Assessment of background levels of autoantibodies as a prognostic marker for severe SARS-CoV-2 infection

This project was funded by The Lung Foundation.Background : Patients with more severe forms of SARS-CoV-2 exhibit activation of immunological cascades. Participants (current or ex-smokers with at least 20 years pack history) in a trial (Early Diagnosis of Lung Cancer, Scotland [ECLS]) of autoantibody detection to predict lung cancer risk had seven autoantibodies measured 5 years before the pandemic. This study compared the response to Covid infection in study participants who tested positive and negative to antibodies to tumour-associated antigens: p53, NY-ESO-1, CAGE, GBU4-5, HuD, MAGE A4 and SOX2. Methods : Autoantibody data from the ECLS study was deterministically linked to the EAVE II database, a national, real-time prospective cohort using Scotland’s health data infrastructure, to describe the epidemiology of SARS-CoV-2 infection, patterns of healthcare use and outcomes. The strength of associations was explored using a network algorithm for exact contingency table significance testing by permutation. Results : There were no significant differences discerned between SARS-CoV-2 test results and EarlyCDT-Lung test results (p = 0.734). An additional analysis of intensive care unit (ICU) admissions detected no significant differences between those who tested positive and negative. Subgroup analyses showed no difference in COVID-19 positivity or death rates amongst those diagnosed with chronic obstructive pulmonary disease (COPD) with positive and negative EarlyCDT results. Conclusions : This hypothesis-generating study demonstrated no clinically valuable or statistically significant associations between EarlyCDT positivity in 2013-15 and the likelihood of SARS-CoV-2 positivity in 2020, ICU admission or death in all participants (current or ex-smokers with at least 20 years pack history) or in those with COPD or lung cancer.Publisher PDFPeer reviewe

Point-of-care tests for urinary tract infections : protocol for a systematic review and meta-analysis of diagnostic test accuracy

Funding: DFN is supported by an NES general practice academic fellowship, AAL is supported by an HDR UK clinical postdoctoral fellowship and VHS is supported by an NRS clinical academic fellowship.Introduction Urinary tract infections (UTIs) are the second most common type of infection worldwide, accounting for a large number of primary care consultations and antibiotic prescribing. Current diagnosis is based on an empirical approach, relying on symptoms and occasional use of urine dipsticks. The diagnostic reference standard is still urine culture, although it is not routinely recommended for uncomplicated UTIs in the community, due to time to diagnosis (48 hours). Faster point-of-care tests have been developed, but their diagnostic accuracy has not been compared. Our objective is to systematically review and meta-analyse the diagnostic accuracy of currently available point-of-care tests for UTIs. Methods and analysis Studies evaluating the diagnostic accuracy of point-of-care tests for UTIs will be included. PubMed, Web of Science, Embase and Cochrane Database of Systematic Reviews were searched from inception to 1 June 2019. Data extraction and risk-of-bias assessment will be assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. Meta-analysis will be performed depending on data availability and heterogeneity. Ethics and dissemination This is a systematic review protocol and therefore formal ethical approval is not required, as no primary, identifiable, personal data will be collected. Patients or the public were not involved in the design of our research. However, the findings from this review will be shared with key stakeholders, including patient groups, clinicians and guideline developers, and will also be presented and national and international conferences.Publisher PDFPeer reviewe

Changes in resistance among coliform bacteraemia associated with a primary care antimicrobial stewardship intervention:a population-based interrupted time series study

