Quantity and quality of interaction between staff and older patients in UK hospital wards: A descriptive study

AbstractBackgroundThe quality of staff-patient interactions underpins the overall quality of patient experience and can affect other important outcomes. However no studies have been identified that comprehensively explore both the quality and quantity of interactions in general hospital settings.Aims & objectivesTo quantify and characterise the quality of staff-patient interactions and to identify factors associated with negative interaction ratings.SettingData were gathered at two acute English NHS hospitals between March and April 2015. Six wards for adult patients participated including medicine for older people (n=4), urology (n=1) and orthopaedics (n=1).MethodsEligible patients on participating wards were randomly selected for observation. Staff-patient interactions were observed using the Quality of Interactions Schedule. 120h of care were observed with each 2h observation session determined from a balanced random schedule (Monday-Friday, 08:00-22:00h). Multilevel logistic regression models were used to determine factors associated with negative interactions.Results1554 interactions involving 133 patients were observed. The median length of interaction was 36s with a mean of 6 interactions per patient per hour. Seventy three percent of interactions were categorized as positive, 17% neutral and 10% negative. Forty percent of patients had at least one negative interaction (95% confidence interval 32% to 49%). Interactions initiated by the patient (adjusted Odds Ratio [OR] 5.30), one way communication (adjusted OR 10.70), involving two or more staff (adjusted OR 5.86 for 2 staff, 6.46 for 3+ staff), having a higher total number of interactions (adjusted OR 1.09 per unit increase), and specific types of interaction content were associated with increased odds of negative interaction (p<0.05). In the full multivariable model there was no significant association with staff characteristics, skill mix or staffing levels. Patient agitation at the outset of interaction was associated with increased odds of negative interaction in a reduced model. There was no significant association with gender, age or cognitive impairment. There was substantially more variation at ward level (variance component 1.76) and observation session level (3.49) than at patient level (0.09).ConclusionThese findings present a unique insight into the quality and quantity of staff-patient interactions in acute care. While a high proportion of interactions were positive, findings indicate that there is scope for improvement. Future research should focus on further exploring factors associated with negative interactions, such as workload and ward culture

Holomorphic Anomalies and the Nonrenormalization Theorem

It has been argued that the superpotential can be renormalized in the presence of massless particles. Possible implications which have been considered include the restoration of supersymmetry at higher loops or a shift to a supersymmetric vacuum state. We argue that even in the presence of massless particles, there are no new contributions to the superpotential at any order in perturbation theory. This confirms the utility of the Wilsonian superpotential for analyzing the moduli space of the low energy theory.Comment: 9 pages, LaTeX, 1 .ps figure, psfig.sty include

Retrieval practice transfer effects for multielement event triplets

Retrieval practice (RP) leads to improved retention relative to re-exposure and is considered a robust phenomenon when the final test conditions are identical to RP conditions. However, the extent to which RP ‘transfers' to related material is less clear. Here, we tested for RP transfer effects under conditions known to induce integration of associated material at encoding, which may make transfer more likely. Participants learned multielement triplets (locations, animals and objects) and one pairwise association from each triplet was tested through RP, re-exposed, or not re-exposed (control). Two days later participants completed a final test of all pairwise associations. We found no evidence for an RP effect compared to re-exposure, but both tested/re-exposed pairs were better remembered than the not re-exposed control condition. We also found that transfer occurred from both tested to untested and re-exposed to not re-exposed pairs. Our results highlight that RP and re-exposure can boost retention for directly tested/re-exposed event pairs and associated but untested/not re-exposed event pairs, suggesting re-exposure of integrated information can be of pedagogical value. The results also question the boundary conditions for an increase in retention for RP relative to re-exposure, highlighting the need for a better theoretical understanding of RP effects

Phenotyping Post-COVID Pain as a Nociceptive, Neuropathic, or Nociplastic Pain Condition

