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Three‐Year Recurrence in People With Diabetic Foot Ulcers and Chronic Limb Threatening Ischemia Is Comparable to Cancer

ABSTRACT

This study aimed to compare the 3-year recurrence rates of diabetic foot ulcers (DFU) and the rate of endovascular reintervention for chronic limb-threatening ischaemia (CLTI) to recurrence rates of advanced-stage cancers. We systematically collected original data reporting 3-year DFU recurrence from studies published through 2024 and calculated a pooled mean. These findings were compared to recurrence rates for advanced breast, prostate, colorectal, and lung cancers using contemporary sources from the National Cancer Institute and American Cancer Society. CLTI reintervention data were drawn from the BEST-CLI trial. The pooled 3-year DFU recurrence rate was 58%, while the CLTI reintervention rate was 50%—comparable to cancer recurrence rates: breast (25%–40%), prostate (30%–40%), colorectal (30%–50%), and lung (60%–80%). Despite these comparable risks, DFU and CLTI remain underrecognized in terms of their recurrent burden on individuals, families, and health systems. The data presented here underscore the need to reframe healed DFU and post-intervention CLTI not as an endpoint but as a remission—a state requiring structured surveillance and proactive management, much like in oncology. Developing interdisciplinary survivorship care plans for individuals with DFU and CLTI, modelled on those used in cancer care, may improve communication, enhance secondary prevention, and foster more ulcer-free, hospital-free, and activity-rich days.

Impact of a community-based asynchronous review clinic on appointment attendance delays across an eye hospital network in London, UK: an interrupted time series analysis

Por: Ndwandwe · S. · Fu · D. J. · Adesanya · J. · Bazo-Alvarez · J. C. · Ramsay · A. I. G. · Fulop · N. J. · Magnusson · J. · Napier · S. · Cammack · J. · Baker · H. · Kumpunen · S. · Alarcon Garavito · G. A. · Elphinstone · H. · Mills · G. · Scully · P. · Symons · A. · Webster · P. · Wilson
Objective

To assess the impact of opening a large community-based asynchronous review ophthalmic clinic on attendance delays among patients with stable chronic eye disease attending a London teaching eye hospital network.

Design

Interrupted time-series analysis of routine electronic health records of appointment attendances.

Setting

A large eye hospital network with facilities across London, UK, between June 2018 and April 2023.

Participants

We analysed 69 257 attendances from 39 357 patients, with glaucoma and medical retina accounting for 62% (n=42 982) and 38% (n=26 275) of visits, respectively. Patients over 65 made up 54% (n=37 824) of attendances, while 53% (n=37 014) were from the more deprived half of the population, and 51% (n=35 048) were males.

Intervention

An asynchronous review clinic opened in a shopping centre in London, in autumn 2021, following the COVID-19 lockdown in spring 2020.

Main outcome measures

Average attendance delays (days), calculated as the difference between follow-up attendance date and the latest clinically appropriate date determined at the preceding attendance.

Results

Pre-COVID-19, attendance delays for chronic eye disease monitoring were increasing by 0.9 days per week (95% CI, 0.8 to 0.9) on average, worsening to 2.0 days per week (95% CI, 2.0 to 2.0) after the first COVID-19 national lockdown, mid-March 2020. Opening the asynchronous review clinic increased appointment capacity, with delays decreasing on average by 8.1 days per week (95% CI, 8.1 to 8.2) shortly after opening. The rate of decrease slowed to 0.3 days per week (95% CI, 0.3 to 0.3) after 5 months. We found no significant differences in average attendance delays by age, gender or level of deprivation.

Conclusion

The asynchronous review clinic significantly reduced attendance delays across the hospital network, addressing pre-existing backlog for stable chronic eye diseases. The reduction appeared to be maintained after the initial backlog had been cleared.

