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Ear splinting for ear anomalies in infants. Is it worth doing and have we missed the boat? A prospective, cohort study
No full textINTRODUCTION: Ear deformities can cause distress to children as they age, especially with ear deformity surgery not routinely available through the NHS. Ear splinting is a non-surgical method that can obviate the need for surgery; however, it is believed that it can only be provided in the first few weeks of life. There is also little evidence in the literature regarding caregiver-reported outcomes of appearance and adherence. METHOD: Over a 5-year period (2018-2023), pre- and post-splinting questionnaires were provided to caregivers of infants who underwent ear splinting for treatment of congenital ear deformities. Caregiver-reported outcomes assessed the appearance of different anatomical areas of the ear, ease of use, complications and referral pathways. RESULTS: In total, 123 participants were recruited. Following ear splinting, there was a significant improvement in the ratings of appearance (p<0.001), shape (p<0.001) and projection (p<0.001) of the ear. Caregiver ratings of anatomical regions of the pinna also showed significant improvements for the helical rim (p<0.001) and scaphoid fossa (p<0.001). A small number of caregivers encountered difficulty using the splints (5%), which included application of the splints and keeping them clean and dry. Excellent results were reported regardless of age, with the oldest child being one year old, but the duration of splinting positively correlated with age (p<0.05). CONCLUSIONS: Ear splinting showed high satisfaction rates in outcomes and adherence, with a low complication rate. It is still preferable to start ear splinting early, but good results were still being found up to one year of age in this study.RDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted
A qualitative exploration of stressors in anaesthesia training in the UK and mechanisms to improve resident wellbeing
No full textINTRODUCTION: High levels of stress and burnout have been identified among resident anaesthetists in UK training programmes. Factors involving clinical roles, workplace culture and training are known stressors, but in-depth research investigating how to improve wellbeing is limited. METHODS: We used a qualitative design in two phases with participants from across the UK. Phase 1 involved semi-structured interviews of resident anaesthetists in the 2nd-5th years of training, and educational stakeholders. Phase 2 involved additional participants in two focus groups, one each for residents and stakeholders. Interviews and focus groups were conducted online, audio-recorded and transcribed for thematic analysis using a framework approach. RESULTS: We interviewed 52 participants in phase 1, comprising resident anaesthetists from England, Wales and Scotland and key educational stakeholders. A further 11 resident anaesthetists and stakeholders participated in the phase 2 focus groups. We identified four overarching themes contributing to stress: clinical work; non-clinical work; structure of training; and workplace culture. We also identified supportive features at individual, local, regional and national levels. Stress and burnout were commonplace, particularly during demanding periods of training. Balancing non-clinical commitments alongside busy workloads was difficult. Clinically, intensive care medicine and obstetrics generated the most stress. Frequent rotations and long commutes increased stress, impacting on working and family relationships. Curriculum changes, examinations and competition for higher training posts caused stress and poor morale. Proposed mechanisms to improve wellbeing include: peer-to-peer support; request-based rotas; adoption of 'lead employers'; decreasing rotation frequency and commuting distances; access to less than full-time working and professional support; and adapting the structure of training to improve the stability of the resident anaesthetist workforce. DISCUSSION: Attention to the factors identified as contributing to stress could improve resident anaesthetists' wellbeing through changes to policy and practice at local, regional and national levels, for which we make research-informed recommendations.This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.RDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted
Management of post-operative anaemia in patients undergoing surgery for colorectal cancer: a qualitative focus group-based study
No full textBACKGROUND: Optimal management of anaemia following surgery for colorectal cancer remains unclear. Peri-operative anaemia is common in patients undergoing resectional surgery for colorectal cancer. A significant amount of research has been conducted into the management of pre-operative anaemia; however, little work has investigated post-operative anaemia. We intended to investigate the facilitators of and barriers against the standardised correction of post-operative anaemia. These can aid in identifying optimum treatment for patients following surgery for colorectal cancer. METHODS: Four focus groups were held with 29 participants from a multidisciplinary panel of healthcare professionals from two different NHS hospital sites in the UK. The discussions were audio recorded and underwent professional transcription. Transcripts were checked against recordings before undergoing thematic analysis using a realist approach. RESULTS: Four themes were identified. The key barriers to standardised post-operative anaemia correction were a lack of protocoled guidelines or a defined pathway, insufficient education and training, and systemic barriers, such as financial drivers and drug availability. The key facilitator identified was collaboration and communication. DISCUSSION: This study has identified several key barriers and thresholds which can be used in future studies to improve the standardised management of post-operative anaemia.RDUH staff can access the full-text of this article by clicking on the 'Additional Link' above and logging in with NHS OpenAthens if prompted
