A programme to spread eGFR graph surveillance for the early identification, support and treatment of people with progressive chronic kidney disease (ASSIST-CKD): protocol for the stepped wedge implementation and evaluation of an intervention to reduce late presentation for renal replacement therapy.

BACKGROUND: Patients who start renal replacement therapy (RRT) for End-Stage Kidney Disease (ESKD) without having had timely access to specialist renal services have poor outcomes. At one NHS Trust in England, a community-wide CKD management system has led to a decline in the incident rate of RRT and the lowest percentage of patients presenting within 90 days of starting RRT in the UK. We describe the protocol for a quality improvement project to scale up and evaluate this innovation. METHODS: The intervention is based upon an off-line database that integrates laboratory results from blood samples taken in all settings stored under different identifying labels relating to the same patient. Graphs of estimated glomerular filtration rate (eGFR) over time are generated for patients <65 years with an incoming eGFR <50 ml/min/1.73 m2 and patients >65 years with an incoming eGFR <40 ml/min/1.73 m2. Graphs where kidney function is deteriorating are flagged by a laboratory scientist and details sent to the primary care doctor (GP) with a prompt that further action may be needed. We will evaluate the impact of implementing this intervention across a large population served by a number of UK renal centres using a mixed methods approach. We are following a stepped-wedge design. The order of implementation among participating centres will be randomly allocated. Implementation will proceed with unidirectional steps from control group to intervention group until all centres are generating graphs of eGFR over time. The primary outcome for the quantitative evaluation is the proportion of patients referred to specialist renal services within 90 days of commencing RRT, using data collected routinely by the UK Renal Registry. The qualitative evaluation will investigate facilitators and barriers to adoption and spread of the intervention. It will include: semi-structured interviews with laboratory staff, renal centre staff and service commissioners; an online survey of GPs receiving the intervention; and focus groups of primary care staff. DISCUSSION: Late presentation to nephrology for patients with ESKD is a source of potentially avoidable harm. This protocol describes a robust quantitative and qualitative evaluation of a quality improvement intervention to reduce late presentation and improve the outcomes for patients with ESKD.

Communicating about death and dying: Developing training for staff working in services for people with intellectual disabilities.

BACKGROUND: Many people with intellectual disabilities are affected by death, yet conversations about death are often avoided by staff working with them. This study aimed to assess staff training needs and to develop, trial and evaluate a training course on communicating about death and dying. METHOD: (i) Semi-structured interviews with 20 staff in residential/supported living services to establish training needs; (ii) three-one-day courses were attended by 114 staff and evaluated through questionnaires. The course consisted of World Café sessions, presentations and feedback by people with intellectual disabilities, and an expert teaching session. RESULTS: Staff fear, cultural influences and inexperience with death-related conversations were major communication barriers. Evaluation of the course was overwhelmingly positive. CONCLUSIONS: Intellectual disabilities services must have clear staff training strategies around death, dying and communication. More work is needed to assess the resource implications and impact on practice of different training methods and other support strategies.

The addition of interstitial needles to intracavitary applicators in the treatment of locally advanced cervical cancer: Why is this important and how to implement in low- and middle-income countries?

PURPOSE: Cervical cancer is the leading cause of cancer mortality of women in low-/middle-income countries. Interstitial needles improve outcomes but require resources beyond those available in endemic regions. We conducted a retrospective review of the use of interstitial needles in locally advanced cervical cancer and simulated both 3D planning without needles and 2D planning to explore the benefit of interstitial needles. METHODS AND MATERIALS: 57 brachytherapy plans of 17 patients who had intracavitary tandem and ring plus interstitial brachytherapy were reviewed. Prescribed dose was 7 Gy × four fractions. 2D plans prescribed to point A were generated to represent a standard Manchester loading. Dosimetric outcomes to clinical target volume and organs at risk (OARs) were compared with those of 3D-based plans. RESULTS: High-risk clinical target volume coverage was excellent: 93.2% for 2D plans, 93.9% for 3D plans without needles, and 96.2% for 3D with needles. The mean dose to 90% of target was 8.5 Gy/fraction for 2D plans, 7.5 for 3D without needles, and 7.9 Gy/fraction for 3D with needles. However, the 2D plans delivered 12% above recommended dose constraints for OARs (except rectum). Dosimetric differences were found between 3D planning and 3D with needles for target coverage (p = 0.002). Dose to OARs was significantly lower when 3D plans with needles were compared with 2D plans. CONCLUSIONS: Interstitial needles provide an optimal therapeutic ratio for patients with high-volume disease or/and unfavorable topography. This justifies additional capital investment in resources for implementation to provide optimal treatment for locally advanced cervical cancer globally.

The Development of Simple Daily Jaw Exercises for Patients Receiving Radical Head and Neck Radiotherapy.

INTRODUCTION: Patients who receive radical radiotherapy to the head and neck may suffer from the late side effect of trismus due to radiation of the jaw. Trismus is progressive once it starts, and can be debilitating due to difficulty eating and inability to perform proper dental hygiene. Although radiotherapy to the temporomandibular joint can restrict mouth opening, the pterygoid muscles-which are responsible for lateral and protrusive motions of the jaw-are more sensitive to radiation. Therefore, damage to these muscles will also limit mouth opening. METHOD: A series of simple jaw exercises was designed to help patients maintain jaw mobility and reduce the effect of trismus. In the study, one group of patients used the exercises and the other did not. To assess whether trismus was occurring, dental gap measurements (measurements taken with a ruler from upper incisor to lower incisor, or gum-to-gum) were taken at the start of radiotherapy treatment and again at scheduled follow-up appointments. RESULTS: There was an overall statistically significant difference between the dental gap measurements of the jaw exercise and the no-jaw exercise group (P = .01, assuming the statistical significance level is .05). Patients who performed the jaw exercises were able to open their mouths wider than the patients who did not do them. Although there appeared to be a difference in decreasing dental gap across time between the two groups in the study, the Wald test did not find this to be statistically significant (P = .1). The use of chemotherapy was not statistically significant; that is, chemotherapy could not be linked with trismus in this study (P = .6171). CONCLUSION: The results of this study demonstrate that jaw exercises can be a useful aid to help prevent side effects of trismus due to radiotherapy treatment. Although it is not possible to accurately quantify the effect in this study due to the use of a compensator technique, this intervention was easy to implement and simple for patients to undertake. The jaw exercises continue to be used in the Cancer Centre for the Southern Interior, and a recent revision to the jaw exercises was made with the collaboration of the dental department.