BACKGROUND: Primary care antimicrobial stewardship interventions can improve antimicrobial prescribing, but there is less evidence that they reduce rates of resistant infection. This study examined changes in broad-spectrum antimicrobial prescribing in the community and resistance in people admitted to hospital with community-associated coliform bacteraemia associated with a primary care stewardship intervention. METHODS AND FINDINGS: Segmented regression analysis of data on all patients registered with a general practitioner in the National Health Service (NHS) Tayside region in the east of Scotland, UK, from 1 January 2005 to 31 December 2015 was performed, examining associations between a primary care antimicrobial stewardship intervention in 2009 and primary care prescribing of fluoroquinolones, cephalosporins, and co-amoxiclav and resistance to the same three antimicrobials/classes among community-associated coliform bacteraemia. Prescribing outcomes were the rate per 1,000 population prescribed each antimicrobial/class per quarter. Resistance outcomes were proportion of community-associated (first 2 days of hospital admission) coliform (Escherichia coli, Proteus spp., or Klebsiella spp.) bacteraemia among adult (18+ years) patients resistant to each antimicrobial/class. 11.4% of 3,442,205 oral antimicrobial prescriptions dispensed in primary care over the study period were for targeted antimicrobials. There were large, statistically significant reductions in prescribing at 1 year postintervention that were larger by 3 years postintervention when the relative reduction was -68.8% (95% CI -76.3 to -62.1) and the absolute reduction -6.3 (-7.6 to -5.2) people exposed per 1,000 population per quarter for fluoroquinolones; relative -74.0% (-80.3 to -67.9) and absolute reduction -6.1 (-7.2 to -5.2) for cephalosporins; and relative -62.3% (-66.9 to -58.1) and absolute reduction -6.8 (-7.7 to -6.0) for co-amoxiclav, all compared to their prior trends. There were 2,143 eligible bacteraemia episodes involving 2,004 patients over the study period (mean age 73.7 [SD 14.8] years; 51.4% women). There was no increase in community-associated coliform bacteraemia admissions associated with reduced community broad-spectrum antimicrobial use. Resistance to targeted antimicrobials reduced by 3.5 years postintervention compared to prior trends, but this was not statistically significant for co-amoxiclav. Relative and absolute changes were -34.7% (95% CI -52.3 to -10.6) and -63.5 (-131.8 to -12.8) resistant bacteraemia per 1,000 bacteraemia per quarter for fluoroquinolones; -48.3% (-62.7 to -32.3) and -153.1 (-255.7 to -77.0) for cephalosporins; and -17.8% (-47.1 to 20.8) and -63.6 (-206.4 to 42.4) for co-amoxiclav, respectively. Overall, there was reversal of a previously rising rate of fluoroquinolone resistance and flattening of previously rising rates of cephalosporin and co-amoxiclav resistance. The limitations of this study include that associations are not definitive evidence of causation and that potential effects of underlying secular trends in the postintervention period and/or of other interventions occurring simultaneously cannot be definitively excluded. CONCLUSIONS: In this population-based study in Scotland, compared to prior trends, there were very large reductions in community broad-spectrum antimicrobial use associated with the stewardship intervention. In contrast, changes in resistance among coliform bacteraemia were more modest. Prevention of resistance through judicious use of new antimicrobials may be more effective than trying to reverse resistance that has become established.</p

Insightful Practice : a robust measure of medical students' professional response to feedback on their performance

Background: Healthcare professionals need to show accountability, responsibility and appropriate response to audit feedback. Assessment of Insightful Practice (engagement, insight and appropriate action for improvement) has been shown to offer a robust system, in general practice, to identify concerns in doctors' response to independent feedback. This study researched the system's utility in medical undergraduates. Methods: Setting and participants: 28 fourth year medical students reflected on their performance feedback. Reflection was supported by a staff coach. Students' portfolios were divided into two groups (n∈=∈14). Group 1 students were assessed by three staff assessors (calibrated using group training) and Group 2 students' portfolios were assessed by three staff assessors (un-calibrated by one-to-one training). Assessments were by blinded web-based exercise and assessors were senior Medical School staff. Design: Case series with mixed qualitative and quantitative methods. A feedback dataset was specified as (1) student-specific End-of-Block Clinical Feedback, (2) other available Medical School assessment data and, (3) an assessment of students' identification of prescribing errors. Analysis and statistical tests: Generalisability G-theory and associated Decision D- studies were used to assess the reliability of the system and a subsequent recommendation on students' suitability to progress training. One-to-one interviews explored participants' experiences. Main outcome measures: The primary outcome measure was inter-rater reliability of assessment of students' Insightful Practice. Secondary outcome measures were the reaction of participants and their self-reported behavioural change. Results: The method offered a feasible and highly reliable global assessment for calibrated assessors, G (inter-rater reliability)∈>∈0.8 (two assessors), but not un-calibrated assessors G∈<∈0.31. Calibrated assessment proved an acceptable basis to enhance feedback and identify concern in professionalism. Students reported increased awareness in teamwork and in the importance of heeding advice. Coaches reported improvement in their feedback skills and commitment to improving the quality of student feedback. Conclusions: Insightful practice offers a reliable and feasible method to evaluate medical undergraduates' professional response to their training feedback. The piloted system offers a method to assist the early identification of students at risk and monitor, where required, the remediation of students to get their level(s) of professional response to feedback back 'on track'.Publisher PDFPeer reviewe

