A Randomized Trial of Drug Route in Out-of-Hospital Cardiac Arrest.

BACKGROUND: In patients with out-of-hospital cardiac arrest, the effectiveness of drugs such as epinephrine is highly time-dependent. An intraosseous route of drug administration may enable more rapid drug administration than an intravenous route; however, its effect on clinical outcomes is uncertain. METHODS: We conducted a multicenter, open-label, randomized trial across 11 emergency medical systems in the United Kingdom that involved adults in cardiac arrest for whom vascular access for drug administration was needed. Patients were randomly assigned to receive treatment from paramedics by means of an intraosseous-first or intravenous-first vascular access strategy. The primary outcome was survival at 30 days. Key secondary outcomes included any return of spontaneous circulation and favorable neurologic function at hospital discharge (defined by a score of 3 or less on the modified Rankin scale, on which scores range from 0 to 6, with higher scores indicating greater disability). No adjustment for multiplicity was made. RESULTS: A total of 6082 patients were assigned to a trial group: 3040 to the intraosseous group and 3042 to the intravenous group. At 30 days, 137 of 3030 patients (4.5%) in the intraosseous group and 155 of 3034 (5.1%) in the intravenous group were alive (adjusted odds ratio, 0.94; 95% confidence interval [CI], 0.68 to 1.32; P = 0.74). At the time of hospital discharge, a favorable neurologic outcome was observed in 80 of 2994 patients (2.7%) in the intraosseous group and in 85 of 2986 (2.8%) in the intravenous group (adjusted odds ratio, 0.91; 95% CI, 0.57 to 1.47); a return of spontaneous circulation at any time occurred in 1092 of 3031 patients (36.0%) and in 1186 of 3035 patients (39.1%), respectively (adjusted odds ratio, 0.86; 95% CI, 0.76 to 0.97). During the trial, one adverse event, which occurred in the intraosseous group, was reported. CONCLUSIONS: Among adults with out-of-hospital cardiac arrest requiring drug therapy, the use of an intraosseous-first vascular access strategy did not result in higher 30-day survival than an intravenous-first strategy. (Funded by the National Institute for Health and Care Research; PARAMEDIC-3 ISRCTN Registry number, ISRCTN14223494.).

The Patient's Experience of Working with Multiple Allied Health Professional Students - A Qualitative Interview Study.

There are increasing numbers of learners in clinical settings as part of approaches to meet workforce demands. As a result, patients are now working with multiple learners at the same time, yet little is known about how people experience this. The aim of this study was to explore the patient experience of working with multiple allied health professional students. Structured interviews were carried out with 22 patients across hospital wards in one hospital in the North-West of England. Data was analysed using thematic analysis and four themes were identified: consent to work with multiple students; responses to working with multiple students; multiple students and feelings of safety; making connections with multiple students. Findings indicated that patients experienced positive relationships and feelings of safety with groups of students. However, patients were given limited advance or tailored information about working with a group of students which is an important area to address.

The impact of a training intervention on knowledge, confidence and attitudes of professionals in a Community Acquired Brain Injury Service about assistive technology for cognition: a before and after survey.

Assistive Technology for Cognition (ATC) can help people to compensate for cognitive impairments following Acquired Brain Injury (ABI). Examples include mainstream devices such as smartphones, watches and environmental controls, and bespoke devices such as medication devices or specific educational software. Evidence suggests that professional support is key to people successfully adopting ATC, yet low confidence amongst clinicians and perceptions about barriers are often cited as reasons for not recommending ATC in practice. The objectives of this service evaluation were to evaluate the impact of an ATC training opportunity on the knowledge and confidence of staff and to explore staff perspectives of the barriers and enablers to implementation of ATC in practice. A survey was completed by 21 members of a Community Acquired Brain Injury Service before and after participating in an ATC training workshop. Survey findings highlighted that attitudes toward, and confidence with ATC, showed positive change after the training, whilst perceptions about barriers to implementation in practice reduced. Responses also highlighted the perceived importance of education for health professionals, service users and families as key enablers to successful implementation. Multi-professional training is therefore an important part of an implementation strategy for ATC.

Route of drug administration in out-of-hospital cardiac arrest: A protocol for a randomised controlled trial (PARAMEDIC-3).

