Feedback on post COVID-19 rehabilitation.

The outbreak of Coronavirus Disease 19 (COVID-19) following the Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) viral infection has placed particular pressure on occidental health systems, especially in terms of acute care resources and critical care skills. A number of affected patients subsequently required a rehabilitation process, due to multiple functional limitations, either as a result of an extended stay in intensive care or the consequences of the infection itself. The aim of this article is to report on the Geneva experience in post COVID19 rehabilitation, through 2 clinical vignettes, illustrating the heterogeneity of symptoms and deficits that may be encountered following this disease.Copyright © 2020 Editions Medecine et Hygiene. All rights reserved.

The value of sick pay

Not all countries provide universal access to publicly funded paid sick pay. Amongst countries that do, compensation rates can be low and coverage incomplete. This leaves a significant role for employer-provided paid sick pay in many countries. In this paper, we study who has access to employer-provided sick pay and how much it is valued by workers for themselves and others. We find that workers in jobs with high contact to others are particularly unlikely to have employer provided sick pay, as are economically insecure workers who are least able to afford unpaid time off work. We find that workers without sick pay are more likely to say that they will work when experiencing cold-like symptoms and are less willing to expose themselves to health risks at work during the pandemic. Using vignettes, we reveal that large shares of workers have a very high, but even more have a very low willingness to sacrifice earnings for access to sick pay. Together our findings highlight the unequal distribution of access to sick pay and the potentially strong negative externalities of not providing it publicly. The pandemic may have made these issues more salient as perceived probabilities of having to self-isolate are positively related to support for publicly provided sick pay. Finally, we find that providing information on the health externality of paid sick leave increases support for the public provision of sick pay, suggesting that there might be a public under-provision because individuals do not factor in the externalities. © 2022 The Authors

Relating in online body psychotherapy: 'Are you there?'

For body pychotherapists (as well as other therapy practitioners working expressly with the body), the unprecedented challenges which have arisen from having to relate via the screen has given rise to much debate and confusion about the efficacy of any somatic-centred therapeutic process offered online. For practitioners accustomed to working with the energies and expressions of the body, what happens to us and our clients when we work in a context wherein the body cannot wholly be seen (and can certainly not be touched)? This article will explore the some of the common threads which have been emerging for practitioners and clients who are working virtually in online body psychotherapy sessions. By integrating theory, clinical vignettes and the author's personal reflections (as therapist and as client), the author will address some of the arising issues and establish ground for further debate on the implications of relating online via virtual platforms. Copyright © 2022 Informa UK Limited, trading as Taylor & Francis Group.

Elicitation of Health State Utility Values in Retinitis Pigmentosa by Time Trade-off in the United Kingdom.

Introduction: Retinitis pigmentosa (RP) is an inherited retinal pathology associated with "night blindness" and progressive loss of peripheral vision, in some cases leading to complete blindness. Health state utility values are required for activities such as modelling disease burden or the cost-effectiveness of new interventions. The current study aimed to generate utility values for health states of varying levels of functional vision in RP, with members of the general public in the UK. Methods: Five health states were defined according to standard clinical measures of visual ability. Health state descriptions were developed following interviews with patients with RP in the UK (n=5). Further interviews were conducted for confirmation with healthcare professionals with specific experience of managing patients with RP in the UK (n=2). Interviews with members of the general public in the UK were conducted to value health states. A time trade-off (TTO) process based on the established Measurement and Valuation of Health (MVH) protocol was used. Due to the ongoing COVID-19 pandemic, all interviews were web-enabled and conducted 1:1 by a trained moderator. Results: In total, n=110 TTO interviews were conducted with members of the UK general public. Mean TTO utility values followed the logical and expected order, with increasing visual impairment leading to decreased utility. Mean values varied between 0.78 ± 0.20 ("moderate impairment"), and 0.33 ± 0.26 ("hand motion" to "no light perception"). Supplementary visual analogue scale (VAS) scores also followed the logical and expected order: mean VAS values varied between 47.95 ± 15.38 ("moderate impairment") and 17.22 ± 12.49 in ("hand motion" to "no light perception"). Discussion: These data suggest that individuals living with RP have substantially impaired quality of life. Utility values for RP have been elicited here using a method and sample that is suitable for economic modelling and health technology assessment purposes.

