Urgent and emergency care (UEC) settings provide an opportunity to prevent ill-health and promote healthy lifestyles with potential to screen and deliver interventions to under-served, at-risk populations. The aim of this study was to synthesise and summarise the evidence on the effectiveness and implementation of interventions for health promotion in UEC settings. PubMed and Embase (OVID) databases were used to search for studies published in English between January 2010 and January 2023. Systematic reviews and meta-analyses of studies that examined the effectiveness or implementation of face-to-face health promotion interventions for lifestyle behaviours delivered in UEC settings were eligible. Extracted data were synthesised and qualitatively summarised by lifestyle behaviour. Reviews were quality assessed using AMSTAR 2. Eighteen reviews met the inclusion criteria; all included studies were conducted in emergency departments or trauma units. We identified 15 reviews on alcohol interventions (13 on effectiveness; 2 on implementation) and 3 on smoking interventions (effectiveness). There were no reviews of intervention studies targeting physical activity or diet and nutrition. There was heterogeneity across studies for study design, target populations, intervention design and content, comparator/control groups and outcomes assessed. The effectiveness of alcohol and smoking interventions in UEC settings varied but some reviews provided evidence of a significant decrease in alcohol consumption, alcohol-related outcomes and smoking in intervention groups, particularly in the short-term and in specific population groups. Research has focused on ‘brief’ interventions as part of screening, brief intervention and referral to treatment (SBIRT) approaches. Interventions are delivered by a wide range of staff with substantial variation in design. Alcohol brief interventions appear to be acceptable to UEC patients but clinicians face barriers in delivering them. UEC settings have been under-researched and appear to be under-utilised for delivering health promotion activities, except for alcohol prevention. Review level evidence suggests alcohol and smoking interventions are warranted in some population groups. However, further research is needed to determine the optimal intervention design, content and delivery mode for lifestyle behaviours which are suitable for implementation in UEC settings and promote long-term intervention effectiveness. Changes in clinical practice may be needed, including increased training, integration into service delivery and supportive policy, to facilitate the implementation of SBIRT for lifestyle behaviours. Interventions may need to be delivered in the wider UEC system such as urgent care centres, minor injury units and walk-in centres, in addition to emergency departments and trauma units, to support and increase health promotion activities in UEC settings.
Background The aim of the study was to ascertain the views and experiences of those working in urgent and emergency care (UEC) settings towards screening, brief intervention, and referral to treatment (SBIRT) for alcohol, to inform future practice. Objectives To explore i) views towards health promotion, ii) views towards and practice of SBIRT, iii) facilitators and barriers to delivering SBIRT, iv) training needs to support future SBIRT practice, and v) comparisons in views and attitudes between demographic characteristics, geographical regions, setting and occupational groups. Methods This was an open cross-sectional international survey, using an online self-administered questionnaire with closed and open-ended responses. Participants were ≥18 years of age, from any occupational group, working in urgent and emergency care (UEC) settings in any country or region. Results There were 362 respondents (aged 21–65 years, 87.8% shift workers) from 7 occupational groups including physicians (48.6%), nurses (22.4%) and advanced clinical practitioners (18.5%). Most believed that health promotion is part of their role, and that SBIRT for alcohol prevention is needed and appropriate in UEC settings. SBIRT was seen to be acceptable to patients. 66% currently provide brief alcohol advice, but fewer screen for alcohol problems or make alcohol-related referrals. The most common barriers were high workload and lack of funding for prevention, lack of knowledge and training on SBIRT, lack of access to high-quality resources, lack of timely referral pathways, and concerns about patient resistance to advice. Some views and attitudes varied according to demographic characteristics, occupation, setting or region. Conclusions UEC workers are willing to engage in SBIRT for alcohol prevention but there are challenges to implementation in UEC environments and concerns about workload impacts on already-burdened staff, particularly in the context of global workforce shortages. UEC workers advocate for clear guidelines and policies, increased staff capacity and/or dedicated health promotion teams onsite, SBIRT education/training/resources, appropriate physical spaces for SBIRT conversations and improved alcohol referral pathways to better funded services. Implementation of SBIRT could contribute to improving population health and reducing service demand, but it requires significant and sustained commitment of time and resources for prevention across healthcare organisations.
