Evidence-based decision-making in a climate of political expediency: insights from local government.

AIMS: Local authorities in England are responsible for public health and health promotion. This article sought to explore how research and decision-making co-exist in a local authority in England. METHODS: An Embedded Researcher was based within the local authority and used qualitative methodology to address the research aim. Interviews and focus groups were employed to ascertain a range of stakeholder views in the local authority. All transcripts were coded on NVivo 12 by the Embedded Researcher and two members of the research team cross-checked a sample for coding accuracy. Data were analysed using framework analysis. RESULTS: The data suggest several barriers to using research to inform decision-making in health promotion and public health. The study shows that research is valued in local authorities, but not always privileged - this is due to cultural factors and practical political reasons which often means that decisions need to be made expediently. Participants outlined a juxtaposition between academic credibility; timeliness to complete the research and the financial cost associated with it; against the independence and credibility that independent academics could bring. CONCLUSION: Policy formulation and delivery is an integral aspect of health promotion and critical to achieving improved population health and reductions in health inequalities. However, there exists tensions between gathering research evidence and making research-informed decisions. The article concludes by advocating the use of Embedded Researchers to fully understand how research is gathered and used to support public health and health promotion policymaking.

The impact of patient-reported frailty on cardiovascular outcomes in elderly patients after non-ST-acute coronary syndrome.

BACKGROUND: As life expectancy increases, the population of older individuals with coronary artery disease and frailty is growing. We aimed to assess the impact of patient-reported frailty on the treatment and prognosis of elderly early survivors of non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS: Frailty data were obtained from two prospective trials, POPular Age and the POPular Age Registry, which both assessed elderly NSTE-ACS patients. Frailty was assessed one month after admission with the Groningen Frailty Indicator (GFI) and was defined as a GFI-score of 4 or higher. In these early survivors of NSTE-ACS, we assessed differences in treatment and 1-year outcomes between frail and non-frail patients, considering major adverse cardiovascular events (MACE, including cardiovascular mortality, myocardial infarction, and stroke) and major bleeding. RESULTS: The total study population consisted of 2192 NSTE-ACS patients, aged ≥70 years. The GFI-score was available in 1320 patients (79 ± 5 years, 37% women), of whom 712 (54%) were considered frail. Frail patients were at higher risk for MACE than non-frail patients (9.7% vs. 5.1%, adjusted hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.01-2.43, p = 0.04), but not for major bleeding (3.7% vs. 2.8%, adjusted HR 1.23, 95% CI 0.65-2.32, p = 0.53). Cubic spline analysis showed a gradual increase of the risk for clinical outcomes with higher GFI-scores. CONCLUSIONS: In elderly NSTE-ACS patients who survived 1-month follow-up, patient-reported frailty was independently associated with a higher risk for 1-year MACE, but not with major bleeding. These findings emphasize the importance of frailty screening for risk stratification in elderly NSTE-ACS patients.

Personal dosimetry for positron emitters, and occupational exposures from clinical use of gallium-68.

The current status and issues regarding positron dosimetry in nuclear medicine are summarized. The suitability of the United Kingdom Health Security Agency extremity and eye beta-gamma personal thermoluminescence dosemeters are then considered. Monte Carlo modelling is performed to determine their responses and derive sets of calibration factors, along withHp(0.07) andHp(3) conversion coefficients, for carbon-11, nitrogen-13, oxygen-15, fluorine-18 and gallium-68 sources, which are commonly used in positron emission tomography (PET) computed tomography; data for these isotopes is assumed extrapolatable to other positron sources. It is found that the dosemeters are adequate for assessing exposures to PET radionuclides, even if their routine calibrations to caesium-137 were maintained. An idealized set of measurements representing gallium-68 exposure scenarios is then described, including reproducible mock-ups of individuals manipulating vials and syringes. Finally, a short case-study is presented that explores occupational doses during routine clinical use of gallium-68. The extremity dosemeter results demonstrated significant variations dependent upon the exposure conditions, with some seen to be comparatively large; whole-body and eye dose rates per activity were found to be lower. The importance of routine dose monitoring of workers is emphasized, with the need for a longer-termed follow-up study demonstrated.

Clinical experience of paediatric self-expanding foam cuffed tracheostomy tubes.

