National Health Service Foundation Trust Research Articles

Use of Direct-Acting Oral Anticoagulants in Patients With Atrial Fibrillation and Chronic Liver Disease

HomeCirculationVol. 147, No. 10Use of Direct-Acting Oral Anticoagulants in Patients With Atrial Fibrillation and Chronic Liver Disease No AccessEditorialRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessEditorialRequest AccessFull TextUse of Direct-Acting Oral Anticoagulants in Patients With Atrial Fibrillation and Chronic Liver Disease Theresa J. Hydes, PhD, Gregory Y.H. Lip, MD and Deirdre A. Lane, PhD Theresa J. HydesTheresa J. Hydes Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, UK (T.J.H., G.Y.H.L., D.A.L.). Liverpool University Hospitals National Health Service Foundation Trust, Aintree University Hospital, Lower Lane, UK (T.J.H.). Search for more papers by this author , Gregory Y.H. LipGregory Y.H. Lip https://orcid.org/0000-0002-7566-1626 Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, UK (T.J.H., G.Y.H.L., D.A.L.). Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, UK (G.Y.H.L., D.A.L.). Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L., D.A.L.). Search for more papers by this author and Deirdre A. LaneDeirdre A. Lane Correspondence to: Deirdre A. Lane, PhD, Liverpool Centre for Cardiovascular Sciences, University of Liverpool, 6 West Derby Street, Liverpool, UK L7 8TX. Email E-mail Address: [email protected] https://orcid.org/0000-0002-5604-9378 Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, UK (T.J.H., G.Y.H.L., D.A.L.). Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, UK (G.Y.H.L., D.A.L.). Department of Clinical Medicine, Aalborg University, Denmark (G.Y.H.L., D.A.L.). Search for more papers by this author Originally published6 Mar 2023https://doi.org/10.1161/CIRCULATIONAHA.122.063195Circulation. 2023;147:795–797This article is a commentary on the followingComparative Effectiveness and Safety of Direct Oral Anticoagulants and Warfarin in Patients With Atrial Fibrillation and Chronic Liver Disease: A Nationwide Cohort StudyFootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.For Disclosures, see page 797.Circulation is available at www.ahajournals.org/journal/circCorrespondence to: Deirdre A. Lane, PhD, Liverpool Centre for Cardiovascular Sciences, University of Liverpool, 6 West Derby Street, Liverpool, UK L7 8TX. Email [email protected]net

Early childhood lower respiratory tract infection and premature adult death from respiratory disease in Great Britain: a national birth cohort study

Lower respiratory tract infections (LRTIs) in early childhood are known to influence lung development and lifelong lung health, but their link to premature adult death from respiratory disease is unclear. We aimed to estimate the association between early childhood LRTI and the risk and burden of premature adult mortality from respiratory disease. This longitudinal observational cohort study used data collected prospectively by the Medical Research Council National Survey of Health and Development in a nationally representative cohort recruited at birth in March, 1946, in England, Scotland, and Wales. We evaluated the association between LRTI during early childhood (age <2 years) and death from respiratory disease from age 26 through 73 years. Early childhood LRTI occurrence was reported by parents or guardians. Cause and date of death were obtained from the National Health Service Central Register. Hazard ratios (HRs) and population attributable risk associated with early childhood LRTI were estimated using competing risks Cox proportional hazards models, adjusted for childhood socioeconomic position, childhood home overcrowding, birthweight, sex, and smoking at age 20-25 years. We compared mortality within the cohort studied with national mortality patterns and estimated corresponding excess deaths occurring nationally during the study period. 5362 participants were enrolled in March, 1946, and 4032 (75%) continued participating in the study at age 20-25 years. 443 participants with incomplete data on early childhood (368 [9%] of 4032), smoking (57 [1%]), or mortality (18 [<1%]) were excluded. 3589 participants aged 26 years (1840 [51%] male and 1749 [49%] female) were included in the survival analyses from 1972 onwards. The maximum follow-up time was 47·9 years. Among 3589 participants, 913 (25%) who had an LRTI during early childhood were at greater risk of dying from respiratory disease by age 73 years than those with no LRTI during early childhood (HR 1·93, 95% CI 1·10-3·37; p=0·021), after adjustment for childhood socioeconomic position, childhood home overcrowding, birthweight, sex, and adult smoking. This finding corresponded to a population attributable risk of 20·4% (95% CI 3·8-29·8) and 179 188 (95% CI 33 806-261 519) excess deaths across England and Wales between 1972 and 2019. In this prospective, life-spanning, nationally representative cohort study, LRTI during early childhood was associated with almost a two times increased risk of premature adult death from respiratory disease, and accounted for one-fifth of these deaths. National Institute for Health and Care Research Imperial Biomedical Research Centre, Royal Brompton and Harefield National Health Service (NHS) Foundation Trust, Royal Brompton and Harefield Hospitals Charity and Imperial College Healthcare NHS Trust, UK Medical Research Council.

