Outpatient paracentesis for the management of ovarian hyperstimulation syndrome: study protocol for the STOP-OHSS randomised controlled trial.

INTRODUCTION: Ovarian hyperstimulation syndrome (OHSS) is the most significant short-term complication of pharmacological ovarian stimulation. Symptoms range from mild abdominal discomfort to rare complications such as renal failure, thromboembolism and respiratory distress syndrome.Currently, clinical practice typically involves monitoring the patient until the condition becomes severe, at which point they are admitted to hospital, where drainage of ascitic fluid (paracentesis) may take place. Preliminary studies have indicated that earlier outpatient paracentesis may reduce the progression of OHSS and prevent hospitalisation in women. METHODS AND ANALYSIS: This UK, multicentre, pragmatic, two-arm, parallel-group, adaptive (group sequential with one interim analysis), open-label, superiority, confirmatory, group sequential, individually randomised controlled trial, with internal pilot will assess the clinical and cost-effectiveness and safety of outpatient paracentesis versus conservative management (usual care) for moderate or severe OHSS. 224 women from 20 National Health Service and private fertility units will be randomised (1:1) and followed up for up to 13.5 months. The primary outcome is the rate of OHSS related hospital admission of at least 24 hours within 28 days postrandomisation. The primary analysis will be an intention to treat with difference in hospitalisation rates as measure of treatment effect. Secondary outcomes include time to resolution of symptoms, patient satisfaction, adverse events and cost-effectiveness. A qualitative substudy will facilitate the feasibility of recruitment. Participant recruitment commenced in June 2022. ETHICS AND DISSEMINATION: London-Southeast Research Ethics Committee approved the protocol (reference: 22/LO/0015). Findings will be submitted to peer-reviewed journals and abstracts to relevant national and international conferences, as well as being disseminated to trial participants and patient groups. TRIAL REGISTRATION NUMBER: ISRCTN71978064.

Role of a medical student neuro-society organized neurosurgical conference: The Glasgow neuro experience.

Background: Entering neurosurgical training in the United Kingdom demands extensive prior commitment and achievement, despite little to no exposure to the specialty in medical school. Conferences run by student "neuro-societies" offer a means to bridge this gap. This paper describes one student-led neuro-society's experience of curating a 1-day national neurosurgical conference supported by our neurosurgical department. Methods: A pre-and post-conference survey was distributed to attendees to ascertain baseline opinions and conference impact using a five-point Likert Scale, and free text questions explored medical students' opinions of neurosurgery and neurosurgical training. The conference offered four lectures and three workshops; the latter provided practical skills and networking opportunities. There were also 11 posters displayed throughout the day. Results: 47 medical students participated in our study. Post-conference, participants were more likely to understand what a neurosurgical career involves and how to secure training. They also reported increased knowledge about neurosurgery research, electives, audits, and project opportunities. Respondents enjoyed the workshops provided and suggested the inclusion of more female speakers in future. Conclusion: Neurosurgical conferences organized by student neuro-societies successfully address the gap between a lack of neurosurgery exposure and a competitive training selection. These events give medical students an initial understanding of a neurosurgical career through lectures and practical workshops; attendees also gain insight into attaining relevant achievements and have an opportunity to present research. Student neuro-society-organized conferences have the potential to be adopted internationally and used as a tool to educate on a global level and greatly aid medical students who are aspiring neurosurgeons.

'The Primacy of 'Home': An exploration of how older adults' transition to life in a care home towards the end of the first year.

