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Primary care services in or alongside emergency\ud departments look and function differently and are\ud described using inconsistent terminology. Research to\ud determine effectiveness of these models is hampered by\ud outdated classification systems, limiting the opportunity\ud for data synthesis to draw conclusions and inform\ud decision-making and policy. We used findings from a\ud literature review, a national survey of Type 1 emergency\ud departments in England and Wales, staff interviews,\ud other routine data sources and discussions from\ud two stakeholder events to inform the taxonomy. We\ud categorised the forms inside or outside the emergency\ud department: inside primary care services may be\ud integrated with emergency department patient flow or\ud may run parallel to that activity; outside services may be\ud offered on site or off site. We then describe a conceptual\ud spectrum of integration: identifying constructs that\ud influence how the services function—from being closer\ud to an emergency medicine service or to usual primary\ud care. This taxonomy provides a basis for future evaluation\ud of service models that will comprise the evidence base\ud to inform policy-making in this domain. Commissioners\ud and service providers can consider these constructs in\ud characterising and designing services depending on local\ud circumstances and context.

PurposeTo study the fungal microbiome (mycobiome) and the virome of the lacrimal sacs in patients with primary acquired nasolacrimal duct obstruction (PANDO).MethodsA prospective study was performed on 10 consecutive samples of the lacrimal sac contents obtained from patients with PANDO. The samples were obtained from the lacrimal sacs under endoscopy guidance and immediately transported on ice to the laboratory. Following DNA extraction and library preparation, a whole shotgun metagenome sequencing was performed on the Illumina platform (NOVASEQ 6000). The fungal internal transcript spacer analysis was performed using the PIPITS v2.7 . The viral taxonomy profiling was performed using Kraken2 against the virus database.ResultsThe taxonomic hit distribution across the lacrimal sac samples showed rich fungal diversity (4 phyla, 12 classed, 21 families and 26 genera). The major phyla wereAscomycotaandBasidiomycota,and the key genera identified wereAlternaria, Hyphopichia, Malassezia, AspergillusandEpicoccum. The virome analysis identified 13 phyla, 15 classes and 27 families. The viruses were commonly from the familiesPoxviridae, Retroviridae, SiphoviridaeandMyoviridae,Poxviridaebeing the most prevalent family. The BeAn 58058 virus, a member of thePoxviridaefamily, was the most abundant in all the samples.ConclusionThe present study is the first whole metagenome sequencing exclusively of the fungal microbiome and virome from the lacrimal sacs of patients with PANDO. The lacrimal sacs harbour diverse fungal and viral communities with distinct ecosystem dynamics. Further studies of their functions and interactions with the hosts would provide valuable insights.

IntroductionAustralia has the highest incidence of melanoma in the world with variable care provided by a diverse range of clinicians. Clinical quality registries aim to identify these variations in care and provide anonymised, benchmarked feedback to clinicians and institutions to improve patient outcomes. The Australian Melanoma Clinical Outcomes Registry (MelCOR) aims to collect population-wide, clinical-level data for the early management of cutaneous melanoma and provide anonymised feedback to healthcare providers.Methods and analysisA modified Delphi process will be undertaken to identify key clinical quality indicators for inclusion in the MelCOR pilot. MelCOR will prospectively collect data relevant to these quality indicators, initially for all people over the age of 18 years living in Victoria and Queensland with a melanoma diagnosis confirmed by histopathology, via a two-stage recruitment and consent process. In stage 1, existing State-based cancer registries contact the treating clinician and provide an opportunity for them to opt themselves or their patients out of direct contact with MelCOR. After stage 1, re-identifiable clinical data are provided to the MelCOR under a waiver of consent. In stage 2, the State-based cancer registry will approach the patient directly and invite them to opt in to MelCOR and share identifiable data. If a patient elects to opt in, MelCOR will be able to contact patients directly to collect patient-reported outcome measures. Aggregated data will be used to provide benchmarked, comparative feedback to participating institutions/clinicians.Ethics and disseminationFollowing the successful collection of pilot data, the feasibility of an Australia-wide roll out will be evaluated. Key quality indicator data will be the core of the MelCOR dataset, with additional data points added later. Annual reports will be issued, first to the relevant stakeholders followed by the public. MelCOR is approved by the Alfred Ethics Committee (58280/127/20).

