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Quality and safety indicators for home care recipients in Australia: development and cross-sectional analyses

Por: Caughey · G. E. · Lang · C. E. · Bray · S. C. E. · Sluggett · J. K. · Whitehead · C. · Visvanathan · R. · Evans · K. · Corlis · M. · Cornell · V. · Barker · A. L. · Wesselingh · S. · Inacio · M. C.
Objectives

To develop and examine the prevalence of quality and safety indicators to monitor care of older Australians receiving home care packages (HCPs), a government-funded aged care programme to support individuals to live at home independently.

Design

Cross-sectional.

Setting

Home care recipients, Australia.

Participants

90 650 older individuals (aged ≥65 years old and ≥50 years old for people of Aboriginal or Torres Strait Islander descent) who received a HCP between 1 January 2016 and 31 December 2016 nationally were included.

Primary and secondary outcome measures

The Registry of Senior Australians developed 15 quality and safety indicators: antipsychotic use, high sedative load, chronic opioid use, antimicrobial use, premature mortality, home medicines reviews, chronic disease management plan, wait-time for HCP, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium/dementia-related hospitalisations, emergency department (ED) presentations and pressure injuries. Risk adjusted prevalence (%, 95% CI) and geographical area (statistical level 3) variation during 2016 were examined.

Results

In 2016, a total of 102 590 HCP episodes were included for 90 650 individuals, with 66.9% (n=68 598) level 1–2 HCP episodes (ie, for basic care needs) and 33.1% (n=33 992) level 3–4 HCP (ie, higher care needs). The most prevalent indicators included: antibiotic use (52.4%, 95% CI 52.0 to 52.7), chronic disease management plans (38.1%, 95% CI 37.8 to 38.4), high sedative load (29.1%, 95% CI 28.8 to 29.4) and ED presentations (26.4%, 95% CI 25.9 to 26.9). HCP median wait time was 134 days (IQR 41–406). Geographical variation was highest in chronic disease management plans and ED presentations (20.7% of areas outside expected range).

Conclusion

A comprehensive outcome monitoring system to monitor the quality and safety of care and variation for HCP recipients was developed. It provides a pragmatic, efficient and low burden tool to support evidence-based quality and safety improvement initiatives for the aged care sector.

The viability and acceptability of a Virtual Wound Care Command Centre in Australia

Abstract

The objective of this study was to assess the viability and acceptability of an innovative Virtual Wound Care Command Centre where patients in the community, and their treating clinicians, have access to an expert wound specialist service that comprises a digitally enabled application for wound analysis, decision-making, remote consultation, and monitoring. Fifty-one patients with chronic wounds from 9 centres, encompassing hospital services, outpatient clinics, and community nurses in one metropolitan and rural state in Australia, were enrolled and a total of 61 wounds were analysed over 7 months. Patients received, on average, an occasion of service every 4.4 days, with direct queries responded to in a median time of 1.5 hours. During the study period, 26 (42.6%) wounds were healed, with a median time to healing of 66 (95% CI: 56-88) days. All patients reported high satisfaction with their wound care, 86.4% of patients recommended the Virtual Wound Care Command Centre with 84.1% of patients reporting the digital wound application as easy to use. Potential mean travel savings of $99.65 for rural patients per visit were recognised. The data revealed that the Virtual Wound Care Command Centre was a viable and acceptable patient-centred expert wound consultation service for chronic wound patients in the community.

Title of research article: An exploration of nurses' knowledge, attitudes and intentions regarding restraint use in elderly residential care facilities

Abstract

Purpose

In Ireland, there is a regulatory focus on restraint minimisation in elderly residential care facilities. Consistent with this focus, this study aimed to explore and identify the relationship between nurses' knowledge levels, attitudes and intentions regarding physical restraint use in two large Irish elderly residential care facilities.

Design

A correlational and cross-sectional survey design was used to collect data on variables including nurses' education levels, years of experience and intentions toward restraint utilization.

Methods

Data was obtained from a sample of 83 nurses in early 2020 via an anonymous, adapted survey measuring knowledge, attitude and intentions.

Results

Results showed high knowledge levels, negative attitudes toward restraint implementation, and moderate mean intention scores. A significant positive relationship existed between knowledge and attitudes, with both variables negatively predicting intentions regarding restraint. Education was significant in predicting knowledge and attitudes; however, years of experience reported no such findings.

Conclusion

Knowledge and attitudes negatively predict nurses' intentions toward restraint, with attitude being the stronger predictor of intentions. Falls risk caused the greatest variation in intention scores.

