IntroductionHeart failure affects over 26 million people worldwide with prevalence expected to grow due to an ageing global population. Palliative care can address the holistic needs of patients with ...heart failure, and integrated palliative care in heart failure management has been indicated to improve outcomes for patients. Despite known benefits for integrated palliative care in heart failure management, implementation is poor across the majority of global health services. Recent systematic reviews have identified the benefits of integrating palliative care into heart failure management and highlighted barriers to implementation. However, there was heterogeneity in terms of countries, healthcare settings, delivery by differing staff across multidisciplinary teams, modes of delivery and different intervention components.Methods and analysisThe aim of this study is to identify how integrated palliative care and heart failure interventions produce desired outcomes, in which contexts, and for which patients. We will undertake a realist synthesis to identify this, using Pawson’s five iterative steps. We will recruit an international stakeholder group comprised of healthcare providers and patients with heart failure to advise and provide feedback throughout the review. Our initial realist programme theory sets out the necessary steps needed to accomplish the final intended outcome(s) from the implementation of integrated palliative care and heart failure. This initial programme theory will be shaped through an iterative process of testing and refinement.Ethics and disseminationEthical approval is not required for this study. With our stakeholder group, we will coproduce a user guide that outlines practical advice to optimise, tailor and implement interventions designed to integrate palliative care and heart failure, taking into consideration local context, alongside user-friendly summaries of the synthesis findings using short animations to convey complex findings. We will draw on the expertise within the stakeholder group to identify key stakeholders for disseminating to relevant audiences, ensuring outputs are tailored for their respective needs.PROSPERO registration numberCRD42021240185.
Patients with Ankylosing Spondylitis frequently have fixed kyphosis of their spine together with pain. This makes achieving acceptable head position for ocular surgery difficult. The proposal of new ...methods that result in successful intraocular surgery will reduce morbidity and sight loss in this group of patients.
To describe a novel technique using a vacuum bean bag positioner which enabled cataract surgery to be performed successfully under local anaesthesia. To allow prospects of technique development to standardise cataract surgery positioning in this cohort.
A 42 year-old male patient underwent phacoemulsification under Sub-Tenon's local anaesthetic with intra-ocular lens implant in the inverted position with no immediate post-operative complications.
Standard operating theatre equipment combined with a vacuum bean bag positioner, soft supports and securing straps can attain a position that is feasible for awake ocular surgery in patients with gross anatomical changes affecting the neck.
•Describe a novel technique for phacoemulsification and intra-ocular lens implant.•Enabling awake cataract surgery in patients with fixed kyphosis.•Successfully undertake surgery in the inverted position due to fixed flexion deformity.
Objectives(1) Develop a programme theory of why, for whom and in what contexts integrated palliative care (PC) and heart failure (HF) services work/do not work; (2) use the programme theory to ...co-produce with stakeholders, intervention strategies to inform best practice and future research.MethodsA systematic review of all published articles and grey literature using a realist logic of analysis. The search strategy combined terms significant to the review questions: HF, PC and end of life. Documents were included if they were in English and provided data relevant to integration of PC and HF services. Searches were conducted in November 2021 in EMBASE, MEDLINE, PsycINFO, AMED, HMIC and CINAHL. Further relevant documents were identified via monthly alerts (up until April 2023) and the project stakeholder group (patient/carers, content experts and multidisciplinary practitioners).Results130 documents were included (86 research, 22 literature reviews, 22 grey literature). The programme theory identified intervention strategies most likely to support integration of PC and HF services. These included protected time for evidence-based PC and HF education from undergraduate/postgraduate level and continuing professional practice; choice of educational setting (eg, online, face-to-face or hybrid); increased awareness and seeing benefits of PC for HF management; conveying the emotive and intellectual need for integrating PC and HF via credible champions; and prioritising PC and HF guidelines in practice.ConclusionsThe review findings outline the required steps to take to increase the likelihood that all key players have the capacity, opportunity and motivation to integrate PC into HF management.PROSPERO registration numberCRD42021240185.
As the nineteenth book of his Decretum, Bishop Burchard of Worms (d. 1025) included a penitential titled the Corrector or Medicus. Although the Corrector has traditionally been described as a manual ...of private confession, this article argues that it was primarily used to judge public penances at church courts and synods. Focusing on the manuscript transmission of the Decretum in the eleventh and twelfth centuries, we find that the Corrector was almost never copied apart from the rest of the Decretum and that it was almost always copied alongside other legal texts. Turning to individual abbreviations, we also find that Burchard's collection was frequently reworked and rearranged so as to integrate canonical and penitential texts. These findings call into question current definitions of canon law collections and penitentials which presume functional exclusivity.
