A post-diagnosis information and support programme for dyads-People living with dementia or mild cognitive impairment and family carers: A feasibility study.

AIM: The aim of the study was to establish the feasibility of delivering a structured post-diagnosis information and support program to dyads (persons living with dementia or mild cognitive impairment and family carers) in two primary care settings. DESIGN: A two-phase explanatory mixed-method approach guided by the Bowen Feasibility Framework focused on acceptability, implementation, adaptation, integration and efficacy of a five-part programme. In phase 1, the quantitative impact of the programme on the dyadic programme recipients' self-efficacy, quality of life, dyadic relationship and volume of care was measured. In phase 2, inductive content analysis focused on nurse and dyad participant experiences of the programme. Quantitative and qualitative data were reviewed to conclude each element of feasibility. METHODS: Four registered nurses working within the participating sites were recruited, trained as programme facilitators and supported to deliver the programme. Eligible dyads attending the respective primary health clinics were invited to participate in the programme and complete surveys at three time points: recruitment, post-programme and 3-month follow-up. Post-programme semi-structured interviews were conducted with dyads and programme facilitators. RESULTS: Twenty-nine dyads completed the program; the majority were spousal dyads. The programme proved acceptable to the dyads with high retention and completion rates. Implementation and integration of the programme into usual practice were attributed to the motivation and capacity of the nurses as programme facilitators. Regarding programme efficacy, most dyads reported they were better prepared for the future and shared the plans they developed during the programme with family members. CONCLUSION: Implementing a structured information and support programme is feasible, but sustainability requires further adaptation or increased staff resources to maintain programme fidelity. Future research should consider selecting efficacy measures sensitive to the unique needs of people living with dementia and increasing follow-up time to 6 months. IMPACT: This study established the feasibility of registered nurses delivering a post-diagnosis information and support programme for people living with early-stage dementia or mild cognitive impairment and their informal carers in primary care settings. The motivation and capacity of nurses working as programme facilitators ensured the integration of the programme into usual work, but this was not considered sustainable over time. Family carer dyads reported tangible outcomes and gained confidence in sharing their diagnosis with family and friends and asking for assistance. Findings from this study can be used to provide direction for a clinical trial investigating the effectiveness of the structured information and support programme in the primary care setting. REPORTING METHOD: The authors have adhered to the EQUATOR STROBE Statement. PATIENT OR PUBLIC CONTRIBUTION: A public hospital memory clinic and general medical practice participated in project design, study protocol development and supported implementation.

Understanding the impact of the COVID-19 pandemic response on GI infection surveillance trends in England, January 2020-April 2022.

Stepwise non-pharmaceutical interventions and health system changes implemented as part of the COVID-19 response have had implications on the incidence, diagnosis, and reporting of other communicable diseases. Here, we established the impact of the COVID-19 outbreak response on gastrointestinal (GI) infection trends using routinely collected surveillance data from six national English laboratory, outbreak, and syndromic surveillance systems using key dates of governmental policy to assign phases for comparison between pandemic and historic data. Following decreases across all indicators during the first lockdown (March-May 2020), bacterial and parasitic pathogens associated with foodborne or environmental transmission routes recovered rapidly between June and September 2020, while those associated with travel and/or person-to-person transmission remained lower than expected for 2021. High out-of-season norovirus activity was observed with the easing of lockdown measures between June and October 2021, with this trend reflected in laboratory and outbreak systems and syndromic surveillance indicators. Above expected increases in emergency department (ED) attendances may have reflected changes in health-seeking behaviour and provision. Differential reductions across specific GI pathogens are indicative of the underlying routes of transmission. These results provide further insight into the drivers for transmission, which can help inform control measures for GI infections.

Child bereavement-what matters to the families. Part 2: The long term.

The death of a child is a devastating event. Families experience profound grief and loss immediately following the death, and this remains and evolves as time progresses. In this, the second in a series, we discuss the importance of longer term bereavement care and how continuing contact with healthcare can be navigated. As bereaved parents who are also doctors, we again share our experiences. The complex nature of parenting, supporting siblings or managing a pregnancy after loss are explored, and we look at the involvement of bereaved parents in developing bereavement services.

Child bereavement-what matters to the families. Part 1: Immediate and short-term communication and care.

