Conservative management versus invasive management of significant traumatic pneumothoraces in the emergency department (the CoMiTED trial): a study protocol for a randomised non-inferiority trial.

INTRODUCTION: Traumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician's discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces. METHODS AND ANALYSIS: The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months. ETHICS AND DISSEMINATION: This trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ISRCTN35574247.

Exploratory study of frequent attenders in general practice to better understand why patients seek help.

BACKGROUND: Frequent attenders (defined as the top 10% of health care users or those making ≥10 visits per year) account for 30-50% of GP consultations. This has significant resource implications. AIM: To understand the characteristics of frequent attenders (≥18-years) at an outer London general practice (list 5,876; deprivation index 5th decile) and reasons for attending. METHOD: A retrospective case note review was conducted using SystmOne of people attending on ≥10 occasions to see a health professional between March 2022 and February 2023. Data were extracted by hand: age, gender, reason and type of consultation, diagnoses, referrals, Charlson Comorbidity Index (CCI), mortality at one year. Patient notes for ≥30 contacts were reviewed by a senior GP. RESULTS: 544 people (9.3%) attended ≥10 appointments. Of these, five interacted with a GP ≥50 occasions (Group 1;mean age:74.6yrs/female: 4 /CCI:5.0), eight ≥40 occasions (Group 2; 69.6yrs/6.0/5.5) and 35 ≥30 occasions (Group 3;70yrs/27/4.7). Forty-eight people accounted for 882 appointments, 29% face to face and 71% by telephone. Frequency increased with age and CCI. Patients in group 3 underwent more investigations (6.0/6.0/10.0). There was no difference in mean numbers of clinicians seen (6.4/7.1/7.4) or referrals (5.0/4.0/5.0) between the three groups. Frequent attenders tended to fall into two groups: people with chronic diseases, typically associated with anxiety and complex needs, and people with ongoing mental health conditions. Coding was challenging due to complexity. CONCLUSION: Frequent attenders presented due to their medical complexity or mental health disorders rather than medically unexplained symptoms. Most interactions with a GP are understandable.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.

OBJECTIVES: The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS: This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading, Recommendation, Assessment, Development and Evaluation). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS: The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS: With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made. SHAREABLE ABSTRACT: This update of an ERS Task Force statement from 2015 provides a concise comprehensive update of the literature base. 24 evidence-based recommendations were made for management of pneumothorax, balancing clinical priorities and patient views.https://bit.ly/3TKGp9e.

Joint ERS/EACTS/ESTS clinical practice guidelines on adults with spontaneous pneumothorax.

BACKGROUND: The optimal management for spontaneous pneumothorax (SP) remains contentious, with various proposed approaches. This joint clinical practice guideline from the ERS, EACTS and ESTS societies provides evidence-based recommendations for the management of SP. METHODS: This multidisciplinary Task Force addressed 12 key clinical questions on the management of pneumothorax, using ERS methodology for guideline development. Systematic searches were performed in MEDLINE and Embase. Evidence was synthesised by conducting meta-analyses, if possible, or narratively. Certainty of evidence was rated with GRADE (Grading of Recommendations, Assessment, Development and Evaluations). The Evidence to Decision framework was used to decide on the direction and strength of the recommendations. RESULTS: The panel makes a conditional recommendation for conservative care of minimally symptomatic patients with primary spontaneous pneumothorax (PSP) who are clinically stable. We make a strong recommendation for needle aspiration over chest tube drain for initial PSP treatment. We make a conditional recommendation for ambulatory management for initial PSP treatment. We make a conditional recommendation for early surgical intervention for the initial treatment of PSP in patients who prioritise recurrence prevention. The panel makes a conditional recommendation for autologous blood patch in secondary SP patients with persistent air leak (PAL). The panel could not make recommendations for other interventions, including bronchial valves, suction, pleurodesis in addition to surgical resection or type of surgical pleurodesis. CONCLUSIONS: With this international guideline, the ERS, EACTS and ESTS societies provide clinical practice recommendations for SP management. We highlight evidence gaps for the management of PAL and recurrence prevention, with research recommendations made.

Comparing the experiences of community and hospital pharmacy learners completing a pre-registrant research training program.

