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The Research and Innovation Department is Medway NHS Foundation Trust's dedicated research department. The department assists staff to undertake medical research, devise new equipment, techniques or systems of care that improve patient care and their experience within the hospital. This is linked with the trust strategy of 'Patient First' to help improve the care and services provided to the people of Medway and Swale. This new improvement system means focus on fewer, more targeted priorities that can have a big impact quickly. Click here for more information about Patient First.
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The Research and Innovation department is comprised of several teams who actively support research and innovation projects in different ways.
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About Research & Innovation

Research is the detailed study of a subject with the aim of discovering new information or reaching a new understanding. Scientific research follows a structured process known as the scientific method. The scientific method aims to ensure the accuracy of the findings while removing an individual's personal point of view.

Medical research is vital in ensuring that medical treatments and healthcare techniques are constantly improving. Medical research has changed the ways we care for and treat people with medical conditions, illnesses and injuries. Indeed, medical research has resulted in the development and improvement of drugs, vaccines, equipment and techniques for many years.
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Transforming Healthcare Through Clinical Research & Innovation | Research & Innovation

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The Research and Innovation Department is Medway NHS Foundation Trust's dedicated research department. The department assists staff to undertake medical research, devise new equipment, techniques or systems of care that improve patient care and their experience within the hospital.

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STAFF PAPER! Acupuncture Based on Regulating Autonomic Nerves for the Prevention of Migraine without Aura: A Prospective, Double-Dummy, Randomized Controlled Clinical Trial [Letter] by Mingrui Xie

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STAFF PAPER! Acupuncture Based on Regulating Autonomic Nerves for the Prevention of Migraine without Aura: A Prospective, Double-Dummy, Randomized Controlled Clinical Trial [Letter] by Mingrui Xie

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STAFF PAPER! A combined qSOFA-lactate model for sepsis-related mortality prediction: a small step towards an elusive answer? by Rahuldeb Sarkar

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STAFF PAPER! A combined qSOFA-lactate model for sepsis-related mortality prediction: a small step towards an elusive answer? by Rahuldeb Sarkar

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Sepsis, or dysregulated host immune response to infection, is a major killer worldwide, responsible for nearly 20% of all deaths globally. Therefore, early identification of patients at increased risk of developing sepsis is important for initiation of appropriate care pathways, and to reduce preventable deaths. However, this identification process requires additional resource allocation, which even high-income countries (HICs) struggle with and contemplate upon.

Efficient prediction tools like the Sequential Organ Failure Assessment (SOFA) score, involving multiple laboratory parameters, have consistently shown high precision, but are challenging to implement in low-income and middle-income countries (LMICs) due to logistical and operational issues. The Sepsis-3 task force showed the quick SOFA (qSOFA) score to have good predictive validity in identifying patients with suspected infection at high risk of mortality in patients outside intensive care units in a HIC setting. This has been subsequently corroborated in LMIC settings.

However, the most recent Surviving Sepsis Guideline strongly recommends against using qSOFA as a single screening tool for sepsis because of low sensitivity.

Therefore, the search for a simplistic effective tool for resource-limited settings continues.

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Sepsis, or dysregulated host immune response to infection, is a major killer worldwide, responsible for nearly 20% of all deaths globally. Therefore, early identification of patients at increased risk of developing sepsis is important for initiation of appropriate care pathways, and to reduce preventable deaths. However, this identification process requires additional resource allocation, which even high-income countries (HICs) struggle with and contemplate upon.

Efficient prediction tools like the Sequential Organ Failure Assessment (SOFA) score, involving multiple laboratory parameters, have consistently shown high precision, but are challenging to implement in low-income and middle-income countries (LMICs) due to logistical and operational issues. The Sepsis-3 task force showed the quick SOFA (qSOFA) score to have good predictive validity in identifying patients with suspected infection at high risk of mortality in patients outside intensive care units in a HIC setting. This has been subsequently corroborated in LMIC settings., However, the most recent Surviving Sepsis Guideline strongly recommends against using qSOFA as a single screening tool for sepsis because of low sensitivity. Therefore, the search for a simplistic effective tool for resource-limited settings continues.

