Secure Care Pathway and Standards Scotland : The Journey of Implementation

This report illustrates the progress made in the implementation of the co-produced Secure Care Pathway and Standards, two years after their launch in October 2020. Through practice examples it provides insight into how agencies have approached the implementation process. Supportive workshops have enabled agencies to take both a single agency and multi-disciplinary approach, with the latter found to be the most effective. Implementation science provided a framework to help support and bridge the gap between theory and its application to practice. Successful implementation required targeted strategies which included knowledge exchange, practice reviews and revision and the development of policies, procedures, and mechanisms. A phased approach to implementation provided focus; phase one supported self-evaluation, learning and improvement. Aligning the Standards with other transformational developments in Scotland helped to cement their significance to practice nationally. Providing dedicated support through CYCJ assisted the implementation process. Stakeholder engagement has been critical to the effectiveness of implementation with the Champions group playing a lead role. Information contained within this report pertains to 21 of the 32 local authority areas within Scotland. A targeted approach to agencies and LAs where there has been limited engagement will be incorporated in the next phase of the implementation process. The co-designed Standards website provides a mechanism for the sharing of information and good practice examples that are consistently accessed locally, nationally, and internationally. It is recognised that achieving the Secure Care Pathway and Standards may require a single, multi-agency and national approach. Secure care centres, other stakeholders, the Secure Care Group and STARR have a crucial role in ongoing Secure Care Pathway and Standards implementation work. Barriers to meeting the Standards are evident at a time of scarce resources and limited capacity. Gaps in alternatives to secure care services have been identified as a challenge for all agencies. The Care Inspectorate’s appreciative inquiry has provided increased impetuses for agencies to continue to engage with the Standards

Frontline Allied Health Professionals in a Tertiary Children’s Hospital: Moving Forward Research Capacity, Culture and Engagement

Higher levels of research activity within healthcare contexts are known to result in improvements to staff and patient satisfaction as well as treatment outcomes. In the United Kingdom (UK), clinical academic careers for Allied Health Professionals (AHPs) are a key priority development area. This article presents the results of a study that aimed to scope the research capacity of four AHP professions in a tertiary children’s hospital using the Research Capacity and Culture Tool. This tool captures individuals’ views of success or skill required for a number of research-related items within the three domains of individual, team and organisation. Response rate ranged between 45-71% across the four groups. Reported barriers to carrying out research included a lack of time, clinical work taking priority, and lack of suitable backfill (i.e., employing a therapist to cover the clinical post for the AHP to complete research activity). Motivators, on the other hand, included skill development, career advancement, and increased job satisfaction. As a first step to strengthen research skills, a systematic process was used to devise a suite of supportive strategies targeting the individuals’ perceived gaps in their research abilities across four pillars: (i) awareness, (ii) accessibility, (iii) opportunity and capacity, and (iv) knowledge and skills. This process drew on previously published accounts of successful research capacity and culture development, as well as the unique needs of staff at this tertiary children’s hospital. The outcome of this process was a structured framework to support research capacity, culture and engagement. The specific details of this framework are reported in this article together with further recommendations to promote research capacity, culture and engagement amongst AHPs

The Effect of a Gluten-Free Diet in Children With Difficult-to-Manage Nephrotic Syndrome

Case reports have linked childhood nephrotic syndrome to food sensitivity, including gluten. We report our experience with 8 children (6 boys, 2 girls; age at implementation of special diet 2–14 years) with difficult-to-manage nephrotic syndrome who were placed on a gluten-free diet for 3.4 ± 4.3 years (range, 0.6–14 years) and who had clinical improvement enabling reduction or discontinuation in steroid dosage

Pharmacokinetics of oral micronized β-estradiol in postmenopausal women receiving maintenance hemodialysis

BACKGROUND: Although 11% of postmenopausal women with end-stage renal disease (ESRD) are prescribed hormone replacement therapy (HRT), the appropriate use remains poorly explored. Although there remains controversy surrounding the benefits of HRT, it may be of particular interest in this population, which has a high risk of bone loss and a fourfold increase in fracture risk compared to the general population. However, the appropriate dose of estrogen for use in postmenopausal women with ESRD is not known. The objective of this study was to evaluate the steady-state pharmacokinetics of oral micronized beta-estradiol in postmenopausal women with ESRD compared with postmenopausal women with normal renal function in order to determine equivalent dosing. METHODS: Six postmenopausal women with ESRD receiving maintenance hemodialysis and 6 healthy postmenopausal controls received 14 days of micronized beta-estradiol (1.0 mg for control, 0.5 mg for ESRD). Blood, urine, and dialysate samples were obtained during a dosage interval on day 14. Estradiol, estrone, albumin, and sex-hormone binding globulin (SHBG) concentrations were determined. Free estradiol concentrations were calculated using a previously described method. RESULTS: Women with ESRD had significantly lower serum albumin (610 +/- 31 micromol/L vs. 684 +/- 83 micromol/L) and SHBG (78 +/- 17 vs. 118 +/- 13 nmol/L) than control subjects. Total clearance of estradiol was not significantly different. Due to difference in binding, free estradiol concentrations were significant higher in ESRD women (53.2 +/- 17.7 pg/mL) than control women (43.5 +/- 8.7 pg/mL), despite receiving 50% of the dose. There was no significant difference in estrone concentrations. Clearance of both estradiol and estrone in the dialysate was minimal. CONCLUSION: Women with ESRD should receive approximately 50% of the dose typically prescribed to women without ESRD

