bluuebunny/crossref_metadata_2025 huggingface dataset:
A Family of Novel Compliant Linear-Motion Mechanisms Based on Compliant Rolling-Contact Element Pivot
Authors: Huo Tonglong , Yu Jingjun , Zhao Hongzhe , Wei Xian
Published: December 2021

Compliant linear-motion mechanisms are of great use in precision machines due to their excellent performances such as infinite resolution and low cost. The accuracy of the mechanisms is an important consideration for mechanical design in applications, especially in the case of large working load. Considering that COmpliant Rolling-contact Element (CORE) pivot is characterized with high bearing capacity, the paper adopts it as a building block to design a family of compliant linear-motion mechanisms for applications of heavy load. These mechanisms are achieved by replacing four rigid pivots in a parallel four-bar mechanism with CORE pivots, and the motion accuracy is improved by means of contacting surfaces design of four CORE pivots. First, structures of CORE pivot are introduced and five extended arrangements for bearing heavy load are presented. Meanwhile, motion for the CORE pivot is analyzed and preconditions for achieving a pure roll are discussed. Then, configuration of the compliant linear-motion mechanisms constructed by CORE pivots is obtained, and kinematics of the mechanisms is analyzed and parametric design condition for rectilinear motion is modeled. Based on the condition, detailed topological structures of the mechanisms are designed. Finally, motion simulations and experiment tests are implemented to verify accuracy of the proposed mechanisms. The results demonstrate that the mechanisms proposed in this paper are capable of offering a high-precision linear motion and providing a promising application prospect in precision machines.
A Contra-Rotating Open Rotor Noise Reduction Methodology by Using Anhedral Blade Tip
Authors: Yang Tianxiao , Yu Wenjun , Liang Dong , He Xiang , Zhao Zhenguo
Published: December 2021

In this article, a novel contra-rotating open rotor (CROR) noise reduction methodology based on the anhedral blade tip applied to the front blade is developed. Results indicate that anhedral blade tip can provide noise reduction over 60 deg. polar angle range in both upstream and downstream areas at takeoff condition. The noise reduction becomes more significant as the lean angle of anhedral blade tip increases, and the maximum noise reduction is over 4 dB. Further analysis shows that anhedral blade tip decreases the strength and size of blade tip vortex shed from the front blade and reduces its interaction with the rear rotor, which decreases the fluctuation of loading acting on the rear rotor and its loading noise. Furthermore, the anhedral blade tip does not have a significant effect on the aerodynamic performance of CROR at cruise.
New insights into organic matter accumulation from high-resolution geochemical analysis of a black shale: Middle and Upper Devonian Horn River Group, Canada
Authors: Zhou Haolin , Harris Nicholas B. , Dong Tian , Ayranci Korhan , Feng Jilu , Rivard Benoit , Hackley Paul , Hatcherian Javin
Published: December 2021

Organic matter (OM) accumulation in organic matter-rich mudstones, or black shales, is generally recognized to be controlled by combinations of bioproductivity, preservation, and dilution. However, specific triggers of OM deposition in these formations are commonly difficult to identify with geochemical proxies, in part because of feedbacks that cause geochemical proxies for these controls to vary synchronously. This apparent synchronicity is partly a function of sample spacing, commonly at decimeter to meter intervals, which may represent longer periods of time than is required for the development of feedbacks. Higher resolution data sets may be required to fully interpret OM accumulation.

This study applies a novel combination of technologies to develop a high-resolution geochemical data set, integrating energy-dispersive X-ray fluorescence (EDXRF) and infrared imagery analyses, to record proxies for redox conditions, bioproductivity, and clastic and carbonate dilution in millimeter-resolution profiles of 133 core slabs from the Middle and Upper Devonian Horn River shale in the Western Canada Sedimentary Basin, which provides decadal-scale temporal resolution. A comparison to a more coarsely sampled data set from the same core results in substantially different interpretations of variations in bioproductivity, redox, and dilution proxies. Stratigraphic distributions of organic matter accumulation patterns (bioproductivity-control, siliciclastic/carbonate-dilution, and redox conditions-control) show that organic enrichment events were highly varied during deposition of the shale and were closely related to second- and third-order sea-level changes. High-resolution profiles indicate that bioproductivity was the predominant trigger for organic matter accumulation in a second-order highstand, particularly during deposition of third-order transgressive systems tracts. Organic matter accumulation was largely controlled by dilution from either carbonate or clastic sediments in a second-order lowstand. Bioproductivity-redox feedbacks developed on timescales of decades to centuries.
Reliability of recommended non-invasive chairside screening tests for diabetes-related peripheral neuropathy: a systematic review with meta-analyses
Authors: McIllhatton Ally , Lanting Sean , Lambkin David , Leigh Lucy , Casey Sarah , Chuter Vivienne
Published: December 2021

