NIHR open research最新文献

Background: Each year in England, 450,000 children and young people (CYP) under 18 years of age are transported by ambulance to emergency departments. Approximately 20% of these suffer acute pain caused by illness or injury. Pain is a highly complex sensory and emotional experience. The intersection between acute pain, unwell CYP and the unpredictable pre-hospital environment is convoluted. Studies have shown that prehospital pain management in CYP is poor, with 61% of those suffering acute pain not achieving effective pain relief (abolition or reduction of pain score by 2 or more out of 10) when attended by ambulance. Consequences of poor acute pain management include altered pain perception, post-traumatic stress disorder and the development of chronic pain. This realist review will aim to understand how ambulance clinicians can provide improved prehospital acute pain management for CYP.

Methods: A realist review will be conducted in accordance with the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidance. A five-stage approach will be adopted; 1) Developing an Initial Programme Theory (IPT): develop an IPT with key stakeholder input and evidence from informal searching; 2) Searching and screening: conduct a thorough search of relevant research databases and other literature sources and perform screening in duplicate; 3) Relevance and rigour assessment: assess documents for relevance and rigour in duplicate; 4) Extracting and organising data: code relevant data into conceptual "buckets" using qualitative data analysis software; and 5) Synthesis and Programme Theory (PT) refinement: utilise a realist logic of analysis to generate context-mechanism-outcome configurations (CMOCs) within and across conceptual "buckets", test and refine the IPT into a realist PT.

Conclusion: The realist PT will enhance our understanding of what works best to improve acute prehospital pain management in CYP, which will then be tested and refined within a realist evaluation.

Registration: PROSPERO Registration: CRD42024505978.

Background: PROTECT ( Platform Randomised evaluation of clinical Outcomes using novel TEChnologies to optimise antimicrobial Therapy) has brought together a team of researchers to design a platform trial to rapidly evaluate and adopt into care multiple diagnostic technologies, bringing immediate benefit to patients. Rapid diagnostic tests will be used to identify patients at risk of deterioration from severe infection, before they become critically unwell. The platform will assess their comparative clinical effectiveness and cost-effectiveness relative to current standard of care. Preliminary work, conducted under a Health Technology Assessment Application Acceleration Award, provided key evidence to optimise the design of the PROTECT platform.

Methods: Qualitative methods which involved consulting key stakeholders in the field of serious infection addressed the key priorities. A high-level care pathway analysis focusing on serious infection in secondary care, captured the points of contact, actions, decisions, and potential outcomes associated with a patient's care.

Results: Two use cases of rapid diagnostic tests for serious infection were identified; (1) in acute emergency medicine to decide on antimicrobial initiation and/or escalation of care, and (2) in hospitalised patients to monitor treatment response. The "ideal" test should be rapid, point-of-care, cheap to procure, have capacity for high usability, and ability to be performed and interpreted by all staff. Facilitators to the adoption of infection diagnostic tests is their clinical need, and the main potential barrier is poor change management and behavioural change.

Conclusions: Any new test should provide robust evidence of its clinical effectiveness and have the potential to accelerate ruling in or out serious infection which benefits the clinical pathway for patients, clinicians, and hospitals as a whole, to be considered for adoption as a new standard of care.

Background: Pulmonary aspiration of gastric contents is the most frequent cause of death associated with complications of airway management during general anaesthesia. Pregnancy increases aspiration risk owing to factors including delayed gastric emptying and increased intragastric pressure. We describe the incidence, risk factors, management, and outcomes of maternal pulmonary aspiration in pregnancy in the UK.

Methods: We conducted a population-based surveillance and case-control study. Between September 2013 and August 2016, all UK consultant-led obstetric units prospectively identified cases of pulmonary aspiration among parturient women using a pre-defined case definition, and reported them via the UK Obstetric Surveillance System (UKOSS). Controls (n=1982) were obtained from four UKOSS studies conducted between 2005 and 2014. We calculated the incidence of pulmonary aspiration using 2013-2015 maternities as the denominator. We explored potential risk factors for aspiration using univariable logistic regression and described outcomes.

