Secondary Care Settings Research Articles

Brain connectivity-guided, Optimised theta burst transcranial magnetic stimulation to improve Central Pain Modulation in knee Osteoarthritis Pain (BoostCPM): protocol of a pilot randomised clinical trial in a secondary care setting in the UK

IntroductionChronic pain is a common health problem that is not efficiently managed by standard analgesic treatments. There is evidence that treatment resistance may result from maladaptive brain changes in areas...

Risk factors associated with the development of chronic suppurative otitis media in children: Systematic review and meta-analysis.

Chronic suppurative otitis media (CSOM) is defined as persistent discharge through a tympanic membrane perforation for greater than 2 weeks. It is associated with a significant disease burden, including hearing loss, and reducing its incidence could significantly improve short- and long-term health. We aimed to identify risk factors associated with the development of CSOM in children. Systematic review and meta-analysis of studies set in community, primary and secondary care settings, identified from Medline, Embase and Cochrane databases from 2000 to 2022. Children 16 years old and below. Clinical diagnosis of CSOM. In total, 739 papers were screened, with 12 deemed eligible for inclusion in the systematic review, of which, 10 were included in the meta-analysis. Risk factors examined included perinatal, patient, dietary, environmental and parental factors. Meta-analysis results indicate that atopy (RR = 1.18, 95% CI [1.01-1.37], p = .04, 2 studies); and birth weight <2500 g (RR = 1.79 [1.27-2.50], p < .01, 2 studies) are associated with an increased risk of CSOM development. Factors not associated were male sex (RR = 0.96 [0.82-1.13], p = .62, 8 studies); exposure to passive smoking (RR = 1.27 [0.81-2.01], p = .30, 3 studies); and parental history of otitis media (RR = 1.14 [0.59-2.20], p = .69, 2 studies). Optimal management of risk factors associated with CSOM development will help reduce the burden of disease and prevent disease progression or recurrence. The current quality of evidence in the literature is variable and heterogeneous. Future studies should aim to use standardised classification systems to define risk factors to allow meta-analysis.

The Use of Extra-oral Bitewing Radiographs for Treatment Planning in Paediatric Patients

The extra-oral bitewing is becoming increasingly popular among clinicians to help overcome some of the challenges posed when taking intra-oral radiographs for paediatric patients. When combined with clinical examination, this radiographic view provides important diagnostic information in the management of caries in the posterior dentition. In this article, the use of extra-oral bitewings will be explored. The introduction of a decision tree provides the dental practitioner working in either a primary or secondary care setting, a pathway to assist with deciding the optimal radiographic prescription. CPD/Clinical Relevance: Extra-oral bitewings can be a useful radiographic tool for dental caries diagnosis in the mixed dentition.

Trends in socioeconomic inequalities in incidence of severe mental illness - A population-based linkage study using primary and secondary care routinely collected data between 2000 and 2017.

In 2008, the UK entered a period of economic recession followed by sustained austerity measures. We investigate changes in inequalities by area deprivation and urbanicity in incidence of severe mental illness (SMI, including schizophrenia-related disorders and bipolar disorder) between 2000 and 2017. We analysed 4.4 million individuals from primary and secondary care routinely collected datasets (2000-2017) in Wales and estimated the incidence of SMI by deprivation and urbanicity measured by the Welsh Index of Multiple Deprivation (WIMD) and urban/rural indicator respectively. Using linear modelling and joinpoint regression approaches, we examined time trends of the incidence and incidence rate ratios (IRR) of SMI by the WIMD and urban/rural indicator adjusted for available confounders. We observed a turning point of time trends of incidence of SMI at 2008/2009 where slope changes of time trends were significantly increasing. IRRs by deprivation/urbanicity remained stable or significantly decreased over the study period except for those with bipolar disorder sourced from secondary care settings, with increasing trend of IRRs (increase in IRR by deprivation after 2010: 1.6% per year, 95% CI: 1.0%-2.2%; increase in IRR by urbanicity 1.0% per year, 95% CI: 0.6%-1.3%). There was an association between recession/austerity and an increase in the incidence of SMI over time. There were variations in the effects of deprivation/urbanicity on incidence of SMI associated with short- and long-term socioeconomic change. These findings may support targeted interventions and social protection systems to reduce incidence of SMI.

