Turning the gaze:Digital patient feedback and the silent pathology of the NHS

Online review and rating sites, where patients can leave feedback on their experience of the health-care encounter, are becoming an increasing feature of primary care in the NHS. Previous research has analysed how digital surveillance is re-shaping the clinical gaze, as health-care professionals are subject to increased public monitoring. Here, we draw on an empirical study of 41 GP practice staff to show how the gaze is turning, not simply from the patient to the health-care provider, but additionally to the body politic of the NHS. Drawing on focus group and interview data conducted in five UK practices, we show how discourses of online reviews and ratings are producing new professional subjectivities among health-care professionals and the extent to which the gaze extends not only to individual health-care interactions but to the health-care service writ large. We identify three counter-discourses characterising the evolving ways in which online reviews and ratings are creating new subjects in primary care practices: victimhood, prosumption versus traditional values and taking control. We show how the ways in which staff speak about online feedback are patterned by the social environment in which they work and the constraints of the NHS they encounter on a day-to-day basis

Case-based review and olinical guidance on the use of genomic assays for early-stage breast cancer: Breast Cancer Therapy Expert Group (BCTEG)

In addition to classical clinicopathologic factors, such as hormone receptor positivity, human epidermal growth factor receptor 2 (HER2) status, and tumor size, grade, and lymph node status, a number of commercially available genomic tests may be used to help inform treatment decisions for early breast cancer patients. Although these tests improve our understanding of breast cancer and help to individualize treatment decisions, clinicians face challenges when deciding on the most appropriate test to order, and the advantages, if any, of one test over another. The Breast Cancer Therapy Expert Group (BCTEG) recently convened a roundtable meeting to discuss issues surrounding the use of genomic testing in early breast cancer, with the goal of providing practical guidance on the use of these tests by the community oncologist, for whom breast cancer may be only one of many tumor types they treat. The group recognizes that genomic testing can provide important prognostic (eg, risk for recurrence), and in some cases predictive, information (eg, benefit of chemotherapy, or extended adjuvant endocrine therapy), which can be used to help guide treatment decisions in breast cancer. The available tests differ in the types of information they provide, and in the patient populations and clinical trials that were conducted to validate them. We summarize the discussion of the BCTEG on this topic, and we also consider several patient cases and clinical scenarios in which genomic testing may, or may not, be useful to guide treatment decisions for the practicing community oncologist

La participación ciudadana en la investigación desde la perspectivade investigadores de atención primaria

Objetivo: Explorar las debilidades, amenazas, fortalezas y oportunidades (DAFO) para el desarrollo de la participación de la ciudadanía en los proyectos de investigación gestionados por el Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol) según los investigadores de atención primaria de salud de Catalu ̃na.Método: Estudio transversal realizado en 2017 con 36 equipos de investigación de atención primaria de salud acreditados por el IDIAPJGol y su personal de gestión. Se dise ̃nó y pilotó un cuestionario abierto(papel y online) para desarrollar una técnica DAFO. Se obtuvieron 65 respuestas (14 en papel y 51 online).Se realizó un análisis de contenido temático.Resultados: La mayoría de informantes considera la participación de la ciudadanía en la investigació nuna estrategia útil, innovadora, viable e imprescindible, pero exige un cambio de mentalidad y un alejamiento del paradigma jerárquico. Puede ser difícil su ejecución y complicar los estudios. Les preocupa a qué ciudadanos implicar, cómo seleccionarlos, los posibles conflictos de intereses y las necesidades deformación. Las principales propuestas para su implementación son difundir estrategias previas, fomentar la motivación y las sinergias entre ciudadanos, investigadores e instituciones, y clarificar los roles delos actores implicados. El IDIAPJGol debería elaborar recomendaciones para la participación de la ciudadanía en la investigación, incentivar su inclusión, disponer de un referente y asesorar a los equipos investigadores. Conclusiones: A pesar de los retos, desarrollar la participación de la ciudadanía en la investigación en atención primaria de salud es imprescindible y factible, pero partiendo de una estrategia participativa con todos los actores. La ciudadanía puede participar en cualquier dise ̃no y fase de la investigación adaptando cada proyecto, siendo la atención primaria un ámbito privilegiado para desarrollar la participación ciudadana en la investigación.Objective: Explore the strengths, weaknesses, opportunities and threats (SWOT) for development of public involvement in research by Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol) according to primary health care researchers in Catalonia (Spain). Methods: Cross-sectional study carried out in 2017 with 36 primary health care research teams accredited by IDIAPJGol and its management staff. An open questionnaire (paper and online) was designed and piloted to develop a SWOT technique, and 65 answers were obtained (14 in paper and 51 online). A thematic content analysis was carried out. Results: Most informants consider public involvement in research a useful, innovative, viable and essential strategy, but it requires a change of mentality and a move away from the hierarchical paradigm. It can be difficult to execute and can complicate studies. They are concerned about which citizens should be involve, how to select them, possible conflicts of interest and training needs. The main proposals for its implementation are to disseminate previous strategies, encourage motivation and synergies among citizens, researchers and institutions, and to clarify the roles of the actors involved. IDIAPJGol should develop recommendations for the public involvement in research, encourage their inclusion, have a mentor and advise the research teams. Conclusions: Despite the challenges, developing public involvement in research in primary health care is essential and feasible, what it is more should be based on a participatory strategy with all actors. The citizens can participate in any kind of design and phase of the research, adapting each project, being the primary health care a privileged area to develop the public involvement in research

