"It's not just about the patient, it's the families too.": End of life care in the home environment

Introduction: Most people when asked say they would prefer to die at home. However, ‘Death in Usual Place of Residence’ (DiUPR) does not give any real insight into the quality and experiences of care received. Additionally, DiUPR involves other family members resident in the home environment and their needs, preferences and experiences also need consideration. Aim(s) and Method(s): The aim of this work was to explore the experiences of patients and informal caregivers receiving at-home care from a specialist palliative care service. We undertook individual interviews with 11 patients and 10 significant others. We used the Pictor technique, a novel interview tool used to sensitively explore networks of support and experiences of palliative care. Interviews were analysed thematically. Results: Caring for a loved one at home was acknowledged as draining, but participants were effusive about the excellent at-home professional support they received from the specialist service. The care provided evidently recognised the needs of both patients and their families. Effective co-ordination of care, including liaison with other services was especially appreciated. Conclusion(s): With increasing trends towards DiUPR, it is vital that there are sufficient well-resourced palliative care services available in the community to support both patients and their families at the end of life. Pictor is a useful means to obtain detailed insight into individual experiences of end of life care. Care co-ordination emerged as key concern for patients receiving End of Life Care and their families

How can NHS trusts in England optimise strategies to improve the mental health and well-being of hospital doctors? The Care Under Pressure 3 (CUP3) realist evaluation study protocol

Introduction: The growing incidence of mental ill health in doctors was a major issue in the UK and internationally, even prior to the COVID-19 pandemic. It has significant and far-reaching implications, including poor quality or inconsistent patient care, absenteeism, workforce attrition and retention issues, presenteeism, and increased risk of suicide. Existing approaches to workplace support do not take into account the individual, organisational and social factors contributing to mental ill health in doctors, nor how interventions/programmes might interact with each other within the workplace. The aim of this study is to work collaboratively with eight purposively selected National Health Service (NHS) trusts within England to develop an evidence-based implementation toolkit for all NHS trusts to reduce doctors’ mental ill health and its impacts on the workforce. Methods and analysis: The project will incorporate three phases. Phase 1 develops a typology of interventions to reduce doctors’ mental ill health. Phase 2 is a realist evaluation of the existing combinations of strategies being used by acute English healthcare trusts to reduce doctors’ mental ill health (including preventative promotion of well-being), based on 160 interviews with key stakeholders. Phase 3 synthesises the insights gained through phases 1 and 2, to create an implementation toolkit that all UK healthcare trusts can use to optimise their strategies to reduce doctors’ mental ill health and its impact on the workforce and patient care. Ethics and dissemination: Ethical approval has been granted for phase 2 of the project from the NHS Research Ethics Committee (REC reference number 22/WA/0352). As part of the conditions for our ethics approval, the sites included in our study will remain anonymous. To ensure the relevance of the study’s outputs, we have planned a wide range of dissemination strategies: an implementation toolkit for healthcare leaders, service managers and doctors; conventional academic outputs such as journal manuscripts and conference presentations; plain English summaries; cartoons and animations; and a media engagement campaign

To exclose nests or not: structured decision making for the conservation of a threatened species

Decisions regarding endangered species recovery often face sparse data and multiple sources of uncertainty about the effects of management. Structured decision making (SDM) provides a framework for assembling knowledge and expert opinion and evaluating the tradeoffs between different objectives while formally incorporating uncertainty. The Atlantic Coast piping plover provides an illustrative case for the utility of SDM in endangered species management because its population growth is simple to model, most populations are monitored, decision alternatives are well defined, and many managers are open to recovery recommendations. We built a model to evaluate the decision to use nest exclosures to protect piping plover eggs from predators, where the objective was to maximize λ and the tradeoff was between nest survival and adult survival. The latter can be reduced by exclosures. We used a novel mixed multinomial logistic exposure model to predict daily nest fates and incorporated the results into a stochastic projection matrix that included renesting after nest failure, and adult mortality associated with abandonment. In our test data set (n = 329 nests from 28 sites over four years), the mean nest survival over 34 days was markedly higher for exclosed nests (0.76 ± 0.03 SE) than for unexclosed nests (0.37 ± 0.07). Abandonment rates were also higher for exclosed nests (0.092 ± 0.017) than for unexclosed nests (0.045 ± 0.017), but the difference was not statistically signifi- cant and the loss rate to “other sources” (mostly predators) was much lower for exclosed nests (0.15 ± 0.03) than for unexclosed nests (0.58 ± 0.07). Population growth rate (λ) was clearly improved by exclosure use at the sites with high background nest loss rates, but λ was still \u3c1 with exclosure use. Where the background nest loss rates were low, the decision to use exclosures was ambiguous, and λ could benefit from reducing uncertainty in vital rates. Our process demonstrated that geographic and temporal variation in nest mortality determines whether exclosures will be useful in attaining positive population growth rates and that other management options must be considered where the background nest mortality rates are high

A genome-wide association study of radiotherapy induced toxicity in head and neck cancer patients identifies a susceptibility locus associated with mucositis

PURPOSE: A two-stage genome-wide association study was carried out in head and neck cancer (HNC) patients aiming to identify genetic variants associated with either specific radiotherapy-induced (RT) toxicity endpoints or a general proneness to develop toxicity after RT.MATERIALS AND METHODS: The analysis included 1780 HNC patients treated with primary RT for laryngeal or oro/hypopharyngeal cancers. In a non-hypothesis-driven explorative discovery study, associations were tested in 1183 patients treated within The Danish Head and Neck Cancer Group. Significant associations were later tested in an independent Dutch cohort of 597 HNC patients and if replicated, summary data obtained from discovery and replication studies were meta-analysed. Further validation of significantly replicated findings was pursued in an Asian cohort of 235 HNC patients with nasopharynx as the primary tumour site.RESULTS: We found and replicated a significant association between a locus on chromosome 5 and mucositis with a pooled OR for rs1131769*C in meta-analysis = 1.95 (95% CI 1.48-2.41; ppooled = 4.34 × 10-16).CONCLUSION: This first exploratory GWAS in European cohorts of HNC patients identified and replicated a risk locus for mucositis. A larger Meta-GWAS to identify further risk variants for RT-induced toxicity in HNC patients is warranted.</p

