Learnings From a National Cyberattack Digital Disaster During the SARS-CoV-2 Pandemic in a Pediatric Emergency Medicine Department

Objective: The primary objective was to analyze the impact of the national cyberattack in May 2021 on patient flow and data quality in the Paediatric Emergency Department (ED), amid the SARS-CoV-2 (COVID-19) pandemic. Methods: A single site retrospective time series analysis was conducted of three 6-week periods: before, during, and after the cyberattack outage. Initial emergent workflows are described. Analysis includes diagnoses, demographic context, key performance indicators, and the gradual return of information technology capability on ED performance. Data quality was compared using 10 data quality dimensions. Results: Patient visits totaled 13 390. During the system outage, patient experience times decreased significantly, from a median of 188 minutes (pre-cyberattack) down to 166 minutes, most notable for the period from registration to triage, and from clinician review to discharge (excluding admitted patients). Following system restoration, most timings increased. Data quality was significantly impacted, with data imperfections noted in 19.7% of data recorded during the system outage compared to 4.7% before and 5.1% after. Conclusions: There was a reduction in patient experience time, but data quality suffered greatly. A hospital’s major emergency plan should include provisions for digital disasters that address essential data requirements and quality as well as maintaining patient flow

A feasibility trial of a digital self-management intervention ‘My Breathing Matters’ to improve asthma-related quality of life for UK primary care patients with asthma

Objective: To assess the feasibility of a randomised controlled trial (RCT) and acceptability of an asthma self-management digital intervention to improve asthma-specific quality of life in comparison with usual care. Design and setting: A two-arm feasibility RCT conducted across seven general practices in Wessex, UK. Participants: Primary care patients with asthma aged 18 years and over, with impaired asthma-specific quality of life and access to the internet. Interventions: ‘My Breathing Matters’ (MBM) is a digital asthma self-management intervention designed using theory, evidence and person-based approaches to provide tailored support for both pharmacological and non-pharmacological management of asthma symptoms. Outcomes: The primary outcome was the feasibility of the trial design, including recruitment, adherence and retention at follow-up (3 and 12 months). Secondary outcomes were the feasibility and effect sizes of specific trial measures including asthma-specific quality of life and asthma control. Results: Primary outcomes: 88 patients were recruited (target 80). At 3-month follow-up, two patients withdrew and six did not complete outcome measures. At 12 months, two withdrew and four did not complete outcome measures. 36/44 patients in the intervention group engaged with MBM (median of 4 logins, range 0–25, IQR 8). Consistent trends were observed to improvements in asthma-related patient-reported outcome measures. Conclusions: This study demonstrated the feasibility and acceptability of a definitive RCT that is required to determine the clinical and cost-effectiveness of a digital asthma self-management intervention. Trial registration number: ISRCTN15698435

The intra and inter-rater reliability of a modified weight-bearing lunge measure of ankle dorsiflexion

This study assessed the intra and inter-rater reliability of a modified weight-bearing lunge measure of ankle dorsiflexion range of movement. Thirteen healthy subjects were recruited. Each subject performed 3 repetitions of the lunging method with one rater and 3 more repetitions with a second rater within 30 min. The process was repeated within 3 h. Intra-rater reliability results indicated excellent correlation of measurements (intraclass correlation coefficients (ICCs) of 0.98e0.99). Standard error of measurement (SEM), 95% limits of agreement (LOA) and coefficient of repeatability (CR) calculations indicated suitably low ranges of measurement variance (SEM ¼ 0.4 cm, LOA ¼ �1.28 to �1.47 cm and CR ¼ 1.21e1.35 cm). Inter-rater reliability was also deemed excellent (ICC ¼ 0.99, SEM ¼ 0.3 cm, LOA ¼ �0.83 to �1.47 cm, CR ¼ 1.44 cm). The modified lunge technique therefore demonstrates excellent intra and inter-rater reliability

