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Introduction: In 2020, stroke and ambulance clinicians in North Central (NC) London and East Kent introduced prehospital video triage, which permitted stroke specialist assessment of suspected stroke patients on scene. Key aims included reducing conveyance of non-stroke patients to stroke services and reducing transmission of Covid-19. Method(s): Rapid, mixed-method evaluation of prehospital video triage in NC London and East Kent (conducted July 2020-September 2021), drawing on: * Interviews with ambulance and stroke clinicians (n=27);observations (n=12);documents (n=23). * Survey of ambulance clinicians (n=233). * Descriptive analysis of local ambulance conveyance data (n=1,400;April-September 2020). * Difference-in-differences regression analysis: team-level national audit data, assessing changes in delivery of clinical interventions in NC London and East Kent relative to elsewhere in England (n=137,650;2018-2020). Result(s): Clinicians perceived prehospital video triage as usable, safe, and preferable to 'business-as-usual'. Several interrelated factors influenced implementation: impetus of Covid- 19, facilitative local governance, receptive professional values, engaging clinical leadership, active training approaches, and stable audio-visual signal. Stroke clinician capacity was a risk to sustainability. Neither area saw increased time from symptom onset to arrival at services. Delivery of clinical interventions either remained unchanged or improved significantly, relative to elsewhere in England. Conclusion(s): Prehospital video triage in NC London and East Kent was perceived as usable, acceptable, and safe;it was associated with some significant improvements in secondary care processes. Key influences included national and local context, characteristics of triage services, and implementation approaches.
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Viruses: From Understanding to Investigation, Second Edition presents the definitions and unique characteristics of viruses. The book includes major topics such as virus lifecycle, structure, taxonomy, evolution, history, host-virus interactions, and methods to study. In addition, the book assesses the connections between the aforementioned topics and provides an integrated approach and in-depth understanding of how viruses work. The new edition also provides an expanded methods chapter containing new information on deep sequencing for in virus identification, mathematical formulas to calculate titers and a description of quantitiative PCR for enumerating viruses. The vaccine chapter has been updated to include vaccine efficacy, mRNA vaccines and SARS-CoV-2 vaccine development. The viral pathogenesis chapter has been expanded to include mechanisms of virally induced cancers. Viral taxonomy sections have been updated and chapters revised to accommodate new virus family designations. New chapters include nucleocytoplasmic viruses (very large DNA viruses), replication of viroids and COVID-19/SARS-CoV-2. © 2023 Elsevier Inc. All rights reserved.
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BACKGROUND: In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene. OBJECTIVE: To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent. DESIGN: A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality);acceptability (whether or not clinicians want to use it);impact (on outcomes, safety, experience and cost-effectiveness);and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23);a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400;April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650;July 2018 to December 2020). RESULTS: (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability - relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for 'refresher' courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability - most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety - clinical leaders monitored and managed potential patient safety issues;clinicians felt strongly that services were safe. Implementation - several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact on safety and quality: we found no evidence of increased times from symptom onset to arrival at services or of stroke clinical interventions reducing in studied areas. We found several significant improvements relative to the rest of England (possibly resulting from other service changes). LIMITATIONS: We could not interview patients and carers. Ambulance data had no historic or regional comparators. Stroke audit data were not at patient level. Several safety issues were not collected routinely. Our survey used a convenience sample. CONCLUSIONS: Prehospital video triage was perceived as usable, acceptable and safe in both areas. FUTURE RESEARCH: Qualitative research with patients, carers and other stakeholders and quantitative analysis of patient-level data on care delivery, outcomes and cost-effectiveness, using national controls. Focus on sustainability and roll-out of services. STUDY REGISTRATION: This study is registered as PROSPERO CRD42021254209. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 26. See the NIHR Journals Library website for further project information.
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Social prescribing is a fundamental aspect of the NHS Long Term Plan. The roll-out of social prescribing is underpinned by the belief that individuals have the capacity to define and solve their own problems and that local communities are rich in social assets, skills and talents which can be tapped into to enhance and improve health and wellbeing. Social Prescribing Link Workers (SPLWs) aim to focus on what matters to each client holistically, looking at social, economic and environmental factors and creating personalised care plans to improve wellbeing linking in to local community resources and assets. This philosophy aligns with both the person centred ethos of hospice care and the Public Health model of Palliative Care. Aims To adopt a partnership approach to develop and deliver social prescribing through hospice partnerships with local VCSE organisations and local PCNs to develop and deliver social prescribing. Commitment to learning and developing together rather than 'doing' social prescribing through service provision, drawing on the strengths of the local community and the partner organisations. Actions•Social prescribers in post fully funded through PCN with commitment for five years - links built with GPs, hospice and other services.•Partnership approach embedded, service launch in March 2020 - impacted by COVID-19 pandemic, an opportunity and a threat. Outcomes•Social prescribing now embedded in local community and GP practices. Over 500 referrals received in year 1: bereavement, end-of-life care plans, carers support identified as some of the key challenges people face.•Data and case studies support difference Social Prescribing is making on individual and system perspective.•NHS Graduate evaluation report completed. Conclusion Involvement in a partnership approach to social prescribing is supporting the hospice in facilitating a public health model to palliative and end-of-life care being adopted as part of the wider system change.
