Talking to parents about talking to their children about parental mental distress

Non peer reviewedFinal Accepted Versio

Growing up in the new age

This issue of Fieldstudy was published as part of the Growing up in the New Age project. It features the archive photographs of Dave Walkling, made in a 1970s' squatted house in South London and at the Kirkdale Free School. It also presents the photographs of Marjolaine Ryley, who was a child in living in the collective housing photographed by Walkling. Ryley has collected Walkling's photographs, and her own new series is a mediation on history and memory

Models of care for the delivery of secondary fracture prevention after hip fracture:a health service cost, clinical outcomes and cost-effectiveness study within a region of England.

Background Professional bodies have produced comprehensive guidance about the management of hip fracture. They recommend orthogeriatric services focusing on achieving optimal recovery, and fracture liaison services (FLSs) focusing on secondary fracture prevention. Despite such guidelines being in place, there is significant variation in how services are structured and organised between hospitals. Objectives To establish the clinical effectiveness and cost-effectiveness of changes to the delivery of secondary fracture prevention services, and to identify barriers and facilitators to changes. Design A service evaluation to identify each hospital’s current models of care and changes in service delivery. A qualitative study to identify barriers and facilitators to change. Health economics analysis to establish NHS costs and cost-effectiveness. A natural experimental study to determine clinical effectiveness of changes to a hospital’s model of care. Setting Eleven acute hospitals in a region of England. Participants Qualitative study – 43 health professionals working in fracture prevention services in secondary care. Interventions Changes made to secondary fracture prevention services at each hospital between 2003 and 2012. Main outcome measures The primary outcome is secondary hip fracture. Secondary outcomes include mortality, non-hip fragility fracture and the overall rate of hip fracture. Data sources Clinical effectiveness/cost-effectiveness analyses – primary hip fracture patients identified from (1) Hospital Episode Statistics (2003–13, n = 33,152); and (2) Clinical Practice Research Datalink (1999–2013, n = 11,243). Results Service evaluation – there was significant variation in the organisation of secondary fracture prevention services, including staffing levels, type of service model (consultant vs. nurse led) and underlying processes. Qualitative – fracture prevention co-ordinators gave multidisciplinary health professionals capacity to work together, but communication with general practitioners was challenging. The intervention was easily integrated into practice but some participants felt that implementation was undermined by under-resourced services. Making business cases for a service was particularly challenging. Natural experiment – the impact of introducing an orthogeriatrician on 30-day and 1-year mortality was hazard ratio (HR) 0.73 [95% confidence interval (CI) 0.65 to 0.82] and HR 0.81 (95% CI 0.75 to 0.87), respectively. Thirty-day and 1-year mortality were likewise reduced following the introduction or expansion of a FLS: HR 0.80 (95% CI 0.71 to 0.91) and HR 0.84 (95% CI 0.77 to 0.93), respectively. There was no significant impact on time to secondary hip fracture. Health economics – the annual cost in the year of hip fracture was estimated at £10,964 (95% CI £10,767 to £11,161) higher than the previous year. The annual cost associated with all incident hip fractures in the UK among those aged ≥ 50 years (n = 79,243) was estimated at £1215M. At a £30,000 per quality-adjusted life-year threshold, the most cost-effective model was introducing an orthogeriatrician. Conclusion In hip fracture patients, orthogeriatrician and nurse-led FLS models are associated with reductions in mortality rates and are cost-effective, the orthogeriatrician model being the most cost-effective. There was no evidence for a reduction in second hip fracture. Qualitative data suggest that weaknesses lie in treatment adherence/monitoring, a possible reason for the lack of effectiveness on second hip fracture outcome. The effectiveness on non-hip fracture outcomes remains unanswered. Future work Reliable estimates of health state utility values for patients with hip and non-hip fractures are required to reduce uncertainty in health economic models. A clinical trial is needed to assess the clinical effectiveness and cost-effectiveness of a FLS for non-hip fracture patients. Funding The National Institute for Health Research (NIHR) Health Services and Delivery Research programme and the NIHR Musculoskeletal Biomedical Research Unit, University of Oxford

The impact of diagnostic microbiology on de-escalation of antimicrobial therapy in hospitalised adults.