The objective is to determine, by systematic review, the reliability of testing methods for diagnosis of diabetes-related peripheral neuropathy (DPN) as recommended by the most recent guidelines from the International Diabetes Foundation, International Working Group on the Diabetic Foot and American Diabetes Association. Electronic searches of Cochrane Library, EBSCO Megafile Ultimate and EMBASE were performed to May 2021. Articles were included if they reported on the reliability of recommended chairside tests in diabetes cohorts. Quality appraisal was performed using a Quality Appraisal of Reliability Studies checklist and where possible, meta-analyses, with reliability reported as estimated Cohen’s kappa (95% CI). Seventeen studies were eligible for inclusion. Pooled analysis found acceptable inter-rater reliability of vibration perception threshold (VPT) (κ=0.61 (0.50 to 0.73)) and ankle reflex testing (κ=0.60 (0.55 to 0.64)), but weak inter-rater reliability for pinprick (κ=0.45 (0.22 to 0.69)) and 128 Hz tuning fork (κ=0.42 (0.15 to 0.70)), though intra-rater reliability of the 128 Hz tuning fork was moderate (κ=0.54 (0.37 to 0.73)). Inter-rater reliability of the four-site monofilament was acceptable (κ=0.61 (0.45 to 0.77)). These results support the clinical use of VPT, ankle reflexes and four-site monofilament for screening and ongoing monitoring of DPN as recommended by the latest guidelines. The reliability of temperature perception, pinprick, proprioception, three-site monofilament and Ipswich touch test when performed in people with diabetes remains unclear.
Risk of a post-colonoscopy colorectal cancer in patients with type 2 diabetes: a Danish population-based cohort study
Authors: Troelsen Frederikke Schønfeldt , Sørensen Henrik Toft , Pedersen Lars , Erichsen Rune
Published: December 2021

Objective

Prevalent type 2 diabetes (T2D) is associated with an increased risk of colorectal cancer and could impair the quality of bowel preparation for colonoscopy. This may in turn increase the risk of overlooked precancerous polyps and subsequent risk of post-colonoscopy colorectal cancer (PCCRC). We investigated whether patients with T2D are at increased risk of PCCRC compared with patients without T2D.

Design

We conducted a population-based cohort study of patients with T2D and without T2D undergoing colonoscopy in Denmark (1995–2015). We investigated the risk of PCCRC by calculating >6 to 36 months cumulative incidence proportions (CIPs) treating death and colectomy as competing risks. Using Cox proportional-hazards regression analyses, we also computed HRs of PCCRC, comparing patients with T2D and non-T2D. According to the World Endoscopy Organization guidelines, we calculated PCCRC 3-year rates to estimate the proportions of T2D and non-T2D CRC patients experiencing PCCRC.

Results

We identified 29 031 patients with T2D and 333 232 patients without T2D undergoing colonoscopy. We observed 250 PCCRCs among patients with T2D and 1658 PCCRCs among patients without T2D. The >6 to 36 months CIP after a first-time colonoscopy was 0.64% (95% CI 0.55% to 0.74%) for T2D and 0.36% (95% CI 0.34% to 0.38%) for patients without T2D. The HRs of PCCRC were 1.43 (95% CI 1.21 to 1.72) after a first-time colonoscopy and 1.18 (95% CI 0.75 to 1.85) after a second-time colonoscopy. The PCCRC 3-year rate was 7.9% for patients with T2D and 7.4% for patients without T2D.

Conclusion

T2D may be associated with an increased HR of PCCRC.
Improving equity in the distribution and financing of health services in Mauritius, a small island state with deeply rooted welfare state standards
Authors: Nundoochan Ajoy
Published: December 2021

Background

Ensuring benefits of free healthcare services are accessible to those in need is essential to achieve universal health coverage (UHC). Mauritius has sustained a welfare state over four decades with free health services in all public facilities. However, paradoxically, the national UHC service coverage index stood at only 63 in 2017. An assessment of who benefits from health interventions is, therefore, vital to shape future health financing strategies.

Methods

The study applied benefit incidence analysis (BIA) to understand the distribution of healthcare utilisation and spending in comparison to income distribution. Also, a financial incidence analysis (FIA) was conducted to assess the progressivity of the health financing systems. Data from the national survey on household out-of-pocket (OOP) expenditure for health were used for the purpose of BIA and FIA. Concentration curves and concentration indices (CI) were nationally estimated and disaggregated to rural/urban levels. Kakwani index (KI) was calculated to assess the progressivity of private healthcare financing.

Results

The CI for outpatient, inpatient and day care within the public health sector is estimated at −0.33, –0.14 and −0.14, respectively. Overall, CI in the public sector is −0.26. Benefit distribution in the private sector is pro-rich with CI of 0.27. Healthcare financing is regressive as demonstrated by a KI of −0.004, with the poorest population groups contributing a large share, in terms of taxes and OOP, to finance the health system.

Conclusion

The BIA posits that government spending on public healthcare has resulted in significant pro-poor services distribution. This is largely offset by pro-rich distribution in the private sector. Thus, implying health financing strategies must be reviewed to promote financial protection against catastrophic health payments and bolster efforts to improve UHC service coverage index and achieve UHC Target 3.8 under Sustainable Development Goal 3.
Comparative efficacy and safety of anti-HGF/MET pathway agents plus chemotherapy versus chemotherapy alone as first-line treatment in advanced gastric cancer: a protocol for a systematic review and meta-analysis
Authors: Jiang Zhiyuan , Cai Zhaolun , Ma Qin , Shen Chaoyong , Yin Yuan , Yin Xiaonan , Liu Chunyu , Chang Chen , Zhao Zhou , Mu Mingchun , Zhang Bo
Published: December 2021

Introduction

Phase I/II clinical trials suggested that the hepatocyte growth factor (HGF)/mesenchymal-epithelial transition (MET) pathway-targeted agents were active in suppression of gastric cancer (GC). Randomised controlled trials (RCTs) were undertaken assessing whether the addition of anti-HGF/MET agent (rilotumumab or onartuzumab) to chemotherapy improves survival outcomes of advanced GC, but conflict conclusions were reached. Therefore, we plan to perform this systematic review and meta-analysis to synthesise evidence concerning efficacy and safety of anti-HGF/MET agents combined with chemotherapy as the first-line treatment to advanced GC.

