Atypical organisms affecting the respiratory tract and their sequelae – a series of case studies

The respiratory tract is exposed to a wide range of environmental constituents including potentially infective agents. This thesis presents two series of papers concerning two atypical organisms and their sequelae or potential sequelae – Coxiella burnetii, which causes Q fever, and flagellated protozoa, which is associated with respiratory symptoms and asthma. The first series of papers examine a Q fever outbreak and its sequelae. They describe one of the largest Q fever outbreaks in the UK and demonstrate the benefit of facsimile cascade in supporting case searching in such an outbreak. Chronic fatigue (Chalder Fatigue scores) and depression (PHQ-9 scores) were raised in post Q fever patients six years later (p<0.05 in both cases). Concordance regarding serological status across three international reference laboratories was as low as 35%, indicating a major problem with international standardisation in this area. Unpublished supplementary clinical and serological findings are also presented to inform future outbreak investigation. The second series of papers examine the role of flagellated protozoa in respiratory disease. Flagellated protozoa were shown to be present in a case series of inpatients. In a subsequent community-based case control study, protozoa were present in 67% (20/30) of induced sputum samples taken from asthmatics and 31% (4/13) of samples from non-atopic controls (p=0.046). In another study of inpatients, 67% of those who were on oral steroids had protozoa in their sputum, compared to 35% of those not on oral steroids. In this study, 45% of smokers/ex-smokers had protozoa in their sputum compared to 30% of non-smokers. Unpublished data using molecular techniques to identify eukaryotes in sputum is also presented. The findings provide a basis for a RCT of antibiotics in patients with post Q fever chronic fatigue and a trial of anti-protozoal agents to eradicate flagellated protozoa in patients with asthma.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Atypical organisms affecting the respiratory tract and their sequelae – a series of case studies

The respiratory tract is exposed to a wide range of environmental constituents including potentially infective agents. This thesis presents two series of papers concerning two atypical organisms and their sequelae or potential sequelae – Coxiella burnetii, which causes Q fever, and flagellated protozoa, which is associated with respiratory symptoms and asthma. The first series of papers examine a Q fever outbreak and its sequelae. They describe one of the largest Q fever outbreaks in the UK and demonstrate the benefit of facsimile cascade in supporting case searching in such an outbreak. Chronic fatigue (Chalder Fatigue scores) and depression (PHQ-9 scores) were raised in post Q fever patients six years later (p<0.05 in both cases). Concordance regarding serological status across three international reference laboratories was as low as 35%, indicating a major problem with international standardisation in this area. Unpublished supplementary clinical and serological findings are also presented to inform future outbreak investigation. The second series of papers examine the role of flagellated protozoa in respiratory disease. Flagellated protozoa were shown to be present in a case series of inpatients. In a subsequent community-based case control study, protozoa were present in 67% (20/30) of induced sputum samples taken from asthmatics and 31% (4/13) of samples from non-atopic controls (p=0.046). In another study of inpatients, 67% of those who were on oral steroids had protozoa in their sputum, compared to 35% of those not on oral steroids. In this study, 45% of smokers/ex-smokers had protozoa in their sputum compared to 30% of non-smokers. Unpublished data using molecular techniques to identify eukaryotes in sputum is also presented. The findings provide a basis for a RCT of antibiotics in patients with post Q fever chronic fatigue and a trial of anti-protozoal agents to eradicate flagellated protozoa in patients with asthma

A confirmed location in the Galactic halo for the high-velocity cloud 'chain A'

The high-velocity clouds of atomic hydrogen, discovered about 35 years ago, have velocities inconsistent with simple Galactic rotation models that generally fit the stars and gas in the Milky Way disk. Their origins and role in Galactic evolution remain poorly understood, largely for lack of information on their distances. The high-velocity clouds might result from gas blown from the Milky Way disk into the halo by supernovae, in which case they would enrich the Galaxy with heavy elements as they fall back onto the disk. Alternatively, they may consist of metal-poor gas -- remnants of the era of galaxy formation, accreted by the Galaxy and reducing its metal abundance. Or they might be truly extragalactic objects in the Local Group of galaxies. Here we report a firm distance bracket for a large high-velocity cloud, Chain A, which places it in the Milky Way halo (2.5 to 7 kiloparsecs above the Galactic plane), rather than at an extragalactic distance, and constrains its gas mass to between 10^5 and 2 times 10^6 solar masses.Comment: 8 pages, including 4 postscript figures. Letter to Nature, 8 July 199

Evaluation of technology-enhanced learning programs for health care professionals: systematic review