Measuring subluxation of the hemiplegic shoulder: Reliability of a method

Objective: Subluxation of the shoulder after stroke can be measured according to the method described by Van Langenberghe and Hogan. Methods: To evaluate the reliability of this method, the shoulder radiographs of 25 patients were available for this study. Two independent raters each assessed these radiographs twice. Results: The intrarater reliability was good: percentage of agreement was 88 and 84%, weighted κ, 0.69 [95% confidence interval (CI), 0.38-1 0] and 0.78 (95% CI, 0.60-0.95) for raters 1 and 2, respectively. The interrater reliability was poor: percentage of agree ment was 36 and 28%, κ, 0.11 (95% CI, 0.0-0.31) and 0.09 (95% CI, 0.0-0.23) in sessions 1 and 2, respectively. Subsequently the original method was adjusted by com bining two categories (no subluxation and beginning subluxation) into one (“no clin ically important subluxation”). Conclusions: After this adjustment of the categories, the interrater reliability improved [percentage of agreement, 72%, and κ, 0.49 (95% CI, 0.18-0.80)], but did not reach acceptable values

Digital interventions for hypertension and asthma to support patient self-management in primary care: the DIPSS research programme including two RCTs

Background: Digital interventions offer a potentially cost-effective means to support patient self-management in primary care, but evidence for the feasibility, acceptability and cost-effectiveness of digital interventions remains mixed. This programme focused on the potential for self-management digital interventions to improve outcomes in two common, contrasting conditions (i.e. hypertension and asthma) for which care is currently suboptimal, leading to excess deaths, illness, disability and costs for the NHS. Objectives: The overall purpose was to address the question of how digital interventions can best provide cost-effective support for patient self-management in primary care. Our aims were to develop and trial digital interventions to support patient self-management of hypertension and asthma. Through the process of planning, developing and evaluating these interventions, we also aimed to generate a better understanding of what features and methods for implementing digital interventions could make digital interventions acceptable, feasible, effective and cost-effective to integrate into primary care. Design: For the hypertension strand, we carried out systematic reviews of quantitative and qualitative evidence, intervention planning, development and optimisation, and an unmasked randomised controlled trial comparing digital intervention with usual care, with a health economic analysis and nested process evaluation. For the asthma strand, we carried out a systematic review of quantitative evidence, intervention planning, development and optimisation, and a feasibility randomised controlled trial comparing digital intervention with usual care, with nested process evaluation. Setting: General practices (hypertension, n = 76; asthma, n = 7) across Wessex and Thames Valley regions in Southern England. Participants: For the hypertension strand, people with uncontrolled hypertension taking one, two or three antihypertensive medications. For the asthma strand, adults with asthma and impaired asthma-related quality of life. Interventions: Our hypertension intervention (i.e. HOME BP) was a digital intervention that included motivational training for patients to self-monitor blood pressure, as well as health-care professionals to support self-management; a digital interface to send monthly readings to the health-care professional and to prompt planned medication changes when patients’ readings exceeded recommended targets for 2 consecutive months; and support for optional patient healthy behaviour change (e.g. healthy diet/weight loss, increased physical activity and reduced alcohol and salt consumption). The control group were provided with a Blood Pressure UK (London, UK) leaflet for hypertension and received routine hypertension care. Our asthma intervention (i.e. My Breathing Matters) was a digital intervention to improve the functional quality of life of primary care patients with asthma by supporting illness self-management. Motivational content intended to facilitate use of pharmacological self-management strategies (e.g. medication adherence and appropriate health-care service use) and non-pharmacological self-management strategies (e.g. breathing retraining, stress reduction and healthy behaviour change). The control group were given an Asthma UK (London, UK) information booklet on asthma self-management and received routine asthma care. Main outcome measures: The primary outcome for the hypertension randomised controlled trial was difference between intervention and usual-care groups in mean systolic blood pressure (mmHg) at 12 months, adjusted for baseline blood pressure, blood pressure target (i.e. standard, diabetic or aged > 80 years), age and general practice. The primary outcome for the asthma feasibility study was the feasibility of the trial design, including recruitment, adherence, intervention engagement and retention at follow-up. Health-care utilisation data were collected via notes review. Review methods: The quantitative reviews included a meta-analysis. The qualitative review comprised a meta-ethnography. Results: A total of 622 hypertensive patients were recruited to the randomised controlled trial, and 552 (89%) were followed up at 12 months. Systolic blood pressure was significantly lower in the intervention group at 12 months, with a difference of –3.4 mmHg (95% confidence interval –6.1 to –0.8 mmHg), and this gave an incremental cost per unit of systolic blood pressure reduction of £11 (95% confidence interval £5 to £29). Owing to a cost difference of £402 and a quality-adjusted life-year (QALY) difference of 0.044, long-term modelling puts the incremental cost per QALY at just over £9000. The probability of being cost-effective was 66% at willingness to pay £20,000 per quality-adjusted life-year, and this was higher at higher thresholds. A total of 88 patients were recruited to the asthma feasibility trial (target n = 80; n = 44 in each arm). At 3-month follow-up, two patients withdrew and six patients did not complete outcome measures. At 12 months, two patients withdrew and four patients did not complete outcome measures. A total of 36 out of 44 patients in the intervention group engaged with My Breathing Matters [with a median of four (range 0–25) logins]