In The Lancet Global Health, Shelton Wright and colleagues assessed a relatively simple bedside prediction model for infection-related mortality in a LMIC setting. The tool was derived from the large Ubon-sepsis cohort, combining qSOFA and point-of-care venous lactate in southeast Asia. In patients with suspected infection, the authors assigned a score of 0 (for lactate concentration <2·0 mmol/L), 1 (for lactate concentration ≥2·0 to <4·0 mmol/L), or 2 (for lactate concentration ≥4 mmol/L) and added this to the usual qSOFA score (0-3), resulting in a 5-point scoring system. The model was externally validated on the multinational SEAICRN cohort. In addition to having good calibration, the qSOFA-lactate score provided better 28-day mortality discrimination than the qSOFA alone and similar discrimination to modified SOFA. There was marginal improvement in 28-day mortality discrimination with qSOFA-lactate score over ternary lactate score in the derivation cohort, but these models showed similar discrimination in the validation dataset. Furthermore, a combined model of qSOFA-lactate and baseline risk factors had a better mortality discrimination than the combined model of qSOFA and baseline risk factors. This discrimination was not better than that of a model combining baseline risk factors with ternary lactate.

The authors should be commended for developing the model in an LMIC setting, where clinicians often have to extrapolate from tools built in HICs, with suboptimal results. Data completeness was close to 100% for most relevant parameters, including complete availability of the 28-day mortality outcome data, even after hospital discharge. A tool such as this might be useful in a peripheral health-care facility in LMICs, to identify patients at risk of deterioration, for transferring out to a referral hospital, and also for triaging in emergency rooms in better-equipped hospitals. Use of venous point-of-care lactate, which is easier than arterial lactate to measure logistically, also makes this model more appealing. Different score cutoffs can be used depending on the trade-offs that a particular health system is willing to accept.

While interpreting the results, we must be mindful of some limitations of this study. First, a large proportion of patients, as high as 77%, in both the derivation and validation cohorts were transferred into the tertiary study hospitals where participants were enrolled. It is likely that these patients might not be entirely representative of patients who were directly admitted to a health-care facility on day 1. It is, however, reassuring that the model performed well in patients without history of transfer. Second, the same numerical qSOFA-lactate score was associated with different mortality risks depending on the score components. For example, a qSOFA-lactate score of 2, entirely contributed by qSOFA score (qSOFA score of 2, ternary lactate score of 0), was associated with a 28-day mortality risk of 8%. However, with a qSOFA-lactate score of 2 entirely contributed by lactate scale (qSOFA score of 0, ternary lactate score of 2) was associated with a mortality of 27%. This difference warrants relevant subgroup analysis in implementation studies. Third, it would be interesting to see how purely clinical parameter-based models (eg, National Early Warning Score) perform compared with the qSOFA-lactate model, as they have been previously shown to perform well in other LMIC settings.

Fourth, the lactate-only model had similar mortality discrimination compared with qSOFA-lactate in the validation cohort. An analysis of feature importance in subsequent studies could shed more light on this. A lactate-only tool could be attractive, as it is devoid of intraobserver and interobserver variability associated with measurement of clinical parameters. Finally, as the authors point out, absence of surgical patients in the dataset limits generalisability to this important patient group.

For a prediction tool, successful implementation process is often a bridge to cross in achieving improved patient outcomes, due to system-based factors not considered in the model development. The pathway from building an algorithm to improved outcomes has previously been described.

The same processes should apply to the qSOFA-lactate model before it is incorporated in widespread clinical decision support. Another important task would be to assess this model in large cohorts within HICs, where widespread adoption of electronic health records enables examination of simple prediction tools in a relatively short time. Replication of similar results will be necessary for reassurance that the clinical underpinning of the model is robust across all settings.

References

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Slawomirski L

Auraaen A

Klazinga N

The economics of patient safety.

OECD, Paris 2017

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Performance assessment of the universal vital assessment score vs other illness severity scores for predicting risk of in-hospital death among adult febrile inpatients in northern Tanzania, 2016-2019.

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Pencina MJ

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Prediction models -- development, evaluation, and clinical application.

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Path from predictive analytics to improved patient outcomes: a framework to guide use, implementation, and evaluation of accurate surgical predictive models.

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DOI: https://doi.org/10.1016/S2214-109X(22)00304-7

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A combined qSOFA-lactate model for sepsis-related mortality prediction: a small step towards an elusive answer?

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Sepsis, or dysregulated host immune response to infection, is a major killer worldwide, responsible for nearly 20% of all deaths globally.1 Therefore, early identification of patients at increased risk of developing sepsis is important for initiation of appropriate care pathways, and to reduce preventable deaths.

