Commentary on: Carlton E, Kohne J, Shankar-Hari, et al. Readmission diagnoses after paediatric severe sepsis hospitalisation. Crit Care Med 2019;47:583–90.
Children with coexisting comorbidities when discharged following severe sepsis have a higher rate of readmission as compared with matched hospitalisations for other acute medical conditions. There is a need for internationally agreed evidence-based guidelines/consensus paper to minimise post-sepsis readmissions through identification of potentially preventable factors, appropriate discharge criteria and parental education. More research is required into strategies towards prevention of readmissions following discharge after an episode of severe sepsis in children.
Children with coexisting comorbidities when discharged following severe sepsis have a higher rate of readmission as compared with matched hospitalisations for other acute medical conditions.
There is a need for internationally agreed evidence-based guidelines/consensus paper to minimise post-sepsis readmissions through identification of potentially preventable factors, appropriate discharge criteria and parental education.
More research is required into strategies towards prevention of readmissions following discharge after an episode of severe sepsis in children.
Sepsis is a leading cause of avoidable death across all age groups.
To analyse the short-term effects of kinesio taping (KT) with tension (KTT) or without tension (KTNT) in older women with knee osteoarthritis (KOA), and compare them to controls who did not receive KT.
Randomised controlled trial.
University physiotherapy school clinic.
Forty-five older women (fifteen participants per group) with 66.8 (±5.6) years and clinical diagnosis of KOA were assessed pre, post and 3 days after intervention.
Participants were randomly allocated to KTT, who received two simultaneous applications of KT with tension on the knee and rectus femoris; KTNT, who received the same application as the KTT group, but without tension and a control group that attended a class on KOA.
Primary outcome was pain intensity and secondary outcomes were knee-related health status, functional capacity, muscle strength and global rating of change.
No between-group differences were observed in pain after the first intervention (KTT vs KTNT: mean difference (MD), –1.8 points; 95% CI –4.2 to 0.5; KTT vs control: MD, –1.2 points; 95% CI –3.6 to 1.2; KTNT vs control: MD, 0.66 points; 95% CI –1.7 to 3.0) or 3 days later (KTT vs KTNT: MD, –1.3 points; 95% CI –3.7 to 1.0; KTT vs control: MD, 0.13 points; 95% CI –2.2 to 2.5; KTNT vs control: MD, 1.4 points; 95% CI –0.9 to 3.8). The lack of between-group differences was also found for secondary outcomes.
The short-term use of KT with or without tension in older woman with KOA had no beneficial effects on pain and function. These findings call into question the clinical use of KT as a non-pharmacological therapy for this population.
The effects of SARS-CoV-2 in pregnancy are not fully delineated. We will describe the incidence of COVID-19 in pregnancy at population level in Scotland, in a prospective cohort study using linked data. We will determine associations between COVID-19 and adverse pregnancy, neonatal and maternal outcomes and the proportion of confirmed cases of SARS-CoV-2 infection in neonates associated with maternal COVID-19.
Prospective cohort study using national linked data sets. We will include all women in Scotland, UK, who were pregnant on or became pregnant after, 1 March 2020 (the date of the first confirmed case of SARS-CoV-2 infection in Scotland) and all births in Scotland from 1 March 2020 onwards. Individual-level data will be extracted from data sets containing details of all livebirths, stillbirth, terminations of pregnancy and miscarriages and ectopic pregnancies treated in hospital or attending general practice. Records will be linked within the Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II) platform, which includes primary care records, virology and serology results and details of COVID-19 Community Hubs and Assessment Centre contacts and deaths. We will perform analyses using definitions for confirmed, probable and possible COVID-19 and report serology results (where available). Outcomes will include congenital anomaly, miscarriage, stillbirth, termination of pregnancy, preterm birth, neonatal infection, severe maternal disease and maternal deaths. We will perform descriptive analyses and appropriate modelling, adjusting for demographic and pregnancy characteristics and the presence of comorbidities. The cohort will provide a platform for future studies of the effectiveness and safety of therapeutic interventions and immunisations for COVID-19 and their effects on childhood and developmental outcomes.