Background: Technology-enhanced learning (TEL) programs are increasingly seen as the way in which education for health care professionals can be transformed, giving access to effective ongoing learning and training even where time or geographical barriers exist. Given the increasing emphasis on this mode of educational support for health care practitioners, it is vital that we can effectively evaluate and measure impact to ensure that TEL programs are effective and fit for purpose. This paper examines the current evidence base for the first time, in relation to the evaluation of TEL programs for health care professionals. Objective: We conducted a systematic review of the current literature relating to the evaluation of TEL programs for health care professionals and critically appraised the quality of the studies. Methods: This review employed specific search criteria to identify research studies that included evaluation of TEL for health care professionals. The databases searched included Medline Ovid, Cumulative Index of Nursing and Allied Health Literature Plus Advanced, Applied Social Sciences Index and Abstracts, ZETOC, Institute of Electrical and Electronics Engineers Explore Digital Library, Allied and Complementary Medicine, and Education Resources Information Center between January 2006 and January 2017. An additional hand search for relevant articles from reference lists was undertaken. Each of the studies identified was critically appraised for quality using the Crowe Critical Appraisal Tool. This approach produced a percentage total score for each study across specified categories. A proportion of the studies were independently assessed by an additional two reviewers. Results: The review identified 21 studies that met the inclusion criteria. The studies included scored totals across eight categories within a range of 37%-95% and an average score of 68%. Studies that measured TEL using learner satisfaction surveys, or combined pretest and posttest knowledge score testing with learner satisfaction surveys, were found to be the most common types of TEL evaluations evident in the literature. The studies reviewed had low scores across reporting on ethical matters, design, and data collection categories. Conclusions: There continues to be a need to develop effective and standard TEL evaluation tools, and good quality studies that describe effective evaluation of TEL education for health care professionals. Studies often fail to provide sufficient detail to support transferability or direct future TEL health care education programs

An Exploratory Qualitative Study of Computer Screening to Support Decision-Making about Use of Palliative Care Registers in Primary Care:GP Think Aloud and Patient and Carer Interviews

Objectives: This study aimed to understand factors that influence general practitioner (GP) use of automated computer screening to identify patients for the palliative care register (PCR) and the experiences of palliative care and this emerging technology from patients’ and carers’ perspectives. Methods: A computer screening program electronically searches primary care records in routine clinical practice to identify patients with advanced illness who are not already on a PCR. Five GPs were asked to “think aloud” about adding patients identified by computer screening to the PCR. Key informant interviews with 6 patients on the PCR and 4 carers about their experiences of palliative care while on the PCR and their views of this technology. Data were analyzed thematically. Results and Conclusions: Using computer screening, 29% additional patients were added by GPs to the PCR. GP decision-making for the PCR was informed by clinical factors such as: if being treated with curative intent; having stable or unstable disease; end-stage disease, frailty; the likelihood of dying within the next 12 months; and psychosocial factors such as, age, personality, patient preference and social support. Six (60%) patients/carers did not know that they/their relative was on the PCR. From a patient/carer perspective, having a non-curative illness was not in and of itself sufficient reason for being on the PCR; other factors such as, unstable disease and avoiding pain and suffering were equally if not more, important. Patients and carers considered that computer screening should support but not replace, GP decision-making about the PCR. Computer screening merits ongoing development as a tool to aid clinical decision-making around entry to a PCR, but should not be used as a sole criterion. Care need, irrespective of diagnosis, disease trajectory or prognosis, should determine care.</p

Identifying seasonal and temporal trends in the pressures experienced by hospitals related to unscheduled care

BACKGROUND: As part of an electronic dashboard operated by Public Health Wales, senior managers at hospitals in Wales report daily 'escalation' scores which reflect management opinion on the pressure a hospital is experiencing and ability to meet ongoing demand with respect to unscheduled care. An analysis was undertaken of escalation scores returned for 18 hospitals in Wales between the years 2006 and 2014 inclusive, with a view to identifying systematic temporal patterns in pressure experienced by hospitals in relation to unscheduled care. METHODS: Exploratory data analysis indicated the presence of within-year cyclicity in average daily scores over all hospitals. In order to quantify this cyclicity, a Generalised Linear Mixed Model was fitted which incorporated a trigonometric function (sine and cosine) to capture within-year change in escalation. In addition, a 7-level categorical day of the week effect was fitted as well as a 3-level categorical Christmas holiday variable based on patterns observed in exploration of the raw data. RESULTS: All of the main effects investigated were found to be statistically significant. Firstly, significant differences emerged in terms of overall pressure reported by individual hospitals. Furthermore, escalation scores were found to vary systematically within-year in a wave-like fashion for all hospitals (but not between hospitals) with the period of highest pressure consistently observed to occur in winter and lowest pressure in summer. In addition to this annual variation, pressure reported by hospitals was also found to be influenced by day of the week (low at weekends, high early in the working week) and especially low over the Christmas period but high immediately afterwards. CONCLUSIONS: Whilst unpredictable to a degree, quantifiable pressure experienced by hospitals can be anticipated according to models incorporating systematic temporal patterns. In the context of finite resources for healthcare services, these findings could optimise staffing schedules and inform resource utilisation

Learning the lessons for public health from the COVID-19 pandemic across British island communities: findings of a peer support group based on action learning

Introduction: The COVID-19 pandemic was a major public health challenge for island communities. Consequently, a peer support group was set up across British islands, led by Directors of Public Health, with the aim of using an action research approach to identify and share learning to inform aspects of the management of COVID-19 that were unique to island communities. Methods: Qualitative analysis of nine group discussions over 13 months was undertaken. Key themes were identified based on two sets of independent records of the meetings. The findings were shared with representatives of the group and refined on the basis of that feedback. Results: Key learning points were around the importance of border control to minimise the importation of new cases, a rapid coordinated response to clusters of disease when these occurred, close cooperation with organisations that provide transport on and off the island, and effective communication and engagement with both local and visiting populations. Conclusion: A peer support group was effective in providing mutual support and shared learning across quite varied island contexts. There was a sense that this had helped in the management of the COVID-19 pandemic and facilitated in maintaining a low prevalence of infection