bluuebunny/crossref_metadata_2025 huggingface dataset:
Remission of treatment-resistant depression with tardive akathisia with electroconvulsive therapy
Authors: Emmanuel Thanos
Published: September 2019

This report presents a case of drug-induced severe tardive akathisia developing after the combination of a selective serotonin reuptake inhibitor and an antipsychotic, in a woman with severe major depression. The trial and combination of multiple medications is common practice in treatment-resistant patients with depression. With the increase in the prevalence of treatment-resistant depression, adverse effects of medication such as tardive akathisia are becoming more common. Tardive akathisia persists even after the withdrawal of the causative agent and is very challenging to treat. The patient did not respond to any standard medications indicated for drug-induced akathisia. As a result, the patient became suicidal and extremely distressed with all treatment options exhausted. Guidelines on the management of drug-induced tardive akathisia are non-existent. This reflects the importance of this case study, which reveals the complete remission of both tardive akathisia and all the patient’s depressive symptoms after electroconvulsive therapy . This report provides evidence of an established treatment intervention used in a new situation.
Postural orthostatic tachycardia syndrome in primary care: diagnosis, treatment and a case of African-American man presenting with POTS
Authors: Del Pozzi Andrew T , Enechukwu Michael , Blitshteyn Svetlana
Published: September 2019

Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous autonomic disorder characterised by orthostatic intolerance and a rise in heart rate by at least 30 bpm or an absolute heart rate value of at least 120 bpm within 10 min of standing or during a tilt table test. Overwhelmingly, POTS affects young Caucasian women, which can lead physicians to miss the diagnosis in men or non-white patients. We describe a case of 29-year-old African-American man who developed lightheadedness, generalised weakness, tachycardia and palpitations and was subsequently diagnosed with POTS. We review its clinical features, differential diagnosis, pathophysiology and treatment options. We also emphasise that POTS should be considered as a differential diagnosis in any patient presenting with typical clinical features, who may not be in the usual demographics of the disorder.
Traumatic bruising of the hepatoduodenal ligament can conceal a catastrophic injury to the hepatic artery
Authors: Gerrard Adam Daniel , Lunevicius Raimundas , Heavey Nicholas
Published: September 2019

We present the case of a 22-year-old man transferred to the regional major trauma centre following a fall of ~15 m. He remained consistently haemodynamically stable for over 10 hours of observation until he deteriorated suddenly with major haemorrhagic shock requiring immediate trauma laparotomy. At laparotomy, 2 L of blood was drained from the abdomen but no source of active bleeding identified. 30 minutes after closure of the abdomen, 500 mL of fresh blood was noted in the drain so he was returned to the theatre where the bleeding source was found to be—after manual compression of a mildly bruised hepatoduodenal ligament—the proper hepatic artery (PHA). This case describes an unusual finding at relaparotomy and shows that even when there is no active bleeding from abdominal organs or classified vessels, it is possible to have isolated injury to PHA.
Insidious onset of headache, diplopia and Horner’s syndrome: a rare case of petrous bone osteomyelitis
Authors: Biart Simon , Panicker Janki
Published: September 2019

We present an unusual case of skull base osteomyelitis in an 88-year-old woman. She presented with gradual onset unilateral headache and diplopia. On examination, there was evidence of a left-sided Horner’s and ipsilateral sixth nerve palsy. In addition to persistent raised inflammatory markers, an MRI neck identified signal change in the petrous bone confirming a diagnosis of skull base osteomyelitis. Skull base osteomyelitis should be considered in presentations of subacute raised inflammatory markers in the context of ipsilateral cranial nerve signs.
Permanent lesion to the corticospinal tract after therapy with capecitabine
Authors: Wagner-Altendorf Tobias A , Heldmann Marcus , Hanssen Henrike , Münte Thomas F
Published: September 2019

Capecitabine is an oral fluoropyrimidine used to treat solid tumours such as colorectal and breast cancer. A rare but severe side effect is capecitabine-induced leukoencephalopathy, including bilateral lesion to the corticospinal tract. However, neurological symptoms due to capecitabine treatment are usually reported to be reversible after discontinuation of capecitabine. Here, we present the case of a patient with bilateral degeneration of the corticospinal tract and progressive spastic tetraplegia after chemotherapy with capecitabine mimicking primary lateral sclerosis. Although therapy with capecitabine was ended, symptoms substantially worsened over the following years and the patient finally died from aspiration pneumonia almost 3 years after the application of capecitabine.
Optic shrinkage and retraction in opacified hydrophilic acrylic intraocular lens: an anterior segment optical CT-based observation
Authors: Agarwal Rinky , Bhardwaj Mayank , Chetan Chetan , Sharma Namrata
Published: September 2019

