Remote monitoring of patients with rheumatoid arthritis in a low disease activity state: a mixed methods evaluation across six hospitals in London, UK.

OBJECTIVES: This study evaluated the scale-up of a remote monitoring service, capturing monthly Rheumatoid Arthritis Impact of Disease scores and patient-generated text messages, for patients with rheumatoid arthritis (RA; in remission or with low disease activity) attending routine outpatient clinics across six hospitals. We explored patients and staff experiences and implementation outcomes. METHODS: A pragmatic, mixed methods approach was used, with active patient involvement throughout. We undertook a rapid review, analysed service-level data, and conducted a patient survey and patient and staff interviews, informed by the Capability, Opportunity, Motivation, Behaviour (COM-B) and Exploration, Preparation, Implementation, Sustainment (EPIS) theoretical frameworks. RESULTS: The review included 37 articles, covering themes of patient and clinician acceptability, engagement, feasibility and clinical impact. Service-level data (n = 202) showed high levels of patient engagement with the service. The patient survey (n = 155) showed patients felt the service was easy to use, had confidence in it and felt it improved access to care. Patient interview (n = 22) findings mirrored those of the survey. Motivating factors included increased responsiveness and ease of contact with clinical teams. Views from staff interviews (n = 16) were more mixed. Some implementation barriers were specific to roll-out sites. Prioritization of staff needs was emphasized. CONCLUSION: Patients were positive about the service and engagement was high. Staff views and engagement were more mixed. Results suggest that equal levels of patient and staff engagement are required for sustainability. These findings further our understanding of the implementation challenges to scaling remote monitoring interventions for patients with rheumatoid arthritis in routine care settings.

First year internal medicine residents' self-report point-of-care ultrasound knowledge and skills: what (Little) difference three years make.

BACKGROUND: With increasing availability of point-of-care ultrasound (POCUS) education in medical schools, it is unclear whether or not learning needs of junior medical residents have evolved over time. METHODS: We invited all postgraduate year (PGY)-1 residents at three Canadian internal medicine residency training programs in 2019 to complete a survey previously completed by 47 Canadian Internal Medicine PGY-1 s in 2016. Using a five-point Likert scale, participants rated perceived applicability of POCUS to the practice of internal medicine and self-reported skills in 15 diagnostic POCUS applications and 9 procedures. RESULTS: Of the 97 invited residents, 58 (60 %) completed the survey in 2019. Participants reported high applicability but low skills across all POCUS applications and procedures. The 2019 cohort reported higher skills in assessing pulmonary B lines than the 2016 cohort (2.3 ± SD 1.0 vs. 1.5 ± SD 0.7, adjusted p-value = 0.01). No other differences were noted. CONCLUSIONS: POCUS educational needs continue to be high in Canadian internal medicine learners. The results of this needs assessment study support ongoing inclusion of basic POCUS elements in the current internal medicine residency curriculum.

Point of care ultrasound training for internal medicine: a Canadian multi-centre learner needs assessment study.

BACKGROUND: Significant gaps currently exist in the Canadian internal medicine point-of-care ultrasound (POCUS) curriculum. From a learner's perspective, it remains unknown what key POCUS skills should be prioritized. This needs assessment study seeks to establish educational priorities for POCUS for internal medicine residents at five Canadian residency training programs. METHODS: All internal medicine trainees [postgraduate year (PGY) 1-5] from five internal medicine residency training programs in Canada (n = 598) were invited to complete an online survey on 15 diagnostic POCUS applications, 9 bedside procedures, and 18 POCUS knowledge items. For POCUS applications and procedures, participants were asked how applicable they are to patient care in internal medicine and the participants' reported skills in those domains. Self-reported knowledge and skills were rated on a 5-point Likert scale, where 1 = very poor and 5 = very good. Applicability was rated, where 1 = not at all applicable and 5 = very applicable. RESULTS: A total of 253 of 598 residents (42%) participated in our study. Data from one centre (n = 15) was removed because of low response rate (15%) and significant baseline differences between those trainees and the remaining participants. Of the remaining analyzable data from four training programs (n = 238), participants reported highest applicability to internal medicine for the following applications and procedures: identifying ascites/free fluid [mean applicability score of 4.9 ± standard deviation (SD) 0.4]; gross left ventricular function (mean 4.8 ± SD 0.5) and pericardial effusion (mean 4.7 ± SD 0.5); thoracentesis (mean score 4.9 ± SD 0.3), central line insertion (mean 4.9 ± SD 0.3), and paracentesis (mean 4.9 ± SD 0.3), respectively. Overall reported knowledge/skills was low, with skill gaps being the highest for identifying deep vein thrombosis (mean gap 2.7 ± SD 1.1), right ventricular strain (mean 2.7 ± SD 1.1), and gross left ventricular function (mean 2.7 ± SD 1.0). CONCLUSIONS: Many POCUS applications and procedures were felt to be applicable to the practice of internal medicine. Significant skill gaps exist in the four Canadian training programs included in the study. POCUS curriculum development efforts should target training based on these perceived skill gaps.