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STAFF PAPER! Effects and Proposed Countermeasures ofAbortion Bans and Restrictions on People With Uteruses and Society, by Oluwateniayo Okpaise et al

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STAFF PAPER! Effects and Proposed Countermeasures ofAbortion Bans and Restrictions on People With Uteruses and Society, by Oluwateniayo Okpaise et al

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With the recent overturning of Roe V. Wade by the Supreme Court, access to abortions in many regions across the United States will become very limited as laws regarding fetal termination will be determined by state legislators rather than on a federal level. This article highlights the effects of Roe V. Wade’s abolishment on individuals that can get pregnant, how unwanted pregnancies will affect society in general, and reasonable steps forward following the ban. We conducted an electronic search using PubMed, Google, and Google Scholar. The search was retrospective, and the preliminary results focused on articles about the rationale behind pregnancy termination and the overall effects of abortion and the ban. Review papers, original papers, and newspaper articles were eligible for use. Sample size and region of publication were not exclusionary criteria. Each author independently reviewed and extracted data to write up each assigned section, and group collaborations occurred to create the final draft. Out of the 93 resources reviewed, 32 sources were deemed eligible and used in this article. These resources included 23 journal articles, eight websites, and one book.. The data gathered showed that while abortions have many potential complications even when performed under regulated conditions, taking away the choice of those with a uterus is also not without consequence. The economic, familial, and societal implications should be considered moving forward as safety nets will need to be implemented for people with uterus and children involved.

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STAFF PAPER! A Clinico-Radiographic Study to Gauge the Correlation between the Remaining Interdental Bone Height and Early Site of Furcation Involvement, by Angel Fenol et al

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STAFF PAPER! A Clinico-Radiographic Study to Gauge the Correlation between the Remaining Interdental Bone Height and Early Site of Furcation Involvement, by Angel Fenol et al

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Background: Periodontal disease is an inflammatory disease affecting the supporting tissues of teeth; triggered by host response to periodontal pathogens. There occurs connective tissue attachment loss first slowly progressing to alveolar bone loss later on. Early bone loss occurring at the furcal area of multirooted teeth are difficult to diagnose clinically alone. Combination of clinical probing and a diagnostic investigation helps in identifying the early bone loss in such areas much easier. Objective: This study aims to investigate the remaining interdental bone height on mesial and distal sides of maxillary and mandibular permanent first molars and to correlate it with early site of furcation involvement. Materials and methods: Fifty Intraoral Periapical Radiographs (IOPARs) of both maxillary and mandibular permanent first molars of subjects with moderate to severe periodontitis (3-4 millimeters (mm) and >5 mm of clinical attachment loss respectively) were evaluated for remaining interdental bone height on mesial and distal aspects. Clinically, the grade of furcation involvement (grade 1 and early grade 2) was assessed using the Naber’s Probe and radiographically interdental bone loss was assessed. Results: The results show that there is statistically significant involvement of the mesial furcation first when there is distal root displaying bone loss. Also, there is statistically significant involvement of the lingual furcation first when there is mesial root showing more bone loss. Conclusion: Assessment of interdental bone levels using radiographic aids can provide a reliable investigatory method to identify early furcation involvement. A thorough clinical and radiographic examination is essential for a successful treatment outcome.

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STAFF PAPER! Preterm and term pre-eclampsia: Relative burdens of maternal and perinatal complications 

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STAFF PAPER! Preterm and term pre-eclampsia: Relative burdens of maternal and perinatal complications 

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Objective: To  determine  the  relative  burdens  of  maternal  and  perinatal  complica-tions for preterm and term pre-eclampsia.
Design: Prospective observational cohort study.
Setting: Two English maternity units.
Population: Unselected  women  with  singleton  pregnancies  who  developed  pre-  eclampsia  (International  Society  for  the  Study  of  Hypertension  in  Pregnancy  def inition).
Methods: Outcomes  were  ascertained  by  health  record  review  and  compared  be-tween pregnancies with preterm (versus term) pre-eclampsia.
Main  outcome  measures:  Severe  maternal  hypertension,  maternal  mortality  or  major maternal morbidity, perinatal mortality or major neonatal morbidity, neonatal unit (NNU) admission ≥48 hours, and birthweight <3rd percentile.
Results: Among  40  241  singleton  pregnancies,  298  (0.7%,  95%  confidence  interval  [CI]  0.66–0.83)  and  1194  (3.0%,  95%  CI  2.8–3.1)  developed  preterm  and  term  pre-  eclampsia,  respectively.  Women  with  preterm  (versus  term)  pre-eclampsia  more  commonly  experienced  adverse  maternal  or  perinatal  events:  severe  hypertension  18.5% (95% CI 14.5–23.3) versus 13.6% (95% CI 11.7–15.6); maternal mortality/major morbidity  7.4%  (95%  CI  4.9–10.9)  versus  2.2%  (95%  CI  1.5–3.2);  perinatal  mortal-ity/major  neonatal  morbidity  29.5%  (95%  CI  24.6–34.9)  versus  2.2%  (95%  CI  1.5–  3.2);  and  birthweight  <3rd  percentile  54.4%  (95%  CI  48.7–59.9)  versus  14.2%  (95%  CI  12.4–16.3).  However,  in  absolute  terms,  most  maternal  complications  occurred  in  women  with  term  pre-eclampsia,  as  did  a  large  proportion  of  perinatal  compli-cations:  severe  hypertension  74.7%  (95%  CI  68.5–80.0);  maternal  mortality/major  morbidity 54.2% (95% CI 40.3–67.4); perinatal mortality/major neonatal morbidity 22.8% (95% CI 16.1–31.3); NNU admission ≥48 hours 38.1% (95% CI 32.4–44.1); and birthweight <3rd percentile 51.2% (95% CI 45.8–56.5).
Conclusions: Although  adverse  event  risks  are  greater  with  preterm  (versus  term)  pre-eclampsia,  term  disease  is  associated  with  at  least  equivalent  total  numbers  of  maternal, and a significant proportion of perinatal, adverse events. Increased efforts should be made to decrease the incidence of term pre-eclampsia.