Intraocular lens (IOL) opacification is a rare phenomenon noted with hydrophilic acrylic IOLs. We report a case of advanced IOL opacification appreciated on anterior segment optical CT (ASOCT)as a shrunken biconcave optic retracted away from the posterior capsule (PC), unlike the other eye which had a clear biconvex IOL of similar material abutting the PC. After IOL exchange, the affected eye was noted to have more folds and Elschnig’s pearls on the PC when compared with the other eye. Our case points towards rare IOL changes seen in advanced cases of opacification, their association with posterior capsular changes and the aid of ASOCT as a non-invasive tool in diagnosing them correctly.
Endoscopic management of limy bile syndrome presenting with obstructive jaundice
Authors: AlMuhsin Ahmed Mohammed , Altaweel Ahmad , Abouleid Ayman
Published: September 2019

Limy bile syndrome is a rare entity in which there is an excessive precipitation of calcium salts, mainly calcium carbonate in the gallbladder (GB) and to a rare extent in the common bile duct (CBD), making it radiopaque in plain radiographs. Laparoscopic cholecystectomy is safe and effective in patients with limy bile confined to the GB. However, for patients with an extension to the CBD, bile duct exploration with a T-tube placement, endoscopic naso-billiary drainage or endoscopic sphincterotomy (EST) may be warranted. We report a case of limy bile syndrome associated with obstructive jaundice in a young female patient. She was managed successfully with EST followed by laparoscopic cholecystectomy.
The inverse relationship between national food security and annual cholera incidence: a 30-country analysis
Authors: Richterman Aaron , Azman Andrew S , Constant Georgery , Ivers Louise C
Published: September 2019

Introduction

Individual and household-level evidence suggests a relationship between food insecurity and cholera risk. The relationship between national food security and the size of cholera outbreaks is unknown.

Methods

We analysed the relationship between national food security and annual cholera incidence rate from 2012 to 2015 across 30 countries. We used components of the Global Food Security Index (GFSI) as measures of food security. We included countries with available GFSI reporting cases of cholera during the study period, excluding high-income countries. We developed multivariable zero-inflated negative binomial models with annual cholera incidence rate as the outcome, GFSI components as the exposure of interest, fixed effects for country and year, and time-varying effects related to water, sanitation, and hygiene, oral cholera vaccine deployment, healthcare expenditure, conflict and extreme weather.

Results

The 30 countries reported 550 106 total cases of cholera from 2012 to 2015, with a median annual incidence rate of 3.1 cases per 100 000 people (IQR 0.3–9.9). We found independent inverse relationships between cholera and Overall GFSI (incidence rate ratio (IRR) 0.57, 95% CI 0.43 to 0.78), GFSI-Availability (IRR 0.81, 95% CI 0.70 to 0.95) and GFSI-Affordability (IRR 0.76, 95% CI 0.62 to 0.92).

Conclusions

We identified a strong inverse relationship between national food security and annual incidence rate of cholera. In the context of prior evidence at the individual and household levels, this suggests that there is a linkage between food insecurity and cholera at the national level that should be further considered in assessing cholera risk in vulnerable regions and in designing cholera control interventions.
Usability testing of a smartphone-based retinal camera among first-time users in the primary care setting
Authors: Li Patrick , Paulus Yannis , Davila Jose , Gosbee John , Margolis Todd , Fletcher Daniel , Kim Tyson
Published: September 2019

Smartphone-based retinal photography is a promising method for increasing accessibility of retinal screening in the primary care and community settings. Recent work has focused on validating its use in detection of diabetic retinopathy. However, retinal imaging can be technically challenging and additional work is needed to improve ease of retinal imaging in the primary care setting. We, therefore, performed usability testing of a smartphone-based retinal camera, RetinaScope, among medical assistants in primary care who had never performed retinal imaging. A total of 24 medical assistants performed first-time imaging in a total of five rounds of testing, and iterative improvements to the device were made between test rounds based on the results. The time to acquire a single ~50° image of the posterior pole of a model eye decreased from 283±60 s to 34±17 s (p<0.01) for first-time users. The time to acquire five overlapping images of the retina decreased from 325±60 s to 118±26 s (p=0.02) for first-time users. Testing in the human eye demonstrated that a single wide-view retinal image could be captured in 65±7 s and five overlapping images in 229±114 s. Users reported high Systems Usability Scores of 86±13 throughout the rounds, reflecting a high level of comfort in first-time operation of the device. Our study demonstrates that smartphone-based retinal photography has the potential to be quickly adopted among medical assistants in the primary care setting.
Community-deliverable exercise and anxiety in adults with arthritis and other rheumatic diseases: a systematic review with meta-analysis of randomised controlled trials
Authors: Kelley George A , Kelley Kristi S , Callahan Leigh F
Published: September 2019

Background/purpose

Given conflicting findings, the purpose of this study was to use the meta-analytic approach to examine the effects of exercise (aerobic, strength training or both) on anxiety in adults with arthritis and other rheumatic diseases (AORD).

Methods

Randomised controlled exercise intervention trials ≥4weeks in adults ≥18 years of age with osteoarthritis, rheumatoid arthritis or fibromyalgia were included. Studies were located by searching eight electronic databases, cross-referencing and expert review. Dual selection and data abstraction of studies were performed. Hedge’s standardised effect size (ES) was calculated for each result and pooled using the recently developed inverse heterogeneity model. Two-tailedz-alpha values ≤0.05 and non-overlapping 95% CI were considered statistically significant. Heterogeneity was estimated using Q andI2with alpha values ≤0.10 for Q considered statistically significant. Small-study effects were examined using funnel plots and Egger’s regression test. In addition, the number needed to treat (NNT), percentile improvement and meta-regression were conducted.

