Emergency paediatric medicine consultation-a practical guide to a consultation with refugee and asylum-seeking children within the paediatric emergency department.

There are increasing numbers of refugee and asylum-seeking children entering the UK annually who face significant barriers to accessing healthcare services. Clinicians working in the emergency department should have an awareness of the journeys children may have taken and the barriers they face in accessing care and have a holistic approach to care provision. We conducted a narrative literature review and used experiential knowledge of paediatricians working in the Paediatric Emergency Department to formulate a step-by-step screening tool. We have formulated a step-by-step screening tool, CCHILDS (Communication, Communicable diseases, Health-physical and mental, Immunisation, Look after (safeguarding), Deficiencies, Sexual health) which can be used by healthcare professionals in the emergency department. CONCLUSION: Due to increasing numbers of refugee and asylum-seeking children, it is important that every point of contact with healthcare professionals is an impactful one on their health, well-being and development. Future work would include validation of our tool. WHAT IS KNOWN: •The number of refugees globally are rapidly increasing, leading to an increase in the number of presentations to the PED. These patients are often medically complex and may have unique and sometimes unexpected presentations that could be attributed to by their past. There are a multitude of resources available outlining guidance on the assessment and management of refugee children. WHAT IS NEW: •This review aims to succinctly summarise the guidance surrounding the assessment of refugee children presenting to the PED and ensure that healthcare professionals are aware of the pertinent information regarding this cohort. It introduces the CCHILDS assessment tool which has been formulated through a narrative review of the literature and acts as a mnemonic to aid professionals in their assessment of refugee children in the PED.

Factors Affecting Engagement in Web-Based Health Care Patient Information: Narrative Review of the Literature.

BACKGROUND: Web-based content is rapidly becoming the primary source of health care information. There is a pressing need for web-based health care content to not only be accurate but also be engaging. Improved engagement of people with web-based health care content has the potential to inform as well as influence behavioral change to enable people to make better health care choices. The factors associated with better engagement with web-based health care content have previously not been considered. OBJECTIVE: The aims of this study are to identify the factors that affect engagement with web-based health care content and develop a framework to be considered when creating such content. METHODS: A comprehensive search of the PubMed and MEDLINE database was performed from January 1, 1946, to January 5, 2020. The reference lists of all included studies were also searched. The Medical Subject Headings database was used to derive the following keywords: "patient information," "online," "internet," "web," and "content." All studies in English pertaining to the factors affecting engagement in web-based health care patient information were included. No restrictions were set on the study type. Analysis of the themes arising from the results was performed using inductive content analysis. RESULTS: The search yielded 814 articles, of which 56 (6.9%) met our inclusion criteria. The studies ranged from observational and noncontrolled studies to quasi-experimental studies. Overall, there was significant heterogeneity in the types of interventions and outcome assessments, which made quantitative assessment difficult. Consensus among all authors of this study resulted in six categories that formed the basis of a framework to assess the factors affecting engagement in web-based health care content: easy to understand, support, adaptability, accessibility, visuals and content, and credibility and completeness. CONCLUSIONS: There is a paucity of high-quality data relating to the factors that improve the quality of engagement with web-based health care content. Our framework summarizes the reported studies, which may be useful to health care content creators. An evaluation of the utility of web-based content to engage users is of significant importance and may be accessible through tools such as the Net Promoter score. Web 3.0 technology and development of the field of psychographics for health care offer further potential for development. Future work may also involve improvement of the framework through a co-design process.

Exploring the barriers and facilitators of psychological safety in primary care teams: a qualitative study.

