bluuebunny/crossref_metadata_2025 huggingface dataset:
Burden of hypoxia and intraventricular haemorrhage in extremely preterm infants
Authors: Ng Isabel Hui Xuan , da Costa Cristine Sortica , Zeiler Fred A , Wong Flora Y , Smielewski Peter , Czosnyka Marek , Austin Topun
Published: June 2019

Objective

Thresholds of cerebral hypoxia through monitoring of near-infrared spectroscopy tissue oxygenation index (TOI) were used to investigate the relationship between intraventricular haemorrhage (IVH) and indices of hypoxia.

Design

Prospective observational study.

Setting

A single-centre neonatal intensive care unit.

Patients

Infants <28 weeks’ gestation with an umbilical artery catheter.

Methods

Thresholds of hypoxia were determined from mean values of TOI using sequential Χ2 tests and used alongside thresholds from existing literature to calculate percentage of time in hypoxia and burden of hypoxia below each threshold. These indices were then compared between IVH groups.

Results

44 infants were studied for a median of 18.5 (range 6–21) hours in the first 24 hours of life. Sequential Χ2 analysis yielded a TOI threshold of 71% to differentiate between IVH (16 infants) and no IVH (28 infants). Percentage of time in hypoxia was significantly higher in infants with IVH than those without, using thresholds of 60%–67%. Burden of hypoxia was significantly higher in infants with IVH than without, using thresholds of 62%–80%. With the threshold of 71%, percentage of time in hypoxia was lower by 12.2% with a 95% CI of (−25.7 to 1.2) (p=0.073), and the burden of hypoxia was lower by 29.2% hour (%h) (95% CI −55.2 to −3.1)%h (p=0.012) in infants without IVH than those with IVH.

Conclusions

Using defined TOI thresholds, infants with IVH spent higher percentage of time in hypoxia with higher burden of cerebral hypoxia than those without, in the first 24 hours of life.
Dorsal dermal sinus presenting as quadriparesis
Authors: Majumdar Ishita , Kundu Ritabrata , Das Joydeep , Mukherjee Devdeep
Published: June 2019

Dorsal dermal sinus (DDS) represents the spectrum of spinal dysraphism. Children may present with features of meningitis. A 13-month male child presented with features of meningitis and quadriparesis. Clinical examination revealed a small pit over the thoracic spine. MRI was suggestive of a DDS. Initially, the patient responded to antibiotics and methylprednisolone, which was given for resolving the mass effect. However, he had a recurrence of symptoms and underwent surgical exploration and resection of DSS with resolution of symptoms. Careful examination of the back is extremely essential in children with meningitis. Radiological investigation helps in visualisation of the DSS. Although rare in children, they may present with recurrent meningitis.
Temozolomide-induced aplastic anaemia and incidental low-grade B-cell non-Hodgkin lymphoma in a geriatric patient with glioblastoma multiforme
Authors: Batalini Felipe , Kaufmann Matthew R , Aleixo Gabriel Francisco , Drews Reed
Published: June 2019

Glioblastoma multiforme is an astrocyte-derived tumour representing the most aggressive primary brain malignancy. The median overall survival is 10–12 months, but it drops to 3–8.5 months for the cohort with more than 65 years old, which account to half of all patients. Initial management in this patient population aims to balance overall patient survival and quality of life with the inherent risks of treatment intervention, which include maximal safe tumour resection, radiation and temozolomide (TMZ) chemotherapy. This is accomplished through risk stratification as a function of patient age, functional status, comorbidities, tumour location and methylguanine methyltransferase promoter methylation status. We describe the care of a patient with prolonged febrile neutropaenia, with a rare but fatal complication from TMZ-induced idiosyncratic reaction, leading to aplastic anaemia and a provoking diagnosis of low-grade B-cell non-Hodgkin’s lymphoma.
Cutaneous leprosy in Central Florida man with significant armadillo exposure
Authors: Logas Christopher Michael , Holloway Kathryn B
Published: June 2019

Leprosy is a chronic infectious, granulomatous disease caused by the intracellular bacillusMycobacterium lepraethat infects macrophages and Schwann cells. While relatively rare in the USA, there is about 200 new cases of leprosy every year with the majority occurring in the southern parts of the country. It is believed to be linked to the region of the nine-banned armadillo in patients with no significant travel history outside of the country. In this case report, we encountered a 58-year-old Central Florida man that had extensive exposure to armadillos and presented with the typical symptoms of large erythaematous patches, numbness and peripheral nerve hypertrophy. Once diagnosed properly, patients are then reported to the National Hansen’s Centre who provides the multidrug therapy for 12–24 months. Due to its rarity and its ability to mimic other more common ailments, leprosy should be included in the differential diagnosis in patients that have significant exposure to armadillos, live in the southern part of the country or have recently travelled to countries that have a high prevalence of leprosy.
Pustules on the back possibly triggering toxic-shock syndrome
Authors: Hagiya Hideharu , Nakagami Futoshi , Minami Yuki , Terada Hiroaki
Published: June 2019