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STAFF PAPER! Development, implementation and evaluation of a seven‑day clinical pharmacy service in a tertiary referral teaching hospital during surge‑2 of the COVID‑19 pandemic, by S Matthews et al

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STAFF PAPER! Development, implementation and evaluation of a seven‑day clinical pharmacy service in a tertiary referral teaching hospital during surge‑2 of the COVID‑19 pandemic, by S Matthews et al

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Abstract Background Seven-day clinical pharmacy services in the acute sector of the National Health Service are limited. There is a paucity of evidential patient beneft. This limits investment and infrastructure, despite United Kingdom wide calls. Aim To optimise medicines seven-days a week during surge-2 of the COVID-19 pandemic through implementation of a seven-day clinical pharmacy service. This paper describes service development, evaluation and sustainability. Setting A tertiary-referral teaching hospital, London, United Kingdom. Development The seven-day clinical pharmacy service was developed to critical care, acute and general medical patients. Clinical leads developed the service specifcation and defned priorities, targeting complex patients and transfer of care. Contributing staf were briefed and training materials developed. Implementation The service was implemented in January 2021 for 11 weeks. Multidisciplinary team communication brought challenges; strategies were employed to overcome these. Evaluation A prospective observational study was conducted in intervention wards over two weekends in February 2021. 1584 beds were occupied and 602 patients included. 346 interventions were reported and rated; 85.6% had high or moderate impact; 56.7% were time-critical. The proportion of medicines reconciliation within 24-h of admission was analysed across the hospital between November 2020 and May 2021. During implementation, patients admitted Friday-Sunday were more likely to receive medicines reconciliation within 24-h (RR 1.41 (95% CI 1.34–1.47), p<0.001). Rostered services were delivered sustainably in terms of shift-fll rate and medicines reconciliation outcome. Conclusion Seven-day clinical pharmacy services beneft patient outcome through early medicines reconciliation and intervention. Investment to permanently embed the service was sustained

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STAFF PAPER! Out at the College, by Ginny Bowbrick

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STAFF PAPER! Out at the College, by Ginny Bowbrick

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Ginny Bowbrick talks to the Bulletin about how celebrating our differences is so important for the future of our workforce and how it can ultimately lead to better care for out patients.

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Abstract

Background: Increasing pressure to publicise research findings and generate impact, alongside an expectation from funding bodies to go beyond publication within academic journals, has generated interest in alternative methods of science communication. Our aim is to describe our experience of using a variety of creative communication tools, reflect on their use in different situations, enhance learning and generate discussion within the systematic review community.

Methods: Over the last 5 years, we have explored several creative communication tools within the systematic review process and beyond to extend dissemination beyond traditional academic mechanisms. Central to our approach is the co-production of a communication plan with potential evidence users which facilitates (i) the identification of key messages for different audiences, (ii) discussion of appropriate tools to communicate key messages and (iii) exploration of avenues to share them. We aim to involve evidence users in the production of a variety of outputs for each research project cognisant of the many ways in which individuals engage with information.

Results: Our experience has allowed us to develop an understanding of the benefits and challenges of a wide range of creative communication tools. For example, board games can be a fun way of learning, may flatten power hierarchies between researchers and research users and enable sharing of large amounts of complex information in a thought provoking way, but they are time and resource intensive both to produce and to engage with. Conversely, social media shareable content can be quick and easy to produce and to engage with but limited in the depth and complexity of shareable information.

Discussion: It is widely recognised that most stakeholders do not have time to invest in reading large, complex documents; creative communication tools can be a used to improve accessibility of key messages. Furthermore, our experience has highlighted a range of additional benefits of embedding these techniques within our project processes e.g. opening up two-way conversations with end-users of research to discuss the implications of findings.

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