A randomised, controlled, feasibility trial of an online, self-guided breathlessness supportive intervention (SELF-BREATHE) for individuals with chronic breathlessness due to advanced disease.

SELF-BREATHE is a complex, transdiagnostic, supportive, digital breathlessness intervention co-developed with patients. SELF-BREATHE seeks to build capacity and resilience within health services by improving the lives of people with chronic breathlessness using nonpharmacological, self-management approaches. This study aimed to determine whether SELF-BREATHE is feasible to deliver and acceptable to patients living with chronic breathlessness. A parallel, two-arm, single-blind, single-centre, randomised controlled, mixed-methods feasibility trial with participants allocated to 1) intervention group (SELF-BREATHE) or 2) control group (usual National Health Service (NHS) care). The setting was a large multisite NHS foundation trust in south-east London, UK. The participants were patients living with chronic breathlessness due to advanced malignant or nonmalignant disease(s). Participants were randomly allocated (1:1) to an online, self-guided, breathlessness supportive intervention (SELF-BREATHE) and usual care or usual care alone, over 6 weeks. The a priori progression criteria were ≥30% of eligible patients given an information sheet consented to participate; ≥60% of participants logged on and accessed SELF-BREATHE within 2 weeks; and ≥70% of patients reported the methodology and intervention as acceptable. Between January 2021 and January 2022, 52 (47%) out of 110 eligible patients consented and were randomised. Of those randomised to SELF-BREATHE, 19 (73%) out of 26 logged on and used SELF-BREATHE for a mean±sd (range) 9±8 (1-33) times over 6 weeks. 36 (70%) of the 52 randomised participants completed and returned the end-of-study postal questionnaires. SELF-BREATHE users reported it to be acceptable. Post-intervention qualitative interviews demonstrated that SELF-BREATHE was acceptable and valued by users, improving breathlessness during daily life and at points of breathlessness crisis. These data support the feasibility of moving to a fully powered, randomised controlled efficacy trial with minor modifications to minimise missing data (i.e. multiple methods of data collection: face-to-face, telephone, video assessment and by post).

Associations of remote mental healthcare with clinical outcomes: a natural language processing enriched electronic health record data study protocol

IntroductionPeople often experience significant difficulties in receiving mental healthcare due to insufficient resources, stigma and lack of access to care. Remote care technology has the potential to overcome these barriers...

Military veterans and civilians’ mental health diagnoses: an analysis of secondary mental health services

PurposeHealthcare provision in the United Kingdom (UK) falls primarily to the National Health Service (NHS) which is free at the point of access. In the UK, there is currently no national marker to identify military veterans in electronic health records, nor a requirement to record it. This study aimed to compare the sociodemographic characteristics and recorded mental health diagnoses of a sample of veterans and civilians accessing secondary mental health services.MethodsThe Military Service Identification Tool, a machine learning computer tool, was employed to identify veterans and civilians from electronic health records. This study compared the sociodemographic characteristics and recorded mental health diagnoses of veterans and civilians accessing secondary mental health care from South London and Maudsley NHS Foundation Trust, UK. Data from 2,576 patients were analysed; 1288 civilians and 1288 veterans matched on age and gender.ResultsDepressive disorder was the most prevalent across both groups in the sample (26.2% veterans, 15.5% civilians). The present sample of veterans accessing support for mental health conditions were significantly more likely to have diagnoses of anxiety, depressive, psychosis, personality, and stress disorders (AORs ranging 1.41–2.84) but less likely to have a drug disorder (AOR = 0.51) than age- and gender-matched civilians.ConclusionVeterans accessing secondary mental health services in South London had higher risks for many mental health problems than civilians accessing the same services. Findings suggest that military career history is a key consideration for probable prognosis and treatment, but this needs corroborating in other geographical areas including national population-based studies in the UK.