A systematic review of short- compared with standard-length Exeter stems in primary total hip arthroplasty
No full textAIMS: The Exeter femoral stem has a cemented, polished taper-slip design, and an excellent track record. The current range includes short-length options for various offsets, but less is known about the performance of these stems. The aim of this study was to compare the survival of short-length stems with standard-length Exeter stems. METHODS: A systematic review of all studies reporting the use of short-length Exeter stems in primary total hip arthroplasty (THA) was undertaken. Survival data, the indication for revision, and patient-reported outcomes were gathered from observational and randomized studies. Studies based on registry data were analyzed separately. RESULTS: The review included nine studies which covered a total of 2,190 short stems. The mean follow-up was 6.4 years (2 to 12) with an all-cause survival of 95.4%. When revisions due to aseptic acetabular loosening were excluded, the survival was 97.7%. Four stems fractured (0.18%). The mean Oxford Hip Score improved from 18.29 (1.33 to 21.6) preoperatively to 41.59 (32.9 to 43.4) at final follow-up. Three studies used data from national registries. A total of 25,895 short stems (offset ≤ 35.5 mm) were used compared with 336,218 standard-length stems. In these studies, short stems had a hazard ratio (HR) for all-cause survival of 1.19 (95% CI 0.96 to 1.43) with a rate of revision per 1,000 component-years of 0.037 compared with 0.035 for standard-length stems. One study from the New Zealand Joint Registry divided short stems into standard and small offset groups. Standard offset short stems (≥ 37.5 mm) had a 0.84 HR (95% CI 0.38 to 1.88) while small offset short stems (≤ 35.5 mm) had a 1.6 HR compared with standard stems (95% CI 1.3 to 1.98). CONCLUSION: Short Exeter stems perform well and are a safe femoral component in primary THA, according to the current literature. There does not appear to be an increased risk of implant fracture associated with these stems.Not hel
Supporting the bereaved child in the adult ICU: a narrative review
No full textChildhood bereavement is a significant issue globally, affecting millions of children each year, with incidence rates significantly increasing following the COVID-19 pandemic. The loss of an important adult, particularly in the ICU environment, can lead to lasting psychological and behavioural challenges for children. While family-centred practices in the ICU have advanced, the unique bereavement needs of grieving children in the family remain insufficiently addressed. Both families and healthcare professionals (HCPs) often feel unprepared and uncomfortable engaging in honest, supportive conversations with children about bereavement, further complicating children's grief processing. This narrative review examines the pivotal role ICU HCPs can play in facilitating child-centred bereavement support, focusing on promoting honest communication, supportive visitation practices, creating a child-friendly and humanised ICU environment, and encouraging child involvement during end-of-life care. It recommends prioritising research on the lived experiences of bereaved children, caregivers, and ICU HCPs to inform targeted interventions addressing children's developmental and psychological needs during ICU bereavement. The review also advocates for specialised training to equip ICU staff with the necessary skills to support grieving children and families. Developing comprehensive, child-centred ICU bereavement guidelines will provide evidence-based frameworks that recognise children as integral family members during end-of-life care while advocating for the participation of children in meaningful rituals will empower families to make informed decisions about their involvement. Together, these recommendations aim to create a more compassionate, inclusive, and supportive bereavement experience in ICU settings, prioritising the unique needs of children and promoting healthy emotional adjustment after losing an important adult.You have full access to this open access articleJournal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text
Experiences of the Management of Uncertainty Amongst Musculoskeletal First Contact Practitioners Working in Primary Care