Relation of maternal prepregnancy body mass index with offspring bone mass in childhood: is there evidence for an intrauterine effect?1234

Background: Evidence indicates that intrauterine skeletal development has implications for bone mass in later life and that maternal fat stores in pregnancy are important for fetal bone mineral accrual

Pacing Ability in Elite Runners with Intellectual Impairment

Purpose. To understand how athletes invest their energy over a race, differences in pacing ability between athletes with and without intellectual impairment (II) were explored using a novel field test. Methods. Well-trained runners (n=67) participated in this study, including 34 runners with II (age = 24.4 +/- 4.5 years; IQ = 63.1 +/- 7.7) and 33 runners without II (age = 31.4 +/- 11.2 years). The ability to perform at a pre-planned submaximal pace was assessed. Two 400m running trials were performed on an athletics track, with an individually standardized velocity. In the first trial, the speed was imposed by auditory signals given in 20m-40m intervals, in combination with coach-feedback during the initial 200m. The participant was instructed to maintain this velocity without any feedback during the final 200m. In trial 2, no coach-feedback was permitted. Results. Repeated measures analyses revealed a significant between-groups effect. II-runners deviated more from the target time than runners without II. The significant trial x group interaction effect (F = 4.15, p<.05) revealed that the ability to self-regulate the pace during the final 200m improved for runners without II (Trial 1: 1.7 +/- 1.0s, Trial 2: 0.9 +/-0.8s) whereas the II-runners deviated even more in Trial 2 (4.4 +/- 4.3s), than in Trial 1 (3.2 +/- 3.9s). Conclusion. Our findings support the assumption that intellectual capacity is involved in pacing. It is demonstrated that II-runners have difficulties maintaining a preplanned submaximal velocity, and this study contributes to understanding problems II-exercisers might experience when exercising. With this field test, we can assess the impact of II on pacing and performance in individual athletes which will lead to a fair Paralympic classification-procedure

Reproducibility of the NEPTUNE descriptor-based scoring system on whole-slide images and histologic and ultrastructural digital images

The multicenter Nephrotic Syndrome Study Network (NEPTUNE) digital pathology scoring system employs a novel and comprehensive methodology to document pathologic features from whole-slide images, immunofluorescence and ultrastructural digital images. To estimate inter- and intra-reader concordance of this descriptor-based approach, data from 12 pathologists (eight NEPTUNE and four non-NEPTUNE) with experience from training to 30 years were collected. A descriptor reference manual was generated and a webinar-based protocol for consensus/cross-training implemented. Intra-reader concordance for 51 glomerular descriptors was evaluated on jpeg images by seven NEPTUNE pathologists scoring 131 glomeruli three times (Tests I, II, and III), each test following a consensus webinar review. Inter-reader concordance of glomerular descriptors was evaluated in 315 glomeruli by all pathologists; interstitial fibrosis and tubular atrophy (244 cases, whole-slide images) and four ultrastructural podocyte descriptors (178 cases, jpeg images) were evaluated once by six and five pathologists, respectively. Cohen’s kappa for inter-reader concordance for 48/51 glomerular descriptors with sufficient observations was moderate (0.40<kappa ≤0.60) for 17 and good (0.60<kappa ≤0.80) for 8, for 52% with moderate or better kappas. Clustering of glomerular descriptors based on similar pathologic features improved concordance. Concordance was independent of years of experience, and increased with webinar cross-training. Excellent concordance was achieved for interstitial fibrosis and tubular atrophy. Moderate-to-excellent concordance was achieved for all ultrastructural podocyte descriptors, with good-to-excellent concordance for descriptors commonly used in clinical practice, foot process effacement, and microvillous transformation. NEPTUNE digital pathology scoring system enables novel morphologic profiling of renal structures. For all histologic and ultrastructural descriptors tested with sufficient observations, moderate-to-excellent concordance was seen for 31/54 (57%). Descriptors not sufficiently represented will require further testing. This study proffers the NEPTUNE digital pathology scoring system as a model for standardization of renal biopsy interpretation extendable outside the NEPTUNE consortium, enabling international collaborations

The prevalence of suicidal ideation identified by the Edinburgh Postnatal Depression Scale in postpartum women in primary care: findings from the RESPOND trial