BACKGROUND: Psychological safety is the concept by which individuals feel comfortable expressing themselves in a work environment, without fear of embarrassment or criticism from others. Psychological safety in healthcare is associated with improved patient safety outcomes, enhanced physician engagement and fostering a creative learning environment. Therefore, it is important to establish the key levers which can act as facilitators or barriers to establishing psychological safety. Existing literature on psychological safety in healthcare teams has focused on secondary care, primarily from an individual profession perspective. In light of the increased focus on multidisciplinary work in primary care and the need for team-based studies, given that psychological safety is a team-based construct, this study sought to investigate the facilitators and barriers to psychological safety in primary care multidisciplinary teams. METHODS: A mono-method qualitative research design was chosen for this study. Healthcare professionals from four primary care teams (n = 20) were recruited using snowball sampling. Data collection was through semi-structured interviews. Thematic analysis was used to generate findings. RESULTS: Three meta themes surfaced: shared beliefs, facilitators and barriers to psychological safety. The shared beliefs offered insights into the teams' background functioning, providing important context to the facilitators and barriers of psychological safety specific to each team. Four barriers to psychological safety were identified: hierarchy, perceived lack of knowledge, personality and authoritarian leadership. Eight facilitators surfaced: leader and leader inclusiveness, open culture, vocal personality, support in silos, boundary spanner, chairing meetings, strong interpersonal relationships and small groups. CONCLUSION: This study emphasises that factors influencing psychological safety can be individualistic, team-based or organisational. Although previous literature has largely focused on the role of leaders in promoting psychological safety, safe environments can be created by all team members. Members can facilitate psychological safety in instances where positive leadership behaviours are lacking - for example, strengthening interpersonal relationships, finding support in silos or rotating the chairperson in team meetings. It is anticipated that these findings will encourage practices to reflect on their team dynamics and adopt strategies to ensure every member's voice is heard.

An economic evaluation for the use of decompressive craniectomy in the treatment of refractory traumatic intracranial hypertension.

Objectives: The management of intracranial hypertension is a primary concern following traumatic brain injury. Data from recent randomized controlled trials have indicated that decompressive craniectomy results in some improved clinical outcomes compared to medical treatment for patients with refractory intracranial hypertension post-traumatic brain injury (TBI). This economic evaluation aims to assess the cost-effectiveness of decompressive craniectomy as a last-tier intervention for refractory intracranial hypertension from the perspective of the National Health Service (NHS).Methods: A Markov model was used to present the results from an international, multicentre, parallel-group, superiority, randomized trial. A cost-utility analysis was then carried out over a 1-year time horizon, measuring benefits in quality adjusted life years (QALYs) and costs in pound sterling.Results: The cost-utility analysis produced an incremental cost-effectiveness ratio (ICER) of £96,155.67 per QALY. This means that for every additional QALY gained by treating patients with decompressive craniectomy, a cost of £96,155.67 is incurred to the NHS.Conclusions: The ICER calculated is above the National Institute for Health and Care Excellence (NICE) threshold of £30,000 per QALY. This indicates that decompressive craniectomy is not a cost-effective first treatment option for refractory intracranial hypertension and maximum medical management is preferable initially.

Thoracic aortic aneurysms in patients with heritable connective tissue disease.

BACKGROUND: Patients with connective tissue diseases are at high lifetime risk of developing thoracic aortic aneurysms (TAAs) due to defects in extracellular matrix composition which compromise the structural integrity of the aortic wall. It is vital to identify and manage aneurysms early to prevent fatal complications such as dissection or rupture. METHOD: This review synthesises information obtained from a thorough literature search regarding the pathophysiology of TAAs in those with heritable connective tissue diseases (HCTDs), the investigations for timely diagnosis and current operative strategies. RESULTS: Major complications of open repair (OR) include pneumonia (32%), haemorrhage (31%) and tracheostomy (18%), with a minor risk of vocal cord paresis (9%). For thoracic endovascular aortic repair (TEVAR), high rates of endoleak were documented (38-66.6%). Reintervention rates for TEVAR are also high at 38-44%. Mortality rates were documented as 25% for open repair and vary from 14% to 44% for TEVAR. CONCLUSION: OR remains the mainstay of surgical management. While TEVAR use is expanding, it remains the alternative choice due to concerns over endograft durability, limited long-term outcome data and the lack of high-quality evidence regarding its use in HCTD patients.

Comparison of outcomes following transfemoral versus trans-subclavian approach for transcatheter aortic valve Implantation: A meta-analysis.