The death of a child is a complex and hugely significant time for a family and community. Sophisticated but sensitive management by clinicians can have both short-term and long-term impacts on how families process the death. There is a paucity of guidance for optimal child bereavement care. A description of the child death review process including key legalities is provided here, and other essential aspects such as memory making, cultural aspects and sibling involvement are explored. Useful agencies and resources are also detailed. We, as both clinicians and bereaved parents, can uniquely provide an overview of the logistics of managing such a challenging event and highlight important subtleties in communication. We attempt, using our own experiences, to provide a framework and best inform future practice.

Extraction vs nonextraction of premolars for orthodontic treatment: A scoping review examining the extent, range, and characteristics of the literature.

INTRODUCTION: The debate about whether malocclusion can or should be treated with or without extraction of premolars continues. This scoping review quantifies the literature, summarizes the outcomes researched and methods, and proposes a way to reduce uncertainty in this area. METHODS: Electronic and gray literature searches were undertaken without language restriction, but non-English language titles and abstracts were not translated. A minimum of 2 people independently screened the titles and abstracts. RESULTS: Searches identified 9010 articles, of which 3851 were duplicates; 5159 were screened, and 4617 were excluded (1092 laboratory or animal studies, 1219 case reports or series, 2306 with no information). By consensus, 399 articles contained information concerning differences between orthodontic patients treated with or without premolar extractions (143 were unclear). The majority (n = 372) reported outcomes in 8 areas. Fifty-seven were review articles (32 systematic reviews and 25 nonsystematic reviews or opinions). The most common research design in the remainder was a cohort (n = 280, 82% of 342 articles reporting primary data), of which a very large majority were considered retrospective (n = 249, 89% of articles reported for subjects over ≥2 time points). Only 28 (8% of articles reporting primary data) were judged to involve prospective data collection (4 randomized controlled trials [RCTs], 23 cohorts, 1 unclear design). Excluding reviews and unclear articles, 99% (332 out of 336) were considered observational research and only 1% were interventional. CONCLUSIONS: There was limited low-quality evidence that extracting premolars in orthodontic patients have a possible negative effect in 2 outcome areas and a positive effect in 1 outcome area. Most study reports were of low methodological quality, and further reviews are unlikely to provide new information. Investigators should concentrate on collecting primary data of outcomes important to patients. A protocol has been made available to help reduce methodological differences, assist future meta-analyses and increase the generalizability of findings: https://doi.org/10.17605/OSF.IO/CQ49Y.

Diabetes status modifies the long-term effect of lipoprotein-associated phospholipase A2 on major coronary events.

AIMS/HYPOTHESIS: Lipoprotein-associated phospholipase A2 (Lp-PLA2) activity has an independent prognostic association with major coronary events (MCE). However, no study has investigated whether type 2 diabetes status modifies the effect of Lp-PLA2 activity or inhibition on the risk of MCE. We investigate the interaction between diabetes status and Lp-PLA2 activity with risk of MCE. Subsequently, we test the resulting hypothesis that diabetes status will play a role in modifying the efficacy of an Lp-PLA2 inhibitor. METHODS: A retrospective cohort study design was utilised in two study populations. Discovery analyses were performed in the Genetics of Diabetes Audit and Research in Tayside Scotland (GoDARTS) cohort based in Scotland, UK. Participants were categorised by type 2 diabetes control status: poorly controlled (HbA1c ≥ 48 mmol/mol or ≥6.5%) and well-controlled (HbA1c < 48 mmol/mol or <6.5%) diabetes (n = 7420). In a secondary analysis of the Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy (STABILITY) trial of Lp-PLA2 inhibitor (darapladib) efficacy, 15,828 participants were stratified post hoc by type 2 diabetes diagnosis status (diabetes or no diabetes) at time of recruitment. Lp-PLA2 activity was then divided into population-specific quartiles. MCE were determined from linked medical records in GoDARTS and trial records in STABILITY. First, the interaction between diabetes control status and Lp-PLA2 activity on the outcome of MCE was explored in GoDARTS. The effect was replicated in the placebo arm of STABILITY. The effect of Lp-PLA2 on MCE was then examined in models stratified by diabetes status. This helped determine participants at higher risk. Finally, the effect of Lp-PLA2 inhibition was assessed in STABILITY in the higher risk group. Cox proportional hazards models adjusted for confounders were used to assess associations. RESULTS: In GoDARTS, a significant interaction between increased Lp-PLA2 activity (continuous and quartile divided) and diabetes control status was observed in the prediction of MCE (p < 0.0001). These effects were replicated in the placebo arm of STABILITY (p < 0.0001). In GoDARTS, stratified analyses showed that, among individuals with poorly controlled diabetes, the hazards of MCE for those with high (Q4) Lp-PLA2 activity was 1.19 compared with individuals with lower (Q1-3) Lp-PLA2 activity (95% CI 1.11, 1.38; p < 0.0001) and 1.35 (95% CI 1.16, 1.57; p < 0.0001) when compared with those with the lowest activity (Q1). Those in the higher risk group were identified as individuals with the highest Lp-PLA2 activity (Q4) and poorly controlled diabetes or diabetes. Based on these observations in untreated populations, we hypothesised that the Lp-PLA2 inhibitor would have more benefit in this higher risk group. In this risk group, Lp-PLA2 inhibitor use was associated with a 33% reduction in MCE compared with placebo (HR 0.67 [95% CI 0.50, 0.90]; p = 0.008). In contrast, Lp-PLA2 inhibitor showed no efficacy in individuals with low activity, regardless of diabetes status, or among those with no baseline diabetes and high Lp-PLA2 activity. CONCLUSIONS/INTERPRETATION: These results support the hypothesis that diabetes status modifies the association between Lp-PLA2 activity and MCE. These results suggest that cardiovascular morbidity and mortality associated with Lp-PLA2 activity is especially important in patients with type 2 diabetes, particularly those with worse glycaemic control. Further investigation of the effects of Lp-PLA2 inhibition in diabetes appears warranted. DATA AVAILABILITY: STABILITY trial data are available from clinicaltrials.gov repository through the GlaxoSmithKline clinical study register https://clinicaltrials.gov/ct2/show/NCT00799903 . GoDARTS datasets generated during and/or analysed during the current study are available following request to the GoDARTS Access Managements Group https://godarts.org/scientific-community/ .

