• Point-of-care lactate measurement for suspected sepsis in the prehospital environment: are we missing the point at the sharp end?

      Lightowler, Bryan (Mark Allen Group, 2020-04-02)
      Expecting ambulance clinicians to dependably differentiate the life-threatening organ dysfunction caused by sepsis from an inflammatory response to a non-infectious aetiology, relying upon vital signs and a physical examination of the patient alone, must be considered unrealistic. Although lactate measurement has been integrated into numerous prehospital sepsis screening tools, it is not yet measured routinely within UK ambulance services. Research has generally focused on whether handheld point-of-care lactate measurement devices are as accurate as laboratory analysis of venous or arterial samples. The weight of literature has concluded negatively in relation to this. However, there is potential for handheld devices to be used independently to monitor trends in lactate elimination or accumulation to inform decisions on the efficacy of prehospital interventions, or simply to report categorical data in terms of whether lactate levels are elevated or not. This offers UK paramedics the opportunity to improve sepsis care through the enhanced assessment of risk and acuity, the identification of patients with cryptic shock, more aggressive fluid resuscitation and advanced notification to receiving units.
    • Policy and practice change at local, regional and international levels: impacts from Born in Bradford

      Small, Neil A. (2015-10)
      Born in Bradford is a prospective pregnancy and birth cohort in the UKs 6th largest city. Between 2007 and 2011 12,453 women (13,776 pregnancies), 3,448 of their partners and 13,818 babies were recruited. Half of families are in the poorest fifth of deprivation for England and Wales, and 45% are of Pakistani origin. Recruitment was in one Metropolitan District. This allows consideration of the impact of local circumstances, including service provision and policy choices, and engagement with the local community to implement evidence based responses to study findings. The introduction of a large study into a local health economy contributed to organizational changes including the development of a paperless maternity data system and better links between primary, secondary, and child health services. Embedding research in practice can lead to improved quality of routine data collected, for example on infant growth, and make routine data available for research, enhancing its cost effectiveness. Early adoption of research findings locally includes the introduction of routine vitamin D supplementation and an oral glucose tolerance test for all pregnant women. Findings that consanguinity was associated with a doubling of risk for congenital anomaly and that 30% of all anomalies in children of Pakistani origin could be attributed to consanguinity reinforced local commitment to community education about genetics and targeted genetic counselling. These findings also led to the establishment of a regional congenital anomalies register. In partnership with the European ESCAPE consortium (14 cohorts in 12 countries) a significant association was found between fetal growth and air pollution. The European Environmental Agency Director stated that this evidence is sufficient to trigger changes in EU regulations. Some findings can be quickly embedded in local provision, some have a resonance that prompts regional changes, some are generated with collaborators and can lead to policy change at international level.
    • Positive Action in the United Kingdom.

      Archibong, Uduak E.; Ashraf, Fahmida (2010)
    • Positive Action Measures Across Different Equality Grounds, Organisations and Sectors in European and Non-european Countries

      Archibong, Uduak E.; Scally, Andy J.; Eferakorho, Jite; Darr, Aliya; Atkin, K.; Baxter, C.; Bell, M.; Waddington, L.; Wladasch, K.; Bedard, T.; et al. (2010)
      Abstract: This article is based on a large-scale European Commission project on international perspectives on positive action measures. The paper presents an analysis of the perceptions of positive action held by respondents from all the countries participating in an international survey, focussing specifically upon differences across equality grounds, sector and organisation type. This paper will also provide examples of positive action being applied in European and non-European countries that participated in the study. The study adopted extensive literate and online survey to obtain data from designers of positive action. Findings are discussed, conclusions drawn and wide-ranging recommendations are made at the European Commission, individual countries and organisational levels.
    • Positive birth experiences: a systematic review of the lived experience from a birthing person’s perspective

