Introduction of Wellbeing Champions in a Paediatric High Dependency Unit (Hdu)

BACKGROUND AND AIM: Alder Hey is a tertiary children's hospital in North-West England. The High Dependency Unit (HDU) is part of a large Critical Care unit consisting of 21 Paediatric Intensive Care beds and 15 HDU beds. All 120 HDU staff including medical, nursing and allied health professionals, were invited to become Wellbeing Champions and eleven members volunteered. Wellbeing Champions, supported by the two Clinical Psychologists, were introduced on HDU in February 2021 with the aim of promoting staff wellbeing, signposting to appropriate support services and developing innovative approaches to engage staff in conversations around their mental wellbeing. AIM: This evaluation aimed to determine utilisation of Wellbeing Champions and explore the perception of support offered. METHOD(S): A short-anonymised survey was circulated by email to all HDU staff and their responses collated. RESULT(S): 26 responses were returned. 92% of respondents were aware of the HDU Wellbeing Champions. 70% of respondents had taken part in psychology-led support session. 50% of respondents had received support from a HDU Wellbeing Champion. 88% of respondents felt supported at work during Covid-19 pandemic. 76% of respondents felt valued at work. Support and ease of accessibility were the top two descriptors for the Wellbeing Champions. CONCLUSION(S): The results show a positive response to the new role of the HDU Wellbeing Champions. HDU Wellbeing Champions have been a useful resource to support staff wellbeing and we aim to continue the staff support in the form staff support meetings every two weeks.

Study protocol for the online adaptation and evaluation of the 'Reboot' (Recovery-boosting) coaching programme, to prepare critical care nurses for, and aid recovery after, stressful clinical events.

BACKGROUND: Critical care nurses (CCNs) are routinely exposed to highly stressful events, exacerbated during the COVID-19 pandemic. Supporting resilience and wellbeing of CCNs is therefore crucial to prevent burnout. One approach for delivering this support is by preparing critical care nurses for situations they may encounter, drawing on evidence-based techniques to strengthen relevant psychological coping strategies. As such, the current study seeks to tailor a Resilience-boosting psychological coaching programme [Reboot] for CCNs, based on cognitive behavioural therapy (CBT) principles and the Bi-Dimensional Resilience Framework (BDF), and (1) to assess the feasibility of delivering Reboot via online, remote delivery to CCNs, and (2) to provide a preliminary assessment of whether Reboot could increase resilience and confidence in coping with adverse events. METHODS: Eighty CCNs (n=80) will be recruited to the 8-week Reboot programme, comprised of two group workshops and two individual coaching calls. The study uses a single-arm before-after feasibility study design and will be evaluated with a mixed-methods approach, using online questionnaires (all participants) and telephone interviews (25% of participants). Primary outcomes will be confidence in coping with adverse events (the Confidence scale) and resilience (the Brief Resilience Scale) measured at four time points. DISCUSSION: Results will determine whether it is feasible to deliver and evaluate a remote version of the Reboot coaching programme to CCNs, and will indicate whether participating in the programme is associated with increases in confidence in coping with adverse events, resilience and wellbeing (as indicated by levels of depression).

Effect of Androgen Suppression on Clinical Outcomes in Hospitalized Men With COVID-19: The HITCH Randomized Clinical Trial.