Fibroblast growth factor signalling influences homologous recombination-mediated DNA damage repair to promote drug resistance in ovarian cancer.

BACKGROUND: Ovarian cancer patients frequently develop chemotherapy resistance, limiting treatment options. We have previously shown that individuality in fibroblast growth factor 1 (FGF1) expression influences survival and chemotherapy response. METHODS: We used MTT assays to assess chemosensitivity to cisplatin and carboplatin following shRNA-mediated knockdown or heterologous over-expression of FGF1 (quantified by qRT-PCR and immunoblot analysis), and in combination with the FGFR inhibitors AZD4547 and SU5402, the ATM inhibitor KU55933 and DNA-PK inhibitor NU7026. Immunofluorescence microscopy was used to quantify the FGF1-dependent timecourse of replication protein A (RPA) and γH2AX foci formation. RESULTS: Pharmacological inhibition of FGF signalling reversed drug resistance in immortalised cell lines and in primary cell lines from drug-resistant ovarian cancer patients, while FGF1 over-expression induced resistance. Ataxia telangiectasia mutated (ATM) phosphorylation, but not DNA adduct formation was FGF1 dependent, following cisplatin or carboplatin challenge. Combining platinum drugs with the ATM inhibitor KU55933, but not with the DNA-PK inhibitor NU7026 re-sensitised resistant cells. FGF1 expression influenced the timecourse of damage-induced RPA and γH2AX nuclear foci formation. CONCLUSION: Drug resistance arises from FGF1-mediated differential activation of high-fidelity homologous recombination DNA damage repair. FGFR and ATM inhibitors reverse platinum drug resistance, highlighting novel combination chemotherapy approaches for future clinical trial evaluation.

Prevalence of colistin heteroresistance in carbapenem-resistant Pseudomonas aeruginosa and association with clinical outcomes in patients: an observational study.