IntroductionUnderstanding the complexities of change in eating behaviours, mental health, well-being and weight is crucial to inform healthcare and service provision, particularly in light of the exacerbating effects of the COVID-19 pandemic. This study aims to address the need for more comprehensive cross-sectional and longitudinal evidence, by tracking eating behaviours, mental health, health related behaviours and weight over a 12-month period, in a sample of young adults (18–35 years) in the UK and Australia.Methods and analysisOnline surveys administered via the Prolific online research platform will be used for data collection at baseline, 6 months and 12 months. The survey (approximately 45 min) measures demographics, the impact of COVID-19, body mass index (BMI), weight management and health service usage, eating behaviours, personality, mental health, and health-related behaviours. An optional substudy component at each time point aims to validate self-reported weight in the main survey through images. Study inclusion criteria are; aged 18–34 years at baseline, BMI ≥20 kg/m2, and residing in the UK or Australia. A target of 500 participants at baseline was set, recruited through Prolific, and with recruitment stratified by BMI, sex and country. The proposed analyses include creating static predictive models using baseline data (eg, using latent class analysis, factor analysis or similar), and mapping changes longitudinally (eg, using multivariate regressions). These analyses will enable changes in the study measures to be identified, as well as predictors and outcomes of change.Ethics and disseminationEthical approval was granted by Leeds Beckett University, UK (reference number 86004) and the University of Newcastle, Australia (reference number H-2022–0110). Study findings will be disseminated through scientific journals, conferences, institute websites and social media, and briefings tailored to policy, practice and the public, with the intention to help inform the future development of health and well-being care and support for young adults across Australia and the UK.

IntroductionUnwarranted variation in patient care among physicians is associated with negative patient outcomes and increased healthcare costs. Care variation likely also exists for resident physicians. Despite the global movement towards outcomes-based and competency-based medical education, current assessment strategies in residency do not routinely incorporate clinical outcomes. The widespread use of electronic health records (EHRs) may enable the implementation of in-training assessments that incorporate clinical care and patient outcomes.Methods and analysisThe General Medicine Inpatient Initiative Medical Education Database (GEMINI MedED) is a retrospective cohort study of senior residents (postgraduate year 2/3) enrolled in the University of Toronto Internal Medicine (IM) programme between 1 April 2010 and 31 December 2020. This study focuses on senior IM residents and patients they admit overnight to four academic hospitals. Senior IM residents are responsible for overseeing all overnight admissions; thus, care processes and outcomes for these clinical encounters can be at least partially attributed to the care they provide. Call schedules from each hospital, which list the date, location and senior resident on-call, will be used to link senior residents to EHR data of patients admitted during their on-call shifts. Patient data will be derived from the GEMINI database, which contains administrative (eg, demographic and disposition) and clinical data (eg, laboratory and radiological investigation results) for patients admitted to IM at the four academic hospitals. Overall, this study will examine three domains of resident practice: (1) case-mix variation across residents, hospitals and academic year, (2) resident-sensitive quality measures (EHR-derived metrics that are partially attributable to resident care) and (3) variations in patient outcomes across residents and factors that contribute to such variation.Ethics and disseminationGEMINI MedED was approved by the University of Toronto Ethics Board (RIS#39339). Results from this study will be presented in academic conferences and peer-reviewed journals.

Each year, the Heart editorial team selects the most meritorious research paper to receive the Heart Best Research Paper Award. Primary considerations are the relevance of the clinical question addressed by the research, the quality of the research study design and data presentation, and the interest generated by the paper among other researchers, clinical cardiologists and the general public. This year, we are pleased to announce the winner and two finalists for the 2020 Heart Best Paper Research Award, highlighting the first author of each paper and sincerely congratulating the entire research team on their outstanding research contribution (table 1). View this table: Table 1 Heart best research paper Award winner and Finalists 2020 Ralph K. Akyea MPH, MBChB (figure 1) is a second-year doctoral student and part-time research associate with the Primary Care Stratified Medicine Research Group, Division of Primary Care, University of Nottingham, UK. He received his medical degree from the University of Ghana Medical School and earned his master’s degree in public health from …