BACKGROUND: Minimising antimicrobial overuse is needed to limit antimicrobial resistance. There is little evidence on how often microbiological testing informs antimicrobial de-escalation (e.g. stopping, shortening duration, switching to narrower spectrum or intravenous to oral switch) at 48-72 h "review and revise". We performed a patient level analysis of diagnostic microbiology and antimicrobial prescribing to determine the impact of microbiology results on antimicrobial review outcomes. METHODS: Antimicrobial prescribing data were collected for hospitalised adults from across Brighton and Sussex University Hospitals NHS Trust using routine monthly audits of prescribing practice from July 2016 to April 2017. Microbiology testing data for cultures of blood, urine, sputum and cerebrospinal fluid (CSF) were gathered from the hospital pathology database and linked to prescriptions with matching patient identification codes. Antimicrobial prescriptions were grouped into "prescription episodes" (PEs), defined as one or more antimicrobials prescribed to the same patient for the same indication. Medical records were reviewed for all PEs with positive microbiology and a randomised sample of those with negative results to assess the impact of the microbiology result on the antimicrobial prescription(s). RESULTS: After excluding topical and prophylactic prescriptions, data were available for 382 inpatient antimicrobial prescriptions grouped into 276 prescription episodes. 162/276 (59%) had contemporaneous microbiology sent. After filtering likely contaminants, 33/276 (12%) returned relevant positive results, of which 20/33 (61%) had antimicrobials changed from empiric therapy as a result with 6/33 (18%) prompting de-escalation. Positive blood and CSF tended to have greater impact than urine or sputum cultures. 124/276 (45%) PEs returned only negative microbiology, and this was documented in the medical notes less often (9/40, 23%) than positive results (28/33, 85%). Out of 40 reviewed PEs with negative microbiology, we identified just one (~ 3%) in which antimicrobials were unambiguously de-escalated following the negative result. CONCLUSIONS: The majority of diagnostic microbiology tests sent to inform clinical management yielded negative results. However, negative microbiology contributed little to clinical decision making about antimicrobial de-escalation, perhaps reflecting a lack of trust in negative results by treating clinicians. Improving the negative predictive value of currently available diagnostic microbiology could help hospital prescribers in de-escalating antimicrobial therapy

Geographic variation in secondary fracture prevention after a hip fracture during 1999-2013:a UK study

Purpose To describe the geographic variation in anti-osteoporosis drug therapy prescriptions before and after a hip fracture during 1999-2013 in the UK. Methods We used primary care data (Clinical Practice Research Datalink) to identify patients with a hip fracture and primary care prescriptions of any anti-osteoporosis drugs prior to the index hip fracture and up to five years after. Geographic variations in prescribing before and after availability of generic oral bisphosphonates were analysed. Multivariable logistic regression models were adjusted for gender, age and body mass index (BMI). Results 13,069 patients (76% female) diagnosed with a hip fracture during 1999-2013 were identified. 11% had any anti-osteoporosis drug prescription in the six months prior to the index hip fracture. In the 0-4 months following a hip fracture 5% of patients were prescribed anti-osteoporosis drugs in 1999, increasing to 51% in 2011 to then decrease to 39% in 2013. The independent predictors (OR (95%CI)) of treatment initiation included gender (male:0.42 (0.36-0.49)), BMI (0.98 per kg/m2 increase (0.97-1.00)) and geographic region (1.29 (0.89-1.87) North East vs. 0.56(0.43-0.73) South Central region). Geographic differences in prescribing persisted over the 5-year follow-up. If all patients were treated at the rate of the highest performing region, then nationally an additional 3,214 hip fracture patients would be initiated on therapy every year. Conclusions Significant geographic differences exist in prescribing of anti-osteoporosis drugs after hip fracture despite adjustment for potential confounders. Further work examining differences in health care provision may inform strategies to improve secondary fracture prevention after hip fracture. </p

Stability testing of the Pfizer-BioNTech BNT162b2 COVID-19 vaccine: a translational study in UK vaccination centres

