Challenges of implementing safer supply programs in Canada during the COVID-19 pandemic: A qualitative analysis.

BACKGROUND: Canada is experiencing an unprecedented drug toxicity crisis driven by a highly toxic unregulated drug supply contaminated with fentanyl, benzodiazepine, and other drugs. Safer supply pilot programs provide prescribed doses of pharmaceutical alternatives to individuals accessing the unregulated drug supply and have been implemented to prevent overdose and reduce related harms. Given the recent emergence of these pilot programs and the paucity of data on implementation challenges, we sought to document challenges in their initial implementation phase. METHODS: We obtained organizational progress reports from Health Canada, submitted between 2020 and 2022 by 11 pilot programs located in British Columbia, Ontario, and New Brunswick. We analyzed the data using deductive and inductive approaches via thematic analysis. Analyses were informed by the consolidated framework for implementation research. RESULTS: We obtained 45 progress reports from 11 pilot programs. Six centres were based in British Columbia, four in Ontario, and one in New Brunswick. Four overarching themes were identified regarding the challenges faced during the establishment and implementation of pilot programs: i) Organizational features (e.g., physical space constraints, staff shortages); ii) Outer contexts (e.g., limited operational funds and resources, structural inequities to access, public perceptions); iii) Intervention characteristics (e.g., clients' unmet medication needs); and iv) Implementation process (e.g., pandemic-related challenges, overly medicalized and high-barrier safer supply models). CONCLUSIONS: Safer supply pilot programs in Canada face multiple inner and outer implementation challenges. Given the potential role of safer supply programs in addressing the drug toxicity crisis in Canada and the possibility of future scale-up, services should be well-supported during their implementation phases. Refining service provision within safer supply programs based on the feedback and experiences of clients and program administrators is warranted, along with efforts to ensure that appropriate medications are available to meet the clients' needs.

Changing characteristics of patients with palliative care needs in acute hospitals.

BACKGROUND: Palliative care services drastically changed over the course of the COVID-19 pandemic between the years 2020 to 2022. AIM: To report on the changes in a specialist palliative care hospital liaison service (SPCHLS) during the COVID-19 pandemic, and consider the impact of this for longer term service modelling. METHODS: A retrospective analysis of patients admitted via the emergency department (ED) in January 2020 and 2021, who were given a palliative care 'code' at the end of their episode of care. Data were collected using electronic records and descriptive statistics were used. FINDINGS: The total number of patients seen in the ED increased by 30%, with a 185% increase in death as an outcome of admission. A total of 50% of patients were seen by a member of the SPCHLS in the ED in 2021, compared to just 28% in 2020. There was a 46% increase in the number of patients transferred to a Specialist Palliative Care Unit. CONCLUSIONS: Delayed diagnoses, long waiting times and changing community services lead to increased pressure and a requirement to meet palliative care needs in acute hospitals. There is a growing need for acute palliative care services to meet the needs of the population.

Palliative care inpatients favour research participation irrespective of prognosis, performance or socioeconomic status: multicentre cohort study.

OBJECTIVES: Palliative care needs to embrace research to guide service development and effective symptom management. Healthcare professionals often feel research is too burdensome for patients who have poor performance status or are near the end of life. Many studies exclude these groups from participating.We aimed to identify whether specialist palliative care inpatients would wish to take part in research and whether preference varies according to study design, demographics, diagnosis, performance status and prognosis. METHODS: 100 inpatients in two National Health Service specialist palliative care units and one independent hospice in the Northeast of England completed a short questionnaire about preferences for involvement in research. RESULTS: 92% of participants stated they were interested in being involved in research. This was mostly unaffected by age, diagnosis, prognosis, performance and socioeconomic status. Three-quarters were within the last 3 months of life. Simple questions or interviews were the preferred methodology, whereas only half of patients would want further investigations or additional medications and fewer still wanted to participate in online activities, lifestyle change or group activities. CONCLUSIONS: Palliative care inpatients welcome the opportunity to be involved in research and should not be excluded on the grounds of advanced disease, poor prognosis and low performance status.

Exploring Patient and Staff Experiences With Video Consultations During COVID-19 in an English Outpatient Care Setting: Secondary Data Analysis of Routinely Collected Feedback Data.

