565 research outputs found
Recommended from our members
Historical title, self-determination and the Kashmir question ::changing perspectives in international law /
No full textIn Historical Title, Self-Determination and the Kashmir Question Fozia Nazir Lone offers a critical re-examination of the Kashmir question. Through an interdisciplinary approach and international law perspective, she analyses political practices and the substantive international law on the restoration of historical title and self-determination. The book analytically examines whether Kashmir was a State at any point in history; the effect of the 1947 occupation by India/Pakistan; the international law implications of the constitutional incorporation of this territory and the ongoing human rights violations; whether Kashmiris are entitled to restore their historical title through the exercise of self-determination; and whether the Kashmir question could be resolved with the formation of international strategic alliance to curb danger of spreading terrorism in Kashmir
The Role of Targeted HIV Screening in the Emergency Department: A Scoping Review
Full text linkBACKGROUND: Human immunodeficiency virus (HIV) infection continues to expand worldwide and a significant proportion of infection is still undiagnosed. Recent studies have addressed the impact and feasibility of 'opt-out' HIV screening in Emergency Departments (EDs) in urban settings at high HIV prevalence, whereas little is known about the yield of implementing 'targeted' HIV testing especially in low-prevalence areas.OBJECTIVE: The present study undertakes a scoping review of research carried out on the implementation of targeted HIV screening in adult EDs to determine the impact, feasibility and acceptability of HIV testing in different HIV prevalence settings.DESIGN: Online databases (EMBASE, MEDLINE) were used to identify papers published between 2000 to 2020. A threeconcept search was employed with HIV (HIV, Human immunodeficiency virus infection, HIV infections), targeted testing (Target, screening or testing) and emergency medicine (Emergency Service, emergency ward, A&E, accident and emergency or Emergency Department) (28th February 2020). Only full-text articles written in English, French, Spanish or Italian and using impact and/or feasibility and/or acceptability of the program as primary or secondary outcomes were analysed.RESULTS: The search returned 416 articles. Of these, 12 met inclusion criteria and were included in the final review. Most of the included studies were carried out in the United States (n=8; 67%) and in areas of high HIV prevalence (n=11; 92%). Three (20%) were randomized control studies. While the rate of newly diagnosed HIV cases varied widely (0.03-2.2%), likely due to methodological heterogeneity between studies, the linkage of new HIV diagnosis was often high (80-100%) and median CD4+ cell count was always greater than 200 cells per microliter. Targeted HIV screening was found to be cost-effective (out of 2 studies) and well accepted by participants (out 2 studies).CONCLUSIONS: Targeted HIV screening at the ED can be impactful, feasible and well accepted, but often requires extra funding and staff. Most previous work has focused on areas of high disease prevalence
sj-docx-1-inc-10.1177_17511437241230260 – Supplemental material for Association between critical care admission and chronic medication discontinuation post-hospital discharge: A retrospective cohort study
No full textSupplemental material, sj-docx-1-inc-10.1177_17511437241230260 for Association between critical care admission and chronic medication discontinuation post-hospital discharge: A retrospective cohort study by Charvi Kanodia, Richard S Bourne, Elizabeth T Mansi and Nazir I Lone in Journal of the Intensive Care Society</p
Supplemental Material - GEospatial aNalysis of ExtRacorporeal membrane oxygenATion in Europe (GENERATE)
No full textSupplemental Material for GEospatial aNalysis of ExtRacorporeal membrane oxygenATion in Europe (GENERATE) by Stuart Gillon, Chunyu Zheng, Zhiqiang Feng, Marcelcel Fleig, Tommaso Scquizzato, Jan Belohlavek, Roberto Lorusso, Nazir Lone, and Justyna Swol in Perfusion</p
