Retrospective analysis of radiological investigation of surgically excised head and neck lipomas.

PURPOSE: Differentiating benign lipomas from malignant causes is challenging and preoperative investigative guidelines are not well-defined. The purpose of this study was to retrospectively identify cases of head and neck lipomas that were surgically resected over a 5-year period and to identify the radiological modality chosen and features discussed in the final report. Multidisciplinary outcomes and pathology reports were examined with a view to identifying high risk features of a lipoma to aid in future risk stratification. METHODS: Retrospective chart review of pathology characteristics, radiological features (modality, size, calcifications, septations, globular/nodular foci), multidisciplinary discussion and history of presenting complaint was performed. RESULTS: Two liposarcomas and 138 lipomas were identified. Twenty-two percent of all lipomas received radiological investigation. Twenty-two percent of imaging referrals were possibly inappropriate. Furthermore, radiological features suggestive of malignancy were not present in the final radiology report, X2 = 28.8, p < 0.0001. CONCLUSION: As expected, the incidence of liposarcoma is low. There is limited awareness of radiology referral guidelines superimposed with a tendency to over-investigate lipomas. Furthermore, radiological features suggestive of malignancy were inconsistently reported on and not documented in multidisciplinary discussions. Therefore, we propose a multidisciplinary checklist for referring physicians and radiologists to aid in diagnostic work-up.

Factors influencing participation in an online national diabetes prevention programme: A qualitative study with attenders and educators.

AIM: To explore factors affecting participation in the pilot of the synchronous online national diabetes prevention programme (NDPP) in Ireland from the perspectives of those who attended and the educators who recruited for and delivered the programme. METHODS: A qualitative study involving semi-structured interviews and focus groups with NDPP attenders (attended the assessment and at least one session) and educators (dietitians) on the programme. The Framework Method using the Theoretical Domains Framework (TDF) guided the analysis. RESULTS: Thirteen attenders took part in two online focus groups and five online or phone interviews. Eight educators took part. Four themes which cut across the TDF domains were identified as factors influencing participation; (i) lack of awareness of prediabetes and fear of diabetes, relating to attenders' fear of diabetes and lack of knowledge of prediabetes and diabetes prevention; (ii) perceived need for programme support to change health behaviour, concerning attenders' and educators' recognition of the need for the NDPP; (iii) trust in healthcare professionals (HCPs), relating to trust in HCPs to convey the seriousness of prediabetes and the value of diabetes prevention programmes (DPPs) and (iv) practical and personal ease of joining online, relating to the flexibility and accessibility of the synchronous online group format, the IT skills of attenders and educators and apprehension about group education. CONCLUSIONS: Raising awareness of prediabetes and the need for prevention programmes should be a priority for health services and HCPs. The synchronous online group format was seen as less daunting to join than a face-to-face programme and may be a useful option to encourage participation.

Implementing an integrated diabetic foot care programme in Ireland: podiatrists' experience.

BACKGROUND: International evidence suggests that an integrated multidisciplinary approach to diabetic foot management is necessary to prevent ulceration and progression to amputation. Many health systems have introduced policies or models of care supporting the introduction of this evidence into practice, but little is known about the experiences of those involved in implementation. This study addresses this gap by examining the experiences of podiatrists providing integrated diabetic foot care. METHODS: Between October 2017 and April 2018, an online survey comprising closed and open-ended questions on podiatrists' demographics, clinical activity, links with other services, continuous professional development activities and experiences of implementing the Model of Care was administered to podiatrists (n = 73) working for Ireland's Health Service Executive in the community and hospital setting. Data were analysed using descriptive statistics and qualitative content analysis. RESULTS: The response rate was 68% (n = 50), with 46% (n = 23), 38% (n = 19) and 16% (n = 8) working across hospital, community and both settings, respectively. Most reported treating high-risk patients (66%), those with active foot disease (61%) and educating people about the risk of diabetes to the lower limb (80%). Reported challenges towards integrated diabetic foot care include a perceived lack of awareness of the role of podiatry amongst other healthcare professionals, poor integration between hospital and community podiatry services, especially where new services had been developed, and insufficient number of podiatrists to meet service demands. CONCLUSION: Previous evidence has shown that there is often a gap between what is set out by a policy and what it looks like when delivered to service users. Results from the current study support this, highlighting that while most podiatrists work in line with national recommendations, there are specific gaps and challenges that need to be addressed to ensure successful policy implementation.