BACKGROUNDAutoimmune pancreatitis (AIP) is recognised as an end organ manifestation of the systemic condition known as IgG4-sclerosing disease. One major characteristic of this disease, regardless of ...its location in the body, is the presence of high levels of circulating serum IgG, in particular IgG4 antibody. In the case of AIP, differential diagnosis from other conditions of the pancreas and biliary system, particularly cancers, can be difficult, but could result in avoiding invasive procedures and surgery. Earlier studies have evaluated the use of checking IgG4 levels in AIP diagnosis; these have produced variable results.
OBJECTIVETo further assess the diagnostic significance of serum IgG4 levels in AIP and investigate its value in differentiating from cancer of the gastroenterological system.
METHODSA retrospective study of 196 IgG4-requested samples from a 24-month period was examined. Samples were sorted into confirmed AIP, cancer or other pancreatic conditions including primary sclerosing cholangitis.
RESULTSPatients with AIP possessed a mean serum IgG level that was significantly higher compared with all other groups (mean serum IgG level=19.0 g/l±2.5, P<0.001). The mean serum IgG4 level of AIP patients was also significantly higher compared with all other conditions including cancer patients (mean IgG4 level=3.7 g/l±0.5, P<0.001).
CONCLUSIONThis data lends support to circulating IgG4 levels only being used as an accompanying diagnostic marker to imaging, histology and clinical presentation. In particular, this may help in differentiating between AIP and pancreatic carcinoma.
We evaluated the analytical performance of the fully automated cobas® 6500 urine work area and its automated components—cobas u 601 and cobas u 701.
The study was conducted at three European centers ...using un-centrifuged surplus routine urine samples; all measurements were performed within 2 h of sample collection. Precision, sample carry-over, and method comparisons were evaluated per Clinical and Laboratory Standards Institute guidelines. Method comparisons: cobas u 601 versus Urisys 2400 and cobas u 411 urine test strips; and cobas u 701 versus KOVA® visual microscopy and iQ200 analyzer. Operability and functionality were assessed using questionnaires.
Precision of the entire cobas 6500 system was within predefined acceptance limits and no significant carry-over was observed. Erythrocytes, leukocytes, nitrites, and protein were in good agreement (≥93%) with cobas u 411 reflectometry. High correlation was shown between the cobas u 701 analyzer and KOVA visual microscopy for red blood cells (RBC; slope, 0.89; Pearson’s r, 0.95) and white blood cells (WBC; slope, 0.96; Pearson’s r, 0.96), demonstrating equivalence of test results. The 97.5% percentile reference values on the cobas u 701 analyzer were 5.3 cells/μL (RBC) and 6.2 cells/μL (WBC). The cobas 6500 system showed good sensitivity for small bacteria (>1 μm) and pathological casts, and the user interface, maintenance wizards, and system design were highly rated by operators.
The fully automated workflow, high precision, and high throughput of the cobas 6500 system have the potential to facilitate standardization of urine screening.
•The cobas u 601 analyzer showed good agreement with cobas u 411 reflectometry.•cobas u 701 analyzer results were highly correlated with KOVA® visual microscopy.•The combined cobas® 6500 system showed excellent precision across laboratories.•No significant carry-over was observed.•The cobas 6500 system design and interface were highly rated by operators.
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•Provides a novel methodology for safely introducing ML in healthcare.•First work proactively incorporating patient safety in ML model for sepsis treatment.•Provides a concrete ...clinical workflow for integrating ML models for sepsis treatment.•Shows how safety analysis techniques can be used to assess and improve ML models.•Shows how to assure safety of ML models in healthcare to assist regulators.
Machine learning (ML) has the potential to bring significant clinical benefits. However, there are patient safety challenges in introducing ML in complex healthcare settings and in assuring the technology to the satisfaction of the different regulators. The work presented in this paper tackles the urgent problem of proactively assuring ML in its clinical context as a step towards enabling the safe introduction of ML into clinical practice. In particular, the paper considers the use of deep Reinforcement Learning, a type of ML, for sepsis treatment. The methodology starts with the modelling of a clinical workflow that integrates the ML model for sepsis treatment recommendations. Then safety analysis is carried out based on the clinical workflow, identifying hazards and safety requirements for the ML model. In this paper the design of the ML model is enhanced to satisfy the safety requirements for mitigating a major clinical hazard: sudden change of vasopressor dose. A rigorous evaluation is conducted to show how these requirements are met. A safety case is presented, providing a basis for regulators to make a judgement on the acceptability of introducing the ML model into sepsis treatment in a healthcare setting. The overall argument is broad in considering the wider patient safety considerations, but the detailed rationale and supporting evidence presented relate to this specific hazard. Whilst there are no agreed regulatory approaches to introducing ML into healthcare, the work presented in this paper has shown a possible direction for overcoming this barrier and exploit the benefits of ML without compromising safety.
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