Methods and analysis

Systematic searches of the PubMed, Embase and the Cochrane Central Register of Controlled Trials will be performed with no language restriction from inception to 31 January 2022 to identify RCTs exploring the comparative efficacy and safety of anti-HGF/MET agents plus chemotherapy as first-line treatment in advanced GC. The primary outcome will be the time-to-event progression-free survival and overall survival, and the secondary outcomes will be disease control rate, overall adverse events rate and grade 3–5 adverse events rate. Statistical heterogeneity will be assessed by visual inspection of forest plots and measured using the I2statistics. A fixed-effect model will be used when heterogeneity is low otherwise, a random-effect model will be chosen. Publication bias will be assessed by funnel plots; subgroup analysis and sensitivity analysis will be performed in the right context. For each outcome, we will perform data synthesis using Rev Man V.5.3 software, and compile ‘summary of findings’ tables using GRADEpro software.

Ethics and dissemination

There is no requirement for ethics approval because no individual data will be collected in this research. It is anticipated that the dissemination of results will take place at conferences and through publication in a peer-review journal, any adjustments from the protocol will be clearly documented and explained in its final report.

PROSPERO registration number

CRD42020177404.
Detecting young people with mental disorders: a cluster-randomised trial of multidisciplinary health teams at the GP office
Authors: Haavet Ole Rikard , Šaltytė Benth Jūratė , Gjelstad Svein , Hanssen-Bauer Ketil , Dahli Mina Piiksi , Kates Nick , Ruud Torleif
Published: December 2021

Background

Young people with mental health challenges present a major global challenge. More than half of adults with mental disorders experience their onset before age 14, but early detection and intervention may change this course. Shared care with mental health professionals in general practitioner (GP) offices has demonstrated its potential for improvement in these conditions.

Aim

To investigate whether shared care with mental health professionals in GP offices increases the detection of youth’s mental health disorders and is associated with a decrease in use of unspecified symptom diagnoses, as a whole and stratified by patient and physician gender and age, and type of consulting physician.

Design and setting

This was a stratified cluster-randomised controlled trial with data extraction from electronic records. Two GP offices were recruited from each of three boroughs. Each borough had 3–8 GP offices. One GP office was randomised to the intervention group and the other to the control group.

Method

We used generalised linear mixed models to assess whether the intervention helped GPs identify more International Classification of Primary Care 2 diagnoses of depression, anxiety and unspecified symptoms in youth.

Results

Over a 18-month period between between 2015 and 2017, the intervention helped GPs identify more youth with anxiety (p=0.002 for interaction), but not depression. The increase was most significant among the patients’ regular GPs, less when patients met other GPs and least among external substitute physicians. The frequency of diagnoses with unspecified symptoms decreased in the intervention arm.

Conclusion

Shared care with mental health professionals located in GP office contributed to increased detection of youth with anxiety symptoms. The increase was most prominent when the primary care physician was the patient’s regular GP. GPs need to pay greater attention to detecting anxiety in youth and embrace shared care models, thereby contributing to reduced mental health disorders in this age group.

Trial registration number

NCT03624829; Results.
Randomised clinical trial research within Aboriginal and Torres Strait Islander primary health services: a qualitative study
Authors: Abbott Penelope , Askew Deborah , Watego Chelsea , Hu Wendy CY , Campbell Letitia , Tyson Claudette , Walsh Robyn , Hussey Sylvia , Doyle Kerrie , Gunasekera Hasantha , Leach Amanda Jane , Usherwood Tim , Armstrong-Kearns Jessica , Reath Jennifer
Published: December 2021

Objective

To better understand how to undertake valuable, ethical and sustainable randomised controlled clinical trial (RCT) research within Aboriginal and Torres Strait Islander primary health services.

Design

In a qualitative approach, we utilised data collected between 2013 and 2020 during the planning and implementation of two RCTs. The data comprised agreed records of research meetings, and semistructured interviews with clinical trial stakeholders. The stakeholders were parents/carers of child participants, and site-based research officers, healthcare providers and community advisory groups. Our thematic analysis was informed by constructivist grounded theory.

Setting

The RCTs investigated the management of otitis media in Aboriginal and Torres Strait Islander children, with the first RCT commencing recruitment in 2014 and the second in 2017. They took place in Aboriginal Medical Services (AMSs), large primary health services for Aboriginal and Torres Strait Islander people, based in urban and regional communities across two Australian states and one territory.

Results

We analysed data from 56 meetings and 67 interviews, generating themes on making research valuable and undertaking ethical and sustainable RCTs. Aboriginal and Torres Strait Islander leadership, and support of AMSs in their service delivery function were critical. The broad benefits of the trials were considered important to sustainability, including workforce development, enhanced ear healthcare and multidirectional research capacity building. Participants emphasised the long-term responsibility of research teams to deliver benefits to AMSs and communities regardless of RCT outcomes, and to focus on relationships, reciprocity and creating positive experiences of research.