Objective - The roll-out of the Pfizer-BioNTech BNT162b2 COVID-19 vaccine has brought many logistical challenges, such as the absence of comprehensive stability data leading to strict handling instructions during dilution and administration. Accidental mishandling therefore presents challenging clinical dilemmas, which often led vaccine providers to err on the side of caution and discard mishandled vials rather than risk administering ineffective vaccine. This study aims to answer key questions about the vaccine’s stability to allow for a more informed decision-making process should a non-conformity occur. Methods - Residual vaccine in freshly used, but appropriately stored vials collected from vaccination centres in Brighton, UK, were tested after exposure to various handling conditions and analysed by dynamic light scattering to determine the size of the lipid-mRNA nanoparticles, and gel electrophoresis to visualise the mRNA integrity and separation from the lipid formulation. Results - Knocking or dropping vaccine samples from small heights resulted in lowest levels of instability, indicating low risk of compromising clinical efficacy. However, repeated drawing and injecting through 23 G needles at high speed and, more significantly, shaking and vortexing led to progressive increase in the size and polydispersity index of the lipid-mRNA nanoparticles, coupled with or caused by up to ~50% release of mRNA from the lipid formulation. This is thought to impact the vaccine’s efficacy due to lack of free mRNA protection and cellular internalisation. Conclusions - These results reiterate the importance of adhering to the manufacturer’s instructions on handling, especially with regard to shaking and exposing the vaccine to excessive vibration

Living in chronic times [Curator]

‘Living In Chronic Times’ responds to “a contemporary ‘war’ on death”. Through a comprehensive investigation with an interdisciplinary survey of arts and health practitioners, Lippett aims to question the cause and affect of a chronically ‘death anxious’ population. She will highlight the paradoxical relationship between false understandings of mortality as a ‘curable’ human condition, particularly at a time of acute funding cuts to the NHS resulting in longer waiting times, dehumanised ‘care’ and an uncanny ‘acceptance’ of unethical or undignified endings. A multilayered project, ‘Living In Chronic Times’ will investigate such false understandings in relation to the recent phenomena of digital legacy and death services that Lippett suggests manipulate contemporary death anxiety in order to profit from our growing web-based labour before, and after, we die. Thursday 7th July / Deptford Cinema, London Screening (1) Oreet Ashery, ’Revisiting Genesis’ (x12 episodes) with supporting film by Duncan Loudon Curator led Panel Discussion. Panel: Oreet Ashery (Artist and Director) Martin O’Brien (Bambi) Vanda Playford (Nurse Jackie) Duncan Loudan (Artist) Tuesday 12th July / Chisenhale Studios, London Workshop 1 : Chronic Time / Ethics Of Care 3 talks and curator led panel discussion Sarah Lippett, ‘Time, Storytelling, Illness and Death’ Martin O’Brien, ’Performing The Chronic Body’ Lisa Baraitser and Laura Salisbury, ‘Waiting Times: Waiting and Care in the Time of Modernity’ Wednesday 13th July / Chisenhale Studios Workshop 2 : Digital Ethics Exhibition: Sarah Derat, ‘Birth Of Anaesthesia’, Video Installation, 2012 Evening: Talk between curator and artist Sarah Derat Thursday 14th July / Chisenhale Studios Workshop 3 : (Anti) Ageing Reading Group: Lynne Segal: ‘Out Of Time : The Pleasures and Perils of Ageing’ Deptford Cinema, London Screening (2) In collaboration with the Richard Saltoun Gallery, London Friedl Kubelka, ‘Me too, too, me too’ and Other Stories (45 mins) and curatorial talk Friday 15th July Workshop 4 : Dawn of The (Digital) Dead ’Digital Legacy Writing Workshop’ led by Samantha Lippett Rachel McRae, ‘Level 350’, Performance and Q&A Saturday 16th July Workshop 5 : Endings / Breaking The Taboo Reading group with texts by: Marion Coutts, ‘The Iceberg : A Memoir’ Atul Gawande, ‘Being Mortal : Medicine and What Matters In The End’ Emma Berentsen, ‘The Last Supper’, Performative Dinner Thomas Cameron, ’At 6 with 7’, Sound Performance and Drinks Ceremon

Digital&Dead at South London Gallery [Curator]

The event considered recent psychosocial shifts in our relationship with death following the growth of digital communication and social media. Inspired by the recent development of memorial websites and the ‘Facebook graveyard’, participants are invited to consider their own digital legacies through a demonstration of Rachel McRae's and Sarah Derat's Augmented Reality work Digital&Dead (2017), as well as a part-screening of the award winning Revisiting Genesis (2016) by artist Oreet Ashery. Has the algorithm made us eternal, or undead and what is the appropriate way to memorialise the deceased, post-body, in an age after the Internet