The Universal Form of Treatment Options (UFTO) as an alternative to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders: a mixed methods evaluation of the effects on clinical practice and patient care.

AIMS: To determine whether the introduction of the Universal Form of Treatment Options (the UFTO), as an alternative approach to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) orders, reduces harms in patients in whom a decision not to attempt cardiopulmonary resuscitation (CPR) was made, and to understand the mechanism for any observed change. METHODS: A mixed-methods before-and-after study with contemporaneous case controls was conducted in an acute hospital. We examined DNACPR (103 patients with DNACPR orders in 530 admissions) and UFTO (118 decisions not to attempt resuscitation in 560 admissions) practice. The Global Trigger Tool was used to quantify harms. Qualitative interviews and observations were used to understand mechanisms and effects. RESULTS: RATE OF HARMS IN PATIENTS FOR WHOM THERE WAS A DOCUMENTED DECISION NOT TO ATTEMPT CPR WAS REDUCED: Rate difference per 1000 patient-days was 12.9 (95% CI: 2.6-23.2, p-value=0.01). There was a difference in the proportion of harms contributing to patient death in the two periods (23/71 in the DNACPR period to 4/44 in the UFTO period (95% CI 7.8-36.1, p-value=0.006). Significant differences were maintained after adjustment for known confounders. No significant change was seen on contemporaneous case control wards. Interviews with clinicians and observation of ward practice revealed the UFTO helped provide clarity of goals of care and reduced negative associations with resuscitation decisions. CONCLUSIONS: Introducing the UFTO was associated with a significant reduction in harmful events in patients in whom a decision not to attempt CPR had been made. Coupled with supportive qualitative evidence, this indicates the UFTO improved care for this vulnerable group. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN85474986 UK Comprehensive Research Network Portfolio 7932

Case finding for dementia during acute hospital admissions: a mixed-methods study exploring the impacts on patient care after discharge and costs for the English National Health Service

Abstract Objective: Between 2012 and 2017 dementia case-finding was routinely carried out on people aged 75 and over with unplanned admissions to acute hospitals across England. The assumption was that this would lead to better planning of care and treatment for patients with dementia following discharge from hospital. However, little is known about the experiences of patients and carers or the impacts on other health services. This study explored the impact of dementia case-finding on older people and their families and on their use of services. Design: Thematic content analysis was conducted on qualitative interview data and costs associated with service use were estimated. Measures included the Mini-Mental State Examination (MMSE), the EuroQol (EQ-5D-5L) quality of life scale and a modified Client Service Receipt Inventory (CSRI). Setting: Four counties in the East of England. Participants: People aged ≥75-years who had been identified by case-finding during an unplanned hospital admission as warranting further investigation of possible dementia and their family carers. Results: We carried out 28 interviews, including 19 joint patient-carer(s), 5 patient only and 4 family carer interviews. Most patients and carers were unaware that memory assessments had taken place, with many families not being informed or involved in the process. Participants had a variety of views on memory testing in hospital and had concerns about how hospitals carried out assessments and communicated results. Overall, case-finding did not lead to general practitioner (GP) follow up after discharge home or lead to referral for further investigation. Few services were initiated because of dementia case-finding in hospital. Conclusions: This study shows that dementia case-finding may not lead to increased GP follow up or service provision for patients after discharge from hospital. There is a need for a more evidence-based approach to the initiation of mandatory initiatives such as case-finding that inevitably consume stretched human and financial resources

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Kondisi dan Variasi Bentuk Pertumbuhan Terumbu Karang di Area Pesisir Bandara Rendani, Manokwari, Indonesia

Coral reefs are unique ecosystems and only occur in the tropics area. Diversity, distribution, and coral growth are influenced by environmental factors. Coral colonies morphologies or coral lifeform rates vary significantly between species and between environmental factors. This study aimed to determine the variations of hard coral based on their lifeform; and assess the condition of reefs by measuring the percent cover of live coral in the coastal area of Rendani Airport. Coral cover and coral damage data gathering used a survey approach with Point Intercept Transect (PIT) method. The results showed the variations of coral lifeform in the coastal area of Rendani was relatively low, as indicated by the absence of some coral lifeforms in the study site. The most variation lifeform was found at 7m depth with five lifeforms, while the lowest was found at 3m depth with three lifeforms. The live coral cover reached 77,66% at station 1 and 75,00% at station 2, and the lowest coverage was 11,33% at station 3. The highest average of rubble at station 1 at 4.33% and dead coral with algae was found to be highest at station 3 at 8.00%.Terumbu karang merupakan ekosistem yang unik dan hanya ditemukan didaerah tropis. Keanekaragaman, distribusi, dan pertumbuhan karang dipengaruhi oleh faktor lingkungan. Morfologi koloni karang atau bentuk pertumbuhan sangat bervariasi antara spesies dan antara faktor lingkungan. Penelitian ini bertujuan untuk mengetahui variasi karang keras berdasarkan bentuk pertumbuhannya; dan menilai kondisi terumbu karang dengan mengukur persen tutupan karang di wilayah pesisir Bandara Rendani. Pengumpulan data tutupan karang dan kerusakan karang menggunakan metode Point Intercept Transect (PIT). Hasil penelitian menunjukkan variasi bentuk pertumbuhan karang di wilayah pesisir Rendani relatif rendah, seperti yang ditunjukkan dengan tidak ditemukannya beberapa bentuk pertumbuhan karang di lokasi studi. Bentuk pertumbuhan yang paling bervariasi ditemukan pada kedalaman 7m dengan lima bentuk pertumbuhan, sedangkan yang terendah ditemukan pada kedalaman 3m dengan tiga bentuk pertumbuhan. Tutupan karang hidup mencapai 77,66% di stasiun 1 dan 75,00% di stasiun 2, dan presentase terendah 11,33% di stasiun 3. Patahan karang tertinggi di stasiun 1 sebesar 4,33% dan karang mati dengan alga tertinggi ditemukan di stasiun 3 sebesar 8,00%

The use of real-time digital video in the assessment of post-operative outcomes of breast reconstruction

Introduction: Outcome measures of breast reconstruction have used panel assessment of photographs. This provides limited information to the assessor as these images are static.. The aim of this study was to assess whether the use of digital video was a valid assessment tool and to compare its use against photography. Methods: 35 patients post-reconstruction underwent photography, digital video capture and completed Breast Cancer Treatment Outcomes Scale (BCTOS) questionnaires. The photographs/video clips were randomised and shown to a 21 member panel. Opinions on aesthetic aspects of the reconstruction were assessed using the BCTOS and Harris scale. Panel inter-rater agreement and patient-panel correlation was assessed using Kendall's Coefficient of Concordance and Spearman's rank correlation tests respectively. Results: There was a “moderate” degree of inter-rater agreement amongst panel members in all categories. Greater agreement occurred using video footage to assess overall cosmesis (0.548 vs 0.507) and shape (0.505 vs 0.486). Video showed a greater degree of correlation with patient self-assessment scores in comparison to photography (0.311 vs 0.281). Conclusion: Video footage coupled with panel assessment is a valid method of assessing post-operative outcomes of breast reconstruction and appears superior to still photographs in terms of inter-rater agreement and correlation with patient self-assessment