How close are we to standardised extended RAS gene mutation testing? The UK NEQAS evaluation

Aims: Since 2008, KRAS mutation status in exon 2 has been used to predict response to anti-EGFR therapies. Recent evidence has demonstrated that NRAS status is also predictive of response. Several retrospective ‘extended RAS’ analyses have been performed on clinical trial material. Despite this, are we really moving towards such extended screening practice in reality? Methods: Data were analysed from four consecutive UK National External Quality Assessment Service for Molecular Genetics Colorectal cancer External Quality Assessment schemes (during the period 2014–2016), with up to 110 laboratories (worldwide) participating in each scheme. Testing of four or five tumour samples is required per scheme. Laboratories provided information on which codons were routinely screened, and provided genotyping and interpretation results for each sample. Results: At least 85% of laboratories routinely tested KRAS codons 12, 13 and 61. Over the four schemes, an increasing number of laboratories routinely tested KRAS codons 59, 117 and 146. Furthermore, more laboratories were introducing next generation sequencing technologies. The pattern of ‘extended testing’ was reassuringly similar for NRAS, although fewer laboratories currently test for mutations in this gene. Alarmingly, still only 36.1% and 24.1% of participating laboratories met the ACP Molecular Pathology and Diagnostics Group and American Society of Clinical Oncology guidelines, respectively, for extended RAS testing in the latest assessment. Conclusions: Despite recommendations in the UK and USA on extended RAS testing, there has clearly been, based on these results, a delay in implementation. Inadequate testing results in patients being subjected to harmful treatment regimens, which would not be the case, were routine practice altered, in line with evidence-based guidelines

Is there an increased risk of falls and fractures in people with early diagnosed hip and knee osteoarthritis? Data from the Osteoarthritis Initiative

Aims: To assess the probability of individuals with early-diagnosed hip or knee osteoarthritis experiencing a fall and/or fracture compared to a cohort without osteoarthritis. Methods: Data were analysed from the Osteoarthritis Initiative dataset. We identified all people who were diagnosed with hip or knee osteoarthritis within a 12 month period, compared to those without osteoarthritis. We determined whether there was a difference in the occurrence of falls, with or without a consequential fractures, between people newly diagnosed with hip or knee osteoarthritis compared to those who had not using odd ratios (OR) and 95% confidence intervals. Results: 552 individuals with hip osteoarthritis were compared to 4244 individuals without hip osteoarthritis. 1350 individuals with knee osteoarthritis were compared to 3445 individuals without knee osteoarthritis. People with knee osteoarthritis had a 54% greater chance of experiencing a fall compared to those without (OR: 1.54; 95% CI: 1.35 to 1.77). People with hip osteoarthritis had a 52% greater chance of experiencing a fall compared to those without hip osteoarthritis (OR: 1.52; 95% CI: 1.26 to 1.84). People with knee and hip osteoarthritis demonstrated over an 80% greater chance of experiencing a fracture in the first 12 months of their diagnosis compared to those without hip or knee osteoarthritis (TKA: OR 1.81; THA: OR 1.84). Conclusions: There is an increased risk of falls and fractures in early-diagnosed knee and hip osteoarthritis compared to those without osteoarthritis. International guidelines on the management of hip and knee osteoarthritis should consider the management of falls-risk

Integrating the digital and the traditional to deliver therapy for depression:lessons from a pragmatic study

Traditional approaches to psychotherapy emphasise face-to-face contact between patients and therapists. In contrast, current computerised approaches tend to minimise this contact. This can limit the range of mental health difficulties for which computerised approaches are effective. Here, we explore an alternative approach that integrates face-to-face contact, electronic contact, online collaboration, and support for between-session activities. Our discussion is grounded in the design of a platform to deliver psychotherapy for depression. We report findings of an 11-month pragmatic study in which 17 patients received treatment for depression via the platform. Results show how design decisions had a significant impact on the dynamics of therapeutic sessions and the establishment of patient-therapist relationships. For example, the use of instant messaging for synchronous, in-session contact slowed communication, but also provided a valuable space for reflection and helped to maintain session focus. We discuss the impact of flexibility and the potential of integrated approaches to both enhance and reduce patient engagement

Access to electronic health records by care setting and provider type: perceptions of cancer care providers in Ontario, Canada

