Investigating the implementation of telemedicine in English prisons

Background Prisoners experience significant health inequalities, tending to suffer poorer access to services and health outcomes than the general population. The delivery of secondary healthcare services by video consultation (telemedicine) offers an opportunity to improve the health outcomes for people in prison, by improving the access, quality and cost of healthcare services available. This PhD thesis investigated how prison telemedicine could improve access and quality of health services for patients in English prisons, and the issues that arise during implementation of prison telemedicine models. The study spanned the period both prior to and during the COVID-19 pandemic, and the research approach was adapted to these changing circumstances. Methods This PhD study employed mixed methods including systematic review, qualitative interviews and autoethnography. The PhD starts by considering how telemedicine could improve the patient experience of accessing secondary care in English prisons, through qualitative analysis of patient interview data collected by peer researchers (pre-pandemic). It then investigates the barriers and facilitators to prison telemedicine implementation, firstly via a systematic review of existing literature on prison telemedicine, secondly through qualitative analysis of a staff interview series relating to a local prison telemedicine implementation project (pre-pandemic). Finally the PhD sought to understand how the pandemic context affected the ability to implement prison telemedicine, through both an auto-ethnographic account from my perspective as a key agent in ensuring national implementation, and staff interviews with senior health and justice stakeholders. Findings Prison telemedicine could potentially improve the equivalence of care for people in prisons. Interviews with prisoners revealed that they experience numerous barriers to accessing secondary care services, and feel stigmatised and dehumanised at hospital sites. They have long delays for appointments, and poor treatment by both hospital and prison officer staff. A systematic review of prison telemedicine literature highlighted that many of these barriers could be overcome through delivery of remote appointments. Video consultations remove the need for prisoners to be chaperoned during appointments by prison security staff, and reduce delays associated with prison officer escorted transfer to the hospital. The systematic review revealed that implementation of prison telemedicine has flourished in countries with vast geographical distances to traverse, such as the USA and Australia, but prior to the pandemic had been limited in English settings. Despite successful overseas implementation, there are numerous operational and systems level barriers that need to be overcome during implementation efforts. These include: securing top-down and bottom-up support for implementation, framing the telemedicine intervention effectively, and considering the differing strategic and operational priorities of prison and hospital healthcare providers. Interviews with stakeholders in prison telemedicine described how a local telemedicine pilot in England struggled to find traction over a three year period, mainly as a result of provider resistance, commissioning barriers and incompatibility between health and justice systems. The COVID-19 pandemic represented a significant contextual shift which supported remote consultations and partnership working, resulting in telemedicine rollout across the entire English prison estate. The autoethnography described my role during the pandemic, working to overcome most barriers to implementation as part of centralised national leadership for the telemedicine agenda. This prompted the prison service to consider and assure innovative technology to improve care continuity by telemedicine. Issues still remained with the complexity of the prison commissioning landscape, existing prison infrastructure and the incompatibility of approved prison and community software solutions

Timing of elective pre-labour caesarean section: a decision analysis

__Background:__ Since caesarean sections (CSs) before 39+0 weeks gestation are associated with higher rates of neonatal respiratory morbidity, it is recommended to delay elective CSs until 39+0 weeks. However, this bears the risk of earlier spontaneous labour resulting in unplanned CSs, which has workforce and resource implications, specifically in smaller obstetric units. __Aim:__ To assess, in a policy of elective CSs from 39+0 weeks onward, the number of unplanned CSs to prevent one neonate with respiratory complications, as compared to early elective CS. __Materials and Methods:__ We performed a decision analysis comparing early term elective CS at 37+0–6 or 38+0–6 weeks to elective prelabour CS, without strict medical indication, at 39+0–6 weeks, with earlier unplanned CS, in women with uncomplicated singleton pregnancies. We used literature data to calculate the number of unplanned CSs necessary to prevent one neonate with respiratory morbidity. __Results:__ Planning all elective CSs at 39+0–6 weeks required 10.9 unplanned CSs to prevent one neonate with respiratory morbidity, compared to planning all elective CSs at 38+0–6 weeks. Compared to planning all elective CSs at 37+0–6 weeks we needed to perform 3.3 unplanned CSs to prevent one neonate with respiratory morbidity. __Conclusion:__ In a policy of planning all elective pre-labour CSs from 39+0 weeks of gestation onward, between three and 11 unplanned CSs have to be performed to prevent one neonate with respiratory morbidity. Therefore, in our opinion, fear of early term labour and workforce disutility is no argument for scheduling elective CSs <39+0 weeks

