documentation of a reason why physical observations were not taken increased from 2.5% (2/77) to 62% (31/50) pre- and post- intervention respectively.

Conclusion

This quality improvement project highlighted that recording of physical observations and use of NEWS was inadequate in this setting, increasing the risk of a delay in identification of acute physical deterioration and thus increase morbidity and mortality. Introducing simple measures and standardising the NEWS assessment process, along with senior nursing and medical oversight, greatly enhanced acquiring and recording of physical observations and NEWS scores. This quality improvement project has shown that practical solutions and staff education can increase efficacy and are hoping further input can consolidate the gains achieved and lead to continued improvements.
Pregnancy and contraceptive questioning within acute inpatient psychiatric admissions: are we asking enough?
Authors: Partington Eleanor
Published: June 2021

Aims

This audit explored how regularly women of childbearing age on an acute psychiatric inpatient ward are asked about pregnancy and contraception.

Background

Unplanned pregnancies and poor compliance with contraception are common in women with severe mental illness, with a significant number seeking abortions or losing custody of their children. As these women are also less likely to consult medical professionals, an admission is an essential point for intervention and support.

Additionally, there are risks associated with prescribing psychotropic medications during pregnancy. Because of this, The Royal College of Psychiatrists and local guidelines state that all female patients admitted onto psychiatric inpatient wards should be asked about their sexual health within seven days of admission.

Method

Data was collected from all 51 women of childbearing age admitted to a mixed-sex, acute adult inpatient psychiatry ward over one year, from January 2019 until the end of December 2019.

Women of childbearing age were deemed to be those between the ages of 15 and 45, based on the World Health Organization's definition. However, the sample for this audit includes females aged 18–45 years due to the minimum age restrictions of the ward.

All eligible female inpatients had their physical health forms and progress notes screened for documentation of whether a) the possibility of them being pregnant was explored b) if a pregnancy test was done and c) if a contraceptive history was taken.

Result

Only 57% of female patients admitted during this period were asked about their contraceptive habits. Furthermore, exploration into the possibility of pregnancy occurred in less than half of admitted patients.

Further analysis was done by age; 18-26, 27-35 and 36-45, but showed minimal variation.

Conclusion

This audit revealed that Royal College of Psychiatrists and local guidelines are not being met, with women not receiving the recommended assessment and counselling in regard to pregnancy and contraception.

Inpatient admissions provide a valuable opportunity for identifying and preventing potential harm in the case of unplanned and undetected pregnancies. All health care professionals need to be aware of the importance of asking the above questions and ensure they are explored at some point during a patient's admission.

The audit will be discussed at forthcoming Clinical Governance meeting for further recommendations followed by re-audit.
The impact of the COVID-19 pandemic on referrals to liaison psychiatry services at University Hospital Hairmyres, NHS Lanarkshire
Authors: Paton Cristina , Hills James , Hegde Rekha
Published: June 2021

Aims

The COVID-19 pandemic has led to sweeping public health restrictions with predictable impact on mental health. In Scotland, lockdown measures during the first wave of the pandemic commenced on 23rd March 2020 and only began to ease after 29th May 2020. The aim of this study was to evaluate the impact of the first wave of the COVID-19 pandemic on the number and type of referrals made to the adult psychiatric liaison nursing service (PLNS) at University Hospital Hairmyres, NHS Lanarkshire.

Method

We collated all of the archived referrals made by our local emergency department to the PLNS at University Hospital Hairmyres for adults (aged 18–65 years) during the period of the first COVID-19 national lockdown (April-July 2020) and the corresponding period one-year prior (April-July 2019) to analyse differences in referral numbers and demographics. Additionally, for referrals made during 2020, we conducted a qualitative review of electronic records to determine the reason for referral, contributory stressors to presentation, and in particular any effect from COVID-19.