Does inspiratory muscle training improve lung function and quality of life in people with inclusion body myositis? A pilot study.

Inclusion body myositis is the most common acquired myositis in adults, predominantly weakening forearm flexor and knee extensor muscles. Subclinical respiratory muscle weakness has recently been recognised in people with inclusion body myositis, increasing their risk of respiratory complications. Inspiratory muscle training, a technique which demonstrates efficacy and safety in improving respiratory function in people with neuromuscular disorders, has never been explored in those with inclusion body myositis. In this pilot study, six adults with inclusion body myositis (age range 53 to 81 years) completed eight weeks of inspiratory muscle training. Measures of respiratory function, quality of life, sleep quality and a two-minute walk test were performed pre and post-intervention. All participants improved their respiratory function, with maximal inspiratory pressure, sniff nasal inspiratory pressure and forced vital capacity increasing by an average of 50 % (p = .002), 43 % (p = .018) and 13 % (p = .003) respectively. No significant change was observed in quality of life, sleep quality or two-minute walk test performance. No complications occurred due to inspiratory muscle training This pilot study provides the first evidence that inspiratory muscle training may be safe and effective in people with Inclusion Body Myositis, potentially mitigating the complications of poor respiratory function.

Study protocol for a cross-sectional online survey investigating patient preferences and experiences of waiting for elective cardiac surgery.

INTRODUCTION: Being on a waiting list for elective (planned) cardiac surgery can be physically and psychologically challenging for patients. Research suggests that stress associated with waiting for surgery is dependent on different individual and contextual factors. However, most data on patients' experiences of waiting for surgery and preferences for waiting list management derives from non-cardiac clinical populations. The aim of the current study is to explore patients' experiences of being on a waiting list for elective cardiac surgery, and their views on how the waiting experience could be improved in the future. This work will inform the patient management strategy during the waiting period for surgery across the four major hospitals in London directly involved in this study, and potentially beyond by transferring learning to other services. METHODS AND ANALYSIS: This is a mixed-methods study that will collect quantitative and qualitative data using a cross-sectional online survey. Patients who are on waiting lists for elective surgery across four major cardiac surgery departments in London hospitals, and are at least 18 years old, will be invited by their healthcare team via text message or letter to complete the survey. The target sample size of non-randomly selected participants will be 268. Bivariable and multivariable regression models will be used to assess associations between survey items measuring the impact of the cardiac condition on specific life domains (eg, daily activities, social and family relationships, hobbies, sexual life), anxiety and depression symptoms as measured by the Patient Health Questionnaire-4 and survey items evaluating experiences of health services. Data on experience and preferences for improvements to the waiting experience will be analysed with qualitative content analysis using an inductive approach. ETHICS AND DISSEMINATION: This study was reviewed and granted ethical approval by the East of England-East Cambridge Research Ethics Committee. Findings from this study will be disseminated through peer-reviewed journals, a research website and social media and with an online event engaging patients, members of the public, healthcare professionals and other relevant stakeholders. TRIAL REGISTRATION NUMB: NCT05996640.

Dynamics of intracellular bacterial replication at the single cell level.