Clinical Relevance

This research offered a seminal study providing insight into the use of restraints in an Irish context with findings that are in line with international research. It highlights the importance of knowledge and attitudes along with education with understanding intentions to use restraints. Furthermore this research demonstrates a useful instrument in the assessment of nurses' knowledge, attitudes, and intentions in Irish elderly residential care facilities, which can possibly be used in other settings.

NANDA International nursing diagnoses in the coping/stress tolerance domain and their linkages to Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions in the pre‐hospital emergency care

Abstract

Aim

To determine the prevalence of NANDA International nursing diagnoses in the coping/stress tolerance domain and their linkages to Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions in the pre-hospital emergency care setting.

Design

Retrospective descriptive study of electronic record review.

Methods

Eight thousand three hundred three episodes recorded during the year 2019 were recovered from the electronic health records of a public emergency care agency. The prevalence of NANDA International nursing diagnosis, Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions was determined. A cross-tabulation analysis was performed to determine the linkages. Data were accessed in November 2020.

Results

NANDA International nursing diagnoses Anxiety (00146) and Fear (00148) represented more than 90% of the diagnoses recorded in the domain. Anxiety level (1211) and emotional support (5270) were the most recorded Nursing Outcomes Classification outcomes and Nursing Interventions Classification interventions, with almost 20% and 5% of total records, respectively. The linkage between nursing diagnosis Anxiety (00146), outcome Anxiety level (1211) and intervention Anxiety reduction (5820) was the most recorded with slightly more than 3% of the total.

Conclusion

Eight different NANDA International nursing diagnoses in the coping/stress tolerance domain were recorded. Nursing Outcomes Classification outcomes were selected aimed mainly at psychological well-being and Nursing Interventions Classification interventions to support coping. In general, linkages were aimed to provide emotional support, physical well-being, information, education and safety.

Impact

This study showed that pre-hospital emergency care nurses diagnose and treat human responses in the coping/stress tolerance domain. Expert consensus-based linkages may be complemented by the results of this study, increasing the levels of evidence of both individualized and standardized care plans for critical patients assisted by pre-hospital emergency care nurses.

Glial-modulating agents for the treatment of pain: protocol for a systematic review

Por: Gilron · I. · Xiao · M. Z. X. · Balanaser · M. · Carley · M. · Ghasemlou · N. · Salter · M. W. · Hutchinson · M. R. · Moulin · D. E. · Moore · R. A. · Ross-White · A.
Introduction

Evidence suggests a role for Central nervous system glia in pain transmission and in augmenting maladaptive opioid effects. Identification of drugs that modulate glia has guided the evaluation of glial suppression as a pain management strategy. This planned systematic review will describe evidence of the efficacy and adverse effects of glial-modulating drugs in pain management.

Methods and analysis

A detailed search will be conducted on the Cochrane Central Register of Controlled Trials, Medline, and Embase from their inception until the date the final searches are run to identify relevant randomised controlled trials. The reference lists of retrieved studies, as well as online trial registries, will also be searched. English language, randomised, double-blind trials comparing various glial-modulating drugs with placebo and/or other comparators, with participant-reported pain assessment, will be included. Two reviewers will independently evaluate studies for eligibility, extract data and assess trial quality and potential bias. Risk of bias will be assessed using criteria outlined in the Cochrane Handbook for Systematic Review of Interventions. Primary outcomes for this review will include any validated measure of pain intensity and/or pain relief. Dichotomous data will be used to calculate risk ratio and number needed to treat or harm. The quality of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation.

Ethics and dissemination

This systematic review does not require formal ethics approval. The findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO registration number

CRD42021262074.

Prognostic decision-making about imminent death within multidisciplinary teams: a scoping review

Por: Bruun · A. · Oostendorp · L. · Bloch · S. · White · N. · Mitchinson · L. · Sisk · A.-R. · Stone · P.
Objective

To summarise evidence on how multidisciplinary team (MDTs) make decisions about identification of imminently dying patients.

Design

Scoping review.

Setting

Any clinical setting providing care for imminently dying patients, excluding studies conducted solely in acute care settings.

Data sources

The databases AMED, CINAHL, Embase, MEDLINE, PsychINFO and Web of Science were searched from inception to May 2021.

Included studies presented original study data written in English and reported on the process or content of MDT discussions about identifying imminently dying adult patients.

