42 research outputs found
Development of recommendations to improve patient experiences of brachytherapy for locally advanced cervical cancer
Brachytherapy is a type of internal radiation treatment where a radioactive source is placed close to a tumour. For locally advanced cervical cancer (LACC), too advanced to be cured by a hysterectomy, radiotherapy with chemotherapy is the standard treatment. Typically, brachytherapy follows five weeks of daily external beam radiotherapy alongside weekly chemotherapy. Brachytherapy requires patients to have applicators/needles positioned inside them in an operating theatre and to remain lying flat and still on a bed for the planning and treatment delivery. Currently, the way the brachytherapy is given is not standardised. It may be given as three or four day case procedures, or one or two inpatient stays for up to three days where the applicators stay in place for this duration. Brachytherapy is a highly invasive procedure and is known to cause pain, anxiety and distress. Currently there is no consensus on how to minimise this in the context of a rapidly developing technique with wide variations in delivery. This research was undertaken to better understand patient experiences of brachytherapy for LACC, to identify areas needing improvement and ways to reduce distress caused by brachytherapy. A total of three studies were carried out. The first study was a survey to ascertain current UK brachytherapy service provision, including pain management and procedures to provide patient care and support. This found that many different treatment regimens were in use, confirming the lack of standardisation of procedures. The second study was a qualitative interview study, to explore patient experiences of brachytherapy across a number of UK centres where brachytherapy is delivered in different ways. This showed that some women had difficult and traumatic experiences with periods of severe pain and a perception of poor nursing care on the wards. Others described more positive experiences, with some having had no pain. Aspects of what had gone well were identified as well as suggestions for how the treatment could be improved. In the final stage of the research, study data were used to develop potential patient care recommendations. These were discussed and ranked by service providers and service users meeting together in nominal group technique workshops. Some recommendations were amended to improve clarity and a few new recommendations were created in the workshops. From the workshops a list of potential recommendations was produced to be taken forwards for future development, with the aim of improving standards and consistency of care in brachytherapy for LACC
Patient experiences of brachytherapy for locally advanced cervical cancer: hearing the patient voice through qualitative interviews
Background Brachytherapy for gynaecological cancer is reported to cause pain, anxiety and distress with no clear guidance for optimising patient experiences. The aim of this study was to explore patient experiences of brachytherapy and views on improvements. Materials and Methods Semi-structured interviews were undertaken with patients who had received brachytherapy for locally advanced cervical cancer. Two cohorts were recruited: cohort one had recently had brachytherapy, cohort two were a year post brachytherapy. Four recruitment sites were selected, where brachytherapy is given in different ways, some with short day case procedures and others having one or two overnight stays with applicators in place. Consecutive patients were invited to interview. Participants were asked to retell their brachytherapy story, with views on their care and ideas for improvement. Interviews were audio-recorded, transcribed and data analysed following Braun and Clarke's method for reflexive thematic analysis.16 Results Thirty five interviews were conducted (20 in cohort one and 15 in cohort two). Participant's ages ranged from 28 to 87 years. The interview duration ranged from 22 to 78 minutes. Difficult and traumatic experiences were reported, including periods of severe pain and perceptions of poor care. However, some participants described positive experiences and what went well. Three themes were developed: 1) How I got through it 2) Unpleasantness, discomfort and the aftermath 3) Emotional consequences and trauma Some aspects of medium and long duration brachytherapy were found to be more problematic compared with short duration brachytherapy. Exploring experiences at one year post brachytherapy has provided insights into the long-lasting impact of brachytherapy experiences. Conclusion Hearing the patient voice has demonstrated that further work is needed to improve patient care in modern brachytherapy techniques using different regimes and durations, to minimise difficult and traumatic patient experiences. Study insights will inform future work to develop clinical care recommendations
Exploring patient experience of rehabilitation within the surgical pathway for lower limb soft tissue sarcoma in the UK: A single-centre study
The primary treatment for localised soft tissue sarcoma (STS) is surgery. Surgery for lower limb sarcoma is associated with poorer functional outcomes than other anatomical sites. Rehabilitation is essential, yet provision is not standardised, and patient experience of current service delivery is unknown. This study therefore aimed to explore patients’ experiences of rehabilitation in the surgical pathway for lower limb STS at a United Kingdom (UK) specialist centre.MethodsA qualitative, descriptive phenomenological study was undertaken to explore patients’ rehabilitation experiences. Eight patients who had undergone lower limb STS surgery at a specialist centre were purposively sampled. Data were collected through semi-structured interviews and analysed using thematic analysis.ResultsThree main themes were identified: (1) Accessing the right services at the right time. Participants described good access to inpatient rehabilitation post-operatively but delays and challenges in accessing local services affected continuity of care. Rehabilitation gaps pre-operatively, and in facilitating return to meaningful activities, were described; (2) “Communication is key” — providing knowledge and support to navigate uncertainty. Unclear and unrealistic expectations of recovery were challenging. Communication was key to patients feeling supported and facilitating access to rehabilitation; (3) The importance of person-centred rehabilitation. Collaborative, person-centred rehabilitation optimised motivation and engagement.ConclusionParticipants experienced good access to inpatient rehabilitation post-operatively. In contrast, gaps and delays at other timepoints led to missed opportunities to support preparation for, and recovery from, surgery. A multidisciplinary approach across settings from diagnosis, to deliver person-centred rehabilitation, may improve access, expectation management and continuity of care
Development and refinement of patient care recommendations in brachytherapy for locally advanced cervical cancer using nominal group technique workshops