Learning from each other: leaders' social representations of career beginners and career beginners' self-assessment

Today's youth face prejudice and stereotyping in the workplace;in times of crisis, such as the COVID-19 pandemic, their prevalence and strength may increase. We conducted a qualitative study of social representations of key exchange partners - leaders and career beginners. In the first phase, we conducted semi-structured interviews to identify the dominant social representations that small business leaders (N = 9) hold about career beginners. In the second phase, we examined how future career beginners (N = 26) responded to five hypothetical work situations based on the leaders' social representations. The social exchange partners shared the narrative that career growth, advancement, and financial incentives are important motivators for career beginners, but contradicted each other in their accounts of career beginners' initiative levels and in their accounts of preferred leadership styles. The findings help to raise awareness of the mutual representations and expectations of different age groups in the work context.

The value of sick pay

Not all countries provide universal access to publicly funded paid sick pay. Amongst countries that do, compensation rates can be low and coverage incomplete. This leaves a significant role for employer-provided paid sick pay in many countries. In this paper, we study who has access to employer-provided sick pay and how much it is valued by workers for themselves and others. We find that workers in jobs with high contact to others are particularly unlikely to have employer provided sick pay, as are economically insecure workers who are least able to afford unpaid time off work. We find that workers without sick pay are more likely to say that they will work when experiencing cold-like symptoms and are less willing to expose themselves to health risks at work during the pandemic. Using vignettes, we reveal that large shares of workers have a very high, but even more have a very low willingness to sacrifice earnings for access to sick pay. Together our findings highlight the unequal distribution of access to sick pay and the potentially strong negative externalities of not providing it publicly. The pandemic may have made these issues more salient as perceived probabilities of having to self-isolate are positively related to support for publicly provided sick pay. Finally, we find that providing information on the health externality of paid sick leave increases support for the public provision of sick pay, suggesting that there might be a public under-provision because individuals do not factor in the externalities.

Between Waves: LINC Instructors' Perspectives on Pandemic Teaching

The 2020 outbreak of the global COVID-19 pandemic imposed emergency remote teaching on adult English as a second language (ESL) programs globally, creating unprecedented challenges not only for language learners but also for instructors. Immense difficulties were produced in the collision between a biological hazard (the novel coronavirus) and the power-inflected social structures that organize language teaching in different locales. In this paper I explore some impacts of the pandemic on three instructors in the single largest adult ESL program in Canada, Language Instruction for Newcomers to Canada (LINC). Grounded in an account of the historical origins and development of the LINC program, a reflexive thematic analysis of instructor responses to vignettes of resonant challenges identified three major issues that were intensified by the pandemic: navigating digital inequities, balancing the teaching of digital literacies and language teaching in an accountability framework, and managing boundaries and expectations. These results are contextualized in the larger conversations around LINC and adult ESL programming globally, and some implications and new directions for the post-pandemic landscape now visible on the horizon are also considered.

Relating in online body psychotherapy: 'Are you there?'

For body pychotherapists (as well as other therapy practitioners working expressly with the body), the unprecedented challenges which have arisen from having to relate via the screen has given rise to much debate and confusion about the efficacy of any somatic-centred therapeutic process offered online. For practitioners accustomed to working with the energies and expressions of the body, what happens to us and our clients when we work in a context wherein the body cannot wholly be seen (and can certainly not be touched)? This article will explore the some of the common threads which have been emerging for practitioners and clients who are working virtually in online body psychotherapy sessions. By integrating theory, clinical vignettes and the author's personal reflections (as therapist and as client), the author will address some of the arising issues and establish ground for further debate on the implications of relating online via virtual platforms. Copyright © 2022 Informa UK Limited, trading as Taylor & Francis Group.