Introduction Lymphoma has been reported in the setting of azathioprine therapy for Crohn's Disease previously. This seems to be a consequence of long-term immunosuppression. We present a case of reversible lymphoma in the setting of azathioprine therapy for Crohn's Disease. Method A 31-year-old male patient, known to have ileocolonic Crohn's disease since 2016 had been under control and in remission, since his diagnosis, having been maintained on azathioprine 150 mg daily. He presented to gastroenterology clinic in May 2021 with few weeks of symptoms including feeling unwell with abdomen pain and constipation. Abdominal X ray showed features of faecal loading. He was started on laxative and booked for colonoscopy. Colonoscopy in June 2021 showed an inflammatory looking stricture in the proximal transverse colon, the scope could not be advanced beyond the stricture, figure 1. Biopsy was taken and the patient was booked for CT colonoscopy. The subsequent CT colonoscopy showed a long, stricturing lesion involving the hepatic flexure, right side of the colon, cecum, and terminal ileum in keeping with an inflammatory stricture. The colonic stricture biopsies showed quite dense monoclonal T lymphocytic infiltrate. The sample was therefore referred to Haematological Malignancy Diagnostics Unit in Nottingham for immuno-phenotyping and reference opinion. Indolent T-cell lymphoma was confirmed by histological and immuno-histochemical features. His symptoms improved with tapering course of prednisolone. In view of these findings, azathioprine was discontinued in July 2021. He was referred to Lymphoma MDT where PET CT scan showed intensely hyper-metabolic right colonic lesion near the hepatic flexure in keeping with the known lymphoma, figure 1. After some debate about the most appropriate management and with recrudescence of his presenting symptoms, a decision was made to undertake surgical resection of the diseased area of the bowel. Results Laparoscopic right Hemicolectomy was performed in Sep 2022. Histopathology of the resected bowel showed features of Crohn's disease but no features of lymphoma. The lymphoma had apparently resolved with withdrawal of azathioprine therapy. Conclusions Lymphoma can be a complication of Crohn's disease in a patient on Azathioprine therapy. We present a case where lymphoma resolved after discontinuation of their Azathioprine therapy.
BACKGROUND:The National Health Service Long Term Plan details plans to make digital interactions available to all patients in 5 years. Teleconsultations can improve access to specialist services; however, there is a lack of evidence for the use of teleconsultations in an oncology setting in the United Kingdom.OBJECTIVE:We aim to describe a service evaluation of teleconsultations for patients attending a regional brain metastases clinic. These patients have unique travel restrictions that prevent them from driving.METHODS:From April to October 2018, all patients attending the brain metastases clinic were offered the choice of teleconsultation in place of a face-to-face appointment. Feedback was assessed using a satisfaction questionnaire, and data of all clinic attendances were collected.RESULTS:A total of 69 individual patients had 119 appointments over the duration of the pilot, of which 36 (30.2%) were new patient appointments and 73 (61.3%) were follow-ups. Of the 69 patients, 24 (35%) took part in teleconsultations (41/119, 34.5%). User satisfaction was high, and no patients who took part in a teleconsultation reverted to face-to-face appointments. These patients avoided 2521 miles (61.6 miles per appointment) of hospital-associated travel and travel costs of £441.48 (US $599.83) to £10.78 (US $14.65) per appointment.CONCLUSIONS:Teleconsultations appear to be acceptable in this cohort of patients with brain metastases attending a regional stereotactic radiosurgery service with the potential for significant savings in travel and expenses.