COVID-19 in Pregnancy in Scotland is a substudy of EAVE II(, which has approval from the National Research Ethics Service Committee. Findings will be reported to Scottish Government, Public Health Scotland and published in peer-reviewed journals.
To examine hospital nurses’ perception of their actual and potential contribution to shared decision‐making about life‐prolonging treatment and their perception of the pre‐conditions for such a contribution.
A qualitative interview study.
Semi‐structured face‐to‐face interviews were conducted with 18 hospital nurses who were involved in care for patients with life‐threatening illnesses. Data were collected from October 2018‐January 2019. The interviews were recorded, transcribed verbatim and analysed using thematic analysis by two researchers.
Nurses experienced varying degrees of influence on decision‐making about life‐prolonging treatment. Besides, we identified different points of contact in the treatment trajectory at which nurses could be involved in treatment decision‐making. Nurses’ descriptions of behaviours that potentially contribute to shared decision‐making were classified into three roles as follows: checking the quality of a decision, complementing shared decision‐making and facilitating shared decision‐making. Pre‐conditions for fulfilling the roles identified in this study were: (a) the transfer of information among nurses and between nurses and other healthcare professionals; (b) a culture where there is a positive attitude to nurses' involvement in decision‐making; (c) a good relationship with physicians; (d) knowledge and skills; (e) sufficient time; and (f) a good relationship with patients.
Nurses described behaviour that reflected a supporting role in shared decision‐making about patients’ life‐prolonging treatment, although not all nurses experienced this involvement as such. Nurses can enhance the shared decision‐making process by checking the decision quality and by complementing and facilitating shared decision‐making.
Nurses are increasingly considered instrumental in the shared decision‐making process. To facilitate their contribution, future research should focus on the possible impact of nurses’ involvement in treatment decision‐making and on evidence‐based training to raise awareness and offer guidance for nurses on how to adopt this role.
Trauma registries are an integral part of a well-organised trauma system. Tanzania, like many low and middle-income countries, does not have a trauma registry. We describe the development, structure, implementation and impact of a context appropriate standardised trauma form based on the adaptation of the WHO Data Set for Injury (DSI), for clinical documentation and use in a national trauma registry.
Our study was conducted in emergency units of five regional referral hospitals in Tanzania.
Mixed methods participatory action research was employed. After an assessment of baseline trauma documentation, we conducted semi-structured interviews with a purposefully selected sample of 33 healthcare providers from all participating hospitals to understand, develop, pilot and implement a standardised trauma form. We compared the number and types of variables captured before and after the form was implemented.
Change in proportion of variables of DSI captured after implementation of a standardised trauma documentation form.
Piloting and feedback informed the development of a context appropriate standardised trauma documentation paper form with carbonless copy that could be used as both the clinical chart and data capture. Among 721 patients (seen by 21 clinicians) during the initial 30-day pilot, overall variable capture was 86.4% of required variables. After modifications of the form and training of healthcare providers, the form was implemented for 7 months, during which the capture improved to 96.3% among 6302 patients (seen by 31 clinicians). The providers reported the form was user-friendly, resulted in less time documenting, and served as a guide to managing trauma patients.
The development and implementation of a contextually appropriate, standardised trauma form were successful, yielding increased capture rates of injury variables. This system will facilitate expansion of the trauma registry across the country and inform similar initiatives in Sub-Saharan Africa.
Ovarian cancer is the eighth most common cancer in women worldwide, and about 1 in 5 women with ovarian cancer do not receive treatment, because they are too unwell by the time they are diagnosed. Symptoms of ovarian cancer are non-specific or can be associated with other common conditions, and women experiencing these symptoms have been shown to self-manage them using over-the-counter medication. Results from a recent proof-of-concept study suggest there may be an increase in the purchases of painkillers and indigestion medication 10–12 months before ovarian cancer diagnosis. We propose a case–control study, as part of a larger project called the Cancer Loyalty Card Study (CLOCS), to investigate whether a significant change in medication purchases could be an indication for early signs of ovarian cancer, using data already collected through store loyalty cards.