Conclusion

We identify principles and strategies to assist in undertaking ethical and sustainable RCTs within Aboriginal and Torres Strait Islander primary health services. Maintaining relationships with AMSs and focusing on mutual workforce development and capacity building creates opportunities for long-term benefits so that health research and RCTs work for Aboriginal and Torres Strait Islander peoples, services, communities and researchers.

Trial registration number

ACTRN12613001068752 (Pre-results); ACTRN12617001652369 (Pre-results).
Prospective comparative study of quantitative X-ray (QXR) versus dual energy X-ray absorptiometry to determine the performance of QXR as a predictor of bone health for adult patients in secondary care
Authors: Rangan Amar , Tuck Stephen P , Scott Paul D , Kottam Lucksy , Jafari Maya , Watson Terence , Lopez Ben , Crone Ben , Whitbread Tim , Ratcliffe Adam
Published: December 2021

Objectives

To evaluate a method of quantitative X-ray (QXR) for obtaining bone health information from standard radiographs aimed at identifying early signs of osteoporosis to enable improved referral and treatment. This QXR measurement is performed by postexposure analysis of standard radiographs, meaning bone health data can be acquired opportunistically, alongside routine imaging.

Design

The relationship between QXR and dual energy X-ray absorptiometry (DEXA) was demonstrated with a phantom study. A prospective clinical study was conducted to establish areal bone mineral density (aBMD) prediction model and a risk prediction model of a non-normal DEXA outcome. This was then extrapolated to a larger patient group with DEXA referral data.

Setting

Secondary care National Health Service Hospital.

Participants

126 consenting adult patients from a DEXA clinic.

Interventions

All participants underwent a DEXA scan to determine BMD at the lumbar spine (L2–L4) and both hips. An additional Antero-Posterior pelvis X-ray on a Siemens Ysio, fixed digital radiograph system was performed for the study.

Outcome

Performance of QXR as a risk predictor for non-normal (osteoporotic) BMD.

Results

Interim clinical study data from 78 patients confirmed a receiver operator curve (area under the ROC curve) of 0.893 (95% CI 0.843 to 0.942) for a risk prediction model of non-normal DEXA outcome. Extrapolation of these results to a larger patient group of 11 029 patients indicated a positive predictive value of 0.98 (sensitivity of 0.8) for a population of patients referred to DEXA under current clinical referral criteria.

Conclusions

This study confirms that the novel QXR method provides accurate prediction of a DEXA outcome.

Trial registration number

ISRCTN98160454; Pre-results.
Targeted Interventions in Tourette’s using Advanced Neuroimaging and Stimulation (TITANS): study protocol for a double-blind, randomised controlled trial of transcranial magnetic stimulation (TMS) to the supplementary motor area in children with Tourette’s syndrome
Authors: Kahl Cynthia K , Swansburg Rose , Kirton Adam , Pringsheim Tamara , Wilcox Gabrielle , Zewdie Ephrem , Harris Ashley , Croarkin Paul E , Nettel-Aguirre Alberto , Chenji Sneha , MacMaster Frank P
Published: December 2021

Introduction

Tourette’s syndrome (TS) affects approximately 1% of children. This study will determine the efficacy and safety of paired comprehensive behavioural intervention for tics (CBIT) plus repetitive transcranial magnetic stimulation (rTMS) treatment in children with Tourette’s syndrome. We hypothesise that CBIT and active rTMS to the supplementary motor area (SMA) will (1) decrease tic severity, and (2) be associated with changes indicative of enhanced neuroplasticity (eg, changes in in vivo metabolite concentrations and TMS neurophysiology measures).

Methods and analysis

This study will recruit 50 youth with TS, aged 6–18 for a phase II, double-blind, block randomised, sham-controlled trial comparing active rTMS plus CBIT to sham rTMS plus CBIT in a 1:1 ratio. The CBIT protocol is eight sessions over 10 weeks, once a week for 6 weeks and then biweekly. The rTMS protocol is 20 sessions of functional MRI-guided, low-frequency (1 Hz) rTMS targeted to the bilateral SMA over 5 weeks (weeks 2–6). MRI, clinical and motor assessments and neurophysiological evaluations including motor mapping will be performed 1 week before CBIT start, 1 week after rTMS treatment and 1 week after CBIT completion. The primary outcome measure is Tourette’s symptom change from baseline to post-CBIT treatment, as measured by the Yale Global Tic Severity Scale. Secondary outcomes include changes in imaging, neurophysiological and behavioural markers.

Ethics and dissemination

Ethical approval by the Conjoint Health Research Ethics Board (REB18-0220). The results of this study will be published in peer-reviewed scientific journals, on ClinicalTrials.gov and shared with the Tourette and OCD Alberta Network. The results will also be disseminated through the Alberta Addictions and Mental Health Research Hub.