We herein describe an irregular case of toxic-shock syndrome (TSS). A previously healthy 28-year-old Japanese man developed a sudden-onset high fever. The patient was suffering from conjunctival hyperaemia, gastrointestinal symptoms such as vomiting and diarrhoea, and systemically diffused macular erythroderma. Further physical examination detected pustules on his back, which self-destructed over time. Laboratory revealed multiple organ failures. Subsequently, scalded skin on the face and desquamation in the limb extremities emerged by day 10, leading to the diagnosis of TSS, despite his stable circulatory dynamics through the course. Learning points for clinicians include that they should recall TSS as a possible disease concurrently causing high fever, systemic rash and multiple organ dysfunctions, even without being in a state of shock. The characteristic desquamations emerged in the limb extremities after hospitalisation were of help in diagnosing TSS.
Medication regimen complexity and its impact on medication adherence and glycemic control among patients with type 2 diabetes mellitus in an Ethiopian general hospital
Authors: Ayele Asnakew Achaw , Tegegn Henok Getachew , Ayele Tadesse Awoke , Ayalew Mohammed Biset
Published: June 2019

Background

Different studies reported that higher diabetes-specific Medication Regimen Complexity Index (MRCI) has a negative impact on glycemic control potentially by decreasing medication adherence. However, information about regimen complexity and its association with adherence and glycemic control in Ethiopian patients with diabetes is unknown.

Aim

To evaluate medication regimen complexity and to assess its impact on medication adherence and glycemic control among patients with type 2 diabetes Mellitus (T2DM).

Methods

A hospital-based cross-sectional design was conducted at Debre Tabor General Hospital from 1 May 2018 to 30 June 2018. Medication regimen complexity was evaluated using the 65-item validated tool called Medication Complexity Index (MRCI). Adherence was measured using Morisky Medication Adherence Scale while patients were classified as having poor or good glycemic control based on the recent record of their fasting blood glucose. Multivariable logistic regression analysis was applied to determine the association between predictive variables and outcome variables.

Results

A total of 275 patients with T2DM who meet the inclusion criteria were included in the final analysis. About 22.2% of the participants were classified as having high diabetes-specific MRCI, whereas 35.6% of the participants were classified as having high patient-level MRCI. The majority (70.5%) of the respondents were adherent to their medications, and 42.9% of the total population were categorized as having good glycemic control. According to the result of the multivariate analysis, patients with low-level and moderate-level MRCI of both diabetes-specific and patient-level MRCI were more adherent to their medication compared with patients with high MRCI. High diabetes medication regimen complexity was associated with poor glycemic control in the adjusted analyses (adjusted OR=0.276; 95% CI=0.100 o 0.759).

Conclusion

The prevalence of high MRCImedication regimen complexity index is high among patients with T2DM. Patients with low and moderate regimen complexity had improved adherence. High diabetes-specific medication regimen complexity was associated with poor glycemic control. Simplification of a complex medication regimen for patients with diabetes should be sought by physicians and pharmacists to improve medication adherence and subsequent improvement in glycemic control.
Multiple factor analysis of eating patterns to detect groups at risk of malnutrition among home-dwelling older subjects in 2015
Authors: Sanchez Marc-Antoine , Armaingaud Didier , Messaoudi Yasmine , Letty Aude , Mahmoudi Rachid , Sanchez Stéphane
Published: June 2019

Objective

We aimed to describe eating patterns among home-dwelling older subjects to establish typologies of eaters at higher or lower risk of malnutrition.

Design

Cross-sectional study between June and September 2015 using a standardised questionnaire. The questionnaire was given to home-help employees (responsible for delivering meals to home-dwelling older persons and helping them to eat). The employees were asked to complete the questionnaire three times during the same week, for the same older adults, in order to identify the totality of their food intake.

Setting

Registered customers of the home meal delivery company ‘Azaé’ (France).

Participants

605 older home-dwelling persons were randomly selected among customers served by the home meal delivery company.

Outcomes

Multiple factor analysis was used to understand the different modes of food consumption and to establish eating profiles. Hierarchical classification was performed to construct eating profiles corresponding to the dietary habits of the respondents.

Results

Average age of the older adults was 85.3 years; 73.5% were women. Overall, 59% of participants reported that they ate out of habit, while 33.7% said they ate for pleasure. We identified four different groups of eaters, at varying levels of risk for malnutrition. Individuals in group 4 had the highest food intake in terms of quantity; and were less dependent than individuals in group 1 (p=0.05); group 1 was at highest risk of malnutrition.

Conclusion

Improved understanding of eating habits can help detect risky behaviours and help caregivers to promote better nutrition among home-dwelling older subjects.
Prevalence of simultaneous use of alcohol and prescription medication in older adults: findings from a cross-sectional survey (Health Survey for England 2013)
Authors: Foster John , Patel Swatee
Published: June 2019

Objectives

To investigate the concurrent use of ‘at-risk’ (AR) drinking (>10 units of alcohol per week) and prescription medications, while controlling for sociodemographic, and health-related factors, among older adults (aged 65–89 years).

Design

Cross-sectional survey.

Setting

Data from Health Survey of England, 2013.

Interventions

None.

Participants

General population survey of 2169 adults aged 65–89 years.

Primary outcome measures

AR drinking (>10 units per week). Secondary outcome was AR drinking defined as >14 units of alcohol per week limit (the cut-off used by the Department of Health for AT drinking).