Test-retest reliability of the Short-Form McGill Pain Questionnaire

Objectives: No previous study has adequately demonstrated the test-retest reliability of the Short-Form McGill Pain Questionnaire, yet it is increasingly being used as a measure of pain. This study evaluates the test-retest reliability in patients with osteoarthritis. Methods: A prospective, observational cohort study was undertaken using serial evaluation of 57 patients at 2 time points. A sample of patients awaiting primary hip or knee joint replacement surgery were recruited in clinic or via mail (mean age 64.8 years). Short-Form McGill Pain Questionnaires were delivered by mail 5 days apart, and a supplementary questionnaire was completed on the second occasion to explore if the patients’ pain report had remained stable. Results: The intraclass correlation coefficient was used as an estimate of reliability. For the total, sensory, affective, and average pain scores, high intra-class correlations were demonstrated (0.96, 0.95, 0.88, and 0.89, respectively). The current pain component demonstrated a lower intraclass correlation of 0.75. The coefficient of repeatability was calculated as an estimation of the minimum metrically detectable change. The coefficients of repeatability for the total, sensory, affective, average, and current pain components were 5.2, 4.5, 2.8, 1.4 cm, and 1.4, respectively. Discussion: Problems of adequate completion of the Short-Form McGill Pain Questionnaire were highlighted in this sample, and supervision via telephone contact was required. Patients recruited in clinic who had practiced completing the Short-Form McGill Pain Questionnaire demonstrated fewer errors than those recruited by mail. The Short-Form McGill Pain Questionnaire was demonstrated to be a highly reliable measure of pain. These results should not be generalized to a more elderly population, as increasing age was correlated with greater variability of the sensory component scores.</p

A preliminary study into the effect of biofeedback on end tidal carbon dioxide levels during slow breathing in healthy volunteers

Objectives: To investigate the effect of visual biofeedback on end tidal carbon dioxide levels during slow breathing in healthy volunteers. Design: Preliminary study with experimental design in which each participant experienced both conditions i.e. slow breathing with and without visual biofeedback Setting: Human Performance Laboratory, university campus Participants: Fifteen university students. Baseline data and outcome measures: Primary outcome measure was end tidal carbon dioxide (ETCO2); Secondary outcomes were respiratory rate; pulserate; non-invasive oxygen saturations; lung function Results: There was a mean rise in ETCO2 of 0.35 k Pa (CI0.09�0.6) during slow breathing with visual biofeedback, and 0.36 k Pa (CI0.13�0.6) without biofeedback. The use of visual feedback had no observable effect on ETCO2 despite participants successfully reducing their respiratory rate further under this condition (mean 5 breaths per minute with feedback, versus 7 without feedback). ETCO2 and respiratory rate were negatively correlated under both conditions (Pearson�sr = 0.42). Conclusions: In this study of healthy volunteers manipulating respiratory rate was found to result in a significant rise in ETCO2 levels under both conditions, but the use of visual biofeedback had no significant additional effect on ETCO2. Visual biofeedback did have a statistically significant effect on respiratory rate, enabling subjects to achieve lower rates than in the absence of biofeedback. This suggests visual biofeedback may have a role in enabling people to reduce breathing rates, but this needs to be confirmed by larger trials

Preliminary investigations into the effects of breathing retraining techniques on end-tidal carbon dioxide measures in patients with asthma and healthy volunteers during a single treatment session