INTRODUCTION: Use of self-expanding foam-filled tracheostomy tube cuffs (Bivona® FOME cuf®) in paediatrics has become a recent practice within our institution for patients with intractable aspiration. The current literature, clinical indications and subsequent management is lacking. We present our experience with a cohort of children with a foam-cuffed tracheostomy tube managed at Great Ormond Street Hospital, describing their indications and outcomes, as well as routine and emergency management. METHOD: Our tracheostomy patient population was reviewed and those with a Bivona® FOME cuf® tracheostomy tube were identified and reviewed. The indications for foam-cuffed tracheostomy tube insertion, progress, and further management, including emergency care, were reviewed. RESULTS: Ten patients were identified, all with a chronic history of respiratory infections secondary to aspiration being the leading indication. All patients had an ongoing improvement in their chest function following insertion with no episodes of cuff trauma. One patient had difficulty when a port line was accidently cut, which resulted in difficulty of removal, and we outline a strategy for dealing with this. CONCLUSION: The foam-cuffed tracheostomy tube is a useful tracheostomy tube to use in the management of chronic aspiration in children with poor chest health, however due to the lack of knowledge and experience they can prove to be a difficult tube to manage. Further educational information should be available as to the indications, routine care and emergency management of Bivona® FOME cuf® tracheostomy tubes. We believe they represent a useful option for institutions to consider in the paediatric population.

Small vessel disease disrupts EEG postural brain networks in 'unexplained dizziness in the elderly'.

OBJECTIVE: To examine the hypothesis that small vessel disease disrupts postural networks in older adults with unexplained dizziness in the elderly (UDE). METHODS: Simultaneous electroencephalography and postural sway measurements were undertaken in upright, eyes closed standing, and sitting postures (as baseline) in 19 younger adults, 33 older controls and 36 older patients with UDE. Older adults underwent magnetic resonance imaging to determine whole brain white matter hyperintensity volumes, a measure of small vessel disease. Linear regression was used to estimate the effect of instability on electroencephalographic power and connectivity. RESULTS: Ageing increased theta and alpha desynchronisation on standing. In older controls, delta and gamma power increased, and theta and alpha power reduced with instability. Dizzy older patients had higher white matter hyperintensity volumes and more theta desynchronisation during periods of instability. White matter hyperintensity volume and delta power during periods of instability were correlated, positively in controls but negatively in dizzy older patients. Delta power correlated with subjective dizziness and instability. CONCLUSIONS: Neural resource demands of postural control increase with age, particularly in patients with UDE, driven by small vessel disease. SIGNIFICANCE: EEG correlates of postural control saturate in older adults with UDE, offering a neuro-physiological basis to this common syndrome.

Mental health plan for workers of the London Nightingale Hospital: following the evidence to support staff.

The COVID-19 pandemic has extracted an enormous physical health toll on many millions worldwide, and the wider societal impact from economic turmoil, unemployment, social isolation and so forth continue to be measured. A less explored aspect has been the psychological impact on treating healthcare staff, with emerging evidence of 'moral injury' and mental illness for some. This review explores the evidence base for implementing a tiered model of care to minimise this and foster 'post-traumatic growth', and describes the authors' implementation of this in the London Nightingale hospital, with lessons for the armed forces.

Angioleiomyoma of the inferior turbinate: a rare cause of isolated facial pain.

We present the case of a 33-year-old man with right-sided facial pain. Clinical examination revealed an isolated mass attached to the right inferior turbinate. This was confirmed with computed tomography. Excision was achieved endoscopically and histology revealed an angioleiomyoma. Full symptomatic relief was achieved after surgical excision. Less than 1% of angioleiomyoma lesions are found within the sinonasal cavity. We describe the first documented presentation of angioleiomyoma as a cause of isolated, unilateral facial pain; a very common presentation to the otorhinolaryngology clinic. We promote consideration of angioleiomyoma as a different diagnosis in the presence of facial pain and a unilateral sinonasal lesion. Endoscopic resection provides complete symptomatic resolution.

Short- and long-term effects of conventional and artificial rearing strategies on the health and performance of growing lambs.