Results

Twenty-seven per cent (n=568) of the sample were AR drinkers. Factors associated with alcohol consumption were gender, age, social class, marital status, rurality of dwelling, deprivation index, self-reported general health, cigarette smoking, body mass index, exercise level, health and well-being scores’ and number of prescription drugs. Logistic regression analysis showed that males were more likely to be AR drinkers (OR 3.44, 95% CI 2.59 to 4.57, p<0.0001) than females. Each year increase in age, lowered the probability of AR drinking by a factor of 0.95 (95% CI 0.93 to 0.98, p<0.0001). Using prescription drugs reduced AR drinking by a factor of 0.92 (95% CI 0.85 to 0.93, p=0.033), after controlling for age, sex and rurality of dwelling. No other predictors were significant. Similar results were obtained for AR drinking of >14units per week.

Conclusion

AR drinking is more likely in older men than women. The odds of AR drinking lessens, as individuals age, and using prescription drugs also reduces AR drinking.
Cybersecurity features of digital medical devices: an analysis of FDA product summaries
Authors: Stern Ariel Dora , Gordon William J , Landman Adam B , Kramer Daniel B
Published: June 2019

Objectives

To more clearly define the landscape of digital medical devices subject to US Food and Drug Administration (FDA) oversight, this analysis leverages publicly available regulatory documents to characterise the prevalence and trends of software and cybersecurity features in regulated medical devices.

Design

We analysed data from publicly available FDA product summaries to understand the frequency and recent time trends of inclusion of software and cybersecurity content in publicly available product information.

Setting

The full set of regulated medical devices, approved over the years 2002–2016 included in the FDA’s 510(k) and premarket approval databases.

Primary and secondary outcome measures

The primary outcome was the share of devices containing software that included cybersecurity content in their product summaries. Secondary outcomes were differences in these shares (a) over time and (b) across regulatory areas.

Results

Among regulated devices, 13.79% were identified as including software. Among these products, only 2.13% had product summaries that included cybersecurity content over the period studied. The overall share of devices including cybersecurity content was higher in recent years, growing from an average of 1.4% in the first decade of our sample to 5.5% in 2015 and 2016, the most recent years included. The share of devices including cybersecurity content also varied across regulatory areas from a low of 0% to a high of 22.2%.

Conclusions

To ensure the safest possible healthcare delivery environment for patients and hospitals, regulators and manufacturers should work together to make the software and cybersecurity content of new medical devices more easily accessible.
Thresholds for clinically important deterioration versus improvement in COPD health status: results from a randomised controlled trial in pulmonary rehabilitation and an observational study during routine clinical practice
Authors: Alma Harma Johanna , de Jong Corina , Jelusic Danijel , Wittmann Michael , Schuler Michael , Sanderman Robbert , Schultz Konrad , Kocks Janwillem , van der Molen Thys
Published: June 2019

Objectives

Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease. Preventing deterioration of health status is therefore an important therapy goal. (Minimal) Clinically Important Differences ((M)CIDs) are used to interpret changes observed. It remains unclear whether (M)CIDs are similar for both deterioration and improvement in health status. This study investigates and compares these clinical thresholds for three widely-used questionnaires.

Design and setting

Data were retrospectively analysed from an inhouse 3-week pulmonary rehabilitation (PR) randomised controlled trial in the German Klinik Bad Reichenhall (study 1), and observational research in Dutch primary and secondary routine clinical practice (RCP) (study 2).

Participants

Patients with COPD aged ≥18 years (study 1) and aged ≥40 years (study 2) without respiratory comorbidities were included for analysis.

Primary outcomes

The COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ) and St George’s Respiratory Questionnaire (SGRQ) were completed at baseline and at 3, 6 and 12 months. A Global Rating of Change scale was added at follow-up. Anchor-based and distribution-based methods were used to determine clinically relevant thresholds.

Results

In total, 451 patients were included from PR and 207 from RCP. MCIDs for deterioration ranged from 1.30 to 4.21 (CAT), from 0.19 to 0.66 (CCQ), and from 2.75 to 7.53 (SGRQ). MCIDs for improvement ranged from −3.78 to −1.53 (CAT), from −0.50 to −0.19 (CCQ), and from −9.20 to −2.76 (SGRQ). Thresholds for moderate improvement versus deterioration ranged from −5.02 to −3.29 vs 3.89 to 8.14 (CAT), from −0.90 to −0.72 vs 0.42 to 1.23 (CCQ), and from −15.85 to −13.63 vs 7.46 to 9.30 (SGRQ).

Conclusions

MCID ranges for improvement and deterioration on the CAT, CCQ and SGRQ were somewhat similar. However, estimates for moderate and large change varied and were inconsistent. Thresholds differed between study settings.

Trial registration number

Routine Inspiratory Muscle Training within COPD Rehabilitation trial: #DRKS00004609; MCID study: #UMCG201500447.
Evidence available for patient-identified priorities in depression research: results of 11 rapid responses
Authors: Sebastianski Meghan , Gates Michelle , Gates Allison , Nuspl Megan , Bialy Liza M , Featherstone Robin M , Breault Lorraine , Mason-Lai Ping , Hartling Lisa
Published: June 2019

Objectives

Patient priority setting projects (PPSPs) can reduce research agenda bias. A key element of PPSPs is a review of available literature to determine if the proposed research priorities have been addressed, identify research gaps, recognise opportunities for knowledge translation (KT) and avoid duplication of research efforts. We conducted rapid responses for 11 patient-identified priorities in depression to provide a map of the existing evidence.