BACKGROUND AND PURPOSE: Research training programs in the community pharmacy sector have not been well established. This study showcases a year-long guided research training program undertaken in hospital and community workplaces by pre-registrant pharmacists, and compares the perceived impact on learners in both sectors. EDUCATIONAL ACTIVITY AND SETTING: A two-year cohort study (2021-2022) of pre-registrant pharmacists enrolled in a research training program requiring them to undertake an individual project at their workplace over one year at either a community or hospital workplace. Outcome measures were pre-registrant perceptions of training impact and type of projects completed. FINDINGS: The results of this study demonstrate that the year-long guided research training program delivered to 403 pre-registrant pharmacists was perceived to be impactful to both community and hospital pre-registrant pharmacists and gave them the confidence to pursue further research and see research skills as an important attribute for the profession. Barriers to research included lack of time for both sectors but workplace support and lack of project ideas were especially noted in the community sector. Research project designs were mainly cross-sectional surveys or retrospective audits. SUMMARY: Programs seeking to adopt a similar model may wish to pay particular attention to supporting community pharmacy learners in providing a pre-selection of project ideas, offering training to workplace supervisors, ensuring enough academic support is given and having more check-in points/deliverables to ensure more feedback opportunities.

Exploring the dynamics of the 2022 mpox outbreak in Canada.

The 2022 mpox outbreak predominantly impacted gay, bisexual, and other men who have sex with men (gbMSM). Two models were developed to support situational awareness and management decisions in Canada. A compartmental model characterized epidemic drivers at national/provincial levels, while an agent-based model (ABM) assessed municipal-level impacts of vaccination. The models were parameterized and calibrated using empirical case and vaccination data between 2022 and 2023. The compartmental model explored: (1) the epidemic trajectory through community transmission, (2) the potential for transmission among non-gbMSM, and (3) impacts of vaccination and the proportion of gbMSM contributing to disease transmission. The ABM incorporated sexual-contact data and modeled: (1) effects of vaccine uptake on disease dynamics, and (2) impacts of case importation on outbreak resurgence. The calibrated, compartmental model followed the trajectory of the epidemic, which peaked in July 2022, and died out in December 2022. Most cases occurred among gbMSM, and epidemic trajectories were not consistent with sustained transmission among non-gbMSM. The ABM suggested that unprioritized vaccination strategies could increase the outbreak size by 47%, and that consistent importation (≥5 cases per 10 000) is necessary for outbreak resurgence. These models can inform time-sensitive situational awareness and policy decisions for similar future outbreaks.

Improving the management of medical emergency team calls due to suspected infections: A before-after study.

Objective: To introduce a management guideline for sepsis-related MET calls to increase lactate and blood culture acquisition, as well as prescription of appropriate antibiotics. Design: Prospective before (Jun-Aug 2018) and after (Oct-Dec 2018) study was designed. Setting: A public university linked hospital in Melbourne, Australia. Participants: Adult patients with MET calls related to sepsis/infection were included. Main outcome measures: The primary outcome measure was the proportion of MET calls during which both a blood culture and lactate level were ordered. Secondary outcomes included the frequency with which new antimicrobials were commenced by the MET, and the presence and class of administered antimicrobials. Results: There were 985 and 955 MET calls in the baseline and after periods, respectively. Patient features, MET triggers, limitations of treatment and disposition after the MET call were similar in both groups. Compliance with the acquisition of lactates (p = 0.101), respectively. There was a slight reduction in compliance with lactate acquisition in the after period (97% vs 99%; p = 0.06). In contrast, there was a significant increase in acquisition of blood cultures in the after period (69% vs 78%; p = 0.035). Conclusions: Introducing a sepsis management guideline and enhanced linkage with an AMS program increased blood culture acquisition and decreased broad spectrum antimicrobial use but didn't change in-hospital mortality.

Transcriptomic comparison of two selective retinal cell ablation paradigms in zebrafish reveals shared and cell-specific regenerative responses.

