Abstract Background Multidrug-resistant infections transmitted through duodenoscopes in ERCP procedures have raised significant concerns. In response, the U.S. Food and Drug Administration (FDA) has suggested shifting from traditional reusable duodenoscopes to newer, more innovative designs. These new models, including completely disposable duodenoscopes and those with disposable endcaps, aim to enhance cleaning efficiency and reduce infection risks. While sterile, single-use duodenoscopes have been a breakthrough in eliminating cross-infections, their adoption poses cost-related challenges. Methods We conducted a systematic literature search across various databases for studies that examined the cost-effectiveness of these two types of duodenoscopes. Four studies met our inclusion criteria, involving diverse settings and study designs, including cost-effectiveness, cost-utility, and cost-minimization analyses. Results All four studies suggested that single use duodenoscopes could be cost-effective compared to reusable ones under certain circumstances, such as specific infection rates, procedure volumes, and willingness to pay thresholds. However, limitations in the generalizability of findings were noted, and the quality of evidence varied across studies. Conclusions Current evidence indicates potential cost-effectiveness for single-use duodenoscopes, although it is context-dependent. More robust, high-quality studies are needed to confirm these findings and further explore the cost-effectiveness in various clinical settings and scenarios. The potential environmental impact of single use duodenoscopes warrants further exploration.

ABSTRACTIntroductionFatigue is an important and distressing symptom for many people living with chronic musculoskeletal (MSK) conditions. Many non-pharmacological interventions have been investigated in recent years and some have been demonstrated to be effective in reducing fatigue and fatigue impact, however there is limited guidance for clinicians to follow regarding the most appropriate management options. The objective of this scoping review is to understand and map the extent of evidence in relation to the impact of non-pharmacological interventions on MSK condition-related fatigue across the lifespan.Methods and analysisThis scoping review will include evidence relating to people of all ages living with chronic MSK conditions who have been offered a non-pharmacological intervention with either the intention or effect of reducing fatigue and its impact. Databases including AMED, PsycINFO, CINAHLPlus, MEDLINE, EMBASE and Scopus will be searched for peer reviewed primary research studies published after 1stJanuary 2007 in English language. These findings will be used to identify factors associated with successful interventions and to map gaps in knowledge.Ethics and disseminationEthical approval was not required for this review. Findings will be disseminated by journal publication, conference presentation and by communicating with relevant healthcare and charity organisations.Article SummaryStrengths and limitations of this study-Patient and Public Involvement and Engagement (PPIE) workshops at key time points will ensure that the protocol, review findings and subsequent discussion are relevant to stakeholders and reflect lived experience of MSK-fatigue-All studies will be reviewed, and data extraction checked by a minimum of two researchers-The effectiveness of specific interventions and methodological quality of included studies is not covered in this scoping review-Only evidence available in English will be reviewed

AbstractBackgroundIn patients with COVID-19 requiring supplemental oxygen, dexamethasone reduces acute severity and improves survival, but longer-term effects are unknown. We hypothesised that systemic corticosteroid administration during acute COVID-19 would be associated with improved health-related quality of life (HRQoL) one year after discharge.MethodsAdults admitted to hospital between February 2020 and March 2021 for COVID-19 and meeting current guideline recommendations for dexamethasone treatment were included using two prospective UK cohort studies. HRQoL, assessed by EQ-5D-5L utility index, pre-hospital and one year after discharge were compared between those receiving corticosteroids or not after propensity weighting for treatment. Secondary outcomes included patient reported recovery, physical and mental health status, and measures of organ impairment. Sensitivity analyses were undertaken to account for survival and selection bias.FindingsIn 1,888 participants included in the primary analysis, 1,149 received corticosteroids. There was no between-group difference in EQ-5D-5L utility index at one year (mean difference 0.004, 95% CI: -0.026 to 0.034,p= 0.77). A similar reduction in EQ-5D-5L was seen at one year between corticosteroid exposed and non-exposed groups (mean (SD) change -0.12 (0.22) vs -0.11 (0.22),p= 0.32). Overall, there were no differences in secondary outcome measures. After sensitivity analyses modelled using a larger cohort of 109,318 patients admitted to hospital with COVID-19, EQ-5D-5L utility index at one year remained similar between the two groups.InterpretationSystemic corticosteroids for acute COVID-19 have no impact on the large reduction in HRQoL one year after hospital discharge. Treatments to address this are urgently needed.Take home messageSystemic corticosteroids given for acute COVID-19 do not affect health-related quality of life or other patient reported outcomes, physical and mental health outcomes, and organ function one year after hospital discharge