Reducing the sting of malnutrition: improving timely identification of at-risk patients in an acute secondary care setting

Reducing the sting of malnutrition: improving timely identification of at-risk patients in an acute secondary care setting

Improving health outcomes among older adults in India: effectiveness and implementability of a novel comprehensive geriatric assessment based intervention

Background: There is significant evidence on the benefits of comprehensive assessment in older adults. But this evidence is primarily from western countries and in secondary care settings. National policies in India recognize this need and envision community-based screening and facility-based assessment programs integrated into the care pathways for the elderly. However, this is yet to translate into specific interventions, primarily due to lack of complex interventions necessary and evidence of their effectiveness. This study aims to design and pilot an integrated (Community + Facility) Elderly Health Status Assessment and Screening (EHSAS) intervention to improve health outcomes of older adults and assess its feasibility for implementation in Indian rural settings. Methods: We propose a hybrid design where we will build the complex intervention, develop and validate the tools needed, pilot it using an exploratory cluster randomized trial and evaluate its implementatbility using the Exploration-Preparation-Implementation-Sustainment (EPIS) framework. Conclusions: This study will fill critical gaps in evidence regarding the effectiveness of geriatric screening and assessment in community and primary care settings in low-middle income countries and provide validated tools and implementation models for adoption into national programs. Registration: CTRI/2023/07/055661

Respiratory Syncytial Virus Infections in Polish Pediatric Patients from an Expert Perspective.

Respiratory syncytial virus (RSV) is the most common pathogen causing respiratory tract infections in infants, affecting over 90% of children within the first two years of life. It may cause lower respiratory tract infections, which constitute a significant healthcare burden both in the primary and secondary care settings. Meanwhile, the data regarding RSV disease in Poland is scarce, and published data significantly differs from the numbers reported for other countries with longstanding surveillance and reporting systems. A literature review and an expert panel were conducted to (1) understand the healthcare burden of RSV infections in Poland; (2) collect data on infection seasonality, patient pathway, and management patterns; and (3) evaluate RSV infection surveillance in Poland. According to the literature, RSV is the major agent responsible for non-influenza respiratory diseases in Poland. The reported rates of hospitalization for RSV infections are 267.5/100,000 for children under 5 years of age and 1132.1/100,000 for those under 1 year of age. Comparisons with data from other countries suggest that these values may be underestimated, possibly due to insufficient access to microbiological testing and a low awareness of RSV. Infections occur mainly between December and April, however, this pattern has changed following the implementation of preventive measures for coronavirus disease 2019 in the past few years. According to available reports, bronchodilators, antibiotics, corticosteroids, and X-ray imaging have been frequently used. The surveillance system in Poland has limitations, but these may be overcome due to recent changes in healthcare law as well as the availability and reimbursement of diagnostic tests.

Pre-eruptive intracoronal resorption: case report

This case describes the presentation of pre-eruptive intracoronal resorption affecting multiple permanent teeth in an 11-year-old female child. Pre-eruptive intracoronal resorption is a lesion that is often located within the dentine, adjacent to the enamel–dentine junction in the occlusal face of the tooth crown. Histological reports have shown the presence of resorptive cells in these lesions. Previous literature presents cases usually affecting a single tooth, in this case 10 permanent teeth were found to be affected. Clinicians should be aware of this diagnosis and its treatment modalities to ensure appropriate management is carried out. CPD/Clinical Relevance: This case highlights pre-eruptive intracoronal resorption for clinicians based in both primary and secondary care settings