What works to recruit general practices to trials? A rapid review.

Background: Recruitment challenges are a barrier to the conduct of trials in general practice, yet little is known about which recruitment strategies work best to recruit practices for randomised controlled trials (RCTs). We aimed to describe the types of strategies used to recruit general practices for trials and synthesize any available evidence of effectiveness. Methods: We conducted a rapid evidence review in line with guidance from Tricco et al. Eligible studies reported or evaluated any strategy to improve practice recruitment to participate in clinical or implementation RCTs. PubMed, Embase, and Cochrane Central Library were searched from inception to June 22 nd, 2021. Reference lists of included studies were screened. Data were synthesized narratively. Results: Over 9,162 articles were identified, and 19 studies included. Most (n=13, 66.7%) used a single recruitment strategy. The most common strategies were: in-person practice meetings/visits by the research team (n=12, 63.2%); phone calls (n=10, 52.6%); financial incentives (n=9, 47.4%); personalised emails (n=7, 36.8%) or letters (n=6, 52.6%) (as opposed to email 'blasts' or generic letters); targeting practices that participated in previous studies or with which the team had existing links (n=6, 31.6%) or targeting of practices within an existing practice or research network (n=6, 31.6%).  Three studies reporting recruitment rates >80%, used strategies such as invitation letters with a follow-up phone call to non-responders, presentations by the principal investigator and study coordinator, or in-person meetings with practices with an existing affiliation with the University or research team.  Conclusions: Few studies directly compared recruitment approaches making it difficult to draw conclusions about their comparative effectiveness. However, the role of more personalised letter/email, in-person, or phone contact, and capitalising on existing relationships appears important. Further work is needed to standardise how recruitment methods are reported and to directly compare different recruitment strategies within one study . PROSPERO registration: CRD42021268140 (15/08/2021).

Implementing a community specialist team to support the delivery of integrated diabetes care: experiences in Ireland during the COVID-19 pandemic.

Background: While models of integrated care for people with chronic conditions have demonstrated promising results, there are still knowledge gaps about how these models are implemented in different contexts and which strategies may best support implementation. We aimed to evaluate the implementation of a multidisciplinary diabetes Community Specialist Team (CST) to support delivery of integrated type 2 diabetes care during COVID-19 in two health networks. Methods: A mixed methods approach was used. Quantitative data included administrative data on CST activity and caseload, and questionnaires with GPs, practice nurses (PN) and people with type 2 diabetes. Qualitative data were collected using semi-structured interviews and focus groups about the service from CST members, GPs, PNs and people with type 2 diabetes. We used the Consolidated Framework for Implementation Research framework to explain what influences implementation and to integrate different stakeholder perspectives. Results: Over a 6-month period (Dec 2020-May 2021), 516 patients were seen by podiatrists, 435 by dieticians, and 545 by CNS. Of patients who had their first CST appointment within the previous 6 months (n=29), 69% (n=20) waited less than 4 weeks to see the HCP. During initial implementation, CST members used virtual meetings to build ' rapport' with general practice staff, supporting ' upskilling' and referrals to the CST. Leadership from the local project team and change manager provided guidance on how to work as a team and ' iron out' issues. Where available, shared space enhanced networking between CST members and facilitated joint appointments. Lack of administrative support for the CST impacted on clinical time. Conclusions: This study illustrates how the CST benefited from shared space, enhanced networking, and leadership. When developing strategies to support implementation of integrated care, the need for administrative support, the practicalities of co-location to facilitate joint appointments, and relative advantages of different delivery models should be considered.

Understanding tailoring to support the implementation of evidence-based interventions in healthcare: The CUSTOMISE research programme protocol.