<p>Abstract</p> <p>Background</p> <p>The use of electronic health records (EHRs) to support the organization and delivery of healthcare is evolving rapidly. However, little is known regarding potential variation in access to EHRs by provider type or care setting. This paper reports on observed variation in the perceptions of access to EHRs by a wide range of cancer care providers covering diverse cancer care settings in Ontario, Canada.</p> <p>Methods</p> <p>Perspectives were sought regarding EHR access and health record completeness for cancer patients as part of an internet survey of 5663 cancer care providers and administrators in Ontario. Data were analyzed using a multilevel logistic regression model. Provider type, location of work, and access to computer or internet were included as covariates in the model.</p> <p>Results</p> <p>A total of 1997 of 5663 (35%) valid responses were collected. Focusing on data from cancer care providers (N = 1247), significant variation in EHR access and health record completeness was observed between provider types, location of work, and level of computer access. Providers who worked in community hospitals were half as likely as those who worked in teaching hospitals to have access to their patients' EHRs (OR 0.45 95% CI: 0.24–0.85, p < 0.05) and were six times less likely to have access to other organizations' EHRs (OR 0.15 95% CI: 0.02–1.00, p < 0.05). Compared to surgeons, nurses (OR 3.47 95% CI: 1.80–6.68, p < 0.05), radiation therapists/physicists (OR 7.86 95% CI: 2.54–25.34, p < 0.05), and other clinicians (OR 4.92 95% CI: 2.15–11.27, p < 0.05) were more likely to report good access to their organization's EHRs.</p> <p>Conclusion</p> <p>Variability in access across different provider groups, organization types, and geographic locations illustrates the fragmented nature of EHR adoption in the cancer system. Along with focusing on technological aspects of EHR adoption within organizations, it is essential that there is cross-organizational and cross-provider access to EHRs to ensure patient continuity of care, system efficiency, and high quality care.</p

Developing core elements and checklist items for global hospital antimicrobial stewardship programmes:a consensus approach

International audienc

A multi-centre study of interactional style in nurse specialist- and physician-led Rheumatology clinics in the UK

Background: Nurse-led care is well established in Rheumatology in the UK and provides follow-up care to people with inflammatory arthritis including treatment, monitoring, patient education and psychosocial support. Aim: The aim of this study is to compare and contrast interactional style with patients in physician-led and nurse-led Rheumatology clinics. Design: A multi-centre mixed methods approach was adopted. Settings: Nine UK Rheumatology out-patient clinics were observed and audio-recorded May 2009-April 2010. Participants: Eighteen practitioners agreed to participate in clinic audio-recordings, researcher observations, and note-taking. Of 9 nurse specialists, 8 were female and 5 of 9 physicians were female. Eight practitioners in each group took part in audio-recorded post-clinic interviews. All patients on the clinic list for those practitioners were invited to participate and 107 were consented and observed. In the nurse specialist cohort 46% were female 71% had a diagnosis of Rheumatoid Arthritis (RA). The physician cohort comprised 31% female 40% with RA and 16% unconfirmed diagnosis. Nineteen (18%) of the patients observed were approached for an audio-recorded telephone interview and 15 participated (4 male, 11 female). Methods: Forty-four nurse specialist and 63 physician consultations with patients were recorded. Roter's Interactional Analysis System (RIAS) was used to code this data. Thirty-one semi-structured interviews were conducted (16 practitioner, 15 patients) within 24 h of observed consultations and were analyzed using thematic analysis. Results: RIAS results illuminated differences between practitioners that can be classified as 'socio-emotional' versus 'task-focussed'. Specifically, nurse specialists and their patients engaged significantly more in the socio-emotional activity of 'building a relationship'. Across practitioners, the greatest proportion of 'patient initiations' were in 'giving medical information' and reflected what patients wanted the practitioner to know rather than giving insight into what patients wanted to know from practitioners. Interviews revealed that continuity of practitioner was highly valued by patients as offering the benefits of an established relationship and of emotional support beyond that of the clinical encounter. This fostered familiarity not only with their particular medical history, but also their individual personal circumstances, and this encouraged patient participation. In contrast, practitioners (mis)perceived waiting times to have a greater impact on patient satisfaction. However, practitioner interviews also revealed that clinic structure is often outside of the practitioner control and can undermine the possibility of maintaining patient-practitioner continuity. Conclusions: This research enhances understanding of nurse specialist consultation styles in Rheumatology, specifically the value of their socio-emotional communication skills to enhance patient participation

A systematic review of the concept and clinical applications of Bone Marrow Aspirate Concentrate in Orthopaedics

INTRODUCTION: Mesenchymal stem cells (MSC's) are believed to have multipotent plasticity with the capability to differentiate along multiple cell lineages such as cartilage, bone, tendon, muscle, and nerve. Such multipotency has the potential to play an important role in the repair and reconstruction of multiple tissues across a number of orthopaedic specialties. Bone marrow and fat are the most abundant and accessible source of MSC's with bone marrow aspirate the most commonly being reported to stimulate healing. METHODS: This review examines the current reported 20 Q2 clinical applications of bone marrow aspirate concentrate and its effectiveness. RESULTS: The published studies reported techniques of collection and preparation of BMAC in addition to its applications in a number of orthopaedic sub-specialities. Studies could be sub-categorised into: techniques of extraction, processing and microscopic examination of BMAC (31), reconstruction of osseous defects/non-union (20), treatment of avascular necrosis (9), repair of cartilage defects (8), treatment of sports injuries and tendon injury/repair (9), injection in regenerative therapy (4), treatment of spine conditions (4) including enhancing postoperative fusion and degenerative disc pathology and orthopaedic oncology (4). A few published studies combined the use of platelet-rich plasma (PRP) with BMAC (4) or compared them in different applications (5). CONCLUSIONS: BMAC has been used in bone, cartilage and tendon injuries with encouraging results

Impact of optical coherence tomography on diagnostic decision-making by UK community optometrists: a clinical vignette study.

