Co‐creating system‐wide improvement for people with traumatic brain injury across one integrated care system in the United Kingdom to initiate a transformation journey through co‐production

Background and Objective There is a need for better integration of services across communities and sectors for people living with traumatic brain injury (TBI) to meet their complex needs. Building on insights gained from earlier pilot work, here we report the outcomes of a participatory workshop that sought to better understand the challenges, barriers and opportunities that currently exist within the care pathway for survivors of TBI. Methods A diverse range of stakeholders from the acute and rehabilitation care pathway and the health and social care system were invited to participate in a 3-h workshop. The participants worked in four mixed subgroups using practice development methodology, which promotes person-centred, inclusive and participatory action. Results Thematic analysis identified shared purposes and values that were used to produce a detailed implementation and impact framework for application at both the level of the care interface and the overarching integrated care system. A variety of enablers were identified that related to collective values and behaviours, case management, team leadership and integrated team working, workforce capability, evidence-based practice and resourcing. The clinical, economic, cultural and social outcomes associated with these enablers were also identified, and included patient safety, independence and well-being, reduced waiting times, re-admission rates, staff retention and professional development. Conclusion The co-produced recommendations made within the implementation and impact framework described here provide a means by which the culture and delivery of health and social care services can be better tailored to meet the needs of people living with TBI. We believe that the recommendations will help shape the formation of new services as well as the development of existing ones. Patient or Public Contribution Patient and public involvement have been established over a 10-year history of relationship building through a joint forum and events involving three charities representing people with TBI, carers, family members, clinicians, service users, researchers and commissioners, culminating in a politically supported event that identified concerns about the needs of people following TBI. These relationships formed the foundation for the interactive workshop, the focus of this publication

Is an excretory urogram mandatory in patients with small to medium-sized renal and ureteric stones treated by extra corporeal shock wave lithotripsy?

Background: An intravenous urogram (IVU) has traditionally been considered mandatory before treating renal and ureteric stones by extracorporeal shock wave lithotripsy (ESWL). This study was designed to see whether there is a difference in complications and the need for ancillary procedures in patients managed by ESWL for renal and ureteric calculi, according to preoperative imaging technique. Methods: This retrospective study compared 133 patients undergoing ESWL from January 2001 to July 2002. Patients were divided into three groups according to the preoperative imaging technique used: i) IVU; ii) non-contrast enhanced helical computed tomography (UHCT); and iii) ultrasound (US) + X-ray kidney, ureter and bladder (KUB). The groups were matched in terms of age and gender, as well as location, side and size of stones. Results: There was no statistically significantly difference for number of ESWL sessions, number of shock waves and use of ancillary procedures between the three groups. The stone-free rate was 98% for the IVU and UHCT groups, and 97% for the US + X-ray KUB group. Conclusions: The complication rate and need for ancillary procedures was comparable across the three groups. Patients imaged by UHCT or US + X-ray KUB prior to ESWL for uncomplicated renal and ureteric stones do not require IVU

Expression of pS2 in prostate cancer correlates with grade and Chromogranin A expression but not with stage

