Midlands Evidence Repository
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From gastrointestinal upset to neuromuscular collapse
No full texthttps://pn.bmj.com/content/early/2024/11/07/pn-2024-00435
The impact of urinary and bowel incontinence: psychological and physical effects and interventions
No full textThis clinical review explores the multifaceted impact of urinary and bowel incontinence on the physical and psychological wellbeing of individuals, particularly older adults. The psychological effects, which often include anxiety, depression and social isolation, are addressed through interventions such as cognitive behavioural therapy and peer support groups, which are crucial for alleviating the emotional burden. The review also examines conservative management strategies, such as pelvic floor muscle training, bladder retraining and dietary changes, as well as discussing pharmacological treatments and surgical options for more severe cases. A key emphasis is placed on the importance of a multidisciplinary approach and incorporating the expertise of continence nurses, physiotherapists, occupational therapists and psychologists to comprehensively address patient needs.https://www.magonlinelibrary.com/doi/abs/10.12968/gasn.2024.009
An investigation into the acceptability of the SAFER-YMH care bundle for transitions out of CAMHS crisis and liaison services
No full textAims. The NHS long-term plan focuses on the improvement of Child and Adolescent Mental Health (CAMHS) community services including the roll out of 24/7 Crisis teams universally across the country. Crisis and Liaison teams form an important alternative to inpatient admission, offering intense, short-term support to young people in mental health crisis and often high levels of risk. The number of referrals to Crisis and Liaison services are rising. In order to maintain patient flow and meet demand, these teams also need safe, evidence-based protocols for efficient discharge, transition and handover of young people to community teams and services. The SAFER care bundle was designed to facilitate discharges from hospital, and this has been adapted to the SAFER-YMH bundle for discharges from adolescent mental health wards. A similar care bundle for discharge from teams offering alternatives to inpatient care has not yet been developed. This study aimed to investigate the acceptability and necessary adaptations required for the use of the SAFER-YMH care bundle to facilitate transitions out of CAMHS Crisis and Liaison teams. Methods. This study used stakeholder feedback from multiple sources through focus groups to adapt the SAFER-YMH care bundle for use in young people in transitions out of CAMHS Crisis and Liaison teams. Normalisation process theory was utilised as the theoretical foundation upon which the development of the adapted care bundle, and its potential implementation in the complex multifaceted healthcare landscape was based. Results. Initial focus groups were held with young people, parents/ carers, healthcare professionals from CAMHS crisis and liaison teams, CAMHS NHS management, NHS IT services, community CAMHS teams and NHS commissioners in two trusts in England. Following each focus group adaptations were made to the care bundle in an iterative manner. In the second round of focus groups, the adapted care bundle was presented to a mixed group of participants and agreed to be acceptable. Conclusion. Through stakeholder feedback this study has adapted the SAFER-YMH to create the SAFER-YCL care bundle; an acceptable version for use in discharges from CAMHS crisis and liaison services. End-user design and involvement is vital in the development of clinical applications and pathways which are user-friendly and time-Saving for healthcare professionals and also helpful for young people and their families.https://www.cambridge.org/core/journals/bjpsych-open/article/an-investigation-into-the-acceptability-of-the-saferymh-care-bundle-for-transitions-out-of-camhs-crisis-and-liaison-services/636F580F08EA72C9CE3E2B6ABFA5CD0
Quality improvement project on standardising GP discharge summaries in liaison psychiatry services for older people in Nottinghamshire Healthcare NHS Trust
No full textAims. Discharge letters to general practitioners (GPs) are pertinent in summarising patients' care in secondary healthcare settings and communicating follow-up management plans for continuity of care. 26 GPs from 13 GP surgeries in the West Midlands thought that discharge letters lacked important information and standardisation. We developed a quality improvement (QI) project to standardise GP discharge summaries within the liaison psychiatry services for older people in Nottinghamshire Healthcare NHS Trust. We aimed to ensure that 100% of GP discharge letters are written in a standardised format and meet the mandatory subheadings within six months. Methods. A comprehensive literature search was performed, and we invited six GPs across Nottinghamshire to comment on the quality of anonymised discharge summaries written by our colleagues. After discussing the findings with our stakeholders, we developed a new discharge summary template with the subheadings of 'Reason for Liaison Psychiatry Involvement', 'Summary', 'Diagnosis (if applicable)', 'Risk Formulation', and 'Treatment or Plan of Action'. We held a team meeting and distributed a guidance document with scoring criteria for each subheading for our clinical colleagues to practise for two weeks. Subsequently, 75 discharge summaries were randomly selected and independently scored across seven weeks by an internal team member and an external QI data analyst to improve inter-rater reliability. 