Using a retrospective case–control design, we aim to recruit 500 women diagnosed with ovarian cancer (cases) and 500 women without ovarian cancer (controls) in the UK who hold a loyalty card with at least one participating high street retailer. We will use pre-existing loyalty card data to compare past purchase patterns of cases with those of controls. In order to assess ovarian cancer risk in participants and their purchase patterns, we will collect information from participants on ovarian cancer risk factors and clinical data including symptoms experienced before diagnosis from recruited women with ovarian cancer.
CLOCS was reviewed and approved by the North West-Greater Manchester South Research Ethics Committee (19/NW/0427). Study outcomes will be disseminated through academic publications, the study website, social media and a report to the research sites that support the study once results are published.
ISRCTN 14897082, CPMS 43323, NCT03994653.
To determine current tobacco use in 2018/2019, quit attempts made and to explore the enablers and barriers in quitting tobacco among tobacco users identified in the Tamil Nadu Tobacco Survey (TNTS) in 2015/2016.
TNTS was conducted in 2015/2016 throughout the state of Tamil Nadu (TN) in India covering 111 363 individuals. Tobacco prevalence was found to be 5.2% (n=5208).
All tobacco users in 11 districts of TN identified by TNTS (n=2909) were tracked after 3 years by telephone. In-depth interviews (n=26) were conducted in a subsample to understand the enablers and barriers in quitting.
Current tobacco use status, any quit attempt and successful quit rate were the primary outcomes, while barriers and enablers in quitting were considered as secondary outcomes.
Among the 2909 tobacco users identified in TNTS 2015/2016, only 724 (24.9%) could be contacted by telephone, of which 555 (76.7%) consented. Of those who consented, 210 (37.8%) were currently not using tobacco (ie, successfully quit) and 337 (60.7%) continued to use any form of tobacco. Of current tobacco users, 115 (34.1%) have never made any attempt to quit and 193 (57.3.8%) have made an attempt to quit. Those using smoking form of tobacco products (adjusted relative risk (aRR)=1.2, 95% CI: 1.1 to 1.4) and exposure to smoke at home (aRR=1.2, 95% CI: 1.1 to 1.3) were found to be positively associated with continued tobacco use (failed or no quit attempt). Support from family and perceived health benefits are key enablers, while peer influence, high dependence and lack of professional help are some of the barriers to quitting.
Two-thirds of the tobacco users continue to use tobacco in the last 3 years. While tobacco users are well aware of the ill-effects of tobacco, various intrinsic and extrinsic factors play a major role as a facilitator and lack of the same act as a barrier to quit.
by Robin S. Cronin, Jessica Wilson, Adrienne Gordon, Minglan Li, Vicki M. Culling, Camille H. Raynes-Greenow, Alexander E. P. Heazell, Tomasina Stacey, Lisa M. Askie, Edwin A. Mitchell, John M. D. Thompson, Lesley M. E. McCowan, Louise M. O’BrienBackground and objectives
Sleep-disordered breathing (SDB) affects up to one third of women during late pregnancy and is associated with adverse pregnancy outcomes, including hypertension, diabetes, impaired fetal growth, and preterm birth. However, it is unclear if SDB is associated with late stillbirth (≥28 weeks’ gestation). The aim of this study was to investigate the relationship between self-reported symptoms of SDB and late stillbirth.Methods
Data were obtained from five case-control studies (cases 851, controls 2257) from New Zealand (2 studies), Australia, the United Kingdom, and an international study. This was a secondary analysis of an individual participant data meta-analysis that investigated maternal going-to-sleep position and late stillbirth, with a one-stage approach stratified by study and site. Inclusion criteria: singleton, non-anomalous pregnancy, ≥28 weeks’ gestation. Sleep data (‘any’ snoring, habitual snoring ≥3 nights per week, the Berlin Questionnaire [BQ], sleep quality, sleep duration, restless sleep, daytime sleepiness, and daytime naps) were collected by self-report for the month before stillbirth. Multivariable analysis adjusted for known major risk factors for stillbirth, including maternal age, body mass index (BMI kg/m2), ethnicity, parity, education, marital status, pre-existing hypertension and diabetes, smoking, recreational drug use, baby birthweight centile, fetal movement, supine going-to-sleep position, getting up to use the toilet, measures of SDB and maternal sleep patterns significant in univariable analysis (habitual snoring, the BQ, sleep duration, restless sleep, and daytime naps). Registration number: PROSPERO, CRD42017047703.Results
In the last month, a positive BQ (adjusted odds ratio [aOR] 1.44, 95% confidence interval [CI] 1.02–2.04), sleep duration >9 hours (aOR 1.82, 95% CI 1.14–2.90), daily daytime naps (aOR 1.52, 95% CI 1.02–2.28) and restless sleep greater than average (aOR 0.62, 95% CI 0.44–0.88) were independently related to the odds of late stillbirth. ‘Any’ snoring, habitual snoring, sleep quality, daytime sleepiness, and a positive BQ excluding the BMI criterion, were not associated.Conclusion
A positive BQ, long sleep duration >9 hours, and daily daytime naps last month were associated with increased odds of late stillbirth, while sleep that is more restless than average was associated with reduced odds. Pregnant women may be reassured that the commonly reported restless sleep of late pregnancy may be physiological and associated with a reduced risk of late stillbirth.
