Preliminary development of recommendations for the inclusion of patient-reported outcome measures in clinical quality registries.

BACKGROUND: Clinical quality registries (CQRs) monitor compliance against optimal practice and provide feedback to the clinical community and wider stakeholder groups. Despite a number of CQRs having incorporated the patient perspective to support the evaluation of healthcare delivery, no recommendations for inclusion of patient-reported outcome measures (PROMs) in CQRs exist. The aim of this study was to develop a core set of recommendations for PROMs inclusion of in CQRs. METHOD: An online two-round Delphi survey was performed among CQR data custodians, quality of life researchers, biostatisticians and clinicians largely recruited in Australia. A list of statements for the recommendations was identified from a literature and survey of the Australian registries conducted in 2019. The statements were grouped into the following domains: rationale, setting, ethics, instrument, administration, data management, statistical methods, and feedback and reporting. Eighteen experts were invited to participate, 11 agreed to undertake the first online survey (round 1). Of these, nine experts completed the online survey for round 2. RESULTS: From 117 statements presented to the Delphi panel in round 1, a total of 72 recommendations (55 from round 1 and 17 from round 2) with median importance (MI) ≥ 7 and disagreement index (DI) < 1 were proposed for inclusion into the final draft set and were reviewed by the project team. Recommendations were refined for clarity and to read as stand-alone statements. Ten overlapped conceptually and, therefore, were merged to reduce repetition. The final 62 recommendations were sent for review to the panel members for their feedback, which was incorporated into the final set. CONCLUSION: This is the first study to develop preliminary recommendations for PROMs inclusion in CQRs. Recommendations for PROMs implementation are critically important for registries to assure meaningful PROMs data capture, use, interpretation, and reporting to improve health outcomes and healthcare value.

Assessing the need for service improvement.

In order to ensure the service they offer is of an appropriate standard, nurses need to know how to assess its quality, identify the need for change, and implement and evaluate that change. This two-part series offers practical guidance on how to bring about an evidence-based change in practice, and how to demonstrate the success, or otherwise, of that change. It uses the example of an initiative undertaken to improve medicines management in a hospice to illustrate the process. The article also illustrates how work undertaken in changing practice can form part of the evidence submitted in the nurse revalidation process. Part 1 considers how to determine when a change in practice is needed, how to assess and measure current practice, and identify gaps or weaknesses. Part 2 will discuss how to find out why the current practice is falling short of the desired level, and how to go about implementing improvements and measuring the effect of changes.

Managing and reviewing evidence-based changes.

Nurses lead many projects to manage change aimed at improving patient safety and care. This two-part series offers practical guidance on how to bring about an evidence-based change in practice, and how to demonstrate the success, or otherwise, of that change. Part 2 is concerned with discovering why the practice is falling short, how to implement improvements and measure the effect of the changes. It also highlights ways in which nurses can use their work as part of the revalidation process.

Understanding clinical review following a death in custody.

This article examines the importance of clinical reviews for people receiving care in custodial settings. A case study is used to illustrate the need for accurate record-keeping, particularly following death. Healthcare professionals have a duty to ensure that prisoners have the same rights as members of the general public in relation to access to health care and opportunities to improve their health.

Stroke clinical coding education program in Australia and New Zealand.

BACKGROUND: Accurate coded diagnostic data are important for epidemiological research of stroke. OBJECTIVE: To develop, implement and evaluate an online education program for improving clinical coding of stroke. METHOD: The Australia and New Zealand Stroke Coding Working Group co-developed an education program comprising eight modules: rationale for coding of stroke; understanding stroke; management of stroke; national coding standards; coding trees; good clinical documentation; coding practices; and scenarios. Clinical coders and health information managers participated in the 90-minute education program. Pre- and post-education surveys were administered to assess knowledge of stroke and coding, and to obtain feedback. Descriptive analyses were used for quantitative data, inductive thematic analysis for open-text responses, with all results triangulated. RESULTS: Of 615 participants, 404 (66%) completed both pre- and post-education assessments. Respondents had improved knowledge for 9/12 questions (p < 0.05), including knowledge of applicable coding standards, coding of intracerebral haemorrhage and the actions to take when coding stroke (all p < 0.001). Majority of respondents agreed that information was pitched at an appropriate level; education materials were well organised; presenters had adequate knowledge; and that they would recommend the session to colleagues. In qualitative evaluations, the education program was beneficial for newly trained clinical coders, or as a knowledge refresher, and respondents valued clinical information from a stroke neurologist. CONCLUSION: Our education program was associated with increased knowledge for clinical coding of stroke. To continue to address the quality of coded stroke data through improved stroke documentation, the next stage will be to adapt the educational program for clinicians.