98 discharge summaries written six weeks before the new letter template was introduced were retrospectively scored for baseline measurement. Results. At baseline, the discharge summary scores ranged between 6 and 20 (out of a maximum of 20), depending on the individual completing them. The mean score was 12.3. The implementation of the new discharge summary template improved the mean score to 19.0, irrespective of the author. The mean score was consistent across seven weeks. Most of our colleagues did not face significant challenges in learning a new style of writing and for some, a standardised template reduced administrative time. The same GPs reviewed the new set of anonymised discharge summaries and were satisfied with the new summary format. Conclusion. Formulating a standardised discharge summary template which adhered to professional guidelines was pivotal in improving the quality of GP discharge summaries. GP involvement throughout the project convinced stakeholders and colleagues to commit to a new writing template and tremendously helped achieve our project aim.https://www.cambridge.org/core/journals/bjpsych-open/article/quality-improvement-project-on-standardising-gp-discharge-summaries-in-liaison-psychiatry-services-for-older-people-in-nottinghamshire-healthcare-nhs-trust/2921A5FC2A15FC77B2C09129360AB94
Phenotypic features determining visual acuity in albinism and the role of amblyogenic factors
No full textAlbinism is a spectrum disorder causing foveal hypoplasia, nystagmus, and hypopigmentation of the iris and fundus along with other visual deficits, which can all impact vision. Albinism is also associated with amblyogenic factors which could affect monocular visual acuity. The foveal appearance in albinism can range from mild foveal hypoplasia to that which is indistinguishable from the peripheral retina. The appearance can be quickly and easily graded using the Leicester Grading System in the clinic. However, interquartile ranges of 0.3 logMAR for the grades associated with albinism limit the accuracy of the grading system in predicting vision. Here, we discuss the potential role of nystagmus presenting evidence that it may not be a major source of variability in the prediction of visual acuity. We also show that interocular differences in visual acuity are low in albinism despite high levels of amblyogenic factors indicating that active suppression of vision in one eye in albinism is uncommon.https://iovs.arvojournals.org/article.aspx?articleid=279335
A call for new theories on the pathogenesis and pathophysiology of endometriosis
No full texthttps://www.jmig.org/article/S1553-4650(24)00073-6/fulltex
Resistant anemia in a kidney transplant recipient: pure red cell aplasia due to parvovirus B19 infection
No full textAnemia in kidney transplant recipients can stem from a diverse array of etiologies, including dietary deficiencies, inflammatory processes, allograft dysfunction, as well as viral and bacterial infections. We present a case of refractory anemia in a 49-year-old male patient occurring within the initial month following a kidney transplant, which persisted despite numerous transfusions, posing a formidable challenge. The patient was maintained on the standard immunosuppressant regimen-Tacrolimus, Mycophenolate, and Prednisolone. Diagnostic evaluations eliminated well-established causes such as dietary deficiencies, gastrointestinal losses, and prevalent infections. Subsequently, after viral PCR testing, a diagnosis of Pure Red Cell Aplasia (PRCA) due to infection with parvovirus B19 was made. Although the patient had a reduction in the immunosuppression drugs and received a course of Intravenous Immunoglobulins (IVIG) on two separate occasions spanning two months, the anemia relapsed. Subsequently, after an additional dose of IVIG with further modification and reduction of the immunosuppressant regimen, including stopping the mycophenolate and switching tacrolimus with cyclosporine, the patient ultimately achieved successful resolution of his symptoms and a significant decrease in viral load. Our case highlights the significance of unconventional etiologies when confronted with anemia in the setting of kidney transplantation. Furthermore, it also provides further insights into therapeutic avenues for addressing PRCA in kidney transplant recipients.https://www.qscience.com/content/journals/10.5339/qmj.2024.
The Difficulties of Managing Pain in People Living with Frailty: The Potential for Digital Phenotyping.