Student Competition (Clinical/Best Practice Implementation) ID 1984705

Background The foremost reported unmet health need for Canadians with chronic neurological conditions is linked to physical maintenance. One way to address this issue is through activity programing offered through public institutions, where rehabilitation can be integrated into secondary health care settings. Parkwood Institute in London, Ontario has developed several programs, including virtual exercise classes, day programs, and a community fitness center. People who have participated in these initiatives can provide insights that could be used to create more robust person-centered rehabilitation physical activity programing. Objectives To explore the lived experiences of individuals participating in activity programs offered through Parkwood Institute to develop recommendations for future program development. Methods Using purposive sampling of individuals with a chronic neurological health condition who have participated in a physical activity program offered through Parkwood, we will use a grounded theory methodology to explore individual perspectives. Data will be collected using semi-structured interviews to gather critical perspectives and data will be analyzed using constant comparative analysis. Data collection and analysis will be an iterative process, meaning codes and categories will be developed from initial interviews, with subsequent data being continuously compared to identify similarities and differences. Results The findings of this research will, once completed, describe the impact of various physical activity programs, including benefits, challenges, and recommendations for future development. Conclusions The theoretical interpretations of the findings will be presented as a list of recommendations for activity programs offered through rehabilitation centers to assist researchers, clinicians, and policy makers in decision-making.

Analysis of Sensitivity, Specificity, and Predictive Values of High-Sensitivity Troponin T in a Secondary Care Setting: A Retrospective Cohort Study.

Background High-sensitivity cardiac troponin (hs-cTn) assays have significantly improved the early detection of myocardial injury and the diagnosis of acute coronary syndrome(ACS). Different diagnostic algorithms exist for the interpretation of hs-cTn in the management of patients with suspected ACS. This study analysed the diagnostic efficacy of hs-cTn using serial and single measurements while also shedding light on the challenges associated with the use of this assay. Methods We reviewed 189 results belonging to 120 unique patient episodes and records for troponin tests performed in a two-week period obtained from the West Cumberland Hospital, North Cumbria Integrated Care (NCIC), Whitehaven, England. These troponin tests were carried out based on the NCIC trust guidelines for the use of troponin assays in the management of acute coronary syndrome(ACS). A positive troponin test is defined using the NCIC trust guidelines and the National Academy of Clinical Biochemistry (NACB) guidelines. The case notes of the unique patients were reviewed to determine the outcome, which is defined as the clinical diagnosis on discharge of the patient following a cardiologist review. These outcomes were then used to calculate the sensitivity, specificity, and predictive values. We also determined the alternate diagnosis for false-positive tests. Results Using both guidelines to assess the clinical effectiveness of the troponin assay yields slightly varying results, with the single positive test of NACB demonstrating a higher sensitivity of 92.8% (>71.4%) and a slightly better negative predictive value of 97.8% (>96%). However, using the serial troponin measurements as per the NCIC trust guideline demonstrates a better specificity of 95.2% (>42.4%) and a positive predictive value of 66% (>17.5%). False positive results are identified, which are due to alternate diagnoses such as stable angina, myocarditis, heart failure, sepsis, and malignancy. Conclusion High-sensitivity troponin (hs-cTn) assays play a crucial role in the early detection and management of patients with suspected ACS. This study supports evidence that serial troponin measurements are more diagnostically accurate than single troponin measurements. Although hs-cTn assays offer significant advantages, there remain challenges and limitations that require careful interpretation and clinical correlation.

349 How a Service Evaluation Carried Out by Junior Doctors Helped the Post Pandemic Management of Lumps and Bumps

Abstract Aim The GI surgery department deals with many clinical conditions including lumps and bumps that affect the torso, posterior neck, groin, buttock, perianal and perineal areas. Over the pandemic it was noted that there were many referrals for ‘lumps and bumps’ at a time where theatre capacity and staffing was limited. To create a referral pathway to assess patients for suitability for referral and treatment in the secondary care setting/ to determine which lesions were suitable for treatment in the community. Method A review of 374 cases of lumps and bumps referred between 2019 and 2021. Various patient factors were taken in to account, as well as the size and type of lesion to determine whether it could be managed in the community under local anaesthetic. Results Of the total cases, 45% were deemed to be suitable for treatment in community. Of all lesion types, epidermoid cysts were most suitable for GP treatment. Patients were travelling long distances to reach the hospital and we were treating patients outside our catchment area. We also found that the average waiting time from referral until treatment for lesions managed in community was nearly 9 times shorter than when managed in the hospital setting. Conclusions A new referral pathway was created for all of South East London to reduce the number of lumps and bumps referred. This ultimately allowed for increased theatre capacity for more complex cases, ensured faster treatment and reduced travel distances for patients.

Development of hidden curriculum skills in a COVID-19 vaccination centre.