Result

A total of 549 referrals were made over the study period, with 320 in 2019 and 229 in 2020, a decrease of almost 30%. In 2019, referrals fell each month from April (n = 89) to July (n = 74), while this trend was reversed in 2020, rising from April (n = 45) to near-usual levels by July (n = 68). Compared to baseline, referrals in April 2020 were for a higher proportion of men (62.2%). On qualitative analysis, 26 records (11.3%) could not be found. Otherwise, the most common reasons for referral were suicidal ideation (43.3%) and/or deliberate self-harm (39.9%). Many patients presented with comorbid substance misuse (54.2%) and the majority were not known to community services (64.5%). COVID-19 was implicated in 48 referrals (23.6%), but only 2 of these arose as a direct result of infection.

Conclusion

We have observed clear differences in the pattern of referrals made to the adult PLNS during the first COVID-19 national lockdown. COVID-19 was implicated in a minority of referrals, but most were related to secondary effects of lockdown restrictions rather than COVID-19 infection. Possible reasons for fewer referrals during this time could be non-presentation through fears of contracting COVID-19 or altruistic avoidance of putting “pressure on the NHS”. Further studies would be insightful; in particular, equivalent analysis of contacts with community services; and qualitative patient perspectives regarding reasons for non-presentation during this time.
The effectiveness of telepsychiatry: a thematic review
Authors: Sharma Gunjan , Devan Karrish
Published: June 2021

Aims

The authors conducted a thematic review on the effectiveness of Telepsychiatry in light of the COVID-19 pandemic. The study aimed to clarify the effectiveness of Telepsychiatry, providing an evidence base for the growing use of Telepsychiatry.

Method

The authors searched three databases - Cochrane, PubMed and PsychINFO - using the terms virtual consultation/telepsychiatry/video consultation AND psychiatry/mental illness.

The authors excluded all papers that were not in English and that did not focus on the psychiatric consultation.

Result

961 papers were identified, reduced to 321 using exclusion criteria and removal of duplicates. Using thematic analysis the authors found five themes that occurred across all papers in relation to the effectiveness of Telepsychiatry.

Patient & Clinician Satisfaction

There is consistently high patient satisfaction with telepsychiatry but lower clinician satisfaction, often as a result of cynicism and a lack of familiarity. Clinician satisfaction increases when clinicians trial Telepsychiatry and become more positive about its uses.

Diagnostic Reliability

Telepsychiatry was found to have high levels of inter-rater reliability equivalent to face-to-face consultations for common disorders including mood and psychotic disorders, substance misuse and dementia. It was also found to have high levels of diagnostic reliability across age groups.

Outcomes

Telepsychiatry has been found to reduce symptoms of common psychiatric disorders and improve quality of life in a variety of environments including emergency departments, inpatient units and prisons. Telepsychiatry increases access to specialised services resulting in quicker access to treatment and reduction in admissions.

Technology

Without adequate internet connectivity clinicians are unable to conduct an appropriate mental state examination and the therapeutic relationship becomes challenging. Inadequate technology can impact the effectiveness of Telepsychiatry amongst those who are socioeconomically disadvantaged and may not have access to appropriate technology.

Professional Guidance

There is a concerning lack of guidance around the use of Telepsychiatry. Without clear protocols there is a lack of standardisation and clinicians are unwilling to integrate Telepsychiatry into their practice. Main concerns raised are around confidentiality, consent, the appropriateness of certain patient groups and emergencies.

Conclusion

This review found evidence for the effectiveness of Telepsychiatry with greatest emphasis on technology and patient satisfaction. The main barrier is the reluctance amongst clinicians to facilitate Telepsychiatry into their practice, often due to cynicism and a lack of familiarity. The authors recommend training in the uses of Telepsychiatry and the provision of professional guidance from medical bodies to allay concerns and provide clear standards.
The prevalence of autism spectrum traits and autism spectrum disorders in children and adolescents with obsessive compulsive disorder: a systematic review
Authors: Tiley Claire , Kyriakopoulos Marinos
Published: June 2021

Aims

Autism Spectrum Disorder (ASD) and Obsessive Compulsive Disorder (OCD) commonly co-occur in children and adolescents (C&A); evidence suggests functional impairment is increased in those diagnosed with both disorders. The aims of this systematic review were: 1) To review studies that report on the prevalence of ASD traits and/or diagnosis in C&A with OCD. 2) To review whether the severity of OCD symptoms is related to the severity of ASD traits in C&A with OCD. 3)To review whether the severity of comorbid ASD traits or diagnosis in C&A with OCD impact on their global functioning.