Although there are effective evidence-based interventions (EBIs) to prevent, treat and coordinate care for chronic conditions they may not be adopted widely and when adopted, implementation challenges can limit their impact.  Implementation strategies are "methods or techniques used to enhance the adoption, implementation, and sustainment of a clinical program or practice". There is some evidence to suggest that to be more effective,  strategies should be tailored; that is, selected and designed to address specific determinants which may influence implementation in a given context. Despite the growing popularity of tailoring the concept is ill-defined, and the way in which tailoring is applied can vary across studies or lack detail when reported. There has been less focus on the part of tailoring where stakeholders prioritise determinants and select strategies, and the way in which theory, evidence and stakeholders' perspectives should be combined to make decisions during the process. Typically, tailoring is evaluated based on the effectiveness of the tailored strategy, we do not have a clear sense of the mechanisms through which tailoring works, or how to measure the "success" of the tailoring process. We lack an understanding of how stakeholders can be involved effectively in tailoring and the influence of different approaches on the outcome of tailoring. Our research programme, CUSTOMISE (Comparing and Understanding Tailoring Methods for Implementation Strategies in healthcare) will address some of these outstanding questions and generate evidence on  the feasibility, acceptability, and efficiency of different tailoring approaches, and build capacity in implementation science in Ireland, developing and delivering training and supports for, and network of, researchers and implementation practitioners. The evidence generated across the studies conducted as part of CUSTOMISE will bring greater clarity, consistency, coherence, and transparency to tailoring, a key process in implementation science.

Healthcare workers' perspectives on barriers and facilitators to referral and recruitment to diabetes prevention programmes: a systematic review protocol.

Background: Diabetes is a growing global health problem. International guidelines recommend identification, screening, and referral to behavioural programmes for those at high risk of developing type 2 diabetes. Diabetes prevention programmes (DPPs) can prevent type 2 diabetes in those at high risk, however many eligible participants are not referred to these programmes. Healthcare workers (HCWs) are pivotal to the referral and recruitment processes. This study aims to identify, appraise and synthesise the evidence on barriers and facilitators to referral and recruitment to DPPs from the perspective of HCWs. Methods: A "best fit" framework synthesis method will synthesise qualitative, quantitative, and mixed methods evidence on factors that affect HCWs referral and recruitment to DPPs, with the Theoretical Domains Framework (TDF) as the a priori framework. MEDLINE, EMBASE, CINAHL, PsychINFO, Web of Science and Scopus will be searched for primary studies published in English. Year of publication will be restricted to the last 26 years (1997-2023). Quality will be assessed using the Mixed Methods Appraisal Tool. A mix of deductive coding using the TDF and inductive coding of data that does not fit the TDF will be synthesised into themes representing the whole dataset. The relationships between the final set of themes will be explored to create a new model to understand HCWs' perspectives on referral and recruitment to DPPs. Sensitivity analysis will be carried out on this conceptual model. Confidence in the synthesised findings will be assessed using the GRADE-CERQual approach. One author will screen, extract, appraise the literature while a second author will independently verify a 20% sample at each stage. Discussion: Participation in DPPs is key for programme impact. HCWs typically identify those at risk and refer them to DPPs. Understanding HCWs' perspectives on the barriers and facilitators to referral and recruitment will inform future implementation of DPPs.

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study.

OBJECTIVES: Multifactorial interventions, which involve assessing an individual's risk of falling and providing treatment or onward referral, require coordination across settings. Using a mixed-methods design, we aimed to develop a process map to examine onward referral pathways following falls risk assessment in primary care. SETTING: Primary care fall risk assessment clinics in the South of Ireland. PARTICIPANTS: Focus groups using participatory mapping techniques with primary care staff (public health nurses (PHNs), physiotherapists (PT),and occupational therapists (OT)) were conducted to plot the processes and onward referral pathways at each clinic (n=5). METHODS: Focus groups were analysed in NVivo V.12 using inductive thematic analysis. Routine administrative data from January to March 2018 included details of client referrals, assessments and demographics sourced from referral and assessment forms. Data were analysed in Stata V.12 to estimate the number, origin and focus of onward referrals and whether older adults received follow-up interventions. Quantitative and qualitative data were analysed separately and integrated to produce a map of the service. RESULTS: Nine staff participated in three focus groups and one interview (PHN n=2; OT n=4; PT n=3). 85 assessments were completed at five clinics (female n=69, 81.2%, average age 77). The average number of risk factors was 5.4 out of a maximum of 10. Following assessment, clients received an average of three onward referrals. Only one-third of referrals (n=135/201, 33%) had data available on intervention receipt. Primary care staff identified variations in how formally onward referrals were managed and barriers, including a lack of client information, inappropriate referral and a lack of data management support. CONCLUSION: Challenges to onward referral manifest early in an integrated care pathway, such as clients with multiple risk factors sent for initial assessment and the lack of an integrated IT system to share information across settings.