Design

Eleven rapid responses.

Data sources

Single electronic database (PubMed).

Eligibility criteria

Each rapid response had unique eligibility criteria. For study designs, we used a stepwise inclusion process that started with systematic reviews (SRs) if available, then randomised controlled trials and observational studies as necessary.

Results

For all but one of the rapid responses we identified existing SRs (median 7 SRs per rapid response, range 0–179). There were questions where extensive evidence exists (ie, hundreds of primary studies), yet uncertainties remain. For example, there is evidence supporting the effectiveness of many non-pharmacological interventions (including psychological interventions and exercise) to reduce depressive symptoms. However, targeted research is needed that addresses comparative effectiveness of promising interventions, specific populations of interest (eg, children, minority groups) and adverse effects.

Conclusions

We identified an extensive body of evidence addressing patient priorities in depression and mapped the results and limitations of existing evidence, areas of uncertainty and general directions for future research. This work can serve as a solid foundation to guide future research in depression and KT activities. Integrated knowledge syntheses bring value to the PPSP process; however, the role of knowledge synthesis in PPSPs and methodological approaches are not well defined at present.
Area deprivation, screen time and consumption of food and drink high in fat salt and sugar (HFSS) in young people: results from a cross-sectional study in the UK
Authors: Thomas Fiona , Thomas Christopher , Hooper Lucie , Rosenberg Gillian , Vohra Jyotsna , Bauld Linda
Published: June 2019

Objectives

To investigate associations between deprivation in young people and consumption of foods high in fat, salt and sugar (HFSS), screen time exposure and health knowledge.

Design

An online cross-sectional survey with people aged 11–19 years in the UK, where participants reported consumption behaviours across 13 HFSS and two non-HFSS groups; screen time for commercial television and streaming services; and knowledge of health conditions and their links to obesity.

Setting

UK

Participants

A total of 3348 young people aged 11–19 years across the UK.

Main outcome measures

The study assessed the consumption behaviours, commercial screen time exposure and the health knowledge of 3348 people aged 11–19 years. Multivariate binary regression analysis, controlling for age and gender, was performed.

Results

Deprivation level was associated with increases in consumption of six of the HFSS products including energy drinks (OR: 2.943, p<0.001) and sugary drinks (OR: 1.938, p<0.001) and a reduction in consumption in the two non-HFSS products included in the study, fruit (OR: 0.668, p=0.004) and vegetables (OR: 0.306, p<0.001). Deprivation was associated with high weekly screen time of both television (OR: 2.477, p<0.001) and streaming (OR: 1.679, p=0.001). Health knowledge was also associated with deprivation. There was lower awareness of the association of obesity and cancer (OR: 0.697, p=0.003), type 2 diabetes (OR: 0.64, p=0.004) and heart disease (OR: 0.519, p<0.001) in the most deprived.

Conclusions

Young people from the more deprived areas of the UK were more likely to consume a range of HFSS products, report increased exposure to HFSS advertising and have a poorer awareness of health conditions associated with overweight and obesity. The findings suggest that population-level measures addressing childhood obesity should account for consumption patterns among different groups of children and young people and the factors that may influence these.
Knowledge mobilisation: an exploratory qualitative interview study to confirm and envision modification of lay and practitioner eczema mindlines to improve consultation experiences and self-management in primary care in the UK
Authors: Cowdell Fiona
Published: June 2019

Objectives

To investigate whether initial eczema mindlines, ‘collectively reinforced, internalised, tacit guidelines’, are an accurate representation of the experiences of lay people and practitioners in primary care and to explore how these mindlines may best be revised to improve eczema care.

Design

Exploratory qualitative interviews with constant comparative analysis and data mining.

Setting

UK, primary care.

Participants

People with eczema or parents of children with eczema (n=19) and primary care practitioners (n=13).

Results

Interview data were analysed using constant comparison of new data with existing initial eczema mindlines to identify areas of agreement and disagreement. Data were mined for participant’s thoughts aboutwhosemindlines should be modified,howthis may be achieved andwhatcore content is essential. Eczema mindlines and the spiral of knowledge creation, from which they evolved, intuitively made sense. Participants offered examples of how their eczema knowledge is continually produced and transformed as they interact with others. They reported diverse and wide-ranging influences on their thinking and recognised the critical relationship between lay and practitioner mindlines. For this reason they advocated modifying lay and practitioner mindlines in parallel. Participants advised amendment based on consistent information directed to all who influence eczema care. Information should come from trusted sources and be easy to access, distilled, practical, contextually relevant and amenable to assimilation.