Objectives: Preliminary investigations into the physiological effects of breathing retraining techniques in order to establish the feasibility of the proposed methodology, produce data for power calculations and determine the potential for future research in this area.Design: Two preliminary, exploratory studies with an experimental design.Setting: Research laboratories.Participants: Study 1: 15 patients with mild to moderate asthma and nine healthy volunteers. Study 2: 15 healthy volunteers.Interventions: Physiological data from asthma patients and healthy volunteers were recorded before, during and after a single session of slow breathing and breath holds. A separate group of healthy participants carried out the slow breathing technique with and without visual biofeedback.Outcome measures: The primary outcome was end-tidal carbon dioxide (ETCO2), and the secondary outcomes were respiratory rate, pulse rate, oxygen saturation and lung function.Results: All groups showed an increase in ETCO2 from baseline during slow breathing. Study 1 found a mean rise in ETCO2 of 0.48 kPa [95% confidence interval (CI) 0.28–0.68] for healthy participants and 0.46 kPa (95% CI 0.29–0.63) for asthma patients. In healthy volunteers, ETCO2 stayed above baseline for 5 minutes after the intervention. ETCO2 rose minimally (mean 0.06 kPa) in both groups after breath holds. Study 2 found a mean rise in ETCO2 of 0.35 kPa (95% CI 0.09–0.60) during slow breathing with visual feedback, and 0.36 kPa (95% CI 0.13–0.60) during slow breathing without visual feedback.Conclusions: The results of these preliminary studies provide data to power larger studies. They suggest that ETCO2 rises during slow breathing in both asthma patients and healthy volunteers, and that this effect may persist beyond the intervention itself in healthy volunteers. The use of visual biofeedback had no effect on ETCO2 in healthy volunteers

Mixed methods process evaluation of My Breathing Matters, a digital intervention to support self-management of asthma

This study aimed to explore user engagement with ‘My Breathing Matters’, a digital selfmanagement intervention for asthma, and identify factors that may influence engagement. In a mixed methods design, adults with asthma allocated to the intervention arm of a feasibility trial (n=44) participated in semi-structured interviews (n=18) and a satisfaction questionnaire (n=36) to explore their views and experiences of the intervention. Usage data highlighted that key intervention content was delivered to most users. The majority of questionnaire respondents (78%; n=28) reported they would recommend the intervention to friends and family. Interviewees expressed positive views of the intervention and experienced several benefits, mainly improved asthma control, medication use, and breathing technique. Factors that may influence user engagement were identified, including perceptions of asthma control, current self-management practices, and appeal of the target behaviours and behaviour change techniques. Findings suggested My Breathing Matters was acceptable and engaging to participants, and it was used as intende

Feasibility trial of a digital self-management intervention ‘My Breathing Matters’ to improve asthma-related quality of life for UK primary care patients with asthma

Objective: to assess the feasibility of a randomised controlled trial (RCT) and acceptability of an asthma self-management digital intervention to improve asthma-specific quality of life in comparison with usual care.Design and setting: a two arm feasibility RCT conducted across 7 general practices in Wessex, UK.Participants: primary care patients with asthma aged 18 years and over, with impaired asthma-specific quality of life and access to the internet.Interventions: ‘My Breathing Matters’ (MBM) is a digital asthma self-management intervention designed using theory, evidence and person-based approaches to provide tailored support for both pharmacological and non-pharmacological management of asthma symptoms.Outcomes: the primary outcome was the feasibility of the trial design, including recruitment, adherence and retention at follow-up (3 and 12 month). Secondary outcomes were the feasibility and effect sizes of specific trial measures including asthma-specific quality of life and asthma control.Results: primary outcomes: 88 patients were recruited (target 80). At 3 month follow-up, 2 patients withdrew and 6 did not complete outcome measures. At 12 month, 2 withdrew and 4 did not complete outcome measures. 36/44 patients in the intervention group engaged with MBM (median of 4 logins, range 0-25, IQR 8). Consistent trends were observed to improvements in asthma-related patient reported outcome measures.Conclusions: this study demonstrated the feasibility and acceptability of a definitive randomised controlled trial that is required to determine the clinical and cost-effectiveness of a digital asthma self-management intervention