Results

40 studies were included in the review. Studies were primarily conducted using interviews and qualitative analysis of themes.

MDT members involved in decision-making were usually doctors and nurses. Some decisions focused on professionals recognising that patients were dying, other decisions focused on initiating specific end-of-life care pathways or clarifying care goals. Most decisions provided evidence for a partial collaborative approach, with information-sharing being more common than joint decision-making. Issues with decision-making included disagreement between staff members and the fact that doctors were often regarded as final or sole decision-makers.

Conclusions

Prognostic decision-making was often not the main focus of included studies. Based on review findings, research explicitly focusing on MDT prognostication by analysing team discussions is needed. The role of allied and other types of healthcare professionals in prognostication needs further investigation as well. A focus on specialist palliative care settings is also necessary.

A feasibility study evaluating the uptake, effectiveness and acceptability of routine screening of pregnant migrants for latent tuberculosis infection in antenatal care: a research protocol

Por: Rahman · A. · Thangaratinam · S. · Copas · A. · Zenner · D. · White · P. J. · Griffiths · C. · Abubakar · I. · McCourt · C. · Kunst · H.
Introduction

Globally, tuberculosis (TB) is a leading cause of death in women of reproductive age and there is high risk of reactivation of latent tuberculosis infection (LTBI) in pregnancy. The uptake of routine screening of migrants for LTBI in the UK in primary care is low. Antenatal care is a novel setting which could improve uptake and can lend insight into the feasibility and acceptability of offering opt-out screening for LTBI.

Methods and analysis

This is an observational feasibility study with a nested qualitative component. The setting will be the antenatal clinics in three hospitals in East London, UK . Inclusion criteria are pregnant migrant women aged 16–35 years attending antenatal clinics who are from countries with a TB incidence of greater than 150/100 000 including sub-Saharan Africa, and who have been in the UK for less than 5 years. Participants will be offered LTBI screening with an opt-out interferon gamma release assay blood test, and be invited to complete a questionnaire. Both participants and healthcare providers will be invited to participate in semistructured interviews or focus groups to evaluate understanding, feasibility and acceptability of routine opt-out LTBI screening. The primary analysis will focus on estimating the uptake of the screening programme along with the corresponding 95% CI. Secondary analysis will focus on estimating the test positivity. Qualitative analysis will evaluate the acceptability of offering routine opt-out LTBI screening to participants and healthcare providers.

Ethics and dissemination

The study has received the following approvals: Health Research Authority (IRAS 247388) and National Health Service Ethics Committee (19/LO/0557). The results will be made available locally to antenatal clinics and primary care physicians, nationally to NHS England and Public Health England and internationally through conferences and journals.

Trial registration number

NCT04098341.

Testing and treatment for latent tuberculosis infection in people living with HIV and substance dependence: a prospective cohort study

Por: Runels · T. · Ragan · E. J. · Ventura · A. S. · Winter · M. R. · White · L. F. · Horsburgh · C. R. · Samet · J. H. · Saitz · R. · Jacobson · K. R.
Objective

To quantify the proportion of people living with HIV (PLWH) with other tuberculosis (TB) risk factors that completed the latent tuberculosis infection (LTBI) care cascade and describe factors associated with attrition. The care cascade was defined as follows: (1) receipt of an LTBI test and result, (2) initiation of LTBI treatment and (3) completion of LTBI treatment.

Design

Prospective cohort study.

Setting

Reactivation of LTBI remains a large source of active TB disease in the USA. PLWH and those who use substances are at greater risk and are harder to engage and retain in care.

Participants

Participants enrolled in a Boston cohort of PLWH from 2012 to 2014.

Primary and secondary outcome measures

Our primary outcome was the number and proportion of participants who completed each stage of the cascade and the factors associated with completing each stage. Our secondary outcomes were differences between participants tested with an interferon gamma release assay (IGRA) versus tuberculin skin test and differences between participants who tested positive versus negative for LTBI.

Results

Only 189 of 219 (86.3%) participants completed testing. Five of the 11 with LTBI initiated and three completed treatment. Participants tested with an IGRA were more likely to complete testing (OR 3.87, 95% CI 1.05 to 14.30) while among participants successfully tested, being foreign-born was associated with a positive test result (OR 3.95; 95% CI 1.13 to 13.77).

Conclusions

Although the majority completed LTBI testing, our findings warrant further investigation in a larger cohort to better understand factors that lead to suboptimal treatment initiation and completion in a low-burden country.