NICE guideline NG115 for COPD recommend Airways Clearance Techniques (ACTs) for people with excessive sputum but there have been no studies comparing different ACTs.AimTo compare Oscillatory Positive Expiratory Pressure (OPEP, Aerobika TM ) vs Active Cycle of Breathing Technique (ACBT) following exacerbations of COPD.MethodA pilot, feasibility randomised controlled trial (ClinicalTrials.gov Identifier: NCT05548036PatientWith confirmed COPD (GOLD 2023) and chronic bronchitis symptoms, who had not received ACTs previously. They were recruited in hospital or through community COPD nurses during (or within 4 days) of starting a moderate-severe exacerbation. Randomisation via sealed envelope determined whether they received 30–60 minutes of training on OPEP or ACBT by respiratory physiotherapists, face-to-face. All participants received antibiotics, steroids, nebulisers and oxygen in the acute phase according to clinical discretion. All were already prescribed optimal inhaled treatments. Participants were advised to continue twice daily OPEP or ACBT at home for at least 6 months.Groups were similar at baseline (all p=N.S). See table 1.Primary OutcomeLeicester Cough Questionnaire (LCQ) at 3 months post-intervention (via intention to treat analysis).ResultsMean (SD) Total LCQ at 3 months in the OPEP group was 87.3 (27.3) vs 91.9 (29.2) in the ACBT group, p=0.73, 95% CI -33 to +23.8. S56 Table 1Participant characteristics at base lineVariable OPEP (n=19) ACBT n=23 Age 66 (10.3) yrs 69.7 (7.3) yrs Male 37% 48% Smokers 32% 13% FEV1% pp 50% 44% MRC 3.4 (1.0) 3.5 (0.7) CAT 31.0 (5.4) 32.6 (4.7) LCQ-Total 63.8 (25.0) 61.2 (17.6) ConclusionBoth groups showed statistically significant and clinically important improvement in LCQ, post-exacerbation (MDCID 1.5–2 LCQ) but there is no significant difference in LCQ scores between OPEP (Aerobika TM ) vs ACBT groups at 3 months.

BackgroundTelemonitoring (TM) for COPD has been shown to reduce hospital admissions in some but not all studies and its cost-effectiveness has been questioned. However, technical advances, real-time coaching as well as increased digital engagement by patients and healthcare professionals, especially since COVID may have changed things. One of the potential barriers to TM is patient adherence and data quality in the home setting.AimTo record TM usage, data quality and patient experience in a real-world clinical setting.MethodsSpecialist COPD community nurses enrolled 54 patients (32 male) mean (SD) age 68(9) years with COPD mean FEV137% predicted, attending secondary care into a TM service between April-December 2022. Patients were onboarded by NuvoAir respiratory physiologists via phone/video calls and were coached in how to perform home spirometry (NuvoAir Air Next spirometer) weekly as well as and other TM measures daily. Data was uploaded through an App on the patient’s own phone/tablet. The NuvoAir team reviewed data and shared reports with the clinical team through alerts and/or in fortnightly 30 minute MS Teams meetings. Patients were sent a questionnaire for feedback on TM in March 2023.ResultsA total of 54 patients were followed for a median of 9 months (range 4 to 13), 4 patients withdrew (at mean 5.5 months) data collected during this period is included. Adherence data are shown in the table 1, 71% of home spirometry was acceptable (graded A-C, ATS/ERS 2005). Patients were offered coaching to improve lower graded tests which were more common during exacerbations.When surveyed, 89% of patients (23 responses) found weekly spirometry useful to understand patterns of their health, 91% found it provided reassurance and 82% felt it was useful to improve their spirometry technique. TM received a net promoter score of 91.ConclusionHigh levels of home TM engagement and adherence to good quality spirometry can be obtained with digital coaching in selected patients with COPD. It is likely that personalised physiologist support drives high engagement and patient experience. P236 Table 1Home monitoring data volume and adherence statisticsTM measure Measurement frequency per week Overall adherence: Number of recorded measures/Total number of days (%) Median (IQR) per participant adherence% Spirometry 1 (weekly) 1,618/2,133 (76%) 85% (58–99%) SpO2 5 (Mon-Fri) 8,485/10,665 (80%) 90% (58–104%) mMRC 6,479/10,665 (61%) 64% (4–87%) Fitbit step count 7 (daily) 8,479/13,234 (64%) 81% (27–98%)