Importance: SARS-CoV-2 entry requires the TMPRSS2 cell surface protease. Antiandrogen therapies reduce expression of TMPRSS2. Objective: To determine if temporary androgen suppression induced by degarelix improves clinical outcomes of inpatients hospitalized with COVID-19. Design, Setting, and Participants: The Hormonal Intervention for the Treatment in Veterans With COVID-19 Requiring Hospitalization (HITCH) phase 2, placebo-controlled, double-blind, randomized clinical trial compared efficacy of degarelix plus standard care vs placebo plus standard care on clinical outcomes in men hospitalized with COVID-19 but not requiring invasive mechanical ventilation. Inpatients were enrolled at 14 Department of Veterans Affairs hospitals from July 22, 2020, to April 8, 2021. Data were analyzed from August 9 to October 15, 2021. Interventions: Patients stratified by age, history of hypertension, and disease severity were centrally randomized 2:1 to degarelix, (1-time subcutaneous dose of 240 mg) or a saline placebo. Standard care included but was not limited to supplemental oxygen, antibiotics, vasopressor support, peritoneal dialysis or hemodialysis, intravenous fluids, remdesivir, convalescent plasma, and dexamethasone. Main Outcomes and Measures: The composite primary end point was mortality, ongoing need for hospitalization, or requirement for mechanical ventilation at day 15 after randomization. Secondary end points were time to clinical improvement, inpatient mortality, length of hospitalization, duration of mechanical ventilation, time to achieve a temperature within reference range, maximum severity of COVID-19, and the composite end point at 30 days. Results: The trial was stopped for futility after the planned interim analysis, at which time there were 96 evaluable patients, including 62 patients randomized to the degarelix group and 34 patients in the placebo group, out of 198 initially planned. The median (range) age was 70.5 (48-85) years. Common comorbidities included chronic obstructive pulmonary disorder (15 patients [15.6%]), hypertension (75 patients [78.1%]), cardiovascular disease (27 patients [28.1%]), asthma (12 patients [12.5%]), diabetes (49 patients [51.0%]), and chronic respiratory failure requiring supplemental oxygen at baseline prior to COVID-19 (9 patients [9.4%]). For the primary end point, there was no significant difference between the degarelix and placebo groups (19 patients [30.6%] vs 9 patients [26.5%]; P = .67). Similarly, no differences were observed between degarelix and placebo groups in any secondary end points, including inpatient mortality (11 patients [17.7%] vs 6 patients [17.6%]) or all-cause mortality (11 patients [17.7%] vs 7 patents [20.6%]). There were no differences between degarelix and placebo groups in the overall rates of adverse events (13 patients [21.0%] vs 8 patients [23.5%) and serious adverse events (19 patients [30.6%] vs 13 patients [32.4%]), nor unexpected safety concerns. Conclusions and Relevance: In this randomized clinical trial of androgen suppression vs placebo and usual care for men hospitalized with COVID-19, degarelix did not result in amelioration of COVID-19 severity. Trial Registration: ClinicalTrials.gov Identifier: NCT04397718.

Dual surgeon operating to improve patient safety.

The COVID-19 pandemic resulted in an unprecedented reduction in the delivery of surgical services worldwide, especially in non-urgent, non-cancer procedures. A prolonged period without operating (or 'layoff period') can result in surgeons experiencing skill fade (both technical and non-technical) and a loss of confidence. While senior surgeons in the UK may be General Medical Council (GMC) validated and capable of performing a procedure, a loss of 'currency' may increase the risk of error and intraoperative patient harm, particularly if unexpected or adverse events are encountered. Dual surgeon operating may mitigate risks to patient safety as surgeons regain currency while returning to non-urgent operating and may also be beneficial after the greatly reduced activity observed during the COVID-19 pandemic for low-volume complex operations. In addition, it could be a useful tool for annual appraisal, sharing updated surgical techniques and helping team cohesion. This paper explores lessons from aviation, a leading industry in human factors principles, for regaining surgical skills currency. We discuss real and perceived barriers to dual surgeon operating including finance, training, substantial patient waiting lists, and intraoperative power dynamics.

Compliance analysis for remote spirometry in subjects with mild to moderate asthma

RATIONALE Remote spirometry measures performed by means of handheld spirometers connected to smartphone applications have gained increased attention as a convenient data collection technique for patients. Additionally, this method provides more frequent data than clinical visits and allows researchers to control for data variability (diurnal variation, seasonal/environmental changes) by increasing statistical degrees of freedom. Moreover, remote and clinic spirometry data was shown to be comparable in patients with asthma and COPD. The need for remote assessments became more acute during the COVID-19 pandemic when healthcare professionals were urged to keep clinic visits to an absolute minimum to minimize the risk of infection to patients. However, a concern about remote spirometry modality is related to patient compliance remains valid: will patients perform spirometry maneuvers remotely while unsupervised? METHODS We analyzed remote spirometry compliance data from 2 clinical trials of patients with mild to moderate asthma conducted in the US and 1 in the UK. The former were single centers studies of 28-day duration and recruited 32 subjects. The latter was a multicenter study which recruited 39 subjects for 5-6 months;however only the first 28-day treatment data was analyzed to match the timeframe of the other studies. The study subjects received both experimental and standard of care treatments. All study subjects were instructed to perform pulmonary function tests at home twice daily, received a handheld spirometer, a dedicated smart phone along with training how to perform spirometry maneuvers remotely. All studies deployed mobile spirometer devices that synchronize with the smartphone application. Patients were asked to contribute spirometry data at predefined time windows (morning and evening). Compliance rates were calculated as a percentage of pulmonary function tests comprising a minimum of 2 complete maneuvers twice daily versus twice days on study. RESULTS The twice daily data compliance across three studies was 88.9%, the compliance for performing spirometry maneuvers within the specified time windows was 85% and compliance for no missing day during the study period was 83%. Additionally, we analyzed the number of compliant subjects over time across all studies: the number of compliant subjects did not decline over the period of 28 days. Moreover, the compliance analysis stratified by the time of the day and weekday/weekend demonstrated no difference in compliance. CONCLUSIONS Our results demonstrate good compliance for remote spirometry data collection for 28-day period indicating that remote spirometry data collection is feasible in the multi-center clinical trials recruiting asthma patients. .