Trial registration

NCT03844919.
Challenging the deficit discourse in medical schools through reverse mentoring—using discourse analysis to explore staff perceptions of under-represented medical students
Authors: Curtis Sally , Mozley Heather , Langford Chloe , Hartland Joseph , Kelly Jacquie
Published: December 2021

Introduction

Despite the increasing diversity of UK medical students, students from low-socioeconomic backgrounds, some minority groups and members of communities with protected identities remain under-represented in medicine. In trying to ascertain why this under-representation persists, literature focuses on the barriers and challenges faced by under-represented students as opposed to the institution’s responsibility to remove or mitigate these obstacles. One UK University created a reverse mentoring scheme enabling students to mentor senior members of the medical faculty to help them understand the perspectives and experiences of students from minority backgrounds. This paper explores whether changes in staff perceptions of under-represented students resulted from engaging with reverse mentoring.

Methods

This qualitative study explored the impact of the reverse mentoring scheme. Staff mentees were required to write a narrative text about the Higher Education journey of an under-represented medical student before and after the reverse mentoring intervention. These texts were compared using discourse analysis to identify shifts in language use that demonstrated a change in perceptions.

Results

The key themes from five senior staff members indicate a positive change in staff characterisation of the students and an acceptance of institutional responsibility for challenges faced. Initial texts revealed a superficial understanding of the student journey that focused on individual deficit but had fairy tale endings depicting the medical school as benevolent. The follow-up texts revealed a deeper understanding reflected by the portrayal of students as capable agents and containing pragmatic endings acknowledging the responsibility of the medical school.

Conclusion

These findings highlight how removed senior staff can be from the reality of the student experience and that engaging with reverse mentoring helps to raise awareness and challenges the students face. This suggests a route for constructive change in medical schools and endorses the benefits of facilitating open discussion around educational inequity.
Assessing the impact of simplified HCV care on linkage to care amongst high-risk patients at primary healthcare clinics in Malaysia: a prospective observational study
Authors: Markby Jessica , Shilton Sonjelle , Sem Xiaohui , Chan Huan Keat , Md Said Rosaida , Siva Sasikala , Zainuddin Zalwani , Abu Bakar Norasiah , Omar Haniza , Ruiz Ryan Jose III , Gaeddert Mary , Tyshkovskiy Alexander , Adee Madeline , Chhatwal Jagpreet , Kumar Suresh , Piedagnel Jean-Michel , Mohd Zain Rozainanee , Menétrey Caroline , Yuswan Fazidah , Hairizan Nasir Nazrila , Andrieux-Meyer Isabelle , Ismail Fatanah , Zakaria Rozita , Hasim Ruziaton , Murad Shahnaz , Easterbrook Philippa , Hassan Muhammad Radzi Abu
Published: December 2021

Introduction

To achieve the elimination of hepatitis C virus (HCV), substantial scale-up in access to testing and treatment is needed. This will require innovation and simplification of the care pathway, through decentralisation of testing and treatment to primary care settings and task-shifting to non-specialists. The objective of this study was to evaluate the feasibility and effectiveness of decentralisation of HCV testing and treatment using rapid diagnostic tests (RDTs) in primary healthcare clinics (PHCs) among high-risk populations, with referral of seropositive patients for confirmatory viral load testing and treatment.

Methods

This observational study was conducted between December 2018 and October 2019 at 25 PHCs in three regions in Malaysia. Each PHC was linked to one or more hospitals, for referral of seropositive participants for confirmatory testing and pretreatment evaluation. Treatment was provided in PHCs for non-cirrhotic patients and at hospitals for cirrhotic patients.

Results

During the study period, a total of 15 366 adults were screened at the 25 PHCs, using RDTs for HCV antibodies. Of the 2020 (13.2%) HCV antibody-positive participants, 1481/2020 (73.3%) had a confirmatory viral load test, 1241/1481 (83.8%) were HCV RNA-positive, 991/1241 (79.9%) completed pretreatment assessment, 632/991 (63.8%) initiated treatment, 518/632 (82.0%) completed treatment, 352/518 (68.0%) were eligible for a sustained virological response (SVR) cure assessment, 209/352 (59.4%) had an SVR cure assessment, and SVR was achieved in 202/209 (96.7%) patients. A significantly higher proportion of patients referred to PHCs initiated treatment compared with those who had treatment initiated at hospitals (71.0% vs 48.8%, p<0.001).

Conclusions

This study demonstrated the effectiveness and feasibility of a simplified decentralised HCV testing and treatment model in primary healthcare settings, targeting high-risk groups in Malaysia. There were good outcomes across most steps of the cascade of care when treatment was provided at PHCs compared with hospitals.
Evaluation of the impact and implementation of a national clinical programme for the management of self-harm in hospital emergency departments: study protocol for a natural experiment
Authors: Griffin Eve , McHugh Sheena M , Jeffers Anne , Gunnell David , Arensman Ella , Perry Ivan J , Cully Grace , McElroy Brendan , Maxwell Margaret , Chang Shu-Sen , Ruane-McAteer Eimear , Corcoran Paul
Published: December 2021

Background

A National Clinical Programme for the Management of Hospital-Presenting Self-Harm (NCP-SH) was introduced in Ireland in 2014. This involved the development of a model of care to standardise the management of self-harm in emergency departments, to be delivered by dedicated clinical nurse specialists. The core components of the programme were to: ensure an empathic and timely response, conduct a biopsychosocial assessment, involve family members in assessment and discharge planning, and provide a bridge to next care. The overall aim of the programme was to reduce the rate of repeat self-harm. This multistage study will evaluate the impact of the NCP-SH on hospital-presenting self-harm and to identify determinants influencing its implementation.