Non-medical prescribing is a key component of advanced practice. In the UK, the Royal Pharmaceutical Society Competency Framework (2021) for prescribers and professional regulators stipulates that all consultations and prescribing must respect and comply with legislation in regards equality, diversity and inclusion (EDI). Evidence indicates that discrimination and unconscious bias is present in health care, with a range of sub-groups experiencing intersectionality and stigma. While EDI was fully embedded in the authors' university's non-medical prescribing programme, informal learner feedback indicated that the EDI content could be expanded further. Therefore, the academic team worked in collaboration with the learners to explore their educational needs and quantify their confidence and knowledge of EDI in clinical practice. The authors identified two key findings. First, that learners, at the start of their non-medical prescribing programme, had disproportionally high levels of ‘perceived’ knowledge and confidence of EDI compared to learners at the end of their programme. This could be related to the ‘Dunning-Kruger effect’ and limited understanding of the complexities associated with intersectionality and unconscious bias. Second, changing the EDI content of the curriculum generated positive learner feedback and evaluations. By sharing their experiences the authors aim to inspire other education providers to critically review their curriculum to ensure that EDI principles are fully embedded and transparent. They also aim to assert that it is the professional responsibility of every practitioner and health and social care worker to improve EDI across health care.

BackgroundSmoking at diagnosis is associated with worse survival in lung cancer but the effects of quitting smoking on survival remain unclear. MethodsIn a UK multi-centre study (NCT01192256) we followed all 2751 patients with newly diagnosed non-small cell lung cancer (NSCLC) for up to 2 years or until death as part of the observational trial. Patients were offered smoking cessation advice and treatments according to national guidelines and local services. Smoking status was verified by exhaled carbon monoxide levels. Kaplan-Meier survival analysis and Cox Proportional Hazards Modelling examined the effects of quitting smoking on survival at 2 years. Findings646 were current smokers at the time of diagnosis. The unadjusted two-year Kaplan-Meier survivor functions for quitters (0.45, 95 %CI 0.37 to 0.53) and continuers (0.32, 0.28 to 0.36) were significantly different (log-rank test p < 0.01). Median survival times were 659 days for quitters and 348 days for continuers. After adjusting for age, sex, stage, performance status, curative intent surgery, radical radiotherapy and comorbidity, the hazard ratio for quitting at diagnosis (0.75, 95 % CI 0.58 to 0.98) indicated a statistically significant reduction in the risk of death across the two-year study period. InterpretationQuitting smoking is independently and significantly associated with improved survival regardless of stage in NSCLC. We recommend that smoking cessation advice and treatments should be offered to smokers with lung cancer. Trial RegistrationClinicalTrials.gov, identifier NCT01192256. FundingThis work was supported by a 2010 Global Research Award for Nicotine Dependence (GRAND), Pfizer.

