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.

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.

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.

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.

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.

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.

The critical power concept in all-out isokinetic exercise.

UNLABELLED: The critical power concept has been applied to constant-load exhaustive exercise and recently validated for 3-min all-out exercise. OBJECTIVES: To test the application of critical power to a 3-min all-out isokinetic cycling exercise. DESIGN: Single-group, experimental, comparative design. METHOD: Nine participants performed a 3-min all-out isokinetic test and 4-5 constant-load exhaustive trials, at 60 and 100 rpm, on an electrically-braked cycle. The linear P-t-1 relationship was modelled using a 2-parameter model (slope: critical power; intercept: Anaerobic Work Capacity). End power and accumulated work done above EP were calculated from the 3-min tests. RESULTS: No significant difference and a significant correlation was found between end power and critical power (60 rpm: 259 ± 40 W vs. 245 ± 38 W, P > 0.05; r = 0.85, P<0.01; 100 rpm: 227 ± 57 W vs. 212 ± 44 W, P > 0.05; r = 0.86, P<0.01). The Bias ± 95% limits of agreement were 14 ± 42 W at 60 rpm and 15 ± 57 W at 100 rpm. Work done above EP (60 rpm: 14.7 ± 3.0 kJ; 100 rpm: 17.3 ± 3.1 kJ) was not significantly different to the anaerobic work capacity (60 rpm: 16.2 ± 3.2 kJ; 100 rpm: 20.6 ± 6.4 kJ; P>0.05) but with only a significant correlation at 60 rpm (r = -0.71, P<0.05). CONCLUSIONS: The 2-parameter model underpinning the critical power construct can be applied to a 3-min all-out isokinetic test. End power does not differ and correlates with critical power. However, a further insight into levels of agreement leads to some scepticism concerning the use of the two variables interchangeably. The great intra-subject differences between work done above EP and the intercept of the P-t-1 relationship should also be considered.

Alterations in the predicted regulatory and coding regions of the sterol 14α-demethylase gene (CYP51) confer decreased azole sensitivity in the oilseed rape pathogen Pyrenopeziza brassicae.

The incidence and severity of light leaf spot epidemics caused by the ascomycete fungus Pyrenopeziza brassicae on UK oilseed rape crops are increasing. The disease is currently controlled by a combination of host resistance, cultural practices and fungicide applications. We report decreases in sensitivity of modern UK P. brassicae isolates to the azole (imidazole and triazole) class of fungicides. By cloning and sequencing the P. brassicae CYP51 (PbCYP51) gene, encoding the azole target sterol 14α-demethylase, we identified two non-synonymous mutations encoding substitutions G460S and S508T associated with reduced azole sensitivity. We confirmed the impact of the encoded PbCYP51 changes on azole sensitivity and protein activity by heterologous expression in a Saccharomyces cerevisiae mutant YUG37:erg11 carrying a controllable promoter of native CYP51 expression. In addition, we identified insertions in the predicted regulatory regions of PbCYP51 in isolates with reduced azole sensitivity. The presence of these insertions was associated with enhanced transcription of PbCYP51 in response to subinhibitory concentrations of the azole fungicide tebuconazole. Genetic analysis of in vitro crosses of sensitive and resistant isolates confirmed the impact of PbCYP51 alterations in coding and regulatory sequences on a reduced sensitivity phenotype, as well as identifying a second major gene at another locus contributing to resistance in some isolates. The least sensitive field isolates carry combinations of upstream insertions and non-synonymous mutations, suggesting that PbCYP51 evolution is ongoing and the progressive decline in azole sensitivity of UK P. brassicae populations will continue. The implications for the future control of light leaf spot are discussed.

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.

Detection and molecular characterisation of Pyrenopeziza brassicae isolates resistant to methyl benzimidazole carbamates.