This grounded theory study sought to explore how older adults' experience the transition from living at home to a care home with a specific focus on the latter part of the first year of the move. The study was carried out within a large Health Trust in the UK between August 2017 and May 2019. Purposive sampling was used in the initial stages of data collection. Thereafter and consistent with grounded theory methodology, theoretical sampling was employed to undertake semi-structured interviews with 17 individuals from eight care homes between 5 and 12 months after the move. This paper reports five key categories which were: (a) The lasting effect of first Impressions 'They helped me make my mind up' (b) On a Journey 'I just take it one day at a time', (c) Staying connected and feeling 'at home' 'You get something good out of it you know…you get hope'. (d) Managing loss and grief 'It was important for me to say cheerio to the house' and (e) Caring relationships 'I didn't realise that I was lonely until I had company'. Together these five categories formed the basis of the core category 'The Primacy of 'Home' which participants identified as a place they would like to feel valued, nurtured and have a sense of belonging. This study identifies that it is important for individual preferences and expectations to be managed from the outset of the move. Individuals and families need to be supported to have honest and caring conversations to promote acceptance and adaptation to living in a care home while continuing to embrace the heart of 'home'. Key recommendations from this study include the need to raise awareness of the significance of the ongoing psychological and emotional well-being needs of older people which should be considered in policy directives and clinical practice.

Primary orbital melanoma arising in an atypical diffuse (plaque-like) blue naevus/melanocytosis: a case report and review of literature.

BACKGROUND: Primary orbital melanoma is a rare disease and can occasionally develop from a pre-existing neoplasm of the blue naevus family of melanocytic lesions. CASE PRESENTATION: Herein we report a rare case of primary orbital melanoma arising from an unusual atypical diffuse (plaque-like) blue naevus/melanocytosis. A 27 year old man presented with mild pain and swelling of the left eye. Magnetic Resonance Imaging revealed a left lateral episcleral orbital mass and an incisional biopsy confirmed the diagnosis of malignant melanoma. Skin-sparing total left orbital exenteration was performed. Histopathological examination of the exenteration specimen revealed a primary orbital melanoma arising in a pre-existing blue naevus like melanocytosis. We demonstrate the evidence for histological progression, characterise the molecular profile of this tumour and discuss the related literature. CONCLUSIONS: This case emphasises the importance of a meticulous clinicopathological correlation in recognising such a tumour as a primary orbital melanoma rather than a metastasis, which is managed differently.

Community Ageing Research 75+ (CARE75+) REMOTE study: a remote model of recruitment and assessment of the health, well-being and social circumstances of older people.

INTRODUCTION: The Community Ageing Research 75+ (CARE75+) study is a longitudinal cohort study collecting extensive health and social data, with a focus on frailty, independence and quality of life in older age. CARE75+ was the first international experimental frailty research cohort designed using trial within cohorts (TwiCs) methodology, aligning epidemiological research with clinical trial evaluation of interventions to improve the health and well-being of older people. CARE75+ REMOTE is an extension of CARE75+ using a remote model that does not require face-to-face interactions for data collection in the current circumstances of a global pandemic and will provide an efficient, sustainable data collection model. METHODS AND ANALYSIS: Prospective cohort study using TwiCs. One thousand community-dwelling older people (≥75 years) will be recruited from UK general practices by telephone. Exclusions include: nursing home/care home residents; those with an estimated life expectancy of 3 months or less; and people receiving palliative care. DATA COLLECTION: Assessments will be conducted by telephone, web-submission or postal questionnaire: baseline, 6 months, 12 months, 18 months, 24 months, 30 months and 36 months. Measures include activities of daily living, mood, health-related quality of life, comorbidities, medications, frailty, informal care, healthcare and social care service use. Consent will be sought for data linkage and invitations to additional studies (sub-studies). ETHICS AND DISSEMINATION: CARE75+ was approved by the National Research Ethics Service (NRES) Committee Yorkshire and the Humber-Bradford Leeds 10 October 2014 (14/YH/1120). CARE75+ REMOTE (amendment 13) was approved on the 18th November 2020. Consent is sought if an individual is willing to participate and has capacity to provide informed consent. Consultee assent is sought if an individual lacks capacity. Results will be disseminated in peer-reviewed scientific journals and conferences. Results will be summarised and disseminated to study participants via newsletters, local engagement events and on a bespoke website. TRIAL REGISTRATION NUMBER: ISRCTN16588124.

"You're at their mercy": Older peoples' experiences of moving from home to a care home: A grounded theory study.