Artificial rearing of young animals represents a challenge in modern ruminant production systems. This work aims to evaluate the short- and long-term effects of the type of rearing on the animal's health, growth, feed utilization and carcass performance. A total of 24 pregnant ewes carrying triplets were used. Within each triplet set, lambs were randomly allocated to one experimental treatment: natural rearing on the ewe (NN); ewe colostrum for 24 h followed by artificial rearing with milk replacer (NA) and 50 g of colostrum alternative supplementation followed by artificial rearing (AA). Milk replacer, ryegrass hay and creep feed were offered ad libitum, and each experimental group was kept in independent pens until weaning at 45 days of age. After weaning all lambs were placed together on the same pasture for fattening for 4 months. Blood samples were taken at 24 h after birth, at weaning and at the end of the fattening period (23 weeks). Results showed that no failure in the passive immune transfer was detected across treatments. Although artificially reared lambs at weaning had lower plasma levels of ß-hydroxy-butyrate (-62%), high-density lipoproteins (-13%) and amylase (-25%), and higher levels of low-density lipoproteins (+38%) and alkaline phosphatase (+30%), these differences disappeared during the fattening period. Only the greater levels of calcium and the lower levels of haemoglobin and white blood cells detected at weaning in artificially reared lambs (+7.2%, -2.8% and -17.8%) persisted by the end of the fattening period (+4.3%, -3.3% and -9.5%, respectively). Minor diarrheal events from weeks 2 to 5 were recorded with artificial rearing, leading to lower growth rates during the 1st month. However, these artificially reared lambs caught up towards the end of the milk feeding period and reached similar weaning weights to NN lambs. During the fattening period NN lambs had a greater growth rate (+16%) possibly as a result of their greater early rumen development, which allowed a higher feed digestibility during the fattening period in comparison to NA lambs (+5.9%). As a result, NN lambs had heavier final BWs (+7.0%), but tended to have lower dressing percentage (-5.7%) than artificially reared lambs, thus no differences were noted in either carcass weight or in carcass conformation across treatments. In conclusion, the use of a colostrum alternative and milk replacer facilitated the successful rearing of lambs, reaching similar productive parameters; however, special care must be taken to maximize the rumen development before weaning.

Paediatric tracheostomy tubes: recent developments and our current practice.

OBJECTIVE: A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital. METHODS: This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments. RESULTS: Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes. CONCLUSION: The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies.

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Offenders with intellectual disabilities in prison: what happens when they leave?

BACKGROUND: People with intellectual disabilities, if convicted of offences, may be sentenced to prison, but little is known about their life when they are released. METHOD: This study followed up men with intellectual disabilities who were leaving prisons in England. RESULTS: The men were hard to contact, but 38 men were interviewed, on average 10 weeks after leaving prison. The men were living in a variety of situations and often were very under-occupied, with limited social networks. A total of 70% were above the clinical cut-off for anxiety, and 59.5% were above the clinical cut-off for depression. The men were receiving little support in the community, and many had been reinterviewed by police. CONCLUSIONS: Community teams need to provide better support to this very vulnerable group.

Vascular risk assessment in older adults without a history of cardiovascular disease.

Modern cardiovascular risk prediction tools, which have their genesis in the Framingham Heart Study, have allowed more accurate risk stratification and targeting of treatments worldwide over the last seven decades. Better cardiovascular risk factor control during this time has led to a reduction in cardiovascular mortality and, at least in part, to improved life expectancy. As a result, western societies as a whole have seen a steady increase in the proportion of older persons in their populations. Unfortunately, several studies have shown that the same tools which have contributed to this increase cannot be reliably extrapolated for use in older generations. Recent work has allowed recalibration of existing models for use in older populations but these modified tools still require external validation before they can be confidently applied in clinical practice. Another complication is emerging evidence that aggressive risk factor modification in older adults, particularly more frail individuals, may actually be harmful. This review looks at currently available cardiovascular risk prediction models and the specific challenges faced with their use in older adults, followed by analysis of recent attempts at recalibration for this cohort. We discuss the issue of frailty, looking at our evolving understanding of its constituent features and various tools for its assessment. We also review work to date on the impact of frailty on cardiovascular risk modification and outline its potentially central role in determining the most sensible approach in older patients. We summarise the most promising novel markers of cardiovascular risk which may be of use in improving risk prediction in older adults in the future. These include markers of vascular compliance (such as aortic pulse wave velocity and pulse wave analysis), of endothelial function (such as flow mediated dilation, carotid intima-media thickness and coronary artery calcium scores), and also biochemical and circulating cellular markers.

The host galaxy of a fast radio burst.