Several important pathogens cause disease by surviving and replicating within host cells. Bacterial proliferation is the product of both replication and killing undergone by the population. However, these processes are difficult to distinguish, and are usually assessed together by determination of net bacterial load. In addition, measurement of net load does not reveal heterogeneity within pathogen populations. This is particularly important in persistent infections in which slow or nongrowing bacteria are thought to have a major impact. Here we report the development of a reporter system based on fluorescence dilution that enables direct quantification of the replication dynamics of Salmonella enterica serovar Typhimurium (S. Typhimurium) in murine macrophages at both the population and single-cell level. We used this technique to demonstrate that a major S. Typhimurium virulence determinant, the Salmonella pathogenicity island 2 type III secretion system, is required for bacterial replication but does not have a major influence on resistance to killing. Furthermore, we found that, upon entry into macrophages, many bacteria do not replicate, but appear to enter a dormant-like state. These could represent an important reservoir of persistent bacteria. The approach could be extended to other pathogens to study the contribution of virulence and host resistance factors to replication and killing, and to identify and characterize nonreplicating bacteria associated with chronic or latent infections.

National study of sleep health for student servicemembers/veterans.

Objective: Investigate sleep health for student servicemember/veterans (SSM/Vs). Method: Data from the National College Health Assessment was used, including 88,178 participants in 2018 and 67,972 in 2019. Propensity score matching was used to compare SSM/Vs (n = 2984) to their most similar non-SSM/V counterparts (n = 1,355). Responses were analyzed using a multivariate analysis of covariance (MANCOVA). Results: SSM/Vs reported significantly higher levels of some sleep health issues than the matched peer group, including more instances of trouble falling asleep, waking too early, and higher rates of insomnia and sleep disorders. However, SSM/Vs reported fewer days per week feeling sleepy and similar impacts of sleep issues on academics when compared to the peer group. Conclusion: Institutions of higher education should consider training faculty and staff to recognize impacts of poor sleep health for SSM/Vs to establish effective practices to support this unique population.

In adults with advanced lung disease, the 1-minute sit-to-stand test underestimates exertional desaturation compared with the 6-minute walk test: an observational study.

QUESTION: In adults with advanced lung disease, do the 6-minute walk test (6MWT) and 1-minute sit-to-stand test (1minSTS) elicit similar cardiorespiratory responses? Can the 6-minute walk distance (6MWD) be estimated from the 1minSTS result? DESIGN: Prospective observational study using data collected during routine clinical practice. PARTICIPANTS: Eighty adults (43 males) with advanced lung disease, a mean age of 64 years (SD 10) and a mean forced expiratory volume in 1 second of 1.65 L (SD 0.77). OUTCOME MEASURES: Participants completed a 6MWT and a 1minSTS. During both tests, oxygen saturation (SpO2), pulse rate, dyspnoea and leg fatigue (Borg 0 to 10) were recorded. RESULTS: Compared with the 6MWT, the 1minSTS resulted in higher nadir SpO2 (MD 4%, 95% CI 3 to 5), lower end-test pulse rate (MD -4 beats/minute, 95% CI -6 to -1), similar dyspnoea (MD -0.3, 95% CI -0.6 to 0.1) and greater leg fatigue (MD 1.1, 95% CI 0.6 to 1.6). Among the participants who demonstrated severe desaturation (SpO2 nadir < 85%) on the 6MWT (n = 18), five and ten participants were classified as moderate (nadir 85 to 89%) or mild desaturators (nadir ≥ 90%), respectively, on the 1minSTS. The relationship between the 6MWD and 1minSTS was: 6MWD (m) = 247 + (7 × number of transitions achieved during the 1minSTS) with poor predictive ability (r2 = 0.44). CONCLUSION: The 1minSTS elicited less desaturation than the 6MWT and classified a smaller proportion of people as 'severe desaturators' on exertion. It is therefore inappropriate to use the nadir SpO2 recorded during a 1minSTS to make decisions about whether strategies are needed to prevent severe transient exertional desaturation during walking-based exercise. Further, the extent to which performance on the 1minSTS can estimate a person's 6MWD is poor. For these reasons, the 1minSTS is unlikely to be helpful when prescribing walking-based exercise.