What adults with ADHD want to know: A Delphi consensus study on the psychoeducational needs of experts by experience.

INTRODUCTION: A lack of knowledge about attention-deficit/hyperactivity disorder (ADHD) can contribute to feelings of distress and difficulty in seeking and accepting an ADHD diagnosis. The present study uses a Delphi consensus design to investigate the psychoeducational needs of adults with ADHD and the information about ADHD they would like included in digital health interventions for adults with ADHD. Inclusion of perspectives of service users in developing such interventions ensures that they are evidence based and addresses the risks of engagement barriers. METHODS: The expert panel consisted of 43 adults with ADHD (age range: 23-67 years). Panel members were asked to rate the importance of the proposed topics and provide additional suggestions. Suggested topics and topics that did not achieve consensus were included for ranking in the second round. RESULTS: Interquartile ratings were used to determine consensus. A high consensus was achieved in both rounds, with an agreement on 94% of topics in the first round and 98% in the second round. Most topics were rated as important or essential. CONCLUSIONS: The findings highlighted that adults with ADHD want to learn about many different aspects of ADHD and the importance of considering their perspectives when developing psychosocial interventions. Findings can be applied when creating psychoeducational content for adult ADHD. PATIENT OR PUBLIC CONTRIBUTION: Adults with ADHD were recruited to the Delphi panel to use an experts-by-experience approach. In doing so, we are engaging service users in the development of a psychoeducational smartphone app. The evaluation of the app will involve interviews with app users. Additionally, the present study was developed and conducted with ADHD Ireland, a charity based in Ireland that advocates for people with ADHD.

Adoption and Initial Implementation of a National Integrated Care Programme for Diabetes: A Realist Evaluation.

Background: The implementation of models of integrated care for chronic conditions is not well understood. We conducted a realist evaluation to determine how and why the implementation of the National Diabetes Programme in Ireland worked (or not). Methods: Documentary analysis and qualitative interviews with a purposive sample of national stakeholders (n = 19), were used to develop an initial theory on expected programme delivery. We refined this theory using semi-structured interviews (n = 38) with professionals from different clinical disciplines involved in programme implementation. Results: Locally important contexts facilitating implementation included staff experience of delivering diabetes care, capacity, and familiarity with the intended purpose of new clinical posts. The extent to which integrated care was adopted and implemented depended on judgements made by professionals working in these contexts; specifically, judging the relative advantage of the programme and whether to engage in negotiations to legitimize their new roles in diabetes care. Conclusions: Our results highlight the need for adequate preparatory work to raise awareness of and support new roles to implement integrated care, clarification on the core components of new care models, and the development of local service infrastructures to support integrated care.

Predictive value of postoperative day 1 parathyroid hormone levels for early and late hypocalcaemia after thyroidectomy.

PURPOSE: Early parathyroid hormone (PTH) levels after total thyroidectomy can predict patients at low risk of hypocalcaemia who can be discharged early without calcium supplementation. For centres without facility to perform early PTH levels, PTH levels sent on the first postoperative day (POD1) may be an alternative. However, there is less data regarding optimal cut-off PTH levels for POD1 discharge. METHODS: Retrospective review of prospective database of thyroid operations between September 2009 and February 2020 at tertiary referral centre. Main outcome measure was symptomatic hypocalcaemia. RESULTS: Five hundred seventy patients undergoing total (521) or completion thyroidectomy with POD1 PTH levels available were included. Among patients with POD1 PTH levels ≥ 20 pg/ml and POD1 calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia was 1% (3/300), and need for intravenous calcium 0.3% (1/300). For POD1 PTH levels 15-19 pg/ml and POD1 calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia and need for intravenous calcium was 5.4% (3/55). For PTH levels 10-14 pg/ml and calcium ≥ 2.0 mmol/l, the incidence of symptomatic hypocalcaemia and need for intravenous calcium was 11.7% (7/60). The risk of permanent hypoparathyroidism was < 1% for POD1 PTH levels ≥ 15 pg/ml; 5.4% for levels 10-14 pg/ml; and 19.8% for levels < 10 pg/ml. CONCLUSIONS: POD1 PTH levels ≥ 15 pg/ml along with calcium ≥ 2.0 mmol/l are associated with low risk of symptomatic hypocalcaemia, and represent a safe criterion for discharge of most patients without calcium supplementation. For certain patient groups, a higher threshold of 20 pg/ml could be considered.