Purpose: Patient experiences of brachytherapy for locally advanced cervical cancer (LACC) are widely variable, with reports of difficult and traumatic experiences and aspects of care requiring improvement. The aim of this study was to develop patient care recommendations and consult with key stakeholders to review, refine and prioritise recommendations. Methods: Phase 1: Patient care recommendations were developed from qualitative exploratory study data. Phase 2: Service users and providers with recent experience of brachytherapy for LACC were recruited to online nominal group technique (NGT) workshops. Four NGT stages were followed: (1) initial voting and silent generation; (2) round robin; (3) clarification; and (4) prioritisation. Voting data were summed across the workshops, deriving inter-group scores. Qualitative data were analysed through content analysis. Results: Phase 1: Fifty-one patient care recommendations were developed. Phase 2: Thirteen participants took part in three online NGT workshops, with a combination of service users and providers. Initial recommendations were voted on; four new recommendations were added; minor changes were made and second voting was undertaken. Recommendations were positively received with 25 recommendations scoring maximum points from all participants. An importance score above 90% was given to 46 recommendations. The remaining recommendations received scores between 74 and 90%. Conclusions: NGT workshops facilitated collaboration between key stakeholders, discussing, refining and prioritising patient care recommendations, leading to verification of achievable and relevant recommendations. These provide a foundation for future development of guidelines and subsequent implementation into clinical practice, aiming to improve consistency of care and patient experiences of brachytherapy for LACC
Cardiovascular disease and the role of oral bacteria
In terms of the pathogenesis of cardiovascular disease (CVD) the focus has traditionally been on dyslipidemia. Over the decades our understanding of the pathogenesis of CVD has increased, and infections, including those caused by oral bacteria, are more likely involved in CVD progression than previously thought. While many studies have now shown an association between periodontal disease and CVD, the mechanisms underpinning this relationship remain unclear. This review gives a brief overview of the host-bacterial interactions in periodontal disease and virulence factors of oral bacteria before discussing the proposed mechanisms by which oral bacterial may facilitate the progression of CVD
Author Correction: The FLUXNET2015 dataset and the ONEFlux processing pipeline for eddy covariance data
The FLUXNET2015 dataset and the ONEFlux processing pipeline for eddy covariance data
The FLUXNET2015 dataset provides ecosystem-scale data on CO2, water, and energy exchange between the biosphere and the atmosphere, and other meteorological and biological measurements, from 212 sites around the globe (over 1500 site-years, up to and including year 2014). These sites, independently managed and operated, voluntarily contributed their data to create global datasets. Data were quality controlled and processed using uniform methods, to improve consistency and intercomparability across sites. The dataset is already being used in a number of applications, including ecophysiology studies, remote sensing studies, and development of ecosystem and Earth system models. FLUXNET2015 includes derived-data products, such as gap-filled time series, ecosystem respiration and photosynthetic uptake estimates, estimation of uncertainties, and metadata about the measurements, presented for the first time in this paper. In addition, 206 of these sites are for the first time distributed under a Creative Commons (CC-BY 4.0) license. This paper details this enhanced dataset and the processing methods, now made available as open-source codes, making the dataset more accessible, transparent, and reproducible.Peer reviewe
Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.
BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)
Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19
IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19.
Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19.
DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022).
INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days.
MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes.
RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively).
CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes.
TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570
TRADE-OFFS IN TREE SPECIES SELECTION AND CARBON OFFSET ON FARMS ADJACENT TO KAKAMEGA-NANDI FOREST ECOSYSTEM IN KENYA
Background: Growing of trees on-farms has contributed significantly in easing pressure on the Kakamega–Nandi Forest Ecosystem. There are however concerns that Eucalyptus species is becoming the dominant tree in this landscape and may have adverse effects on the environment. Objectives: To determine the trade-offs in tree species selection and carbon offsets on farms in the margins of the Kakamega - Nandi Forest Ecosystem. Methodology: It employed a nested experimental design where the study area was divided into three 3x1 km sentinel blocks. Three different landscape models were chosen: Eucalyptus dominated tree stand, mixed tree stands and pure native tree stands. A sample plot comprised a main plot of 20m by 10m plot for measuring trees with a diameter at breast height (DBH) ≥ 10 cm, a sub-plot of 10m by 5m nested within the main plot for measuring saplings and shrubs of DBH less than 10cm. Data was collected on tree species type, stem DBH for trees, tree height, counts of trees, saplings and shrubs. The data was subjected to both exploratory and inferential statistical analysis using R Gui Version 4.2.1. Woody species diversity and carbon stocks were subjected to analysis of variance (ANOVA) at 5% significance level. Results: Native dominated tree stands had the highest biomass carbon (0.50-512.84 MgC ha-1) followed by mixed tree stands (0.10-110.82 MgC ha-1). Eucalyptus dominated was the least (0.10- 68.58 MgC ha-1) The above ground biomass in the Eucalyptus dominated tree stands and mixed trees stands was significantly lower than in the adjacent native trees stands (p=0.001). The mean carbon estimated in the treatments was 2.62 MgC ha-1 in the Eucalyptus trees dominated stands, 3.09 MgC ha-1 in mixed trees species stands and 19.05 MgC ha-1 in native tree species stand. Implications: Increase in the concentration of Eucalyptus trees led to a reduction in tree diversity. Trees in the Eucalyptus dominated tree stand and mixed trees stand had significantly lower stem diameters, basal area and tree biomass than in the adjacent indigenous trees stand. The fast rate of growth of Eucalyptus trees may have ensured that the trees grow fast at the expense of other woody species due to water and nutrient competition. Conclusion: The study revealed a general trend of increasing biomass carbon with increasing tree size in all the treatments. The majority of large trees were found in native tree stand indicating that they store majority of biomass carbon stocks. Across the treatment, carbon sequestration in the trees was directly related to above ground biomass production