Characteristics associated with COVID-19 vaccine uptake among adults aged 50 years and above in England (8 December 2020-17 May 2021): a population-level observational study

Por: Tessier · E. · Rai · Y. · Clarke · E. · Lakhani · A. · Tsang · C. · Makwana · A. · Heard · H. · Rickeard · T. · Lakhani · S. · Roy · P. · Edelstein · M. · Ramsay · M. · Lopez-Bernal · J. · White · J. · Andrews · N. · Campbell · C. N. J. · Stowe · J.
Objective

To determine characteristics associated with COVID-19 vaccine coverage among individuals aged 50 years and above in England since the beginning of the programme.

Design

Observational cross-sectional study assessed by logistic regression and mean prevalence margins.

Setting

COVID-19 vaccinations delivered in England from 8 December 2020 to 17 May 2021.

Participants

30 624 257/61 967 781 (49.4%) and 17 360 045/61 967 781 (28.1%) individuals in England were recorded as vaccinated in the National Immunisation Management System with a first dose and a second dose of a COVID-19 vaccine, respectively.

Interventions

Vaccination status with COVID-19 vaccinations.

Main outcome measures

Proportion, adjusted ORs and mean prevalence margins for individuals not vaccinated with dose 1 among those aged 50–69 years and dose 1 and 2 among those aged 70 years and above.

Results

Of individuals aged 50 years and above, black/African/Caribbean ethnic group was the least likely of all ethnic groups to be vaccinated with dose 1 of the COVID-19 vaccine. However, of those aged 70 years and above, the odds of not having dose 2 was 5.53 (95% CI 5.42 to 5.63) and 5.36 (95% CI 5.29 to 5.43) greater among Pakistani and black/African/Caribbean compared with white British ethnicity, respectively. The odds of not receiving dose 2 was 1.18 (95% CI 1.16 to 1.20) higher among individuals who lived in a care home compared with those who did not. This was the opposite to that observed for dose 1, where the odds of being unvaccinated was significantly higher among those not living in a care home (0.89 (95% CI 0.87 to 0.91)).

Conclusions

We found that there are characteristics associated with low COVID-19 vaccine coverage. Inequalities, such as ethnicity are a major contributor to suboptimal coverage and tailored interventions are required to improve coverage and protect the population from SARS-CoV-2.

Diagnostic features, management and prognosis of type 2 myocardial infarction compared to type 1 myocardial infarction: a systematic review and meta-analysis

Por: White · K. · Kinarivala · M. · Scott · I.
Importance

Distinguishing type 2 (T2MI) from type 1 myocardial infarction (T1MI) in clinical practice can be difficult, and the management and prognosis for T2MI remain uncertain.

Objective

To compare precipitating factors, risk factors, investigations, management and outcomes for T2MI and T1MI.

Data sources

Medline and Embase databases as well as reference list of recent articles were searched January 2009 to December 2020 for term ‘type 2 myocardial infarction’.

Study selection

Studies were included if they used a universal definition of MI and reported quantitative data on at least one variable of interest.

Data extraction and synthesis

Data were pooled using random-effect meta-analysis. Risk of bias was assessed using Newcastle-Ottawa quality assessment tool. Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed. All review stages were conducted by two reviewers.

Main outcomes and measures

Risk factors, presenting symptoms, cardiac investigations such as troponin and angiogram, management and outcomes such as mortality.

Results

40 cohort studies comprising 98 930 patients with T1MI and 13 803 patients with T2MI were included. Compared with T1MI, patients with T2MI were: more likely to have pre-existing chronic kidney disease (OR 1.87; 95% CI 1.53 to 2.28) and chronic heart failure (OR 2.35; 95% CI 1.82 to 3.03), less likely to present with typical cardiac symptoms of chest pain (OR 0.19; 95% CI 0.13 to 0.26) and more likely to present with dyspnoea (OR 2.64; 95% CI 1.86 to 3.74); more likely to demonstrate non-specific ST-T wave changes on ECG (OR 2.62; 95% CI 1.81 to 3.79) and less likely to show ST elevation (OR 0.22; 95% CI 0.17 to 0.28); less likely to undergo coronary angiography (OR 0.09; 95% CI 0.06 to 0.12) and percutaneous coronary intervention (OR 0.06; 95% CI 0.04 to 0.10) or receive cardioprotective medications, such as statins (OR 0.25; 95% CI 0.16 to 0.38) and beta-blockers (OR 0.45; 95% CI 0.33 to 0.63). T2MI had greater risk of all cause 1-year mortality (OR 3.11; 95% CI 1.91 to 5.08), with no differences in short-term mortality (OR 1.34; 95% CI 0.63 to 2.85).