Randomised controlled trial to compare the efficacy of integrated cognitive-behavioural therapy (COPE-A) for substance use and traumatic stress among adolescents and young adults delivered via telehealth versus in person: trial protocol

Por: Mills · K. · Winter · V. · Cobham · V. · Peach · N. · Arunogiri · S. · Chatterton · M. L. · Bendall · S. · Back · S. E. · Perrin · S. · Brady · K. · COPE-A Trial Team · Barrett · Teesson · Slade · Hamilton · Rickwood · Reid · Leicester · Milne · Curtis · Harvey · Kay-Lambkin
Introduction

Emerging research indicates that integrated treatment of co-occurring post-traumatic stress disorder (PTSD) and substance use disorder can be effective among adolescents and young people. However, various barriers exist to young people accessing evidence-based treatments. Telehealth offers an opportunity to address these barriers and provide a scalable and accessible alternative to inperson treatment. This paper describes the study protocol for a randomised controlled trial (RCT) examining the efficacy, safety and cost-effectiveness of an integrated trauma-focused cognitive-behavioural treatment for traumatic stress and substance use among adolescents and young adults (Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure – Adolescent and Young Adult version (COPE-A)) when delivered in person compared with via telehealth.

Methods and analysis

A two-arm, parallel group, single-blind, non-inferiority RCT with follow-up at 4 months and 12 months post study entry will be conducted in Sydney, Australia. Participants (170 adolescents and young adults aged 12–25 years) will be allocated to receive COPE-A either in person or via telehealth (allocation ratio 1:1) using minimisation. Project psychologists will administer treatment via both modes of delivery over a maximum of 16 sessions of 60–90 min. The primary outcome will be between-group differences in change in the severity of PTSD symptoms from baseline to 4-month follow-up, as measured by the Clinician-Administered PTSD Scale for Children and Adolescents for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Ethics and dissemination

This study has been approved by the Sydney Children’s Hospitals Network Human Research Ethics Committee (2024/ETH01050). Research findings will be published in peer-reviewed journals and presented at scientific conferences.

Trial registration number

ACTRN12624000776505.

Protocol version

V.2.3, 20 March 2025.

Feasibility randomised controlled trial to assess the delivery of a novel isometric exercise intervention for people diagnosed with uncomplicated stage 1 hypertension in the National Health Service: key quantitative findings

Por: Wiles · J. D. · Santer · E. · Rees-Roberts · M. · Borthwick · R. · Doulton · T. · Swift · P. A. · Pellatt-Higgins · T. · Saxby · K. · Mills · A. · Gousia · K. · MacInnes · D. · ODriscoll · J. · West · A. · Darby · J. · Short · V. · Farmer · C. K.
Objectives

The aim of this study was to determine the feasibility of delivering personalised isometric exercise (IE) for people with stage 1 hypertension. Is it feasible to deliver an isometric wall squat intervention in the National Health Service and what sample size is required to conduct an appropriately powered effectiveness randomised controlled trial (RCT)?

Design

Randomised controlled open-label multicentre feasibility study of IE compared with standard care in unmedicated people with stage 1 hypertension.

Setting

Initially, the study aimed to recruit through primary care, but this process coincided with the advent of the COVID-19 pandemic. Therefore, we shifted focus to direct-to-public advertising and delivery in secondary care.

Participants

People with unmedicated stage 1 hypertension aged over 18 able to perform IE were included. Patients were excluded if average home systolic blood pressure (sBP)

Intervention participants were randomised (1:1) to either standard lifestyle advice or an individualised isometric wall squat prescription, performed 4x2-min bouts three times a week for 6 months.

Primary and secondary outcome measures

We assessed deliverability, attrition, adherence and variance in blood pressure (BP) change.

Results

IE was found to be easily deliverable to all participants. At 6 months, 34% had withdrawn. Of those who completed IE, 85% of their sessions were at the correct intensity, meeting our retention criterion for success. Variance in BP change was 14.4 mm Hg. The study was not powered to show a difference in BP between groups; however, BP reductions were seen in the intervention group at all study time points compared with baseline. There were no adverse events related to study participation.

Conclusions

We met our a priori recruitment criteria which allowed us to calculate a sample size (n=542) for a full RCT. The results demonstrate good acceptability and adherence rates to the treatment protocol. Our results show a signal towards a consistent sBP reduction in the IE group compared with baseline.