Results

Of the 639 citations screened, 14 studies representing 926 initially enrolled participants (539 exercise, 387 control) met the criteria for inclusion. Length of training (mean±SD) averaged 15.8±6.7 weeks, frequency 3.3±1.3 times per week and duration 28.8±14.3 min per session. Overall, statistically significant reductions in anxiety were found (exercise minus control changes ES=−0.40, 95% CI −0.65 to −0.15, tau2=0.14; Q=40.3, P=0.0004;I2=62.8%). The NNT was 6 with a percentile improvement of 15.5% and an estimated 5.3 million inactive US adults with AORD improving their anxiety if they started exercising regularly. Statistically significant small-study effects were observed (P<0.0001).

Conclusions

Exercise is associated with reductions in anxiety among adults with selected types of AORD. However, a need exists for additional, well-designed, randomised controlled trials on this topic.

PROSPERO registration number

CRD42016048728.
Evaluating the impact of type 2 diabetes mellitus on CYP450 metabolic activities: protocol for a case–control pharmacokinetic study
Authors: Gravel Sophie , Chiasson Jean-Louis , Dallaire Suzanne , Turgeon Jacques , Michaud Veronique
Published: September 2019

Introduction

Diabetes affects more than 9% of the adult population worldwide. Patients with type 2 diabetes mellitus (T2DM) show variable responses to some drugs which may be due, in part, to variability in the functional activity of drug-metabolising enzymes including cytochromes P450 (CYP450s). CYP450 is a superfamily of enzymes responsible for xenobiotic metabolism. Knowledge must be gained on the impact of T2DM and related inflammatory processes on drug metabolism and its consequences on drug response. The aim of this study is to characterise the activity of CYP1A2, CYP2B6, CYP2C9, CYP2C19, CYP2D6, CYP2E1 and CYP3A4/5 in T2DM versus non-T2DM subjects following the administration of a cocktail of probe drug substrates.

Methods and analysis

This single-centre clinical study proposes the first detailed characterisation of T2DM impacts on major CYP450 drug-metabolising enzyme activities. We intend to recruit 42 patients with controlled T2DM (A1C≤7%), 42 patients with uncontrolled T2DM (A1C>7%) and 42 non-diabetic control subjects. The primary objective is to determine and compare major CYP450 activities in patients with T2DM versus non-diabetic subjects by dosing in plasma and urine probe drug substrates and metabolites following the oral administration of a drug cocktail: caffeine (CYP1A2), bupropion (CYP2B6), tolbutamide (CYP2C9), omeprazole (CYP2C19), dextromethorphan (CYP2D6), chlorzoxazone (CYP2E1) and midazolam (CYP3A4/5). Secondary objectives will evaluate the influence of variables such as glycaemia, insulinaemia, genetic polymorphisms and inflammation. The value of an endogenous biomarker of CYP3A activity is also evaluated. The first patient was recruited in May 2015 and patients will be enrolled up to completion of study groups.

Ethics and dissemination

Approval was obtained from the ethic review board of the CHUM research centre (Montreal, Canada).

Trial registration number

NCT02291666.
Association of platelet-to-lymphocyte count ratio with myocardial reperfusion and major adverse events in patients with acute myocardial infarction: a two-centre retrospective cohort study
Authors: Maimaiti Ailifeire , Li Yang , Wang Yong-Tao , Yang Xiang , Li Xiao-Mei , Yang Yi-Ning , Ma Yi-Tong
Published: September 2019

Objective

Insufficient myocardial reperfusion for patients with acute myocardial infarction (AMI) during primary percutaneous coronary intervention (PPCI) has a great influence on prognosis. The aim of this study was to investigate the association of the platelet-to-lymphocyte ratio (PLR) with myocardial reperfusion and in-hospital major adverse cardiac events (MACEs) in patients with AMI undergoing PPCI.

Design

Retrospective cohort study.

Setting

Patients and researchers from two tertiary hospitals.

Participants

A total of 445 consecutive AMI patients who underwent PPCI between January 2015 and December 2017 were enrolled. Patients were divided into two groups based on the PLR value: patients with PLR values in the third tertile were defined as the high-PLR group (n=150), and those in the lower two tertiles were defined as the low-PLR group (n=295). Explicit criteria for inclusion and exclusion were applied.

Interventions

No interventions.

Primary and secondary outcome measures

Primary outcome measures were defined as cardiovascular death, reinfarction or target vessel revascularisation. Secondary outcome measures were defined as stroke, non-lethal myocardial infarction, ventricular tachycardia/ventricular fibrillation and in-hospital mortality.