BACKGROUND: The biological potential of prostate cancer is extremely variable. Particular interest is focused on markers not expressed in normal prostatic tissues. pS2 protein expression has been demonstrated in a range of malignant tissues in an oestrogen-independent pathway. Recently, it has been demonstrated that pS2, in prostate cancer, is closely associated with neuro-endocrine differentiation. In the present study, we have analyzed, the potential of Neuro-endocrine and pS2 (TFF1) expression in human prostate cancer determined by immunohistochemistry, in primary adenocarcinoma of the prostate and attempted to correlate this with the clinico-pathologic features of the patient and neuroendocrine expression. METHODS: Ninety-five malignant prostatic specimens from primary adenocarcinoma, obtained from either transurethral resection of prostate or radical retropubic prostatectomy, from 84 patients between January 1991 and December 1998 were evaluated by immuno-histochemical staining using selected neuroendocrine tumor markers i.e. chromogranin A (CgA) and estrogen inducible pS2 protein. The relationship between the expressions of pS2 was studied with CgA expression, clinical stage (TNM) and tumour grade (Gleason system). Fischer exact test was used for statistical analysis. RESULTS: The mean age of the patients was 70 + /- 9.2 years. The pS2 expression was seen in 10% of primary prostate cancers. Worsening histological grade was associated with greater expression of pS2 (p < 0.001). The expression of CgA was noted in 31% of malignant prostatic tissue. In pS2, positive cases 2/3rd of patients were also CgA +ve. However, there was no significant correlation between pS2 expression and the stage of disease. CONCLUSION: pS2 expression in prostate cancer significantly correlates with histological grade and the neuroendocrine differentiation, as demonstrated by Chromogranin A expression but not with the clinical stage of the disease. However, the overall expression was low consequently; no definitive conclusions can be drawn. We feel further work is required in a larger series, both in primary and metastatic cancer

A Targeted Parathyroidectomy Using Guide Wire Technique in a Pregnant Patient with Primary Hyperparathyroidism

Primary hyperparathyroidism may cause fetal demise in pregnant patients if prompt diagnosis and treatment is not initiated. The paper describes a novel guide wire technique for a targeted parathyroidectomy, which may reduce the risk to mother and fetus and be useful in other related circumstances

Concordance between a neuroradiologist, a consultant radiologist and trained reporting radiographers interpreting MRI head examinations: An empirical study

Introduction: This study assessed agreement between MRI reporting radiographers and a consultant radiologist compared with an index neuroradiologist when reporting MRI head (brain/internal auditory meati [IAMs]) examinations. The effect on patient management of any discordant reports was also examined. Methods: Two trained MRI reporting radiographers (RRs), a consultant radiologist (CR) and an index neuroradiologist (INR) reported on a random sample of 210 MRI examinations. The radiographers reported during clinical practice and the radiologists in clinical practice conditions. Two independent consultant physicians (neuro-rehabilitation and neuropsychiatry) compared these reports with the index neuroradiologist report for agreement and the clinical importance of discrepant reports. Results: Overall observer agreement between the RRs and CR was comparable in relation to agreement with the INR: RR; 93/210 (44.3%); and the CR; 83/210 (39.4%) for all head MRI examinations (p = 0.32). For brain examinations the difference was similar: RR; 64/180 (35.6%); and CR; 54/190 (30.0%), p = 0.26. Agreement rates for the IAMs examinations were identical, 29/30 (97.7%). For all head MRI examinations (n = 210) there was a very small observed difference of <0.5% in mean agreement between the reporting radiographers and the consultant radiologist (p = 0.92) for examinations where a major disagreement would have been likely to have led to a change in patient management. Conclusion: MRI reporting radiographers reported during clinical practice on MRI head examinations to a level of agreement comparable with a consultant radiologist. Implications for practice: This is an area in which radiographers could provide additional reporting roles to the reporting service to increase capacity. Wider potential benefits include cost-effectiveness and role development/retention of radiographers

Encapsulation of olanzapine into beeswax microspheres: preparation, characterization and release kinetics

The objective of the present study was to minimise the unwanted side effects of olanzapine (OZ) drug by kinetic control of drug release by entrapping into gastro resistant, biodegradable waxes such as beeswax (BW) microspheres using meltable emulsified dispersion cooling induced solidification technique utilizing a wetting agent. Solid, discrete, reproducible free flowing microspheres were obtained. The yield of the microspheres was up to 94.0 %. The microspheres had smooth surfaces, with free flowing and good packing properties, indicating that the obtained angle of repose, % Carr’s index and tapped density values were well within the limit. More than 97.0 % of the isolated spherical microspheres were in the particle size range of 312-330 μm were confirmed by scanning electron microscopy (SEM) photographs. The drug loaded in microspheres was stable and compatible, as confirmed by DSC and FTIR studies. The release of drug was controlled for more than 8 h. Intestinal drug release from microspheres was studied and compared with the release behaviour of commercially available formulation Olanex®. The release kinetics followed different transport mechanisms. The drug release from the bees wax microspheres was found sufficient for oral delivery and the drug release profile was significantly affected by the properties of wax used in the preparation of microspheres. These results demonstrate the potential use of wax for the fabrication of controlled delivery devices for many water soluble drugs.Colegio de Farmacéuticos de la Provincia de Buenos Aire