Methods

Employing a sequential mixed methods design, the first stage will use data from the National Self-Harm Registry Ireland to examine the impact of the NCP-SH on self-harm repetition, along with other aspects of care, including provision of psychosocial assessments and changes in admissions and postdischarge referrals. A cost-effectiveness analysis will assess the cost per repeat self-harm attendance avoided as a result of the NCP-SH. The second stage will identify the influences of implementation fidelity—adherence to the programme’s core components—using a combination of document analysis and semistructured interviews with staff of the programme, guided by the Consolidated Framework for Implementation Research.

Ethics and dissemination

This study has received full ethical approval and will run until August 2023. This study is novel in that it will identify important factors influencing successful implementation of complex programmes. It is expected that the findings will provide important learnings for the integration of mental health services in general hospital settings and will be disseminated via peer-review publications along with reports for clinicians and policy-makers.
Clinical management and impact of scarlet fever in the modern era: findings from a cross-sectional study of cases in London, 2018–2019
Authors: Herdman Michael Trent , Cordery Rebecca , Karo Basel , Purba Amrit Kaur , Begum Lipi , Lamagni Theresa , Kee Chuin , Balasegaram Sooria , Sriskandan Shiranee
Published: December 2021

Objectives

In response to increasing incidence of scarlet fever and wider outbreaks of group A streptococcal infections in London, we aimed to characterise the epidemiology, symptoms, management and consequences of scarlet fever, and to identify factors associated with delayed diagnosis.

Design and setting

Cross-sectional community-based study of children with scarlet fever notified to London’s three Health Protection Teams, 2018–2019.

Participants

From 2575 directly invited notified cases plus invitations via parental networks at 410 schools/nurseries with notified outbreaks of confirmed/probable scarlet fever, we received 477 responses (19% of those directly invited), of which 412 met the case definition. Median age was 4 years (range <1 to 16), 48% were female, and 70% were of white ethnicity.

Outcome measures

Preplanned measures included quantitative description of case demographics, symptoms, care-seeking, and clinical, social, and economic impact on cases and households. After survey completion, secondary analyses of factors associated with delayed diagnosis (by logistic regression) and consequences of delayed diagnosis (by Cox’s regression), and qualitative analysis of free text comments were added.

Results

Rash was reported for 89% of cases, but followed onset of other symptoms for 71%, with a median 1-day delay. Pattern of onset varied with age: sore throat was more common at onset among children 5 years and older (OR3.1, 95% CI 1.9 to 5.0). At first consultation, for 28%, scarlet fever was not considered: in these cases, symptoms were frequently attributed to viral infection (60%, 64/106). Delay in diagnosis beyond first consultation occurred more frequently among children aged 5+ who presented with sore throat (OR 2.8 vs 5+without sore throat; 95% CI 1.3 to 5.8). Cases with delayed diagnosis took, on average, 1 day longer to return to baseline activities.

Conclusions

Scarlet fever may be initially overlooked, especially among older children presenting with sore throat. Raising awareness among carers and practitioners may aid identification and timely treatment.
Striving for autonomy in everyday diabetes self-management—qualitative exploration via grounded theory approach
Authors: Sallay Viola , Klinovszky Andrea , Csuka Sára Imola , Buzás Norbert , Papp-Zipernovszky Orsolya
Published: December 2021

Objectives

The rapid worldwide increase in the incidence of diabetes significantly influences the lives of individuals, families and communities. Diabetes self-management requires personal autonomy and the presence of a supportive social environment. These attributes can considerably ameliorate the outcomes of the chronic condition. However, little is known about individual variations in overcoming the illness-related challenges and in the achievement of autonomy in daily activities. This paper seeks to bridge this knowledge gap.

Design

This qualitative study used the grounded theory approach. Semi-structured interviews were conducted, and the data collection and data analysis probed participant experiences of autonomy through the self-management of their daily socio-physical environments.

Setting

Participants were recruited from the outpatient ward of a university clinic in Hungary.

Participants

The study was conducted with 26 adult patients with type 2 diabetes mellitus (15 females and 11 males aged between 26 and 80 years; M=62.6 years; SD=13.1). The inclusion criteria were: T2D diagnosis at least 1 year before the beginning of the study; prescribed insulin injection therapy; aged over 18 years; native Hungarian speaker and not diagnosed with dementia or any form of cognitive impairment.

Results

The study established three principal aspects of the active construction of personal autonomy in diabetes self-management: coping strategies vis-à-vis threats posed by the symptoms and the treatment of the disease; autonomous ways of creating protective space and time and relationship processes that support everyday experiences of self-directedness.

Conclusions

The results of this study confirm the validity of the self-determination theory in diabetes self-management. They also imply that pathways towards constructing everyday experiences of self-directedness in participants lead through self-acceptance, supporting family relationships and a doctor–patient relationship characterised by partnership. The tentative empirical model of pathways towards patients’ experience of self-directedness can serve as a framework for future research, patient-centred clinical practice, and education.
Specificity of early-career general practitioners’ problem formulations in patients presenting with dizziness: a cross-sectional analysis
Authors: Ledger Jocelyn , Tapley Amanda , Levi Christopher , Davey Andrew , van Driel Mieke , Holliday Elizabeth G , Ball Jean , Fielding Alison , Spike Neil , FitzGerald Kristen , Magin Parker
Published: December 2021

Objectives

Dizziness is a common and challenging clinical presentation in general practice. Failure to determine specific aetiologies can lead to significant morbidity and mortality. We aimed to establish frequency and associations of general practitioner (GP) trainees’ (registrars’) specific vertigo provisional diagnoses and their non-specific symptomatic problem formulations.