Reducing barriers to learning with ebooks: An internationally accessible and affordable resource

Introduction: Training in Urology is often limited at an undergraduate level, especially in the wake of the COVID-19 pandemic. It is not uncommon that a trainee's first experience of Urology is when they encounter urological patients as a clinician and studies have revealed that graduates are lacking knowledge and confidence in managing urological pathology. Many trainees across the world are unable to access vital learning resources to address this gap in knowledge due to exorbitant prices set by publishing companies. Method: To address the need for affordable standardised education, 'Urology for Medical Students and Junior Doctors' was created. This self-published eBook was written and peer-reviewed by urologists to create a relevant learning resource that is affordable for all. Results: Over 1000 copies of the eBook were downloaded in the first 90 days after publication by trainees across the world. It has been downloaded internationally by a diverse range of allied healthcare professionals. All profits generated from sales are donated to charities investing in medical education. Conclusions: This eBook stands as an example of how we as educationalists and clinicians can produce affordable learning resources for trainees worldwide;standardising training, improving patient safety and reducing barriers to learning.

AKI lingering in a patient with novel coronavirus

Introduction: Renal manifestations of the novel Coronavirus infection has been reported during the actual pandemic. While the renal injury was more pronounced in critically ill patients, the levels of AKI, proteinuria and hematuria predicted the severity of the infection. We are reporting a severe case of AKI and proteinuria with SARS-CoV- 2 infection out of proportion of its clinical manifestation. Case Description: This is a 55 year old African American male patient with PMH of hypertension, aortic valve replacement on Warfarin anticoagulation and CKDIII-b with baseline eGFR of 50 ml/min/1.73m2 (creatinine of 1.5 mg/dL) and recent diagnosis of COVID-19 related gastroenteritis 10 days prior to presentation, was admitted with general malaise and decreased intake. He had no cardiac nor respiratory symptoms. He was afebrile and physical examination was non remarkable. His labs were significant for BUN level of 129 mg/dL and creatinine of 22.0 mg/dL. His blood glucose was 88 mg/dL. Urinalysis showed glucose 100 mg/dL, 0-3 RBCs, 3-10 WBC with a protein/creatinine ratio of 12.8 g/g. His renal ultrasound showed increased cortical echogenicity with edema. His serological workup was unrevealing with negative hepatitis B and C testing, low ASO levels, negative ANA, Anti-PR3, Anti-MPO and Anti-GBM antibodies. He had normal C3, C4 and negative serum immunofixation with free Kappa/lambda ratio of 1.7. His Alb was 1.7g/dL with triglycerides levels of 184 mg/dL. A kidney biopsy was deferred for its high complication risk. Repeatedly, the patient tested positive for SARS-CoV-2 on reverse transcription polymerase chain reaction assay with a nasopharyngeal swab. During the hospital stay, the patient was non-oliguric and afebrile and was treated with supportive medical care. On day 8 of hospitalization, his labs showed creatinine of 14 mg/dL and BUN of 99 mg/dL with persistent proteinuria estimated at 14 g/g. At present, he continues to asymptomatic and is being monitored outpatient for his kidney recovery. Discussion: Variable histopathological lesions (FSGS, collapsing glomerulopathy, podocytopathy and tubular interstitial disease) has been described in the renal manifestations of the novel coronavirus. While its physiopathological mechanisms remain unclear, the severity of proteinuria and renal injury observed in this clinically asymptomatic patient highlight an unusual infection-driven mechanism.

Virtual postgraduate exams and assessments: the challenges of online delivery and optimising performance.