      Hill, E.; Firth, Amanda (2018-03)
      Background: Positive birth (PB) experiences assist with successful transition into parenthood and psychological growth. Identifying contributing factors, which assist in the achievement of such experiences, could inform birth workers and maternity service providers and improve experiences for future parents. Objective: To undertake a systematic review of factors which the birthing person perceived as contributing to their PB experience. Search strategy: Six databases were searched with English language restriction. Grey literature sources and relevant journal content were searched. Main results: Sixty-eight participants were included from studies conducted in Norway, Sweden, the United States (US) and the United Kingdom (UK). The major themes of the thematic synthesis were: strength through preparation; a positive mental attitude; feeling safe and connected through autonomy; the presence of others; and fond memories that were formulated. Findings informed birth workers that their authentic presence is valued by birthing people, and that a person’s or provider’s birthing culture impacts on a person’s perception of their birth experiences. In order to experience PB, maternity services should support individualised care. Conclusions: A PB experience matters to families, and enables self-esteem and confidence to be felt as a new parent. The unique individualised care and authentic presence of the birth workers provided strength, reassurance and encouragement during the birth process.
    • Postacute Care for Older People in Community Hospitals: A Multicentre Randomised, Controlled Trial

      Young, J.; Green, J.R.; Forster, A.; Small, Neil A.; Lowson, K.; Bogle, S.; George, J.; Heseltine, D.; Jayasuriya, T.; Rowe, J. (2007)
      OBJECTIVES: To compare the effects of community hospital care on independence for older people needing rehabilitation with that of general hospital care. DESIGN: Randomized, controlled trial. SETTING: Seven community hospitals and five general hospitals in the midlands and north of England. PARTICIPANTS: Four hundred ninety patients needing rehabilitation after hospital admission with an acute illness. INTERVENTION: Multidisciplinary team care for older people in community hospitals. MEASUREMENTS: The primary outcome was the Nottingham extended activities of daily living scale (NEADL); secondary outcomes were the Barthel Index, Nottingham Health Profile, Hospital Anxiety and Depression Scale, mortality, discharge destination, 6-month residence status, and satisfaction with services. RESULTS: Loss of independence at 6 months was significantly less likely in the community hospital group (mean adjusted NEADL change score group difference 3.27; 95% confidence interval 0.26–6.28; P=.03). The results for the secondary outcome measures were similar for the two groups. CONCLUSION: Postacute community hospital rehabilitation care for older people is associated with greater independence.
    • Posterolateral corner injuries of the knee: a serious injury commonly missed

      Pacheco, R.J.; Ayre, Colin A.; Bollen, S.R. (2011)
      We retrospectively reviewed the hospital records of 68 patients who had been referred with an injury to the posterolateral corner of the knee to a specialist knee surgeon between 2005 and 2009. These injuries were diagnosed based on a combination of clinical testing and imaging and arthroscopy when available. In all, 51 patients (75%) presented within 24 hours of their injury with a mean presentation at eight days (0 to 20) after the injury. A total of 63 patients (93%) had instability of the knee at presentation. There was a mean delay to the diagnosis of injury to the posterolateral corner of 30 months (0 to 420) from the time of injury. In all, the injuries in 49 patients (72%) were not identified at the time of the initial presentation, with the injury to the posterolateral corner only recognised in those patients who had severe multiple ligamentous injuries. The correct diagnosis, including injury to the posterolateral corner, had only been made in 34 patients (50%) at time of referral to a specialist knee clinic. MRI correctly identified 14 of 15 injuries when performed acutely (within 12 weeks of injury), but this was the case in only four of 15 patients in whom it was performed more than 12 weeks after the injury. Our study highlights a need for greater diligence in the examination and investigation of acute ligamentous injuries at the knee with symptoms of instability, in order to avoid failure to identify the true extent of the injury at the time when anatomical repair is most straightforward.
    • Postural stability changes in the elderly during sensory perturbations and dual tasking: the influence of refractive blur

      Anand, Vijay; Buckley, John G.; Scally, Andy J.; Elliott, David B. (2003)
      PURPOSE. To determine the influence of refractive blur on postural stability during somatosensory and vestibular system perturbation and dual tasking. METHODS. Fifteen healthy, elderly subjects (mean age, 71 ± 5 years), who had no history of falls and had normal vision, were recruited. Postural stability during standing was assessed using a force platform, and was determined as the root mean square (RMS) of the center of pressure (COP) signal in the anterior-posterior (A-P) and medial-lateral directions collected over a 30-second period. Data were collected under normal standing conditions and with somatosensory and vestibular system perturbations. Measurements were repeated with an additional physical and/or cognitive task. Postural stability was measured under conditions of binocular refractive blur of 0, 1, 2, 4, and 8 D and with eyes closed. The data were analyzed with a population-averaged linear model. RESULTS. The greatest increases in postural instability were due to disruptions of the somatosensory and vestibular systems. Increasing refractive blur caused increasing postural instability, and its effect was greater when the input from the other sensory systems was disrupted. Performing an additional cognitive and physical task increased A-P RMS COP further. All these detrimental effects on postural stability were cumulative. CONCLUSIONS. The findings highlight the multifactorial nature of postural stability and indicate why the elderly, many of whom have poor vision and musculoskeletal and central nervous system degeneration, are at greater risk of falling. The findings also highlight that standing instability in both normal and perturbed conditions was significantly increased with refractive blur. Correcting visual impairment caused by uncorrected refractive error could be a useful intervention strategy to help prevent falls and fall-related injuries in the elderly.
    • Postural Stability Changes in the Elderly with Cataract Simulation and Refractive Blur