Developing a typology of interventions to support doctors’ mental health and wellbeing

Background: The problem of mental ill-health in doctors is complex, accentuated by the COVID-19 pandemic, and impacts on healthcare provision and broader organisational performance. There are many interventions to address the problem but currently no systematic way to categorise them, which makes it hard to describe and compare interventions. As a result, implementation tends to be unfocussed and fall short of the standards developed for implementing complex healthcare interventions. This study aims to develop: 1) a conceptual typology of workplace mental health and wellbeing interventions and 2) a mapping tool to apply the typology within research and practice. Methods: Typology development was based on iterative cycles of analysis of published and in-practice interventions, incorporation of relevant theories and frameworks, and team and stakeholder group discussions. Results: The newly developed typology and mapping tool enable interventions to be conceptualised and/or mapped into different categories, for example whether they are designed to be largely preventative (by either improving the workplace or increasing personal resources) or to resolve problems after they have arisen. Interventions may be mapped across more than one category to reflect the nuance and complexity in many mental health and wellbeing interventions. Mapping of interventions indicated that most publications have not clarified their underlying assumptions about what causes outcomes or the theoretical basis for the intervention. Conclusion: The conceptual typology and mapping tool aims to raise the quality of future research and promote clear thinking about the nature and purpose of interventions, In doing so it aims to support future research and practice in planning interventions to improve the mental health and wellbeing of doctors

Epidemiology, prehospital care and outcomes of patients arriving by ambulance with dyspnoea: An observational study

Background: This study aimed to determine epidemiology and outcome for patients presenting to emergency departments (ED) with shortness of breath who were transported by ambulance. Methods: This was a planned sub-study of a prospective, interrupted time series cohort study conducted at three time points in 2014 and which included consecutive adult patients presenting to the ED with dyspnoea as a main symptom. For this sub-study, additional inclusion criteria were presentation to an ED in Australia or New Zealand and transport by ambulance. The primary outcomes of interest are the epidemiology and outcome of these patients. Analysis was by descriptive statistics and comparisons of proportions. Results: One thousand seven patients met inclusion criteria. Median age was 74 years (IQR 61-68) and 46.1 % were male. There was a high rate of co-morbidity and chronic medication use. The most common ED diagnoses were lower respiratory tract infection (including pneumonia, 22.7 %), cardiac failure (20.5%) and exacerbation of chronic obstructive pulmonary disease (19.7 %). ED disposition was hospital admission (including ICU) for 76.4 %, ICU admission for 5.6 % and death in ED in 0.9 %. Overall in-hospital mortality among admitted patients was 6.5 %. Discussion: Patients transported by ambulance with shortness of breath make up a significant proportion of ambulance caseload and have high comorbidity and high hospital admission rate. In this study, >60 % were accounted for by patients with heart failure, lower respiratory tract infection or COPD, but there were a wide range of diagnoses. This has implications for service planning, models of care and paramedic training. Conclusion: This study shows that patients transported to hospital by ambulance with shortness of breath are a complex and seriously ill group with a broad range of diagnoses. Understanding the characteristics of these patients, the range of diagnoses and their outcome can help inform training and planning of services

Risk factors for postoperative complications after adrenalectomy for phaeochromocytoma: multicentre cohort study

Background: To determine the incidence and risk factors for postoperative complications and prolonged hospital stay after adrenalectomy for phaeochromocytoma. Methods: Demographics, perioperative outcomes and complications were evaluated for consecutive patients who underwent adrenalectomy for phaeochromocytoma from 2012 to 2020 in nine high-volume UK centres. Odds ratios were calculated using multivariable models. The primary outcome was postoperative complications according to the Clavien–­­Dindo classification and secondary outcome was duration of hospital stay. Results: Data were available for 406 patients (female n = 221, 54.4 per cent). Two patients (0.5 per cent) had perioperative death, whilst 148 complications were recorded in 109 (26.8 per cent) patients. On adjusted analysis, the age-adjusted Charlson Co-morbidity Index ≥3 (OR 8.09, 95 per cent c.i. 2.31 to 29.63, P = 0.001), laparoscopic converted to open (OR 10.34, 95 per cent c.i. 3.24 to 36.23,

The Met Office Unified Model Global Atmosphere 6.0/6.1 and JULES Global Land 6.0/6.1 configurations

We describe Global Atmosphere 6.0 and Global Land 6.0: the latest science configurations of the Met Office Unified Model and JULES land surface model developed for use across all timescales. Global Atmosphere 6.0 includes the ENDGame dynamical core, which significantly increases mid-latitude variability improving a known model bias. Alongside developments of the model’s physical parametrisations, ENDGame also increases variability in the tropics, which leads to an improved representation of tropical cyclones and other tropical phenomena. Further developments of the atmospheric and land surface parametrisations improve other aspects of model performance, including the forecasting of surface weather phenomena. We also describe Global Atmosphere 6.1 and Global Land 6.1, which include a small number of long-standing differences from our main trunk configurations that we continue to require for operational global weather prediction. Since July 2014, GA6.1/GL6.1 has been used by the Met Office for operational global NWP, whilst GA6.0/GL6.0 was implemented in its remaining global prediction systems over the following year