Perinatal patients with symptoms of anxiety

This chapter provides descriptions, typical clinical presentations, and case reviews of perinatal anxiety and perinatal obsessive-compulsive disorder. The discussed anxiety disorders include generalized anxiety disorder, panic disorder, and illness anxiety disorder as encountered in the perinatal period including pregnancy and 12 months' postpartum. Suggestions for provider advocacy during increased rates of intimate partner violence during COVID-19 are provided. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

COMPLICATED COMMUNICATIONS DURING THE PANDEMIC

CASE: The Pandemic has been one of the greatest challenges in health care. Communication is the most vital part of the patient visit. The pandemic hindered the doctor-patient communiciation in unimaginable ways. Besides using Televisits with its new set of challenges, I present these clinic visits with complicated communication. Case 1-Deaf mute patient 45 year male deaf mute with chronic kidney disease stage 3a with hypertension and med "non compliance." The interpreter used Americal sign language along with lip reading. Lip reading is hindered by the standard mask. This interpreter used a special type of lip tranparent mask. We discovered that the patient was confused regarding the BP medications attributing to his non compliance. Repeat BP check at 1 and 3 months was at goal after he understood the instructions. Other patients also found the lip transparent mask to be useful when they had hearing deficit or English accent problem and relied on lip reading for communication. Case 2-Grieving 42 year old Spanish only speaking lady just lost her husband to COVID. She herself was recovering from COVID and was grieving. Computer based interpreter was used along with social distancing and shield and mask. This made comforting the patient challenging. Case 3-Computer based interpreters A 28 year female patient speaking only Amharric had breast pain. I used computer based interpreter with audio only option and kept the video off, especially during the physical examination. 89 year Vietnamese only speaking male had multi organ failure. I had to use the computer based interpreter to explain the situation to him and family and offer them hospice. Hospice concept was totally new to them. They were committed to caring for him at home and felt that hospice was an intrusion that God did not want and was not culturally acceptable. Today they are happy with home hospice care. Case 4-Intellectually challenged patients-Cerebral palsy 40 year aphasic male with cerebral palsy came with his host caregiver. Patient had open sores on his neck that he had been scratching. He was cooperative but was pulling at his mask and was unable to understand my simple instructions through my mask and shield. IMPACT/DISCUSSION: Clear communication is a key to a good clinic visit and patient and provider satisfaction. Low English proficiency (LEP) is a road block that we try to overcome by using interpreters. This vignette is an excellent demonstration of challenges to communication that we encountered during the pandemic. Publication here will give an opportunity to identify with our struggles, exchange ideas and help our trainees. CONCLUSION: Wearing mask and social distancing saved countless lives during the COVID pandemic.It presented unprecendented challenges to doctor-patient communication. It is important to anticipate, understand and educate our learners about these challenges and continue to provide culturally competant care.