OBJECTIVES: To describe the prevalence of colistin heteroresistance in carbapenem-resistant Pseudomonas aeruginosa (CRPA) and evaluate the association with clinical outcomes. METHODS: Colistin heteroresistance was evaluated in CRPA isolates collected from patients without cystic fibrosis in Atlanta, Georgia, USA using two definitions: HR1, growth at 4 and 8 mg/L of colistin at a frequency ≥1 × 10-6 the main population; and HR2, growth at a colistin concentration ≥8× the MIC of the main population at a frequency ≥1 × 10-7. A modified population analysis profile (mPAP) technique was compared with reference PAP for detecting heteroresistance. For adults hospitalized at the time of or within 1 week of CRPA culture, multivariable logistic regression estimated the association between heteroresistance and 90 day mortality. RESULTS: Of 143 colistin-susceptible CRPA isolates, 8 (6%) met the HR1 definition and 37 (26%) met the HR2 definition. Compared with the reference PAP, mPAP had a sensitivity and specificity of 50% and 100% for HR1 and 32% and 99% for HR2. Of 82 hospitalized patients, 45 (56%) were male and the median age was 63 years (IQR 49-73). Heteroresistance was not associated with 90 day mortality using HR1 (0% in heteroresistant versus 22% in non-heteroresistant group; P = 0.6) or HR2 (12% in heteroresistant versus 24% in non-heteroresistant group; P = 0.4; adjusted OR 0.8; 95% CI 0.2-3.4). CONCLUSIONS: Colistin heteroresistance was identified in up to 26% of patients with CRPA in our sample, although the prevalence varied depending on the definition. We did not observe an apparent association between colistin heteroresistance and 90 day mortality.

Fragility fractures of the pelvis in the older population.

Pelvic fractures are an increasingly common injury seen in the older population and represent a significant burden of morbidity and mortality in this age group, as well as a large financial burden on the health service. It is well established that early fixation of femoral neck and acetabular fractures improves outcomes and increases the chances of patients returning close to their premorbid functional baseline. However, fixation of fragility fractures of the pelvis is less well established in current practice. There has been recent development of novel stabilisation techniques for unstable pelvic fractures, designed to tackle the difficulties associated with fixation in poor bone quality, along with medical trials of parathyroid hormone analogue treatment. However, it is still current practice to manage nearly all fragility fractures of the pelvis conservatively. In this article, we consider whether the development of surgical stabilisation techniques for pelvic fragility fractures may have the potential to improve the well-described morbidity and mortality associated with them.

Investigating regional variation of respiratory infections in a general practice syndromic surveillance system.

BACKGROUND: Established surveillance systems can follow trends in community disease and illness over many years. However, within England there are known regional differences in healthcare utilisation, which can affect interpretation of trends. Here, we explore regional differences for a range of respiratory conditions using general practitioner (GP) consultation data. METHODS: Daily data for respiratory conditions were extracted from a national GP surveillance system. Average daily GP consultation rates per 100 000 registered patient population were calculated by each region of England and for each study year (2013-17). Consultation rates and incidence rate ratios were also calculated for each condition by deprivation quintile and by rural, urban, and conurbation groups. RESULTS: Upper and lower respiratory tract infections and asthma were higher in the North and the Midlands than in London and the South, were highest in the most deprived groups and tended to be higher in more urban areas. Influenza-like illness was highest in the least deprived and rural areas. CONCLUSIONS: There are consistent differences in GP consultation rates across the English regions. This work has improved our understanding and interpretation of GP surveillance data at regional level and will guide more accurate public health messages.

Describing the indirect impact of COVID-19 on healthcare utilisation using syndromic surveillance systems.

BACKGROUND: Since the end of January 2020, the coronavirus (COVID-19) pandemic has been responsible for a global health crisis. In England a number of non-pharmaceutical interventions have been introduced throughout the pandemic, including guidelines on healthcare attendance (for example, promoting remote consultations), increased handwashing and social distancing. These interventions are likely to have impacted the incidence of non-COVID-19 conditions as well as healthcare seeking behaviour. Syndromic Surveillance Systems offer the ability to monitor trends in healthcare usage over time. METHODS: This study describes the indirect impact of COVID-19 on healthcare utilisation using a range of syndromic indicators including eye conditions, mumps, fractures, herpes zoster and cardiac conditions. Data from the syndromic surveillance systems monitored by Public Health England were used to describe the number of contacts with NHS 111, general practitioner (GP) In Hours (GPIH) and Out-of-Hours (GPOOH), Ambulance and Emergency Department (ED) services over comparable periods before and during the pandemic. RESULTS: The peak pandemic period in 2020 (weeks 13-20), compared to the same period in 2019, displayed on average a 12% increase in NHS 111 calls, an 11% decrease in GPOOH consultations, and a 49% decrease in ED attendances. In the GP In Hours system, conjunctivitis consultations decreased by 64% and mumps consultations by 31%. There was a 49% reduction in attendance at EDs for fractures, and there was no longer any weekend increase in ED fracture attendances, with similar attendance patterns observed across each day of the week. There was a decrease in the number of ED attendances with diagnoses of myocardial ischaemia. CONCLUSION: The COVID-19 pandemic drastically impacted healthcare utilisation for non-COVID-19 conditions, due to a combination of a probable decrease in incidence of certain conditions and changes in healthcare seeking behaviour. Syndromic surveillance has a valuable role in describing and understanding these trends.