Endoscopic surveillance with systematic random biopsy for the early diagnosis of hereditary diffuse gastric cancer: a prospective 16-year longitudinal cohort study

Hereditary diffuse gastric cancer, generally caused by germline pathogenic variants in CDH1, presents with early-onset signet ring cell carcinoma. Prophylactic total gastrectomy is the definitive treatment. Endoscopic surveillance can inform the timing of prophylactic total gastrectomy through detection of microscopic signet ring cell carcinoma foci. However, evidence is scarce about the optimal endoscopic sampling technique and characterisation of signet ring cell carcinoma foci in hereditary diffuse gastric cancer. We aimed to formally assess the diagnostic yield of different sampling strategies and to identify criteria for the characterisation of endoscopic lesions. For this prospective longitudinal cohort study, we included individuals aged 18 years or older at the Cambridge University Hospitals National Health Service (NHS) Foundation Trust who fulfilled testing criteria for hereditary diffuse gastric cancer between June 1, 2005, and July 31, 2021. The primary outcome was detection of intramucosal signet ring cell carcinoma foci. We assessed the detection rate and anatomical location of signet ring cell carcinoma in random biopsy samples taken according to a systematic protocol compared with biopsies targeted to endoscopic findings. Endoscopic lesions were examined with white-light and narrow band imaging with magnification to assess the likelihood of cancerous foci. 145 individuals were included, of whom 68 (47%) were male and 92 (63%) carried the CDH1 pathogenic variant. 58 (40%) patients were diagnosed with invasive signet ring cell carcinoma over a median follow-up time of 51 months (IQR 18-80). The first diagnosis of signet ring cell carcinoma was most commonly made from random biopsies (29 [50%] of 58 patients), rather than targeted biopsies (15 [26%] patients). The anatomical distribution of signet ring cell carcinoma foci detected by random biopsies more accurately reflected those identified in prophylactic total gastrectomy specimens than did targeted biopsies. Omitting random biopsies in our cohort would have led to an under-diagnosis rate of 42%. Using a novel panel of endoscopic criteria, gastric lesions containing signet ring cell carcinoma were predicted with a sensitivity of 67·3% and a specificity of 90·2%. Random biopsies enhance the early detection of signet ring cell carcinoma and are complementary to targeted biopsies in surveillance of hereditary diffuse gastric cancer. This sampling method should be the standard of care when performing all surveillance endoscopies for individuals with hereditary diffuse gastric cancer. UK Medical Research Council.

Factors influencing conveyance of older adults with minor head injury by paramedics to the emergency department: a multiple methods study

BackgroundHead injury (HI) in older adults due to low-energy falls result in a substantial number of emergency department (ED) attendances. However, mortality associated with minor HI is very low. Reducing conveyance to hospital is important for older adults and is a priority for the National Health Service (NHS). Therefore, paramedics are required to make accurate decisions regarding conveyance to the ED. This study used routine data and semi-structured interviews to explore the factors that influence paramedic decision-making when considering whether to convey an adult aged 65 years and over with a minor HI to the ED.MethodsSemi-structured telephone interviews were completed with ten UK paramedics from a single EMS (ambulance) provider organisation. Interviews explored the factors influencing the paramedics’ conveyance decision-making in adults aged 65 years and over with a minor HI. Data were initially analysed inductively to develop a thematic framework. A retrospective analysis of ambulance service data was also completed to determine the scope and scale of the issue in Southwest England. An in-depth audit of 100 conveyed patient records was used to determine the proportion of patients conveyed to the ED who met National Institute for Health and Care Excellence (NICE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidelines.ResultsIn 2019 South Western Ambulance Service NHS Foundation Trust (SWASFT) attended 15,650 emergency calls to patients aged 65 and over with minor HI, with 70.5% conveyed to ED. 81% of conveyed patients met NICE and JRCALC guideline criteria for conveyance, with the remainder conveyed due to wound care or other medical concerns. The framework developed from the interviews comprised four themes: resources; patient factors; consequences; paramedic factors. Important factors included: the patient’s social situation; guidelines; clinical support availability; the history and presentation of the patient; risk.ConclusionThis study examined paramedic conveyance decisions for older people with minor HI. It identified multiple influencing factors, highlighting the complex nature of these decisions, and may serve as a basis for developing an intervention to safely decrease ED conveyance in this patient group.