Background: Studies have reported students’ satisfaction with and learning from undergraduate interprofessional education (IPE). However, there is insufficient research reporting on any longer-term effects of IPE. The objective is to assess the longer-term impact of learning by 3rd/4th year medical and pharmacy students 12-24 months after a therapeutics/prescribing IPE session. Methods: Semi-structured interview transcriptions were explored inductively using thematical analysis, and deductively by using the Modified Kirkpatrick’s evaluation model. Exactly 34 interviews were conducted. Results: Inductively, six themes were identified: preparedness; students as learners and teachers; knowledge/skills development; application of learning; session value; and suggestions for change. Deductively, participants found the session enjoyable and interesting (level 1), had modified attitudes of peers (level 2a), acquired knowledge and skills (level 2b), and, those in employment, provided examples of behavioural change (level 3). No organisational change (level 4) or improved patient outcomes (level 5) were reported. Conclusion: Both medical and pharmacy participants were able to recall a therapeutic/prescribing IPE session that took place 12-24 months earlier. Participants emphasised the usefulness of interacting with peers, increasing their understanding of each others’ roles, improving communication skills and applying learning within practice. Those developing IPE should consider early consistent delivery, utilise multidisciplinary faculty members and ensure an appropriate student knowledge gap.

There are more octogenarians presenting with gallstone disease each year. Many are not suitable for surgical intervention. An alternative treatment option for common bile duct stones in the elderly is endoscopic retrograde cholangiopancreatography (ERCP) with or without stent insertion. We conducted a retrospective study using a prospectively collected database, analysing the outcomes of consecutive patients >80 years old who underwent an ERCP in a single centre for the treatment of common bile duct stones. In total, 156 patients, with a median age of 91 years, underwent an ERCP for choledocholithiasis over a 3-year period. ERCP was successful in 90% of patients but a proportion required repeat intervention. Forty-six (29%) patients had a concurrently inserted stent due to incomplete stone extraction. Six (4%) patients required a post-ERCP cholecystectomy due to ongoing symptoms. The overall ERCP complication rate was 7% (4% Clavien-Dindo 1 and 3% Clavien-Dindo 2), with no cases of post-ERCP pancreatitis or death. Patients were followed up over 5 years following index ERCP. There was a 60% 3-year survival and 30% 5-year survival rate following index ERCP. Importantly, of those who did not survive, only four patients (2.6%) had a death attributable to a biliary cause and none were fit for definitive surgery. ERCP can be considered as a possible definitive management option for treating common bile duct stones in the elderly, particularly in the comorbid population. Concurrent stenting is an effective temporizing strategy and mitigator of biliary-related readmission, but routine stent changes should be considered. Key messages What is already known on this topic Current guidelines advocate for laparoscopic cholecystectomy and common bile duct exploration in patients with choledocholithiasis. What this study adds Endoscopic retrograde cholangiopancreatography with or without stent insertion is a safe, alternative single-treatment modality for choledocholithiasis in the elderly comorbid population. How this study might affect research, practice, or policy Studies and guidelines evaluating treatment options for choledocholithiasis may be altered to accommodate patient-specific factors, including age and comorbid status, and the concurrent use of stenting as a either a temporizing or longer-term measure for complex stone disease.

Background: The seasonal Influenza is a contagious respiratory illness. The most important step in preventing flu is to get a flu vaccination each year along with everyday preventive actions. The objective of this research was to study the acceptance and awareness of Influenza vaccine among health care workers of a tertiary care centre, Kerala and to explore the preventive practices. Methods: This study was a hospital based cross sectional study conducted among 204 health care workers in a tertiary centre in Kerala. A simple random sampling technique was adopted. Data was collected using self-administered pretested semi structured questionnaires. Results: 165 (80.9%) are aware of the Influenza vaccine while 39 (19.1%) are not aware of the Influenza vaccine. 30 (14.7%) has received at least one dose of Influenza vaccine in last five years while 174 (85.2%) has not received the vaccine. 161(78.9%) says they are willing to get vaccinated against Influenza while 43(21.1%) are not willing to get vaccinated. Conclusions: Even though there is good awareness about Influenza vaccine, the number of vaccine recipients is less than ideal. However, majority are willing to take Influenza vaccine in the future which shows good acceptance.