The impact of social and physical distancing measures on COVID-19 activity in England: findings from a multi-tiered surveillance system.

BackgroundA multi-tiered surveillance system based on influenza surveillance was adopted in the United Kingdom in the early stages of the coronavirus disease (COVID-19) epidemic to monitor different stages of the disease. Mandatory social and physical distancing measures (SPDM) were introduced on 23 March 2020 to attempt to limit transmission.AimTo describe the impact of SPDM on COVID-19 activity as detected through the different surveillance systems.MethodsData from national population surveys, web-based indicators, syndromic surveillance, sentinel swabbing, respiratory outbreaks, secondary care admissions and mortality indicators from the start of the epidemic to week 18 2020 were used to identify the timing of peaks in surveillance indicators relative to the introduction of SPDM. This timing was compared with median time from symptom onset to different stages of illness and levels of care or interactions with healthcare services.ResultsThe impact of SPDM was detected within 1 week through population surveys, web search indicators and sentinel swabbing reported by onset date. There were detectable impacts on syndromic surveillance indicators for difficulty breathing, influenza-like illness and COVID-19 coding at 2, 7 and 12 days respectively, hospitalisations and critical care admissions (both 12 days), laboratory positivity (14 days), deaths (17 days) and nursing home outbreaks (4 weeks).ConclusionThe impact of SPDM on COVID-19 activity was detectable within 1 week through community surveillance indicators, highlighting their importance in early detection of changes in activity. Community swabbing surveillance may be increasingly important as a specific indicator, should circulation of seasonal respiratory viruses increase.

Withdrawal of pharmacological treatment for heart failure in patients with recovered dilated cardiomyopathy (TRED-HF): an open-label, pilot, randomised trial.

BACKGROUND: Patients with dilated cardiomyopathy whose symptoms and cardiac function have recovered often ask whether their medications can be stopped. The safety of withdrawing treatment in this situation is unknown. METHODS: We did an open-label, pilot, randomised trial to examine the effect of phased withdrawal of heart failure medications in patients with previous dilated cardiomyopathy who were now asymptomatic, whose left ventricular ejection fraction (LVEF) had improved from less than 40% to 50% or greater, whose left ventricular end-diastolic volume (LVEDV) had normalised, and who had an N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) concentration less than 250 ng/L. Patients were recruited from a network of hospitals in the UK, assessed at one centre (Royal Brompton and Harefield NHS Foundation Trust, London, UK), and randomly assigned (1:1) to phased withdrawal or continuation of treatment. After 6 months, patients in the continued treatment group had treatment withdrawn by the same method. The primary endpoint was a relapse of dilated cardiomyopathy within 6 months, defined by a reduction in LVEF of more than 10% and to less than 50%, an increase in LVEDV by more than 10% and to higher than the normal range, a two-fold rise in NT-pro-BNP concentration and to more than 400 ng/L, or clinical evidence of heart failure, at which point treatments were re-established. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02859311. FINDINGS: Between April 21, 2016, and Aug 22, 2017, 51 patients were enrolled. 25 were randomly assigned to the treatment withdrawal group and 26 to continue treatment. Over the first 6 months, 11 (44%) patients randomly assigned to treatment withdrawal met the primary endpoint of relapse compared with none of those assigned to continue treatment (Kaplan-Meier estimate of event rate 45·7% [95% CI 28·5-67·2]; p=0·0001). After 6 months, 25 (96%) of 26 patients assigned initially to continue treatment attempted its withdrawal. During the following 6 months, nine patients met the primary endpoint of relapse (Kaplan-Meier estimate of event rate 36·0% [95% CI 20·6-57·8]). No deaths were reported in either group and three serious adverse events were reported in the treatment withdrawal group: hospital admissions for non-cardiac chest pain, sepsis, and an elective procedure. INTERPRETATION: Many patients deemed to have recovered from dilated cardiomyopathy will relapse following treatment withdrawal. Until robust predictors of relapse are defined, treatment should continue indefinitely. FUNDING: British Heart Foundation, Alexander Jansons Foundation, Royal Brompton Hospital and Imperial College London, Imperial College Biomedical Research Centre, Wellcome Trust, and Rosetrees Trust.