Conclusions

The purpose here is to improve primary care consultation experiences and self-management in eczema. The remaining challenge is to find novel, simple and pragmatic methods of modifying eczema mindlines to instil shared and consistent understanding. Given the prevalence of eczema and the scope of people who influence self-care, interventions should transcend patient-practitioner boundaries and address the wider community. One conceptually congruent approach is to create aBa, which in this case would be a virtual space for generating and sharing eczema knowledge.
Post-traumatic growth in mental health recovery: qualitative study of narratives
Authors: Slade Mike , Rennick-Egglestone Stefan , Blackie Laura , Llewellyn-Beardsley Joy , Franklin Donna , Hui Ada , Thornicroft Graham , McGranahan Rose , Pollock Kristian , Priebe Stefan , Ramsay Amy , Roe David , Deakin Emilia
Published: June 2019

Objectives

Post-traumatic growth, defined as positive psychological change experienced as a result of the struggle with challenging life circumstances, is under-researched in people with mental health problems. The aim of this study was to develop a conceptual framework for post-traumatic growth in the context of recovery for people with psychosis and other severe mental health problems.

Design

Qualitative thematic analysis of cross-sectional semi-structured interviews about personal experiences of mental health recovery.

Setting

England.

Participants

Participants were adults aged over 18 and: (1) living with psychosis and not using mental health services (n=21); (2) using mental health services and from black and minority ethnic communities (n=21); (3) underserved, operationalised as lesbian, gay, bisexual and transgender community or complex needs or rural community (n=19); or (4) employed in peer roles using their lived experience with others (n=16). The 77 participants comprised 42 (55%) female and 44 (57%) white British.

Results

Components of post-traumatic growth were present in 64 (83%) of recovery narratives. Six superordinate categories were identified, consistent with a view that post-traumatic growth involves learning about oneself (self-discovery) leading to a new sense of who one is (sense of self) and appreciation of life (life perspective). Observable positively valued changes comprise a greater focus on self-management (well-being) and more importance being attached to relationships (relationships) and spiritual or religious engagement (spirituality). Categories are non-ordered and individuals may start from any point in this process.

Conclusions

Post-traumatic growth is often part of mental health recovery. Changes are compatible with research about growth following trauma, but with more emphasis on self-discovery, integration of illness-related experiences and active self-management of well-being. Trauma-related growth may be a preferable term for participants who identify as having experienced trauma. Trauma-informed mental healthcare could use the six identified categories as a basis for new approaches to supporting recovery.

Trial registration number

ISRCTN11152837
What is the best catheter lock solution in preventing catheter-related blood infections? A protocol for a Bayesian network meta-analysis of randomised controlled trials
Authors: Dang Fangping , Li Huiju , Tian Jinhui , Wang Ruijuan , Ren Jingjie
Published: June 2019

Introduction

Catheter-related bloodstream infection (CRBSI) is a major complication after central venous catheter insertion, which is associated with significant morbidity, mortality and additional medical costs. Many lock solutions for CRBSI have been evaluated. However, using traditional pairwise meta-analyses to summarise the evidence does not allow the inclusion of data from treatments that have not been compared head to head, which could impact the precision of pooled estimates in a meta-analysis. Therefore, we evaluated the efficacy and safety of the different lock solutions for CRBSI through a network meta-analysis.

Methods and analysis

The primary outcome of this network meta-analysis is the CRBSI. The secondary outcomes are exit-site infection and catheter-related thrombosis. We will search the PubMed, Embase, Web of Science and the Cochrane Library databases for recent relevant meta-analysis and their reference lists to include randomised controlled trials (RCTs) that compared lock solutions for CRBSI prevention. Two individuals will independently extract data from each included RCT according to a predesigned Excel spreadsheet and will assess the methodological quality using the Cochrane risk of bias tool. We will analyse the data using WinBUGS (V.1.4.3) and Stata (V.15.0). We will also estimate the pooled direct and indirect effects for all lock solutions using the network meta-analysis.

Ethics and dissemination

As the present meta-analysis is performed based on previous published studies, no ethical approval and patient safety considerations are required. This study commenced on 18 January 2019, and its expected completion date is 1 December 2019. We will disseminate the results of our network meta-analysis through an international peer-reviewed journal.

PROSPERO registration number

CRD42019121089.
IMproving the practice of intrapartum electronic fetal heart rate MOnitoring with cardiotocography for safer childbirth (the IMMO programme): protocol for a qualitative study
Authors: Lamé Guillaume , Liberati Elisa , Burt Jenni , Draycott Tim , Winter Cathy , Ward James , Dixon-Woods Mary
Published: June 2019

Introduction

Suboptimal electronic fetal heart rate monitoring (EFM) in labour using cardiotocography (CTG) has been identified as one of the most common causes of avoidable harm in maternity care. Training staff is a frequently proposed solution to reduce harm. However, current approaches to training are heterogeneous in content and format, making it difficult to assess effectiveness. Technological solutions, such as digital decision support, have not yet demonstrated improved outcomes. Effective improvement strategies require in-depth understanding of the technical and social mechanisms underpinning the EFM process. The aim of this study is to advance current knowledge of the types of errors, hazards and failure modes in the process of classifying, interpreting and responding to CTG traces. This study is part of a broader research programme aimed at developing and testing an intervention to improve intrapartum EFM.