Trial registration number

NCT04936022 (https://classic.clinicaltrials.gov/ct2/show/NCT04936022?cond=isometric+exercise&draw=2&rank=7); registry identifier: ISRCTN 13472393.

Out-of-hospital births and the experiences of emergency ambulance clinicians and birthing parents: a scoping review of the literature

Por: Hill · M. · Miles · A. · Flanagan · B. · Hansen · S. · Mills · B. · Hopper · L.
Objective

Emergency ambulance services attend a wide array of medical and trauma patients. Infrequently, this includes imminent or out-of-hospital births (OOHBs). This scoping review explores emergency ambulance clinician involvement with OOHBs, and patient and clinician experiences with birthing in the out-of-hospital setting.

Design

Scoping review using the Joanna Briggs Institute framework and ‘participant, concept, context’ criteria.

Data sources

CINAHL, Embase, Medline, Web of Science and Wiley Online were searched until 20 February 2024.

Eligibility criteria for selecting articles

Articles discussing an unplanned OOHB, or a planned home birth with complications where an emergency ambulance was required, were included.

Data extraction and synthesis

Two reviewers independently determined inclusion using Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews guidelines. A data extraction tool summarised findings for descriptive synthesis.

Results

63 articles were included. 36 articles involved retrospective research. 38 articles were published since 2015, with USA (n=17) and Australia (n=13) the highest contributors. Risk factors for OOHBs were varied, with maternal age or being multigravida/multiparous often cited. 99 complications were described, ranging from relatively minor ailments (ie, nausea and vomiting) to life-threatening situations such as maternal or neonatal cardiac arrest. Common management/interventions reported were assisting with birth, maternal intravenous cannulation and medication administration.

Birth parents, partners and clinicians all describe OOHBs as anxiety-provoking but joyous when a healthy neonate is born. The OOHB experience is enhanced for patients when clinicians communicate well, while those who appeared inexperienced increased patient anxiety.

OOHBs experience many challenges to optimal care, categorised as ‘emergency ambulance clinicians desiring additional education and training’, ‘communication and collaboration difficulties’, ‘environmental issues’, ‘technology and aids’ and ‘other’ limitations.

Conclusions

OOHBs are rare events requiring expert assistance to optimise patient outcomes. There remain significant challenges to unplanned OOHBs; ongoing training and skill competency is required to improve patient safety and clinician confidence. Further research investigating patient outcomes and experiences is recommended.

Nurses' work environment and health promotion in relation to psychological distress symptoms, and sleep disturbance: A structural equation modeling approach

Abstract

Background

The healthcare work environment has numerous stressors that can contribute to distress and poor health outcomes among nurses. The impact of distress can be detrimental, resulting in nurses leaving the profession. Thus, it is critical to explore factors in the work environment that contribute to the distress symptoms and behaviors that promote nurses' health.

Objective

This study aimed to examine the constructs associated with the conceptual model of distress, such as the work environment, specifically workload and the practice environment (quality of care, salary, staffing, time, and satisfaction) and associations with psychological distress, sleep disturbance, and health promotion behaviors in nurses, using structural equation modeling.

Design

This study was a cross-sectional survey design collected as part of the Nurse Worklife and Wellness Study (NWWS) using balanced stratified sampling methods.

Methods

A confirmatory factor analysis tested the factorial structure of the latent constructs using weighted least squares estimation with missing data (WLSMV) for the sample (n = 1170). A structural equation modeling approach examined the direct and indirect associations between workload, practice environment, health promotion behaviors, psychological distress symptoms, sleep disturbance, and health.

Results

Based on the confirmatory factor analysis, the measurement model reported adequate model fit (CFI = 0.96; TLI = 0.95; SRMR = 0.048 and RMSEA = 0.039). The structural model showed that the workload was related to significantly increased psychological distress (β = 1.47, p < 0.001), sleep disturbance (β = 1.22, p < 0.01), and decreased overall health (β = −1.36, p < 0.01). Similarly, a positive practice environment was associated with significantly higher psychological distress (β = 1.61, p < 0.001), sleep disturbance (β = 1.31, p < 0.01), and lower overall health (β = −1.51, p < 0.01). Workload and the practice environment were associated with significantly increased health promotion behaviors such as interpersonal relations, spiritual growth, stress management, physical activity, and nutrition. A statistically significant indirect relationship was found between workload and psychological distress, mediated by health promotion behaviors. Psychological and physical health promotion had restorative effects in relation to decreasing the impact of distress and sleep disturbance while increasing overall health.

