A crisis planning and monitoring intervention to reduce compulsory hospital readmissions (FINCH study): protocol for a randomised controlled feasibility study.

BACKGROUND: Rates of compulsory (also known as involuntary) detention under mental health legislation have been rising over several decades in countries including England. Avoiding such detentions should be a high priority given their potentially traumatic nature and departure from usual ethical principles of consent and collaboration. Those who have been detained previously are at high risk of being detained again, and thus a priority group for preventive interventions. In a very sparse literature, interventions based on crisis planning emerge as having more supporting evidence than other approaches to preventing compulsory detention. METHOD: We have adapted and manualised an intervention previously trialled in Zürich Switzerland, aimed at reducing future compulsory detentions among people being discharged following a psychiatric admission that has included a period of compulsory detention. A co-production group including people with relevant lived and clinical experience has co-designed the adaptations to the intervention, drawing on evidence on crisis planning and self-management and on qualitative interviews with service users and clinicians. We will conduct a randomised controlled feasibility trial of the intervention, randomising 80 participants to either the intervention in addition to usual care, or usual care only. Feasibility and acceptability of the intervention and trial procedures will be assessed through process evaluation (including rates of randomisation, recruitment, and retention) and qualitative interviews. We will also assess and report on planned trial outcomes. The planned primary outcome for a full trial is repeat compulsory detention within one year of randomisation, and secondary outcomes include compulsory detention within 2 years, and symptoms, service satisfaction, self-rated recovery, self-management confidence, and service engagement. A health economic evaluation is also included. DISCUSSION: This feasibility study, and any subsequent full trial, will add to a currently limited literature on interventions to prevent involuntary detention, a goal valued highly by service users, carers, clinicians, and policymakers. There are significant potential impediments to recruiting and retaining this group, whose experiences of mental health care have often been negative and traumatising, and who are at high risk of disengagement. TRIAL REGISTRATION: ISRCTN, ISRCTN11627644. Registered 25th May 2022, https://www.isrctn.com/ISRCTN11627644 .

The assessment of a manikin-based low-dose, high-frequency cardiac resuscitation quality improvement program in early UK adopter hospitals.

BACKGROUND: Adult and paediatric basic life support (BLS) training are often conducted via group training with an accredited instructor every 24 months. Multiple studies have demonstrated a decline in the quality of cardio-pulmonary resuscitation (CPR) performed as soon as 3-month post-training. The 'Resuscitation Quality Improvement' (RQI) programme is a quarterly low-dose, high-frequency training, based around the use of manikins connected to a cart providing real-time and summative feedback. We aimed to evaluate the effects of the RQI Programme on CPR psychomotor skills in UK hospitals that had adopted this as a method of BLS training, and establish whether this program leads to increased compliance in CPR training. METHODS: The study took place across three adopter sites and one control site. Participants completed a baseline assessment without live feedback. Following this, participants at the adopter sites followed the RQI curriculum for adult CPR, or adult and infant CPR. The curriculum was split into quarterly training blocks, and live feedback was given on technique during the training session via the RQI cart. After following the curriculum for 12/24 months, participants completed a second assessment without live feedback. RESULTS: At the adopter sites, there was a significant improvement in the overall score between baseline and assessment for infant ventilations (N = 167, p < 0.001), adult ventilations (n = 129, p < 0.001), infant compressions (n = 163, p < 0.001) adult compressions (n = 205, p < 0.001), and adult CPR (n = 249, p < 0.001). There was no significant improvement in the overall score for infant CPR (n = 206, p = 0.08). Data from the control site demonstrated a statistically significant improvement in mean score for adult CPR (n = 22, p = 0.02), but not for adult compressions (N = 18, p = 0.39) or ventilations (n = 17, p = 0.08). No statistically significant difference in improvement of mean scores was found between the grouped adopter sites and the control site. The effect of the duration of the RQI curriculum on CPR performance appeared to be minimal in this data set. Compliance with the RQI curriculum varied by site, one site maintained hospital compliance at 90% over a 1 year period, however compliance reduced over time at all sites. CONCLUSIONS: This data demonstrated an increased adherence with guidelines for high-quality CPR post-training with the RQI cart, for all adult and most infant measures, but not infant CPR. However, the relationship between a formalised quarterly RQI curriculum and improvements in resuscitation skills is not clear. It is also unclear whether the RQI approach is superior to the current classroom-based BLS training for CPR skill acquisition in the UK. Further research is required to establish how to optimally implement the RQI system in the UK and how to optimally improve hospital wide compliance with CPR training to improve the outcomes of in-hospital cardiac arrests.