Comparison of statistical algorithms for daily syndromic surveillance aberration detection.

MOTIVATION: Public health authorities can provide more effective and timely interventions to protect populations during health events if they have effective multi-purpose surveillance systems. These systems rely on aberration detection algorithms to identify potential threats within large datasets. Ensuring the algorithms are sensitive, specific and timely is crucial for protecting public health. Here, we evaluate the performance of three detection algorithms extensively used for syndromic surveillance: the 'rising activity, multilevel mixed effects, indicator emphasis' (RAMMIE) method and the improved quasi-Poisson regression-based method known as 'Farrington Flexible' both currently used at Public Health England, and the 'Early Aberration Reporting System' (EARS) method used at the US Centre for Disease Control and Prevention. We model the wide range of data structures encountered within the daily syndromic surveillance systems used by PHE. We undertake extensive simulations to identify which algorithms work best across different types of syndromes and different outbreak sizes. We evaluate RAMMIE for the first time since its introduction. Performance metrics were computed and compared in the presence of a range of simulated outbreak types that were added to baseline data. RESULTS: We conclude that amongst the algorithm variants that have a high specificity (i.e. >90%), Farrington Flexible has the highest sensitivity and specificity, whereas RAMMIE has the highest probability of outbreak detection and is the most timely, typically detecting outbreaks 2-3 days earlier. AVAILABILITY AND IMPLEMENTATION: R codes developed for this project are available through https://github.com/FelipeJColon/AlgorithmComparison. SUPPLEMENTARY INFORMATION: Supplementary data are available at Bioinformatics online.

The COVID-19 pandemic: a new challenge for syndromic surveillance.

The COVID-19 pandemic is exerting major pressures on society, health and social care services and science. Understanding the progression and current impact of the pandemic is fundamental to planning, management and mitigation of future impact on the population. Surveillance is the core function of any public health system, and a multi-component surveillance system for COVID-19 is essential to understand the burden across the different strata of any health system and the population. Many countries and public health bodies utilise 'syndromic surveillance' (using real-time, often non-specific symptom/preliminary diagnosis information collected during routine healthcare provision) to supplement public health surveillance programmes. The current COVID-19 pandemic has revealed a series of unprecedented challenges to syndromic surveillance including: the impact of media reporting during early stages of the pandemic; changes in healthcare-seeking behaviour resulting from government guidance on social distancing and accessing healthcare services; and changes in clinical coding and patient management systems. These have impacted on the presentation of syndromic outputs, with changes in denominators creating challenges for the interpretation of surveillance data. Monitoring changes in healthcare utilisation is key to interpreting COVID-19 surveillance data, which can then be used to better understand the impact of the pandemic on the population. Syndromic surveillance systems have had to adapt to encompass these changes, whilst also innovating by taking opportunities to work with data providers to establish new data feeds and develop new COVID-19 indicators. These developments are supporting the current public health response to COVID-19, and will also be instrumental in the continued and future fight against the disease.

Do point-of-care tests (POCTs) offer a new paradigm for the management of patients with influenza?

The introduction of point-of-care tests (POCTs) has presented new opportunities for the management of patients presenting to healthcare providers with acute respiratory symptoms. This Perspective article is based on the experiences of national infection teams/those managing acute respiratory infections across the United Kingdom in terms of the challenges and opportunities that this may present for public health. This Perspective article was conceived and written pre-coronavirus disease (COVID-19), however the principles we outline here for influenza can also be translated to COVID-19 and some key points are made throughout the article. The greatest challenge for intergrating POCTs into non-traditional environments is the capture of data and samples for surveillance purposes which provides information for public health action. However, POCTs together with measures outlined in this article, offer a new paradigm for the management and public health surveillance of patients with influenza.

Emergency department use during COVID-19 as described by syndromic surveillance.