Method

This systematic review was registered in PROSPERO. Prisma guidelines were followed . Electronic searches were carried out on Pubmed, EMBASE and Psychinfo with the use of selected keywords. Inclusion criteria : 1) Participants up to the age of 18 who had an ICD or DSM diagnosis of OCD. 2) Journal articles published in the English, with no date specifications. 3) Papers evaluating ASD diagnosis or traits, or where data on this could be extracted. Exclusion criteria: 1) Papers looking at OCD related disorders such as body dysmorphic disorder, compulsive skin picking, trichotillomania and hoarding disorder. 2) Samples including adults where C&A data could not be extracted. 3) Posters, abstracts and dissertations.

Result

A total of 15 studies were included in the systematic review. Seven of these studies directly compared the prevalence of ASD traits (measured by questionnaires) or diagnosis in OCD to a control group or normative data, with all studies reporting a significant elevation in ASD trait scores and diagnosis in OCD. Ten of the studies reported on the correlation between ASD trait severity and OCD severity. Four studies identified a significant correlation between ASD and OCD total scores or specified subscales. In contrast, one study found significantly elevated OCD scores in an OCD only group when compared to a comorbid OCD and ASD group. Three studies reported on the correlation between ASD scores and functional impairment or compared an OCD only group to a comorbid group. All three studies demonstrated that the presence ASD or ASD traits are associated with elevated scores in global functional impairment.

Conclusion

In conclusion, this review suggests that there is an increased prevalence of ASD traits and diagnosis amongst C&A with OCD. Elevated ASD traits within this population are associated with a greater impact on global functioning.
Identifying Risk Factors for Re-admission: A Service Evaluation from an Adult Inpatient Mental Health Unit
Authors: Ward Kirsty , Prasad Suveera
Published: June 2021

Aims

To identify risk factors for re-admission to an acute inpatient general adult mental health ward. There is need to ensure that mental health services adapt to the increasing demand for inpatient beds

Method

We conducted a single centre retrospective analysis of electronic records of 85 discharges from an adult mental health unit from 4th March 2019 – 5th August 2019. We collected information on demographics, admission details, substance use, forensic history, diagnosis as per the International Classification of Diseases 10th Edition (ICD-10), and discharge details and compared two cohorts; those re-admitted within three months of discharge and those who were not. Odds ratio (OR), 95% confidence intervals (CI) and p values were calculated where possible.

Result

Among seventeen service users who were re-admitted within the three month period there were nine women and eight men. There was no difference in ethnicity, employment or marital status. The mean length of admission for those readmitted was 48.2 days (range 1–140 days) and 47.1 days (range 1–350 days) for those who were not readmitted. Certain features were more prevalent among the readmitted group including forensic history (58.8% [10] vs 26.5% [18], OR 3.97, CI 1.31–11.9, p value 0.007), substance misuse history (70.6% [12] vs 55.9% [38], OR 1.89, CI 0.60–5.97, p value 0.138), previous contact with mental health services (100% [17] vs 76.5% [52]) and the rate of detention under the Mental Health Act at point of admission (76.5% [13] vs 66.2% [45], OR 1.66, CI 0.49, 5.67, p value 0.209).

Among those readmitted, a diagnosis of emotionally unstable personality disorder (17.6% [3] vs 10.3% [7], OR 1.87, CI 0.43,-8.14, p values 0.203) and substance misuse disorder (41.2 % [7] vs 17.6 % [12], OR 3.27, CI 1.04–10.31, p value 0.218) were more prevalent. They were more likely to use illicit substances whilst they were an inpatient (23.5% [4] versus 7.6% [5], OR 3.88, CI 0.92–16.43, p value 0.033) and to be involved in police incidents (35.3% [6] versus 17.6% [12], OR 2.55, CI 0.79–8.23, p value 0.059).

Conclusion

Our trends demonstrate that people with substance misuse, emotionally unstable personality disorder and forensic history are more likely to be readmitted to an adult mental health inpatient unit. They were more likely to misuse illicit substances and be involved with police during admission.