Improving uptake of hepatitis B and hepatitis C testing in South Asian migrants in community and faith settings using educational interventions - a prospective descriptive study

Background Chronic viral hepatitis (CVH) is a leading contributor to the UK liver disease epidemic, with global migration from high-prevalence areas (e.g. South Asia-SA). Despite international guidance for testing high-risk groups in line with elimination targets, there is no consensus on how to achieve this. Objectives (i) Feasibility of recruiting SA migrants to view an educational film on CVH (ii) Effectiveness of the film in promoting testing, knowledge of CVH (iii) Methodological issues relevant to scale-up to randomized trial. Methods We recruited SA migrants to view the film (intervention) in community venues (primary care, religious, community), offering dried-blood spot CVH testing immediately afterwards. Pre/post-film questionnaires assessed the interventions effectiveness. Results Two hundred and nineteen first generation migrants >18yrs (53% female) were recruited to view the film;184 (84%) underwent CVH testing (HBc Ab or HCV Ab positive, demonstrating exposure in 8.5%) at the following sites: n = 112 (51%) religious, n = 98(45%) community, and primary care, n = 9 (4%). Pre (n = 173, 79%) and post (n = 154, 70%) intervention questionnaires were completed. Conclusions We demonstrate the feasibility of recruiting first generation migrants to participate in a community-based educational film, promoting CVH testing in this higher-risk group, confirming value of developing interventions to facilitate global WHO plan for targeted case finding, elimination and future randomized controlled trial. We highlight the importance of culturally relevant interventions including faith, and culturally sensitive settings appearing to minimize logistical issues effective at engaging minority groups and allowing ease of access to individuals ‘at risk’

Prisoners co-infected with tuberculosis and HIV: a systematic review.

INTRODUCTION: Almost from the beginning of the HIV epidemic in 1981, an association with tuberculosis (TB) was recognized. This association between HIV and TB co-infection has been particularly evident amongst prisoners. However, despite this, few studies of TB in prisons have stratified results by HIV status. Given the high prevalence of HIV-positive persons and TB-infected persons in prisons and the documented risk of TB in those infected with HIV, it is of interest to determine how co-infection varies amongst prison populations worldwide. For this reason we have undertaken a systematic review of studies of co-infected prisoners to determine the incidence and/or prevalence of HIV/TB co-infection in prisons, as well as outcomes in this group, measured as treatment success or death. METHODS: A literature search was undertaken using the online databases PubMed, Embase, IBSS, Scopus, Web of Science, Global Health and CINAHL Plus. No restrictions were set on language or publication date for article retrieval, with articles included if indexed up to 18 October 2015. A total of 1975 non-duplicate papers were identified. For treatment and outcome data all eligible papers were appraised for inclusion; for incidence/prevalence estimates papers published prior to 2000 were excluded from full text review. After full text appraisal, 46 papers were selected for inclusion in the review, 41 for incidence/prevalence estimates and nine for outcomes data, with four papers providing evidence for both outcomes and prevalence/incidence. RESULTS: Very few studies estimated the incidence of TB in HIV positive prisoners, with most simply reporting prevalence of co-infection. Co-infection is rarely explicitly measured, with studies simply reporting HIV status in prisoners with TB, or a cross-sectional survey of TB prevalence amongst prisoners with HIV. Estimates of co-infection prevalence ranged from 2.4 to 73.1% and relative risks for one, given the other, ranged from 2.0 to 10.75, although some studies reported no significant association between HIV and TB. Few studies provided a comparison with the risk of co-infection in the general population. CONCLUSIONS: Prisoners infected with HIV are at high risk of developing TB. However, the magnitude of risk varies between different prisons and countries. There is little evidence on treatment outcomes in co-infected prisoners, and the existing evidence is conflicting in regards to HIV status influence on prisoner treatment outcomes.PROSPERO Number: CRD42016034068