ObjectivesPatient and public involvement (PPI) in health research is required by some funders and publications but we know little about how common it is. In this study we estimated the frequency of PPI inclusion in health research papers and analysed how it varied in relation to research topics, methods, funding sources and geographical regions.DesignCross-sectional.MethodsOur sample consisted of 3000 research papers published in 2020 in a general health-research journal (BMJ Open) that requires a statement on whether studies included PPI. We classified each paper as ‘included PPI’ or ‘did not include PPI’ and analysed the association of this classification with location (country or region of the world), methods used, research topic (journal section) and funding source. We used adjusted regression models to estimate incident rate ratios of PPI inclusion in relation to these differences.Results618 (20.6%) of the papers in our sample included PPI. The proportion of papers including PPI varied in relation to location (from 44.5% (95% CI 40.8% to 48.5%) in papers from the UK to 3.4% (95% CI 1.5% to 5.3%) in papers from China), method (from 38.6% (95% CI 27.1% to 50.1%) of mixed-methods papers to 5.3% (95% CI –1.9% to 12.5%) of simulation papers), topic (from 36.9% (95% CI 29.1% to 44.7%) of papers on mental health to 3.4% (95% CI –1.3% to 8.2%) of papers on medical education and training, and funding source (from 57.2% (95% CI 51.8% to 62.6%) in papers that received funding from the UK’s National Institute for Health Research to 3.4% (95% CI 0.7% to 6.0%) in papers that received funding from a Chinese state funder).ConclusionsMost research papers in our sample did not include PPI and PPI inclusion varied widely in relation to location, methods, topic and funding source.

In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion’s share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners’ capacity to think through difficult ethical decisions in daily clinical practice.

Several documents presented to the UK government from its scientific advisers analysing how and when it may be safe to reopen schools in England on 1 June have now been released after pressure from experts and trade unions. However, the papers have not reassured unions and experts about the wisdom of the timetable and have been described as containing “inconclusive” evidence. The government’s advisory body, the Scientific Advisory Group for Emergencies (SAGE), has produced several documents1 looking at various scenarios or “options” for relaxing school closures that were implemented in March because of the coronavirus. One of these documents says, “There is substantial uncertainty, with the relative contribution of school openings being driven also by the relative susceptibility and infectivity of children of different ages compared to adults, as …

IntroductionLung cancer is the leading cause of cancer mortality, comprising the largest national cancer disease burden in Australia and New Zealand. Regional reports identify substantial evidence-practice gaps, unwarranted variation from best practice, and variation in processes and outcomes of care between treating centres. The Australia and New Zealand Lung Cancer Registry (ANZLCR) will be developed as a Clinical Quality Registry to monitor the safety, quality and effectiveness of lung cancer care in Australia and New Zealand.Methods and analysisPatient participants will include all adults >18 years of age with a new diagnosis of non-small-cell lung cancer (NSCLC), SCLC, thymoma or mesothelioma. The ANZLCR will register confirmed diagnoses using opt-out consent. Data will address key patient, disease, management processes and outcomes reported as clinical quality indicators. Electronic data collection facilitated by local data collectors and local, state and federal data linkage will enhance completeness and accuracy. Data will be stored and maintained in a secure web-based data platform overseen by registry management. Central governance with binational representation from consumers, patients and carers, governance, administration, health department, health policy bodies, university research and healthcare workers will provide project oversight.Ethics and disseminationThe ANZLCR has received national ethics approval under the National Mutual Acceptance scheme. Data will be routinely reported to participating sites describing performance against measures of agreed best practice and nationally to stakeholders including federal, state and territory departments of health. Local, regional and (bi)national benchmarks, augmented with online dashboard indicator reporting will enable local targeting of quality improvement efforts.

IntroductionVitreoretinal lymphoma is a rare ocular cancer with high morbidity and mortality despite treatment. Diagnosis by cytopathology is often delayed, and various molecular and image-based investigations have been developed. Diverse treatments are used, but there is a limited medical evidence to differentiate their effectiveness. We designed an international registry that would collect diagnostic, treatment and outcomes data, to establish new evidence for the management of this cancer.Methods and analysisThe International Vitreoretinal B-Cell Lymphoma Registry will accrue data retrospectively for individuals aged 18 years or older, diagnosed with new or recurrent vitreoretinal B-cell lymphoma on or after 1 January 2020. A steering committee of subspecialised ophthalmologists identified 20 key clinical data items that describe patient demographics, tissue involvements, diagnostic testing, ocular and systemic treatments and treatment complications, and visual acuity and survival outcomes. Customised software was designed to permit collection of these data across a single baseline and multiple follow-up forms. The platform collects data without identifiers and at 3 month reporting intervals. Outcomes of the project will include: (1) descriptions of clinical presentations, and diagnostic and therapeutic preferences; (2) associations between clinical presentations, and diagnostics and treatments, and between diagnostics and treatments (assessed by ORs with 95% CIs); and (3) estimations of rates of vision loss, and progression-free and overall survival (assessed by Kaplan-Meier estimates).Ethics and disseminationThe registry has received Australia-wide approval by a national human research ethics committee. Sites located outside Australia are required to seek local human research ethics review. Results generated through the registry will be disseminated primarily by peer-reviewed publications that are expected to inform clinical practice, as well as educational materials.