Locomotor Kinematics and Kinetics Following High-Intensity Stepping Training in Variable Contexts Poststroke

Background and Purpose Previous studies suggest individuals post-stroke can achieve substantial gains in walking function following high-intensity locomotor training (LT). Recent findings also indicate practice of variable stepping tasks targeting locomotor deficits can mitigate selected impairments underlying reduced walking speeds. The goal of this study was to investigate alterations in locomotor biomechanics following three different LT paradigms. Methods This secondary analysis of a randomized trial recruited individuals 18–85 years old and >6 months post-stroke. We compared changes in spatiotemporal, joint kinematics and kinetics following up to 30 sessions of high-intensity (>70% heart rate reserve [HRR]) LT of variable tasks targeting paretic limb and balance impairments (high-variable, HV), high-intensity LT focused only on forward walking (high-forward, HF), or low-intensity LT (<40% HRR) of variable tasks (low-variable, LV). Sagittal spatiotemporal and joint kinematics, and concentric joint powers were compared between groups. Regressions and principle component (PC) analyses were conducted to evaluate relative contributions or importance of biomechanical changes to between and within groups. Results Biomechanical data were available on 50 participants who could walk ≥0.1 m/s on a motorized treadmill. Significant differences in spatiotemporal parameters, kinematic consistency, and kinetics were observed between HV and HF vs LV. Resultant PC analyses were characterized by paretic powers and kinematic consistency following HV, while HF and LV were characterized by non-paretic powers. Conclusion High-intensity LT results in greater changes in kinematics and kinetics as compared to lower-intensity interventions. The results may suggest greater paretic-limb contributions with high-intensity variable stepping training that targets specific biomechanical deficits

Transseptal puncture for left atrial ablation: Risk factors for cardiac tamponade and a proposed causative classification system

AIMS: Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the associations of TSP‐related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our center from 2016 to 2020. METHODS AND RESULTS: Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinized to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. A total of 3239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP‐related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above‐median age [odds ratio (OR): 2.4 (1.19–4.2), p = .006] and those undergoing re‐do procedures [OR: 1.95 (1.29–3.43, p = .042] were at higher risk of TRCT. Of the operator‐dependent variables, choice of transseptal needle (Endrys vs. Brockenbrough, p > .1) or puncture sheath (Swartz vs. Mullins vs. Agilis vs. Vizigo vs. Cryosheath, all p > .1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk [OR: 4.42 (2.45–8.2), p = .001], whilst top quartile operator experience [OR: 0.4 (0.17–0.85), p = .002], transoesophageal echocardiogram [TOE prevalence: 26%, OR: 0.51 (0.11–0.94), p = .023], and use of the SafeSept transseptal guidewire [OR: 0.22 (0.08–0.62), p = .001] reduced TRCT risk. An increase in transseptal guidewire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R (2) = 0.72, p < .001) and was associated with a relative risk reduction of 70%. CONCLUSIONS: During left atrial ablation, the risk of TRCT was reduced by operator experience, TOE‐guidance, and use of a transseptal guidewire, and was increased by patient age, re‐do procedures, and failure to cross the septum first pass

Golf Swing Rotational Velocity: The Essential Follow-Through

Objective To evaluate if shoulder and pelvic angular velocities differ at impact or peak magnitude between professional and amateur golfers. Golf swing rotational biomechanics are a key determinant of power generation, driving distance, and injury prevention. We hypothesize that shoulder and pelvic angular velocities would be highly consistent in professionals. Methods Rotational velocities of the upper-torso and pelvis throughout the golf swing and in relation to phases of the golf swing were examined in 11 professionals and compared to 5 amateurs using three-dimensional motion analysis. Results Peak rotational velocities of professionals were highly consistent, demonstrating low variability (coefficient of variation [COV]), particularly upper-torso rotational velocity (COV=0.086) and pelvic rotational velocity (COV=0.079) during down swing. Peak upper-torso rotational velocity and peak X-prime, the relative rotational velocity of uppertorso versus pelvis, occurred after impact in follow-through, were reduced in amateurs compared to professionals (p=0.005 and p=0.005, respectively) and differentiated professionals from most (4/5) amateurs. In contrast, peak pelvic rotational velocity occurred in down swing. Pelvic velocity at impact was reduced in amateurs compared to professionals (p=0.019) and differentiated professionals from most (4/5) amateurs. Conclusion Golf swing rotational velocity of professionals was consistent in pattern and magnitude, offering benchmarks for amateurs. Understanding golf swing rotational biomechanics can guide swing modifications to help optimize performance and prevent injury

The Blister Score: A Novel, Externally Validated Tool for Predicting Cardiac Implantable Electronic Device Infections, and Its Cost-utility Implications for Antimicrobial Envelope Use.