Conclusion and relevance

This review has identified clinical, management and survival differences between T2MI and T1MI with greater precision and scope than previously reported. Differential use of coronary revascularisation and cardioprotective medications highlight ongoing uncertainty of their utility in T2MI compared with T1MI.

The reported external traumas among people with diabetes‐related foot ulcers and their outcomes: A systematic review of case reports

Abstract

The objective of this systematic review was to collate evidence published in case reports on the reported origins of external traumas that contribute to the development of diabetic foot ulcers and their outcomes. The review also aimed to suggest reporting criteria for external traumas contributing to the development of diabetic foot ulcers. The search strategy led to the identification of 1224 articles across six electronic databases. Additional articles were also sourced from other electronic platforms (Google scholar) and the reference lists of the included case reports. Ninety-four articles met the inclusion criteria and were published between 1989 and 2020. The included case reports were independently assessed for methodological quality using a Joanna Briggs Institute (JBI) checklist. Following the verbatim extraction of data, the JBI three steps approach to “meta-aggregation” for managing qualitative data was used to synthesise the data on external traumas that contributed to the development of foot ulcers along with the reported outcome. Information on the included case report characteristics was also extracted. The case reports included 155 patients. Average age was 57.2 years with a range from 17 to 86 years. External traumas were mainly experienced in the domestic setting and were categorised into two main categories, mechanical trauma (n = 87, 60%) or burns (n = 58, 40%). The most frequently reported origins of external trauma were contact with a hot surface, animal bites, friction, and puncture wounds. Although healing was the most frequent outcome, a prolonged time was recorded for the ulcers to heal highlighting the importance of prevention. Prevention might not eradicate origins of external trauma 100%, showing the importance of patient and/or family role in monitoring domestic risks, early detection of ulcer and seeking immediate professional care. Foot ulcers need to be reported against standardised criteria considering local characteristics of the ulcer and the individual's general profile.

Systematic review of perception of barriers and facilitators to chronic disease self‐management among older adults: Implications for evidence‐based practice

Abstract

Background

An aging population has contributed to an increased prevalence in chronic disease. To empower patients, healthcare systems are shifting toward chronic disease self-management. However, no review on how older adults self-manage chronic disease and the barriers and facilitators they experience has been published.

Aims

To explore barriers and facilitators perceived by older adults during the process of self-managing chronic disease.

Methods

A systematic review of qualitative literature was performed using the Joanna Briggs Institute methodology. The literature search was conducted using Ovid databases (MEDLINE, CINAHL with full text, and PsycINFO) for the period of 1988–2020. All records were screened using predetermined eligibility criteria. The critical appraisal instrument QARI (Qualitative Assessment and Review Instrument) was employed to assess the quality of the included studies. Data from the included papers were extracted using the QARI data extraction tool. Extracted data were then synthesized to produce final sets of themes and sub-themes relating to the review question.

Results

A total of 267 abstracts were screened, and 13 studies reporting barriers and facilitators perceived by older adults during the process of managing chronic diseases were included in the review. Physical and cognitive decline, low-health literacy, culture, and relationships with healthcare professionals were described as barriers. Facilitators were described as resources that supported disease self-management and included family, social networks, healthcare professionals, and religious beliefs.

Linking evidence to action

This study highlights the importance of understanding the patients' perspectives of the barriers and enablers of self-management of chronic illness for health professionals across settings. Understanding barriers and facilitators to chronic disease self-management will support health professionals to identify strength-based approaches to self-management that meet the needs of individual older adults.

'Trying to fly the plane while we were building it. Applying a learning health systems approach to evaluate early-stage barriers and facilitators to implementing primary care transformation: a qualitative study

Por: Pestka · D. L. · White · K. M. · DeRoche · K. K. · Benson · B. J. · Beebe · T. J.
Objective

A learning health system (LHS) uses data to generate evidence and answer questions required to continually improve system performance and patient care. Given the complexities of practice transformation, an area where LHS is particularly important is the study of primary care transformation (PCT) as PCT generates several practice-level questions that require study where the findings can be readily implemented. In May 2019, a large integrated health delivery system in Minnesota began implementation of a population management PCT in two of its 40 primary care clinics. In this model of care, patients are grouped into one of five service bundles based on their complexity of care; patient appointment lengths and services provided are then tailored to each service bundle. The objective of this study was to examine the use of a LHS in PCT by utilising the Consolidated Framework for Implementation Research (CFIR) to categorise implementation lessons from the initial two PCT clinics to inform further implementation of the PCT within the health system.