Retinal Müller glia (MG) can act as stem-like cells to generate new neurons in both zebrafish and mice. In zebrafish, retinal regeneration is innate and robust, resulting in the replacement of lost neurons and restoration of visual function. In mice, exogenous stimulation of MG is required to reveal a dormant and, to date, limited regenerative capacity. Zebrafish studies have been key in revealing factors that promote regenerative responses in the mammalian eye. Increased understanding of how the regenerative potential of MG is regulated in zebrafish may therefore aid efforts to promote retinal repair therapeutically. Developmental signaling pathways are known to coordinate regeneration following widespread retinal cell loss. In contrast, less is known about how regeneration is regulated in the context of retinal degenerative disease, i.e., following the loss of specific retinal cell types. To address this knowledge gap, we compared transcriptomic responses underlying regeneration following targeted loss of rod photoreceptors or bipolar cells. In total, 2,531 differentially expressed genes (DEGs) were identified, with the majority being paradigm specific, including during early MG activation phases, suggesting the nature of the injury/cell loss informs the regenerative process from initiation onward. For example, early modulation of Notch signaling was implicated in the rod but not bipolar cell ablation paradigm and components of JAK/STAT signaling were implicated in both paradigms. To examine candidate gene roles in rod cell regeneration, including several immune-related factors, CRISPR/Cas9 was used to create G0 mutant larvae (i.e., "crispants"). Rod cell regeneration was inhibited in stat3 crispants, while mutating stat5a/b, c7b and txn accelerated rod regeneration kinetics. These data support emerging evidence that discrete responses follow from selective retinal cell loss and that the immune system plays a key role in regulating "fate-biased" regenerative processes.

Teaching digital interprofessional collaboration.

BACKGROUND: Interprofessional communication in Australian clinical practice has recently shifted from paper records to electronic medical records (EMRs), and there is therefore a need for universities to prepare health graduates for digital communication. APPROACH: An interprofessional team co-designed and co-facilitated an online interprofessional activity for third year pharmacy and fifth year medical students utilising a simulated EMR (EHR Go™). Students completed a series of profession-specific tasks relating to a simulated patient, then came together in interprofessional groups of 10-12 to establish a collaborative medication charting plan. EVALUATION: A total of 640 students participated in the activity, of which 60% (386/640) were medical students. Immediately after the interprofessional workshop, students were invited to complete a voluntary anonymous evaluation. Five-point Likert scales were used to rate the relevance to practice, achievement of learning outcomes, organisation and overall quality of the activity. Students were also asked to contribute qualitative feedback. Of the participants, 28% (180/640) completed the survey, and 53% (96/180) of respondents were medical students. A majority of survey respondents agreed or strongly agreed that the activity was relevant to practice (94%; 170/180), achieved the learning outcomes (84%; 151/180), was well organised (74%; 133/180) and was a quality learning experience (79%; 143/180). The positive feedback focused on appreciating the opportunity to discuss with interdisciplinary colleagues the rationale for admission medications. Constructive feedback included the need for clearer directives regarding pre-workshop activities. IMPLICATIONS: This interprofessional education (IPE) activity presents a feasible, innovative approach to teaching pharmacy and medical students digital communication and collaboration using a simulated EMR. Overall, a majority of learners were satisfied with the learning experience and felt that the IPE activity achieved the learning outcomes and was relevant to practice.

Investigating How Preregistrant Pharmacists Respond in Job Interviews.

OBJECTIVE: To investigate what competencies and attributes preregistrant pharmacists draw upon in job interviews. METHODS: We used a virtual mock job interview assessment asking preregistrant pharmacists to apply for an entry-level pharmacist position. Data were analyzed using a team-based framework analysis using an inductive and deductive approach and mapping responses to the National Competency Standards. RESULTS: A total of 143 interview transcripts were included in the analysis. The top skills mentioned were leadership of self (98.6%) and communication and collaboration (96.5%). Despite graduating from a course with an integrated research curriculum, participants rarely reflected on research skills (31.5%) and no participant discussed any expertise in clinical topics or knowledge of specific professional services. Responses generally lacked specific skills and skills were spoken about broadly without relating to evidence/experience and were often not targeted to the job description. A proposal for educators aligned with competency standards was also developed based on the findings. CONCLUSION: Preregistrant pharmacists perceive experience within the workforce and communication and collaboration as the most desired by employers for entry-level pharmacy positions. Education and research competencies were seen as least useful to the job. There was a disconnect between skills gained in university and translation to practice. Academics could enhance the better preregistrant pharmacists' reflection of the skills and competencies they have developed employability by (1) providing portfolio management from the beginning of the course that collects evidence and maps to competencies; (2) integrating learning opportunities across all competencies; and (3) regular skills coaching/mentoring from practicing pharmacists to ensure students are aware of current needs in the job market.