Insightful Practice:a robust measure of medical students’ professional response to feedback on their performance

Background:&nbsp; Healthcare professionals need to show accountability, responsibility and appropriate response to audit feedback. Assessment of Insightful Practice (engagement, insight and appropriate action for improvement) has been shown to offer a robust system, in general practice, to identify concerns in doctors' response to independent feedback. This study researched the system's utility in medical undergraduates.&nbsp; Methods:&nbsp; Setting and participants: 28 fourth year medical students reflected on their performance feedback. Reflection was supported by a staff coach. Students' portfolios were divided into two groups (n&isin;=&isin;14). Group 1 students were assessed by three staff assessors (calibrated using group training) and Group 2 students' portfolios were assessed by three staff assessors (un-calibrated by one-to-one training). Assessments were by blinded web-based exercise and assessors were senior Medical School staff.&nbsp; Design: Case series with mixed qualitative and quantitative methods. A feedback dataset was specified as (1) student-specific End-of-Block Clinical Feedback, (2) other available Medical School assessment data and, (3) an assessment of students' identification of prescribing errors.&nbsp; Analysis and statistical tests: Generalisability G-theory and associated Decision D- studies were used to assess the reliability of the system and a subsequent recommendation on students' suitability to progress training. One-to-one interviews explored participants' experiences.&nbsp; Main outcome measures: The primary outcome measure was inter-rater reliability of assessment of students' Insightful Practice. Secondary outcome measures were the reaction of participants and their self-reported behavioural change.&nbsp; Results:&nbsp; The method offered a feasible and highly reliable global assessment for calibrated assessors, G (inter-rater reliability)&isin;&gt;&isin;0.8 (two assessors), but not un-calibrated assessors G&isin;&lt;&isin;0.31. Calibrated assessment proved an acceptable basis to enhance feedback and identify concern in professionalism. Students reported increased awareness in teamwork and in the importance of heeding advice. Coaches reported improvement in their feedback skills and commitment to improving the quality of student feedback. Conclusions: Insightful practice offers a reliable and feasible method to evaluate medical undergraduates' professional response to their training feedback. The piloted system offers a method to assist the early identification of students at risk and monitor, where required, the remediation of students to get their level(s) of professional response to feedback back 'on track'. &copy; 2015 Murphy et al

Lived experience of long COVID in health workers in Scotland (LoCH study).

This is the final project report for project COV/LTE/20/32 ("Lived Experience of Long-Term COVID-19 on NHS Workers in Health Care Settings in Scotland: a Longitudinal Mixed Methods Study"). The Long COVID in health workers (LoCH) study investigated the lived experience of the longer term effects of COVID-19 (long COVID) on professional and ancillary staff employed in the NHS across Scotland. These staff were asked about: their symptoms of long COVID; health and wellbeing; use of healthcare and self management strategies; working in the NHS; and personal and household finances. The report outlines the methodology and results of the study, and identifies key findings and potential impacts

Constrained candidacy: exploring different barriers to attaining healthcare access and treatment for long COVID illness by NHS workers in Scotland.