Aims: The PARAMEDIC-3 trial evaluates the clinical and cost-effectiveness of an intraosseous first strategy, compared with an intravenous first strategy, for drug administration in adults who have sustained an out-of-hospital cardiac arrest. Methods: PARAMEDIC-3 is a pragmatic, allocation concealed, open-label, multi-centre, superiority randomised controlled trial. It will recruit 15,000 patients across English and Welsh ambulance services. Adults who have sustained an out-of-hospital cardiac arrest are individually randomised to an intraosseous access first strategy or intravenous access first strategy in a 1:1 ratio through an opaque, sealed envelope system. The randomised allocation determines the route used for the first two attempts at vascular access. Participants are initially enrolled under a deferred consent model.The primary clinical-effectiveness outcome is survival at 30-days. Secondary outcomes include return of spontaneous circulation, neurological functional outcome, and health-related quality of life. Participants are followed-up to six-months following cardiac arrest. The primary health economic outcome is incremental cost per quality-adjusted life year gained. Conclusion: The PARAMEDIC-3 trial will provide key information on the clinical and cost-effectiveness of drug route in out-of-hospital cardiac arrest.Trial registration: ISRCTN14223494, registered 16/08/2021, prospectively registered.

Clinicoradiological outcomes after radical radiotherapy for lung cancer in patients with interstitial lung disease.

Objective: Interstitial lung disease (ILD) is relatively common in patients with lung cancer with an incidence of 7.5%. Historically pre-existing ILD was a contraindication to radical radiotherapy owing to increased radiation pneumonitis rates, worsened fibrosis and poorer survival compared with non-ILD cohorts. Herein, the clinical and radiological toxicity outcomes of a contemporaneous cohort are described. Methods: Patients with ILD treated with radical radiotherapy for lung cancer at a regional cancer centre were collected prospectively. Radiotherapy planning, tumour characteristics, and pre- and post-treatment functional and radiological parameters were recorded. Cross-sectional images were independently assessed by two Consultant Thoracic Radiologists. Results: Twenty-seven patients with co-existing ILD received radical radiotherapy from February 2009 to April 2019, with predominance of usual interstitial pneumonia subtype (52%). According to ILD-GAP scores, most patients were Stage I. After radiotherapy, localised (41%) or extensive (41%) progressive interstitial changes were noted for most patients yet dyspnoea scores (n = 15 available) and spirometry (n = 10 available) were stable. One-third of patients with ILD went on to receive long-term oxygen therapy, which was significantly more than the non-ILD cohort. Median survival trended towards being worse compared with non-ILD cases (17.8 vs 24.0 months, p = 0.834). Conclusion: Radiological progression of ILD and reduced survival were observed post-radiotherapy in this small cohort receiving lung cancer radiotherapy, although a matched functional decline was frequently absent. Although there is an excess of early deaths, long-term disease control is achievable. Advances in knowledge: For selected patients with ILD, long-term lung cancer control without severely impacting respiratory function may be possible with radical radiotherapy, albeit with a slightly higher risk of death.

Social Prescribing Nomenclature, Occupational Therapy and the Theory of Institutional Work: Creating, Maintaining and Disrupting Medical Dominance.

Social prescribing is a process of helping people to access non-medical activities and services which address health and wellbeing needs. The process is frequently (although not exclusively) initiated by primary health care professionals and often involves prescribing activities or initiatives provided by community and voluntary organizations. To occupational therapy, the links between activity, social-connectedness and health are clearly not new, although there are emerging international examples of social prescribing initiatives, and examples of newly developed roles, processes and funding opportunities, all of which are creating momentum behind the agenda.In this commentary, we draw upon the theory of Institutional Work to examine how the language of "prescription," and the purposive action of policy-makers and practitioners, is shaping thinking and action in relation to activity and health. Arguably, this language has helped to translate the recommendation of activity to meet a range of health needs in to an accessible and implementable concept. However, it has also potentially contributed to positioning the concept within a medical model of health, upholding medical dominance, and leaving occupational therapy on the margins of the debate.

'Hello, my name is ': an exploratory case study of inter-professional student experiences in practice.

BACKGROUND: The 'Hello my name is …' campaign emphasises the importance of compassionate care and focuses on health professionals introducing themselves to patients. Research has found that using names is key to providing individuals with a sense of belonging and can be vital in ensuring patient safety. OBJECTIVE: To investigate the student experience of having 'Hello my name is …' printed on student uniforms and implement this campaign in practice. DESIGN: A case study was used to capture the experiences of 40 multiprofessional healthcare students in practice. Participants were asked to complete a reflective diary during their first week in practice and attend a focus group with 4-8 other students. SETTING: A higher education institution in the north east of England with students from adult, child and learning disability nursing, occupational therapy, physiotherapy and midwifery programmes, in a variety of clinical placements throughout the region. FINDINGS: The implementation of the campaign and logo branding on the uniforms of students resulted in an increase in the number of times students were addressed by their name in practice. Participants reported that the study helped them to quickly develop a sense of belonging when on placement, and aided them in delivering compassionate care. Occasions when patient safety was improved were also reported. CONCLUSION: The use of names is a key feature in human relationships and the delivery of compassionate care, and the authors advocate use of the 'Hello my name is …' campaign for all health professionals.

The meaning of rehabilitation: a qualitative study exploring perspectives of occupational therapists and physiotherapists working with older people in acute care.