High Flow Nasal Cannula Use: A Survey on Weaning Practices

Rationale: High flow nasal cannula (HFNC) is first line therapy for patients with acute hypoxic respiratory failure (AHRF). HFNC utilization among hospitalized patients with AHRF has increased substantially during the COVID-19 pandemic. While good evidence exists to guide initiation of HFNC, evidence-based strategies for HFNC weaning are lacking. Therefore, we sought to characterize HFNC weaning practices among respiratory therapists (RTs) to determine the degree of practice variability and assess general approaches to HFNC weaning. Methods: We conducted a cross-sectional survey evaluating HFNC weaning practices of adult inpatient RTs at an academic, tertiary care medical center in the United States. Survey participants were asked about their practice of HFNC weaning and whether use of an institutional protocol provided guidance for HFNC weaning. Survey questions also assessed RT knowledge of institutional policies regarding HFNC use in hospitalized patients, including location of HFNC use within the hospital, personnel involved in HFNC titration, and methods of weaning through clinical vignettes. Survey responses were analyzed using descriptive statistics. Results: Overall, 21 of 68 RTs surveyed completed the survey (response rate 31%). The majority of participants (95%) worked primarily in an ICU, general wards, or emergency department. Approximately one-third of participants were unaware of a HFNC weaning protocol at their institution. Among those who endorsed the existence of a HFNC weaning protocol at their institution, 79% reported using the protocol “always or often.” We found substantial variation in RT knowledge of institutional policies regarding which practitioners were permitted to wean HFNC, with approximately one-half of participants believing that any practitioner could wean FiO2 and 43% believing that only RTs could wean flow. Additionally, participants' approaches to weaning varied substantially in response to clinical vignettes. For example, in the vignette of a clinically stable patient on HFNC at 60L and 100%, 62% of participants chose to wean only FiO2, 14% to wean only flow, and 24% to wean both. Conclusion: Nearly one-third of respiratory therapists were unaware of the existing HFNC weaning protocol at their institution, potentially contributing to the substantial variability in HFNC weaning practices between surveyed RTs. More research is needed to identify and successfully implement optimal weaning strategies for HFNC among patients hospitalized with AHRF.

Who Should Get Vaccinated First? Limits of Solidarity during the First Week of the Danish Vaccination Programme

The coronavirus disease 2019 (COVID-19) pandemic resulted in several acute shortages of healthcare provision and thereby posed a challenge to solidarity among citizens of welfare states. One example was the limited number of vaccine batches at the outset of European COVID-19 vaccination campaigns. This resulted in a rare constellation in which citizens faced both a unifying collective threat but also a scarcity of healthcare resources that necessitated the prioritization of certain groups for an early vaccination. On that premise, we conducted a survey experiment during the first week of the Danish vaccination programme. Our results demonstrate that citizens judged who deserves early access to preventive healthcare along established lines of welfare chauvinism. Fictitious diabetes patients with a Muslim name and those who recently immigrated were regarded as less deserving of an early vaccination. That said, concerns over responsibility for one's hardship and anti-social free-rider behaviour drive citizens considerations, too. Contra our hypotheses, we find only weak evidence that immigrants or Muslims are penalized more harshly for an irresponsible lifestyle or free-rider behaviour. Compared with previous research, we study a unique moment in history and are the first to disentangle minority status from stereotypes about their anti-social free-riding behaviour and irresponsibly unhealthy lifestyles.

Feedback on post COVID-19 rehabilitation

The outbreak of Coronavirus Disease 19 (COVID-19) following the Severe Acute Respiratory Syndrome-Coronavirus 2 (SARS-CoV-2) viral infection has placed particular pressure on occidental health systems, especially in terms of acute care resources and critical care skills. A number of affected patients subsequently required a rehabilitation process, due to multiple functional limitations, either as a result of an extended stay in intensive care or the consequences of the infection itself. The aim of this article is to report on the Geneva experience in post COVID19 rehabilitation, through 2 clinical vignettes, illustrating the heterogeneity of symptoms and deficits that may be encountered following this disease.

Development of a Blended Learning Module in the PJ Elective Family Medicine

Background Due to the decentralized distribution of family medicine teaching practices in Thuringia and against the background of the SARS-CoV-2-restrictions, the academic teaching of students during the practical year was complemented by a blended learning (BL) format in order to enable time- and location-independent learning. BL refers to the combination of classroom and synchronous or asynchronous online learning situations. This article describes the development, implementation and evaluation of an accompanying seminar in the BL-format. Methods The didactic concept was based on the constructive alignment. To achieve the learning objectives, the approach of case-based learning was chosen. In the initial online-phase, a corresponding learning environment with a virtual case was created. In different folder levels, students found a welcome field, organizational information, and the patient record with a link to the virtual work platform where assignments were completed. In the subsequent presence-phase, knowledge was secured via mc questions and the aspects resulting from the assignments were processed and discussed. Results The course reached a total of nine medical students in their practical year. A cardiovascular clinical case was chosen for the vignette. In addition to evaluating an ECG, cardiovascular risk scores were to be calculated, laboratory values interpreted, and medication suggestions provided. The sequence was designed in such a way that the students, guided by questions, elaborate the workflow of a family physician in a structured way. In the presence-phase, the acquired knowledge is secured and discussed. Overall, the majority of the nine students agreed with the positively formulated statements on the digital learning environment. Conclusions The described BL-module proved to be suitable to bring casebased learning into a digital framework, to further use the advantages of face-to-face teaching and to respond to the decentralized distribution of teaching practices in family medicine in Thuringia.