Association between number of parathyroid glands identified during total thyroidectomy and functional parathyroid preservation.

PURPOSE: Systematic identification of all 4 parathyroid glands has been recommended during total thyroidectomy (TT); however, it is unclear whether this strategy necessarily translates into optimized functional parathyroid preservation. We wished to investigate the association between number of parathyroids identified intraoperatively during TT, and incidence of incidental parathyroidectomy, and postoperative hypoparathyroidism. METHODS: Retrospective review of prospectively maintained database of 511 consecutive patients undergoing TT at an academic teaching hospital. The association between number of parathyroid glands identified intraoperatively and incidence of biochemical hypocalcaemia (defined as any calcium < 2 mmol/L n first 48 h after surgery), symptomatic hypocalcaemia; permanent hypoparathyroidism (defined as any hypocalcaemia or need for calcium or vitamin D > 6 months after surgery), and incidental parathyroidectomy, was investigated. The association between number of parathyroid glands visualized and postoperative parathyroid hormone (PTH) levels was investigated in a subset of 454 patients. RESULTS: Patients in whom a greater number of parathyroids had been identified had a significantly higher incidence of biochemical and symptomatic hypocalcaemia, and significantly lower postoperative PTH levels, than patients with fewer glands identified. There were no significant differences in incidence of permanent hypoparathyroidism or incidental parathyroidectomy. On multivariate analysis, malignancy, Graves disease, and identification of 3-4 parathyroids were independent predictors of biochemical hypocalcaemia. For symptomatic hypocalcaemia, identification of 2-4 parathyroids, and identification of 3-4 parathyroids, were significant. CONCLUSIONS: Systematic identification of as many parathyroid glands as possible during TT is not necessary for functional parathyroid preservation.

Conceptual tensions and practical trade-offs in tailoring implementation interventions.

Tailored interventions have been shown to be effective and tailoring is a popular process with intuitive appeal for researchers and practitioners. However, the concept and process are ill-defined in implementation science. Descriptions of how tailoring has been applied in practice are often absent or insufficient in detail. This lack of transparency makes it difficult to synthesize and replicate efforts. It also hides the trade-offs for researchers and practitioners that are inherent in the process. In this article we juxtapose the growing prominence of tailoring with four key questions surrounding the process. Specifically, we ask: (1) what constitutes tailoring and when does it begin and end?; (2) how is it expected to work?; (3) who and what does the tailoring process involve?; and (4) how should tailoring be evaluated? We discuss these questions as a call to action for better reporting and further research to bring clarity, consistency, and coherence to tailoring, a key process in implementation science.

What and how do different stakeholders contribute to intervention development? A mixed methods study.

Background: UK Medical Research Council guidelines recommend end-user involvement in intervention development. There is limited evidence on the contributions of different end-users to this process. The aim of this Study Within A Trial (SWAT) was to identify and compare contributions from two groups of end-users - people with diabetes' (PWD) and healthcare professionals' (HCPs), during consensus meetings to inform an intervention to improve retinopathy screening uptake. Methods: A mixed method, explanatory sequential design comprising a survey and three semi-structured consensus meetings was used. PWD were randomly assigned to a diabetes only or combined meeting. HCPs attended a HCP only or combined meeting, based on availability. In the survey, participants rated intervention proposals on acceptability and feasibility. Survey results informed the meeting topic guide. Transcripts were analysed deductively to compare feedback on intervention proposals, suggestions for new content, and contributions to the final intervention. Results: Overall, 13 PWD and 17 HCPs completed the survey, and 16 PWD and 15 HCPs attended meetings. For 31 of the 39 intervention proposals in the survey, there were differences (≥10%) between the proportion of HCPs and PWD who rated proposals as acceptable and/or feasible. End-user groups shared and unique concerns about proposals; both were concerned about informing but not scaring people when communicating risk, while concerns about resources were mostly unique to HCPs and concerns about privacy were mostly unique to PWD.  Fewer suggestions for new intervention content from the combined meeting were integrated into the final intervention as they were not feasible for implementation in general practice. Participants contributed four new behaviour change techniques not present in the original proposals: goal setting (outcome), restructuring the physical environment, material incentive (behaviour) and punishment. Conclusions: Preferences for intervention content may differ across end-user groups, with feedback varying depending on whether end-users are involved simultaneously or separately.