Pain after an acute Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) condition (post-COVID pain) is becoming a new healthcare emergency. Precision medicine refers to an evidence-based method of grouping patients based on their diagnostic/symptom presentation and then tailoring specific treatments accordingly. Evidence suggests that post-COVID pain can be categorized as nociceptive (i.e., pain attributable to the activation of the peripheral receptive terminals of primary afferent neurons in response to noxious chemical, mechanical, or thermal stimuli), neuropathic (i.e., pain associated with a lesion or disease of the somatosensory nervous system and limited to a &ldquo;neuroanatomically plausible&rdquo; distribution of the system), nociplastic (i.e., pain arising from altered nociception despite no clear evidence of actual or threatened tissue damage causing the activation of peripheral nociceptors or evidence for disease or lesion of the somatosensory system causing the pain), or mixed type (when two pain phenotypes co-exist). Each of these pain phenotypes may require a different treatment approach to maximize treatment effectiveness. Accordingly, the ability to classify post-COVID pain patients into one of these phenotypes would likely be critical for producing successful treatment outcomes. The 2021 International Association for the Study of Pain (IASP) clinical criteria and grading system provide a framework for classifying pain within a precision pain medicine approach. Here we present data supporting the possibility of grouping patients with post-COVID pain into pain phenotypes, using the 2021 IASP classification criteria, with a specific focus on nociplastic pain, which is probably the primary mechanism involved in post-COVID pain. Nociplastic pain, which is usually associated with comorbid symptomology (e.g., poor sleep quality, fatigue, cognitive&ndash;emotional disturbances, etc.) and is considered to be more difficult to treat than other pain types, may require a more nuanced multimodal treatment approach to achieve better treatment outcomes

Alignment to the Actions of a Robot

Alignment is a phenomenon observed in human conversation: Dialog partners’ behavior converges in many respects. Such alignment has been proposed to be automatic and the basis for communicating successfully. Recent research on human–computer dialog promotes a mediated communicative design account of alignment according to which the extent of alignment is influenced by interlocutors’ beliefs about each other. Our work aims at adding to these findings in two ways. (a) Our work investigates alignment of manual actions, instead of lexical choice. (b) Participants interact with the iCub humanoid robot, instead of an artificial computer dialog system. Our results confirm that alignment also takes place in the domain of actions. We were not able to replicate the results of the original study in general in this setting, but in accordance with its findings, participants with a high questionnaire score for emotional stability and participants who are familiar with robots align their actions more to a robot they believe to be basic than to one they believe to be advanced. Regarding alignment over the course of an interaction, the extent of alignment seems to remain constant, when participants believe the robot to be advanced, but it increases over time, when participants believe the robot to be a basic version

Informing efficient randomised controlled trials: Exploration of challenges in developing progression criteria for internal pilot studies

Objectives: Designing studies with an internal pilot phase may optimise the use of pilot work to inform more efficient randomised controlled trials (RCTs). Careful selection of preagreed decision or 'progression' criteria at the juncture between the internal pilot and main trial phases provides a valuable opportunity to evaluate the likely success of the main trial and optimise its design or, if necessary, to make the decision not to proceed with the main trial. Guidance on the appropriate selection and application of progression criteria is, however, lacking. This paper outlines the key issues to consider in the optimal development and review of operational progression criteria for RCTs with an internal pilot phase. Design: A structured literature review and exploration of stakeholders' opinions at a Medical Research Council (MRC) Hubs for Trials Methodology Research workshop. Key stakeholders included triallists, methodologists, statisticians and funders. Results: There is considerable variation in the use of progression criteria for RCTs with an internal pilot phase, although 3 common issues predominate: trial recruitment, protocol adherence and outcome data. Detailed and systematic reporting around the decisionmaking process for stopping, amending or proceeding to a main trial is uncommon, which may hamper understanding in the research community about the appropriate and optimal use of RCTs with an internal pilot phase. 10 top tips for the development, use and reporting of progression criteria for internal pilot studies are presented. Conclusions: Systematic and transparent reporting of the design, results and evaluation of internal pilot trials in the literature should be encouraged in order to facilitate understanding in the research community and to inform future trials

REFINE (reduced frequency ImmuNE checkpoint inhibition in cancers): A multi-arm phase II basket trial testing reduced intensity immunotherapy across different cancers