INC900099 Supplemental Material - Supplemental material for Community prescribing of potentially nephrotoxic drugs and risk of acute kidney injury requiring renal replacement therapy in critically ill adults: A national cohort study
No full textSupplemental material, INC900099 Supplemental Material for Community prescribing of potentially nephrotoxic drugs and risk of acute kidney injury requiring renal replacement therapy in critically ill adults: A national cohort study by Steven Tominey, Alan Timmins, Robert Lee, Timothy S Walsh and Nazir I Lone in Journal of the Intensive Care Society</p
sj-docx-1-inc-10.1177_17511437231223470 – Supplemental material for Psychotropic prescribing after hospital discharge in survivors of critical illness, a retrospective cohort study (2012–2019)
No full textSupplemental material, sj-docx-1-inc-10.1177_17511437231223470 for Psychotropic prescribing after hospital discharge in survivors of critical illness, a retrospective cohort study (2012–2019) by Elizabeth T Mansi, Christopher T Rentsch, Richard S Bourne, Bruce Guthrie and Nazir I Lone in Journal of the Intensive Care Society</p
The experience of bedside nurses delivering and intensive care sedation study: a process evaluation within the A2B study
No full textProcess Evaluation of the A2B randomised controlled trial: an exploration of the factors influencing successful implementation, delivery, and outcomes in an intensive care sedation study
No full textBackground: choice of sedation of critically ill patients is a core element of intensive care practice. The A2B trial tested the effectiveness of two alpha agonist sedatives versus propofol in reducing time on mechanical ventilation in 38 intensive care units (ICUs) in the United Kingdom (UK). To evaluate both how this complex trial was implemented and how this may have influenced trial outcomes, an understanding of the contextual and practice variation across multiple sites was required. Aim and Objectives: the aim of this process evaluation of the A2B trial was to determine how the intervention was delivered, the extent to which it was delivered as intended, and the impact this had on outcomes. Specifically, we aimed to: 1. Establish the degree to which the A2B intervention was delivered as intended, specifically in relation to fidelity, dose and reach across patients. 2. Understand factors that impacted on successful delivery of both the A2B intervention and trial, in relation to attitudes and perceptions of staff, including context and standard care. Design and methods: a mixed-methods, multi-phase design was used following extensive pre-trial exploration of current practice. Quantitative data were drawn from the main trial database covering 38 sites to assess the intervention’s fidelity, dose and reach in each site. Data were analysed descriptively and provided a low-moderate-high rating. Qualitative data were collected by interviews mid-trial (phase 1) and end of trial (phase2). Participants were recruited from a random sample of 30 ICUs active at the time of sampling and included the principal investigator, research nurses and clinical staff. Semi-structured interviews, informed by the trial’s logic model, lasted 45 – 60 minutes. Data collection focused on whether the intervention could be delivered as intended, factors that impacted upon successful delivery and understanding intervention adherence. Analysis used a framework approach based on the logic model. Data collection and qualitative analyses were completed prior to knowing the primary results of the trial. Results: site intervention adherence ratings for fidelity, dose and reach were low (4), moderate (20) and high (14). Participants from 12 ICUs in each of Phase 1 (33 staff) and 2 (36 staff) provided qualitative data; participating ICUs differed between phases. Factors identified in Phase 1 focused on intervention delivery and trial conduct and incorporated both organisational and participant-related factors. In Phase 2 participant-related factors included clinician preference, individual equipoise, clinician resistance and staff capability and capacity, while A2B trial-related factors included concerns relating to safety and side effects, overnight deep sedation practice, patient comfort and trial documentation. Many of these factors were impacted by the COVID-19 pandemic, particularly in regard to