Opportunities to improve the impact of two national clinical audit programmes: a theory-guided analysis.

BACKGROUND: Audit and feedback is widely used in healthcare improvement, with evidence of modest yet potentially important effects upon professional practice. There are approximately 60 national clinical audit programmes in the UK. These programmes often develop and adapt new ways of delivering feedback to optimise impacts on clinical practice. Two such programmes, the National Diabetes Audit (NDA) and the Trauma Audit Research Network (TARN), recently introduced changes to their delivery of feedback. We assessed the extent to which the design of these audit programmes and their recent changes were consistent with best practice according to the Clinical Performance Feedback Intervention Theory (CP-FIT). This comprehensive framework specifies how variables related to the feedback itself, the recipient, and the context operate via explanatory mechanisms to influence feedback success. METHODS: We interviewed 19 individuals with interests in audit and feedback, including researchers, audit managers, healthcare staff, and patient and public representatives. This range of expert perspectives enabled a detailed exploration of feedback from the audit programmes. We structured interviews around the CP-FIT feedback cycle and its component processes (e.g. Data collection and analysis, Interaction). Our rapid analytic approach explored the extent to which both audits applied features consistent with CP-FIT. RESULTS: Changes introduced by the audit programmes were consistent with CP-FIT. Specifically, the NDA's increased frequency of feedback augmented existing strengths, such as automated processes (CP-FIT component: Data collection and analysis) and being a credible source of feedback (Acceptance). TARN's new analytic tool allowed greater interactivity, enabling recipients to interrogate their data (Verification; Acceptance). We also identified scope for improvement in feedback cycles, such as targeting of feedback recipients (Interaction) and feedback complexity (Perception) for the NDA and specifying recommendations (Intention) and demonstrating impact (Clinical performance improvement) for TARN. CONCLUSIONS: The changes made by the two audit programmes appear consistent with suggested best practice, making clinical improvement more likely. However, observed weaknesses in the feedback cycle may limit the benefits of these changes. Applying CP-FIT via a rapid analysis approach helps identify strengths and remediable weaknesses in the design of audit programmes that can be shared with them in a timely manner.

Muscle hypertrophy as the presenting sign in a patient with a complete FHL1 deletion.

Four and a half LIM protein 1 (FHL1/SLIM1) has recently been identified as the causative gene mutated in four distinct diseases affecting skeletal muscle that have overlapping features, including reducing body myopathy, X-linked myopathy, X-linked dominant scapuloperoneal myopathy and Emery-Dreifuss muscular dystrophy. FHL1 localises to the sarcomere and the sarcolemma and is believed to participate in muscle growth and differentiation as well as in sarcomere assembly. We describe in this case report a boy with a deletion of the entire FHL1 gene who is now 15 years of age and presented with muscle hypertrophy, reduced subcutaneous fat, rigid spine and short stature. This case is the first, to our knowledge, with a complete loss of the FHL1 protein and MAP7D3 in combination. It supports the theory that dominant negative effects (accumulation of cytotoxic-mutated FHL1 protein) worsen the pathogenesis. It extends the phenotype of FHL1-related myopathies and should prompt future testing in undiagnosed patients who present with unexplained muscle hypertrophy, contractures and rigid spine, particularly if male.

The impact of HENRY on parenting and family lifestyle: A national service evaluation of a preschool obesity prevention programme.