BACKGROUND: Video consultations (VCs) were rapidly implemented in response to COVID-19 despite modest progress before. OBJECTIVE: We aim to explore staff and patient experiences with VCs implemented during COVID-19 and use feedback insights to support quality improvement and service development. METHODS: Secondary data analysis was conducted on 955 patient and 521 staff responses (from 4234 consultations; 955/4234, 22.6% and 521/4234, 12.3%, respectively) routinely collected following a VC between June and July 2020 in a rural, older adult, and outpatient care setting at a National Health Service Trust. Responses were summarized using descriptive statistics and inductive thematic analysis and presented to Trust stakeholders. RESULTS: Most patients (890/955, 93.2%) reported having good (210/955, 22%) or very good (680/955, 71.2%) experience with VCs and felt listened to and understood (904/955, 94.7%). Most patients accessed their VC alone (806/955, 84.4%) except for those aged ≥71 years (23/58, 40%), with ease of joining VCs negatively associated with age (P<.001). Despite more difficulties joining, older adults were most likely to be satisfied with the technology (46/58, 79%). Patients and staff generally felt that patients' needs had been met (860/955, 90.1% and 453/521, 86.9%, respectively), although staff appeared to overestimate patient dissatisfaction with VC outcomes (P=.02). Patients (848/955, 88.8%) and staff (419/521, 80.5%) felt able to communicate everything they wanted, although patients were significantly more positive than staff (P<.001). Patient satisfaction with communication was positively associated with technical performance satisfaction (P<.001). Most staff members (466/521, 89.4%) reported positive (185/521, 35.5%) or very positive (281/521, 53.9%) experiences with joining and managing VCs. Staff reported reductions in carbon footprint (380/521, 72.9%) and time (373/521, 71.6%). Most patients (880/955, 92.1%) would choose VCs again. We identified three themes in responses: barriers, including technological difficulties, patient information, and suitability concerns; potential benefits, including reduced stress, enhanced accessibility, cost, and time savings; and suggested improvements, including trial calls, turning music off, photo uploads, expanding written character limit, supporting other internet browsers, and shared online screens. This routine feedback, including evidence to suggest that patients were more satisfied than clinicians had anticipated, was presented to relevant Trust stakeholders, allowing for improved processes and supporting the development of a business case to inform the Trust decision on continuing VCs beyond COVID-19 restrictions. CONCLUSIONS: The findings highlight the importance of regularly reviewing and responding to routine feedback following digital service implementation. The feedback helped the Trust improve the VC service, challenge clinician-held assumptions about patient experience, and inform future use of VCs. It has focused improvement efforts on patient information; technological improvements such as blurred backgrounds and interactive whiteboards; and responding to the needs of patients with dementia, communication or cognitive impairment, or lack of appropriate technology. These findings have implications for other health care providers.

General practitioners' and psychiatrists' attitudes towards antidepressant withdrawal.

BACKGROUND: There has been a recent rise in antidepressant prescriptions. After the episode for which it was prescribed, the patient should ideally be supported in withdrawing the medication. There is increasing evidence for withdrawal symptoms (sometimes called discontinuation symptoms) occurring on ceasing treatment, sometimes having severe or prolonged effects. AIMS: To identify and compare current knowledge, attitudes and practices of general practitioners (GPs) and psychiatrists in Cornwall, UK, concerning antidepressant withdrawal symptoms. METHOD: Questions about withdrawal symptoms and management were asked of GPs and psychiatrists in a multiple-choice cross-sectional study co-designed with a lived experience expert. RESULTS: Psychiatrists thought that withdrawal symptoms were more severe than GPs did (P = 0.003); 53% (22/42) of GPs and 69% (18/26) of psychiatrists thought that withdrawal symptoms typically last between 1 and 4 weeks, although there was a wide range of answers given; 35% (9/26) of psychiatrists but no GPs identified a pharmacist as someone they may use to help manage antidepressant withdrawal. About three-quarters of respondents claimed they usually or always informed patients of potential withdrawal symptoms when they started a patient on antidepressants, but patient surveys say only 1% are warned. CONCLUSIONS: Psychiatrists and GPs need to effectively warn patients of potential withdrawal effects. Community pharmacists might be useful in supporting GP-managed antidepressant withdrawal. The wide variation in responses to most questions posed to participants reflects the variation in results of research on the topic. This highlights a need for more reproducible studies to be carried out on antidepressant withdrawal, which could inform future guidelines.

Sequence Variation in Multidrug-Resistant Plasmid pLUH01, Isolated from Human Nasopharyngeal Swabs.

Three variants of the multidrug-resistant plasmid pLUH01 were assembled by deep sequencing from nasopharyngeal swabs. All have a 21-bp deletion in the RS14515 hypothetical gene. Variants 1 through 3 have 2, 6, and 3 nucleotide substitutions, respectively, compared to the pLUH01 reference genome. We named the new plasmid variants pLUH01/Lancaster/2015/1 to pLUH01/Lancaster/2015/3.

Nasopharyngeal metagenomic deep sequencing data, Lancaster, UK, 2014-2015.