Characterising processes and outcomes of tailoring implementation strategies in healthcare: a protocol for a scoping review.

Background: Tailoring strategies to target the salient barriers to and enablers of implementation is considered a critical step in supporting successful delivery of evidence based interventions in healthcare. Theory, evidence, and stakeholder engagement are considered key ingredients in the process however, these ingredients can be combined in different ways. There is no consensus on the definition of tailoring or on a single method for tailoring strategies to optimize impact, ensure transparency, and facilitate replication. Aim: The purpose of this scoping review is to describe how tailoring has been undertaken within healthcare to answer questions about how it has been conceptualised, described, and conducted in practice, and to identify research gaps. Methods: The review will be conducted in accordance with best practice guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping reviews (PRISMA-ScR) will be used to guide the reporting. Searches will be conducted of MEDLINE, Embase, Web of Science, Scopus, from 2005 to present. Reference lists of included articles will be searched. Grey literature will be searched on Google Scholar. Screening and data extraction will be conducted by two or more members of the research team, with any discrepancies resolved by consensus discussion with a third reviewer. Initial analysis will be quantitative involving a descriptive numerical summary of the characteristics of the studies and the tailoring process. Qualitative content analysis aligned to the research questions will also be conducted, and data managed using NVivo where applicable. This scoping review is pre-registered with the Open Science Framework. Conclusions: The findings will serve as a resource for implementation researchers and practitioners to guide future research in this field and facilitate systematic, transparent, and replicable development of tailored implementation strategies.

Feasibility of a multifaceted implementation intervention to improve attendance at diabetic retinopathy screening in primary care in Ireland: a cluster randomised pilot trial.

OBJECTIVES: Diabetic retinopathy screening (DRS) uptake is suboptimal in many countries with limited evidence available on interventions to enhance DRS uptake in primary care. We investigated the feasibility and preliminary effects of an intervention to improve uptake of Ireland's national DRS programme, Diabetic RetinaScreen, among patients with type 1 or type 2 diabetes. DESIGN/SETTING: We conducted a cluster randomised pilot trial, embedded process evaluation and cost analysis in general practice, July 2019 to January 2020. PARTICIPANTS: Eight practices participated in the trial. For the process evaluation, surveys were conducted with 25 staff at intervention practices. Interviews were conducted with nine staff at intervention practices, and 10 patients who received the intervention. INTERVENTIONS: The intervention comprised practice reimbursement, an audit of attendance, electronic prompts targeting professionals, General Practice-endorsed patient reminders and a patient information leaflet. Practices were randomly allocated to intervention (n=4) or wait-list control (n=4) (usual care). OUTCOMES: Staff and patient interviews explored their perspectives on the intervention. Patient registration and attendance, including intention to attend, were measured at baseline and 6 months. Microcosting was used to estimate intervention delivery cost. RESULTS: The process evaluation identified that enablers of feasibility included practice culture and capacity to protect time, systems to organise care, and staff skills, and workarounds to improve intervention 'fit'. At 6 months, 22/71 (31%) of baseline non-attenders in intervention practices subsequently attended screening compared with 15/87 (17%) in control practices. The total delivery cost across intervention practices (patients=363) was €2509, averaging €627 per practice and €6.91 per audited patient. Continuation criteria supported proceeding to a definitive trial. CONCLUSIONS: The Improving Diabetes Eye screening Attendance intervention is feasible in primary care; however, consideration should be given to how best to facilitate local tailoring. A definitive trial of clinical and cost-effectiveness is required with preliminary results suggesting a positive effect on uptake. TRIAL REGISTRATION NUMBER: NCT03901898.

