Towards codesign in respiratory care: development of an implementation-ready intervention to improve guideline-adherent adult asthma care across primary and secondary care settings (The SENTINEL Project)

Short-acting beta agonist (SABA) overuse (≥3 canisters annually) is associated with worse asthma outcomes and accounts for the majority of greenhouse gas emissions from asthma inhalers in England. Reducing SABA overuse aligns with the National Health Service long-term plan to optimise asthma treatment while minimising environmental impact, but adoption of local asthma guidelines for a SABA-free maintenance and reliever therapy strategy for step 3 asthma patients is limited. In this Perspective, we describe patient and staff involvement in a codesign process adapted from experience-based codesign (EBCD) principles to develop an implementation-ready intervention within a practice-relevant timescale.The codesigned intervention consists of five pillars: healthcare professional education; implementation of 'gold standard' prescribing practices; targeted asthma reviews; patient education and support; and real-time data monitoring and reporting of asthma care metrics. The codesign process contributed to all pillars and, by identifying potential individual and organisational barriers to implementation, enabled the development of plans to address these barriers.In this Perspective, we reflect on the strengths and weaknesses of our codesign process, outline how EBCD principles can be used in respiratory research and propose actions for patients, health professionals, researchers and funders to develop the potential of EBCD in respiratory research

Dementia Inpatient Study on The Recognition and Evaluation of Signs Signalling Emotional Distress - DISTRESSED

Dementia is a common comorbidity in older people admitted to general hospital. People with dementia have a high prevalence of psychological symptoms, pain and delirium, which if left untreated can cause distress and predispose the person to worse outcomes. Identifying individual symptoms or the causes of distress can be difficult because people with more severe dementia often struggle to communicate. Systems are in place to help healthcare professionals recognise and treat individual symptoms, but they require the user to be able to apply and use them appropriately. This thesis describes the development and feasibility testing of a novel screening tool, which aims to improve distress recognition for dementia patients in a hospital setting. Initially, to understand areas of unmet need, a retrospective review of 116 case notes of people with dementia admitted to hospital was undertaken. The results suggested a discrepancy between observed and expected psychological symptoms, delirium, and pain, and that existing systems used to identify and manage them were underutilised. It was hypothesised that encouraging healthcare professionals to identify distress, rather than specific symptoms, may be a simple and sensitive method for improving the recognition of psychological symptoms, pain and delirium downstream. However, how hospital healthcare professionals identify distress in dementia patients was previously undescribed. Existing methods were explored using thematic analysis of 25 semi-structured interviews with healthcare professionals who regularly care for people with dementia. The participants interviewed all believed they could innately identify distress. However, common facilitators and barriers to this process were identified including: how the patient presents, familiarity with the patient, using the person’s usual community carer as a source of information, staff training, ward culture, and competing ward priorities. Following a series of design phases, the themes generated were combined with existing theories on implementing healthcare interventions to develop a novel distress screening tool, for use by healthcare professionals to assess dementia patients in a hospital setting. The Distress Recognition Tool (DRT), was deliberately simple and designed to complement existing hospital physical observation systems. As part of the assessment, community carers for the person with dementia are also asked to contribute to the process when visiting the ward. The DRT was further refined using feedback from focus groups comprising healthcare professionals and community carers of people with dementia. To test the use, usefulness and potential mechanistic impacts of the DRT, the tool was feasibility tested during the routine care of 32 consented patients with dementia admitted to a large teaching hospital. All staff on participating wards received DRT training and consequently the tool was used on average 0.9 times per participant day. Carers contributed to the assessment process on average 0.4 times per patient day. The feedback from healthcare professionals and community carers was positive but highlighted that more complex aspects of the DRT need refinement

Gender-specific association of the K121Q Ectonucleotide Pyrophosphatase Phosphodiesterase (ENPP) 1 polymorphism with subcutaneous adiposity in a South African Black population

Purpose: This study aimed to determine whether the ENPP-1 K121Q (rs1044498) polymorphism was associated with adiposity and cardiometabolic disease markers within a South African Black population. Methods: Black participants from the greater Johannesburg–Soweto area in South Africa, for whom metabolic syndrome status, cardiometabolic disease markers, adipokine levels and body fat distribution had already been measured, were genotyped by PCR-RFLP for the presence of the K121Q polymorphism.Results: Within a cohort of 345 Black South Africans, the frequency of the ENPP-1 K121Q C allele was 0.89. In the total cohort, the K121Q polymorphism was not significantly associated with any cardiometabolic disease markers or adipokine levels. However, in the female population the CC genotype was shown to be associated with increased abdominal subcutaneous fat levels (p=0.007). Conclusion: This cohort of Black South Africans had a higher frequency of the C allele when compared to reported data for Asian and Caucasian populations, however this frequency was comparable to other African data. The presence of the rs1044498 polymorphism was not associated with markers of cardiometabolic disease, suggesting that these associations may be population dependent. The gender-specific genotypic association with subcutaneous fat levels is a novel finding requiring further investigation