This paper aims to investigate resident, facility and country characteristics associated with length of stay in long-term care facilities (LTCFs) across six European countries.
Data from a cross-sectional study of deceased residents, conducted in LTCFs in Belgium, England, Finland, Italy, the Netherlands and Poland.
All residents aged 65 years and older at admission who died in a 3-month period residing in a proportional random sample of LTCFs were included.
The primary outcome was length of stay in days, calculated from date of admission and date of death. Resident, facility and country characteristics were included in a proportional hazards model.
The proportion of deaths within 1 year of admission was 42% (range 32%–63%). Older age at admission (HR 1.04, 95% CI 1.03 to 1.06), being married/in a civil partnership at time of death (HR 1.47, 95% CI 1.13 to 1.89), having cancer at time of death (HR 1.60, 95% CI 1.22 to 2.10) and admission from a hospital (HR 1.84, 95% CI 1.43 to 2.37) or another LTCF (HR 1.81, 95% CI 1.37 to 2.40) were associated with shorter lengths of stay across all countries. Being female (HR 0.72, 95% CI 0.57 to 0.90) was associated with longer lengths of stay.
Length of stay varied significantly between countries. Factors prior to LTCF admission, in particular the availability of resources that allow an older adult to remain living in the community, appear to influence length of stay. Further research is needed to explore the availability of long-term care in the community prior to admission and its influence on the trajectories of LTCF residents in Europe.
A relevant subsample of patients with chronic low back pain (CLBP) have manifested augmented central pain processing, central sensitisation (CS). Patients with CLBP have limited functioning and participation. Theoretically, physical functioning in patients with CLBP can plausibly be linked to CS; however, evidence to explain such association is scarce. Moreover, there is no gold standard for CS diagnosis. The objectives of the study are: (1) to analyse the association between instruments assessing reference symptoms and signs attributed to CS; (2) to analyse whether reference symptoms and signs attributed to CS are associated with functioning measurement outcomes; and (3) to analyse whether changes (between baseline and discharge) in reference symptoms and signs attributed to CS are related to changes in each of the functioning measurement outcomes.
A cross-sectional and longitudinal observational study is performed with measurements taken at baseline and discharge of an interdisciplinary rehabilitation programme. A sample size of 110 adult patients with CLBP has been calculated for the study. CS measurements are: Central Sensitisation Inventory, quantitative sensory testing and heart rate variability. Functioning measurements are: lifting capacity, maximal aerobic capacity, accelerometry and reported functioning. Statistical analyses to be performed are: (1) correlation between CS measurements, (2) multiple regression between functioning (dependent variable) and CS measurements (independent variable), and (3) multiple regression between changes in scores of functioning (dependent variable) and CS measurements (independent variable), and corrected for sex and age.
The study obtained the clearance to its implementation from the Medical Research Ethics Committee of the University Medical Center Groningen in July 2017. The results will be disseminated through scientific publications in peer-reviewed journals, presentations at relevant conferences, and reports to stakeholders.