Design

This was a formative evaluation in which semistructured qualitative interviews were carried out. Observational field notes were also taken. Inductive coding of the data was performed and resultant codes were mapped to the CFIR.

Setting

Two suburban primary care clinics in the Twin Cities, Minnesota.

Participants

Twenty-two care team members from the first two clinics to adopt the PCT.

Results

Seventeen codes emerged to describe care team members’ perceived implementation influences. Codes occurred in each of the five CFIR domains (intervention characteristics, outer setting, inner setting, characteristics of individuals and process), with most codes occurring in the ‘inner setting’ domain.

Conclusions

Using an LHS approach to determine early-stage implementation influences is key to guiding further PCT implementation, understanding modifications that need to be made and additional research that needs to occur.

Estimands: bringing clarity and focus to research questions in clinical trials

Por: Clark · T. P. · Kahan · B. C. · Phillips · A. · White · I. · Carpenter · J. R.

Precise specification of the research question and associated treatment effect of interest is essential in clinical research, yet recent work shows that they are often incompletely specified. The ICH E9 (R1) Addendum on Estimands and Sensitivity Analysis in Clinical Trials introduces a framework that supports researchers in precisely and transparently specifying the treatment effect they aim to estimate in their clinical trial. In this paper, we present practical examples to demonstrate to all researchers involved in clinical trials how estimands can help them to specify the research question, lead to a better understanding of the treatment effect to be estimated and hence increase the probability of success of the trial.

Prevalence of distress and its associated factors among caregivers of people diagnosed with cancer: A cross‐sectional study

Abstract

Aims and Objectives

To (i) determine prevalence of distress among caregivers of people living with cancer, (ii) describe caregivers’ most commonly reported problems and (iii) investigate which factors were associated with caregivers’ distress.

Background

The psychological distress associated with a cancer diagnosis jointly impacts those living with cancer and their caregivers(s). As the provision of clinical support moves towards a dyadic model, understanding the factors associated with caregivers’ distress is increasingly important.

Design

Cross-sectional study.

Methods

Distress screening data were analysed for 956 caregivers (family and friends) of cancer patients accessing the Cancer Council Western Australia information and support line between 1 January 2016 and 31 December 2018. These data included caregivers' demographics and reported problems and their level of distress. Information related to their care recipient's cancer diagnosis was also captured. Caregivers' reported problems and levels of distress were measured using the distress thermometer and accompanying problem list (PL) developed by the National Comprehensive Cancer Network. A partial-proportional logistic regression model was used to investigate which demographic factors and PL items were associated with increasing levels of caregiver distress. Pearlin's model of caregiving and stress process was used as a framework for discussion. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist was followed.

Results

Nearly all caregivers (96.24%) recorded a clinically significant level of distress (≥4/10) and two thirds (66.74%) as severely distressed (≥7/10). Being female, self-reporting sadness, a loss of interest in usual activities, sleep problems or problems with a partner or children were all significantly associated with increased levels of distress.

Conclusions

Caregivers of people with cancer reporting emotional or familial problems may be at greater risk of moderate and severe distress.

Relevance to Clinical Practice

Awareness and recognition of caregiver distress are vital, and referral pathways for caregivers are the important area of development.

Nurses' perceptions and beliefs related to the care of adults living with multimorbidity: A systematic qualitative review

Abstract

Aims and objectives

To identify and synthesise the available qualitative evidence on nurses’ perceptions and beliefs related to the care of adults living with multimorbidity.

Background

The rising prevalence of adults living with multimorbidity has increased demand for health care and challenges nursing care. No review has been conducted to date of the studies of nurses’ perceptions and beliefs related to the provision of care to guide policy makers, practitioners and further research to identify and deliver quality care for persons living with multimorbidity.

Design

Systematic review of qualitative studies conducted in line with the PRISMA checklist.

Methodology

Eight electronic publication databases and sources of grey literature were searched to identify original qualitative studies of the experience of nurses caring for adults with multiple chronic conditions with no restrictions on the date of publication or study context. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Data were extracted using the Joanna Briggs Institute standardised data extraction tool for qualitative research. Data synthesis was undertaken through meta-aggregation.