Results

The high-PLR group had insufficient myocardial perfusion (23% vs 13%, p=0.003), greater postprocedural thrombolysis in myocardial infarction flow grade (0–2) (17% vs 10%, p=0.037), greater myocardial blush grade (0–1) (11% vs 4%, p=0.007) and higher B-type natriuretic peptide (BNP) (614±600 vs 316±429, p<0.001) compared with the low-PLR group. Multivariate logistic regression analysis indicated that the independent risk factors for impaired myocardial perfusion were high PLR (OR 1.256, 95% CI 1.003 to 1.579, p=0.056) and high BNP (OR 1.328, 95% CI 1.056 to 1.670, p=0.015). The high-PLR group had significantly more MACEs (43% vs 32%, p=0.029).

Conclusions

This study suggested that high PLR and BNP were independent risk factors for insufficient myocardial reperfusion in patients with AMI. Higher PLR was related to advanced heart failure and in-hospital MACEs in patients with AMI undergoing PPCI.
Biobanking for discovery of novel cardiovascular biomarkers using imaging-quantified disease burden: protocol for the longitudinal, prospective, BioHEART-CT cohort study
Authors: Kott Katharine A , Vernon Stephen T , Hansen Thomas , Yu Christine , Bubb Kristen J , Coffey Sean , Sullivan David , Yang Jean , O'Sullivan John , Chow Clara , Patel Sanjay , Chong James , Celermajer David S , Kritharides Leonard , Grieve Stuart M , Figtree Gemma A
Published: September 2019

Introduction

Coronary artery disease (CAD) persists as a major cause of morbidity and mortality worldwide despite intensive identification and treatment of traditional risk factors. Data emerging over the past decade show a quarter of patients have disease in the absence of any known risk factor, and half have only one risk factor. Improvements in quantification and characterisation of coronary atherosclerosis by CT coronary angiography (CTCA) can provide quantitative measures of subclinical atherosclerosis—enhancing the power of unbiased ‘omics’ studies to unravel the missing biology of personal susceptibility, identify new biomarkers for early diagnosis and to suggest new targeted therapeutics.

Methods and analysis

BioHEART-CT is a longitudinal, prospective cohort study, aiming to recruit 5000 adult patients undergoing clinically indicated CTCA. After informed consent, patient data, blood samples and CTCA imaging data are recorded. Follow-up for all patients is conducted 1 month after recruitment, and then annually for the life of the study. CTCA data provide volumetric quantification of total calcified and non-calcified plaque, which will be assessed using established and novel scoring systems. Comprehensive molecular phenotyping will be performed using state-of-the-art genomics, metabolomics, proteomics and immunophenotyping. Complex network and machine learning approaches will be applied to biological and clinical datasets to identify novel pathophysiological pathways and to prioritise new biomarkers. Discovery analysis will be performed in the first 1000 patients of BioHEART-CT, with validation analysis in the following 4000 patients. Outcome data will be used to build improved risk models for CAD.

Ethics and dissemination

The study protocol has been approved by the human research ethics committee of North Shore Local Health District in Sydney, Australia. All findings will be published in peer-reviewed journals or at scientific conferences.

Trial registration number

ACTRN12618001322224.
Randomised controlled clinical trial of a structured cognitive rehabilitation in patients with attention deficit following mild traumatic brain injury: study protocol
Authors: Hamzah Norhamizan , Narayanan Vairavan , Ramli Norlisah , Mustapha Nor Atikah , Mohammad Tahir Nor Adibah , Tan Li Kuo , Danaee Mahmoud , Muhamad Nor Asiah , Drummond Avril , das Nair Roshan , Goh Sing Yau , Mazlan Mazlina
Published: September 2019

Objectives

To measure the clinical, structural and functional changes of an individualised structured cognitive rehabilitation in mild traumatic brain injury (mTBI) population.

Setting

A single centre study, Malaysia.

Participants

Adults aged between 18 and 60 years with mTBI as a result of road traffic accident, with no previous history of head trauma, minimum of 9 years education and abnormal cognition at 3 months will be included. The exclusion criteria include pre-existing chronic illness or neurological/psychiatric condition, long-term medication that affects cognitive/psychological status, clinical evidence of substance intoxication at the time of injury and major polytrauma. Based on multiple estimated calculations, the minimum intended sample size is 50 participants (Cohen’s d effect size=0.35; alpha level of 0.05; 85% power to detect statistical significance; 40% attrition rate).

Interventions

Intervention group will receive individualised structured cognitive rehabilitation. Control group will receive the best patient-centred care for attention disorders. Therapy frequency for both groups will be 1 hour per week for 12 weeks.

Outcome measures

Primary:Neuropsychological Assessment Battery-Screening Module (S-NAB) scores.Secondary:Diffusion Tensor Imaging (DTI) parameters and Goal Attainment Scaling score (GAS).

Results

Results will include descriptive statistics of population demographics, CogniPlus cognitive program and metacognitive strategies. The effect of intervention will be the effect size of S-NAB scores and mean GAS T scores. DTI parameters will be compared between groups via repeated measure analysis. Correlation analysis of outcome measures will be calculated using Pearson’s correlation coefficient.

Conclusion

This is a complex clinical intervention with multiple outcome measures to provide a comprehensive evidence-based treatment model.

Ethics and dissemination

The study protocol was approved by the Medical Research Ethics Committee UMMC (MREC ID NO: 2016928–4293). The findings of the trial will be disseminated through peer-reviewed journals and scientific conferences.