TCTAP C-005 Conundrum of a ‘Primary’ Angioplasty: Provisional Stenting of Left Main Stem / Left Anterior Descending During STEMI With Double Bifurcation

Clinical Information Patient Initials or Identifier Number: R Relevant Clinical History and Physical Exam: A 64-year-old lady with underlying dyslipidemia presented to our emergency department with typical chest pain. Immediate electrocardiogram was performed which showed sinus rhythm, ST elevation at lead 1, aVL and V1, hyperacute T wave at V2 till V3 with ST depression at leads II, III and aVF. Hence a diagnosis of acute anterolateral myocardial infarction, Killip 1 was given and urgent referral to cardiologist was made. Subsequently, she was subjected for primary angioplasty. Relevant Test Results Prior to Catheterization: Blood results showed sodium of 134 mmol/L, potassium of 3.5 mmol/L, urea of 3.2 mmol/L and creatinine of 67 mmol/L. Liver enzymes were within normal limits with aspartate transaminase of 38 U/L and alkaline phosphatase of 91 U/L. Creatinine kinase was 330 U/L but increased to 2861 U/L during subsequent day. In addition, COVID-19 RTK antigen was negative. Relevant Catheterization Findings: Coronary angiogram revealed mild disease at proximal right coronary artery and proximal left circumflex. Minimal disease was noted at distal left main stem, but severe disease was observed from proximal left anterior descending till mid left anterior descending. Heterogenous plague suggesting thrombus was seen at ostial first diagonal as well. [Formula presented] [Formula presented] Interventional Management Procedural Step: Right femoral assess was obtained with 7Fr sheath, and SL 3.5 7Fr guiding catheter was engaged to left coronary artery. Intracoronary heparin and tirofiban were given prior to wiring. First diagonal was wired with Sion Blue while left anterior descending was wired with Runthrough Floppy. Post-wiring both vessels, coronary flow remained TIMI 3 and hence we decided to proceed with IVUS. From IVUS, noted fibrous elastic plague with heavy thrombus burden. Intracoronary streptokinase was given and noted improvement of thrombus from IVUS. BMW wired to left circumflex. Lesion predilated with scoring balloon and associated with no reflow events, resolved post vasodilators. Left main stem was stented with Onyx 3.5 x 26 mm and deployed at 16 atm. Both side branches wires were rewired into same branches via Crusade microcatheter. LMS stent was post dilated with NC Euphora 4.5 mm at nominal pressure. Noted impingement of both ostium diagonal and circumflex branches. Balloon kissing inflation was performed for both LAD/Diagonal bifurcation and LMS/LAD/circumflex bifurcation. POT was performed post balloon kissing inflation with NC Euphora 3.5 mm and 4.5 mm for both LAD and LMS respectively. Next, IVUS was repeated for mid LAD stent length and Onyx 3.0 mm X 15 mm was deployed at nominal pressure. IVUS repeated and noted under-expansion of overlapped segments and post dilated with NC Euphora 3.0 mm at high pressure. [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusions: Our clinical vignette demonstrated few learning points including utilization of IVUS during primary angioplasty. Understanding of plague characteristic ensures adequate stents expansion especially with fibro elastic plague. In addition, we also demonstrated several precautions in dealing with bifurcation lesions including usage of double lumen microcatheter for wiring the side branches. Even though we opted for provisional stenting, balloon kissing inflation played pivotal role in preserving flow into side branches.