Results

Eleven qualitative studies were included in the review. All studies met eight or more of the 10 assessment criteria of the JBI Critical Appraisal Checklist for Qualitative Research. Four synthesised findings were generated from the aggregated findings: (i) the challenge of providing nursing care; (ii) the need to deliver holistic and person-centred nursing care; (iii) the importance of developing a therapeutic nurse–patient relationship, and (iv) delivering nursing care as part of an interprofessional care team.

Conclusions

The complexity of multimorbidity and the predominant single-disease model of chronic care present challenges for the delivery of nursing care to adults living with multimorbidity.

Relevance to clinical practice

The nursing care of persons with multimorbidity needs to incorporate holistic assessment and person-centred care principles as part of a collaborative and interprofessional team approach.

PROSPERO Registration

CRD42020186773.

Effect of a Nurse-Led Community Health Worker Intervention on Latent Tuberculosis Medication Completion Among Homeless Adults

imageBackground Tuberculosis (TB) disproportionately affects marginalized and impoverished homeless adults. Although active TB can be prevented by treating latent TB infection (LTBI), individual factors, such as high prevalence of depression and anxiety, drug and alcohol use, and unstable housing, lead to poor LTBI treatment adherence and completion among homeless adults. Objectives We hypothesized that the delivery of a tailored nurse-led, community health worker (RN/CHW) program across the LTBI continuum of care (e.g., screening, diagnosis, and treatment) that delivers 3HP treatment (3HP: rifapentine plus isoniazid) for homeless adults (e.g., sheltered and unsheltered) and is tailored to their health and social service needs will overcome existing treatment completion barriers. We also hypothesized that mental health symptoms (e.g., depression and anxiety), drug use score, and problematic alcohol use will decline over time among clients receiving this treatment. Methods We assessed the effect of delivering a theoretically guided, RN/CHW-based, single-arm study among eligible LTBI-positive homeless adults (N = 50) on completion of a weekly, directly observed, 12-dose 3HP LTBI treatment in Central City East (Skid Row). Completing 3HP treatment was compared to the only known historical, clinic-based control that obtained 65% completion among homeless adults. Secondary outcomes included drug and alcohol use, depression, and anxiety. Results The RN/CHW program achieved a 91.8% 3HP treatment completion rate among homeless adults. Younger homeless adults (

CATALYST trial protocol: a multicentre, open-label, phase II, multiarm trial for an early and accelerated evaluation of the potential treatments for COVID-19 in hospitalised adults

Por: Veenith · T. · Fisher · B. A. · Slade · D. · Rowe · A. · Sharpe · R. · Thickett · D. R. · Whitehouse · T. · Rowland · M. · Scriven · J. · Parekh · D. · Bowden · S. J. · Savage · J. S. · Richards · D. · Bion · J. · Kearns · P. · Gates · S. · CATALYST Trial Investigators · On behalf of CA
Introduction

Severe SARS-CoV-2 infection is associated with a dysregulated immune response. Inflammatory monocytes and macrophages are crucial, promoting injurious, proinflammatory sequelae. Immunomodulation is, therefore, an attractive therapeutic strategy and we sought to test licensed and novel candidate drugs.

Methods and analysis

The CATALYST trial is a multiarm, open-label, multicentre, phase II platform trial designed to identify candidate novel treatments to improve outcomes of patients hospitalised with COVID-19 compared with usual care. Treatments with evidence of biomarker improvements will be put forward for larger-scale testing by current national phase III platform trials. Hospitalised patients >16 years with a clinical picture strongly suggestive of SARS-CoV-2 pneumonia (confirmed by chest X-ray or CT scan, with or without a positive reverse transcription PCR assay) and a C reactive protein (CRP) ≥40 mg/L are eligible. The primary outcome measure is CRP, measured serially from admission to day 14, hospital discharge or death. Secondary outcomes include the WHO Clinical Progression Improvement Scale as a principal efficacy assessment.

Ethics and dissemination

The protocol was approved by the East Midlands-Nottingham 2 Research Ethics Committee (20/EM/0115) and given urgent public health status; initial approval was received on 5 May 2020, current protocol version (V.6.0) approval on 12 October 2020. The MHRA also approved all protocol versions. The results of this trial will be disseminated through national and international presentations and peer-reviewed publications.

Trial registration numbers

EudraCT2020-001684-89, ISRCTN40580903.