The COVID-19 pandemic has catalysed the computerisation and online delivery of postgraduate examinations. Social distancing regulations and lockdown measures resulted in many written and clinical examinations being cancelled during the initial surge of the virus. In an effort to reinstate the assessment of trainees and enable career progression, the UK medical regulator, the General Medical Council (GMC) has approved unprecedented changes to clinical examinations, including virtual assessment. We outline the changes made and the advantages and disadvantages of these new examination formats. We discuss ways for candidates and examiners to optimise their virtual environment and develop skills that can improve performance.

Surgical training during the COVID-19 pandemic: preparing for future uncertainty.

The COVID-19 pandemic has brought unprecedented changes in healthcare and surgical training, with elective operating reduced or stopped, conferences rearranged and examinations cancelled. Trainees and trainers have adapted, creating innovative and resourceful ways to continue learning, enabling progression through surgical training. With rising COVID-19 cases across the world and further waves of infections likely, we reflect on recent changes to surgical training and discuss how best to support the next generation of surgeons during this period of uncertainty.

A critical review of urological practice during the coronavirus disease 2019 pandemic and the emerging role of telemedicine

The recent coronavirus disease 2019 outbreak was met by major reconfiguration of Urology health care services with cancellation of elective surgery and deployment of non face to face models for providing outpatient care. Urologists were faced with challenging decisions to stratify their patients into risk groups for assigning the appropriate, safe method of care delivery. Guidelines were swiftly produced by Urological societies to enhance this process but there has been limited uniformity and multiple publications from several institutions. We have conducted this critical review to appraise the current recommendations for providing Urology care during the coronavirus disease 2019 pandemic. The secondary outcome was identifying novel models for care delivery. Results were presented in tables categorising the recommendation by disease and its risk stratification. Results were presented according to the aspect of care: triage for surgery, operative, post-operative and outpatient care. This review reported differing recommendations from Urological societies on the prioritisation of services with limited consideration for individual patient-related factors. Telemedicine has been utilised well during the pandemic to maintain patient pathways. The role of telemedicine in future Urological practice looks promising and more development is required.Level of evidence:Not applicable.

Estradiol, Progesterone, Immunomodulation, and COVID-19 Outcomes.

Severe outcomes and death from the novel coronavirus disease 2019 (COVID-19) appear to be characterized by an exaggerated immune response with hypercytokinemia leading to inflammatory infiltration of the lungs and acute respiratory distress syndrome. Risk of severe COVID-19 outcomes is consistently lower in women than men worldwide, suggesting that female biological sex is instrumental in protection. This mini-review discusses the immunomodulatory and anti-inflammatory actions of high physiological concentrations of the steroids 17ß-estradiol (E2) and progesterone (P4). We review how E2 and P4 favor a state of decreased innate immune inflammatory response while enhancing immune tolerance and antibody production. We discuss how the combination of E2 and P4 may improve the immune dysregulation that leads to the COVID-19 cytokine storm. It is intended to stimulate novel consideration of the biological forces that are protective in women compared to men, and to therapeutically harness these factors to mitigate COVID-19 morbidity and mortality.

Operating during the COVID-19 pandemic: How to reduce medical error.

Our professional and private lives changed on March 11 2020 when the coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO. By March 16, surgical training was suspended, MRCS and FRCS examinations cancelled and all courses postponed. In theory, essential cancer surgery, emergency and trauma operating will continue. All elective, non-essential cases are currently cancelled. While we adapt to our new ways of working, we remind ourselves that surgeons are flexible, resilient and, ultimately, we are doctors in the first instance. We present a short article on operating during the COVID-19 pandemic.

The effects of COVID-19 on training within urology: Lessons learned in virtual learning, human factors, non-technical skills and reflective practice

The COVID-19 pandemic has changed training and recruitment in urology in unprecedented ways. As efforts are made to ensure trainees can continue to progress, lessons can be learned to improve training and urological practice even after the acute phase of the pandemic is over. Novel methods of education through virtual learning have burgeoned amidst the social distancing the pandemic has brought. The importance of training in human factors and non-technical skills has also been brought to the fore while operating under the constraints of personal protective equipment and working in new teams and unfamiliar environments. This paper critically appraises the available evidence of how urological training has been affected by COVID-19 and the lessons we have learned and continue to learn going forward.Level of Evidence:Not Applicable.