Integrating pocus education with critical care in the era of distance learning

Learning Objectives: Teach the use of POCUS in critically ill patients with respect to image acquisition, image interpretation, and clinical decision-making in the setting of distance learning. : Introduction: Point-of-care ultrasound (POCUS) is integral to Emergency Medicine Residency training and often a fundamental component of a senior medical student EM rotation. The Covid-19 pandemic has dramatically limited in-person instruction and necessitated innovative methods of ultrasound education. Using video-conferencing software, we created a novel simulation experience that integrates POCUS into the core EM content delivery of a virtual EM sub-internship. Curricular Design: Following a brief didactic session, a group of 20 sub-interns was divided into 5 “breakout rooms,” each with 1 resident facilitator. The students then progressed through 4 critical care cases in slide format. For each case, students were able to choose from a variety of diagnostic and therapeutic options, and when the students selected POCUS, they then chose both the order and anatomic region of the scans. Images of normal and abnormal findings were provided in GIF format as they pertained to the given case. After verbalizing and interpreting the findings, students could then perform additional scans or interventions until the patient was stabilized. Following the initial session, some ambiguity was added to the vignettes to increase the number of scans typically performed prior to intervening. Impact/Effectiveness: Based on post-session feedback, students felt this approach was highly effective in helping interpret POCUS images and apply the information to a clinical scenario. Mean Likert scale feedback on organization, applicability to clinical practice, and effectiveness was 4.92 out of 5 for each of the categories based on 25 total responses. Written feedback revealed students would have preferred less didactic time and more time with cases. Qualitatively, this feedback did not notably differ from similar in-person sessions held previously. Similar approaches could be used to teach these skills to providers of all levels from the next room or a location across the world.

Asynchronous case-based learning using slack: A pilot

Learning Objectives: We prospectively evaluated the feasibility and usability of Slack as an e-learning platform for case-based learning (CBL) for PGY-1 EM residents. : Introduction/Background: The use of internet technologies to facilitate asynchronous learning is common in graduate medical education. Advantages to virtual learning in EM include accommodating shift schedules and remote learning in the setting of the COVID-19 pandemic. Slack is a channel-based messaging application used in many industries to facilitate communication. The use of Slack has been described by EM residency programs as a recruitment tool, but little is known about the use of Slack as an educational tool. Educational Objectives: We prospectively evaluated the feasibility and usability of Slack as an e-learning platform for case-based learning (CBL) for PGY-1 EM residents. Curricular design: Clinical case vignettes for common EM chief complaints were written by a senior resident and reviewed by two EM board-certified faculty for content. Cases consisted of a prompt and residents progressed through cases by asking questions and requesting diagnostic studies. Additionally, prompts were provided to discuss clinical controversies in diagnosis and management. Slack was chosen as the platform due to free cost, ease of uploading multimedia, and the ability for anonymous participation. Cases were discussed as a group, one at a time, asynchronously, without dedicated participation time. Three cases were covered in the one month pilot period. The system usability scale (SUS), a validated ten-question survey that classifies tool usability, was then distributed to all interns via SurveyMonkey. Impact/effectiveness: Fifteen of seventeen interns completed the survey. Mean SUS score was 77.2 (95% CI 70.6-83.7) indicating above average usability. This pilot study indicates that Slack is a feasible and usable platform for asynchronous CBL learning. Further study is needed to better understand how to maximize resident learning using Slack. Plans for implementation and evaluation of Slack-based cases for all resident classes and medical students is ongoing.