Modified forced expiration technique using expiratory resistance in adults with cystic fibrosis.

BACKGROUND: Participation in airway clearance techniques (ACT) is important to minimise development of irreversible airway obstruction in patients with cystic fibrosis (CF). Positive expiratory pressure (PEP) and expiratory resistance devices (ERD) are often used as they can improve collateral ventilation and aid in the shearing of mucus from airways. This project looked to identify whether utilising an ERD during a forced expiration technique (FET) improves ease of expectoration, sputum amount and coughing frequency in patients with CF. METHOD: Patients with CF admitted for a respiratory exacerbation completed two sessions of 10 cycles of their usual ACT with half of the FET components performed with an ERD, half with FET alone. RESULTS: EOE, sputum wet weight, cough frequency and patient preference were similar between groups. Improved EOE without the ERD was found in participants who usually use PEP for their ACT regime. CONCLUSION: Combining the FET with a PEP mask did not improve EOE and other outcomes in this small study. Investigating the efficacy of this technique within a larger population is warranted.

Can simulation replace part of clinical time? Two parallel randomised controlled trials.

CONTEXT: Education in simulated learning environments (SLEs) has grown rapidly across health care professions, yet no substantive randomised controlled trial (RCT) has investigated whether SLEs can, in part, substitute for traditional clinical education. METHODS: Participants were physiotherapy students (RCT 1, n = 192; RCT 2, n = 178) from six Australian universities undertaking clinical education in an ambulatory care setting with patients with musculoskeletal disorders. A simulated learning programme was developed as a replica for clinical education in musculoskeletal practice to replace 1 week of a 4-week clinical education placement. Two SLE models were designed. Model 1 provided 1 week in the SLE, followed by 3 weeks in clinical immersion; Model 2 offered training in the SLE in parallel with clinical immersion during the first 2 weeks of the 4-week placement. Two single-blind, multicentre RCTs (RCT 1, Model 1; RCT 2, Model 2) were conducted using a non-inferiority design to determine if the clinical competencies of students part-educated in SLEs would be any worse than those of students educated fully in traditional clinical immersion. The RCTs were conducted simultaneously, but independently. Within each RCT, students were stratified on academic score and randomised to either the SLE group or the control ('Traditional') group, which undertook 4 weeks of traditional clinical immersion. The primary outcome measure was a blinded assessment of student competency conducted over two clinical examinations at week 4 using the Assessment of Physiotherapy Practice (APP) tool. RESULTS: Students' achievement of clinical competencies was no worse in the SLE groups than in the Traditional groups in either RCT (Margin [Δ] ≥ 0.4 difference on APP score; RCT 1: 95% CI - 0.07 to 0.17; RCT 2: 95% CI - 0.11 to 0.16). CONCLUSIONS: These RCTs provide evidence that clinical education in an SLE can in part (25%) replace clinical time with real patients without compromising students' attainment of the professional competencies required to practise.

Respiratory muscle training in neuromuscular disease: a systematic review and meta-analysis.

BACKGROUND: Neuromuscular disease causes a progressive decline in ventilatory function which respiratory muscle training may address. Previous systematic reviews have focussed on single diseases, whereas this study systematically reviewed the collective evidence for respiratory muscle training in children and adults with any neuromuscular disease. METHODS: Seven databases were searched for randomised controlled trials. Three reviewers independently reviewed eligibility, extracted characteristics, results, determined risk of bias and combined results using narrative synthesis and meta-analysis. RESULTS: 37 studies (40 publications from 1986-2021, n=951 participants) were included. Respiratory muscle training improved forced vital capacity (standardised mean difference (SMD) 0.40 (95% confidence interval 0.12-0.69)), maximal inspiratory (SMD 0.53 (0.21-0.85)) and maximal expiratory pressure (SMD 0.70 (0.35-1.04)) compared to control (usual care, sham or alternative treatment). No impact on cough, dyspnoea, voice, physical capacity or quality of life was detected. There was high degree of variability between studies. DISCUSSION: Study heterogeneity (children and adults, different diseases, interventions, dosage and comparators) suggests that the results should be interpreted with caution. Including all neuromuscular diseases increased the evidence pool and tested the intervention overall. CONCLUSIONS: Respiratory muscle training improves lung volumes and respiratory muscle strength in neuromuscular disease, but confidence is tempered by limitations in the underlying research.