<p>1 Abstract</p> <p>1.1 Background</p> <p>Suicide is a leading cause of perinatal maternal deaths in industrialised countries but there has been little research to investigate prevalence or correlates of postpartum suicidality. The Edinburgh Postnatal Depression Scale is widely used in primary and maternity services to screen for perinatal depressive disorders, and includes a question on suicidal ideation (question 10). We aimed to investigate the prevalence, persistence and correlates of suicidal thoughts in postpartum women in the context of a randomised controlled trial of treatments for postnatal depression.</p> <p>1.2 Methods</p> <p>Women in primary care were sent postal questionnaires at 6 weeks postpartum to screen for postnatal depression before recruitment into an RCT. The Edinburgh Postnatal Depression Scale (EPDS) was used to screen for postnatal depression and in those with high levels of symptoms, a home visit with a standardised psychiatric interview was carried out using the Clinical Interview Schedule-Revised version (CIS-R). Other socio-demographic and clinical variables were measured, including functioning (SF12) and quality of the marital relationship (GRIMS). Women who entered the trial were followed up for 18 weeks.</p> <p>1.3 Results</p> <p>9% of 4,150 women who completed the EPDS question relating to suicidal ideation reported some suicidal ideation (including hardly ever); 4% reported that the thought of harming themselves had occurred to them sometimes or quite often. In women who entered the randomised trial and completed the EPDS question relating to suicidal ideation (n = 253), suicidal ideation was associated with younger age, higher parity and higher levels of depressive symptoms in the multivariate analysis. Endorsement of 'yes, quite often' to question 10 on the EPDS was associated with affirming at least two CIS-R items on suicidality. We found no association between suicidal ideation and SF-12 physical or mental health or the EPDS total score at 18 weeks.</p> <p>1.4 Conclusions</p> <p>Healthcare professionals using the EPDS should be aware of the significant suicidality that is likely to be present in women endorsing 'yes, quite often' to question 10 of the EPDS. However, suicidal ideation does not appear to predict poor outcomes in women being treated for postnatal depression.</p> <p>Trial registration</p> <p>Current Controlled Trials <a href="http://www.controlled-trials.com/ISRCTN16479417">ISRCTN16479417</a>.</p

Urinary Epidermal Growth Factor as a Marker of Disease Progression in Children With Nephrotic Syndrome.

Introduction: Childhood-onset nephrotic syndrome has a variable clinical course. Improved predictive markers of long-term outcomes in children with nephrotic syndrome are needed. This study tests the association between baseline urinary epidermal growth factor (uEGF) excretion and longitudinal kidney function in children with nephrotic syndrome. Methods: The study evaluated 191 participants younger than 18 years enrolled in the Nephrotic Syndrome Study Network, including 118 with their first clinically indicated kidney biopsy (68 minimal change disease; 50 focal segmental glomerulosclerosis) and 73 with incident nephrotic syndrome without a biopsy. uEGF was measured at baseline for all participants and normalized by the urine creatinine (Cr) concentration. Renal epidermal growth factor (EGF) mRNA was measured in the tubular compartment microdissected from kidney biopsy cores from a subset of patients. Linear mixed models were used to test if baseline uEGF/Cr and EGF mRNA expression were associated with change in estimated glomerular filtration rate (eGFR) over time. Results: Higher uEGF/Cr at baseline was associated with slower eGFR decline during follow-up (median follow-up = 30 months). Halving of uEGF/Cr was associated with a decrease in eGFR slope of 2.0 ml/min per 1.73 m Conclusion: uEGF/Cr may be a useful noninvasive biomarker that can assist in predicting the long-term course of kidney function in children with incident nephrotic syndrome

Bone Marrow Osteoblast Damage by Chemotherapeutic Agents

Hematopoietic reconstitution, following bone marrow or stem cell transplantation, requires a microenvironment niche capable of supporting both immature progenitors and stem cells with the capacity to differentiate and expand. Osteoblasts comprise one important component of this niche. We determined that treatment of human primary osteoblasts (HOB) with melphalan or VP-16 resulted in increased phospho-Smad2, consistent with increased TGF-β1 activity. This increase was coincident with reduced HOB capacity to support immature B lineage cell chemotaxis and adherence. The supportive deficit was not limited to committed progenitor cells, as human embryonic stem cells (hESC) or human CD34+ bone marrow cells co-cultured with HOB pre-exposed to melphalan, VP-16 or rTGF-β1 had profiles distinct from the same populations co-cultured with untreated HOB. Functional support deficits were downstream of changes in HOB gene expression profiles following chemotherapy exposure. Melphalan and VP-16 induced damage of HOB suggests vulnerability of this critical niche to therapeutic agents frequently utilized in pre-transplant regimens and suggests that dose escalated chemotherapy may contribute to post-transplantation hematopoietic deficits by damaging structural components of this supportive niche