Trial registration number

NCT03237676
Differences between the Canadian military’s Regular and Reserve Forces in perceived need for care, mental health services use and perceived sufficiency of care: a cross-sectional survey
Authors: Boulos David , Fikretoglu Deniz
Published: September 2019

Objective

The primary objective was to explore differences in perceived need for care (PNC), mental health services use (MHSU) and perceived sufficiency of care (PSC) between Canadian Armed Forces Regular Force (RegF) and Reserve Force (ResF) personnel with an objective need for mental health services.

Design

Data came from the 2013 Canadian Armed Forces Mental Health Survey, a cross-sectional survey of serving personnel (n=72 629). Analyses were among those with an Afghanistan deployment and an identified mental disorder (population n=6160; sampled n=868). Logistic regression compared PNC, MHSU and PSC between RegF and ResF. Covariate-adjusted marginal prevalence difference estimates were computed.

Primary outcome measure

The primary outcomes were PNC, MHSU and PSC. Each had three service categories, including an aggregate ‘any’ of the three: (1) information about problems, treatments or services; (2) medication and (3) counselling.

Results

ResF had an 10.5% (95% CI −16.7% to −4.4%) lower perceived need for medication services but PNC differences were not significant for other service categories. MHSU tended to be lower for ResF; 9.1% (95%CI −15.5% to −2.6%) lower for medication, 5.4% (95% CI −11.5% to 0.7%) lower, with marginal significance, for counselling and 11.3% (95% CI −17.3% to −5.2%) lower for the ‘any’ service category. Additionally, ResF tended to have a lower fully met need for care; 13.4% (95% CI −22.1% to −4.6%) lower for information, 15.3% (95% CI −22.9% to −7.6%) lower for counselling and 14.6% (95% CI −22.4% to −6.8%) lower for the ‘any’ service category.

Conclusions

Our findings suggest MHSU and PSC differences between Canadian RegF and ResF personnel that are not fully accounted for by PNC differences. Deficits in ResF members’ perceptions of the sufficiency of information services and counselling services suggest perceived, or experienced, barriers to care beyond any PNC barriers. Additional research assessing barriers to mental healthcare is warranted.
The effectiveness of general practice-based health checks on health behaviour and incidence on non-communicable diseases in individuals with low socioeconomic position: a randomised controlled trial in Denmark
Authors: Kamstrup-Larsen Nina , Dalton Susanne Oksbjerg , Grønbæk Morten , Broholm-Jørgensen Marie , Thomsen Janus Laust , Larsen Lars Bruun , Johansen Christoffer , Tolstrup Janne
Published: September 2019

Background

The effectiveness of health checks aimed at the general population is disputable. However, it is not clear whether health checks aimed at certain groups at high risk may reduce adverse health behaviour and identify persons with metabolic risk factors and non-communicable diseases (NCDs).

Objectives

To assess the effect of general practice-based health checks on health behaviour and incidence on NCDs in individuals with low socioeconomic position.

Methods

Individuals with no formal education beyond lower secondary school and aged 45–64 years were randomly assigned to the intervention group of a preventive health check or to control group of usual care in a 1:1 allocation. Randomisation was stratified by gender and 5-year age group. Due to the real-life setting, blinding of participants was only possible in the control group. Effects were analysed as intention to treat (ITT) and per protocol. The trial was undertaken in 32 general practice units in Copenhagen, Denmark.

Intervention

Invitation to a prescheduled preventive health check from the general practitioner (GP) followed by a health consultation and an offer of follow-up with health risk behaviour change or preventive medical treatment, if necessary.

Primary outcome measures

Smoking status at 12-month follow-up. Secondary outcomes included status in other health behaviours such as alcohol consumption, physical activity and body mass index (measured by self-administered questionnaire), as well as incidence of metabolic risk factors and NCDs such as hypertension, hypercholesterolaemia, chronic obstructive pulmonary disease, diabetes mellitus, hypothyroidism, hyperthyroidism and depression (drawn from national healthcare registries).

Results

1104 participants were included in the study. For the primary outcome, 710 participants were included in the per protocol analysis, excluding individuals who did not attend the health check, and 1104 participants were included in the ITT analysis. At 12-month follow-up, 37% were daily smokers in the intervention group and 37% in the control group (ORs=0.99, 95% CI: 0.76 to 1.30). No difference in health behaviour nor in the incidence of metabolic risk factors and NCDs between the intervention and control group were found. Side effects were comparable across the two groups.

Conclusion

The lack of effectiveness may be due to low intensity of intervention, a high prevalence of metabolic risk factors and NCDs among the participants at baseline as well as a high number of contacts with the GPs in general or to the fact that general practices are not an effective setting for prevention.