BACKGROUND: Internationally, it is recognised that the transition to a care home environment can be an emotional and stressful occasion for older people and their families. There is a paucity of research that takes into consideration the initial phase of the relocation process, incorporating individuals' experiences of the move. AIM: To explore individuals' experiences of moving into a care home. This paper has a specific focus on the preplacement (7 days) and immediate postplacement (within 3 days) period of the move to the care home. DESIGN: A grounded theory method was used to conduct semi-structured interviews with 23 participants. RESULTS: Data analysis revealed five distinct categories that captured the experience of the preplacement and immediate postplacement period. These were as follows: (a) inevitability of the move: "I had to come here," (b) making the move: "Abrupt Departures," (c) decision-making and exercising choice: "What can I do, I have no choice," (d) maintaining identity: "Holding on to self" and (e) maintaining connections: "I like my family to be near." Together, these five categories formed the basis of the concept "You're at their Mercy" which encapsulates the perceived transition experience of the older people within the study. Participants felt that the move was out of their control and that they were "at the mercy" of others who made decisions about their long-term care. CONCLUSIONS: Moving to a care home represents a uniquely significant relocation experience for the individual. Key factors influencing the move were the individuals' perceived lack of autonomy in the pre- and postrelocating period of moving to a care home. Nurses have a key role to play in working with older people to influence policy and practice around decision-making, planning and moving to a care home with greater emphasis on autonomy and choice so that older people do not feel "at the mercy" of others as they navigate such a major transition. IMPLICATIONS FOR PRACTICE: There is a need to standardise approaches and develop person-centred interventions to support older people considering relocation to a care home and nurses have a key role to play in making this happen.

Study protocol for a randomised controlled trial assessing the clinical and cost-effectiveness of the Journeying through Dementia (JtD) intervention compared to usual care.

INTRODUCTION: Services are being encouraged to provide postdiagnostic treatment to those with dementia but the availability of evidence-based interventions following diagnosis has not kept pace with increase in demand. To address this need, the Journeying through Dementia (JtD) intervention was created. A randomised controlled trial (RCT), based on a pilot study, is in progress. METHODS AND ANALYSIS: The RCT is a pragmatic, two-arm, parallel group trial designed to test the clinical and cost-effectiveness of JtD compared with usual care. Recruitment will be through NHS services, third sector organisations and Join Dementia Research. The sample size is 486 randomised (243 to usual care and 243 to the intervention usual care). Participants can choose to ask a friend or relative (supporter) to become involved in the study. The primary outcome measure for participants is Dementia-Related Quality of Life (DEMQOL), collected at baseline and at 8 months' postrandomisation. Secondary outcome measures will be collected from participants and supporters at those visits. Participants will also be followed up at 12 months' postrandomisation with a reduced set of measures. A process evaluation will be conducted through qualitative and fidelity substudies. Analyses will compare the two arms of the trial on an intention to treat as allocated basis. The primary analyses will compare the mean DEMQOL scores of the participants at 8 months between the two study arms. A cost-effectiveness analysis will consider the incremental cost per Quality Adjusted Life Years of the intervention compared with usual care. Qualitative and fidelity substudies will be analysed through framework analysis and fidelity assessment tools respectively. ETHICS AND DISSEMINATION: REC and HRA approval were obtained. A Data Monitoring and Ethics Committee has been constituted. Dissemination will be via publications, conferences and social media. Intervention materials will be made open access. TRIAL REGISTRATION NUMBER: ISRCTN17993825.

Student perceptions of faculty feedback following medication errors - A descriptive study.

Nursing students make medication errors as they progress through educational programs. It is important that faculty feedback is such that students feel comfortable reporting subsequent medication errors. The objectives of this study are to determine factors which increase the likelihood of nursing students reporting medication errors; to elicit nursing student perception of faculty feedback following a medication error, and determine how this faculty feedback impacts reporting of subsequent medication errors; and to develop recommendations regarding the most effective faculty approaches when providing feedback to nursing students following medication errors. This quantitative study uses a non-experimental, descriptive design. A convenience sample of 106 nursing students in one Canadian province completed a self-report questionnaire. The factors identified as increasing the likelihood of reporting medication errors for students who made a medication error were the same as for those who did not make an error. Group sizes were too small to determine if characteristics of faculty feedback had a significant impact on likelihood of reporting future errors. Students in both groups indicated intention to report errors based upon professional attitudes, behaviors and/or values. The researchers concluded that professional socialization, in combination with supportive learning environments, may increase student comfort in reporting medication errors.