Sputum smear microscopy is the cornerstone of tuberculosis (TB) diagnosis under the Revised National Tuberculosis Control Programme (RNTCP) in India. Instructions on how to produce a good sputum sample are a part of RNTCP training manuals, but its assessment is not emphasised. Healthcare provider’s instruction to expectorate a good sputum sample has limitations. Presumptive TB patients often submit inadequate (in quantity and/or quality) sputum samples, which may result in false-negative results. Objectives of the study are, among the selected RNTCP designated microscopy centres in Dakshina Kannada district, Karnataka, India, (a) to assess the effectiveness of mobile phone instructional video demonstrating sputum expectoration on sputum quality and quantity and (b) to explore the mobile phone video implementation challenges as perceived by the healthcare providers.
This is a pragmatic, prospective, non-randomised controlled trial in two pairs of RNTCP Designated Microscopy Centres (located at secondary and primary healthcare facilities) of Dakshina Kannada district, India. Presumptive pulmonary TB patients aged ≥18 years will be included. We will exclude who are severely ill, blind, hearing impaired, patients who have already brought their sputum for examination, and transported sputum. In the intervention group, participants will watch a mobile phone instructional video demonstrating submission of an adequate sputum sample. The control group will follow the usual ongoing procedure for sputum submission. This study would require 406 participants for each group to achieve a power of 90% for detecting a difference of 15% between the two groups. The participant enrolment started in December 2019.
Yenepoya University Ethics Committee, Mangaluru, India, has approved the study protocol (YEC-1/158/2019). It complies with the Declaration of Helsinki, local laws, and the International Council for Harmonization-good clinical practices. Investigators will present the results in scientific forums, publish in a scientific journal, and share with RNTCP officers.
Clinical Trial Registry of India (CTRI/2019/06/019887).
South Korea regards tuberculosis (TB) incidence in congregate settings as a serious problem. To this end, systematic latent TB infection (LTBI) diagnosis and treatment were provided to approximately 1.2 million individuals in high-risk congregate settings.
We designed a prospective cohort study of individuals tested for LTBI, based on the data collected on all persons screened for LTBI as part of the 2017 congregate settings programme in South Korea. Four types of databases are kept: LTBI screening database (personal information and LTBI test results), national health information (NHI) database (socio-demographic data and comorbidities), public healthcare information system (PHIS) database, and the Korean national TB surveillance system database (TB outcomes). Information regarding LTBI treatment at private hospitals and public health centres is collected from NHI and PHIS databases, respectively. The screening data are cleaned, duplicates are removed, and, where appropriate, re-coded to analyse specific exposures and outcomes. The primary objective is to compare the number of active TB cases prevented within 2 years between participants undergoing treatment and not undergoing treatment in the LTBI screening programme in congregate settings. Cascade of care for LTBI diagnosis and treatment will be evaluated among those with a positive LTBI test result. A Cox proportional hazards model will be applied to determine the risk factors for developing active TB.
The protocol is approved by the institutional review boards of Incheon St. Mary’s Hospital, the Catholic University of Korea. Study results will be disseminated through peer-reviewed journals and conference presentations.
To understand clinical reasoning and decision‐making of triage nurses during telephone conversations with callers suspected of having acute cardiac events, and support from a computer decision support system (CDSS) herewith.
In telephone triage, nurses assess the urgency of callers’ conditions with clinical reasoning, often supported by CDSS. The use of CDSS may trigger interactional workability dilemmas.
Qualitative study using principles of a grounded theory approach following COREQ criteria for qualitative research.
Audio‐stimulated recall interviews were conducted amongst twenty‐four telephone triage nurses at nine out‐of‐hours primary care centres (OHS‐PC).
Telephone triage nurses use clinical reasoning elements for urgency assessment. Typically in telephone triage, they interpret the vocal—but not worded—elements in communication (paralanguage) such as tone of voice and shortness of breath and create a mental image to compensate for lack of visual information. We confirmed that interactional workability dilemmas occur. Congruence, established when the CDSS supports the triage nurses’ decision‐making, is essential for the CDSS’ value. If congruence is absent, triage nurses may apply four working strategies: (a) tinker to make CDSS final recommendation align with their own assessment, (b) overrule the CDSS recommendation, (c) comply with the CDSS recommendation or (d) transfer responsibility to the GP.
Triage nurses who assess urgency may experience absence of congruence between the CDSS and their decision‐making. Awareness of how triage nurses reason and make decisions about urgency and what aspects influence their working strategies can help in achieving optimal triage of callers suspected of acute cardiac events at OHS‐PC.