OBJECTIVES: One in five children in England are overweight/obese at school entry. Tackling obesity is therefore a priority. Right from the Start with HENRY is a widely-commissioned programme delivered by trained facilitators to small groups of parents over eight weekly sessions. It is designed to provide parents of infants and preschool children with the skills, knowledge and confidence required for a healthier family lifestyle. The aim of this work was to investigate programme impact using data collected routinely for quality control purposes. STUDY DESIGN: Analysis of routinely collected pre-post data from programmes delivered in the UK from January 2012 to February 2014. METHODS: Data were analysed from 144 programmes, including questionnaires relating to parenting, family eating behaviours, dietary intake, and physical activity/screen time. RESULTS: Over 24 months, 1100 parents attended programmes running in 86 locations. 788 (72%) completed >5 sessions of whom 624 (79%) provided baseline and completion questionnaires. Parents reported increases in healthiness of family lifestyle, parenting attributes, and emotional wellbeing following attendance (all P < .001). Both parents and children were reported to have increased their daily fruit/vegetable consumption, and reduced their consumption of high fat/sugar foods (both P < .001). There were also positive changes in eating behaviours, physical activity (P < .001) and children's screen time (P < .001). CONCLUSIONS: Significant changes were reported in all domains similar to those reported in a previous, smaller study in locations selected for experience and quality. The HENRY approach appears to have a beneficial impact even when delivered at scale in non-selected locations. Such changes, if maintained, may serve to protect against later obesity.

Combating child obesity: impact of HENRY on parenting and family lifestyle.

BACKGROUND: One-quarter of children in England are overweight/obese at school entry. We investigated the impact of a programme designed to provide parents of infants and preschool children with the skills required for a healthier family lifestyle. METHOD: A cohort of families was followed across the 8-week HENRY (Health Exercise Nutrition for the Really Young) parent course at nine locations in England. Seventy-seven parents enrolled on the course, of which 71 agreed to complete questionnaires addressing eating behaviours, dietary intake and parental self-efficacy. Pre- and post-course data was available from 60 (84.5%) parents (8-week follow-up data from 58 parents) and was analysed using repeated measures analyses. RESULTS: Significant changes were observed, with most sustained at follow-up. Parents reported increased self-efficacy and ability to encourage good behaviour (P < 0.001). Increased consumption of fruits and vegetables was reported in both children and adults, together with reduced consumption of sweets, cakes and fizzy drinks in adults (all P < 0.01). There were also positive changes in eating behaviours (e.g., frequency of family mealtimes and eating while watching television or in response to negative emotion [P < 0.01] ) and reduced screen time in adults (P < 0.001). DISCUSSION: The results build upon earlier evaluation, indicating that the HENRY intervention has a beneficial impact upon the families of infants and preschool children. Furthermore, the findings suggest that positive changes inspired by the programme can be maintained beyond its completion. Such changes may serve to protect against later obesity.

Understanding of and attitudes to genetic testing for inherited retinal disease: a patient perspective.

BACKGROUND/AIMS: The views of people with inherited retinal disease are important to help develop health policy and plan services. This study aimed to record levels of understanding of and attitudes to genetic testing for inherited retinal disease, and views on the availability of testing. METHODS: Telephone questionnaires comprising quantitative and qualitative items were completed with adults with inherited retinal disease. Participants were recruited via postal invitation (response rate 48%), approach at clinic or newsletters of relevant charitable organisations. RESULTS: Questionnaires were completed with 200 participants. Responses indicated that participants' perceived understanding of genetic testing for inherited retinal disease was variable. The majority (90%) considered testing to be good/very good and would be likely to undergo genetic testing (90%) if offered. Most supported the provision of diagnostic (97%) and predictive (92%) testing, but support was less strong for testing as part of reproductive planning. Most (87%) agreed with the statement that testing should be offered only after the individual has received genetic counselling from a professional. Subgroup analyses revealed differences associated with participant age, gender, education level and ethnicity (p<0.02). Participants reported a range of perceived benefits (eg, family planning, access to treatment) and risks (eg, impact upon family relationships, emotional consequences). CONCLUSIONS: Adults with inherited retinal disease strongly support the provision of publicly funded genetic testing. Support was stronger for diagnostic and predictive testing than for testing as part of reproductive planning.

Training community practitioners to work more effectively with parents to prevent childhood obesity: the impact of HENRY upon Children's Centres and their staff.