A test to assess aerobic and anaerobic parameters during maximal exercise in young girls.

The Wingate cycle test (WAnT) is a 30-s test commonly used to estimate anaerobic work capacity (AWC). However, the test may be too short to fully deplete anaerobic energy reserves. We hypothesized that a 90-s all-out isokinetic test (ISO_90) would be valid to assess both aerobic and anaerobic capacities in young females. Eight girls (11.9 ± 0.5 y) performed an exhaustive incremental test, a WAnT and an ISO_90. Peak VO2 attained during the ISO_90 was significantly greater than VO2peak. Mean power, end power, fatigue index, total work done and AWC were not significantly different between the WAnT and after 30 s of the 90-s test (i.e., ISO_30). However, 95% limits of agreement showed large variations between the two tests when comparing all anaerobic parameters. It is concluded that an ISO-90 may be a useful test to assess aerobic capacity in young girls. However, since the anaerobic parameters derived from the ISO_30 did not agree with those derived from a traditional WAnT, the validity of using an ISO_90 to assess anaerobic performance and capacity within this population group remains unconfirmed.

Time to exhaustion and time spent at a high percentage of VO2max in severe intensity domain in children and adults.

The aim of the study was to compare time spent at a high percentage of VO2max (>90% of VO2max) (ts90%), time to achieve 90% of VO2max (ta90%), and time to exhaustion (TTE) for exercise in the severe intensity domain in children and adults. Fifteen prepubertal boys (10.3 ± 0.9 years) and 15 men (23.5 ± 3.6 years) performed a maximal graded exercise to determine VO2max, maximal aerobic power (MAP) and power at ventilatory threshold (PVTh). Then, they performed 4 constant load exercises in a random order at PVTh plus 50 and 75% of the difference between MAP and PVTh (PΔ50 and PΔ75) and 100 and 110% of MAP (P100 and P110). VO2max was continuously monitored. The P110 test was used to determine maximal accumulated oxygen deficit (MAOD). No significant difference was found in ta90% between children and adults. ts90% and TTE were not significantly different between children and adults for the exercises at PΔ50 and PΔ75. However, ts90% and TTE during P100 (p < 0.05 and p < 0.01, respectively) and P110 (p < 0.001) exercises were significantly shorter in children. Children had a significantly lower MAOD than adults (34.3 ± 9.4 ml · kg vs. 53.6 ± 11.1 ml · kg). A positive relationship (p < 0.05) was obtained between MAOD and TTE values during the P100 test in children. This study showed that only for intensities at, or higher than MAP, lower ts90% in children was linked to a reduced TTE, compared to adults. Shorter TTE in children can partly be explained by a lower anaerobic capacity (MAOD). These results give precious information about exercise intensity ranges that could be used in children's training sessions. Moreover, they highlight the implication of both aerobic and anaerobic processes in endurance performances in both populations.

Implementing a health promotion model in a young offender institution.

Young people in young offender institutions experience more physical and mental health problems than the general population. This article explores how the primary nursing service at HM Young Offenders Institution Huntercombe used national policy as a framework for managing change. In outlining the challenges and opportunities that influence practice development, we hope to demystify nursing in a prison setting, which is a hidden and often misunderstood aspect of healthcare.

Cycling efficiency in trained male and female competitive cyclists.