During the COVID-19 pandemic, many medical students were deployed as vaccinators. This study set out to capture the lived experience of students at a London-based mass vaccination site, understand what they learned, how this learning compared to their experience of usual medical education and how any identified benefits might be leveraged in a post-pandemic context. Student vaccinators (n = 8) were recruited from the vaccine clinic workforce and invited to complete semi-structured interviews about their experiences. Thematic analysis was conducted on interview transcripts to identify significant concepts, which were interpreted in the context of available literature. Participants' experiences aligned broadly with the undergraduate curriculum. However, many also identified hidden curriculum areas developed through their work as vaccinators, including professionalism, self-regulating learning and ethical decision-making. The need for adequate support, whilst promoting autonomy, was highlighted as vital in supporting professional identity formation within a community of practice, benchmarking clinical knowledge and performance, and in support of student wellbeing, in the face of challenging real-world clinical encounters. Increased entrustment of clinical activity could be implemented in primary and secondary care settings to reproduce the benefits experienced by student vaccinators in front-line roles during the COVID-19 pandemic. Further work might consider how to maximise these benefits and increase inclusion and participation.

Key Considerations When Developing and Implementing Digital Technology for Early Detection of Dementia-Causing Diseases Among Health Care Professionals: Qualitative Study.

The World Health Organization (WHO) promotes using digital technologies to accelerate global attainment of health and well-being. This has led to a growth in research exploring the use of digital technology to aid early detection and preventative interventions for dementia-causing diseases such as Alzheimer disease. The opinions and perspectives of health care professionals must be incorporated into the development and implementation of technology to promote its successful adoption in clinical practice. This study aimed to explore health care professionals' perspectives on the key considerations of developing and implementing digital technologies for the early detection of dementia-causing diseases in the National Health Service (NHS). Health care professionals with patient-facing roles in primary or secondary care settings in the NHS were recruited through various web-based NHS clinical networks. Participants were interviewed to explore their experiences of the current dementia diagnostic practices, views on early detection and use of digital technology to aid these practices, and the challenges of implementing such interventions in health care. An inductive thematic analysis approach was applied to identify central concepts and themes in the interviews, allowing the data to determine our themes. A list of central concepts and themes was applied systematically to the whole data set using NVivo (version 1.6.1; QSR International). Using the constant comparison technique, the researchers moved backward and forward between these data and evolving explanations until a fit was made. Eighteen semistructured interviews were conducted, with 11 primary and 7 secondary care health care professionals. We identified 3 main categories of considerations relevant to health care service users, health care professionals, and the digital health technology itself. Health care professionals recognized the potential of using digital technology to collect real-time data and the possible benefits of detecting dementia-causing diseases earlier if an effective intervention were available. However, some were concerned about postdetection management, questioning the point of an early detection of dementia-causing diseases if an effective intervention cannot be provided and feared this would only lead to increased anxiety in patients. Health care professionals also expressed mixed opinions on who should be screened for early detection. Some suggested it should be available to everyone to mitigate the chance of excluding those who are not in touch with their health care or are digitally excluded. Others were concerned about the resources that would be required to make the technology available to everyone. This study highlights the need to design digital health technology in a way that is accessible to all and does not add burden to health care professionals. Further work is needed to ensure inclusive strategies are used in digital research to promote health equity.

Importance of timely administration of dopaminergic medications to improve Parkinson's patients' clinical outcomes.

This article explores the challenges posed when ensuring the effective management of patients with Parkinson's in the secondary care setting. The evidence base around the appropriate timing and administration of medications is explored and highlights key themes in the literature to support best practice and raise clinical awareness. Failure to follow prescribed treatments for patients with Parkinson's can have significant implications for both patients and nursing care.