Trial registration number

NCT01979107.
From EHR to PHR: let’s get the record straight
Authors: Symons Joshua D , Ashrafian Hutan , Dunscombe Rachel , Darzi Ara
Published: September 2019

This article reflects on the changing nature of health information access and the transition of focus from electronic health records (EHRs) to personal health records (PHRs) along with the challenges and need for alignment of national initiatives for EHR and PHR in the National Health Service (NHS) of the UK. The importance of implementing integrated EHRs as a route to enhance the quality of health delivery has been increasingly understood. EHRs, however, carry several limitations that include major fragmentation through multiple providers and protocols throughout the NHS. Questions over ownership and control of data further complicate the potential for fully utilising records. Analysing the previous initiatives and the current landscape, we identify that adopting a patient health record system can empower patients and allow better harmonisation of clinical data at a national level. We propose regional PHR ‘hubs’ to provide a universal interface that integrates digital health data at a regional level with further integration at a national level. We propose that these PHR hubs will reduce the complexity of connections, decrease governance challenges and interoperability issues while also providing a safe platform for high-quality scalable and sustainable digital solutions, including artificial intelligence across the UK NHS, serving as an exemplar for other countries which wish to realise the full value of healthcare records.
Facilitators and barriers to safer care in Scottish general practice: a qualitative study of the implementation of the trigger review method using normalisation process theory
Authors: de Wet Carl , Bowie Paul , O'Donnell Catherine A
Published: September 2019

Objectives

Patient safety is a key concern of modern health systems, with numerous approaches to support safety. One, the trigger review method (TRM), is promoted nationally in Scotland as an approach to improve the safety of care in general medical practice. However, it remains unclear which factors are facilitating or hindering its implementation. The aim of this study was to identify the important factors that facilitate or hinder the implementation of the TRM in this setting.

Design

Qualitative study employing semi-structured interviews. Data analysis was theoretically informed using normalisation process theory (NPT).

Setting

Scottish general practice.

Participants

We conducted 28 semistructured interviews with general practitioners (n=12), practice nurses (n=11) and practice managers (n=5) in Scotland.

Results

We identified four important factors that facilitated or hindered implementation: (1) the amount of time and allocated resources; (2) integration of the TRM into existing initiatives and frameworks facilitated implementation and justified participants’ involvement; (3) the characteristics of the reviewers—implementation was facilitated by experienced, reflective clinicians with leadership roles in their teams; (4) the degree to which participants perceived the TRM as acceptable, feasible and useful.

Conclusions

This study is the first known attempt to investigate how the TRM is implemented and perceived by general practice clinicians and staff. The four main factors that facilitated TRM implementation are comparable with the wider implementation science literature, suggesting that a small number of specific factors determine the success of most, if not all, complex healthcare interventions. These factors can be identified, described and understood through theoretical frameworks such as NPT and are amenable to intervention. Researchers and policymakers should proactively identify and address these factors.
Barriers, enablers and initiatives for uptake of advance care planning in general practice: a systematic review and critical interpretive synthesis
Authors: Risk Jo , Mohammadi Leila , Rhee Joel , Walters Lucie , Ward Paul R
Published: September 2019

Objectives

How advance care planning (ACP) is conceptualised in Australia including when, where and how ACP is best initiated, is unclear. It has been suggested that healthcare delivered in general practice provides an optimal setting for initiation of ACP discussions but uptake remains low. This systematic review and critical interpretive synthesis sought to answer two questions: (1) What are the barriers and enablers to uptake of ACP in general practice? (2) What initiatives have been used to increase uptake of ACP in general practice?

Design

A systematic review and critical interpretive synthesis of the peer-reviewed literature was undertaken. A socioecological framework was used to interpret and map the literature across four contextual levels of influence including individual, interpersonal, provider and system levels within a general practice setting.

Setting

Primary care general practice settings

Data sources

Searches were undertaken from inception to July 2019 across Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, Scopus, ProQuest and Cochrane Library of systematic reviews.

Results

The search yielded 4883 non-duplicate studies which were reduced to 54 studies for synthesis. Year of publication ranged from 1991 to 2019 and represented research from nine countries. Review findings identified a diverse and disaggregated body of ACP literature describing barriers and enablers to ACP in general practice, and interventions testing single or multiple mechanisms to improve ACP generally without explicit consideration for level of influence. There was a lack of cohesive guidance in shaping effective ACP interventions and some early indications of structured approaches emerging.

Conclusion

Findings from this review present an opportunity to strategically apply the ACP research evidence across targeted levels of influence, and with an understanding of mediators and moderators to inform the design of new and enhanced ACP models of care in general practice.

PROSPERO registration number

CRD42018088838
Heart Rehabilitation in patients awaiting Open heart surgery targeting to prevent Complications and to improve Quality of life (Heart-ROCQ): study protocol for a prospective, randomised, open, blinded endpoint (PROBE) trial
Authors: Hartog Johanneke , Blokzijl Fredrike , Dijkstra Sandra , DeJongste Mike J L , Reneman Michiel F , Dieperink Willem , van der Horst Iwan C C , Fleer Joke , van der Woude Lucas H V , van der Harst Pim , Mariani Massimo A
Published: September 2019

Introduction

The rising prevalence of modifiable risk factors (eg, obesity, hypertension and physical inactivity) is causing an increase in possible avoidable complications in patients undergoing cardiac surgery. This study aims to assess whether a combined preoperative and postoperative multidisciplinary cardiac rehabilitation (CR) programme (Heart-ROCQ programme) can improve functional status and reduce surgical complications, readmissions and major adverse cardiac events (MACE) as compared with standard care.