In recent years, millisecond-duration radio signals originating in distant galaxies appear to have been discovered in the so-called fast radio bursts. These signals are dispersed according to a precise physical law and this dispersion is a key observable quantity, which, in tandem with a redshift measurement, can be used for fundamental physical investigations. Every fast radio burst has a dispersion measurement, but none before now have had a redshift measurement, because of the difficulty in pinpointing their celestial coordinates. Here we report the discovery of a fast radio burst and the identification of a fading radio transient lasting ~6 days after the event, which we use to identify the host galaxy; we measure the galaxy's redshift to be z = 0.492 ± 0.008. The dispersion measure and redshift, in combination, provide a direct measurement of the cosmic density of ionized baryons in the intergalactic medium of ΩIGM = 4.9 ± 1.3 per cent, in agreement with the expectation from the Wilkinson Microwave Anisotropy Probe, and including all of the so-called 'missing baryons'. The ~6-day radio transient is largely consistent with the radio afterglow of a short γ-ray burst, and its existence and timescale do not support progenitor models such as giant pulses from pulsars, and supernovae. This contrasts with the interpretation of another recently discovered fast radio burst, suggesting that there are at least two classes of bursts.

An investigation into the content validity of the Antimicrobial Self-Assessment Toolkit for NHS Trusts (ASAT v15a) using cognitive interviews with antimicrobial pharmacists.

WHAT IS KNOWN AND OBJECTIVE: The Antimicrobial Self-Assessment Toolkit for NHS Trusts (ASAT) was developed to evaluate the organizational strategies used to implement hospital-based antimicrobial stewardship programmes. An iterative approach was used to develop ASAT v15a, which has been previously investigated for face validity; however, further investigation into other types of validity was required. Therefore, the aim of this study was to investigate the content validity of ASAT v15a and hence modify and improve the content validity of the toolkit. METHODS: A purposive sample of eight antimicrobial pharmacists was interviewed using cognitive interviewing techniques from within the former North-west Strategic Health Authority in England. Respondents were asked to 'think aloud' and to verbally express their thought processes as they generated responses to each question with the ASAT. RESULTS: There were no cognitive difficulties reported by respondents in response to 26/83 (31·3%) questions within the ASAT. However, cognitive difficulties were reported by respondents at each stage of the cognitive processing pathway in response to 57/83 (68·7%) questions. These difficulties were comprehension/interpretation in 27/83 (32·5%) questions, information retrieval in 10/83 (12%) questions, judgment/decision in 6/83 (7·2%) questions and response generation/formatting in 13/83 (15·7%) questions. Other findings included disagreement with the weightings applied to 13/83 (15·7%) questions. Respondents recommended that these questions should be modified to reflect their impact on hospital-based antimicrobial stewardship programmes (ASPs). Based on these findings, modifications were made to ASAT v15a to produce the next iteration (ASAT v16). Furthermore, respondents indicated that the role of clinical microbiologists was underrepresented in the current version of the toolkit; therefore, seven proposed questions were drafted, based on a literature review. WHAT IS NEW AND CONCLUSION: Cognitive interviews were effectively able to detect problems encountered by respondents along the cognitive processing pathway by identifying words and/or phrases that required further modifications. Also, this method highlighted that there was a disparity between the respondents' interpretation and the ASAT developers' intent within some questions. Although respondents indicated that the toolkit evaluated the most pertinent components of ASPs, further modifications and testing would be required to improve its validity. These results highlight the importance of the inclusion of end-users in the development of reporting and/or evaluation tools or questionnaires.

Fatal herpes simplex virus hepatitis following neoadjuvant chemoradiotherapy and anterior resection for rectal cancer.

We describe the case of a young patient who contracted fatal herpes simplex virus hepatitis following neoadjuvant chemoradiotherapy and anterior resection for rectal cancer. The rarity and non-specific presentation of this treatable disease, which masqueraded as the sequelae of postoperative sepsis, resulted in a diagnosis following death. Features that should prompt inclusion of herpes simplex virus hepatitis in the differential diagnoses are suggested and the case is a reminder of how neoadjuvant therapy may subtly alter a patient's immunocompetency.

Antibacterial usage in English NHS hospitals as part of a national Antimicrobial Stewardship Programme.

Antimicrobial resistance (AMR) has become a global problem for health care services, with fewer antimicrobials entering the market and some pathogenic organisms becoming resistant to commonly used antimicrobials. Antimicrobial stewardship (AS), including evidence-based standard setting, education and communication, and audits of practice, has become a key method of preventing the rise in the rise in AMR. Data on antibiotic consumption are often obtained through prospective and retrospective point prevalence audits of antibiotic usage, but such studies are very resource intensive and only provide a snapshot of consumption. The objective of the study reported here was to examine longitudinal total antibacterial usage at a national level and cross-sectional usage at an individual hospital trust level using a commercial database that captures antimicrobial prescribing from at least 99% of English hospital Trusts.