Mortality and life-years lost following subsequent physical comorbidity in people with pre-existing substance use disorders: a national registry-based retrospective cohort study of hospitalised individuals in Czechia

Substance use disorders constitute a major global public health problem, attributable largely to their subsequent comorbidity with other health conditions. This study aimed to investigate the risk of all-cause death and life-years lost following hospitalisation for 28 subsequent physical comorbid conditions in people with a previous hospitalisation for substance use disorder, compared with matched counterparts without substance use disorder. We did a retrospective cohort study on data from Czech nationwide registers of all-cause hospitalisations and deaths during the period from Jan 1, 1994, to Dec 31, 2017. The cohorts consisted of individuals who had initially been hospitalised between 15 and 70 years of age (index hospitalisation) and who were subsequently hospitalised with one or more of 28 comorbid physical health conditions. We included individuals with an index hospitalisation for substance use disorders and up to three counterparts without substance use disorders with a subsequent hospitalisation for the same physical health condition, with matching on sex, age (±3 years), work status, and discharge year at first hospitalisation for the subsequent condition. Data on ethnicity were not available. Risk of death due to any cause following the first hospitalisation for each physical health condition until Dec 31, 2017, and life-years lost after disease onset at ages 30, 45, and 60 years, and before 81 years of age, were examined. From a total 56 229 563 records of hospitalisations identified, we included 121 153 people with hospitalisation for substance use disorders and 6 742 134 people without hospitalisation for substance use disorders in the study. The 28 condition-specific cohorts comprised a median of 6444 individuals (IQR 2033-12 358), ranging from 444 for multiple sclerosis to 36 356 for diseases of the circulatory system. Across the cohorts, the proportion of males ranged from 31·4% for thyroid disorder to 100·0% for prostate disorders. The mean baseline age ranged from 30·0 years (SD 9·1) for chronic viral hepatitis in people with pre-existing substance use disorders to 62·2 years (9·7) for Parkinson's disease in people without pre-existing substance use disorders. After adjusting for potential confounders using stratified Cox proportional hazards models, individuals with a pre-existing substance use disorder had an increased risk of death due to any cause after the onset of 26 out of 28 physical health conditions, relative to their counterparts without substance use disorders, with adjusted hazard ratios ranging from 1·15 (1·09-1·21) for chronic liver disease to 3·86 (2·62-5·67) for thyroid disorder. For seven subsequent health conditions, the risk of death was more than doubled in the group with pre-existing substance use disorders. When compared with the general population via mortality tables, people with pre-existing substance use disorders had substantial losses in life-years after the onset of most of the subsequent physical health conditions regardless of age of onset, and, for the majority of comorbidities, lost considerably more life-years than their counterparts without substance use disorders. A history of hospitalisation for substance use disorders appears to have a significant negative effect on prognosis following the development of various subsequent physical health conditions. These findings strongly suggest that clinical vigilance and high-quality integrated treatment for people with substance use disorders could be life-saving and should be given higher priority on the public health agenda. National Institute for Health and Care Research Applied Research Collaboration East of England at Cambridge and Peterborough National Health Service Foundation Trust.