      Anand, Vijay; Buckley, John G.; Scally, Andy J.; Elliott, David B. (2003)
      PURPOSE. To determine the influence of cataractous and refractive blur on postural stability and limb-load asymmetry (LLA) and to establish how postural stability changes with the spatial frequency and contrast of the visual stimulus. METHODS. Thirteen elderly subjects (mean age, 70.76 ± 4.14 [SD] years) with no history of falls and normal vision were recruited. Postural stability was determined as the root mean square [RMS] of the center of pressure (COP) signal in the anterior¿posterior (A-P) and medial¿lateral directions and LLA was determined as the ratio of the average body weight placed on the more-loaded limb to the less-loaded limb, recorded during a 30-second period. Data were collected under normal standing conditions and with somatosensory system input disrupted. Measurements were repeated with four visual targets with high (8 cyc/deg) or low (2 cyc/deg) spatial frequency and high (Weber contrast, ¿95%) or low (Weber contrast, ¿25%) contrast. Postural stability was measured under conditions of binocular refractive blur of 0, 1, 2, 4, and 8 D and with cataract simulation. The data were analyzed in a population-averaged linear model. RESULTS. The cataract simulation caused significant increases in postural instability equivalent to that caused by 8-D blur conditions, and its effect was greater when the input from the somatosensory system was disrupted. High spatial frequency targets increased postural instability. Refractive blur, cataract simulation, or eye closure had no effect on LLA. CONCLUSIONS. Findings indicate that cataractous and refractive blur increase postural instability, and show why the elderly, many of whom have poor vision along with musculoskeletal and central nervous system degeneration, are at greater risk of falling. Findings also highlight that changes in contrast sensitivity rather than resolution changes are responsible for increasing postural instability. Providing low spatial frequency information in certain environments may be useful in maintaining postural stability. Correcting visual impairment caused by uncorrected refractive error and cataracts could be a useful intervention strategy to help prevent falls and fall-related injuries in the elderly.
    • The potential role of the occupational therapist in acute psychiatric services: A comparative evaluation

      Fitzgerald, Martin (2016)
      Aims and background: This analysis paper describes a comparative evaluation of service deliverables within the Service Level Agreements (SLA) of two acute psychiatric services; one inclusive and the other exclusive of occupational therapy. Methods: Six SLA agreements provided the standards by which the two services were evaluated. The SLAs were evaluated because they are used by the service managers and commissioners to measure performance and clinical effectiveness. The role of the occupational therapists and their contribution to the planning and delivery of the performance indicators is also considered. An evaluation framework was applied to explore the potential role occupational therapy may have had in any performance difference between the two sites. In doing so it is hoped to provide some evidence to support and inform occupational therapists and service managers on the role and of occupational therapy in acute mental health services. This comparative evaluation followed the first three of the five audit stages: 1. Preparing for audit; 2. Selecting criteria; and 3. Measuring performance level. Findings: The service with occupational therapy performed better on home leave day use, ward occupancy and less than 3-day admissions. Conclusions: By delivering their key roles of individual assessment, therapeutic groups, individual treatment and discharge planning occupational therapist were able to contribute to the overall efficiency of service delivery. These findings support the role of the occupational therapist in an acute psychiatric setting and provide guidance for managers on how to utilise occupational therapy in the delivery of service outcomes.
    • Potential social, economic and general health benefits of consanguineous marriage: results from the Born in Bradford cohort study