Type 1 diabetes is one of the most challenging long-term medical conditions to manage. Over the past five years, technologically skilled people with type 1 diabetes have developed communication systems and algorithms that allow insulin delivery from insulin pumps to be automatically controlled. These systems combine glucose data from a continuous glucose monitor with an original algorithm that communicates with an insulin pump to sustain, reduce, or increase insulin delivery to maintain glucose levels within a target range. Use of such systems is increasing, with OpenAPS reporting more than 1500 users worldwide.1OpenAPSOpenAPS Ouctomes.https://openaps.org/outcomes/Date accessed: January 27, 2020Google Scholar Users perceive the system as safe, and self-reported improvements have been seen in HbA1c, time in target glucose range, and quality of life.2Lewis D Leibrand S Open APSC Real-world use of open source artificial pancreas systems.J Diabetes Sci Technol. 2016; 101411Crossref PubMed Scopus (87) Google Scholar, 3Litchman ML Lewis D Kelly LA Gee PM Twitter analysis of #OpenAPS DIY artificial pancreas technology use suggests improved A1C and quality of life.J Diabetes Sci Technol. 2019; 13: 164-170Crossref PubMed Scopus (42) Google Scholar However, the algorithms and the systems used, unlike commercially available closed-loop systems (eg, Medtronic MiniMed 670G), have not been through the rigorous safety testing required by regulators such as the US Food and Drug Administration and the UK Medicines and Healthcare products Regulatory Agency. As such, they do not have regulatory approval, and the use of such do-it-yourself (DIY) systems raises many medicolegal and ethical concerns.4Crabtree TSJ McLay A Wilmot EG DIY artificial pancreas systems: here to stay?.Pract Diabetes. 2019; 36: 63-68Crossref Scopus (11) Google Scholar, 5Wilmot EG Danne T DIY artificial pancreas systems: the clinician perspective.Lancet Diabetes Endocrinol. 2020; 8: 175-184Google Scholar This situation has generated uncertainty among health-care professionals about what their approach should be to these systems. The Diabetes Technology Network UK sought to gain an understanding of professional health-care attitudes and clinical practice with respect to DIY artificial pancreas systems. We created a survey (in SurveyMonkey) and distributed it via the Association of British Clinical Diabetologists–Diabetes Technology Network UK and the Association of Children's Diabetes Clinicians, targeting predominantly health-care professionals working in pump multidisciplinary teams in the UK. The survey took place from Feb 22 to April 29, 2019. Of 317 responses, 146 (46%) were from consultants, 24 (8%) were from registrars specialising in diabetes, 122 (38%) were from diabetes-specialist nurses or dietitians, and the remaining 25 (8%) were from other health professionals. Almost a third of responses (85 [27%]) were from health-care professionals working in paediatrics. Most respondents (289 [91%]) said that they would not initiate conversations about DIY artificial pancreas systems as a treatment option; 212 (67%) indicated that a reason for this position was because these systems are “not regulated/approved”, 200 (63%) indicated “limited knowledge of the system”, and 101 (32%) indicated “fears around indemnity”. Respondents were cautious of potential risk, perceiving DIY systems as “risky in the wrong hands” (136 [43%]) or “slightly riskier than approved options” (76 [24%]). However, only 2% (seven respondents) perceived DIY systems as “dangerous”. More than half (174 [55%]) expressed a willingness to support users in some way, whereas a minority (41 [13%]) said that they would refuse to supply devices if the patient wanted to use a DIY artificial pancreas system; 25 (8%) said that they would actively warn against use. More than half (187 [59%]) did not feel comfortable providing clinical support, but only 12 (4%) felt unable to provide ongoing care. There was a shared belief that health-care professionals should learn more about DIY artificial pancreas systems to support users (308 [97%]). Notably, when asked if they would they use a DIY artificial pancreas system themselves if they had type 1 diabetes, almost half (149 [47%]) of respondents said yes. To our knowledge, this survey is the first to explore health-care professionals’ attitudes to DIY artificial pancreas systems. Health-care