Comparison of COVID-19 survival in relation to CPAP length of treatment and by comorbidity and transmission setting (community or hospital acquired) in a medium-sized UK hospital in 2020: a retrospective study

ObjectiveTo estimate continuous positive airway pressure (CPAP) length of treatment effect on survival of hospitalised COVID-19 patients in a medium-sized UK Hospital, and how this effect changes according to the...

Vitamin D status: a U-shaped relationship for SARS-CoV-2 seropositivity in UK healthcare workers

BackgroundThere is increasing evidence that vitamin D (VD) deficiency may increase individuals’ risk of COVID-19 infection and susceptibility. We aimed to determine the relationship between VD deficiency and sufficiency and...

Observational Study of the Impact of COVID-19 on Sleep in Children With and Without Special Educational Needs

Objectives: Children and young people (CYP) with special educational needs (SEN) are more likely to experience disturbed sleep and poor mental wellbeing. This study explored the differential impact of the coronavirus disease 2019 (COVID-19) pandemic on the sleep and mental wellbeing of CYP with and without SEN.Methods: The National Institute of Health Research Children and Young People MedTech Cooperative, Sheffield Children’s National Health Service (NHS) Foundation Trust, and The Sleep Charity carried out an online survey between June 23, 2020, and August 17, 2020. The 77-item survey was shared on social media platforms.Results: A total of 559 participants were included in the analyses, and 15.74% of them reported having CYP with SEN. While sleep changes due to the pandemic were largely similar for both groups, CYP with SEN were more likely to get up or wake up during the night than those without SEN (40.91% vs. 27.18%). CYP with SEN were significantly more likely than those without SEN to be demotivated (61.44% vs. 31.57%), sad and tearful (36.15% vs. 19.35%), or anxious and stressed (41.67% vs. 18.54%) during the pandemic, and the increased anxiety was more likely to contribute to poorer sleep (43.48% vs. 14.82%).Conclusions: While the majority of CYP in both groups reported sleep changes due to the pandemic, CYP with SEN experienced more sleep disturbance. The findings provide initial evidence to suggest that the pandemic may have had a greater impact on the sleep and mental wellbeing of CYP with SEN than those without SEN.

Protocol for an observational study investigating hormones triggering the onset of sustained lactation: the INSIGHT study

IntroductionLactation is a hormonally controlled process that promotes infant growth and neurodevelopment and reduces the long-term maternal risk of diabetes, cardiovascular disease and breast cancer. Hormones, such as prolactin and...

An integrated discrete event simulation and particle swarm optimisation model for optimising efficiency of cancer diagnosis pathways

The National Health Service (NHS) constitution sets out minimum standards for rights of access of patients to NHS services. The ‘Faster Diagnosis Standard’ (FDS) states that 75% of patients should be told whether they have a diagnosis of cancer or not within 28 days of an urgent GP referral. Timely diagnosis and treatment lead to improved outcomes for cancer patients, however, compliance with these standards has recently been challenged, particularly in the context of operational pressures and resource constraints relating to the COVID-19 pandemic. In order to minimise diagnostic delays, the National Physical Laboratory in collaboration with the Royal Free London (RFL) NHS Foundation Trust address this problem by treating it as a formal resource optimisation, aiming to minimise the number of patients who breach the FDS. We use discrete event simulation and particle swarm optimisation to identify areas for improving the efficiency of cancer diagnosis at the RFL. We highlight capacity-demand mismatches in the current cancer diagnosis pathways at the RFL, including imaging and endoscopy investigations. This is due to the volume of patients requiring these investigations to meet the 28-day FDS target. We find that increasing resources in one area alone does not fully solve the problem. By looking at the system as a whole we identify areas for improvement which will have system-wide impact even though individually they do not necessarily seem significant. The outcomes and impact of this project have the potential to make a valuable impact on shaping future hospital activity.