staffing numbers and experience. Limitations: due to the impact of the COVID-19 pandemic most data collection occurred remotely through video-conferencing rather than planned at site observation and interviews. Conclusion: optimal sedation practice is influenced by multiple factors related to clinician perceptions, capacity and capability. Priorities in care focus on short term safety and comfort. Limitations in staffing mean that longer term consequences related to recovery and rehabilitation are second tier considerations. Future work: findings highlight the multiple contextual factors, including both organisational and participant-related characteristics, that should be considered when planning both clinical trials and changes to routine care. Multiple strategies for achieving behaviour change when implementing complex interventions are essential
Supplemental material for The association between ICU admission and emergency hospital readmission following emergency general surgery
No full textSupplemental Material for The association between ICU admission and emergency hospital readmission following emergency general surgery by Michael A Gillies, Sadia Ghaffar, Ewen Harrison, Catriona Haddow, Lorraine Smyth, Timothy S Walsh, Rupert M Pearse and Nazir I Lone in Journal of the Intensive Care Society</p
Incidence of and risks associated with psychotropic prescribing after critical care in the United Kingdom
Full text linkBackground
Mental health problems and insomnia affect up to half of all critical care survivors within a
year of hospital discharge. Such conditions contribute to increased morbidity and mortality
observed in survivors. Studies undertaken in Canada, the Netherlands, and Sweden have
shown that psychotropic medicines such as anxiolytics and hypnotics (e.g., benzodiazepines
and z-drugs) are commonly prescribed to intensive care unit (ICU) survivors after hospital
discharge, but there is limited evidence on the safety of such prescriptions in survivors. My
PhD work is comprised of four retrospective studies which examined community prescribing to
adults following hospitalisation for critical care. The studies: 1) described psychotropic
prescribing patterns in Lothian, Scotland from 2012–2019; 2) estimated the association of
critical care and new psychotropic prescribing in hospitalised survivors; 3) assessed patient
factors associated with new benzodiazepine or z-drug prescribing; and 4) estimated the risk of
rehospitalisation and death associated with benzodiazepine and z-drug prescribing after
critical care. I performed all data cleaning, analyses, and visualisations in R.
Descriptive study
The aim of my first study was to describe patterns of community psychotropic prescribing after
hospitalisation for critical care in Lothian, Scotland from 2012–2019. I found that one-third
(33.7%) of survivors were prescribed psychotropic medicines within 90 days of hospital
discharge (25.4% antidepressants; 14.8% anxiolytics/hypnotics; and 4.3% antipsychotics/mania
medicines). Prescribing patterns did not vary extensively over the study period. I also
examined prescriptions by subgroup and generic name. Serotoninergic antidepressants (48%)
were the most common antidepressant prescribed. Benzodiazepines (71%) were the most
common anxiolytic/hypnotic prescribed (particularly diazepam (47.5%)). Lastly, second-generation antipsychotics (62%) were the most frequently prescribed subgroup of
antipsychotic/mania medicines.
Cohort studies
The primary aim of my first analytic cohort study was to examine the association of critical
care and community psychotropic prescribing, by comparing critical care survivors to non-critical care hospitalised survivors using multivariable Cox regression. Among patients without
psychotropic prescriptions within 180 days prior to hospitalisation, the critical care group had
a higher incidence of psychotropic prescribing within 90 days of hospital discharge (10.3%;
1610/15,609) compared with the non-critical care group (3.2%; 9743/307,429); unadjusted
hazard ratio (HR) 3.39, 95%CI 3.22–3.57. After adjustment for potential confounders, the risk
remained elevated (adjusted HR 2.03, 95% confidence interval (CI) 1.91–2.16) and persisted
later in follow-up (90–365 day; adjusted HR 1.38, 95%CI 1.30–1.46).