Dynamics of growth and dissemination of Salmonella in vivo.

The last decade has witnessed increasing research on dissemination of bacterial pathogens in their hosts and on the processes that underlie bacterial spread and growth during organ colonization. Here, we discuss work on the mouse model of human typhoid fever caused by Salmonella enterica serovar Typhimurium. This has revealed the use of several routes of systemic dissemination that result in colonization and growth within the spleen and liver, the major sites of bacterial proliferation. We also highlight techniques that enable in vivo analysis of the infecting population at the spatiotemporal and single cell levels. These approaches have provided more detailed insights into the events underlying the dynamics of Salmonella replication, spread and clearance within host organs and tissues.

Methods Used to Evaluate the Immediate Effects of Airway Clearance Techniques in Adults with Cystic Fibrosis: A Systematic Review and Meta-Analysis.

This review reports on methods used to evaluate airway clearance techniques (ACT) in adults with CF and examined data for evidence of any effect. Sixty-eight studies described ACT in adequate detail and were included in this review. Frequently reported outcomes were sputum expectoration (72%) and spirometric lung function (60%). Compared with cough alone, following any ACT, there was a trend for greater sputum wet weight, however FEV1 was not different. The mean (95% CI) within-group effect for sputum wet weight following any ACT was 12.43 g (9.28 to 15.58) (n = 30 studies) and for FEV1 was 0.03 L (-0.17 to 0.24) (n = 14 studies). Meta-regression demonstrated that, when compared with cough alone, greater sputum wet weight was reported in groups that received additional ACT by between 2.45 and 3.94 g (F3,66 = 2.97, p = 0.04). These data suggest the addition of ACT to cough alone may optimise sputum clearance; however, FEV1 lacked sensitivity to detect this change. Importantly, this review highlights the lack of appropriate measures to assess ACT efficacy.

Simulation of realistic nephrology case scenarios to facilitate intra-professional team learning.

BACKGROUND: Learning in the workplace maximises relevance to clinical practice and facilitates the education of the whole multiprofessional team. Provision of structured teaching is becoming increasingly challenging with shift pattern working and staff shortages. This article describes a simulation course designed to facilitate team learning to improve the care of nephrology patients, and presents outcome data over 2 years. METHODS: A full-day course, using high fidelity manikins, was designed for nephrology specialty trainees and nurse specialists. Nineteen learners (eleven specialty trainees and eight nurse specialists) and nine multidisciplinary team faculty members attended. Evaluation used pre- and post-course assessments, with a 1-year follow-up questionnaire. RESULTS: Following the course, improved knowledge scores, 56% to 72% (P<0.05), and confidence scores, 57% to 71% (P<0.005), were demonstrated. Qualitative analysis found 'intra-disciplinary interaction', 'reflection' and 'practical skills' were the greatest enablers of learning. In the 1-year follow-up questionnaire, specialty trainees reported that the course improved clinical practice and helped preparation for consultant roles. CONCLUSIONS: This course improved knowledge and confidence in managing nephrology scenarios across the multidisciplinary learning group, and the model could be used in other hospital specialties.

Safety and hospital costs of Achilles tendon surgery: the serendipitous impact of a randomized clinical trial.