The aim of this study was to examine differences in cycling efficiency between competitive male and female cyclists. Thirteen trained male (mean ± SD: 34 ± 8 yr, 74.1 ± 6.0 kg, Maximum Aerobic Power (MAP) 414 ± 40 W, VO2max 61.3 ± 5.4 ml·kg(-1)·min(-1)) and 13 trained female (34 ± 9 yr, 60.1 ± 5.2 kg, MAP 293 ± 22 W, VO2max 48.9 ± 6.1 ml·kg(-1)·min(-1)) competitive cyclists completed a cycling test to ascertain their gross efficiency (GE). Leg and lean leg volume of all cyclists was also measured. Calculated GE was significantly higher in female cyclists at 150W (22.5 ± 2.1 vs 19.9 ± 1. 8%; p < 0.01) and 180W (22.3 ± 1.8 vs 20.4 ± 1.5%; p = 0.01). Cadence was not significantly different between the groups (88 ± 6 vs 91 ± 5 rev·min(-1)). Lean leg volume was significantly lower for female cyclists (4.04 ± 0.5 vs 5.51 ± 0.8 dm(3); p < 0.01) and was inversely related to GE in both groups at 150 and 180W (r = -0.59 and -0.58; p < 0.05). Lean leg volume was shown to account for the differences in GE between the males and females. During an "unloaded "pedalling condition, male cyclists had a significantly higher O2 cost than female cyclists (1.0 ± 0.1 vs 0.7 ± 0.1 L·min(-1); p < 0.01), indicative of a greater non-propulsive cost of cycling. These results suggest that differences in efficiency between trained male and female cyclists can be partly accounted for by sex-specific variation in lean leg volume. Key pointsDifferences in GE exist between male and female cyclists.Males have a higher oxygen cost of "unloaded "cycling, as predicted by the intercept of the O2 cost-power output relationshipThis suggests that in addition to work rate, leg volume/mass may be an important determinant of observed differences in oxygen cost and therefore GE, between male and female competitive cyclists.

New-Onset Nephrotic Syndrome in a Child Associated With COVID-19 Infection.

Introduction: The COVID-19 outbreak has become a worldwide public health emergency. The renal histopathological features of acute tubular necrosis or thrombotic microangiopathy have been previously reported in adults with severe COVID-19 infections. In children, the renal manifestations associated with COVID-19 disease are not widely reported. Here we describe a case report of a child with new-onset nephrotic syndrome associated with COVID-19 infection. Case Presentation: An 8-year-old boy with no previous significant medical history presented with bilateral eyelid and facial swelling soon after his parents were diagnosed with COVID-19 infection. He had diarrhea but no fever or shortness of breath. At 1 week after the onset of swelling, the boy tested positive for the COVID-19 virus. Based on clinical findings of significant proteinuria (urine protein and creatinine ratio of 11.4), hypoalbuminemia (serum albumin of 2 g/dl), and hypercholesterolemia (total cholesterol of 384 mg/dl), he was diagnosed with nephrotic syndrome. He responded well to standard-dose prednisone treatment for nephrotic syndrome. At 1 week after starting the prednisone treatment, he went into clinical remission. Lymphopenia continued to be present for 4 weeks after the onset of symptoms. There were no complications related to clot formation or secondary infections with this presentation. Conclusion: COVID-19 can be associated with new-onset nephrotic syndrome in children. The patient responded well to the standard-dose prednisone treatment that is typically used for new-onset nephrotic syndrome. Summary: We describe the unique presentation of COVID-19 in a child as new-onset nephrotic syndrome. We offer insight on the success of standard treatment of nephrotic syndrome with COVID-19.

Stapled transanal rectal resection for obstructed defecation: a cautionary tale.

PURPOSE: This prospective study was designed to assess the efficacy and safety of a novel technique in treating outlet obstruction syndrome using a transanal double-stapling procedure. METHODS: Two hundred thirty patients (187 female) with obstructed defecation underwent stapled transanal rectal resection over a six-year period with follow-up at 2, 6, and 12 months, then yearly; median follow-up was 24 (range, 12-68) months. All failed conservative measures. Patients with slow transit constipation and puborectalis dyssynergia were excluded. RESULTS: Operating time was short (median, 35 (range, 20-95) minutes), with 159 (69%) performed as day cases (outpatient). Major complications were seen in 16 (7%); there were no deaths. Twelve (5%) patients reported severe postoperative pain. Immediate postoperative fecal urgency was reported by 107 (46%) patients, but persisted at six months in only 26 (11%). Three (1%) developed recurrent rectal prolapse. Nearly all incontinent patients (98%) reported an improvement, with a median Wexner score reduction of 5 points (P < 0.0001). Constipation improved in 77% of patients. Seventy-seven percent of patients were "very glad" they had the operation, and 86% "recommended" stapled transanal rectal resection to a friend. CONCLUSION: Stapled transanal rectal resection can be performed on a day-case basis with high levels of patient satisfaction. Incontinence and constipation are improved. However, significant morbidity occurs in 7% of patients, and urgency of defecation persists beyond six months in 11%.