The performativity and politics of emotions in NHS boards

ABSTRACT This paper highlights the performative value and political power of emotions in public sector board governance. We explore how board members display, manage and (re)negotiate emotions both purposefully and unconsciously through interactions in a UK National Health Service (NHS) Foundation Trust. This topic is investigated through an ethnonarrative approach and a performative perspective to understand the role and value of emotions in this particular organizational setting. Our data, captured through interviews and participant observations, highlight the inherent performative and political nature of emotions established through ritualized practice, impromptu displays, emotion norms, and power dynamics. We also highlight the purposeful instigation and manipulation of emotions to pursue individual or collective agendas. This paper thus contributes to both performance theory and the study of emotions management in organizations by exploring how the politics of emotions and emotion norms are experienced as valuable resources in the context of public board governance.

Selective internal radiation therapy (SIRT) for hepatocellular carcinoma (HCC): informing clinical practice for multidisciplinary teams in England

ObjectiveHepatocellular carcinoma (HCC) deaths are rising alarmingly. Many patients are unsuitable for available therapies. Poor response rates further hamper outcomes for those that are. Selective internal radiation therapy (SIRT) offers...

Development of a Mortality Prediction Model in Hospitalised SARS-CoV-2 Positive Patients Based on Routine Kidney Biomarkers.

Acute kidney injury (AKI) is a prevalent complication in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive inpatients, which is linked to an increased mortality rate compared to patients without AKI. Here we analysed the difference in kidney blood biomarkers in SARS-CoV-2 positive patients with non-fatal or fatal outcome, in order to develop a mortality prediction model for hospitalised SARS-CoV-2 positive patients. A retrospective cohort study including data from suspected SARS-CoV-2 positive patients admitted to a large National Health Service (NHS) Foundation Trust hospital in the Yorkshire and Humber regions, United Kingdom, between 1 March 2020 and 30 August 2020. Hospitalised adult patients (aged ≥ 18 years) with at least one confirmed positive RT-PCR test for SARS-CoV-2 and blood tests of kidney biomarkers within 36 h of the RT-PCR test were included. The main outcome measure was 90-day in-hospital mortality in SARS-CoV-2 infected patients. The logistic regression and random forest (RF) models incorporated six predictors including three routine kidney function tests (sodium, urea; creatinine only in RF), along with age, sex, and ethnicity. The mortality prediction performance of the logistic regression model achieved an area under receiver operating characteristic (AUROC) curve of 0.772 in the test dataset (95% CI: 0.694–0.823), while the RF model attained the AUROC of 0.820 in the same test cohort (95% CI: 0.740–0.870). The resulting validated prediction model is the first to focus on kidney biomarkers specifically on in-hospital mortality over a 90-day period.

Physical Health Screening in a Mental Health Setting

AimsResearch demonstrates greater mortality and physical health morbidity in those with mental illness, as compared to the general population. National Health Service (NHS) England has introduced policies to reflect this and promote improvements in physical healthcare for mental health patients. Inpatient admission provides a valuable opportunity to action such recommendations and offer a detailed health review, guided by local frameworks. A new annual audit commenced in Cheshire and Wirral Partnership NHS Foundation Trust (CWP) assesses admission physical health screening on its adult acute inpatient wards.MethodsAudit standard was 100% compliance to CWP's admission pathway (Policy CP35). Parameters included doctor's review, medical history, physical examination, drug history, medication chart, allergy status, venous thromboembolic risk, blood tests, electrocardiogram (ECG), physiological observations, smoking history, body mass index (BMI) and falls risk. Data were collected retrospectively for all patients admitted or transferred to Juniper Ward, an acute adult inpatient unit in Bowmere Hospital in Chester, during October 2020 (cycle 1) and September 2021 (cycle 2). Different months were assessed due to senior staff changes in October 2021.Results30 patients were identified in 2020 and 37 in 2021. In 2020 the most consistently achieved parameters were, in order, medication chart/drug history, doctor's review and past medical history. In 2021 the most consistently achieved parameters were medication chart/drug history, smoking status and past medical history. Across both years completion of the cardiometabolic tool was lowest, although this improved from 6.7% to 16.2%. In 2020 there were 5 parameters achieving &lt;50% compliance (cardiometabolic, physiological observations, smoking status, BMI and falls risk). In 2021 this reduced to 3 parameters (doctor's review, cardiometabolic tool, falls risk). Local policy was updated following the 2020 results, amending the criteria for doctor's review from commenced within 6 hours, to completed within 12 hours. Improvement was seen in all other areas in 2021, with medication chart/drug history documentation achieved in 100% of admissions.ConclusionGeneralised improvement was seen following the 2020 audit, although only one parameter reached 100% compliance and most remained under 75%. The first cycle led to a policy change with respect to the doctor's review timeframe, although this limited direct comparison between years. A flow chart will be trialled on Juniper Ward, highlighting required tasks and assigning ownership to specific team members. The local Medical Education team were also made aware of the results to inform junior doctor induction. The audit will be repeated in Autumn 2022.