BACKGROUND: Surgical management is currently the most common treatment offered for ruptured Achilles tendon; however, the length of hospital stay varies among hospitals. The objective of our study was to compare the costs associated with hospital stay and safety in 2 groups of patients undergoing surgical treatment of Achilles tendon ruptures. The first group of patients represented the surgical arm of a randomized clinical trial, the Multicentre Achilles Tendon Treatment Study (MATTS), and the second group comprised surgically treated patients not included in that trial (non-MATTS). METHODS: We performed an observational analytical retrospective chart review of all patients surgically treated for acute Achilles tendon ruptures at all Calgary-area hospitals over a 3-year period (October 2002-September 2005) who met our inclusion criteria. We determined the costs associated with hospital stay, complications and readmissions for all patients. RESULTS: A total of 282 patients met our inclusion criteria. Hospital admission costs of patients enrolled in the MATTS trial were less than those of non-MATTS patients treated at each of the 3 Calgary adult hospitals. Non-MATTS patients remained in hospital for 1-4 days in contrast to MATTS patients, who were typically admitted and discharged the day of surgery. The complication rate was similar in both groups (MATTS 9% v. non-MATTS 8%). There were no readmissions in the MATTS group and 2 in the non-MATTS group. Between October 2002 and September 2005, an additional $236,436 was spent on non-MATTS patients who underwent surgery for Achilles tendon rupture. CONCLUSION: Acute achilles tendon repair surgery is safe and less costly as an out-patient procedure.

Sick Note to Fit Note: one trust's project to improve usage by hospital clinicians.

INTRODUCTION: In April 2010, the government introduced a new Statement of Fitness to Work or 'Fit Note' for patients requiring time off of work or adaptations to their work due to illness. Responsibility to issue these documents has shifted from primary to secondary care. Hospital clinicians are required to issue for inpatients and for outpatients where clinical responsibility has not been taken over by the general practitioner (GP). However, awareness of this change is lacking. Misdirecting patients to their GP for the sole purpose of receiving a 'Fit Note' is an unnecessary use of appointment time and negatively impacts on patients. King's College Hospital NHS Trust receives a number of quality alerts from primary care regarding this issue. METHODS: A trust-wide educational initiative was designed and implemented to increase staff awareness of Fit Notes and their correct usage in order to reduce the number of patients being misdirected to their GP to obtain one. Interventions included direct staff engagement, a trust-wide promotional campaign and creation of an electronic version of the document. RESULTS: Uptake of the electronic version of the Fit Note has steadily increased and there has been a fall in the number of quality alerts received by the trust. However, staff awareness on the whole remains low. CONCLUSIONS: Patients being misdirected to their general practice for Fit Notes is an important issue and one on which the baseline level of awareness among hospital clinicians is low. Challenges during this intervention have been in penetrating a trust of this size and getting the message across to staff. However, digitising the Fit Note can help to increase its use.

Interprofessional bedside teaching: setting up a novel teaching programme.

BACKGROUND: An ageing population and health-care advances mean that patients have increasingly complex medical health and social needs, requiring a multidisciplinary team. However, despite working as an interprofessional team, team members still largely train in professional silos. Furthermore health-care professionals report a poor understanding of the skills of colleagues from different professions. This article describes the set up and outcomes of a novel interprofessional bedside teaching programme. METHODS: An in-centre interprofessional teacher training course was established to facilitate interprofessional bedside teaching, along with supported ward-based sessions to apply the skills. RESULTS: Three in-centre courses and five workplace sessions have run, with forty-five and twenty-eight interprofessional participants respectively. Statistically significant improvements in confidence facilitating interprofessional teaching were seen, with participants more likely to teach at the bedside and involve the multidisciplinary team. CONCLUSIONS: This article shows evidence of a teaching programme which improves the confidence of the multidisciplinary team in facilitating interprofessional bedside teaching.

Internalization of Salmonella by macrophages induces formation of nonreplicating persisters.

Many bacterial pathogens cause persistent infections despite repeated antibiotic exposure. Bacterial persisters are antibiotic-tolerant cells, but little is known about their growth status and the signals and pathways leading to their formation in infected tissues. We used fluorescent single-cell analysis to identify Salmonella persisters during infection. These were part of a nonreplicating population formed immediately after uptake by macrophages and were induced by vacuolar acidification and nutritional deprivation, conditions that also induce Salmonella virulence gene expression. The majority of 14 toxin-antitoxin modules contributed to intracellular persister formation. Some persisters resumed intracellular growth after phagocytosis by naïve macrophages. Thus, the vacuolar environment induces phenotypic heterogeneity, leading to either bacterial replication or the formation of nonreplicating persisters that could provide a reservoir for relapsing infection.