Long COVID (LC) affects 1.2 million people in the UK, including 120,000 NHS workers. LC remains poorly understood, comprising manifold symptoms ranging in severity, disrupting quality of life and work abilities. Emerging qualitative findings suggest attaining healthcare for LC is challenging. This study aims to explore the experiences of NHS workers with LC to understand their illness experiences, conceptualisations of healthcare eligibility, and barriers to attaining healthcare. We apply Candidacy theory, how persons conceptualise eligibility for healthcare, to interpret the findings. Study design was mixed methods, including an online questionnaire and in-depth qualitative interviews, and with follow-up data collection after six months. Participants (n=471) were purposefully sampled for interview following initial questionnaire completion using maximum variation sampling. All interviews were conducted remotely and transcribed verbatim, and data were analysed thematically, inductively and deductively using framework analysis in NVivo software. 50 participants were interviewed in the first phase of interviews, 44 in the second phase. LC caused devastating, long-standing disruptions to many aspects of life as indicated by questionnaires (51% reporting ability to undertake day-to-day activities had been "limited a lot") and interview data collected. Shared in interviews, NHS workers experienced manifold candidacy-driven barriers to health care access including feelings of reluctance to seek help for fears of "overburdening" the NHS, perceptions that LC was not taken seriously or understood by GPs and specialists, and little occupational and healthcare supports existed. Some accessed limited supports via services and work contacts, sought private healthcare, engaged with online support groups and utilised medical experience and knowledge to keep abreast of published LC literatures. NHS workers struggle to access healthcare for LC. Access journeys are complex and inexorably connected to notions of illness candidacy. Feelings of a lack of entitlement to healthcare, a lack of legitimisation of LC illness and participants' expectations of low success when attempting to seek help, which was often driven by past healthcare experiences, constrain access. Professional role and role-identity represented significant components in participants' conceptualising of their eligibility for access and how access was approached. Nuances between professional groups, identity and healthcare access will be discussed in the presentation. The findings of this study are important; giving a voice to those suffering from LC, and highlighting the multiple barriers that prevent and constrain NHS workers from receiving healthcare for LC illness, which ultimately impacts return to work and fulfilment of their functional - and essential - role in the struggling NHS healthcare system

Living with long COVID: the problem of lack of legitimation.

The notion of the "sick role" (Parsons, 1951), where affected individuals are exempt from certain normative expectations and responsibilities (e.g. work) in line with societal judgements, rests heavily on the 'legitimation' of illness, principally through a formal diagnosis. Whilst extensively critiqued in later work (Frank, 2016; Vassiley, et al, 2017), and particularly in relation to chronic illness (Segall, 1976; Radley, 1994), it can be argued that critical aspects of the theory are still useful in understanding illness experiences today (Williams, 2005; Varul, 2010; Hallowell et al., 2015). Here, the sick role theory is applied to the context of long COVID, offering an understanding around the problem of the lack of legitimation of this condition amongst the medical profession. This is based on the findings of a longitudinal, qualitative study looking at the impact of long COVID on 50 NHS workers across Scotland. Presenting with a constellation of common and often debilitating symptoms, the impacts of long COVID are wide-ranging, very often necessitating suspension of normal social responsibilities, including paid work. Yet, as a relatively new condition with few visible symptoms, a lack of evidence base, and poor understanding around the condition, long COVID is generally not legitimised in the same way as other chronic conditions. Many individuals report a sense of not being 'believed', having their needs unrecognised, misdiagnosed, barriers in accessing healthcare, a lack of support at work, emotional burdens and a need for validation of their symptoms and experiences

Unforeseen emotional labour: a collaborative autoethnography exploring researcher experiences of studying long COVID in health workers during the COVID-19 pandemic.