Get PDFPain and frailty are closely linked. Chronic pain is a risk factor for frailty, and frailty is a risk factor for pain. People living with frailty also commonly have cognitive impairment, which can make assessment of pain and monitoring of pain management even more difficult. Pain may be sub-optimally treated in people living with frailty, people living with cognitive impairment and those with both these factors. Reasons for sub-optimal treatment in these groups are pharmacological (increased drug side effects, drug–drug interactions, polypharmacy), non-pharmacological (erroneous beliefs about pain, ageism, bidirectional communication challenges), logistical (difficulty in accessing primary care practitioners and unaffordable cost of drugs), and, particularly in cognitive impairment, related to communication difficulties. Thorough assessment and characterisation of pain, related sensations, and their functional, emotional, and behavioural consequences (“phenotyping”) may help to enhance the assessment of pain, particularly in people with frailty and cognitive impairment, as this may help to identify who is most likely to respond to certain types of treatment. This paper discusses the potential role of “digital phenotyping” in the assessment and management of pain in people with frailty. Digital phenotyping is concerned with observable characteristics in digital form, such as those obtained from sensing-capable devices, and may provide novel and more informative data than existing clinical approaches regarding how pain manifests and how treatment strategies affect it. The processing of extensive digital and usual data may require powerful algorithms, but processing these data could lead to a better understanding of who is most likely to benefit from specific and targeted treatments.https://link.springer.com/article/10.1007/s40266-024-01101-
Survival differences in rheumatoid arthritis interstitial lung disease and idiopathic pulmonary fibrosis may be explained by delays in presentation: results from multivariate analysis in a monocentric UK study
No full textRheumatoid arthritis-associated interstitial lung disease (RA-ILD) has a better prognosis compared to idiopathic pulmonary fibrosis (IPF). Recent data suggest that antifibrotics are effective in slowing progression across both groups. Hence, we designed this study to investigate the similarities and differences between these groups of patients. This is a retrospective cohort study examining baseline data, progression and outcomes in patients with RA-ILD and IPF prior to antifibrotic use in the Coventry ILD database. Ethics approval was obtained from the University Hospital Coventry and Warwickshire NHS Trust. Statistical analysis was performed using R software and Cox's proportional hazards technique was used for survival analysis. We identified 131 cases, including 49 patients with IPF, 34 patients with RA-ILD and 48 patients with other forms of idiopathic interstitial pneumonia. At baseline, there were significant differences in the groups with RA-ILD patients being significantly younger (65.7 vs 72.4 years), had preserved lung volumes (FVC 95% vs 84.7%) and higher gas transfer (61.5% vs 48.2%) compared to IPF patients. 5-year survival was better for RA-ILD compared to IPF (87.5% vs 40.4%, p = 0.0042). Univariate analysis revealed gas transfer, FVC, age, sex and phenotype (IPF or RA-ILD) were all significant predictors, but multivariate analysis revealed that gas transfer and age were both significantly associated with prognosis, whereas sex, FVC or phenotype were not significant. This study suggests that the difference between RA-ILD and IPF prognosis may be due to demographics and early diagnosis rather than the diseases behaving differently. This has important management implications.https://link.springer.com/article/10.1007/s00296-023-05505-
Advances in the treatment of keratoconus: Epithelial-On (EPI-On) Corneal-Collagen Cross-Linking (CXL) and CXL-Plus Procedures
No full textKeratoconus (KC) incidence is on the increase. The advent of corneal-collagen cross-linking (CXL) has revolutionized the management of KC. This systematic review looks at the efficacy and complications of two novel treatments within CXL: Epithelial-On (Epi-On) and CXL-plus procedures. Two separate literature searches were carried out up until July 1, 2021. Articles only published in the last two years were included to ensure that only the most recent articles were reviewed. A total of 15 articles were selected for this review. There were varied results regarding the efficacy of Epi-On. No significant difference was found between Epi-On and standard Epithelial-Off (Epi-Off) CXL. However, it was found that Epi-On was inferior to standard CXL in terms of reducing KMAX. There was a higher risk of progression in patients treated with Epi-On CXL, with an increased rate of patients requiring re-treatment due to the advancement of their KC. While some studies report CXL-plus procedures demonstrate long-term efficacy and safety, a considerable number of studies advise caution, reporting a significant deterioration in corrected distance visual acuity (CDVA). Consequently, a question persists regarding the safest and most efficacious approach, given the lack of robust large randomized controlled trials (RCTs) in the current literature.https://www.cureus.com/articles/217478-advances-in-the-treatment-of-keratoconus-epithelial-on-epi-on-corneal-collagen-cross-linking-cxl-and-cxl-plus-procedures#!