Triage nurses’ reasoning and their working strategies are vital for outcome of triage decisions. Understanding these processes is essential for CDSS developers and OHS‐PC managers, who should value how triage nurses interact with the CDSS, while they have the benefit of callers in mind.
To evaluate the effects of anaesthesia on postoperative outcome in elderly patients who underwent hip fracture surgery.
Nationwide National Health Insurance Sharing Service database of Korea.
All patients aged ≥65 years old who underwent hip fracture surgery, covered by the Korean National Health Insurance, between 1 January 2009 and 31 December 2015.
Hip fracture surgery under general anaesthesia (group GA) or regional anaesthesia (group RA), with a principal diagnosis of femoral fracture.
The primary outcome was the anaesthetic-type effect on 30-day mortality and the secondary outcome was postoperative delirium requiring pharmacological intervention.
Among the 96 289 patients who underwent hip fracture surgery, 25 593 and 70 696 patients received GA and RA, respectively. After propensity score matching, 25 593 remained in each group. Postmatching mortality was lower in the RA than in the GA group (574 (2.24%) vs 654 (2.55%), p=0·0047, 95% CI –0.0099 to 0.0159). Delirium incidence was lower in the RA than in the GA group (5187 (20.27%) vs 5828 (22.77%), p
RA was associated with better outcomes than GA, in terms of mortality, delirium, intensive care unit admission and ventilator care, in elderly patients who underwent hip fracture surgery.
To assess a targeted ‘therapy as required’ model of post-discharge outpatient physiotherapy provision. Specifically, we investigated what proportion of patients accessed post-discharge physiotherapy following total hip arthroplasty (THA) and total knee arthroplasty (TKA), whether accessing therapy was associated with post-arthroplasty patient reported outcomes and whether it was possible to predict which patients would access post-discharge physiotherapy from pre-operative data.
Prospective, observational, longitudinal cohort study.
Single National Health Service orthopaedic teaching hospital in the UK.
1395 patients undergoing total hip arthroplasty and 1374 patients undergoing total knee arthroplasty.
Self-reported access of post-discharge physiotherapy, the Oxford Hip or Knee Score, EuroQol 5-dimension questionnaire and post-operative surgical episode satisfaction metric.
662 (48.2%) patients with TKA and 493 (35.3%) patients with THA accessed additional post-discharge physiotherapy. Patient-reported outcomes (p
In a choice-based service model of ‘therapy as required’ following hip and knee arthroplasty only a third of THA and half of TKA patients accessed post-discharge therapy. Patients who did not access physiotherapy reported greater post-operative outcomes. This variation in the need for post-discharge physiotherapy suggests that targeting of rehabilitation may be a cost-effective model, however it was not possible to reliably predict which patients would access post-discharge physiotherapy from pre-operative data.
The Buffalo Osteoporosis and Periodontal Disease (OsteoPerio) study is a prospective cohort study focused on the relationship between the microbiome and oral and systemic health outcomes in postmenopausal women. The cohort was established to examine how the oral microbiome is affected by (and how it affects) periodontal disease presence, severity and progression and to characterise the relationship between the microbiome, lifestyle habits and systemic disease outcomes.
Participants (n=1342) were postmenopausal women who were participating in the Women’s Health Initiative observational study at the Buffalo, New York clinical centre. There were 1026 participants at the 5-year follow-up visit and 518 at the 15-year visit.
Data collected include questionnaires, anthropometric measures, serum blood and saliva samples. At each clinic visit, participants completed a comprehensive oral examination to measure oral health and the oral microbiome. Preliminary findings have contributed to our understanding of risk factors for periodontal disease and the relationship between the oral microbiome and periodontal disease.
The novel microbiome data collected on a large sample of participants at three time points will be used to answer a variety of research questions focused on temporal changes in the microbiome and the relationship between the oral microbiome and oral and systemic disease outcomes. Little is currently known about the relationship between the oral microbiome and health outcomes in older adults; data from the OsteoPerio cohort will fill this gap. Microbiome samples are currently being analysed using next-generation sequencing technology with an anticipated completion date of late 2018.