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Background: Chronic lymphocytic leukemia (CLL) and myelodysplastic syndromes (MDS) are two of the most frequent hematological malignancies. CLL and MDS are also considerably heterogeneous in terms of clinical course and response to treatment, ranging from relatively indolent to extremely aggressive. Thus, open issues abound regarding the impact of CLL and MDS and their treatment on patients' quality of life (QoL). Patient-reported outcomes (PROs) have been identified as an emerging paradigm, aiming to capture the patient's perspective onselfassessed health status. Obviously, these data are critical with regards to the evaluation of the treatment effects and the patients' QoL, while also enabling the positioning of the patient as a key stakeholder within the healthcare decision making process. Novel methodologies and eHealth approaches can be valuable for the adoption of the PRO paradigm in real-world settings as they can promote richer, less obtrusive and preemptive communication which could facilitate early recognition of potential symptoms of disease or treatment adverse effects (e.g., adverse drug reactions, lack of physical activity, worsening of QoL etc.). Aims: In this , we present the lessons learned thus far from the implementation of the MyPal project, a Horizon 2020 Research & Innovation Action aiming to foster palliative care for patients with CLL and MDS by leveraging the ePRO paradigm. Methods: MyPal aspires to empower patients and their caregivers to more accurately capture their symptoms/conditions, communicate them in a seamless and effective way to their healthcare providers (HCPs);and, ultimately, to foster action through advanced methods of identification of important deviations relevant to the patient's state and QoL. To this end, MyPal developed a technical platform including a mobile app for patients with CLL and MDS, collecting information via standardized questionnaires and other information sources (e.g., wearable sensors), also enabling spontaneous symptoms reporting, educational material provision, motivational messages, discussion guides, notifications etc. A data intensive web-based dashboard platform is also provided for healthcare professionals, providing real-time analytics, enabling a better view of collected PROs and other relevant information on patients' health status. Currently, a randomised clinical study is being conducted in 4 European countries to evaluate the proposed intervention and its potential impact on patients' QoL. Results: Based on this experience, a number of key issues have emerged: (a) while patients are generally positive about the use of eHealth, they are still reluctant about engaging in eHealth clinical studies;(b) digital literacy levels differ across different age groups as well as among different cultural contexts;(c) the COVID-19 pandemic seriously hindered patient recruitment due to the widely adopted recommendations for patients to avoid visits to hospitals unless absolutely necessary but (d) the COVID-19 pandemic also highlighted the potential benefits for HCPs of using eHealth tools in order to deliver patient care in a more decentralized and patient-centric fashion. Summary/Conclusion: In conclusion, MyPal is likely to provide important new evidence about how digital health systems can be used to improve QoL and facilitate better communication between patients with hematological malignancies and HCPs.
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Background: In 2020, North Central (NC) London and East Kent introduced prehospital video triage, where stroke and ambulance clinicians used videoconferencing to assess suspected stroke patients on scene. The aim was to reduce conveyance of non-stroke patients to stroke services and reduce transmission of Covid-19. Methods: Rapid, mixed-method evaluation of prehospital video triage in NC London and East Kent (July 2020-September 2021), drawing on: • Interviews with ambulance and stroke clinicians (n=27);observations (n=12);documents (n=23);• Survey of ambulance clinicians (n=233) in NC London and East Kent. • Descriptive statistical analysis of local ambulance conveyance data (n=1,400;April-September 2020). • Difference-in-differences regression analysis of team-level national audit data, to understand changes in delivery of clinical interventions in NC London and East Kent relative to the rest of England (n=137,650;2018-2020). Results: Interview and survey data suggested clinicians perceived prehospital video triage as usable, safe, and preferable to 'business-as-usual'. Several interrelated factors influenced implementation, including impetus of Covid-19, facilitative local governance, receptive professional values, engaging clinical leadership, active training approaches, and stable audiovisual signal;stroke clinician capacity was a potential risk to sustainability. Neither area saw increased time from symptom onset to arrival at services, while delivery of clinical interventions either remained unchanged or improved significantly, relative to the rest of England. Conclusions: Prehospital video triage in NC London and East Kent was perceived as usable, acceptable, and safe;it was associated with some significant improvements in secondary care processes. Key influences included national and local context, characteristics of triage services, and implementation approaches.