A Case vignette of melioidosis pneumonia as Covid mimic: Role of microbiology laboratory in accurate diagnosis

Background:During the ongoing COVID19 pandemic period, any new cases of acute-onset respiratory illness are likely to be treated as suspected COVID-19 by default. Methods:A 42year-old lady was admitted with a 4-week history of fever and cough, followed by a 4-days history of increasing short- ness of breath. Fever was intermittent, high grade and was associated with chills and rigor. The patient had a history of uncontrolled type II diabetes mellitus and on admission HbA1C was 15.5%. On examination she had a temperature of 102° F, blood pressure (BP) of 101/67mm Hg, heart rate of 130 beats per minute, respiratory rate (RR) of 24 breaths per minute and O2 saturations of 92% in room air. On respiratory examination, there were crackles in the left infrascapular and infraaxillary area. The patient was admitted in the COVID suspect ward with an impression of moderate COVID-19 infection and nasopharyngeal swab was sent for SARS-CoV-2 on RT-PCR. The patient underwent a CECT scan of thorax, abdomen and pelvis that revealed consolidation in bilateral lung fields with a cavity in lingular lobe with presence of air-fluid level. Mediastinal and hilar lymphadenopathy were present. [Formula presented] Results: SARS-CoV-2 RT-PCR was negative. The patient’s sputum sample revealed pure growth of purple, flat, dry, wrinkled colonies on Ashdown agar after 48 hours which was identified as Burkholderia pseudomallei. The Isolate was susceptible to ceftazidime, mero- penem, co-trimoxazole, amox-clav and chloramphenicol. The patient was started on I.V Meropenem 500mg every 8hourly for 21 days and was discharged on co-trimoxazole tablet. Conclusions: The case definitions of COVID-19 such as fever, cough and shortness of breath can be associated with other infectious etiologies. The role of the microbiology laboratory is thus very crucial in COVID-19 from overshadowing other infec- tious diseases, particularly in endemic areas, hence preventing misdiagnosis and consequent adverse outcomes for patients.

Implications for the design of a Diagnostic-Decision Support System to reduce time and cost to diagnosis in paediatric shoulder instability

Keywords: Shoulder;Instability;Diagnostic Decision Support System Purpose: Diagnosis of shoulder instability in children, is difficult and recurrent rates of instability are high (70–90%). Time to a formal diagnosis is normally two years diagnostic delays can lead to poorer outcome and long-term complications e.g. shoulder arthritis (odds ratio 19.3). There is a need to improve diagnostic accuracy and prevent the development of long-term complications. Healthcare services are increasingly drawing upon technological solutions to improve diagnostic accuracy and efficiency, particularly within the context of the COVID-19 pandemic and subsequent ‘Rebuilding of the NHS’ strategy. A Diagnostic Decision Support System (DDSS) has the potential to reduce time to diagnosis and improve outcomes for patients. The aim of this study was to elicit physiotherapists clinical decision-making processes and develop a concept map for a future DDSS in shoulder instability. Methods: A qualitative study, using modified nominal focus group technique, involving three clinical vignettes, was used to elicit physiotherapists decision-making processes. Participants from across four separate clinical sites were recruited within their capacity as physiotherapists with a specialist interest in paediatric shoulder instability. All focus group sessions were audio recorded and transcribed verbatim. Thematic analysis was conducted according to the stages of Braune and Clarke. Results: Twenty-five physiotherapists, (18F:7M) from four separate clinical sites participated. The themes identified related to • Variability in diagnostic processes and lack of standardised practice 1. Differences in diagnoses and diagnostic processes 2. Differences in diagnoses and diagnostic processes 3. Diagnostic process occurs over a long period of time 4. Diagnostic test choices influenced by factors beyond objective markers associated with the patient injury 5. Planning for prognosis influenced by factors beyond assessment findings 6. Trust in staff relationships • General distrust in individuals or modes of medicine used outside of the department • Unity within the department • Knowledge and attitudes towards novel technologies for facilitating assessment and clinical decision making and 1. Lack of knowledge and rejection of 3D motion capture. Conclusion(s): No common structured approach towards assessment and diagnosis was identified. Decision-making processes were not explicit, therefore, limiting the ability to develop a DDSS around current practice. Several systematic biases were identified in the assessment of paediatric shoulder instability, most notably regarding gender. Lack of knowledge, perceived usefulness, access, and cost were identified as barriers to adoption of new technology. Impact: Based on the information elicited a conceptual design of a future DDSS has been developed. Implementation of a DDSS may act as a vehicle for establishing wider consensus in practice and alert clinical end users of potential bias in order to mitigate against it. These findings have wider implications for the training and education of physiotherapists regarding assessment and clinical decision-making. Use of more objective measures, derived from technology, and used alongside an appropriate DDSS may reduce bias and the negative effects on patient outcomes. Development of any subsequent DDSS and software will need to address the barriers identified which are likely to limit the use of novel technology in practice. There is a risk that even if additional information and technology was available to clinicians, they would not use it. Funding acknowledgements: This work was supported by the Keele University, Faculty of Natural Sciences Research Development Fund under Grant C3700-0958.