Conclusions

Our results highlight the need to improve the work environment by decreasing the nurses' workload and using health promotion behaviors to mitigate nurses' psychological distress. Future studies should focus on exploring distress in the context of non-pandemic work conditions and finding ways to promote coping behaviors in nurses. In addition, healthcare organizations should develop policies and strategies to incentivize nurses' participation in health promotion behaviors to promote their well-being and ultimately stabilize the nursing workforce.

Using a Mobile Application to Promote Patient Education for Patients With Liver Cirrhosis

imagePatient education and self-management are essential for patients with liver cirrhosis. Based on Fisher and Fisher's Information-Motivation-Behavior Skills model, a Cirrhosis Care App was developed to support the education and self-management of these patients. To evaluate the effectiveness of the application, a randomized controlled trial was conducted with patients having liver cirrhosis who were being followed up in the outpatient area of ​​a medical center in Taiwan. The experimental group used the app for 1 month, whereas a control group continued to receive conventional patient education. A pretest and posttest questionnaire was used to evaluate the app's effectiveness in improving the knowledge and practice of self-care. In addition, a questionnaire was developed based on the Technology Acceptance Model to understand satisfaction with the app. Results showed that following the implementation of the Cirrhosis Care App, patients' self-care knowledge and ability to promote self-care practice improved. User satisfaction with the app was measured and reflected in its frequency of use. This study confirmed that the Cirrhosis Care App, based on the Information-Motivation-Behavior Skills model, can improve patient knowledge and self-care practice and be actively promoted to benefit patients with cirrhosis.

Exploring Nurse Use of Digital Nursing Technology

imageTechnological developments and nursing shortages have become global trends. To solve the problem of shortage of healthcare professionals, technology may be used as a backup. Nurses constitute the largest working group in the healthcare system. Therefore, nurses are very important to the success of implementing digitization in hospitals. This cross-sectional study used the characteristics and adoption roles of innovation diffusion theory to understand technology use within the organization. Data were collected through structured questionnaires and open-ended questions from March 21 to May 31, 2022, in two hospitals in Taiwan. In total, 159 nurses agreed to participate in the study. The results of this study revealed that observability, simplicity, advantage, trialability, and compatibility positively improved the acceptance of digital nursing technology. In the distribution of users' innovative roles, early adopters had a significant impact on innovation characteristics and technology acceptance. Nurses in acute and critical care units perceived a greater comparative advantage and trial availability of digital nursing technology use than did those in general wards and outpatient clinics. In addition, based on user opinions and suggestions, the development of smart healthcare and the use of digital technology are expected to improve the quality of nursing care.

Most individuals with diabetes‐related foot ulceration do not meet dietary consensus guidelines for wound healing

Abstract

The inaugural expert consensus and guidance for Nutrition Interventions in Adults with Diabetic Foot Ulcers (DFU) have been welcomed by clinicians internationally. This short report aimed to determine how the macronutrient and micronutrient status of individuals living with DFU compared to the American Limb Preservation Society Nutrition Interventions in Adults with DFU expert consensus and guidance. Descriptive analysis was conducted as a secondary analysis of an existing dataset. Mean (SD) dietary intake, the proportion meeting the nutrition recommendations and the proportion exceeding the upper limit (UL) for specific vitamins and minerals were reported. Most individuals with DFU do not meet current consensus guidelines for optimal dietary intake for wound healing, with inadequacies evident for fibre, zinc, protein, vitamin E and vitamin A. Future iterations of the consensus guideline should consider using evidence-informed recommendations for clinical practice, with the inclusion of all nutrients that are essential for wound healing in DFU.

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