Physiological and performance effects of low- versus mixed-intensity rowing training.

PURPOSE: To examine the impact of low-intensity and a mixture of low- and high-intensity training on physiological and performance responses in rowing. METHODS: Eighteen experienced rowers undertook a 12-wk program of 100% < or = lactate threshold (LT) training (LOW) or 70% training at < or = LT and 30% at halfway (50%Delta) between the V O2 at LT and V O2peak (MIX). Responses were assessed before and after training by a progressive exercise test to exhaustion; multiple "square-wave" rest-to-exercise transitions of 6-min duration at 50%Delta; and a maximal 2000-m ergometer time trial. RESULTS: Improvements (P < 0.001) in 2000-m ergometer performance and V O2peak occurred independently of groups (P = 0.8 and 0.42, respectively). LOW improved the power at LT (23.5 +/- 12.2 vs 5.1 +/- 5.0 W, P = 0.013) and power at a [blood lactate] of 4 mM (32.3 +/- 6.9 vs 13.1 +/- 3.7 W, P = 0.03) compared with MIX. The time constant and gain of the primary component were unchanged with training, whereas the gain of the V O2 slow component was reduced with training, but independently of group. CONCLUSIONS: Both LOW and MIX training programs improved performance and V O2peak by the same magnitude, whereas LOW attenuated the blood lactate response to a given exercise intensity more so than MIX.

Estimating primary care attendance rates for fever in infants after meningococcal B vaccination in England using national syndromic surveillance data.

BACKGROUND: In September 2015, the United Kingdom became the first country to introduce the multicomponent group B meningococcal vaccine (4CMenB) into a national infant immunisation programme. In early clinical trials 51-61% of infants developed a fever when 4CMenB was administered with other routine vaccines. Whilst administration of prophylactic paracetamol is advised, up to 3% of parents may seek medical advice for fever following vaccination. We used research-level general practitioner consultations to identify any increase in attendances for all-cause fever in vaccine-eligible infants following 4CMenB introduction in England. METHODS: Consultations for infant all-cause fever in the year following the vaccine introduction were identified from The Phoenix Partnership (TPP) ResearchOne general practice database using Read (CTV3) codes. Average daily consultation rates and incidence rate ratios (IRRs) were calculated for vaccine-eligible age groups and compared to the two years preceding vaccine introduction. The difference between pre- and post-vaccine all-cause fever consultations was estimated. RESULTS: All-cause fever consultations in vaccine-eligible 7-10 week olds were 1.6-fold higher (IRR, 1.58; 95% CI, 1.22-2.05) compared to the two previous years and 1.5-fold higher (IRR 1.47; 95% CI, 1.17-1.86) in 15-18 week-olds. There were no significant differences in 0-6 or 11-14 week-olds. Applying the difference between pre- and post-vaccine consultation rates to the 4CMenB vaccine-eligible age groups across England estimated 1825 additional fever consultations in the year following 4CMenB introduction. CONCLUSIONS: We found a small but significant difference in all-cause fever consultation rates in vaccine-eligible infants who would have received 4CMenB with other vaccines.

Comparison of the oxygen uptake kinetics of club and olympic champion rowers.

PURPOSE: To test the hypothesis that elite rowers would possess a faster, more economic oxygen uptake response than club standard rowers. METHODS: Eight Olympic champion (ELITE) rowers were compared with a cohort of eight club standard (CLUB) rowers. Participants completed a progressive exercise test to exhaustion, repeated 6-min moderate and heavy square-wave transitions, and a maximal 2000-m ergometer time trial. RESULTS: The time constant (tau) of the primary component (PC) was faster for the ELITE group compared with CLUB for moderate-intensity (13.9 vs 19.4 s, P = 0.02) and heavy-intensity (18.7 vs 22.4 s, P = 0.005) exercise. ELITE rowers consumed less oxygen for moderate (14.2 vs 15.6 mL x min(-1) x W(-1); P = 0.009) and heavy (12.1 vs 13.7 mL x min(-1) x W(-1); P = 0.01) exercise. A greater absolute slow component was observed in the ELITE group (P = 0.009), but no differences were noted when the slow component was expressed relative to work rate performed (P = 0.14). Intergroup correlation with time trial performance speed was significant for tauPC during heavy-intensity exercise (r = -0.59, P = 0.02). CONCLUSIONS: Compared with CLUB rowers, the shorter time constant response and greater economy observed in ELITE rowers may suggest advantageous adjustment of oxidative processes from rest to work. Training status or performance level do not seem to be associated with a smaller slow component when comparing CLUB and ELITE oarsmen.