Expression profiles of metamorphosis-related genes during natural transformations in tadpoles of wild Wood Frogs (Lithobates sylvaticus)

Numerous studies using laboratory-reared tadpoles have shown the importance of thyroid hormones (TH), thyroid receptors (TR), and deiodinase (Dio) enzymes during anuran metamorphosis. Our study focuses on the analysis of thyroidrelated genes in tadpoles of wild Wood Frogs (Lithobates sylvaticus (LeConte, 1825); also known as Rana sylvatica (Cope, 1889)) during metamorphosis. Results showed that, in concordance with laboratory-reared studies, thyroid receptor beta (trb) gene expression profiles presented the most marked changes. At climax and compared with premetamorphic stages, brains, tails, and gonad–mesonephros complex (GMC) tissues increased trb expression levels 5-, 21-, and 41-fold, respectively (p < 0.05). In addition, gene expression levels of brain deiodinase type II and III showed opposite trends, where 3- fold decrease and 10-fold increase were, respectively, found. This finding supports the idea that thyroid hormone, as it has been demonstrated in laboratory-reared tadpoles, is also involved in natural metamorphosis in wild tadpoles. Interestingly, and contrary to our predictions, we observed that whole brain corticotropin-releasing factor (crf) and crf receptor 1 (crfr1) gene expression levels significantly decrease through metamorphosis in wild L. sylvaticus tadpoles. Further analyses are required to determine if a role of TH in the timing of anuran gonadal development exists, as well as the importance of cellspecific and tissue-specific expression of crf and crfr1 to metamorphosis

Using telemedicine to improve access, cost and quality of secondary care for people in prison in England: a hybrid type 2 implementation effectiveness study.

INTRODUCTION: People in prison tend to experience poorer health, access to healthcare services and health outcomes than the general population. Use of video consultations (telemedicine) has been proven effective at improving the access, cost and quality of secondary care for prisoners in the USA and Australia. Implementation and use in English prison settings has been limited to date despite political drivers for change. We plan to research the implementation of a new prison-hospital telemedicine model in an English county to understand what factors drive or hinder implementation and whether the model can improve healthcare outcomes as demonstrated in other contextual settings. METHODS AND ANALYSIS: We will undertake a hybrid type 2 implementation effectiveness study to gather evidence on both clinical and implementation outcomes. Data collection will be guided by the theoretical constructs of Normalisation Process Theory. We will prospectively collect data through: (1) prisoner/patient focus groups, interviews and questionnaires, (2) prison healthcare, hospital and wider prison staff interviews and questionnaires, (3) routine quality improvement and service evaluation data. Up to four prisons and three hospital settings in Surrey (England) will be included in the telemedicine research, dependent on their telemedicine readiness during the study period. Prisons proposed include male and female prisoners, remand (not yet sentenced) and sentenced individuals and different security categorisations. In addition, focus groups in five telemedicine naïve prisons will provide information on patient preconceptions and concerns surrounding telemedicine. ETHICS AND DISSEMINATION: This study has received National Health Service Research Ethics Committee, Her Majesty's Prison and Probation Service National Research Committee and Health Research Authority approval. Dissemination of results will take place through peer-reviewed journals, conferences and existing health and justice networks

Expression profiles of metamorphosis-related genes during natural transformations in tadpoles of wild Wood Frogs (Lithobates sylvaticus)

Numerous studies using laboratory-reared tadpoles have shown the importance of thyroid hormones (TH), thyroidreceptors (TR), and deiodinase (Dio) enzymes during anuran metamorphosis. Our study focuses on the analysis of thyroidrelatedgenes in tadpoles of wild Wood Frogs (Lithobates sylvaticus (LeConte, 1825); also known as Rana sylvatica (Cope,1889)) during metamorphosis. Results showed that, in concordance with laboratory-reared studies, thyroid receptor beta(trb) gene expression profiles presented the most marked changes. At climax and compared with premetamorphic stages, brains, tails, and gonad–mesonephros complex (GMC) tissues increased trb expression levels 5-, 21-, and 41-fold, respectively (p < 0.05). In addition, gene expression levels of brain deiodinase type II and III showed opposite trends, where 3-fold decrease and 10-fold increase were, respectively, found. This finding supports the idea that thyroid hormone, as it has been demonstrated in laboratory-reared tadpoles, is also involved in natural metamorphosis in wild tadpoles. Interestingly, and contrary to our predictions, we observed that whole brain corticotropin-releasing factor (crf) and crf receptor 1 (crfr1) gene expression levels significantly decrease through metamorphosis in wild L. sylvaticus tadpoles. Further analyses are required to determine if a role of TH in the timing of anuran gonadal development exists, as well as the importance of cell-specific and tissue-specific expression of crf and crfr1 to metamorphosis