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Without always knowing its source, contemporary commentators often invoke some variant of the expression 'dark night of the soul' in trying to characterize the multiple crises of our times, including the COVID-19 pandemic and its economic consequences, global warming and environmental degradation, a renewed reckoning with systemic racism, and political unrest of all sorts. This paper recalls the origins and understanding of the 'dark night' symbol and terminology in the writings of John of the Cross. After presenting an overview of the relevant Sanjuanist texts, especially the treatise known to us as The Dark Night of the Soul, as well as a concise summary of John's main teachings therein, this paper looks at how these have come to be applied (and perhaps sometimes misapplied) today, raising several critical questions and paying special attention to the ways in which John's sixteenth-century message might help us weather our 21st-century storms.
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Background: The Coronavirus Disease 2019 (COVID-19) pandemic has caused unprecedented disruption to the delivery and usage of healthcare services worldwide. Given that most people spend their last year of life at home, the delivery of out-of-hours (OOH) care is vital, yet little is known about such care. Aim: To examine the response to, and impact of, the COVID-19 pandemic on community OOH hospice services. Method: An online questionnaire, containing open and closed questions, was circulated by email to 150 managers of UK adult hospices providing OOH palliative care in October 2020. Questions, adapted from COVPALL (Higginson et al. 2020), concerned service configuration, patient referral and staffing. Descriptive analysis was undertaken with quantitative and qualitative data. Results: 47/150 responses contained COVID-19 data. All of these hospices had experienced COVID-19 cases among patients and staff. Several had rapidly implemented changes such as redeployment of staff (n=7), developed new services or expanded existing services (n=11), and risk assessment for COVID-19 among staff and patients (n=12). Whilst hospices reported that they were responsive and flexible to patient and family needs;staffing issues (n=21) and procurement/use of personal protective equipment (n=17) posed considerable challenges to service delivery. Conclusion / Discussion: The COVID-19 pandemic has resulted in a reactive response from hospices to ensure the continued delivery of OOH services, the implications of which are unknown. However, such rapid change highlights opportunities to review and redesign how OOH palliative care is delivered.
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Background: As the COVID-19 pandemic evolves healthcare organizations in the UK, US, and Europe have called for greater access to palliative care. This call has been echoed by palliative care practitioners in the low- and middle-income countries (LMICs). While the need for palliative care may be universal, there are cultural and resource differences between the high-income countries where palliative care and its ethical principles was first developed and the LMICs. These differences may have an impact on the application of ethical principles to palliative care which could hamper efforts to deliver palliative care in areas where the need is greatest. Many key challenges to the delivery of palliative care in LMICs, particularly during public health emergencies, remain unaddressed and in some cases, unidentified. Aims: To review the literature on the delivery of palliative care in public health emergencies and the COVID-19 pandemic. We sought to identify key challenges and questions on how LMICs should deliver culturally sensitive, ethically acceptable palliative care at scale. Approach taken: We conducted a search of the recent literature on the challenges of delivering palliative care in public health emergencies such as the COVID-19 pandemic. Our analysis grouped the challenges according to emergent themes. We then defined questions with which to interrogate each theme, and the components that must be investigated to answer the questions. Results: Four challenge themes and defining questions to be addressed were identified. Conclusion: To deliver palliative care successfully during public health emergencies in resource-poor settings, several questions have to be considered. Answering these questions will require targeted research and discussion across disciplines and around the world.
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Introduction: The medical professional at a direct clinical interface with COVID 19 has been under enormous strain. But how has the pandemic impacted urologists whose skills may have been under-utilized? Materials and Methods: An online survey was emailed to BAUS trainee and consultant members between the first and second pandemic lockdowns. Data were sought regarding individuals' views on work/life balance (WLB) before and after the lockdown on a 10-point Visual Analogue Scale (VAS);0 was biased towards "work" and 10 towards "life". Mean scores were analyzed for trainees and then in quinquennials from consultant appointment, up to 20 years. Data were also sought regarding the impact of lockdown on consultants' views of retirement in the same groupings. Results: 59 trainees and 261 consultants responded to the pre- and post-lockdown WLB questions and 324 consultants to the question about retirement intentions. Work/Life balance was positively influenced across all groups during the first lockdown (table 1), whilst consultants in post for >11 years considered their lockdown experiences an influence to consider earlier retirement (table 2). Conclusions: Urologists' WLB improved during lockdown but more senior consultants questioned their desire to continue working. This data concurs with the GMC's. 'The state of medical education and practice in the UK 2020' report which demonstrates that specialist doctors were poorly re-deployed, possibly with underemployment, during lockdown. Deployment to a protected elective treatment environment would appear to be the best way of utilizing a specialist surgical workforce during emergency crises and, maybe, for the long-term.