BACKGROUND: The subclavian artery is an alternative access route for transcatheter aortic valve implantation (TAVI), with a potential advantage in patients unsuitable for traditional access routes such as the femoral artery. This study aimed to determine the safety and efficacy of the trans-subclavian (TSc) compared to the trans-femoral (TF) approach. METHODS: A systematic review was conducted on two online databases: Embase and Medline. The initial search returned 508 titles. Nine observational studies were included: n = 2938 patients (2382 TF and 556 TSc). RESULTS: Both TSc and TF groups were comparable for: 30-day mortality (Odds ratio, OR 0.75, 95% CI 0.49 - 1.16, p = 0.195); in-hospital stroke (OR 1.05, 95% CI 0.60-1.85, p = 0.859); myocardial infarction (OR 1.97, 95% CI 0.74-5.23, p = 0.176); paravalvular leaks (OR 1.20, 95% CI 0.76-1.90, p = 0.439); rates of postoperative permanent pacemaker implantation (OR 1.49, 95% CI 0.92-2.41, p = 0.105); in-hospital bleeding and meta-analysis demonstrated no significant difference between access points (OR 3.44, 95% CI 0.35-34.22, p = 0.292). Procedural time was found to be longer in the TSc group (SMD 1.02; 95% CI 0.815-1.219, p < 0.001). Major vascular complications were significantly higher in the TF group (OR 0.55, 95% CI 0.32-0.94, p = 0.029). Meta regression found no influence of the covariates on the outcomes. CONCLUSION: Subclavian access is both a safe and feasible alternative access route for TAVI with lower risks of major vascular complications. This study supports the use of subclavian access as a viable alternative in patient groups where transfemoral TAVI is contraindicated.

A reflection on Imperial College London's Community Action Project.

The diverse and versatile roles that doctors today hold highlight the importance of encouraging personal and professional development within medical students enabling them to become confident leaders and innovators. The introduction of core curriculum projects such as the Community Action Project (CAP) endorses the development of skills required to prepare all students for their future role as doctors. The aim of this report is to reflect on our experiences having taken part in the CAP during our third year at medical school. The CAP at Imperial College London provides all medical undergraduates in their third year of medical school with an opportunity to undertake a quality improvement project. The CAP required students to engage with the local community and members of staff at the general practice to identify a need and deliver an appropriate intervention which was then evaluated. The CAP enabled us to deliver an intervention in the form of a creative stop-motion video created with patients at the practice. The project encouraged students to find creative ways to tackle prominent health-care issues within local communities and also acted as a stepping-stone for students to consider how to tackle larger healthcare issues on a national scale.

Addressing the void of entrepreneurship development amongst medical students in the UK.

Entrepreneurship and innovation are important skills doctors must be equipped with to face the economic crisis engulfing the NHS. The £30 billion funding gap the NHS will face by 2020 requires doctors who are able to face these upcoming financial and organizational difficulties. Frontline staff are uniquely placed to identify inefficiencies in the health care system and develop solutions to them, so changing the medical school curricula to provide entrepreneurship and innovation development will benefit the NHS. Students can opt into this on an optional basis. The NHS is starting to recognize the importance of developing entrepreneurship and innovation as it has already introduced the Clinical Entrepreneur Programme in 2015. Offering entrepreneurship teaching in medical schools will not only diversify the skills of future health care professionals, but will also empower them with the right mindset to tackle the problems facing the health care system and sustain the NHS.

Using Experts by Personal and Professional Experience (EPPE) to increase interest in Psychiatry as a Career at Sixth-Form Level.

BACKGROUND: Psychiatrists play a multifaceted and critical role in improving the lives of people with mental illness. However, despite how rewarding, important and thrilling a career in mental health is, there continues to remain a shortage of psychiatrists in Low-, Middle- and High-Income Countries. There has been resurgence in interest in improving the image of psychiatry over recent years and several initiatives have been launched to increase recruitment into the specialty at Sixth Form level in the UK. DESIGN: We conducted a single-arm, pre-post, comparison study with Sixth Form students at an inner-city school in London. Students were invited to complete a survey before and after exposure to an assembly on mental health that was delivered by an Expert by Personal and Professional Experience (EPPE). Our aims were to detect and measure if there were any changes in perceptions of psychiatry and if there was an increase in interest in pursuing this profession as a career in this group. RESULTS: 63 out of 123 participants completed the before and after survey (51% response rate). Following exposure to the assembly, there were statistically significant improvements between the pre- and post- intervention means for, "Psychiatry has a positive impact on peoples' lives" (p value <0.0001), "People with mental illness can achieve success and be the best at what they do" (p value <0.0001) and, "I would consider psychiatry as a career" (p value <0.0001). CONCLUSION: Notwithstanding the limitations of this pilot study, our findings suggest that an assembly on mental health delivered by an EPPE (i.e. 'Wounded Healer') might be effective at increasing interest in psychiatry as a career at Sixth Form level. We suggest that assemblies on mental health and psychiatry be delivered by 'Wounded Healers' in schools and colleges nationwide to help drive recruitment into psychiatry.