Developmental trends in voice onset time: some evidence for sex differences

This study reports on an investigation into the voice onset time (VOT) patterns of the plosives /p b t d/ in a group of 30 children aged 7 (n = 10), 9 (n = 10) and 11 (n = 10) years. Equal numbers of girls and boys participated in the study. Each child named a series of letter objects to elicit /p b t d/ in a syllable onset position with a fixed vowel context. VOT data were examined for age, sex and plosive differences with the following hypotheses: Firstly, that there would be sex differences in the VOT patterns of preadolescent children. Secondly, that the sex differences in VOT patterns would be linked to age and development, and that these would eventually become marked by the age of 11 years, by which time adult-like VOT values should have been achieved. Finally, that the extent of sex and age differences would be dependent upon the plosive being investigated. Results indicated patterns of decrease with age in the VOT values of /p b/ for the boys, with some evidence of increases in the VOT values of /t/ for the girls. In addition, 'voiced' and 'voiceless' cognates showed a more marked bimodal distribution in the girls' VOT patterns. This bimodal distribution was investigated by examining the degree of difference between the VOT values of voiced and voiceless cognate pairs /p b/ and /t d/, and examining the effects of age, sex and cognate pair. These results indicated that more marked sex differences in the 'voiced'/'voiceless' contrast emerged between the data of the 9- and 11-year-olds, a pattern, which was more marked for the alveolar plosives. These preliminary results confirmed all three hypotheses. The findings are presented and discussed both within a developmental and sociophonetic framework

The Characteristics and Outcomes of People with Dementia in Inpatient Mental Health Care: A Review

Objectives: Inpatient mental health beds for people with dementia are a limited resource. Practitioners need an understanding of this population to provide high-quality care and design services. This review examines the characteristics, care, and outcomes of people with dementia admitted to inpatient mental health services. Methods: Systematic searches of key databases were undertaken up to November 2021. Findings were grouped into categories and then synthesized into a narrative review. Results: The review identified 36 international papers, the majority of which were retrospective audits. The literature describes significant psychiatric and medical comorbidity and significant risk of change in residence and death associated with admission. Conclusions: We found a limited literature describing the characteristics, care, and outcomes of people with dementia in inpatient mental health services. The lack of research is striking given the complexity and vulnerability of this client group. More research is needed to describe the needs of this group, current and best practice to optimize care. Clinical Implications: Professionals working in inpatient mental health services need to be aware of the evidence base available, consider how they evaluate patient outcomes, review their staffing and skills mix, and seek the views of patients and relatives in improving services

Validation of plantar pressure and reaction force measured by Moticon pressure sensor insoles on a Concept2 rowing ergometer

The purpose of this study was to determine the reliability and validity of plantar pressure and reaction force measured using the Moticon and Pedar-x sensor insoles while rowing on a Concept2 ergometer. Nineteen participants performed four 500 m trials of ergometer rowing at 22–24 strokes/min; two trials wearing Moticon insoles and two wearing Pedar-x insoles in a randomised order. Moticon and Pedar-x insoles both showed moderate to strong test–retest reliability (ICC = 0.57–0.92) for mean and peak plantar pressure and reaction force. Paired t-test demonstrated a significant difference (p 1.13), and Pearson’s correlation (r < 0.37) showed poor agreement for all plantar pressure and reaction force variables. Compared to Pedar-x, the Moticon insoles demonstrated poor validity, however, the Moticon insoles had strong reliability. Due to poor validity, caution should be used when considering Moticon insoles to assess changes in pressure and force reliably over time, across multiple trials or sessions. Moticon’s wireless and user-friendly application would be beneficial for assessing and monitoring biomechanical parameters in rowing if validity between measures of interest and Moticon’s results can be established

A FUSE Survey of Interstellar Molecular Hydrogen in the Small and Large Magellanic Clouds