The assessment and management of breathing dysfunction in musculoskeletal conditions: A survey of current United Kingdom physiotherapy practice

Keywords: Breathing dysfunction, Evolving musculoskeletal practice, Survey Purpose: The prevalence of breathing dysfunction (BD) is estimated at 10% of the United Kingdom (UK) adult population, and higher in those with asthma (Thomas et al., 2005), while an estimated 20% of adults attend primary care each year with musculoskeletal conditions (Department of Health and Social Care, 2019). Current research indicates a possible relationship between BD and musculoskeletal conditions including alterations in thoracic mechanics, respiratory muscle strength and spirometry, however, there is a lack of evidence regarding the most appropriate BD assessment and management strategies. Therefore, this study investigated physiotherapists’ use of BD assessment and management strategies for patients with musculoskeletal conditions and explored relationships between professional characteristics and current practice variation. Methods: An observational cross-sectional online survey was utilised. UK-based musculoskeletal physiotherapists were invited to participate via social media, professional networks and email. The survey consisted of 28 closed and 16 open questions informed by similar surveys and relevant BD literature. The survey was piloted by five musculoskeletal physiotherapists and was open for eight weeks between 22/05/2020 - 17/07/2020 with a half-way reminder. Data analysis included descriptive statistics and Fishers exact test. Results: 257 questionnaires were completed. 81% (n = 208) of participants worked within the NHS and 31.1% (n = 80) in private practice, with the majority working at an equivalent band 6 (23%, n = 58), band 7 (33%, n = 84) and band 8a (31%, n = 79). 13.2% (n = 34) reported a special interest in BD. 72% (n = 185) of participants did not assess or manage BD, 28% (n = 72) did. In this latter group 100% (n = 72) assessed using subjective indicators and patient observation, while muscle-length testing (69%, n = 50), physical assessment (68%, n = 49), respiratory parameters (26%, n = 19) and BD specific questionnaires (14%, n = 10) were less commonly reported. BD management consistently included breathing retraining (94%, n = 68), general exercise and BD education (89%, n = 64). The inclusion of BD assessment and management in musculoskeletal conditions was statistically significantly associated with BD special interest (p < 0.001), NHS equivalent banding (p = 0.034) and post-graduate BD training including self-directed learning, in-service training, online training, formal lectures, short courses and PhD level study (p < 0.001-0.049). Conclusion(s): This is the first survey of BD assessment and management in musculoskeletal conditions and indicates infrequent assessment and management of BD. For physiotherapists who do assess and manage BD, subjective indicators and observation were the most commonly assessed, while breathing retraining was the most frequent management strategy. BD special interest, relevant post-graduate training and NHS equivalent banding were statistically significantly associated with use of BD assessment and management. Impact: Findings will inform future survey design including international surveys comparing findings across a more diverse sample. Qualitative work or use of vignettes could explore rationales regarding the inclusion of BD assessment and management in musculoskeletal practice. Due to the potentially detrimental clinically important reduced respiratory muscle function associated with mechanical ventilation (Lu et al., 2016;Nassar et al., 2018) and COVID-19 illness (Brosnahan et al., 2020), future quantitative research could investigate whether there is an association between COVID-19 and BD or the effect of long COVID on breathing mechanics. Funding acknowledgements: Project was unfunded.