Results: We identified 12 cases of pulmonary aspiration, giving an incidence of 5.2 per 1,000,000 maternities (95% CI 2.69-9.09). Cases were significantly less likely than controls to be multiparous (unadjusted odds ratio [uOR] 0.255, 95% CI 0.069-0.946), and significantly more likely to undergo caesarean section (uOR 24.89, 95% CI 3.18-194.85) and to receive general anaesthetic for caesarean section (p<0.001). Gestation was significantly shorter in cases than controls (uOR 0.782, 95% CI 0.702-0.870). Women who aspirated were significantly more likely to be admitted to the intensive therapy unit than controls (p<0.001). Infants of women who aspirated had significantly lower Apgar scores and were more likely to be admitted to the neonatal intensive care unit or to be stillborn compared with infants of women in the control group.

Conclusions: Pulmonary aspiration is rare in UK obstetric anaesthetic practice; however, it remains a risk of general anaesthesia. Despite a large study population, our analyses lacked power to evaluate many potential risk factors. Future research should focus on developing methods to accurately identify pregnant women at risk of aspiration.

Background: Opioids are frequently prescribed for short-term acute pain following surgery. Used appropriately, opioids deliver extremely favourable pain relief. Used longer than 90-days, however, can result in health complications, including unintentional overdose and addiction. Globally, >40 million people are dependent on opioids and annually >100,000 die from opioid misuse. With >4.7 million surgical procedures occurring annually in the United Kingdom it is imperative that opioid-use is managed upon discharge. A declining General Practitioner (GP) workforce and increased patient numbers, however, means gaps in healthcare during transfer of care. Here we report a mixed-methods protocol to understand the feasibility, and acceptability of a clinical pharmacist (CP)-led early opioid deprescribing intervention for discharged surgical patients.

Methods: DESCALE is a multicentre, non-randomised, pragmatic feasibility study. Participants aged ≥18 years who have undergone a surgical procedure at a single NHS trust in Southeast England and discharged with opioids and without a history of long-term opioid use, cancer diagnosis or study contraindications will be offered a Medicines Use Review (MUR) within 7-10 days of discharge. The MUR will be delivered by CPs at participating GP practices. Feasibility outcomes will focus on recruitment, fidelity of CPs to deliver the MUR, and barriers within primary care that affect delivery of the intervention, with a maximum sample size of 100. Clinical outcomes will focus on the number of participants that reduce or stop opioid use within 91 days. Prescribing, medical, surgical, and demographic data for individual participants will be collected and analysed to inform future trial design. Qualitative interviews with participants and associated healthcare professionals will explore acceptability and implementation of the intervention.

Conclusion: Data collected with respect to opioid use post-surgery, feasibility and acceptability of the intervention, patient experience and outcome data will inform the design of future research and larger clinical trials.

Background: The incidence of breast cancer first arising during pregnancy has been estimated in several countries to be 2.4-7.8/100,000 births, but has not been established in the United Kingdom (UK). We aimed to estimate the incidence of breast cancer diagnosed during pregnancy in the UK and to describe its management and short-term outcomes for mothers and babies.

Methods: This population-based descriptive study used the UK Obstetric Surveillance System (UKOSS). Cases were prospectively identified through monthly UKOSS mailings to all UK consultant-led maternity units. All cases of breast cancer diagnosed first during pregnancy, between October 1, 2015, and September 30, 2017, were eligible, with 84 confirmed cases analysed. Women with breast cancer diagnosed before pregnancy or with a recurrence were excluded. The primary outcomes were the incidence of breast cancer first diagnosed during pregnancy, maternal mortality, severe maternal morbidity, perinatal mortality, and severe neonatal morbidity.

Results: The incidence was 5.4/100,000 maternities (95% CI 4.37, 6.70). Nine women (11%) had undergone in vitro fertilisation (IVF), compared with a contemporaneously estimated 2.6% IVF pregnancies in the UK. During pregnancy, 30 women (36%) underwent surgery and 37 (44%) received chemotherapy. Three women had major maternal morbidity during pregnancy. Two women died and two perinatal deaths occurred.

Conclusions: The incidence of breast cancer arising in pregnancy in the UK is similar to that reported elsewhere. The higher proportion of IVF pregnancies among affected women needs further investigation, as it may not be entirely explained by relatively advanced maternal age. With caveats, management followed that outside pregnancy, but there was considerable variation in practice. Although short-term outcomes were generally good for mothers and babies, a larger prospective study is required. Iatrogenic pre-term delivery and its associated risks to the infant can often be avoided; treatment was administered during pregnancy without evidence of harms to the infant.