Clinical accuracy of the AAPOS pediatric vision screening referral criteria.

BACKGROUND: The American Association for Pediatric Ophthalmology and Strabismus (AAPOS) referral criteria for amblyogenic risk factors are consensus criteria that were determined by the best-available data as well as survey results of pediatric ophthalmologists. In 2003 the AAPOS Vision Screening Committee published guidelines to standardize reporting the ability of vision screening devices to detect these factors. We attempted to assess the accuracy of the AAPOS referral criteria. METHODS: Billing records of one pediatric ophthalmologist were reviewed to identify all children who were seen in 2002. Records were excluded if photoscreening had not been performed at the initial visit or if photoscreening results were not available in the record. Of the remaining records, one-half were randomly selected for analysis. Cycloplegic refraction and binocular alignment were evaluated to determine whether the child would have been considered to be at risk for amblyopia on the basis of AAPOS referral critera. The sensitivity and specificity of these factors for detecting amblyopia was then determined. RESULTS: A total of 1,575 records were identified, of which 529 were randomly selected; 7 were excluded for incomplete data. AAPOS referral criteria would have referred 266 patients, of whom 255 had amblyopia and 11 did not; of the 256 patients who would not have been referred, 46 had amblyopia and 210 did not. In this population, the AAPOS referral criteria would have had an 85% sensitivity, 95% specificity, a 5% false-positive rate and a 15% false-negative rate for detecting amblyopia. CONCLUSIONS: Application of the AAPOS referral criteria resulted in underreporting of amblyopia in this study. We propose modifications that may result in increased sensitivity and a lower false-negative rate.

Baseline compartment pressure measurements in isolated lower extremity fractures without clinical compartment syndrome.

BACKGROUND: The diagnosis of compartment syndrome is most commonly made by clinical examination. Direct compartmental measurements generally serve an adjunctive role in establishing the diagnosis, except when patients have an alteration in mental status. There is little known on what are the expected baseline elevations in compartments after the simple occurrence of a fracture when clinical compartment syndrome does not exist. Knowledge of such measurements might influence the utility of pressure measurements in diagnosing compartment syndrome. METHODS: A prospective analysis of compartment measurements was performed in 19 isolated lower extremity fractures with the opposite leg as the control. The patients had no clinical evidence of compartment syndrome, had no alteration in mental status, and underwent planned surgical treatment within 48 hours of injury. RESULTS: Average compartment measurements were 35.5 +/- 13.6 mm Hg (range 10 to 62 mm Hg) in the injured leg versus 16.6 +/- 7.5 mm Hg (range 3 to 40 mm Hg) in the control leg (p = 0.0001). Eighteen patients (95%) had at least one compartment measurement that exceeded a single threshold of 30 mm Hg and 12 patients (63%) exceeded a threshold of 45 mm Hg. Eleven patients (58%) had at least one compartment reading within 20 mm Hg of their diastolic pressure and 16 patients (84%) had one within 30 mm Hg of their diastolic pressure. Ten patients (53%) had a reading within 40 mm Hg of their mean arterial pressure (delta P) and eight patients (42%) had a reading within 30 mm Hg of the mean arterial pressure. No patient developed sequelae or required surgery related to an unrecognized compartment syndrome during a minimum 1-year follow-up. CONCLUSIONS: Based on our data, use of direct compartment measurements with existing thresholds and formulations to determine the diagnosis of compartment syndrome may not accurately reflect a true existence of the syndrome. A search for other quantitative measures to more accurately reflect the presence of compartment syndrome is warranted.