BACKGROUND: One in four children in England is overweight/obese upon starting school. HENRY (Health Exercise Nutrition for the Really Young) offers a novel, preventive approach to this problem by training practitioners to work more effectively with the parents of preschool children around obesity and lifestyle issues. The programme is being delivered to all Sure Start Children's Centres (the UK government initiative providing family support and childcare in disadvantaged areas) in Leeds, UK. METHODS: The evaluation covered the first 12 Centres to be trained (these had a reach of approximately 5000 families). A series of semi-structured interviews were conducted with Centre managers, and 'drop boxes' were provided for all staff to leave their comments. Interviews took place up to 11 months post-training, allowing a consideration of any long-term impact. RESULTS: Data from 12 interviews and 106 comment slips indicated that HENRY training was associated with considerable changes to the Centre environment. Immediate effects included changes to Centre policy and practice, including the provision of age-appropriate portion sizes and the introduction of healthy snacks; a strengthening of team working and increased staff confidence around tackling lifestyle change; and enhanced skills when working with families. Training also induced changes within the staff's personal lives (e.g. increased physical activity and family mealtimes). CONCLUSIONS: The findings suggest that positive and lasting lifestyle effects can be achieved by brief training courses involving Children's Centre staff teams. Both staff and attendant families appear to benefit. The effect on levels of preschool obesity across the city once HENRY has extended to the remaining Centres is yet to be seen.

Cortisol awakening rise in middle-aged women in relation to psychological stress.

OBJECTIVES: The cortisol awakening rise (CAR) is defined as cortisol secretory activity in the first 45-60 min immediately post-awakening. It has been suggested that psychological factors may disrupt the normal awakening rise. Recent research has shown that psychological stress may influence the magnitude of the CAR, however the findings have been mixed. This study examined the impact of stress on the CAR and the diurnal mean in a sample of middle-aged women. METHOD: One hundred and eighteen healthy female participants who reported experiencing high or low stress were recruited. Salivary cortisol levels were measured immediately upon awakening (at 0, 15, 30, and 45 min) and at 3, 6, 9 and 12 h on two consecutive days. A number of metabolic and inflammatory biomarkers were also assessed together with measures of mood disturbance and health behaviour. RESULTS: The magnitude of the CAR, assessed by the area under the response curve (AURC) estimate, was significantly lower in the high stress group compared to the low stress group indicating that participants who experienced high stress secreted lower levels of cortisol. The effect was largely accounted for by differences 30 min after waking. The diurnal mean was also lower for the high stress group. Although participants in the high stress group had a slightly worse inflammatory profile, only low-density lipoprotein levels were found to be significantly higher, compared to the low stress group. Lifestyle indicators and mood were also found to be significantly poorer in the high stress group. CONCLUSIONS: The results suggest that psychological stress may be associated with a smaller cortisol awakening rise, a lower diurnal mean, poor lifestyle choices and high levels of psychological distress. These findings may have broader implications for future health risk and for an individual's ability to cope with imminent daily stressors and demands.

Cardioversion by venepuncture in sustained stable supraventricular tachycardia.

Two cases are described of cardioversion from stable supraventricular tachycardia after venepuncture. In both cases usual vagal manoeuvres at home and in the casualty department were unsuccessful. However, attempts to site intravenous cannulas by the attending medical staff terminated his supraventricular tachycardia. Venepuncture is probably the commonest vagal manoeuvre performed in hospital but has not previously been reported as a method of cardioversion.

Biocompatibility of NDGA-polymerized collagen fibers. I. Evaluation of cytotoxicity with tendon fibroblasts in vitro.