Early PREdiction of Severe Sepsis (ExPRES-Sepsis) study: protocol for an observational derivation study to discover potential leucocyte cell surface biomarkers.

INTRODUCTION: Sepsis is an acute illness resulting from infection and the host immune response. Early identification of individuals at risk of developing life-threatening severe sepsis could enable early triage and treatment, and improve outcomes. Currently available biomarkers have poor predictive value for predicting subsequent clinical course in patients with suspected infection. Circulating leucocytes provide readily accessible tissues that reflect many aspects of the complex immune responses described in sepsis. We hypothesise that measuring cellular markers of immune responses by flow cytometry will enable early identification of infected patients at risk of adverse outcomes. We aim to characterise leucocyte surface markers (biomarkers) and their abnormalities in a population of patients presenting to the hospital emergency department with suspected sepsis, and explore their ability to predict subsequent clinical course. METHODS AND ANALYSIS: We will conduct a prospective, multicentre, clinical, exploratory, cohort observational study. To answer our study question, 3 patient populations will be studied. First, patients with suspected sepsis from the emergency department (n=300). To assess performance characteristics of potential tests, critically ill patients with established sepsis, and age and gender matched patients without suspicion of infection requiring hospital admission (both n=100) will be recruited as comparator populations. In all 3 groups, we plan to assess circulating biomarker profiles using flow cytometry. We will select candidate biomarkers by cross-cohort comparison, and then explore their predictive value for clinical outcomes within the cohort with suspected sepsis. ETHICS AND DISSEMINATION: The study will be carried out based on the principles in the Declaration of Helsinki and the International Conference on Harmonisation Good Clinical Practice. Ethics approval has been granted from the Scotland A Research Ethics Committee (REC) and Oxford C REC. On conclusion of this study, the results will be disseminated via peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02188992; Pre-results.

"Knowing that I'm not alone": client perspectives on counselling for self-injury.

BACKGROUND: Self-injury is an increasingly common phenomenon among clinical and non-clinical populations. Health care providers generally recommend behavioural interventions that address coping skills for people who self-injure despite a lack of a consistent evidence base about their effectiveness. There is limited understanding about experiences of counselling for self-injury from the perspectives of clients. AIM: To understand clients' experiences of counselling for self-injury. METHOD: Ten interviews were conducted, audio-recorded and transcribed. Data were analysed using Grounded Theory (GT). RESULTS: One central category, "Developing a healing reconnection with self and others" and four categories: (i) Building trust; (ii) seeing beyond the cutting; (iii) human contact and (iv) integrating experiences. CONCLUSIONS: Overcoming self-injury is possible within the context of a trusting and accepting therapeutic relationship. Participants perceived counselling to be helpful when counsellors were willing to work with underlying issues rather than focus primarily on the cessation of self-injury. Counsellors and mental health practitioners must look beyond the behaviour to meet with the person and facilitate the development of a therapeutic relationship, which promotes a healing reconnection with self and others.

The diagnostic and prognostic significance of monitoring blood levels of immature neutrophils in patients with systemic inflammation.