      Bhopal, R.S.; Petherick, E.S.; Wright, J.; Small, Neil A. (2014)
      BACKGROUND: More than 1 billion people live in societies where consanguineous marriages are common. When children are born to consanguineous unions, there is an increased probability of the expression of single-gene disorders with a recessive mode of inheritance. There are presumptive social benefits of consanguineous marriages reported in the literature. METHODS: The UK's Born in Bradford birth cohort study recruited 12 453 women at 26-28 weeks' gestation between 2007 and 2010. In all, 11 396 completed a questionnaire, including questions about their relationship to their baby's father. We compared Pakistani and Other ethnic groups in consanguineous relationships and Pakistani, Other and White British groups not in consanguineous relationships, calculating percentages and age-adjusted prevalence ratios (95% confidence intervals). RESULTS: In the Pakistani group, 59.3% of women (n = 3038) were blood relatives of their baby's father. Consanguinity was uncommon in the Other ethnic group (7.3%, n = 127) and rare (n = 5) in the White British group. Compared with non-consanguineous counterparts, mothers in consanguineous relationships were socially and economically disadvantaged (e.g. never employed, less likely to have higher education). The Pakistani consanguineous group's social, economic and health lifestyle circumstances were equivalent to, in some cases better than, women in non-consanguineous relationships (e.g. up-to-date in paying bills, or in disagreeing that they wished for more warmth in their marital relationship). The consanguineous relationship group had less separation/divorce. Rates of cigarette smoking during pregnancy were lower in mothers in consanguineous relationships. CONCLUSION: Debate about consanguinity should balance the potential protective effect of consanguineous relationships with established genetic risk of congenital anomaly in children.
    • The Power of Belief? Review of the Evidence on Religion or Belief and Equalities in Great Britain.

      Macey, Marie; Carling, Alan; Furness, Sheila M. (University of Bradford, 2009)
      A new legal framework has been developed in Great Britain over the last ten years which protects individuals against unfair treatment on the grounds of their religion or belief. This framework regards all the major faith groups, secular belief systems (such as Humanism or Atheism), and non-belief on formally equal terms. There has also been a rapid growth of research interest in religion/belief in contemporary scholarship on equalities. This report provides a critical overview of this extensive research base relating mainly to England, Scotland and Wales up until 2008.
    • A practical introduction to medical statistics.

      Scally, Andy J. (2014-04-23)
      Medical statistics is a vast and ever-growing field of academic endeavour, with direct application to developing the robustness of the evidence base in all areas of medicine. Although the complexity of available statistical techniques has continued to increase, fuelled by the rapid data processing capabilities of even desktop/laptop computers, medical practitioners can go a long way towards creating, critically evaluating and assimilating this evidence with an understanding of just a few key statistical concepts. While the concepts of statistics and ethics are not common bedfellows, it should be emphasised that a statistically flawed study is also an unethical study.[1] This review will outline some of these key concepts and explain how to interpret the output of some commonly used statistical analyses. Examples will be confined to two-group tests on independent samples, using both a continuous and a dichotomous/binary outcome measure.
    • Practitioner-based research and qualitative interviewing: Using therapeutic skills to enrich research in counselling and psychotherapy

      McVey, Lynn; Lees, J.; Nolan, G. (2015-06)
      The researcher’s reflexive use of self forms part of a well-established tradition in counselling and psychotherapy research. This paper reviews that tradition briefly, with particular reference to an approach known as ‘practitioner-based research’ that has developed from it. In this approach, researcher-practitioners use their therapeutic skills and judgement and thereby enrich their understanding of research participants, themselves and their relationship. Aim: The paper aims to contribute to the practitioner-based approach by showing how it can impact on data collection, using an example from a qualitative interview. Methodology: A moment of interaction between a participant and a therapy researcher in a qualitative interview is examined, framed within psychotherapeutic intersubjectivity theory. The researcher’s reflexive awareness of micro-aspects of the relationship with the participant is reviewed, captured in their language and the split-second daydreams or reveries that arose as they interacted. Findings: The authors argue that the approach enhanced this small-scale study by intensifying the researcher’s engagement with the participant and enriching her understanding of their relationship and the subject under investigation. Implications: The paper highlights the unique value and contribution that this approach offers to therapy research and practice.
    • Predicting mortality among a general practice-based sample of older people with heart failure