Design

A cross-sectional analysis of Registrar Clinical Encounters in Training (ReCEnT) cohort study data between 2010 and 2018. ReCEnT is an ongoing, prospective cohort study of registrars in general practice training in Australia. Data collection occurs once every 6 months midtraining term (for three terms) and entails recording details of 60 consecutive clinical consultations on hardcopy case report forms. The outcome factor was whether dizziness-related or vertigo-related presentations resulted in a specific vertigo provisional diagnosis versus a non-specific symptomatic problem formulation. Associations with patient, practice, registrar and consultation independent variables were assessed by univariate and multivariable logistic regression.

Setting

Australian general practice training programme. The training is regionalised and delivered by regional training providers (RTPs) (2010–2015) and regional training organisations (RTOs) (2016–2018) across Australia (from five states and one territory).

Participants

All general practice registrars enrolled with participating RTPs or RTOs undertaking GP training terms.

Results

2333 registrars (96% response rate) recorded 1734 new problems related to dizziness or vertigo. Of these, 546 (31.5%) involved a specific vertigo diagnosis and 1188 (68.5%) a non-specific symptom diagnosis. Variables associated with a non-specific symptom diagnosis on multivariable analysis were lower socioeconomic status of the practice location (OR 0.94 for each decile of disadvantage, 95% CIs 0.90 to 0.98) and longer consultation duration (OR 1.02, 95% CIs 1.00 to 1.04). A specific vertigo diagnosis was associated with performing a procedure (OR 0.52, 95% CIs 0.27 to 1.00), with some evidence for seeking information from a supervisor being associated with a non-specific symptom diagnosis (OR 1.39, 95% CIs 0.92 to 2.09; p=0.12).

Conclusions

Australian GP registrars see dizzy patients as frequently as established GPs. The frequency and associations of a non-specific diagnosis are consistent with the acknowledged difficulty of making diagnoses in vertigo/dizziness presentations. Continuing emphasis on this area in GP training and encouragement of supervisor involvement in registrars’ diagnostic processes is indicated.
Neurocysticercosis presenting as bipolar disorder: a case report
Authors: Batra Surbhi , Kumar Sumit , Shekhawat Lokesh Singh
Published: December 2021

Neurocysticercosis is the most common neuro-parasitosis caused by the larval stage ofTaenia solium. The most common manifestations include seizures and hydrocephalus. Psychiatric abnormalities are relatively rare but depressive symptoms are frequent in patients with neurocysticercosis. However, mania as a presentation is relatively rare. Pregnancy and the postpartum period are relatively vulnerable times and they can lead to reactivation of existing neurocysterci lesions. We are discussing the case of a 23-year-old female patient with neurocysticercosis leading to the reactivation of lesions in the peripartum and postpartum period leading to bipolar affective disorder. Improvement in the patient was seen with a combination of antipsychotics, antihelmintics, antiepileptics and steroids, along with improved radiological signs of neurocysterci lesions. Although neurocysticercosis is a common illness, its prevalence presenting as a manic episode is merely 2.6% and, hence, missed easily. Therefore, it is important to rule out organic aetiology in patients even with a classic presentation of bipolar affective disorder and those having any other neurological symptoms and signs.
Abdominal aortic calcification, cardiac troponin I and atherosclerotic vascular disease mortality in older women
Authors: Teh Ryan , Prince Richard L , Sim Marc , Schousboe John T , Raymond Warren D , Szulc Pawel , Lim Wai , Hodgson Jonathan M , Zhu Kun , Kiel Douglas P , Schultz Carl , Thompson Peter L , Lewis Joshua R
Published: December 2021

Objective

Examine if two inexpensive measures of atherosclerotic vascular diseases (ASVD), abdominal aortic calcification (AAC) and high-sensitivity cardiac troponin I (hs-cTnI) provide complementary information for 10-year ASVD mortality and all-cause mortality risk in older women.

Methods

908 community-dwelling women without prevalent ASVD (≥75 years) were followed-up between 2003 and 2013. AAC and plasma hs-cTnI measures were obtained in 2003. AAC was assessed on lateral spine images using a semiquantitative method (AAC24). Linked health records were used for mortality outcomes.

Results

Mean±SD age was 79.9±2.6 years. 276 (30.4%) women died during follow-up, including 138 (15.2%) ASVD-related deaths. AAC24 and hs-cTnI were independently associated with ASVD and all-cause mortality (p<0.001). The cohort was dichotomised into four groups: (1) low AAC24 (AAC24: 0 or 1) and 1) and <median hs-cTnI (n=280), (3) low AAC24 and ≥median hs-cTnI (n=148) and (4) moderate-extensive AAC24 and ≥median hs-cTnI (n=317). Compared with the referent group, a stepwise increase in relative hazard (HR (95% CI)) for ASVD mortality was seen at 2.39 (1.05 to 5.46), 3.18 (1.35 to 7.79) and 5.38 (2.44 to 11.85), respectively. A similar associations were observed for all-cause mortality, at 1.58 (0.99–2.52), 2.38 (1.46–3.89) and 3.02 (1.93–4.72), respectively (all p<0.05).