Predictors of attendance at diabetic retinopathy screening among people with type 2 diabetes: Secondary analysis of data from primary care.

AIMS: To estimate the uptake of diabetic retinopathy screening among adults with type 2 diabetes and to identify and compare factors associated with attendance at the national diabetic retinal screening programme, and other screening services provided by ophthalmic surgeons, community ophthalmologists and optometrists. METHODS: An observational retrospective cohort study was carried out using data from the 2016 audit of care delivered by general practices (n = 30) enrolled in a structured diabetes care initiative. Attendance at any screening in the previous 12 months, and attendance across different types of service (national programme and other screening services) was calculated. Logistic regression was performed to examine predictors associated with (1) attendance at any screening and (2) attendance at the national programme (RetinaScreen). Sociodemographic, clinical, and lifestyle factors were examined as predictors. RESULTS: Data were available for 1106 people with type 2 diabetes aged ≥18 years. Overall, 863 (78%) of patients had a record of screening attendance in the previous 12 months. Of those screened, 494 (57.2%) attended RetinaScreen only, 258 (28.7%) attended other screening services only, and 111 (12.9%) attended both services. Statistically significant predictors of attendance at any screening were tablet/injectable controlled diabetes, attendance at a diabetes nurse specialist (DNS) in the past 12 months and a blood glucose level which was not on target (HbA1c >7.0% or >53 mmol/mol). In addition to these factors, when examining predictors of attendance at the national screening programme specifically, females were less likely to attend. CONCLUSIONS: Most patients managed in a structured diabetes care programme in primary care attended screening. Those with on target blood glucose control, those who were on oral or injectable medication or had been seen by a DNS were more likely to attend for annual screening. Of those who attended screening, almost one-third attended other screening services and so were not availing of the national programme, which is free, quality assured and has an integrated treatment arm.

Capnocytophaga canimorsus meningitis and bacteraemia without a dog bite in an immunocompetent individual.

We describe the case of an immunocompetent 75-year-old man with Capnocytophaga canimorsus bacteraemia and meningitis. C. canimorsus is commonly found in the oral flora of dogs with human infection typically occurring following a bite. Unusually, while our patient was a dog owner, there was no history of bite nor scratch mark. Admission blood cultures flagged positive for Gram-negative bacilli, but prolonged molecular analysis was required before C. canimorsus was isolated in blood and cerebrospinal fluid. There is a high mortality rate in invasive infection, and in our patient's case, antibiotic therapy was commenced prior to laboratory confirmation with our patient making a complete recovery. This case highlights the importance of including C. canimorsus in the differential diagnosis of unwell patients who keep dogs, even without a bite. This case occurred amid heightened awareness of COVID-19, which may represent predisposition for zoonoses during social isolation and increased human-pet contact.

The diagnostic yield of transthoracic echocardiography in the intensive care unit: A retrospective observational analysis.

BACKGROUND: Transthoracic echocardiography (TTE) is a commonly requested ICU investigation. Despite this, limited data exist regarding the diagnostic yield of unselected TTEs in a heterogenous ICU population. METHODS: A retrospective, cross-sectional, single-center study was performed. All ICU patients admitted from January 2018 to February 2019 were included. AIMS: The primary aim was to define the indications for, and diagnostic yield of, TTEs performed in the ICU. We also investigated the association between major abnormalities identified on TTE and mortality. RESULTS: There were 358 patients admitted to the ICU during the study period. Of these patients, 115 (32%) had a TTE performed during their ICU stay. The primary indication was to assess left ventricular function. Just under two-thirds of TTEs (65%) were normal or had minor abnormalities. Compared to the rest of the ICU population in our study (including both patients without a TTE performed and patients with a normal TTE), patients with an abnormal TTE had higher ICU (35.9% vs 21.3%, Odds Ratio [OR], 2.06; 95% CI, 1.02-4.19, P = .04) and in-hospital (43.6% vs 30.3%, OR, 2.64; 95% CI, 1.33-5.25, P = .01) mortality. CONCLUSIONS: A formal TTE was performed in one-third of patients during their ICU admission. Major abnormalities were identified in over one-third of these TTEs. ICU and in-hospital mortality were higher in patients with an abnormal TTE.