Association between surgeon grade and implant survival following hip and knee replacement: a systematic review and meta-analysis

Por: Fowler · T. J. · Aquilina · A. L. · Blom · A. W. · Sayers · A. · Whitehouse · M. R.
Objective

To investigate the association between surgeon grade (trainee vs consultant) and implant survival following primary hip and knee replacement.

Design

A systematic review and meta-analysis of observational studies.

Data sources

MEDLINE and Embase from inception to 6 October 2021.

Setting

Units performing primary hip and/or knee replacements since 1990.

Participants

Adult patients undergoing either a primary hip or knee replacement, predominantly for osteoarthritis.

Intervention

Whether the surgeon recorded as performing the procedure was a trainee or not.

Primary and secondary outcome measures

The primary outcome was net implant survival reported as a Kaplan-Meier survival estimate. The secondary outcome was crude revision rate. Both outcomes were reported according to surgeon grade.

Results

Nine cohort studies capturing 4066 total hip replacements (THRs), 936 total knee replacements (TKRs) and 1357 unicompartmental knee replacements (UKRs) were included (5 THR studies, 2 TKR studies and 2 UKR studies). The pooled net implant survival estimates for THRs at 5 years were 97.9% (95% CI 96.6% to 99.2%) for trainees and 98.1% (95% CI 97.1% to 99.2%) for consultants. The relative risk of revision of THRs at 5 and 10 years was 0.88 (95% CI 0.46 to 1.70) and 0.68 (95% CI 0.37 to 1.26), respectively. For TKRs, the net implant survival estimates at 10 years were 96.2% (95% CI 94.0% to 98.4%) for trainees and 95.1% (95% CI 93.0% to 97.2%) for consultants. We report a narrative summary of UKR outcomes.

Conclusions

There is no strong evidence in the existing literature that trainee surgeons have worse outcomes compared with consultants, in terms of the net survival or crude revision rate of hip and knee replacements at 5–10 years follow-up. These findings are limited by the quality of the existing published data and are applicable to countries with established orthopaedic training programmes.

PROSPERO registration number

CRD42019150494.

Defining CD4 T helper and T regulatory cell endotypes of progressive and remitting pulmonary sarcoidosis (BRITE): protocol for a US-based, multicentre, longitudinal observational bronchoscopy study

Por: Koth · L. L. · Harmacek · L. D. · White · E. K. · Arger · N. K. · Powers · L. · Werner · B. R. · Magallon · R. E. · Grewal · P. · Barkes · B. Q. · Li · L. · Gillespie · M. · Collins · S. E. · Cardenas · J. · Chen · E. S. · Maier · L. A. · Leach · S. M. · OConnor · B. P. · Hamzeh · N. Y.
Introduction

Sarcoidosis is a multiorgan granulomatous disorder thought to be triggered and influenced by gene–environment interactions. Sarcoidosis affects 45–300/100 000 individuals in the USA and has an increasing mortality rate. The greatest gap in knowledge about sarcoidosis pathobiology is a lack of understanding about the underlying immunological mechanisms driving progressive pulmonary disease. The objective of this study is to define the lung-specific and blood-specific longitudinal changes in the adaptive immune response and their relationship to progressive and non-progressive pulmonary outcomes in patients with recently diagnosed sarcoidosis.

Methods and analysis

The BRonchoscopy at Initial sarcoidosis diagnosis Targeting longitudinal Endpoints study is a US-based, NIH-sponsored longitudinal blood and bronchoscopy study. Enrolment will occur over four centres with a target sample size of 80 eligible participants within 18 months of tissue diagnosis. Participants will undergo six study visits over 18 months. In addition to serial measurement of lung function, symptom surveys and chest X-rays, participants will undergo collection of blood and two bronchoscopies with bronchoalveolar lavage separated by 6 months. Freshly processed samples will be stained and flow-sorted for isolation of CD4 +T helper (Th1, Th17.0 and Th17.1) and T regulatory cell immune populations, followed by next-generation RNA sequencing. We will construct bioinformatic tools using this gene expression to define sarcoidosis endotypes that associate with progressive and non-progressive pulmonary disease outcomes and validate the tools using an independent cohort.

Ethics and dissemination

The study protocol has been approved by the Institutional Review Boards at National Jewish Hospital (IRB# HS-3118), University of Iowa (IRB# 201801750), Johns Hopkins University (IRB# 00149513) and University of California, San Francisco (IRB# 17-23432). All participants will be required to provide written informed consent. Findings will be disseminated via journal publications, scientific conferences, patient advocacy group online content and social media platforms.

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