Expert Review on Spontaneous Pneumothorax: Advances, Controversies, and New Directions.

For decades, there has been scanty evidence, most of which is of poor quality, to guide clinicians in the assessment and management of pneumothorax. A recent surge in pneumothorax research has begun to address controversies surrounding the topic and change the face of pneumothorax management. In this article, we review controversies concerning the etiology, pathogenesis, and classification of pneumothorax, and discuss recent advances in its management, including conservative and ambulatory management. We review the evidence base for the challenges of managing pneumothorax, including persistent air leak, and suggest new directions for future research that can help provide patient-centered, evidence-based management for this challenging cohort of patients.

Nanoparticle-based targeting of microglia improves the neural regeneration enhancing effects of immunosuppression in the zebrafish retina.

Retinal Müller glia function as injury-induced stem-like cells in zebrafish but not mammals. However, insights gleaned from zebrafish have been applied to stimulate nascent regenerative responses in the mammalian retina. For instance, microglia/macrophages regulate Müller glia stem cell activity in the chick, zebrafish, and mouse. We previously showed that post-injury immunosuppression by the glucocorticoid dexamethasone accelerated retinal regeneration kinetics in zebrafish. Similarly, microglia ablation enhances regenerative outcomes in the mouse retina. Targeted immunomodulation of microglia reactivity may therefore enhance the regenerative potential of Müller glia for therapeutic purposes. Here, we investigated potential mechanisms by which post-injury dexamethasone accelerates retinal regeneration kinetics, and the effects of dendrimer-based targeting of dexamethasone to reactive microglia. Intravital time-lapse imaging revealed that post-injury dexamethasone inhibited microglia reactivity. The dendrimer-conjugated formulation: (1) decreased dexamethasone-associated systemic toxicity, (2) targeted dexamethasone to reactive microglia, and (3) improved the regeneration enhancing effects of immunosuppression by increasing stem/progenitor proliferation rates. Lastly, we show that the gene rnf2 is required for the enhanced regeneration effect of D-Dex. These data support the use of dendrimer-based targeting of reactive immune cells to reduce toxicity and enhance the regeneration promoting effects of immunosuppressants in the retina.

A scoping review of therapeutic reasoning process research.

Therapeutic reasoning is when the purpose, task, or goal for engaging in reasoning is to determine the patient's management plan. As the field's understanding of the process of therapeutic reasoning is less well understood, we focused on studies that collected data on the process of therapeutic reasoning. To synthesize previous studies of therapeutic reasoning characteristics, methodological approaches, theoretical underpinnings, and results. We conducted a scoping review with systematic searching for English language articles with no date limits. Databases included MEDLINE, CINAHL Plus, Scopus, Embase, Proquest Dissertations and Theses Global, and ERIC. Search terms captured therapeutic reasoning in health professions education research. Initial search yielded 5450 articles. The title and abstract screening yielded 180 articles. After full-text review, 87 studies were included in this review. Articles were excluded if they were outside health professions education, did not collect data on the process of therapeutic reasoning, were not empirical studies, or not focused on therapeutic reasoning. We analyzed the included articles according to scoping questions using qualitative content analysis. 87 articles dated from 1987 to 2019 were included. Several study designs were employed including think-aloud protocol, interview and written documentation. More than half of the articles analyzed the data using qualitative coding. Authors often utilized several middle-range theories to explain therapeutic reasoning processes. The hypothetico-deductive model was most frequently mentioned. The included articles rarely built off the results from previous studies. Six key result categories were found: identifying themes, characterizing and testing previous local theory, exploring factors, developing new local theory, testing tools, and testing hypothesis. Despite the cast body of therapeutic reasoning research, individual study results remain isolated from previous studies. Our future recommendations include synthesizing pre-existing models, developing novel methodologies, and investigating other aspects of therapeutic reasoning.