Predicting hospitalisation for heart failure and death in patients with, or at risk of, heart failure before first hospitalisation: a retrospective model development and external validation study

SummaryBackgroundIdentifying people who are at risk of being admitted to hospital (hospitalised) for heart failure and death, and particularly those who have not previously been hospitalised for heart failure, is a priority. We aimed to develop and externally validate a prognostic model involving contemporary deep phenotyping that can be used to generate individual risk estimates of hospitalisation for heart failure or all-cause mortality in patients with, or at risk of, heart failure, but who have not previously been hospitalised for heart failure.MethodsBetween June 1, 2016, and May 31, 2018, 3019 consecutive adult patients (aged ≥16 years) undergoing cardiac magnetic resonance (CMR) at Manchester University National Health Service Foundation Trust, Manchester, UK, were prospectively recruited into a model development cohort. Candidate predictor variables were selected according to clinical practice and literature review. Cox proportional hazards modelling was used to develop a prognostic model. The final model was validated in an external cohort of 1242 consecutive adult patients undergoing CMR at the University of Pittsburgh Medical Center Cardiovascular Magnetic Resonance Center, Pittsburgh, PA, USA, between June 1, 2010, and March 25, 2016. Exclusion criteria for both cohorts included previous hospitalisation for heart failure. Our study outcome was a composite of first hospitalisation for heart failure or all-cause mortality after CMR. Model performance was evaluated in both cohorts by discrimination (Harrell's C-index) and calibration (assessed graphically).FindingsMedian follow-up durations were 1118 days (IQR 950–1324) for the development cohort and 2117 days (1685–2446) for the validation cohort. The composite outcome occurred in 225 (7·5%) of 3019 patients in the development cohort and in 219 (17·6%) of 1242 patients in the validation cohort. The final, externally validated, parsimonious, multivariable model comprised the predictors: age, diabetes, chronic obstructive pulmonary disease, N-terminal pro-B-type natriuretic peptide, and the CMR variables, global longitudinal strain, myocardial infarction, and myocardial extracellular volume. The median optimism-adjusted C-index for the externally validated model across 20 imputed model development datasets was 0·805 (95% CI 0·793–0·829) in the development cohort and 0·793 (0·766–0·820) in the external validation cohort. Model calibration was excellent across the full risk profile. A risk calculator that provides an estimated risk of hospitalisation for heart failure or all-cause mortality at 3 years after CMR for individual patients was generated.InterpretationWe developed and externally validated a risk prediction model that provides accurate, individualised estimates of the risk of hospitalisation for heart failure and all-cause mortality in patients with, or at risk of, heart failure, before first hospitalisation. It could be used to direct intensified therapy and closer follow-up to those at increased risk.FundingThe UK National Institute for Health Research, Guerbet Laboratories, and Roche Diagnostics International.

Requirements for a Bespoke Intensive Care Unit Dashboard in Response to the COVID-19 Pandemic: Semistructured Interview Study.