      Barnes, S.; Gott, M.; Payne, S.; Parker, C.; Seamark, D.; Gariballa, S.; Small, Neil A. (2008)
      Objective: To identify factors available to general practitioners (GPs) that are predictive of mortality within a general practice-based population of heart failure patients, and to report the sensitivity and specificity of prognostic information from GPs. Methods: Five hundred and forty-two heart failure patients aged >60 years were recruited from 16 UK GP surgeries. Patients completed quality-of-life and services use questionnaires every 3 months for 24 months or until death. Factors with independent significant association with survival were identified using Cox proportional hazards regression analysis. Results: Women had a 58% lower risk of death. Patients self-reporting New York Heart Association Classification III or IV had an 81% higher risk of death. Patients aged 85+ years had over a five-fold risk of death as compared with those aged <65 years. Patients with a co-morbidity of cancer had a 78% higher risk of death. Of the 14 patients who died in a 12-month period, the GPs identified 11 (sensitivity 79%). They identified 133 of the 217 who did not die (specificity 61%). Discussion: Predictors readily available to GPs, such as patient characteristics, are easy to adapt to use in general practice, where most heart failure patients are diagnosed and treated. Identifying factors likely to influence death is useful in primary care, as this can initiate discussion about end-of-life care.
    • Predictive accuracy of enhanced versions of the on-admission National Early Warning Score in estimating the risk of COVID-19 for unplanned admission to hospital: a retrospective development and validation study

      Faisal, Muhammad; Mohammed, A. Mohammed; Richardson, D.; Steyerberg, E.W.; Fiori, M.; Beatson, K. (2021-09-13)
      The novel coronavirus SARS-19 produces 'COVID-19' in patients with symptoms. COVID-19 patients admitted to the hospital require early assessment and care including isolation. The National Early Warning Score (NEWS) and its updated version NEWS2 is a simple physiological scoring system used in hospitals, which may be useful in the early identification of COVID-19 patients. We investigate the performance of multiple enhanced NEWS2 models in predicting the risk of COVID-19. Our cohort included unplanned adult medical admissions discharged over 3 months (11 March 2020 to 13 June 2020 ) from two hospitals (YH for model development; SH for external model validation). We used logistic regression to build multiple prediction models for the risk of COVID-19 using the first electronically recorded NEWS2 within ± 24 hours of admission. Model M0' included NEWS2; model M1' included NEWS2 + age + sex, and model M2' extends model M1' with subcomponents of NEWS2 (including diastolic blood pressure + oxygen flow rate + oxygen scale). Model performance was evaluated according to discrimination (c statistic), calibration (graphically), and clinical usefulness at NEWS2 ≥ 5. The prevalence of COVID-19 was higher in SH (11.0 %=277/2520) than YH (8.7 %=343/3924) with a higher first NEWS2 scores ( SH 3.2 vs YH 2.8) but similar in-hospital mortality (SH 8.4 % vs YH 8.2 %). The c-statistics for predicting the risk of COVID-19 for models M0',M1',M2' in the development dataset were: M0': 0.71 (95 %CI 0.68-0.74); M1': 0.67 (95 %CI 0.64-0.70) and M2': 0.78 (95 %CI 0.75-0.80)). For the validation datasets the c-statistics were: M0' 0.65 (95 %CI 0.61-0.68); M1': 0.67 (95 %CI 0.64-0.70) and M2': 0.72 (95 %CI 0.69-0.75) ). The calibration slope was similar across all models but Model M2' had the highest sensitivity (M0' 44 % (95 %CI 38-50 %); M1' 53 % (95 %CI 47-59 %) and M2': 57 % (95 %CI 51-63 %)) and specificity (M0' 75 % (95 %CI 73-77 %); M1' 72 % (95 %CI 70-74 %) and M2': 76 % (95 %CI 74-78 %)) for the validation dataset at NEWS2 ≥ 5. Model M2' appears to be reasonably accurate for predicting the risk of COVID-19. It may be clinically useful as an early warning system at the time of admission especially to triage large numbers of unplanned hospital admissions.
    • The predictive moment: reverie, connection and predictive processing

      McVey, Lynn; Nolan, G.; Lees, J. (2020-07)
      According to the theory of predictive processing, understanding in the present involves non-consciously representing the immediate future, based on probabilistic inference shaped by learning from the past. This paper suggests links between this neuroscientific theory and the psychoanalytic concept of reverie–an empathic, containing attentional state–and considers implications for the ways therapists intuit implicit material in their clients. Using findings from a study about therapists’ experiences of this state, we propose that reverie can offer practitioners from diverse theoretical backgrounds a means to enter the predictive moment deeply, making use of its subtle contents to connect with clients.