The concept of "emotional labour" describes the regulation of feelings and expressions to fulfil a specific job role, discussed extensively in relation to commercial and caring professions, with more recent scholarship recognising the emotional role performed by qualitative researchers. During the COVID-19 pandemic, this role was likely further heightened due to changes in the socio-political context affecting both individual circumstances and research practice. Despite this, accounts of emotional labour performed by qualitative researchers during this time are lacking. This paper presents a collaborative, autoethnographic account reflecting on the emotional labour experiences of a small team of researchers working on a highly emotive and often distressing study. This longitudinal, mixed methods study: "Long COVID in Health Workers" (LoCH), investigated the lived experiences of healthcare workers from across Scotland, living with the long-term impacts of COVID-19 or Long COVID. Remote interviews were used to explore their experiences in relation to work, their personal and home lives, and coping mechanisms. Collectively, various factors served to construct and intensify our emotional labour experiences: the novelty of Long COVID; its devastating, unpredictable nature and impacts; and a web of factors pertaining to the socio-political context at the time. National lockdowns, enforced social-distancing, homeworking and inaccessibility of NHS services meant a lack of formal and informal support for participants. This heightened their willingness to share highly personal, emotional and often distressing experiences during interviews, with participants often suggesting researchers fulfilled an emotional support role - conseqentially, the usual defined research parameters became blurred. Reactively, researchers engaged in lengthy, ongoing processes in order to negotiate unintended and unforeseen levels of emotional labour, so that they could continue to collect data and remain "professional" during interviews. This was challenging to negotiate in an already difficult homeworking and lockdown climate, with researchers having their own workplace and personal challenges, concerns and responsibilities to balance, in addition to their new and unplanned emotional role. This context also dictated the use of remote methods for both data-gathering and interacting with colleagues, which impeded our ability to provide and receive support. Emotional labour needs to be recognised and acknowledged, and formal plans need to be put in place to support researchers across individual, research team and institutional levels, with critical consideration of socio-political influences at the time of study - an area which merits further consideration. This paper firstly outlines the context for the unforeseen emotional labour borne by the researchers while conducting the LoCH study during the COVID-19 pandemic, before drawing on the collected data to discuss researchers' experiences, and the strategies they employed to cope during and after interviews. Goffman's dramaturgical perspective is employed as a lens to make sense of researcher experience, and to highlight challenges with managing and maintaining professional and emotionally-neutral presentation of self during interviews. The emotional costs of such presentations are explored through emotional vignettes from the researchers. The paper also discusses implications for future research, with regards to managing difficult subject matter in challenging conditions, and mechanisms for coping, emotional management and successful project delivery. Outcomes are relevant to future studies in this subject area, and help to draw attention to and normalise discussions of researcher wellbeing and unanticipated role-pressures

Understanding and supporting NHS employees with long COVID return to and remain in work: key barriers and facilitators.

Long COVID (LC) is a debilitating illness with complex and dynamic symptoms, affecting all aspects of personal and work life. The process and implications of returning to work following chronic illness have been considered across various conditions; however, published literature exploring LC is sparse. Person-environment fit (PEF) theory has been used to unpick the employer-worker dynamic in the process of returning to work, providing an analytical framework that offers both an understanding of and practical means for supporting this process with a view towards a positive outcome for both parties. We apply this framework to NHS workers suffering LC, utilising PEF theory as a lens through which to provide a sociological perspective for interrogating experiences of returning to and remaining at work, while experiencing symptoms that are often fluctuating, complex and debilitating. Findings are based on a longitudinal, in-depth interview study, exploring impacts of LC on 50 NHS Scotland workers in clinical or ancillary roles. This study highlights the importance and interplay of key factors facilitating successful return to work: improvements in symptoms; specific supports and understanding; workplace flexibility; and considerations around professional role and identity. Understanding and addressing these factors is imperative, as around 10,000 NHS employees in UK are off work because of their LC, at a time of acute crisis in the NHS with understaffing and unprecedented demand. Key outcomes around how workplaces must adapt to facilitate reintegration of workers experiencing LC are discussed, and some additions to theory are proposed to allow for further application to understanding the impact of LC upon return to work