The focus of my second cohort study was restricted to benzodiazepine and z-drug prescribing. I
examined patient characteristics and practice variation associated with new community
benzodiazepine or z-drug prescriptions in critical care survivors without pre-admission
prescribing. Patient characteristics assessed included sociodemographic information, medical
history, and in-hospital factors. Using the UK Clinical Practice Research Datalink (CPRD) Aurum
datasets of adults hospitalised in 2010 and 2018, I performed multilevel multivariable logistic
regression for new (any prescription within 90 days) and for new-and-persistent (2+
prescriptions within 180 days) benzodiazepine or z-drug prescribing, as well as evaluated
variation by primary care practice. I found that 5.2% (2769/52,846) of treatment-naïve
survivors were prescribed a benzodiazepine or z-drug after hospital discharge, with almost half
of those having new-and-persistent prescribing (2.5% of total, 1311/52,846). Zopiclone was
the most common drug prescribed (50%) followed by diazepam (19%). A history of insomnia
(adjusted odds ratio (OR) 1.96; 95%CI 1.74–2.21), anxiety or depression (adjusted OR 1.40;
95%CI 1.28–1.53), and recent opioid prescription (adjusted OR 1.47; 95%CI 1.34–1.61) were
associated with new community prescription. The combination of opioid and benzodiazepine
has been associated with increased risk of hospitalisation and death in other studies, making
this finding concerning. After adjusting for other confounders, sex was not associated with
new prescription and older patients were less likely to receive a prescription. Among new
prescriptions, 2.6% of the variation was attributable to the prescribing practice.
The aim for the final cohort study was to assess the risk of adverse events associated with
benzodiazepine or z-drug prescribing in adult critical care survivors hospitalised in 2010 or
2018 (not limited to treatment-naïve patients as in the previous study). I used linked data from
the UK CPRD to evaluate the risk of rehospitalisation or death due to falls or trauma-related
events and due to any cause, comparing critical care survivors prescribed benzodiazepine or z-drugs to those not prescribed. I used risk-set matching: each exposed patient was matched to
up to five unexposed patients by days from hospital discharge to prescription (or match date in
unexposed patients), as well as by primary care practice and cohort year. Patients were
followed up for 30 days from prescription or match date for outcome assessment. HRs were
estimated using stratified Cox regression and adjusted for confounders. Additionally, I
performed subgroup analyses of treatment-naïve patients. For the full cohort, I matched 4884
exposed survivors to up to five unexposed survivors (n=23,834). The median days to
prescription (and match date in the unexposed) was 11 days (interquartile range (IQR) 4–25
days). Prescription of benzodiazepines or z-drugs showed no conclusive evidence of increased
risk of falls or trauma-related events in the full cohort (adjusted HR 1.27; 95%CI 0.76–2.14) or
in treatment-naïve individuals (adjusted HR 1.79; 95%CI 0.61–5.26), because estimates lacked
precision due to low event rates. For all-cause rehospitalisation or death, benzodiazepines or
z-drugs were associated with increased risk (full cohort adjusted HR 1.24, 95%CI 1.14–1.36;
treatment-naïve adjusted HR 1.66, 95%CI 1.49–1.86). However, after excluding patients
treated for palliative care, the association persisted only in treatment-naïve individuals (full
cohort adjusted HR 1.08, 95%CI 0.98–1.19; treatment-naïve adjusted HR 1.42, 95%CI 1.25–
1.62).
Conclusions
This research demonstrated that one third of adult survivors of critical illness received a
psychotropic prescription within 90 days after hospital discharge, while one in ten
psychotropic-naïve critical care survivors received a new psychotropic prescription.
Prospective studies and/or availability of in-hospital prescribing data are needed to address
whether community prescriptions are the result of recommendations from the discharging
hospital, inappropriate continuation, or initiation post-discharge. Focussing on community
benzodiazepine or z-drug prescribing, I found that one in 20 treatment-naïve adult critical care
survivors received a new community prescription within 90 days of hospital discharge, with
almost half of those receiving more than one such prescription. Survivors of critical illness can
have new or worsened physiological impairments, making them potentially vulnerable to
adverse events of these medicines. Indeed, this research demonstrated that community
benzodiazepine and z-drug prescribing was associated with increased risk of all-cause
rehospitalisations and deaths in critical care survivors who had not been prescribed these
before hospitalisation. Clinicians should balance the possible benefits with the likely harms of
prescribing these drugs in this potentially vulnerable patient group
- …