Effect of prior exercise above and below critical power on exercise to exhaustion.

PURPOSE: The aim of the present study was to ascertain whether the intensity of prior exercise altered the time to exhaustion at critical power (CP). METHODS: Eleven participants volunteered to take part in the study (mean +/- SD: VO2max 4.1 +/- 0.5 L x min(-1); age 30.1 +/- 7.2 yr; body mass 74.6 +/- 9.1 kg) and completed three trials to exhaustion at their CP under differing prior exercise conditions: 1) a control trial (CON); 2) a trial preceded by three 60-s efforts at 110% CP (severe); and 3) a trial preceded by three 73-s efforts at 90% CP (heavy). All trials followed a 5-min baseline at 50 W. RESULTS: Time to exhaustion was significantly lengthened after prior heavy exercise (1071 +/- 18 s) when compared with CON (973 +/- 16 s, F = 9.53, P = 0.006). However, there was no effect on TTE after prior severe exercise (967 +/- 16 s). Oxygen deficit was significantly reduced from that in CON (3.8 +/- 0.2 L) after prior heavy (3.2 +/- 0.3 L) and prior severe exercise (3.1 +/- 0.3 L, F = 10.95, P = 0.001). Concurrently, there was a significant reduction in the magnitude of the VO2 slow component (SC) in the trials with prior exercise (197 +/- 34 and 126 +/- 19 mL x min(-1) after heavy and severe exercise, respectively) when compared with CON (223 +/- 31 mL x min(-1), F = 9.62, P = 0.006). CONCLUSION: Prior heavy exercise does appear to improve the time to exhaustion at CP by approximately 10% and is associated with a reduction in the VO2 SC. However, the reduction in the SC, with no change in performance after prior severe exercise, suggests that a reduced SC may not necessarily lead to improved TTE.

Deep brain stimulation for phantom limb pain.

Phantom limb pain is an often severe and debilitating phenomenon that has been reported in up to 85% of amputees. Its pathophysiology is poorly understood. Peripheral and spinal mechanisms are thought to play a role in pain modulation in affected individuals; however central mechanisms are also likely to be of importance. The neuromatrix theory postulates a genetically determined representation of body image, which is modified by sensory input to create a neurosignature. Persistence of the neurosignature may be responsible for painless phantom limb sensations, whereas phantom limb pain may be due to abnormal reorganisation within the neuromatrix. This study assessed the clinical outcome of deep brain stimulation of the periventricular grey matter and somatosensory thalamus for the relief of chronic neuropathic pain associated with phantom limb in three patients. These patients were assessed preoperatively and at 3 month intervals postoperatively. Self-rated visual analogue scale pain scores assessed pain intensity, and the McGill Pain Questionnaire assessed the quality of the pain. Quality of life was assessed using the EUROQOL EQ-5D scale. Periventricular gray stimulation alone was optimal in two patients, whilst a combination of periventricular gray and thalamic stimulation produced the greatest degree of relief in one patient. At follow-up (mean 13.3 months) the intensity of pain was reduced by 62% (range 55-70%). In all three patients, the burning component of the pain was completely alleviated. Opiate intake was reduced in the two patients requiring morphine sulphate pre-operatively. Quality of life measures indicated a statistically significant improvement. This data supports the role for deep brain stimulation in patients with phantom limb pain. The medical literature relating to the epidemiology, pathogenesis, and treatment of this clinical entity is reviewed in detail.

Somatotopic organization of the human periventricular gray matter.