OBJECTIVE: To explore how occupational therapists and physiotherapists constructed and interpreted the meaning of rehabilitation in relation to older people in acute care. DESIGN: A focussed ethnographic study was undertaken, primarily using observation, interviewing and review of clinical records within one acute medical ward in a general hospital in the UK. Five patient participants gave consent for their episode of care to be studied, with observations and interviews primarily involving the identified patients and five occupational therapy and physiotherapy professionals. RESULTS: Four themes were identified: rehabilitation as a process to facilitate physical improvement; rehabilitation as physiotherapy-led; rehabilitation as a place…but not here; and rehabilitation as a process which prioritises safety over function. Such conceptualisations of rehabilitation were recognised as rooted in social and historical perceptions and challenged the ideals of rehabilitation professionals. CONCLUSIONS: The meaning of rehabilitation in acute care is shaped by a range of cultural, contextual and systemic influences. Recognising these influences, and subsequent challenges to rehabilitation ideals, can encourage professionals to work towards meaningful change.Implications for RehabilitationA reductionist version of rehabilitation was evident within this context which placed value on physical improvement, achieving optimum safety and led by physiotherapy.This version of rehabilitation was unsatisfactory to occupational therapists and physiotherapists in this setting and different to their ideals.Where rehabilitation may be associated with another place, practitioners should reflect on whether this is influencing patients becoming a lower priority for interventions whilst waiting and address this, if required, within their own reasoning, prioritisation and delegation.Those who recognise similarities with their own practice context could individually, and within teams, revisit definitions of rehabilitation to notice, document and have conversations about the ideals of their professions versus the reality of practice.Occupational therapists and physiotherapists can be champions for organisational and cultural change to promote rehabilitation as a multi-disciplinary phase of care working towards optimising improvements in wellbeing, function and safety, irrespective of location.

Input from Ras is required for maximal PI(3)K signalling in Drosophila.

Class I phosphoinositide 3-kinases (PI(3)Ks) are activated through associated adaptor molecules in response to G protein-coupled and tyrosine kinase receptor signalling. They contain Ras-binding domains (RBDs) and can also be activated through direct association with active GTP-bound Ras. The ability of Ras to activate PI(3)K has been established in vitro and by overexpression analysis, but its relevance for normal PI(3)K function in vivo is unknown. The Drosophila class I PI(3)K, Dp110, is activated by nutrient-responsive insulin signalling and modulates growth, oogenesis and metabolism. To investigate the importance of Ras-mediated PI(3)K activation for normal PI(3)K function, we replaced Dp110 with Dp110(RBD), which is unable to bind to Ras but otherwise biochemically normal. We found that Ras-mediated Dp110 regulation is dispensable for viability. However, egg production, which requires large amounts of growth, is dramatically lowered in Dp110(RBD) flies. Furthermore, insulin cannot maximally activate PI(3)K signalling in Dp110(RBD) imaginal discs and Dp110(RBD) flies are small. Thus, Dp110 integrates inputs from its phosphotyrosine-binding adaptor and Ras to achieve maximal PI(3)K signalling in specific biological situations.

Amino acids and the humoral regulation of growth: fat bodies use slimfast.

The mechanisms by which animals coordinate the growth of different tissues in response to nutrient levels is poorly understood. In this issue of Cell, Colombani et al. demonstrate that amino acid-responsive TOR signaling in the Drosophila fat body modulates insulin signaling and growth in peripheral tissues.

Regulated disruption of inositol 1,4,5-trisphosphate signaling in Caenorhabditis elegans reveals new functions in feeding and embryogenesis.

Inositol 1,4,5-trisphosphate (IP(3)) is an important second messenger in animal cells and is central to a wide range of cellular responses. The major intracellular activity of IP(3) is to regulate release of Ca(2+) from intracellular stores through IP(3) receptors (IP(3)Rs). We describe a system for the transient disruption of IP(3) signaling in the model organism Caenorhabditis elegans. The IP(3) binding domain of the C. elegans IP(3)R, ITR-1, was expressed from heat shock-induced promoters in live animals. This results in a dominant-negative effect caused by the overexpressed IP(3) binding domain acting as an IP(3) "sponge." Disruption of IP(3) signaling resulted in disrupted defecation, a phenotype predicted by previous genetic studies. This approach also identified two new IP(3)-mediated processes. First, the up-regulation of pharyngeal pumping in response to food is dependent on IP(3) signaling. RNA-mediated interference studies and analysis of itr-1 mutants show that this process is also IP(3)R dependent. Second, the tissue-specific expression of the dominant-negative construct enabled us to circumvent the sterility associated with loss of IP(3) signaling through the IP(3)R and thus determine that IP(3)-mediated signaling is required for multiple steps in embryogenesis, including cytokinesis and gastrulation.