No full textAIM: To develop a deeper understanding of strategies used to manage uncertainty by Musculoskeletal First Contact Practitioners (MSK FCPs), including barriers to and facilitators for these strategies. BACKGROUND: MSK FCP services provide patients with an alternative to seeing their GP regarding MSK complaints. Research suggests that the role demands different skills and attributes from traditional physiotherapy roles, including the ability to deal with greater clinical uncertainty. There is a lack of research evaluating the strategies FCPs find most helpful for managing uncertainty. METHOD: A qualitative study using semi-structured online interviews. Participants were recruited using convenience sampling. Data was analysed using Braun & Clarke's reflexive approach to thematic analysis. The research was underpinned by a theoretical framework of hermeneutic phenomenology. FINDINGS: Nine participants were recruited. Three main themes were developed: (1) Being comfortable with being uncomfortable; (2) Teamwork makes the dream work and (3) Navigating uncertainty with patients. CONCLUSION: This study provides further insight into how FCPs manage uncertainty. Management of uncertainty was influenced by many factors, including: clinician experience, patient complexity and wider medical knowledge, fear of over-medicalising patients, communication and consultation styles and having protected non-clinical time. Recommendations for clinical practice include: consideration of the challenges facing FCPs, and what support is needed to maintain staff retention, health and wellbeing; consideration of how FCPs might best approach meeting the needs of an ageing population and supporting change in health and wellness behaviour. The key to successful management of uncertainty was having a supportive team which encouraged open non-judgemental discussions about uncertainty.This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text
A novel, dominant disease mechanism of distal renal tubular acidosis with specific variants in ATP6V1B1
No full textBACKGROUND AND HYPOTHESIS: ATP6V1B1 encodes a subunit of the vacuolar H+-ATPase and pathogenic variants are associated with autosomal recessive distal renal tubular acidosis (dRTA) with deafness. Heterozygous variants predicted to affect a specific amino acid, Arg394, have been recurrently reported in dRTA but their significance has been unclear. We hypothesised that these variants are associated with a dominant disease mechanism. METHODS: Retrospective analysis of cases identified in our genetic laboratories and through European nephrology organisations. Data regarding demographics, clinical presentation, laboratory findings, hearing and imaging studies of kidneys were collected from the index patient and, if available, from other family members. The potential disease mechanism was investigated through structural modelling in silico. RESULTS: Twenty index patients in total were included, of which 19 carried the variant c.1181G>A; p.(Arg394Gln) and one c.1180C>G; p.(Arg394Gly). In 7 families, more than one member was affected and the variant segregated with the disease in those with available information (15 affected, 6 unaffected), except for the unaffected mother of 2 affected children, who was mosaic. In no patient was a second causative variant in trans identified. In 8 sporadic patients and 1 affected parent, the variant was confirmed to be de novo. Both variants are absent in gnomAD. Sensorineural hearing loss was reported in 8 of the 22 patients with available information. Structural modelling supports a crucial role for Arg394 in nucleotide binding. CONCLUSION: We provide strong evidence for the pathogenicity of heterozygous variants affecting Arg394 and thus a novel inheritance modus for ATP6V1B1-associated dRTA. Clinically, this form differs from the recessive one by the lower prevalence of hearing loss. The prominent position of Arg394 in the nucleotide binding fold of the H+-ATPase structure is consistent with a dominant negative mechanism. Our findings inform the diagnosis and management of patients with dRTA and variants of Arg394.This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)New Full Text unavailable for 1 year from time of publication. Please click an article to explore additional access options
Mapping the Microbial Landscape and Variations Based on Biological Sex, Age and Biopsy Location in the Shoulder Skin Microbiome
No full textBACKGROUND: The organisms responsible for periprosthetic joint infections (PJI) of the shoulder are often skin pathogens originating from the patient's own skin flora at the time of surgery. Understanding the normal skin flora around the shoulder is an important step to identify the range of organisms that could be responsible for PJI, and ensure optimization of culture mediums to identify them. This study aimed to provide the first description of the shoulder skin microbiome using high-throughput next-generation sequencing methodology, and explore variations by age, biological sex and biopsy location. METHODS: Patients undergoing arthroscopic surgery were approached for informed consent to have punch biopsies taken from anterior, lateral and posterior arthroscopy portal sites. DNA extraction was undertaken followed by Illumina sequencing, focusing on the V3-V4 regions of the 16S rRNA gene. Amplicon sequence variants (ASV) were generated using Deblur workflow and used for taxonomic assignment. Variation in the microbiota community based on age, biological sex and biopsy location was assessed through alpha and beta diversity metric calculations using phyloseq R package. RESULT: Sixty-two