The periventricular gray (PVG) matter is an established anatomical target for chronic deep brain stimulation (DBS) in the treatment of certain intractable pain syndromes. Data relating to the representation of pain and other somatosensory modalities within the PVG in humans are negligible. We examined the character and location of somatosensory responses elicited by electrical stimulation along the length of the PVG in a patient who underwent unilateral DBS for intractable nociceptive head pain. Consistent responses were obtained and indicated the presence of a somatotopic representation in this region. The contralateral lower limb was represented cranially, followed by the upper limb and trunk, with the face area located caudally, near the level of the superior colliculi. Bilateral representation was only observed in the forehead and scalp.

Physiological responses to 90 s all out isokinetic sprint cycling in boys and men.

The purpose of this study was to compare the VO2 kinetic and mechanical power responses of boys and men to all out 90 s sprint cycle exercise. Eight boys (14.6 ± 0.3 y) and eight men (33.8 ± 6.5 y) volunteered to participate and completed a ramp test (to determine VO2peak and ventilatory threshold, VT) and then on subsequent days, two 90 s all out cycle sprints on an isokinetic cycle ergometer. During each test, breath-by-breath pulmonary gas exchange and power output were measured. Parameters from the power output profiles were derived from the average response of the two tests including peak power (PP, highest power output in 1 s), end power (EP60-90, power over the last 30 s), and mean power over the 90 s (MP90). Independent pairwise and dependent t-tests were used to compare the data from tests between adults and boys subject groups. Significant differences between adults and boys were found for absolute PP (881.4 ± 60.7 vs 533.6 ± 50.7 W), EP60-90 (288.6 ± 25.7 vs 134.3 ± 17.6 W) and MP90 (434.5 ± 27.4 vs 238.4 ± 17.3 W, p =0.001) respectively. Relative to body mass significant differences between adults and boys were found for EP60-90, MP90 and total work (p < 0.002). The boys attained 90 s VO2 values that were closer to VO2peak than their adult counterparts (93.3 ± 2.6 vs 84.9 ± 2.3 %, p = 0.03). They also demonstrated faster VO2 kinetics (10.8 ± 1.5 vs 17.6 ± 1.0 s, p < 0.01). In conclusion, during all out 90 s cycle sprinting boys were able to attain VO2 values that were closer to VO2peak and a faster time constant than adult men. These findings provide insight into the contribution and speed of response of the aerobic system during an 'anaerobic' test. Key PointsThe results of this study confirm the significant contributions of the aerobic energy systems during so called 'anaerobic tests'.Boys were able to attain VO2 values from an all out 90 s sprint cycle that were closer to their aerobic VO2 peak test than adults. More detailed studies are required to investigate the limiting factors that prevent VO2 peak being reached in an all out sprint cycle.All out tests of a duration > 30 s and coupled with gas and power analyses offer paediatric physiologists considerable scope to examine the contributions of the anaerobic and aerobic energy systems until more ethically viable methods are found.

Introduction of a manual vacuum aspiration service: a model of service within a NHS Sexual Health Service.

BACKGROUND: We assessed the applicability, acceptability and cost implications of introducing the manual vacuum aspiration (MVA) technique with local anaesthesia for fully conscious first-trimester termination of pregnancy within our service and for our population. SETTING: The outpatient setting of a Pregnancy Advisory Service within a NHS Sexual Health Service. METHODS: Self-administered misoprostol and diclofenac, extra-amniotic local anaesthetic gel and paracervical mepivicaine prior to MVA. Routinely collected data were used to provide information on uptake, demographic details, timing, pain score, complications, contraceptive uptake, and economic implications for our service. RESULTS: MVA was chosen by 305/1681 potentially eligible women. Forty percent had the procedure on the day they attended for assessment. Seventy-nine percent gave a pain score of 3 or less out of 10. Complications occurred in six cases (2%); these included cervical rigidity, a false passage, retained products of conception, bleeding (more than 200 ml) and one allergic reaction. Eighty percent of women chose to commence a long-acting reversible contraception (LARC) method at the time of MVA. Operating theatre utilisation was reduced by one termination list per week and cost savings of around £60,000 per annum were realised. CONCLUSIONS: The technique for fully conscious MVA was very suitable for our outpatient setting. It was associated with very low levels of pain and bleeding. The uptake of LARC was high, and particularly the ability to provide intrauterine contraception at MVA was associated with a very high uptake.