Conclusion

Higher AAC and elevated hs-cTnI were associated with higher risk of ASVD mortality and all-cause mortality, independent of each other. Stratifying by moderate to extensive AAC and elevated hs-cTnI identified women at very high risk. Further studies investigating whether combining factors may improve risk prediction are needed.

Trial registration number

ACTRN12617000640303.
Professionals’ views on shared decision-making in severe aortic stenosis
Authors: van Beek-Peeters Judith J A M , van der Meer Jop B L , Faes Miriam C , de Vos Annemarie J B M , van Geldorp Martijn W A , Van den Branden Ben J L , Pel-Littel Ruth E , van der Meer Nardo J M , Minkman Mirella M N
Published: December 2021

Objective

To provide insight into professionals’ perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS).

Methods

A semistructured interview study was performed in the heart centres of academic and large teaching hospitals in the Netherlands between June and December 2020. Cardiothoracic surgeons, interventional cardiologists, nurse practitioners and physician assistants (n=21) involved in the decision-making process for treatment of severe AS were interviewed. An inductive thematic analysis was used to identify, analyse and report patterns in the data.

Results

Four primary themes were generated: (1) the concept of SDM, (2) knowledge, (3) communication and interaction, and (4) implementation of SDM. Not all respondents considered patient participation as an element of SDM. They experienced a discrepancy between patients’ wishes and treatment options. Respondents explained that not knowing patient preferences for health improvement hinders SDM and complicating patient characteristics for patient participation were perceived. A shared responsibility for improving SDM was suggested for patients and all professionals involved in the decision-making process for severe AS.

Conclusions

Professionals struggle to make highly complex treatment decisions part of SDM and to embed patients’ expectations of treatment and patients’ preferences. Additionally, organisational constraints complicate the SDM process. To ensure sustainable high-quality care, professionals should increase their awareness of patient participation in SDM, and collaboration in the pathway for decision-making in severe AS is required to support the documentation and availability of information according to the principles of SDM.
A disorder clinically resembling cystic fibrosis caused by biallelic variants in the AGR2 gene
Authors: Bertoli-Avella Aida , Hotakainen Ronja , Al Shehhi Maryam , Urzi Alice , Pareira Catarina , Marais Anett , Al Shidhani Khoula , Aloraimi Sumaya , Morales-Torres Galina , Fisher Steffen , Demuth Laura , Moteleb Selim Laila Abdel , Al Menabawy Nihal , Busehail Maryam , AlShaikh Mohammed , Gilani Naser , Chalabi Dler Nooruldeen , Alharbi Nasser S , Alfadhel Majid , Abdelrahman Mohammed , Venselaar Hanka , Anjum Nadeem , Saeed Anjum , Alghamdi Malak Ali , Aljaedi Hamad , Arabi Hisham , Karageorgou Vasiliki , Khan Suliman , Hajjari Zahra , Radefeldt Mandy , Al-Ali Ruslan , Tripolszki Kornelia , Jamhawi Amer , Paknia Omid , Cozma Claudia , Cheema Huma , Ameziane Najim , Al-Muhsen Saleh , Bauer Peter
Published: December 2021

Purpose

We sought to describe a disorder clinically mimicking cystic fibrosis (CF) and to elucidate its genetic cause.

Methods

Exome/genome sequencing and human phenotype ontology data of nearly 40 000 patients from our Bio/Databank were analysed. RNA sequencing of samples from the nasal mucosa from patients, carriers and controls followed by transcriptome analysis was performed.

Results

We identified 13 patients from 9 families with a CF-like phenotype consisting of recurrent lower respiratory infections (13/13), failure to thrive (13/13) and chronic diarrhoea (8/13), with high morbidity and mortality. All patients had biallelic variants in AGR2, (1) two splice-site variants, (2) gene deletion and (3) three missense variants. We confirmed aberrant AGR2 transcripts caused by an intronic variant and complete absence of AGR2 transcripts caused by the large gene deletion, resulting in loss of function (LoF). Furthermore, transcriptome analysis identified significant downregulation of components of the mucociliary machinery (intraciliary transport, cilium organisation), as well as upregulation of immune processes.

Conclusion

We describe a previously unrecognised autosomal recessive disorder caused by AGR2 variants. AGR2-related disease should be considered as a differential diagnosis in patients presenting a CF-like phenotype. This has implications for the molecular diagnosis and management of these patients. AGR2 LoF is likely the disease mechanism, with consequent impairment of the mucociliary defence machinery. Future studies should aim to establish a better understanding of the disease pathophysiology and to identify potential drug targets.
Where the ethical action is
Authors: Hardman Doug , Hutchinson Phil
Published: December 2021

It is common to think of medical and ethical modes of thought as different in kind. In such terms, some clinical situations are made more complicated by an additional ethical component. Against this picture, we propose that medical and ethical modes of thought are not different in kind, but merely different aspects of what it means to be human. We further propose that clinicians are uniquely positioned to synthesise these two aspects without prior knowledge of philosophical ethics.