Nano-mechanical single-cell sensing of cell-matrix contacts

Extracellular protein matrices provide a rigidity interface exhibiting nano-mechanical cues that guide cell growth and proliferation. Cells sense such cues using actin-rich filopodia extensions which encourage favourable cell–matrix contacts to recruit more actin-mediated local forces into forming stable focal adhesions. A challenge remains in identifying and measuring these local cellular forces and in establishing empirical relationships between them, cell adhesion and filopodia formation. Here we investigate such relationships using a micromanipulation system designed to operate at the time scale of focal contact dynamics, with the sample frequency of a force probe being 0.1 ms, and to apply and measure forces at nano-to-micro Newton ranges for individual mammalian cells. We explore correlations between cell biomechanics, cell–matrix attachment forces and the spread areas of adhered cells as well as their relative dependence on filopodia formation using synthetic protein matrices with a proven ability to induce enhanced filopodia numbers in adherent cells. This study offers a basis for engineering exploitable cell–matrix contacts in situ at the nanoscale and single-cell levels

Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial.

BACKGROUND: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency. METHODS: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544. FINDINGS: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0·78 [95% CI 0·56-1·09]; p=0·144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0·53 [95% CI -0·97 to -0·08]; p=0·020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1·64 [95% CI 1·22 to 2·20]; p=0·001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6·16 [95% CI 1·48 to 10·84]; p=0·010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4·12 [95% CI -6·35 to -1·89]; p<0·001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1·65 [95% CI -2·96 to -0·35]; p=0·013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1·67 [95% CI -2·90 to -0·44]; p=0·008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0·66 [95% CI 0·26 to 1·04]; p=0·001) and by clinicians (estimated mean difference 0·47 [95% CI 0·21 to 0·73]; p<0·001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0·90 [95% CI 0·48 to 1·31]; p<0·001). No significant differences in patient-reported seizure severity (estimated mean difference -0·11 [95% CI -0·50 to 0·29]; p=0·593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1·77 [95% CI 0·93 to 3·37]; p=0·083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1·27 [95% CI 0·80 to 2·02]; p=0·313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1·78 [95% CI -0·37 to 3·92]; p=0·105; estimated mean difference for the Mental Component Summary score 2·22 [95% CI -0·30 to 4·75]; p=0·084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1·09 [95% CI -2·27 to 0·09]; p=0·069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1·10 [95% CI -2·41 to 0·21]; p=0·099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events. INTERPRETATION: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach. FUNDING: National Institute for Health Research, Health Technology Assessment programme

Public perceptions of demand side management and a smarter energy future

Demand side management (DSM) is a key aspect of many future energy system scenarios1,2. DSM refers to a range of technologies and interventions designed to create greater efficiency and flexibility on the demand side of the energy system3. Examples include the provision of more information to users to support efficient behaviour and new ‘smart’ technologies that can be automatically controlled. Key stated outcomes of implementing DSM are benefits for consumers, such as cost savings3, 4 and greater control over energy use. Here, we use results from an online survey to examine public perceptions and acceptability of a range of current DSM possibilities in a representative sample of the British population (N = 2441). We show that, whilst cost is likely to be a significant reason for many people to uptake DSM measures, those concerned about energy costs are actually less likely to accept DSM. Notably, individuals concerned about climate change are more likely to be accepting. A significant proportion of people, particularly those concerned about affordability, indicated unwillingness or concerns about sharing energy data, a necessity for many forms of DSM. We conclude substantial public engagement and further policy development is required for widespread DSM implementation