Engraftment of Human Stem Cell Derived Otic Progenitors in the Damaged Cochlea

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Effects of the glyphosate-based herbicide Roundup WeatherMax® on metamorphosis of wood frogs (Lithobates sylvaticus) in natural wetlands

Amphibian tadpoles develop in aquatic environments where they are susceptible to the effects of pesticides and other environmental contaminants. Glyphosate-based herbicides are currently the most commonly used herbicide in the world and have been shown to affect survival and development of tadpoles under laboratory and mesocosm conditions. In the present study, whole wetland manipulations were used to determine if exposure to an agriculturally relevant application of Roundup WeatherMax®, a herbicide formulation containing the potassium salt of glyphosate and an undisclosed surfactant, influences the development of wood frog tadpoles (Lithobates sylvaticus) under natural conditions. Wetlands were divided in half with an impermeable curtain so that each wetland contained a treatment and control side. Tadpoles were exposed to two pulses of this herbicide at an environmentally realistic concentration (ERC, 0.21 mg acid equivalent (a.e.)/L) and the predicted maximum environmental concentration (PMEC, 2.89 mg a.e./L), after which abundance, growth, development, and mRNA levels of genes involved in tadpole metamorphosis were measured. Results present little evidence that exposure to this herbicide affects abundance, growth and development of wood frog tadpoles. As part of the Long-term Experimental Wetlands Area (LEWA) project, this research demonstrates that typical agricultural use of Roundup WeatherMax® poses minimal risk to larval amphibian development. However, our gene expression data (mRNA levels) suggests that glyphosate-based herbicides have the potential to alter hormonal pathways during tadpole developmeNo Full Tex

Interventions for the detection, monitoring, and management of chronic non-communicable diseases in the prison population:an international systematic review

Background: High rates of health inequalities and chronic non-communicable diseases exist amongst the prison population. This places people in and/or released from prison at heightened risk of multimorbidity, premature mortality, and reduced quality of life. Ensuring appropriate healthcare for people in prison to improve their health outcomes is an important aspect of social justice. This review examines the global literature on healthcare interventions to detect, monitor and manage chronic non-communicable diseases amongst the prison population and people recently released from prison. Methods: Systematic searches of EMBASE, MEDLINE, CINAHL, Web of Science, Scopus, and the Cochrane Library were conducted and supplemented by citation searching and review of the grey literature. The literature searches attempted to identify all articles describing any healthcare intervention for adults in prison, or released from prison in the past 1 year, to detect, monitor, or manage any chronic non-communicable illness. 19,061 articles were identified, of which 1058 articles were screened by abstract and 203 articles were reviewed by full text. Results: Sixty-five studies were included in the review, involving 18,311 participants from multiple countries. Most studies were quasi-experimental and/or low to moderate in quality. Numerous healthcare interventions were described in the literature including chronic disease screening, telemedicine, health education, integrated care systems, implementing specialist equipment and staff roles to manage chronic diseases in prisons, and providing enhanced primary care contact and/or support from community health workers for people recently released from prison. These interventions were associated with improvement in various measures of clinical and cost effectiveness, although comparison between different care models was not possible due to high levels of clinical heterogeneity. Conclusions: It is currently unclear which interventions are most effective at monitoring and managing chronic non-communicable diseases in prison. More research is needed to determine the most effective interventions for improving chronic disease management in prisons and how these should be implemented to ensure optimal success. Future research should examine interventions for addressing multimorbidity within prisons, since most studies tested interventions for a singular non-communicable disease.</p