Anticardiolipin antibody associated arterial thrombosis following fibula fracture.

A case is described of a 20-year-old college student in whom open reduction and internal fixation of a Weber B fibula fracture was complicated by arterial thrombosis and gangrene of the foot. The patient subsequently required a below-knee amputation. A hypercoagulability workup revealed the presence of an anticardiolipin antibody. Although this is an extremely unusual complication, young female patients with a positive personal or family history of early thrombotic events, such as DVT, multiple pregnancy loss, or early myocardial infarction, should be viewed as being at increased risk. Additional risk factors such as oral contraceptive use, should be sought during the initial history.

Effect of arthroscopic procedures on the acromioclavicular joint.

The objective of the current study was to determine the effect of arthroscopic acromioplasty, and combined acromioplasty and distal clavicle resection on joint kinematics and in situ forces in response to an anterior, posterior, and superior load of 70 N. The loading conditions were applied to 10 fresh-frozen cadaveric shoulders using a robotic and universal force and moment sensor testing system. Translations in response to a posterior load increased by approximately 30% after combined acromioplasty and distal clavicle resection when compared with the intact and acromioplasty conditions. The in situ force in the trapezoid and conoid ligaments increased significantly from 13 +/- 15 N to 40 +/- 25 N and 13 +/- 13 N to 38 +/- 28 N, respectively, between the intact and combined acromioplasty and distal clavicle resection conditions during anterior loading. The results suggest that an arthroscopic acromioplasty alone does not significantly affect the mechanics of the acromioclavicular joint with these loading conditions. However, an acromioplasty combined with a distal clavicular resection does result in significant increases in joint motion and ligament forces. In some circumstances, such as after a previous joint separation, the increased forces in the coracoclavicular ligaments could result in additional damage to weak ligaments.

Stress response to waterborne Cu during early life stages of carp, Cyprinus carpio.

Following in vitro fertilization, eggs/embryos and larvae of the common carp (Cyprinus carpio) were exposed to 0 (control), 0.3 or 0.8 micromol.l(-1) Cu in artificially prepared fresh water for 168 h. The total amounts of Cu, Na, Ca, adrenocorticotropic hormone (ACTH), alpha-melanocyte-stimulating hormone (alpha-MSH) and cortisol were measured in homogenates of eggs (up to 60 h post fertilization, hpf), isolated embryos (between 60 hpf and hatching) and free-swimming larvae. Only in embryos of eggs exposed to 0.8 micromol.l(-1) Cu a significant accumulation of Cu was observed as well as a concurrent increase in the incidence of spinal cord deformation and larval mortality. Further, when exposed to 0.8 micromol.l(-1) Cu, the whole-body Ca and Na contents were lower at 48 and 72 hpf compared to the controls and those exposed to 0.3 micromol.l(-1) Cu. Conversely, in larvae (>72 hpf) exposed to 0.3 micromol.l(-1) Cu, the Ca content was elevated from 96 hpf onwards. At 48 hpf and onwards, the whole-body ACTH and cortisol contents of the embryos exposed to 0.8 micromol.l(-1) Cu were higher than those in either controls or those exposed to 0.3 micromol.l(-1) Cu. By 96 hpf, ACTH and cortisol contents of the group exposed to 0.3 micromol.l(-1) Cu also surpassed those in controls. The alpha-MSH content in both Cu exposed groups was lower than in controls from 48 hpf onwards. It thus appears that ACTH cells and MSH cells in early life stages of carp exposed to waterborn Cu respond differently; we conclude that in prehatch carp pituitary corticotropes and interrenal cortisol producing cells respond to the chemical stressor Cu and that the resulting hormonal changes provide a sensitive diagnosis for stress as well as toxicity tests.