IntroductionPractice-based research networks (PBRNs) are sustained collaborations between healthcare professionals, researchers and members of the community that develop, conduct and report on research relevant to local needs. While PBRNs have traditionally been focused towards primary care practices and their patients, there has been increasing interest in how they may help facilitate healthcare integration. Yet, little is known on the ways in which PBRNs can best integrate with the broader healthcare system, in particular Advanced Health Research and Translation Centres. The overall project aim is to build a sustainable collaboration between a PBRN and an Advanced Health Research and Translation Centre to generate a research platform suitable for planning, undertaking and translating research to improve care across the healthcare continuum.Methods and analysisWe will use a developmental evaluation design. Our iterative approach will be informed by a programme logic model and consists of: preparation work (pre-implementation assessment, literature review, community and stakeholder engagement), adaptation and building for a sustainable collaboration (strategy for recruitment and sustainment of members) and planning for network action (designing and implementing priority initiatives, monitoring and follow-up).Ethics and disseminationThis project was approved by the Monash Health ethics committee (ERM Reference Number: 76281; Monash Health Ref: RES-21-0000-392L) and the Monash University Human Research ethics committee (Reference Number: 29786). Dissemination will take place via various channels, including relevant national and international committees and conferences, peer-reviewed journals and social media. Continuous dissemination to and communication with all participants in this project as well as other relevant stakeholders will help strengthen and sustain the network.

It is 40 years since the seminal description of ‘Munchausen Syndrome by Proxy’ (MSbP) by UK Paediatrician Professor Sir Roy Meadow.1 There have been a number of developments since, which include terminology, definition, prevalence and management. The Royal College of Paediatrics and Child Health (RCPCH) adopted the term ‘Fabricated or Induced Illness by Carers’ (FII) in 2002,2 and updated their guidance in 2009.3 The most recent version of the RCPCH Child Protection Companion extended FII to embrace perplexing presentations with suggestions for management.4 The important evolution in the UK has been towards earlier diagnosis and intervention without the need for proof of deliberate deception. In the USA terms such as ‘Pediatric Condition Falsification’, ‘Medical Child Abuse’ and ‘Caregiver-Fabricated Illness in a Child’ have been introduced although MSbP is still widely used and deception is still implicit.5–7 In adult psychiatry, The Diagnostic and Statistic Manual of Mental Disorders produced by the American Psychiatric Association (DSM-5) replaces Factitious Disorder by Proxy with Factitious Disorder Imposed on Another (FDIoA).8 However, as DSM-5 stipulates that the carer behaviour is associated with identified deception, this excludes many carers involved in paediatric FII. In this paper, FII will be the term used to encompass all of these terms. Paediatricians in the UK have expressed significant concerns about FII, including when and how to recognise it, how to assess risk and how to manage these cases. Even in recent literature, most cases being reported still involve deliberate physical abuse by the carer. There are few descriptions of the earlier presentations and those involving erroneous reporting that form the majority of cases seen by paediatricians. While cases continue to be brought within the umbrella of FII and into the scope of national and local FII procedures for safeguarding children,9 there have …

To investigate if paper-based documentation in the authors' emergency medical service (EMS) satisfies scientific requirements.From 1 July 2007 to 28 February 2008, data from all paper-based protocols of a physician-run EMS in Aachen, Germany, were transferred to a SQL database (n=4815). Database queries were conducted after personal data had been anonymised. Documentation ratios of 11 individual parameters were analysed at two points in time (T1, scene; T2, arrival in emergency department). The calculability of the Mainz Emergency Evaluation Score (MEES, embracing seven vital parameters) was investigated. The calculability of the Revised Trauma Score (RTS) was also determined for all trauma patients (n=408). Fisher's exact test was used to compare differences in ratios at T1 versus T2.The documentation ratios of vital parameters ranged from 99.33% (Glasgow Coma Scale, T1) to 40.31% (respiratory rate, T2). The calculability of the MEES was poor (all missions: 28.31%, T1; 22.40%, T2; p0.001). In missions that required cardiopulmonary resuscitation (n=87), the MEES was calculable in 9.20% of patients at T1 and 29.89% at T2 (p0.001). In trauma missions, the RTS was calculable in 37.26% at T1 and 27.70% at T2 (p=0.004).Documentation of vital parameters is carried out incompletely, and documentation of respiratory rate is particularly poor, making calculation of accepted emergency scores infeasible for a significant fraction of a given test population. The suitability of paper-based documentation is therefore limited. Electronic documentation that includes real-time plausibility checks might improve data quality. Further research is warranted.