PURPOSE: In recent years, there has been widespread investment in imaging technologies by community optometrists in the UK, most notably optical coherence tomography (OCT). The aim of the current study was to determine the value of OCT in the diagnosis of posterior segment diseases in a representative sample of community optometrists using a clinical vignette methodology. METHODS: A group of community optometrists (n = 50) initially completed a standardised training package on OCT interpretation followed by a computer-based assessment featuring 52 clinical vignettes, containing images of healthy (n = 8) or glaucomatous (n = 18) discs or healthy (n = 8) or diseased (n = 18) fundi. Each vignette featured either a single fundus/disc photographic image, or a combination of a fundus/disc image with the corresponding OCT scan. An expert panel confirmed that the fundus images presented alone and those in combination with OCT data were of a similar level of difficulty and that the cases were typical of those seen in primary care. For each case, the optometrist selected their diagnosis from a pull-down list and reported their confidence in their decision using a 10-point Likert scale. Pairwise comparisons of the fundus image alone and fundus image/OCT combination were made for both diagnostic performance and confidence. RESULTS: The mean percentage of correct diagnoses using fundus imaging alone was 62% (95% CI 59-64%) and for the combination of fundus image/OCT was 80% (95% CI 77-82%). The mean false negative rate with fundus alone was 27% reducing to 13% with the OCT combination. Median confidence scores for fundus imaging alone was 8.0 (IQR 7.0-8.0) and 8.3 (IQR 8.0-9.0) for the combination. Improvements in performance and confidence were statistically significant (p < 0.001). CONCLUSION: The results from this vignette study suggests that OCT improves optometrists' diagnostic performance compared to fundus observation alone. These initial results suggest that OCT provides valuable additional data that could augment case-finding for glaucoma and retinal disease; however, further research is needed to assess its diagnostic performance in a routine clinical practice setting

Self-management toolkit and delivery strategy for end-of-life pain: the mixed-methods feasibility study

Background: Pain affects most people approaching the end of life and can be severe for some. Opioid analgesia is effective, but evidence is needed about how best to support patients in managing these medicines. Objectives: To develop a self-management support toolkit (SMST) and delivery strategy and to test the feasibility of evaluating this intervention in a future definitive trial. Design: Phase I – evidence synthesis and qualitative interviews with patients and carers. Phase II – qualitative semistructured focus groups and interviews with patients, carers and specialist palliative care health professionals. Phase III – multicentre mixed-methods single-arm pre–post observational feasibility study. Participants: Phase I – six patients and carers. Phase II – 15 patients, four carers and 19 professionals. Phase III – 19 patients recruited to intervention that experienced pain, living at home and were treated with strong opioid analgesia. Process evaluation interviews with 13 patients, seven carers and 11 study nurses. Intervention: Self-Management of Analgesia and Related Treatments at the end of life (SMART) intervention comprising a SMST and a four-step educational delivery approach by clinical nurse specialists in palliative care over 6 weeks. Main outcome measures: Recruitment rate, treatment fidelity, treatment acceptability, patient-reported outcomes (such as scores on the Brief Pain Inventory, Self-Efficacy for Managing Chronic Disease Scale, Edmonton Symptom Assessment Scale, EuroQol-5 Dimensions, Satisfaction with Information about Medicines Scale, and feasibility of collecting data on health-care resource use for economic evaluation). Results: Phase I – key themes on supported self-management were identified from evidence synthesis and qualitative interviews. Phase II – the SMST was developed and refined. The delivery approach was nested within a nurse–patient consultation. Phase III – intervention was delivered to 17 (89%) patients, follow-up data at 6 weeks were available on 15 patients. Overall, the intervention was viewed as acceptable and valued. Descriptive analysis of patient-reported outcomes suggested that interference from pain and self-efficacy were likely to be candidates for primary outcomes in a future trial. No adverse events related to the intervention were reported. The health economic analysis suggested that SMART could be cost-effective. We identified key limitations and considerations for a future trial: improve recruitment through widening eligibility criteria, refine the SMST resources content, enhance fidelity of intervention delivery, secure research nurse support at recruiting sites, refine trial procedures (including withdrawal process and data collection frequency), and consider a cluster randomised design with nurse as cluster unit. Limitations: (1) The recruitment rate was lower than anticipated. (2) The content of the intervention was focused on strong opioids only. (3) The fidelity of intervention delivery was limited by the need for ongoing training and support. (4) Recruitment sites where clinical research nurse support was not secured had lower recruitment rates. (5) The process for recording withdrawal was not sufficiently detailed. (6) The number of follow-up visits was considered burdensome for some participants. (7) The feasibility trial did not have a control arm or assess randomisation processes. Conclusions: A future randomised controlled trial is feasible and acceptable