Methods and analysis

Patients (n=350) are randomised to the Heart-ROCQ programme or standard care. The Heart-ROCQ programme consists of a preoperative optimisation phase while waiting for surgery (three times per week, minimum of 3 weeks), a postoperative inpatient phase (3 weeks) and an outpatient CR phase (two times per week, 4 weeks). Patients receive multidisciplinary treatment (eg, physical therapy, dietary advice, psychological sessions and smoking cessation). Standard care consists of 6 weeks of postsurgery outpatient CR with education and physical therapy (two times per week). The primary outcome is a composite weighted score of functional status, surgical complications, readmissions and MACE, and is evaluated by a blinded endpoint committee. The secondary outcomes are length of stay, physical and psychological functioning, lifestyle risk factors, and work participation. Finally, an economic evaluation is performed. Data are collected at six time points: at baseline (start of the waiting period), the day before surgery, at discharge from the hospital, and at 3, 7 and 12 months postsurgery.

Ethics and dissemination

This study will be conducted according to the principles of the Declaration of Helsinki (V.8, October 2013). The protocol has been approved by the Medical Ethical Review Board of the UMCG (no 2016/464). Results of this study will be submitted to a peer-reviewed scientific journal and can be presented at national and international conferences.

Trial registration number

NCT02984449.
Improving laboratory test utilisation at the multihospital Yale New Haven Health System
Authors: Harb Roa , Hajdasz David , Landry Marie L , Sussman L Scott
Published: September 2019

Background

Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management.

Methods

In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings.

Results

Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period.

Conclusion

Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients’ blood.
Validation of the Swedish Multidimensional Dyspnea Profile (MDP) in outpatients with cardiorespiratory disease
Authors: Ekström Magnus , Bornefalk Hans , Sköld Magnus , Janson Christer , Blomberg Anders , Sandberg Jacob , Bornefalk-Hermansson Anna , Igelström Helena , Sundh Josefin
Published: September 2019

Introduction

Breathlessness is a cardinal symptom in cardiorespiratory disease. An instrument for measuring different aspects of breathlessness was recently developed, the Multidimensional Dyspnea Profile (MDP). This study aimed to validate the MDP in terms of the underlying factor structure, internal consistency, test–retest reliability and concurrent validity in Swedish outpatients with cardiorespiratory disease.

Methods

Outpatients with stable cardiorespiratory disease and breathlessness in daily life were recruited. Factor structure of MDP was analysed using confirmatory factor analysis; internal consistency was analysed using Cronbach’s alpha; and test–retest reliability was analysed using intraclass correlation coefficients (ICCs) for patients with unchanged breathlessness between assessments (baseline, after 30–90 min and 2 weeks). Concurrent validity was evaluated using correlations with validated scales of breathlessness, anxiety, depression and health-related quality of life.

Results

In total, 182 outpatients with cardiorespiratory disease and breathlessness in daily life were included; 53.3% were women; main diagnoses were chronic obstructive pulmonary disease (24.7%), asthma (21.4%), heart failure (19.2%) and idiopathic pulmonary fibrosis (18.7%). The MDP total, immediate perception and emotional response scores, and individual item scores showed expected factor structure and acceptable measurement properties: internal consistency (Cronbach’s alpha, range 0.80–0.93); test–retest reliability at 30–90 min and 2 weeks (ICC, range 0.67–0.91); and concurrent validity. There was no evidence of a learning effect. Findings were similar between diagnoses.

Discussion

MDP is a valid instrument for multidimensional measurement of breathlessness in Swedish outpatients across cardiorespiratory diseases.
Is a low Functional Movement Screen score (≤14/21) associated with injuries in sport? A systematic review and meta-analysis
Authors: Trinidad-Fernandez Manuel , Gonzalez-Sanchez Manuel , Cuesta-Vargas Antonio I
Published: September 2019

Objective

To assess whether Functional Movement Screen (FMS) score is associated with subsequent injuries in healthy sportspeople.

Design

Systematic review and meta-analysis.

Data sources

The following electronic databases were searched to December 2017: Medline, PubMed, PsycINFO, SPORTDiscus, Cumulative Index of Nursing and Allied Health Literature, Scopus, Embase, and Physiotherapy Evidence Database.

Eligibility criteria for selecting studies

Eligibility criteria included (1) prospective cohort studies that examined the association between FMS score (≤14/21) and subsequent injuries, (2) a sample of healthy and active participants without restrictions in gender or age, and (3) the OR was the effect size and the main outcome.

Results

Thirteen studies met the criteria for the systematic review and 12 were included in the meta-analysis. In 5 of the 12 studies, and among female athletes in 1 study, FMS score ≤14 out of 21 points was associated with subsequent injuries. The overall OR of the selected studies in the meta-analysis was 1.86 (95% CI 1.32 to 2.61) and showed substantial heterogeneity (I2=70%).