Methods and analysis

The study is organised into two workstreams. First, we will conduct observations and interviews in three UK maternity units to gain an in-depth understanding of how intrapartum EFM is performed in routine clinical practice. Data analysis will combine the insights of an ethnographic approach (focused on the social norms and interactions, values and meanings that appear to be linked with the process of EFM) with a systems thinking approach (focused on modelling processes, actors and their interactions). Second, we will use risk analysis techniques to develop a framework of the errors, hazards and failure modes that affect intrapartum EFM.

Ethics and dissemination

This study has been approved by the West Midlands—South Birmingham Research Ethics Committee, reference number: 18/WM/0292. Dissemination will take the form of academic articles in peer-reviewed journals and conferences, along with tailored communication with various stakeholders in maternity care.
Comorbid insomnia, psychological symptoms and widespread pain among patients suffering from musculoskeletal pain in general practice: a cross-sectional study
Authors: Sørensen Louise , Jensen Morten Sig Ager , Rathleff Michael Skovdal , Holden Sinead
Published: June 2019

Objective

The aim of this study was to examine the association between musculoskeletal (MSK) pain, insomnia, anxiety and depressive symptoms in patients from general practice.

Design

This is a cross-sectional study.

Setting

This study was conducted in general practice in Denmark.

Participants

A consecutive sample of 390 general practice patients (aged 12 years or older) were included; 183 patients with MSK pain and 207 patients without MSK pain. To be included in the MSK pain group, participants with MSK pain were required to report MSK pain at least weekly during the preceding month, which had a negative impact on daily activities.

Primary and secondary outcomes measures

The primary outcome was insomnia evaluated by the Athens Insomnia Scale. The secondary outcomes were psychological symptoms assessed by the Hospital Anxiety and Depression Scale.

Results

Patients with MSK pain had a significantly higher prevalence of insomnia (difference 25.5%, p<0.0001), anxiety (difference 24.3%, p<0.0001) and depressive symptoms (difference 11%, p<0.0001) compared with patients without MSK pain. Furthermore, patients with MSK pain and comorbid insomnia had significantly higher levels of anxiety and symptoms of depression compared with patients with MSK pain without insomnia (p<0.0001). These relationships remained robust when controlling for age, sex and body mass index in linear regression.

Conclusion

One in two patients in general practice report MSK pain. Comorbid MSK pain and insomnia are common and are associated with a higher prevalence of anxiety and depression. This highlights the importance of establishing the presence of insomnia and affective disorders as potentially modifiable factors during treatment of MSK pain in general practice.
Increasing colorectal cancer screening orders using unlicensed assistive personnel
Authors: Ishida Kanako , Weiss Erin , Kee Summer A , Yingling Charles T
Published: June 2019

Background

Colorectal cancer (CRC) is among the leading cancer diagnoses affecting both men and women worldwide. Prevention and early detection of CRC is possible by increasing access to and utilisation of screening tests. Although CRC screening is highly recommended, screening rates remain suboptimal in the USA, particularly among underserved populations. Our project site, an urban federally qualified health centre, was not meeting the national screening target of 80% of eligible adults.

Objective

The aim of this quality improvement project was to increase the number of orders for CRC screening to eligible patients by using unlicensed assistive personnel and automated telephone outreach calls to offer 100 patients CRC screening during an 8-week period.

Methods

40 patients received outreach calls from care coordinators (CC). 40 patients received automated telephone call reminders to call a CC to obtain an order for CRC screening. 20 patients were offered CRC screening by a medical assistant (MA) as part of their scheduled office visits. We used two plan-do-study-act (PDSA) cycles to deliver these three screening interventions.

Results

A total of 100 patients received one of the interventions. Ten of those patients received an order for either colonoscopy or faecal immunochemical testing by the conclusion of the second PDSA cycle. The MA-offered screening resulted in the highest percentage of patients accepting CRC screenings and patients preferred this outreach approach compared with CC outreach or automated voice messages. CC outreach yielded a lower rate of accepted screenings. None of the patients who received the automated calls followed up to obtain a screening order.

Conclusion

Our project demonstrates that unlicensed assistive personnel have the potential to increase patient access to CRC screening.
Impact of blood group on survival following critical illness: a single-centre retrospective observational study
Authors: Slade Robert , Alikhan Raza , Wise Matt P , Germain Lam , Stanworth Simon , Morgan Matt
Published: June 2019

Background

Predicting patient outcomes following critical illness is challenging. Recent evidence has suggested that patients with blood group AB are more likely to survive following major cardiac surgery, and this is associated with a reduced number of blood transfusions. However, there are no current data to indicate whether a patient’s blood group affects general intensive care outcomes.

Objective

The objective of this study was to determine if ABO blood group affects survival in intensive care. The primary outcome measure was 90-day mortality with a secondary outcome measure of the percentage of patients receiving a blood transfusion.

Design

Retrospective analysis of electronically collected intensive care data, blood group and transfusion data.

Setting

General intensive care unit (ICU) of a major tertiary hospital with both medical and surgical patients.

Patients

All patients admitted to ICU between 2006 and 2016 who had blood group data available.

Intervention

None.