INTRODUCTION: In this cohort study, we investigated whether monitoring blood levels of immature neutrophils (myelocytes, metamyelocytes and band cells) differentiated patients with sepsis from those with the non-infectious (N-I) systemic inflammatory response syndrome (SIRS). We also ascertained if the appearance of circulating immature neutrophils was related to adverse outcome. METHODS: Blood samples were routinely taken from 136 critically ill patients within 48 hours of ICU entry and from 20 healthy control subjects. Clinical and laboratory staff were blinded to each other's results, and patients were retrospectively characterised into those with SIRS (n = 122) and those without SIRS (n = 14). The patients with SIRS were further subdivided into categories of definite sepsis (n = 51), possible sepsis (n = 32) and N-I SIRS (n = 39). Two established criteria were used for monitoring immature white blood cells (WBCs): one where band cells >10% WBCs and the other where >10% of all forms of immature neutrophils were included but with a normal WBC count. Immature neutrophils in blood smears were identified according to nuclear morphology and cytoplasmic staining. RESULTS: With the first criterion, band cells were present in most patients with SIRS (mean = 66%) when compared with no SIRS (mean = 29%; P <0.01) and with healthy subjects (0%). The prevalence of band cells was higher in definite sepsis (mean = 82%) than in patients with possible sepsis (mean = 63%; P <0.05) or with N-I SIRS (mean = 39%; P <0.001), and they had a sensitivity of 84% and a specificity of 71% for the detection of definite sepsis. With the second criterion (that is, patients with normal WBC counts), we noted that immature neutrophils did not differentiate any of the patient groups from one another. Patients who died within 1 week of blood sample provision had higher levels of myelocytes and metamyelocytes (median = 9%; P <0.05) than patients who died at 2 to 4 weeks (median =0.5%). CONCLUSIONS: Raised blood levels of band cells have diagnostic significance for sepsis, provided that measurements are not confined to patients with normal WBC counts, whereas an increased prevalence of myelocytes and metamyelocytes may have prognostic application.

The healing journey: help seeking for self-injury among a community population.

Help seeking is known to be a complex and difficult journey for people who self-injure. In this article, we explore the process of help seeking from the perspective of a group of people living in Northern Ireland with a history of self-injury. We conducted 10 semistructured interviews and employed a grounded theory approach to data analysis. We created two major categories from the interview transcript data: (a) "involution of feeling," which depicts participants' perspectives on barriers to help seeking; and (b) "to be treated like a person," in which participants communicate their experiences of help seeking. The findings pose important implications for policy, practice, theory, and future research, including the need to increase the uptake of follow-up care among people who arrive at hospitals as a result of self-injury, self-harm, or suicidal behaviors.

How distressing is it to participate in medical research? A calibration study using an everyday events questionnaire.

OBJECTIVES: To investigate how distressing participating in medical research is perceived to be, compared to everyday events. DESIGN: Anonymous questionnaire. SETTING: Scotland and New Zealand. PARTICIPANTS: One hundred members of the Scottish general public, 94 University of Auckland students, 22 New Zealand Ministry of Health ethics committee members. MAIN OUTCOME MEASURES: Distress ratings made on a 0-10 scale for everyday events and common medical research procedures. RESULTS: Both general population and student samples generally rated the distress caused by participating in various medical research procedures as low or very low. Most research procedures were rated less than the distress caused by not being able to find a car park at a supermarket. In contrast, the ethics committee members rated the distress caused by most of the medical research procedures at a significantly higher level than the ratings of the student and general population samples. Ethics committee members overestimated the distress caused by interview or questionnaire assessments (M = 203.31%, SE = 11.42, 95% CI [179.79, 226.83]) more than medical testing for research (M = 158.06%, SE = 12.33, 95% CI [132.66, 183.46], p = 0.04) and everyday events (M = 133.10%, SE = 7.80, 95% CI [117.03, 149.16], p < 0.001). CONCLUSIONS: Common medical research procedures are not rated as particularly distressing by the general public, and ethics committees may be adopting an over-protective role when evaluating research applications that involve the use of questionnaire or survey methodology.

Community-dwelling older adults with memory loss: needs assessment.

OBJECTIVE: To identify the health-related needs of community-dwelling older adults with mild memory loss. DESIGN: Qualitative study using semistructured, audiotaped, face-to-face interviews and focus groups. SETTING: A large community in Newfoundland. PARTICIPANTS: Twenty-two adults between the ages of 58 and 80 years. METHODS: This needs assessment used a qualitative methodology of collecting and analyzing narrative data to develop an understanding of the issues, resources, and constraints of community-dwelling older adults with mild memory loss. Data were collected through semistructured, audiotaped, face-to-face interviews and focus groups. Transcripts of the interviews were analyzed using interpretive phenomenologic analysis. MAIN FINDINGS: Three constitutive patterns with relational themes and subthemes were identified: forgetting and remembering, normalizing yet questioning, and having limited knowledge of resources. Participants described many examples of how their daily lives were affected by forgetfulness. They had very little knowledge of resources that provided information or support. Most of the participants believed they could not discuss their memory problems with their family doctors. CONCLUSION: It is important for older adults with mild memory loss to have access to resources that will assist them in understanding their condition and make them feel supported.