Background: Antimicrobial envelopes reduce the incidence of cardiac implantable electronic device (CIED) infections, but their cost restricts routine use in the UK. Risk scoring could help identify which patients would most benefit from this technology. Methods: A novel risk score (BLISTER) was derived from multivariate analysis of factors associated with CIED infection. Diagnostic utility was assessed against the existing PADIT score in both standard and high-risk external validation cohorts, and cost-utility models examined different BLISTER and PADIT score thresholds for TYRXTM antimicrobial envelope (AE) allocation. Results: In a derivation cohort (n=7,383), CIED infection occurred in 59 individuals within 12 months of a procedure (event rate: 0.8%). In addition to the PADIT score constituents, lead extraction (HR 3.3 (1.9-6.1), p50mg/l (HR 3.0 (1.4-6.4), p=0.005), re-intervention within two years (HR 10.1 (5.6-17.9), p<0.0001), and top-quartile procedure duration (HR 2.6 (1.6-4.1), p=0.001) were independent predictors of infection. The BLISTER score demonstrated superior discriminative performance versus PADIT in the standard-risk (n=2,854, event rate: 0.8%, AUC 0.82 vs 0.71, p=0.001) and high-risk validation cohorts (n=1,961, event rate: 2.0%, AUC 0.77 vs 0.69, p=0.001), and in all patients (n=12,198, event rate: 1%, AUC 0.8 vs 0.75, p=0.002). In decision-analytic modelling, the optimum scenario assigned AEs to patients with BLISTER scores ≥ 6 (10.8%), delivering a significant reduction in infections (relative risk reduction: 30%, p=0.036) within the NICE cost-utility thresholds (ICER: ￡18,446). Conclusions: The BLISTER score (https://qxmd.com/calculate/calculator_876/the-blister-score-for-cied-infection) was a valid predictor of CIED infection, and could facilitate cost-effective AE allocation to high-risk patients

An international modified Delphi process supported updating the web-based "right review" tool

Objectives: The proliferation of evidence synthesis methods makes it challenging for reviewers to select the ‘‘right’’ method. This study aimed to update the Right Review tool (a web-based decision support tool that guides users through a series of questions for recommending evidence synthesis methods) and establish a common set of questions for the synthesis of both quantitative and qualitative studies (https://rightreview.knowledgetranslation.net/). Study Design and Setting: A 2-round modified international electronic modified Delphi was conducted (2022) with researchers, health-care providers, patients, and policy makers. Panel members rated the importance/clarity of the Right Review tool's guiding questions, evidence synthesis type definitions and tool output. High agreement was defined as at least 70% agreement. Any items not reaching high agreement after round 2 were discussed by the international Project Steering Group. Results: Twenty-four experts from 9 countries completed round 1, with 12 completing round 2. Of the 46 items presented in round 1, 21 reached high agreement. Twenty-seven items were presented in round 2, with 8 reaching high agreement. The Project Steering Group discussed items not reaching high agreement, including 8 guiding questions, 9 review definitions (predominantly related to qualitative synthesis), and 2 output items. Three items were removed entirely and the remaining 16 revised and edited and/or combined with existing items. The final tool comprises 42 items; 9 guiding questions, 25 evidence synthesis definitions and approaches, and 8 tool outputs. Conclusion: The freely accessible Right Review tool supports choosing an appropriate review method. The design and clarity of this tool was enhanced by harnessing the Delphi technique to shape ongoing development. The updated tool is expected to be available in Quarter 1, 2025

Use of cyclin-dependent kinase (CDK) 4/6 inhibitors for hormone receptor-positive, human epidermal growth factor receptor 2-negative, metastatic breast cancer: a roundtable discussion by The Breast Cancer Therapy Expert Group (BCTEG)

Purpose: To provide an overview of clinical data supporting the use of cyclin-dependent kinases 4 and 6 (CDK 4/6) inhibitors in the treatment of hormone receptor-positive (HR+), human epidermal growth factor receptor 2-negative (HER2−), metastatic breast cancer (mBC), from the perspective of the practicing oncologist community. Methods: A recent roundtable discussion was convened by The Breast Cancer Therapy Expert Group (BCTEG) to review existing data on this topic and its impact on their current practice. Results: Level 1 evidence now supports use of a CDK 4/6 inhibitor in combination with endocrine therapy for patients with HR+, HER2−, mBC. Currently, there are no biomarkers that reliably define patients who will, or will not, benefit from the addition of a CDK 4/6 inhibitor to their endocrine therapy. Additional research is needed to identify the optimal sequencing of CDK 4/6 inhibitors in relation to other therapies as well as the optimal duration of therapy; at present, evidence suggests that use in the upfront setting is better than waiting for a later line of therapy, or adding after endocrine therapy has started. Conclusions: Thus far, three CDK 4/6 inhibitors—palbociclib, ribociclib, and more recently, abemaciclib—have been approved for use in the setting of HR+, HER2−, mBC. The degrees to which these agents differ in terms of CDK4/6 affinity, side-effect profiles, dosing, degree of central nervous system (CNS) penetration, optimal use in combination with antiestrogen therapy, and across other subsets of breast cancer, remain an active area of investigation