Prevalence and awareness of Herpes Zoster Among Saudi Patients with Diabetes Mellitus, A Cross Sectional Study in Al-Ahsa, Saudi Arabia

Background: Herpes zoster (HZ) is a painful vesicular rash that happens when an infection with the varicella-zoster virus in the sensory ganglia is reactivated. The incidence and severity of HZ and its complications increase with advancing age, with a marked increase after 50 years of age. In addition, diabetes mellitus has been found to be a risk factor for severe, persistent postherpetic neuralgia.&#x0D; Methods: This descriptive cross-sectional hospital-based study was conducted in Al-Ahsa City, Eastern Saudi Arabia, in 2023. The study population included patients with DM who visit outpatient (ambulatory care) in primary or secondary health care setting. The convenience sample included 224 participants. A validated closed-ended interview questionnaire was used to collect data. The collected data were analyzed by the SPSS program version 28, and both descriptive and inferential statistics were used.&#x0D; Results: The study included 224 participants, more than half (54.5%) of whom were female. The mean (SD) age of the sample was 61.1 ± 8 years. Most of the participants (97.8%) were married, and 29.0% had a secondary school education level. More than half of the participants (56.7%) had heard of HZ. Only 6.7% had been diagnosed with HZ, and 23.7% knew someone who had been diagnosed with HZ. In addition, 18.8% had been vaccinated against HZ. Most patients (80.8%) cited healthcare providers as their primary source of HZ knowledge, followed by friends/relatives (37.9%). More than half of the participants were aware of HZ (62.1%) and had a positive attitude towards HZ (55.8%) respectively. Awareness of HZ was positively correlated with a higher level of education, a high income, a short duration of diabetes, having heard of HZ, being diagnosed with HZ, knowing someone who had been diagnosed with HZ, and being vaccinated against HZ among diabetic patients.&#x0D; Conclusion: The results revealed low vaccination rates and low awareness of HZ. The study recommends that education in simple language should be provided through various media to increase community awareness about HZ and its vaccine. Additionally, healthcare providers should promote and recommend HZ vaccinations for DM patients.

Perceptions of Barriers to Using Opioid Analgesics: A Mixed Methods Study.

Availability and accessibility of opioids are a worldwide problem. In low-resource settings, such as Ethiopia, access to opioids is either limited or nonexistent and legally restricted in health care settings. This study aimed to identify barriers for the availability and accessibility of opioids in Ethiopian rural and regional health care settings. A mixed-method case study design was used. A total of 220 nurses from primary, secondary, and tertiary health care settings were invited to participate in a survey of knowledge and practice. For the qualitative interview, 38 participants were recruited from educational facilities, health services, and the community across a region. Barriers in availability and accessibility of opioid analgesics were expressing pain considered as a sign of weakness, lack of knowledge, side effect concerns about prescribing morphine, only doctors being authorized to prescribe morphine, lack of foreign currency to import morphine ingredients, and inequity in accessing morphine in hospitals and none in rural health care settings. The findings of this study indicate that opioids, particularly morphine, were not consistently available and accessible to all patients in need. Health professionals lacked knowledge about opioids. Strengthening the existing pain-free initiatives and improving the type, dose, and supply of morphine could help reduce needless suffering and enhance access to essential pain medicines for those in need.

QGenome: a smart app-based clinical decision aid for inherited cardiac conditions

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Guy’s and St Thomas’ Charity South East Genomic Medicine Service Alliance Background QGenome is a smart application designed by a Regional Genetics service, in partnership with a Genomic Medicine Service Alliance (GMSA) and a technology company. The aims were to facilitate streamlined genomic testing, risk assessment, and referral guidance to relevant healthcare professionals in primary, secondary, and tertiary care settings; and to provide equity of "Genomics care" for patients across the UK, through standardized genomic testing and referral pathways. Due to high clinical demand, and following a design workshop with stakeholders, the initial version of QGenome was implemented for Cancer Genomics pathways. The scope has been extended to include workflows for Cardiology and Renal Genomics. The current Inherited Cardiac Conditions (ICC) workflow includes initial genomic testing/risk assessment pathways developed for familial hypercholesterolaemia, long QT syndrome, and vascular Ehlers Danlos Syndrome (vEDS). Methods For each clinical indication/condition, QGenome provides workflow assessments to determine eligibility for genomic testing and/or specialist tertiary referral. The workflow takes the user through a series of questions about their patient’s personal, past medical, and family history in a user-friendly format, to assess inherited susceptibility to disease. Eligibility criteria are derived from the UK National Genomic Test Directory, published literature and guidance from relevant advisory board working groups. The app can be used to find relevant forms, save reports, and activate referrals to specialist services or genetics clinics. QGenome is freely available on iOS, android and web-based platforms. Results The ICC workflows are demonstrated through the vEDS case studies (Figure). Conclusion QGenome offers a quick, efficient clinical decision tool for healthcare professionals, including cardiovascular nurses and allied professionals, in busy clinical settings, to differentiate between patients with likely sporadic cardiac disease and those with probable genetic/hereditary susceptibility for ICC.