BackgroundIntensive care units (ICUs) around the world are in high demand due to patients with COVID-19 requiring hospitalization. As researchers at the University of Bristol, we were approached to develop a bespoke data visualization dashboard to assist two local ICUs during the pandemic that will centralize disparate data sources in the ICU to help reduce the cognitive load on busy ICU staff in the ever-evolving pandemic.ObjectiveThe aim of this study was to conduct interviews with ICU staff in University Hospitals Bristol and Weston National Health Service Foundation Trust to elicit requirements for a bespoke dashboard to monitor the high volume of patients, particularly during the COVID-19 pandemic.MethodsWe conducted six semistructured interviews with clinical staff to obtain an overview of their requirements for the dashboard and to ensure its ultimate suitability for end users. Interview questions aimed to understand the job roles undertaken in the ICU, potential uses of the dashboard, specific issues associated with managing COVID-19 patients, key data of interest, and any concerns about the introduction of a dashboard into the ICU.ResultsFrom our interviews, we found the following design requirements: (1) a flexible dashboard, where the functionality can be updated quickly and effectively to respond to emerging information about the management of this new disease; (2) a mobile dashboard, which allows staff to move around on wards with a dashboard, thus potentially replacing paper forms to enable detailed and consistent data entry; (3) a customizable and intuitive dashboard, where individual users would be able to customize the appearance of the dashboard to suit their role; (4) real-time data and trend analysis via informative data visualizations that help busy ICU staff to understand a patient’s clinical trajectory; and (5) the ability to manage tasks and staff, tracking both staff and patient movements, handovers, and task monitoring to ensure the highest quality of care.ConclusionsThe findings of this study confirm that digital solutions for ICU use would potentially reduce the cognitive load of ICU staff and reduce clinical errors at a time of notably high demand of intensive health care.

A Survey of Diagnostic Delay in Axial Spondyloarthritis Across Two National Health Service (NHS) Rheumatology Services.

IntroductionDiagnostic delay is an ongoing challenge in axial spondyloarthritis (axial SpA). A recent, comprehensive literature review has found a mean average of 8.7 years of delay between symptom onset and formal diagnosis in the United Kingdom (UK). The primary aim of this study was to identify delays to diagnosis experienced by patients with axial SpA under the ongoing care of two urban National Health Service (NHS) rheumatology services. The secondary aims were (a) to count healthcare professional (HCP) interactions after symptom onset but prior to the diagnosis, (b) to compare our data to published delay to diagnosis research and (c) to explore contributing factors locally and the variation between the two UK rheumatology services.MethodsA 14-question survey was created to identify the delay to diagnosis and contributing factors across two urban NHS axial SpA services, from the onset of symptoms to diagnosis and commencement of treatment. Participants were recruited from clinic visits between August and November 2021 and completed the survey either on paper or via online survey software, both with HCP support.ResultsThose completing the survey formed a cohort of 106 participants with an established diagnosis of axial SpA who attended the axial SpA services at either Royal Free NHS Foundation Trust or Salford Care Organisation, Northern Care Alliance NHS Foundation Trust. The mean time from the onset of symptoms to the diagnosis of axial SpA was similar across centres despite the differences in demographics, with Royal Free at 5.72 years and Salford Royal at 5.96 years. When reviewing via median diagnostic delay, there was a notable difference with Royal Free at 6.09 years and Salford Royal at 4.27 years.Across the two sites, between the onset of symptoms and the diagnosis of axial SpA, 90% of the participants saw a general practitioner (GP), of which 63% of the patients saw a GP 1-5 times, 23% saw 5-10 times and 14% saw more than 10 times. Many participants also saw other HCPs, including physiotherapists, other manual therapists and hospital specialists prior to diagnosis. In addition, 32% saw one other HCP, 18% two other HCPs, 9% three, 7% four and 2.7% five other HCPs prior to diagnosis. Close to 80% of the patients stated that they had received adequate axial SpA education at diagnosis, and 76% of the patients were aware of who to contact in the event of a flare.ConclusionsThese data highlight that the mean average time to diagnosis for both trusts was between five and six years, somewhat lower than the 8.7-year national UK average. However, despite being specialist centres, these data are a long way from the National Axial Spondyloarthritis Society (NASS) “Gold Standard” of one year time to diagnosis. The contributors to this include lack of HCP and community awareness about axial SpA, its recognition and appropriate onwards referral. There is a need for concerted ways of working for the development of patient pathways and public and HCP education to reduce this delay to allow the ambitious NASS Gold Standard of one year time to diagnosis to be achieved.