Measurements and main results

7340 patients were included in the study, blood group AB accounted for 3% (221), A 41% (3008), B 10.6% (775) and O 45.4% (3336). These values are similar to UK averages. Baseline characteristics between the groups were similar. Blood group AB had the greatest survival benefit (blood group AB 90-day survival estimate 76.75, 95% CI 72.89 to 80.61 with the overall estimate 72.07, 95% CI 71.31 to 72.82) (log-rank χ216.128, p=0.001). Transfusion requirements were similar in all groups with no significant difference between the percentages of patients transfused (AB 23.1%, A 21.5%, B 18.7%, O 19.9%, Pearson χ25.060 p=0.167).

Conclusion

Although this is primarily a hypothesis generating study, intensive care patients with blood group AB appeared to have a higher 90-day survival compared with other blood groups. There was no correlation between blood group and percentage of patients receiving transfusion.
The translational neural circuitry of anxiety
Authors: Robinson Oliver J , Pike Alexandra C , Cornwell Brian , Grillon Christian
Published: June 2019

Anxiety is an adaptive response that promotes harm avoidance, but at the same time excessive anxiety constitutes the most common psychiatric complaint. Moreover, current treatments for anxiety—both psychological and pharmacological—hover at around 50% recovery rates. Improving treatment outcomes is nevertheless difficult, in part because contemporary interventions were developed without an understanding of the underlying neurobiological mechanisms that they modulate. Recent advances in experimental models of anxiety in humans, such as threat of unpredictable shock, have, however, enabled us to start translating the wealth of mechanistic animal work on defensive behaviour into humans. In this article, we discuss the distinction between fear and anxiety, before reviewing translational research on the neural circuitry of anxiety in animal models and how it relates to human neuroimaging studies across both healthy and clinical populations. We highlight the roles of subcortical regions (and their subunits) such as the bed nucleus of the stria terminalis, the amgydala, and the hippocampus, as well as their connectivity to cortical regions such as dorsal medial and lateral prefrontal/cingulate cortex and insula in maintaining anxiety responding. We discuss how this circuitry might be modulated by current treatments before finally highlighting areas for future research that might ultimately improve treatment outcomes for this common and debilitating transdiagnostic symptom.
Japanese civilian and US military interaction in the evacuation of casualties from Camp Fuji
Authors: Yanagawa Youichi , Oode Y , Adegawa Y , Muramatsu K-i , Kushida Y , Nagasawa H , Takeuchi I , Jitsuiki K , Ohsaka H , Omori K
Published: June 2019

Historically, if US soldiers at Camp Fuji become severely ill or suffer trauma, they are transported by the ground ambulance, as the doctor-led air ambulance in eastern Shizuoka has never been permitted to land at Camp Fuji. However, it is widely recognised that severely ill or traumatised patients require time-dependent medical management. It was therefore agreed to undertake a joint exercise between the US medical assets of Camp Fuji and the doctor helicopters in eastern Shizuoka prefecture in evacuating a simulated severely ill or traumatised US soldier. The aim of this article is to describe the background and rationale between this collaboration between the civilian Japanese air ambulance and the US medical assets in Camp Fuji.
Prevalence of coronary artery calcification in young patients with SLE of predominantly Hispanic and African–American descent
Authors: Gartshteyn Yevgeniya , Braverman Genna , Mahtani Sharan , Geraldino-Pardilla Laura , Bokhari Sabahat , Askanase Anca
Published: June 2019

Objectives

Cardiovascular disease (CVD) is a leading cause of death in SLE. Coronary artery calcium (CAC) scores predict CVD events, independent of traditional risk factors. Patients with SLE aged >45 years have an increased prevalence of CAC in a predominantly white population. Little is known about CAC in younger patients with SLE. We evaluated CAC in younger patients with SLE of predominantly African–American and Hispanic ancestry, compared with healthy controls.

Methods

We identified 76 patients with SLE meeting 1997 American College of Rheumatology classification criteria, without known coronary artery disease and who had a non-contrast chest CT performed as part of their clinical care, with images retrievable for calculation of CAC scores. Demographics, disease characteristics and comorbidities were ascertained and adjusted for.

Results

42.1% of patients with SLE (mean age 40±13 years, 90% female, 33% Hispanic and 40% African–American) had CAC>0, 32% for age ≤45 years and 61.6% for age >45. Patients with SLE with CAC>0 were older and had more comorbid hypertension. Women with SLE aged ≤45 years, had a 12.6-fold higher adjusted odds of CAC>0 compared with age-matched and sex-matched controls (95% CI 5.2 to 30.7, p<0.001). Furthermore, 29% of patients with SLE aged 18–32 years (median disease duration of 5 years) had CAC>0.