patients (24 female, 38 male) aged 18 to 80 were recruited, resulting in 186 punch biopsy samples for analysis. Following removal of low-prevalence taxa, 606 ASVs were aggregated at genus level resulting in 214 genera across 13 phyla. The top 20 most abundant genera accounted for 73.5% of the overall sequence count. Cutibacterium was the most abundant genus within the study population, followed by Ralstonia, Staphylococcus, Bacteroides and Streptococcus. Significant differences were observed in beta diversity metrics when comparing by biological sex, which accounted for 3.9%-5.3% of variation in the microbial community, but not age or biopsy location. Males displayed a greater proportion of Gram-positive and aerobic bacteria while females exhibited a greater proportion of Gram-negative and stress tolerant bacteria. CONCLUSION: This is the first study to look specifically at the microbiome of the cutaneous shoulder and describe the most abundant genera and compositional differences based on age, biological sex and biopsy location. Biological sex was the only host co-variant studied which reached significance in explaining microbiota variation. The top 20 most abundant genera, accounting for 74% of the overall sequence count, would be isolated with standard microbiological culture. As such this study does not highlight a need to change current culture investigation practice for shoulder PJI, but serves as an important catalogue of skin commensals around the operative site in shoulder surgery.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text
Clinical and socio-demographic characteristics of people with multiple sclerosis at the time of diagnosis: Influences on outcome trajectories
No full textBACKGROUND: It has long been accepted that multiple sclerosis (MS) is heterogenous regarding presentation and disease course, so that outcomes are diverse; however, there is less data on variation in the immediate period after diagnosis. METHODS: Our objective was to identify the clinical and demographic factors present at diagnosis. Two cohorts were compared from the Trajectories of Outcome in Neurological Conditions-MS study: those joining within one year of diagnosis (inception cohort) compared to 9-11 years following diagnosis (decade cohort). Patient reported outcome data were fitted to the Rasch model to yield interval estimates, longitudinal data were analysed by group-based trajectory models. RESULTS: The inception cohort (n = 813) showed impact on fatigue, disability, health status and quality of life (QOL), although as expected, less than the decade cohort (n = 679), who also had more depressive symptoms. The average trajectory of health status was deceptive, as analysis showed two distinct groups, 13.8 % having much poorer health status, sustained for at least 3 years from diagnosis. Similarly, there were distinct groups with different trajectories identified for disability and QOL. These groups varied for depression, anxiety, sleep problems, employment, comorbidities, smoking history, and deprivation indices, highlighting influences prior to diagnosis. CONCLUSIONS: MS care must be personalised from diagnosis; service design should account for those people with MS experiencing poor health status from diagnosis. Basing capacity planning on average trajectories would be misleading. Furthermore, this evidence shows that service provision to support symptom management and disability clearly needs to be resourced from the diagnostic year.This is an open access article distributed under the terms of the Creative Commons CC-BY license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Journal content freely available via Open Access. Some content may be unavailable due to publisher embargo. Click on the 'Additional link' above to access the full-text
Implementation of a national AI technology program on cardiovascular outcomes and the health system
No full textCoronary artery disease (CAD) is a major cause of ill health and death worldwide. Coronary computed tomographic angiography (CCTA) is the first-line investigation to detect CAD in symptomatic patients. This diagnostic approach risks greater second-line heart tests and treatments at a cost to the patient and health system. The National Health Service funded use of an artificial intelligence (AI) diagnostic tool, computed tomography (CT)-derived fractional flow reserve (FFR-CT), in patients with chest pain to improve physician decision-making and reduce downstream tests. This observational cohort study assessed the impact of FFR-CT on cardiovascular outcomes by including all patients investigated with CCTA during the national AI implementation program at 27 hospitals (CCTA n = 90,553 and FFR-CT n = 7,863). FFR-CT was safe, with no difference in all-cause (n = 1,134 (3.2%) versus 1,612 (2.9%), adjusted-hazard ratio (aHR) 1.00 (0.93-1.08), P = 0.97) or cardiovascular mortality (n = 465 (1.3%) versus 617 (1.1%), aHR 0.96 (0.85-1.08), P = 0.48), while reducing invasive coronary angiograms (n = 5,720 (16%) versus 8,183 (14.9%), aHR 0.93 (0.90-0.97), P < 0.001) and noninvasive cardiac tests (189/1,000 patients versus 167/1,000), P < 0.001). Implementation of an AI-diagnostic tool as part of a health intervention program was safe and beneficial to the patient pathway and health system with fewer cardiac tests at 2 years.CC BY 4.0 (Creative Commons Attribution