We describe a moderate-resolution FUSE survey of H2 along 70 sight lines to the Small and Large Magellanic Clouds, using hot stars as background sources. FUSE spectra of 67% of observed Magellanic Cloud sources (52% of LMC and 92% of SMC) exhibit absorption lines from the H2 Lyman and Werner bands between 912 and 1120 A. Our survey is sensitive to N(H2) >= 10^14 cm^-2; the highest column densities are log N(H2) = 19.9 in the LMC and 20.6 in the SMC. We find reduced H2 abundances in the Magellanic Clouds relative to the Milky Way, with average molecular fractions = 0.010 (+0.005, -0.002) for the SMC and = 0.012 (+0.006, -0.003) for the LMC, compared with = 0.095 for the Galactic disk over a similar range of reddening. The dominant uncertainty in this measurement results from the systematic differences between 21 cm radio emission and Lya in pencil-beam sight lines as measures of N(HI). These results imply that the diffuse H2 masses of the LMC and SMC are 8 x 10^6 Msun and 2 x 10^6 Msun, respectively, 2% and 0.5% of the H I masses derived from 21 cm emission measurements. The LMC and SMC abundance patterns can be reproduced in ensembles of model clouds with a reduced H2 formation rate coefficient, R ~ 3 x 10^-18 cm^3 s^-1, and incident radiation fields ranging from 10 - 100 times the Galactic mean value. We find that these high-radiation, low-formation-rate models can also explain the enhanced N(4)/N(2) and N(5)/N(3) rotational excitation ratios in the Clouds. We use H2 column densities in low rotational states (J = 0 and 1) to derive a mean kinetic and/or rotational temperature = 82 +/- 21 K for clouds with N(H2) >= 10^16 cm^-2, similar to Galactic gas. We discuss the implications of this work for theories of star formation in low-metallicity environments. [Abstract abridged]Comment: 30 pages emulateapj, 14 figures (7 color), 7 tables, accepted for publication in the Astrophysical Journal, figures 11 and 12 compressed at slight loss of quality, see http://casa.colorado.edu/~tumlinso/h2/ for full version

SMT19969 as a treatment for Clostridium difficile infection : an assessment of antimicrobial activity using conventional susceptibility testing and an in vitro gut model

© The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/ 4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.OBJECTIVES: We investigated the efficacy of the novel antimicrobial agent SMT19969 in treating simulated Clostridium difficile infection using an in vitro human gut model. METHODS: Concentrations of the predominant cultivable members of the indigenous gut microfloras and C. difficile (total and spore counts) were determined by viable counting. Cytotoxin titres were determined using cell cytotoxicity and expressed as log10 relative units (RU). Clindamycin was used to induce simulated C. difficile PCR ribotype 027 infection. Once high-level cytotoxin titres (≥ 4 RU) were observed, SMT19969 was instilled for 7 days. Two SMT19969 dosing regimens (31.25 and 62.5 mg/L four times daily) were evaluated simultaneously in separate experiments. MICs of SMT19969 were determined against 30 genotypically distinct C. difficile ribotypes. RESULTS: SMT19969 was 7- and 17-fold more active against C. difficile than metronidazole and vancomycin, respectively, against a panel of genotypically distinct isolates (P < 0.05). Both SMT19969 dosing regimens demonstrated little antimicrobial activity against indigenous gut microflora groups except clostridia. SMT19969 inhibited C. difficile growth and repressed C. difficile cytotoxin titres in the gut model. CONCLUSIONS: These data suggest that SMT19969 is a narrow-spectrum and potent antimicrobial agent against C. difficile. Additional studies evaluating SMT19969 in other models of C. difficile infection are warranted, with human studies to place these gut model observations in context.Peer reviewedFinal Published versio

Cardiac monitoring in memory clinics: national survey of UK practice

Aims and method People diagnosed with dementia are often started on acetylcholinesterase inhibitors (AChEIs). As AChEIs can be associated with cardiac side-effects, an electrocardiogram (ECG) is sometimes requested before treatment. Previous work has suggested there is little consensus as to when or how ECGs should be obtained. This can create inconsistent practice, with patient safety, economic and practical repercussions. We surveyed 305 UK memory clinic practitioners about prescribing practice. Results More than 84% of respondents completed a pulse and cardiac history before prescribing AChEIs. Opinion was divided as to who should fund and conduct ECGs. It was believed that obtaining an ECG causes patients inconvenience and delays treatment. Despite regularly interpreting ECGs, 76% of respondents did not update this clinical skill regularly. Clinical implications The variation in practice observed has service-level and patient implications and raises potential patient safety concerns. Implementing national guidelines or seeking novel ways of conducting cardiac monitoring could help standardise practice