Understanding the Impact of COVID-19 on Angioplasty Service and Outcome of Patients Treated for Chronic Limb-Threatening Ischaemia: A Single-Centre Retrospective Cohort Study.

We evaluated the impact of COVID-19 restriction on the angioplasty service and outcome of chronic limb-threatening ischaemia (CLTI) patients undergoing lower-limb angioplasty in a UK secondary care setting. Consecutive patients were analysed retrospectively. Pre-COVID-19 (08/2018-02/2020), 106 CLTI patients (91% Fontaine 4; 60% diabetes mellitus) and during COVID-19 (03/2020-07/2021) 94 patients were treated (86% Fontaine 4; 66% diabetes mellitus). While the average monthly number of patients treated did not change, the proportion of day cases significantly increased (53% to 80%), and hospitalised patients decreased. Patients treated in ≤14/5 days after referral significantly increased to 64/63%. Kaplan-Meier survival analysis (30-day/1-year) showed that neither wound healing nor mortality were significantly changed during COVID-19. In day cases, 1-year but not 30-day major amputations significantly increased, and clinically driven target-lesion revascularisation decreased during COVID-19. One-year mortality was significantly worse in hospitalised compared to day cases (14% vs. 43%) at similar wound healing rates (83% vs. 84%). The most frequent known cause of death was infectious disease (64%), while cardiovascular (21%) was less frequent. Despite COVID-19 restrictions, a safe and effective angioplasty service was maintained while shortening waiting times. Very high mortality rates in hospitalised patients may indicate that CLTI patients need to be referred and treated more aggressively earlier.

Excision of trochanteric bursa during total hip replacement: Does it reduce the incidence of post-operative trochanteric bursitis?

Trochanteric bursitis is a common complication following total hip replacement (THR), and it is associated with high level of disability and poor quality of life. Excision of the trochanteric bursa prophylactically during THR could reduce the occurrence of post-operative trochanteric bursitis. To evaluate whether synchronous trochanteric bursectomy at the time of THR affects the incidence of post-operative trochanteric bursitis. This retrospective cohort study was conducted in the secondary care setting at a large district general hospital. Between January 2010 and December 2020, 954 patients underwent elective primary THR by two contemporary arthroplasty surgeons, one excising the bursa and the other not (at the time of THR). All patients received the same post-operative rehabilitation and were followed up for 1 year. We reviewed all cases of trochanteric bursitis over this 11-year period to determine the incidence of post-THR bursitis. Two proportion Z-test was used to compare incidences of trochanteric bursitis between groups. 554 patients underwent synchronous trochanteric bursectomy at the time of THR whereas 400 patients did not. A total of 5 patients (incidence 0.5%) developed trochanteric bursitis following THR; 4 of whom had undergone bursectomy as part of their surgical approach, 1 who had not. There was no statistically significant difference between the two groups (Z value 1.00, 95%CI: -0.4% to 1.3%, P = 0.32). There were also 8 other patients who had both trochanteric bursitis and hip osteoarthritis prior to their THR; all of whom were treated with THR and synchronous trochanteric bursectomy, and 7 had resolution of their lateral buttock pains but 1 did not. Synchronous trochanteric bursectomy during THR does not materially affect the incidence of post-operative bursitis. However, it is successful at treating patients with known trochanteric bursitis and osteoarthritis requiring THR.

Characteristics of patients with severe asthma in primary and secondary care settings considered eligible for biological therapy - the Bulgarian RECOGNISE study.

Asthma is a major non-communicable disease. It affects both children and adults, but is the most common chronic condition among the former. While inhaled controller drugs stabilize the disease in most asthma patients, there are a certain number of people who suffer from severe asthma, which requires treatment escalation. Oral corticosteroids are usually added, but they are associated with various side effects that may limit their application. The introduction of biologicals targeting inflammatory mediators has opened a new era of asthma treatment highlighting the importance of patient characterization.