Background Immune checkpoint inhibitors (ICI) have revolutionised treating advanced cancers. ICI are administered intravenously every 2–6 weeks for up to 2 years, until cancer progression/unacceptable toxicity. Physiological efficacy is observed at lower doses than those used as standard of care (SOC). Pharmacodynamic studies indicate sustained target occupancy, despite a pharmacological half-life of 2–3 weeks. Reducing frequency of administration may be possible without compromising outcomes. The REFINE trial aims to limit individual patient exposure to ICI whilst maintaining efficacy, with potential benefits in quality of life and reduced drug treatment/attendance costs. Methods/Design REFINE is a randomised phase II, multi-arm, multi-stage (MAMS) adaptive basket trial investigating extended interval administration of ICIs. Eligible patients are those responding to conventionally dosed ICI at 12 weeks. In stage I, patients (n = 160 per tumour-specific cohort) will be randomly allocated (1:1) to receive maintenance ICI at SOC vs extended dose interval. REFINE is currently recruiting UK patients with locally advanced or metastatic renal cell carcinoma (RCC) who have tolerated and responded to initial nivolumab/ipilimumab, randomised to receive maintenance nivolumab SOC (480 mg 4 weekly) vs extended interval (480 mg 8 weekly). Additional tumour cohorts are planned. Subject to satisfactory outcomes (progression-free survival) stage II will investigate up to 5 different treatment intervals. Secondary outcome measures include overall survival, quality-of-life, treatment-related toxicity, mean incremental pathway costs and quality-adjusted life-years per patient. REFINE is funded by the Jon Moulton Charity Trust and Medical Research Council, sponsored by University College London (UCL), and coordinated by the MRC CTU at UCL

Clinical outcomes of patients with corticosteroid refractory immune checkpoint inhibitor induced enterocolitis treated with infliximab

Introduction Immune Checkpoint Inhibitors (CPI) have changed the treatment landscape for many cancers, but also cause severe inflammatory side effects including enterocolitis. CPI-induced enterocolitis is treated empirically with corticosteroids, and infliximab (IFX) is used in corticosteroid-refractory cases. However, robust outcome data for these patients are scarce. Methods We conducted a multi-centre (six cancer centres), cohort study of outcomes in patients treated with IFX for corticosteroid-refractory CPI-induced enterocolitis between 2007 and 2020. The primary outcome was corticosteroid-free clinical remission (CFCR) with CTCAE grade 0 for diarrhoea at 12 weeks after IFX initiation. We also assessed cancer outcomes at one year using RECIST criteria. Results 127 patients (73 male; median age 59 years) were treated with IFX for corticosteroid-refractory CPI-induced enterocolitis. Ninety-six (75.6%) patients had diarrhoea CTCAE grade >2 and 115 (90.6%) required hospitalisation for colitis. CFCR was 41.2% at 12 weeks and 50.9% at 26 weeks. In multivariable logistical regression, IFX-resistant enterocolitis was associated with rectal bleeding (OR 0.19; 95% CI 0.04-0.80; p=0.03) and absence of colonic crypt abscesses (OR 2.16; 95% CI 1.13-8.05; p=0.03). Cancer non-progression was significantly more common in patients with IFX-resistant enterocolitis (64.4%) as compared to patients with IFX-responsive enterocolitis (37.5%; p=0.013). Conclusion This is the largest study to date reporting outcomes of IFX therapy in patients with corticosteroid-refractory CPI-induced enterocolitis. Utilizing pre-defined robust endpoints, we have demonstrated that fewer than half of patients achieved CFCR. Our data also indicate that cancer outcomes may be better in patients developing prolonged and severe inflammatory side effects of CPI-therapy

Crimmigration and Refugees: Bridging Visas, Criminal Cancellations and ‘Living in the Community’ as Punishment and Deterrence

Australia’s status as the only state with a policy of mandatory indefinite detention of all unlawful non-citizens, including asylum seekers, who are within Australian territory is a fact that is both well-known and frequently cited. From its inception, mandatory immigration detention was touted as ‘the method of deterrence for those seeking asylum onshore’ and since then ‘mandatory detention has been at the forefront of a deterrence as control and control as deterrence discourse’2. The imagined subjects of deterrence are frequently asylum seekers presented as ‘bogus’ or as economic migrants, and the sites for control are Australia’s ‘immigration program’ and borders. While these dual factors have animated the implementation and continuation of the policy for over 25 years, the contemporary practice and enforcement of detention in Australia presents a much more complex picture