Nasopharyngeal swabs were taken from volunteers attending a general medical practice and a general hospital in Lancaster, UK, and at Lancaster University, in the winter of 2014-2015. 51 swabs were selected based on high RNA yield and allocated to deep sequencing pools as follows: patients with chronic obstructive pulmonary disease; asthmatics; adults with no respiratory symptoms; adults with feverish respiratory symptoms; adults with respiratory symptoms and presence of antibodies against influenza C; paediatric patients with respiratory symptoms (2 pools); adults with influenza C infection (2 pools), giving a total of 9 pools. Illumina sequencing was performed, with data yields per pool in the range of 345.6 megabases to 14 gigabases after removal of reads aligning to the human genome. The data were deposited in the Sequence Read Archive at NCBI, and constitute a resource for study of the viral, bacterial and fungal metagenome of the human nasopharynx in healthy and diseased states and comparison with other metagenomic studies on the human respiratory tract.

Genome Sequence of Human Papillomavirus Type 20, Strain HPV-20/Lancaster/2015.

The genome sequence of human papillomavirus type 20 (HPV-20; family Papillomaviridae, genus Betapapillomavirus, species Betapapillomavirus 1, type 20) was assembled by deep sequencing from nasopharyngeal swabs. The assembled genome is 0.37% divergent over its full length from the single complete genome of HPV-20 in GenBank (U31778). We named the strain HPV-20/Lancaster/2015.

Genome Sequence of Human Papillomavirus 23 Strain HPV-23/Lancaster/2015.

The genome of human papillomavirus type 23 (HPV-23; family Papillomaviridae, genus Betapapillomavirus, species Betapapillomavirus 2, type 23) was assembled by deep sequencing from nasopharyngeal swabs. The assembled genome is 2.7% divergent over its full length from the single complete genome of HPV-23 in GenBank (accession no. U31781). We named the strain HPV-23/Lancaster/2015.

Influenza C in Lancaster, UK, in the winter of 2014-2015.

Influenza C is not included in the annual seasonal influenza vaccine, and has historically been regarded as a minor respiratory pathogen. However, recent work has highlighted its potential role as a cause of pneumonia in infants. We performed nasopharyngeal or nasal swabbing and/or serum sampling (n = 148) in Lancaster, UK, over the winter of 2014-2015. Using enzyme-linked immunosorbent assay (ELISA), we obtain seropositivity of 77%. By contrast, only 2 individuals, both asymptomatic adults, were influenza C-positive by polymerase chain reaction (PCR). Deep sequencing of nasopharyngeal samples produced partial sequences for 4 genome segments in one of these patients. Bayesian phylogenetic analysis demonstrated that the influenza C genome from this individual is evolutionarily distant to those sampled in recent years and represents a novel genome constellation, indicating that it may be a product of a decades-old reassortment event. Although we find no evidence that influenza C was a significant respiratory pathogen during the winter of 2014-2015 in Lancaster, we confirm previous observations of seropositivity in the majority of the population. (170 words).

Genome Sequence of Human Rhinovirus A22, Strain Lancaster/2015.

The genome of human rhinovirus A22 (HRV-A22) was assembled by deep sequencing RNA samples from nasopharyngeal swabs. The assembled genome is 8.7% divergent from the HRV-A22 reference strain over its full length, and it is only the second full-length genome sequence for HRV-A22. The new strain is designated strain HRV-A22/Lancaster/2015.

A Stab in the Dark? Point-of-Care Testing in the Population With Hip Fracture.

Hip fracture incidence rises globally in an aging population who live in an era of financial austerity. Health service providers are under pressure both to optimize care and to increase efficiencies in the management of this vulnerable patient group. One area of inefficiency in perioperative processes is the assessment of deranged clotting profiles secondary to warfarinization and in the monitoring of hemoglobin. Delays are inherent in these processes, threatening patient care and impacting on financial incentivisation of performance. Point-of-care testing, while widespread in other areas of health care, is underutilized in hip fracture management. This work explores the application to hip fracture care of this technology and suggests future direction to investigate its potential benefits.

Austrian syndrome: a case report and review of the literature.

A usually fit and well 69-year-old woman presented with headache and altered consciousness. Initial clinical findings and investigations were consistent with a diagnosis of pneumococcal meningitis and pneumonia. Cultures of blood and cerebrospinal fluid grew Streptococcus pneumoniae. The patient continued to spike temperatures and developed cardiac failure. A transoesophageal echocardiogram demonstrated a large vegetation of the aortic valve causing severe aortic regurgitation. A diagnosis of Austrian syndrome, the triad of pneumococcal meningitis, pneumonia and endocarditis, was made. The patient has completed a course of appropriate antibiotic therapy and is awaiting aortic valve surgery.