Summary/Conclusion

Whether or not a low FMS score ≤14 out of 21 points is associated with increased risk of injury is unclear. The heterogeneity of the study populations (type of athletes, age and sport exposure) and the definition of injury used in the studies make it difficult to synthesise the evidence and draw definitive conclusions.

Trial registration number

CRD42015015579.
International consensus statement on the psychosocial and policy-related approaches to mental health awareness programmes in sport
Authors: Breslin Gavin , Smith Andy , Donohue Brad , Donnelly Paul , Shannon Stephen , Haughey Tandy Jane , Vella Stewart A , Swann Christian , Cotterill Stewart , Macintyre Tadhg , Rogers Tim , Leavey Gerard
Published: September 2019

Background

Research focused on mental health in sport has revealed a need to develop evidence-supported mental health practices that are sensitive to sport culture, particularly for non-elite athletes. A consensus statement was produced to assist effective mental health awareness in sport and guide programme implementation in this rapidly emerging field.

Method

The AGREE Reporting Checklist 2016 was used in two international expert consultation meetings, followed by two online surveys. Experts from 10 countries and over 30 organisations contributed.

Results

Six objectives were agreed: (1) to define mental health awareness and service implementation constructs for inclusion in programmes delivered in sporting environments; (2) to identify the need to develop and use valid measures that are developmentally appropriate for use in intervention studies with sporting populations, including measures of mental health that quantify symptom severity but also consider causal and mediating factors that go beyond pathology (ie, well-being and optimisation); (3) to provide guidance on the selection of appropriate models to inform intervention design, implementation and evaluation; (4) to determine minimal competencies of training for those involved in sport to support mental health, those experiencing mental illness and when to refer to mental health professionals; (5) to provide evidence-based guidance for selecting mental health awareness and implementation programmes in sport that acknowledge diversity and are quality assured; and (6) to identify the need for administrators, parents, officials, coaches, athletes and workers to establish important roles in the promotion of mental health in various sports settings.

Conclusion

This article presents a consensus statement on recommended psychosocial and policy-related approaches to mental health awareness programmes in sport.
Cancer as a chronic illness: support needs and experiences
Authors: Boele Florien , Harley Clare , Pini Simon , Kenyon Lucille , Daffu-O'Reilly Amrit , Velikova Galina
Published: September 2019

Objectives

Patients are living longer with active, advanced or metastatic disease that cannot be cured, but may be managed (ie, ‘chronic cancer’). The experiences and needs within this growing group are likely to be different from those shortly after diagnosis, on active curative treatment, or in the palliative or end-of-life phase, yet are poorly defined. We described chronic cancer patient experiences and support needs in a quantitative, multicentre cross-sectional study.

Methods

Patients from five district general hospitals in England completed the 75-item Chronic Cancer Experiences Questionnaire (CCEQ). Responses were described and linear regression analysis was performed to explore the associations between poorer patient experiences and clinical/sociodemographic variables.

Results

In total, 416 patients with prostate cancer (28%), breast cancer (24%), gynaecological cancer (19%), colorectal/gastrointestinal cancer (17%) and renal cancer (12%) completed the CCEQ (response rate 90%). Younger patients, those who had a longer interval between primary and advanced diagnosis and those not in a relationship, had worse experiences (R2=0.098, p<0.05). Cancer-specific symptoms were common, with 80% of participants experiencing fatigue. Areas related to poorest experiences include the coordination of care, general practitioner involvement, coping with limitations, and worries and anxieties.

Conclusions

Psychological burden remains high in the chronic phase of cancer, and patients experience ongoing difficulties in accessing support and services. Younger patients who have been ill for longer and those who have less social support may be particularly vulnerable, and future studies are needed to investigate the best way to meet the unique needs of this growing patient population.
Death at home: predictive factors in a medical home care unit
Authors: Rasch-Westin Martina , Helde-Frankling Maria , Björkhem-Bergman Linda
Published: September 2019

Objectives

The aim of this study was to investigate factors predictive for ‘death at home’ for patients admitted to an advanced medical home care unit in Stockholm, Sweden, with a focus on possible gender differences. In addition, place of death in relation to the patient’s wishes was studied.

Method

A retrospective review of medical records of all 456 deceased patients, 233 men and 223 women, admitted to the unit during 2017 was performed. Data on age, diagnosis, living conditions, Swedish language skills, desired place of death (if stated) and place of death were retrieved from the patients’ charts.

Results

A total of 114 of 456 patients died at home (25%). The probability of ‘death at home’ was independent of gender, age, diagnosis, living conditions and Swedish language skills. In a binary logistic regression model, the only factor significantly associated with death at home was ‘the wish to die at home’ (p<0.001). In the study population, 154 patients (34%) had expressed a preferred place of death, 116 (75%) wanted to die at home and 38 (25%) wanted to die in hospice. Of all patients who expressed a preferred place of death, 80% (n=123) had their wishes fulfilled and there were no differences between the sexes.

Conclusion

This study indicates equal opportunities regarding the possibility to die at home for patients admitted to advanced medical home care. It emphasises the importance of asking patients where they want to be at the end of life, as it was the foremost prognostic factor for place of death.