professionals are generally supportive of users but remain cautious regarding the unlicensed and unregulated nature of the systems and the potential risks (panel). Most of the survey respondents do not discuss DIY systems as a treatment option but will continue to support those who choose to use such systems. This survey provides unique insight into standard UK clinical care of users of DIY artificial pancreas system and has informed the development of the Diabetes UK joint societies national consensus statement on DIY closed-loop systems.6Diabetes UK Royal College of NursingDo it yourself (DIY) closed loop for people living with type 1 diabetes.https://www.diabetes.org.uk/professionals/position-statements-reports/do-it-yourself-closed-loopDate accessed: January 27, 2020Google ScholarPanelKey messages from the 2019 Diabetes Technology Network UK survey of health-care professional perspectives on DIY artificial pancreas systems•Most respondents were keen to support users of DIY artificial pancreas systems; few actively warned against the use of DIY systems•Most respondents did not initiate discussions about DIY artificial pancreas systems in clinic because of concerns that the systems are not regulated or approved, insufficient knowledge of the systems, and fears of indemnity•Almost all respondents had been able to provide ongoing care for users of DIY artificial pancreas systems, although more than half did not feel comfortable providing clinical support•Most respondents were not comfortable describing the risks and benefits of DIY artificial pancreas systems; many agreed that DIY systems could be “risky in the wrong hands” or were “riskier than approved systems”•Almost all respondents were keen to learn more about DIY artificial pancreas systems•Almost half of respondents indicated that they would opt to use a DIY artificial pancreas system if they had type 1 diabetes themselvesDIY=do-it-yourself. •Most respondents were keen to support users of DIY artificial pancreas systems; few actively warned against the use of DIY systems•Most respondents did not initiate discussions about DIY artificial pancreas systems in clinic because of concerns that the systems are not regulated or approved, insufficient knowledge of the systems, and fears of indemnity•Almost all respondents had been able to provide ongoing care for users of DIY artificial pancreas systems, although more than half did not feel comfortable providing clinical support•Most respondents were not comfortable describing the risks and benefits of DIY artificial pancreas systems; many agreed that DIY systems could be “risky in the wrong hands” or were “riskier than approved systems”•Almost all respondents were keen to learn more about DIY artificial pancreas systems•Almost half of respondents indicated that they would opt to use a DIY artificial pancreas system if they had type 1 diabetes themselves DIY=do-it-yourself. EGW reports personal fees and previous writing support from Abbott Diabetes Care, Sanofi Aventis, and Novo Nordisk, and personal fees from Eli Lilly, Dexcom, Medtronic, and Insulet. PC has received personal fees from Abbott Diabetes Care, Medtronic, Dexcom, Insulet, Roche, Novo Nordisk, Sanofi Aventis, Lilly Diabetes, and Novartis. PH has received personal fees from Medtronic, Insulet, Abbott Diabetes Care, Novo Nordisk, Lilly Diabetes, Sanofi Aventis, and Roche. AL has received personal fees from Dexcom, Insulet, Abbott Diabetes Care, and Novo Nordisk. AM is a user of artificial pancreas systems and has received personal fees from Eli Lilly and Novo Nordisk. TSJC declares no competing interests. DIY artificial pancreas systems: the clinician perspectiveWe are witnessing a technological revolution in type 1 diabetes, with a race to bring commercial closed-loop (artificial pancreas) systems to market. However, only one automated insulin-delivery system, the Medtronic MiniMed 670G, has received both US Food and Drug Administration (FDA) and European CE mark approval and is commercially available in several countries. The French Diabeloop system, designed to work with several continuous glucose monitors and insulin pumps, has received a CE mark, and the FDA have awarded the Tandem Diabetes Care t:slim X2 the status of an alternate controller enabled interoperable pump, facilitating efficient premarket review; however, neither are commercially available yet. Full-Text PDF