Experimental infections with the tropical monogenean, Gyrodactylus bullatarudis: potential invader or experimental fluke?

Introduced exotic species have the potential to spread their associated parasites to native species which can be catastrophic if these hosts are immunologically naïve to the novel parasite. The guppy (Poecilia reticulata) has been disseminated worldwide outside of its native habitat and therefore could be an important source of infection to native fish species. Its parasite fauna is dominated by the ectoparasitic monogeneans, Gyrodactylus turnbulli and Gyrodactylus bullatarudis. The current study tested the host specificity of G. bullatarudis by experimentally infecting a range of isolated fish hosts, including temperate species. Surprisingly, the parasite was capable of establishing and reproducing, for several days, on the three-spined stickleback when transferred directly to this host. We also established that G. bullatarudis could be transmitted under aquarium conditions at both 25 degrees C and 15 degrees C. At the higher temperature, the parasite was even capable of reproducing on this atypical host. The implications of these findings are discussed in terms of host specificity, host switching and climate change.

The application of the Things I Worry About Scale to a sample of at-risk American adolescents: an examination of psychometric properties.

To date, published studies regarding the Things I Worry About Scale have been conducted exclusively in Northern Ireland and have included relatively homogeneous samples of students. The present study reexamined the psychometric properties of the scale using data collected from a sample of at-risk adolescents in the United States. The factor structure of the instrument was examined to determine the reliability of the instrument with a culture other than that with which the instrument was developed, and salient group differences were identified and discussed. The cross-cultural applicability of the instrument and the stability of the factor structure were explored and found to be relatively robust. However, differences were identified which were specifically related to the emergence of a highly salient component representing a very pessimistic view of what the future held. The results suggest the need for confirmatory factor analytical studies and further examination of the utility of the instrument with diverse populations.

Ex-clients' evaluation of bereavement counselling in a voluntary sector agency.

This study aims to carry out an evaluation of bereavement counselling provided by a voluntary charity from the perspective of clients who had availed themselves of the service. A questionnaire survey of ex-clients of one branch of a major voluntary sector bereavement care organization was carried out. Based on a sample of 89 returned questionnaires (representing a response rate of 45%), findings indicated that paraprofessional voluntary counsellors can provide a counselling service to bereaved people that satisfies the majority of clients who report positive experiences in counselling and post-counselling outcomes, and generally rate their counselling as helpful. Nonetheless, there was a minority of ex-clients who did not regard their status, 6 weeks after counselling, as being more positive. Further, the reputation of the voluntary agency within the community and among potential referrers and ex-clients appears strong, offering additional positive evidence of the status of their bereavement counselling service in the locality.

Tetanus and the plastic surgeon.

Tetanus in the United States is decidedly rare, and most of us will not see a case of it during our careers. Given its lethality, it is a disease about which one must be aware. Be willing to consider it as a diagnosis, no matter the immunization status of the patient, if clinical signs and symptoms warrant. To emphasize this point, the authors present a case of an otherwise healthy 41-year-old man who sustained electrical burns when he fell from a ladder and struck a power line on his way to the ground. He developed a compartment syndrome of his left leg at the exit site and subsequently underwent fasciotomies. When he later began to exhibit signs and symptoms of sepsis, his wound was debrided, and most of his anterior compartment was resected. Despite this, his condition worsened, and his clinical picture was suggestive of tetanus, including the classic findings of trismus, risus sardonicus, and opisthotonus. Using mechanical ventilation, paralysis, narcotics, and muscle-relaxing sedatives, the authors supported him until his tetany subsided. He survived and was discharged to home when complete coverage of his burns and left leg anterior compartment was obtained. The authors discuss the presentation, diagnosis, and treatment of tetanus, as well as its incidence in the general population and in the previously immunized patient.