Background: Detecting Adverse Drug Events (ADEs) is an emerging research area, attracting great interest in the research community. Better anticipatory management of predisposing factors has considerable potential to improve outcomes. Automatic extraction of ADEs using Natural Language Processing (NLP) has a great potential to significantly facilitate efficient and effective distillation of such knowledge, to better understand and predict risk of adverse events.

Methods: This systematic review follows the six-stage including the literature from 6 databases (Embase, Medline, Web Of Science Core Collection, ACM Guide to Computing Literature, IEEE Digital Library and Scopus). Following the title, abstract and full-text screenings, characteristics and main findings of the included studies and resources will be tabulated and summarized. The risk of bias and reporting quality was assessed using the PROBAST tool.

Results: We developed our search strategy and collected all relevant publications. As of December 2024, we have completed all the stages of the systematic review. We identified 178 studies for inclusion through the academic literature search (where data was extracted from all of the papers). Right now, we are writing up the systematic review paper where we are synthesising the different findings. Further refinement of the eligibility criteria and data extraction has been ongoing since August 2022.

Conclusion: In this systematic review, we will identify and consolidate information and evidence related to the use and effectiveness of existing NLP approaches and tools for automatically detecting ADEs from free text (discharge summaries, General Practitioner notes, social media, etc.). Our findings will improve the understanding of the current landscape of the use of NLP for extracting ADEs. It will lead to better anticipatory management of predisposing factors with the potential to improve outcomes considerably. Our results will also be valuable both to NLP researchers developing methods to extract ADEs and to translational/clinical researchers who use NLP for this purpose and in healthcare in general. For example, from our initial analysis of the studies, we can conclude that the majority of the proposed works are about the detection (extraction) of ADEs from text. An important portion of studies also focus on the binary classification of text (for highlighting if it includes or not ADEs). Different challenges related to the unbalanced dataset, abbreviations and acronyms but also to the lower results with rare ADEs were also mentioned by the studied papers.

Background: Vasa praevia is an obstetric condition in which the fetal vessels run through the membrane over the internal cervical os, unprotected by the placenta or umbilical cord. It is associated with perinatal mortality if not diagnosed antenatally. We estimated the incidence and investigated outcomes of vasa praevia in the UK.

Methods: We conducted a population-based descriptive study using the UK Obstetric Surveillance System (UKOSS). Cases were identified prospectively through monthly UKOSS submissions from all UK hospitals with obstetrician-led maternity units. All women diagnosed with vasa praevia who gave birth between 1st December 2014 and 30th November 2015 were included. The main outcome was estimated incidence of vasa praevia with 95% confidence intervals, using 2015 maternities as the denominator.

Results: Fifty-one women met the case definition. The estimated incidence of diagnosed vasa praevia was 6.64 per 100,000 maternities (95% CI 5.05-8.73). Of 198 units, 10 (5%) had a vasa praevia screening programme; one of these 10 units identified 25% of the antenatally diagnosed cases. Among women who had vasa praevia diagnosed or suspected antenatally (n=28, 55%), there were no perinatal deaths or hypoxic ischaemic encephalopathy (HIE). Twenty-four women with antenatal diagnosis were hospitalised at a median 32 weeks' gestation and caesarean section was scheduled at a median 36 weeks' gestation. When vasa praevia was diagnosed peripartum (n=23, 45%), the perinatal mortality rate was 37.5% and 47% of survivors developed HIE.

Conclusions: The incidence of diagnosed vasa praevia was lower than anticipated. There was high perinatal mortality and morbidity for cases not diagnosed antenatally. The incidence of antenatally identified cases was much higher in the few centres that actively screened for this condition, and the perinatal outcomes were better. However, this group were all delivered by caesarean section and may include women who would not have experienced any adverse perinatal outcome.

Background and aims: Scotland has the highest rate of deaths from chronic liver disease (CLD) in the UK. Socioeconomic and geographic isolation represent significant challenges to delivery of care. The multidisciplinary Scottish Hepatology Access Research Partnership (SHARP) aimed to identify and break down barriers to diagnosing and treating liver disease in Scotland.