Early in the COVID-19 pandemic there was widespread concern that healthcare systems would be overwhelmed, and specifically, that there would be insufficient critical care capacity in terms of beds, ventilators or staff to care for patients. In the UK, this was avoided by a threefold approach involving widespread, rapid expansion of critical care capacity, reduction of healthcare demand from non-COVID-19 sources by temporarily pausing much of normal healthcare delivery, and by governmental and societal responses that reduced demand through national lockdown. Despite high-level documents designed to help manage limited critical care capacity, none provided sufficient operational direction to enable use at the bedside in situations requiring triage. We present and describe the development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity. The document combines a wide variety of factors known to impact on outcome from critical illness, integrated with broad-based clinical judgement to enable structured, explicit, transparent decision-making founded on robust ethical principles. It aims to improve communication and allocate resources fairly, while avoiding triage decisions based on a single disease, comorbidity, patient age or degree of frailty. It is designed to support and document decision-making. The document has not been needed to date, nor adopted as hospital policy. However, as the pandemic evolves, the resumption of necessary non-COVID-19 healthcare and economic activity mean capacity issues and the potential need for triage may yet return. The document is presented as a starting point for stakeholder feedback and discussion.

IntroductionDiabetes mellitus (DM) is a major non-communicable disease with an increasing prevalence. Undiagnosed DM is not uncommon and can lead to severe complications and mortality. Identifying high-risk individuals at an earlier disease stage, that is, pre-diabetes (pre-DM), is crucial in delaying progression. Existing risk models mainly rely on non-modifiable factors to predict only the DM risk, and few apply to Chinese people. This study aims to develop and validate a risk prediction function that incorporates modifiable lifestyle factors to detect DM and pre-DM in Chinese adults in primary care.Methods and analysisA cross-sectional study to develop DM/Pre-DM risk prediction functions using data from the Hong Kong’s Population Health Survey (PHS) 2014/2015 and a 12-month prospective study to validate the functions in case finding of individuals with DM/pre-DM. Data of 1857 Chinese adults without self-reported DM/Pre-DM will be extracted from the PHS 2014/2015 to develop DM/Pre-DM risk models using logistic regression and machine learning methods. 1014 Chinese adults without a known history of DM/Pre-DM will be recruited from public and private primary care clinics in Hong Kong. They will complete a questionnaire on relevant risk factors and blood tests on Oral Glucose Tolerance Test (OGTT) and haemoglobin A1C (HbA1c) on recruitment and, if the first blood test is negative, at 12 months. A positive case is DM/pre-DM defined by OGTT or HbA1c in any blood test. Area under receiver operating characteristic curve, sensitivity, specificity, positive predictive value and negative predictive value of the models in detecting DM/pre-DM will be calculated.Ethics and disseminationEthics approval has been received from The University of Hong Kong/Hong Kong Hospital Authority Hong Kong West Cluster (UW19-831) and Hong Kong Hospital Authority Kowloon Central/Kowloon East Cluster (REC(KC/KE)-21-0042/ER-3). The study results will be submitted for publication in a peer-reviewed journal.Trial registration numberUS ClinicalTrial.gov: NCT04881383; HKU clinical trials registry: HKUCTR-2808; Pre-results.

IntroductionThe number of new biomedical manuscripts published on important topics exceeds the capacity of single persons to read. Integration of literature is an even more elusive task. This article describes a pilot study of a scalable online system to integrate data from 1000 articles on COVID-19.MethodsArticles were imported from PubMed using the query ‘COVID-19’. The full text of articles reporting new data was obtained and the results extracted manually. An online software system was used to enter the results. Similar results were bundled using note fields in parent–child order. Each extracted result was linked to the source article. Each new data entry comprised at least four note fields: (1) result, (2) population or sample, (3) description of the result and (4) topic. Articles underwent iterative rounds of group review over remote sessions.ResultsScreening 4126 COVID-19 articles resulted in a selection of 1000 publications presenting new data. The results were extracted and manually entered in note fields. Integration from multiple publications was achieved by sharing parent note fields by child entries. The total number of extracted primary results was 12 209. The mean number of results per article was 15.1 (SD 12.0). The average number of parent note fields for each result note field was 6.8 (SD 1.4). The total number of all note fields was 28 809. Without sharing of parent note fields, there would have been a total of 94 986 note fields.ConclusionThis pilot study demonstrates the feasibility of a scalable online system to extract results from 1000 manuscripts. Using four types of notes to describe each result provided standardisation of data entry and information integration. There was substantial reduction in complexity and reduction in total note fields by sharing of parent note fields. We conclude that this system provides a method to scale up extraction of information on very large topics.