Conclusion

Patients with SLE aged ≤45 years have an increased prevalence of detectable CAC compared with the general population. Our data suggest that subclinical atherosclerosis in SLE develops early and warrants timely screening and cardioprotective interventions.
Further defence of legal age change: a reply to the critics
Authors: Räsänen Joona
Published: June 2019

In ‘Moral case for legal age change’, I argue that sometimes people should be allowed to change their age. I refute six immediate objections against the view that age change is permissible. I argue that the objections cannot show that legal age change should always be prohibited. In this paper, I consider some further objections against legal age change raised by Iain Brassington, Toni Saad and William Simkulet. I argue that the objections fail to show that age change should never be allowed.
The Third China National Stroke Registry (CNSR-III) for patients with acute ischaemic stroke or transient ischaemic attack: design, rationale and baseline patient characteristics
Authors: Wang Yongjun , Jing Jing , Meng Xia , Pan Yuesong , Wang Yilong , Zhao Xingquan , Lin Jinxi , Li Wei , Jiang Yong , Li Zixiao , Zhang Xinmiao , Yang Xiaomeng , Ji Ruijun , Wang Chunjuan , Wang Zhimin , Han Xinsheng , Wu Songdi , Jia Zhengchang , Chen Yongming , Li Hao
Published: June 2019

Background and purpose

Stroke is the leading cause of mortality and disability in China. Precise aetiological classification, imaging and biological markers may predict the prognosis of stroke. The Third China National Stroke Registry (CNSR-III), a nationwide registry of ischaemic stroke or transient ischaemic attack (TIA) in China based on aetiology, imaging and biology markers, will be considered to clarify the pathogenesis and prognostic factors of ischaemic stroke.

Methods

Between August 2015 and March 2018, the CNSR-III recruited consecutive patients with ischaemic stroke or TIA from 201 hospitals that cover 22 provinces and four municipalities in China. Clinical data were collected prospectively using an electronic data capture system by face-to-face interviews. Patients were followed for clinical outcomes at 3 months, 6 months and 1–5 year annually. Brain imaging, including brain MRI and CT, were completed at baseline. Blood samples were collected and biomarkers were tested at baseline.

Results

A total of 15 166 stroke patients were enrolled, among which 31.7% patients were women with the average age of 62.2±11.3 years. Ischaemic stroke was predominant (93.3%, n=14 146) and 1020 (6.7%) TIAs were enrolled.

Conclusions

CNSR-III is a large scale nationwide registry in China. Data from this prospective registry may provide opportunity to evaluate imaging and biomarker prognostic determinants of stroke.
Success in career transitions in veterinary practice: perspectives of employers and their employees
Authors: Bell Melinda , Cake Martin , Mansfield Caroline
Published: June 2019

This study qualitatively explored success factors across career transitions in veterinary practice. Semistructured interviews were conducted independently with pairs of veterinary employers and their recent graduate employees, focusing on success in gaining initial employment, their transition to practising veterinarian and longevity in the veterinary profession. The divergence and convergence of interviewees’ perspectives, the changing emphasis of capabilities over different career phases, and the meaning of success were explored. Overall, the perspectives of employers and employees were similar, and highlighted communication skills, confidence, diligence and reliability, and technical skills and knowledge as important themes for initial employment and transition to practice. Other important success factors for initial employment included interpersonal skills, teamwork and team fit, enthusiasm, willingness to learn, and previous experience with the graduate. Support, resilience and work–life balance were important to the transition to practice phase. For career longevity, work–life balance remained an important theme, but also continual learning, business skills and goal‐setting. Success was defined around enjoyment and personal satisfaction, developing proficiency, and maintaining passion for the profession. Job fit was a persistent theme throughout. This exploratory study highlights the capabilities and factors supporting success in veterinary career transitions, some of which may be inconspicuous in traditional competency‐based frameworks.
Associations of Weight Change With Changes in Calf Muscle Characteristics and Functional Decline in Peripheral Artery Disease
Authors: Polonsky Tamar S. , Tian Lu , Zhang Dongxue , Bazzano Lydia A. , Criqui Michael H. , Ferrucci Luigi , Guralnik Jack M. , Kibbe Melina R. , Leeuwenburgh Christiaan , Sufit Robert L. , McDermott Mary M.
Published: June 2019

Background

Among people with lower extremity peripheral artery disease, obesity is associated with faster functional decline than normal weight. The association of weight loss with functional decline in peripheral artery disease is unknown.

Methods and Results

Adults with an ankle‐brachial index <0.90 were identified from Chicago‐area hospitals in 2002–2004. Weight and 6‐minute walk distance were measured annually. Weight change categories were weight loss or gain (≥5 pounds/year at ≥1 visit) or stable (weight change <5 pounds at each visit). Participants reported whether weight loss was “intentional” or “unintentional.” Calf muscle area was measured with computed tomography every 2 years. Associations of weight change with changes in calf muscle area and 6‐minute walk distance were analyzed using mixed‐effects models and adjusted for age, body mass index, ankle‐brachial index, physical activity, and other confounders. Among 389 participants, mean ankle‐brachial index was 0.63±0.16, mean age was 74.5±7.8, and mean body mass index was 28.1±5.1 kg/m
2
. Over 3.23±1.37 years, muscle area declined more in adults with intentional weight loss versus stable or gain (pair‐wise comparisons,
P
<0.001). Intentional weight loss was associated with less annual decline in 6‐minute walk distance than weight gain (intentional loss, 3.7 m; stable, –14.0 m; gain, −28.5 m; unintentional loss, −20.8 m; pair‐wise comparison intentional loss versus gain,
P
=0.003).

Conclusions

Despite a greater loss of calf muscle area, adults with peripheral artery disease who intentionally lost ≥5 pounds experienced less functional decline than those who gained weight. A randomized trial is needed to establish whether benefits of weight loss in peripheral artery disease outweigh potential adverse effects.