BACKGROUND: Methyl benzimidazole carbamate (MBC) fungicides are used to control the oilseed rape pathogen Pyrenopeziza brassicae. Resistance to MBCs has been reported in P. brassicae, but the molecular mechanism(s) associated with reductions in sensitivity have not been verified in this species. Elucidation of the genetic changes responsible for resistance, hypothesised to be target-site mutations in ß-tubulin, will enable resistance diagnostics and thereby inform resistance management strategies. RESULTS: P. brassicae isolates were classified as sensitive, moderately resistant or resistant to MBCs. Crossing P. brassicae isolates of different MBC sensitivities indicated that resistance was conferred by a single gene. The MBC-target encoding gene ß-tubulin was cloned and sequenced. Reduced MBC sensitivity of field isolates correlated with ß-tubulin amino acid substitutions L240F and E198A. The highest level of MBC resistance was measured for isolates carrying E198A. Negative cross-resistance between MBCs and the fungicides diethofencarb and zoxamide was only measured in E198A isolates. PCR-RFLP was used to screen isolates for the presence of L240F and E198A. The substitutions E198G and F200Y were also detected in DNA samples from P. brassicae populations after cloning and sequencing of PCR products. The frequencies of L240F and E198A in different P. brassicae populations were quantified by pyrosequencing. There were no differences in the frequencies of these alleles between P. brassicae populations sampled from different locations or after fungicide treatment regimes. CONCLUSIONS: The molecular mechanisms affecting sensitivity to MBCs in P. brassicae have been identified. Pyrosequencing assays are a powerful tool for quantifying fungicide-resistant alleles in pathogen populations.

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.

Limitations to high intensity exercise prescription in chronic heart failure patients.

BACKGROUND: Interval training is recommended for chronic heart failure patients (CHF), but specific guidelines on setting appropriate workloads have not been fully established. The aim of this study was to compare a traditional method of interval training prescription with a protocol specifically designed for CHF. METHODS: Ten CHF and 7 healthy controls performed 2 maximal incremental cycle tests to determine interval training workload; a standard test (10Wmin(-)(1)) and a steep test (25W.10(-)(s)). Peak work rate and oxygen uptake (VO(2 peak)) were determined. Training workloads were defined as 100% standard test and 50% steep test peak work rate. RESULTS: Training workload determined from the standard test was higher than from the steep test in healthy controls (151 ± 17W vs 118 ± 13W; P<0.01), whereas in CHF there was no significant difference between methods (88 ± 10W vs 96 ± 9W; P>0.05). Steep test VO(2peak) reached 91 ± 5% of standard test VO(2 peak) in controls, and 99 ± 4% in CHF, with no significant differences between tests in either group. CONCLUSION: Prescribing interval training from a standard test results in higher workloads than from a steep test in healthy individuals, but in CHF both methods prescribe similar workloads. However it should not be assumed that the two tests can be used interchangeably for CHF. This small-sized study raises issues about interval training prescription that may be hypothesis-generating for future larger-scale studies.

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.

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%.

Critical power is not attained at the end of an isokinetic 90-second all-out test in children.

The purpose of this study was to establish whether critical power, as traditionally determined from the performance of three constant-load tests to exhaustion, is attained at the end of a 90-s all-out test in children. Sixteen healthy children (eight males and eight females; mean age 12.3 years, s(x) = 0.1; body mass 39.6 kg, s(x) = 1.8; peak VO(2) 2.0 litres . min(-1), s(x) = 0.1) completed an incremental test to exhaustion to determine peak oxygen uptake (peak VO(2)), three separate constant-load tests to exhaustion to calculate critical power, and an isokinetic 90-s all-out test. The end power of the 90-s test averaged over the last 10 s (140 W, s(x) = 8) was significantly higher than critical power (105 W, s(x) = 6; t = 6.8; P < 0.01), yet the two parameters were strongly correlated (r = 0.74; P < 0.01). After 60 s, there were no further reductions in power output during the 90-s test (P < 0.0001). In conclusion, at the end of a 90-s all-out test, children are able to produce power outputs well above critical power. This suggests that 90 s is not long enough to completely exhaust the anaerobic work capacity in children.

Attenuation of amphetamine-induced activity by the non-selective muscarinic receptor agonist, xanomeline, is absent in muscarinic M4 receptor knockout mice and attenuated in muscarinic M1 receptor knockout mice.

The muscarinic acetylcholine receptor (mAChR) agonist, xanomeline, attenuates amphetamine-induced activity in WT mice. This effect is abolished in mice lacking the M(4) muscarinic acetylcholine receptor (M(4) mAChR KO) and partially attenuated in mice lacking M(1) muscarinic acetylcholine receptor (M(1) mAChR KO). Collectively, these data suggest that the efficacy exhibited by xanomeline in the mouse amphetamine-induced hyperactivity model, is mediated predominantly by M(4) muscarinic acetylcholine receptors, and that M(1) muscarinic acetylcholine receptors may play a more minor role. This supports the hypothesis that activation of M(4), and to a lesser extent M(1) muscarinic acetylcholine receptors, may represent a potential target for the treatment of psychosis seen in schizophrenia.