On 12 March 2020 the UK entered the 'delay phase' of the COVID-19 pandemic response. The Public Health England Emergency Department Syndromic Surveillance System (EDSSS) carries out daily (near real-time) public health surveillance of emergency department (ED) attendances across England. This retrospective observational analysis of EDSSS data aimed to describe changes in ED attendances during March-April 2020, and identify the attendance types with the largest impact. Type 1 ED attendances were selected from 109 EDs that reported data to EDSSS for the period 1 January 2019 to 26 April 2020. The daily numbers of attendances were plotted by age group and acuity of presentation. The 2020 'COVID-19' period (12 March 2020 to 26 April 2020) attendances were compared with the equivalent 2019 'pre-COVID-19' period (14 March 2019 to 28 April 2019): in total; by hour and day of the week; age group(<1, 1-4, 15-14, 15-44, 45-64 and 65+ years); gender; acuity; and for selected syndromic indicators(acute respiratory infection, gastroenteritis, myocardial ischaemia). Daily ED attendances up to 11 March 2020 showed regular trends, highest on a Monday and reduced in children during school holidays. From 12 March 2020 ED attendances decreased across all age groups, all acuity levels, on all days and times. Across age groups the greatest percentage reductions were seen in school age children (5-14 years). By acuity, the greatest reduction occurred in the less severe presentations. Syndromic indicators showed that the greatest reductions were in non-respiratory indicators, which fell by 44-67% during 2020 COVID-19, while acute respiratory infection was reduced by -4.4% (95% CI -9.5% to 0.6%). ED attendances in England have been particularly affected during the COVID-19 pandemic due to changes in healthcare seeking behaviour. EDSSS has enabled real-time daily monitoring of these changes, which are made publicly available to facilitate action. The EDSSS provides valuable surveillance of ED attendances in England. The flexibility of EDSSS allowed rapid development of new indicators (including COVID-19-like) and reporting methods.

Interventions to prevent in-hospital falls in older people with cognitive impairment for further research: A mixed studies review.

BACKGROUND: While advances in falls prevention in the adult population have occurred, the care requirements for older patients with cognitive impairment at risk of falling are less established. OBJECTIVES: To identify interventions to prevent in-hospital falls in older patients with cognitive impairment for further research and describe the strategies used to implement those interventions. DESIGN: A seven-stage mixed studies review was used. METHODS: Seven electronic databases were searched. The SPIDER framework guided the review question and selection of search terms. The Mixed Methods Assessment Tool was used to appraise the quality of research studies, and the Quality Improvement Minimum Quality Data Set was used to appraise the quality of quality improvement projects. A convergent qualitative synthesis was used to analyse the extracted data. The adapted PRISMA guideline informed the procedures. RESULTS: Ten projects (five quality improvements and five researches) were included. Five themes emerged from the synthesis: engaging with families in falls prevention, assessing falls risk to identify interventions, extending nursing observation through technology, conducting a medication review and initiating nonpharmacological delirium prevention interventions. Implementation was not well described and commonly focused on capital investment to initiate a falls prevention programme and education to introduce staff to the new techniques for practice. CONCLUSIONS: Emerging research and quality improvement studies demonstrate that effective falls prevention with this vulnerable population is possible but requires further investigation before widespread practice recommendations can be made. Further research and quality improvement in this area should consider adoption of an implementation framework to address sustainability. RELEVANCE TO CLINICAL PRACTICE: Reducing falls in older people with cognitive impairment requires nurses to work more closely with pharmacists, occupational therapists and social workers to develop strategies that work and are sustainable.

Safety of buccal infiltration local anaesthesia for dental procedures.

AIM: To assess the safety of buccal infiltration local anaesthetic (LA) without additional factor replacement in patients with haemophilia (PWH) and association with clinical experience of the operator. METHODS: A consecutive sample of participants with mild, moderate and severe haemophilia scheduled to have dental treatment were recruited from a comprehensive care centre in Ireland. Infiltration LA was administered using a standard technique. Safety was defined as any adverse event at time of administration, immediate postoperative, or postoperative period. Clinical experience was dichotomized into fewer or greater than three years clinical experience. RESULTS: N = 135 buccal infiltration LAs without additional factor replacement were provided to N = 71 participants with mild (n = 20; 28%) and moderate to severe haemophilia (n = 51; 72%). Successful local anaesthesia was achieved in n = 133 cases (99%). No (0%) adverse bleeding events were recorded for any participants at time of administration of LA or during follow-up. Three out of 135 (2.2%) LAs recorded superficial bleeding 30 seconds after administration of LA, all of which resolved within 2 minutes with application of pressure; 4 out of 135 (3%) LAs produced a superficial haematoma at the site of injection no greater than 2 mm all of which resolved at 4 minutes. There were no differences in bleeding rates between clinicians by level of experience (P = 0.435) or by severity of bleeding disorder (P = 1.0). CONCLUSION: Local anaesthetic is safe to administer via buccal infiltration for people with mild, moderate and severe haemophilia without additional factor cover. This finding holds true regardless of operator experience.