Methods: SHARP comprised a core Partnership Management Group that developed projects and a Partnership Advisory Group which provided oversight.

Results: SHARP established workstreams to achieve its aims: Understanding current access to liver services To identify barriers to liver patient care in Scotland we audited liver services and surveyed the experience of patients (n=276); primary care physicians (n=199) and Gastroenterologists/Hepatologists (n=99). Technologies to monitor and diagnose CLD Liver disease is diagnosed and monitored using routine blood testing which disadvantages isolated patients. We plan to develop a point of use test to analyse ALT and AST to enable community-based identification and monitoring of liver disease. Identification of patients at risk of liver disease CLD is often diagnosed late. We propose developing an artificial intelligence tool to predict an individual's risk of an emergent admission to hospital due to CLD. This tool will be validated in a Welsh cohort. Barriers to engagement with care for liver disease Hepatology did-not-attend rates are the highest of any specialty. We propose research to co-design a suite of recommendations to improve engagement with care for CLD patients. We aim to achieve this by interviewing practitioners alongside patients who do and don't engage with services.

Conclusions: Through a national survey SHARP has developed an understanding of the issues affecting access to hepatology services in Scotland. SHARP has developed projects that will help address the issues that socioeconomically and geographically isolated patients face when it comes to identifying and treating liver disease.

Background: Dementia affects over 55 million people globally, projected to double by 2050. In the UK, non-registered staff, including healthcare assistants (HCAs) and clinical support workers, provide a significant portion of dementia care, yet receive limited training. This study explores the knowledge, training, and attitudes of support workers towards dementia.

Methods: A cross-sectional web-based survey was conducted from February 1 to April 1, 2024, targeting support workers in England. The survey included demographic information, dementia knowledge (using the Dementia Knowledge Assessment Scale, DKAS), and attitudes (using the Dementia Attitudes Scale, DAS). Data were analysed using descriptive statistics, ANOVA, t-tests, and Pearson's correlation.

Results: One hundred and nine support workers responded, predominantly female (90%) and white British (76.4%), from various NHS settings and occupational groups. The majority (79.8%) had received dementia training, primarily from their organisations. Challenges included managing behavioural and psychological symptoms and communication difficulties. There was no significant correlation between years of experience and dementia knowledge (r = -0.019) or attitudes (r = -0.057). However, higher occupational grades were associated with greater dementia knowledge (p = <0.01). A moderate positive correlation was found between dementia knowledge and attitudes (r = 0.35, p = <0.01).Despite high levels of knowledge, support workers often feel inadequately prepared to provide optimal dementia care, indicating a need for more comprehensive training. Challenges in communication and managing symptoms highlight areas for improvement. The study suggests that better training can improve both knowledge and attitudes, enhancing care quality for people living with dementia.

Conclusion: Support workers play a crucial role in dementia care but require more robust training programs to meet the growing demands. Enhanced training can improve their knowledge and attitudes, leading to better care outcomes for people with dementia.

Background: Efforts to build and foster adult social care research in England have historically encountered more challenges to its growth and expansion compared with health research, with a sector facing significant barriers in facilitating research activity due to a lack of resourcing, poor valuation or understanding of the profile of social care research. The landscape for supporting the social care workforce to use, engage in and undertake research in adult social care has been rather bleak, but in recent years there has been recognition of the need to foster a social care workforce research community. The National Institute for Health and Care Research in England have committed to investing in social care research capacity by funding six adult social care partnerships, with one based in Southeast England. Setting up Communities of Practice (COPs) offers a model to build a shared learning space to foster a social care research community. Process developing COPs: Three online networking events were held in the first year of the project to engage managers and practitioners from the local authority and from the wider adult social care sector, taking place in July and November 2021, and March 2022. Two COPs were identified, following an ordering and thematising process of feedback from the networking events, of: (a) Supporting people with complex needs throughout the lifespan, and (b) Enhancing, diversifying and sustaining the social care workforce. Whilst it would be premature to identify their long-term impacts, the COPs have provided a space for regular communication, knowledge sharing and networking between members.

Conclusions: The COP framework offers a collaborative approach to initiating research from the grass-roots level in adult social care. This paper focuses on how the COP model offers great promise for knowledge-exchange providing a forum to generate and disseminate knowledge around social care in two COP domains.