The material properties of tendon type I collagen fibers polymerized with nordihydroguaiaretic acid (NDGA) are equivalent to native tendon, suggesting that NDGA crosslinking may provide a viable approach to stabilizing collagenous materials for repairing ruptured, lacerated, or surgically transected fibrous tissues, such as tendon and ligament (Koob & Hernandez, Biomaterials, in press). Using standard cytotoxicity tests, the present study evaluated the biocompatibility of these fibers with cultured bovine tendon fibroblasts. Primary fibroblasts obtained from calf digital extensor tendons were exposed to NDGA, reaction products generated from the polymerization protocol, and the crosslinked fibers. NDGA was cytotoxic to these cells at concentrations above 100 microM. NDGA oxidation products were similarly cytotoxic. At concentrations below 100 microM, fibroblast viability was not affected by NDGA or its oxidation products. At these lower concentrations, fibroblast proliferation was unaffected compared to controls not exposed to NDGA. Fibers crosslinked with NDGA contained no unreacted NDGA, but they did contain soluble reaction products that were cytotoxic to tendon fibroblasts in both the elution and the direct contact tests. Washing the fibers in 70% ethanol and phosphate-buffered saline eliminated cytotoxicity of the fibers. Ethanol simultaneously sterilized the fibers. Tensile tests established that the ethanol/phosphate buffer wash did not adversely affect the material properties of the fibers. The results of these experiments indicate that NDGA-crosslinked fibers can be rendered nontoxic to tendon fibroblasts and may provide a novel approach for producing biologically based, biocompatible, tendon bioprostheses.

Biocompatibility of NDGA-polymerized collagen fibers. II. Attachment, proliferation, and migration of tendon fibroblasts in vitro.

The material properties of collagen fibers polymerized with nordihydroguaiaretic acid (NDGA) are equivalent to native tendon, suggesting that NDGA crosslinking may provide a viable approach to stabilizing collagenous materials for use in repairing ruptured, lacerated, or surgically transected fibrous tissues, such as tendons and ligaments (Koob & Hernandez, Biomaterials, in press). The present study evaluated the biocompatibility of these fibers with cultured bovine tendon fibroblasts. Fibroblast attachment, migration, and proliferation on NDGA-crosslinked materials were compared to those on prepolymerized type I tendon collagen constructs as well as on tissue-culture-treated plastic. Fibroblast attachment on NDGA-crosslinked collagen fibrils was equivalent to attachment on plates coated with collagen alone. Over a period of 8 days in culture, attached fibroblasts proliferated on NDGA-crosslinked collagen at a rate identical to that of fibroblasts attached to native collagen. In order for the biomaterial effectively to bridge gaps in fibrous tissues, fibroblasts must be able to migrate and replicate on the bridging fiber. Control and crosslinked fibers were inserted in calf tendon explants, with a portion of the fiber extending out of the sectioned end of the tendon. Explants were cultured for 9 weeks, and the number of cells was measured at weekly intervals. Cells appeared on the fibers after 1 week of culture. By 2 weeks, cells had colonized the entire fiber. The number of cells continued to increase throughout the 9 weeks in culture, forming a layer several cells thick. Histologic analysis indicated that the fibroblasts populating the fibers appeared to originate in the epitenon. There was no difference in the rate of fibroblast migration and replication, nor in the ultimate number of colonizing cells, between control collagen fibers and NDGA-crosslinked fibers. NDGA-crosslinked fibers may provide a means of bridging gaps in ruptured, lacerated, or surgically transected tendons by providing a mechanically competent scaffold on which tendon fibroblasts can migrate, attach, and proliferate.

Cytochrome oxidase deficiency presenting as birth asphyxia.

Hypoxic-ischaemic encephalopathy (HIE) was diagnosed in an infant with acidosis. At 7 weeks of age further investigations revealed abnormal neuroimaging (CT and MRI scans) and a raised plasma and CSF lactate. A skeletal-muscle biopsy at 2 months of age confirmed the diagnosis of cytochrome oxidase deficiency. The course of the patient's disorder has taken that of a static encephalopathy (cerebral palsy). Inborn disorders of the respiratory chain should be considered in the differential diagnosis of HIE.