Aneurin Bevan University Health Board

INTRODUCTION There is a need to understand the clinical meaningfulness of symptom score changes in treatment trials of dementia‐related agitation. We estimated minimal clinically important differences (MCIDs) for commonly employed agitation scales and contextualized their clinical application. METHODS We employed anchor‐ and distribution‐based approaches to determine changes in scores corresponding to minimal symptom improvement. An opinion‐based approach assessed expert clinicians’ agreement on the meaningfulness of score changes through three clinical vignettes. RESULTS Minimal symptom improvement for Cohen‐Mansfield Agitation Inventory total score ranged from −4 (over <1 month) to −11 (over 1 to 3 months) points. Greater symptom severity correlated with higher MCID estimates. The clinical importance of score changes was influenced by treatment duration, pharmacological side effects, and impacts on caregiver distress/time resources. DISCUSSION The clinical meaningfulness of agitation scale MCIDs is influenced by trial‐specific and clinical factors. Shorter trial durations and measuring caregiver distress/time resources enhance the clinical interpretation of agitation treatment outcomes. Highlights For the CMAI total score, the MCID was −4 points over shorter time scales and −11 points for longer time scales. Worse agitation severity was associated with higher MCID estimates. There was high expert consensus that a noticeable treatment benefit was not worthwhile if it occurred after 12 weeks or had no impact on caregiver/staff distress/time resources.

Background Recent years have seen changes and uncertainties in evidence and guideline recommendations in Graves' disease treatment. To understand the impact of these developments on current practice, we undertook a survey of Graves' disease management in the United Kingdom and compared this to other national and international surveys. Method Members of the British Thyroid Association, the UK Society for Endocrinology and regional endocrinology networks, were invited by e‐mail to complete a 15‐min online survey (October 2022 to March 2023). Results Out of 158 eligible respondents, 99% were endocrinologists. For a 40‐year‐old female with a first presentation of Graves' hyperthyroidism, TSH‐receptor antibodies (TRAb) were requested at diagnosis and at follow‐up by 95% and 76%, respectively. Isotope scans and ultrasound were rarely requested (< 5%). Majority (95%) would treat with antithyroid drugs (ATD), predominantly Carbimazole (CMZ), while radioactive iodine (RAI) was preferred for recurrent disease (81%). Common reasons for avoiding RAI were thyroid eye disease, pregnancy intention, or contact with young children whereas biochemical severity, goitre, or male sex did not influence decision to use RAI. Propylthiouracil (PTU) was preferred in preconception and early pregnancy, but after the first‐trimester, 50% would continue PTU while 50% switch back to CMZ. Conclusions The survey confirms a growing application of TRAbs, both for diagnostic and prognostic purposes. ATDs remain the preferred first‐line therapy for Graves' disease, which is consistent with global trends but contrary to National Institute of Health and Care Excellence (NICE) guidance. Further studies are required to explore the clinical and pragmatic determinants of current treatment approaches.

Aims The aim of this study was to report the implant survival, quality of life, and patient-reported outcome measures (PROMs) in a cohort of adolescent patients who underwent total hip arthroplasty (THA). Methods This was retrospective review of all adolescent patients treated with THA in a single centre. Survival was estimated using the Kaplan-Meier method. Hip-specific PROMs included the Oxford Hip Score (OHS) and the modified Harris Hip Score (mHHS). Health-related quality of life was recorded using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L) and a subjective health assessment using a visual analogue scale. Results A total of 68 THAs were undertaken in 49 patients with a median age of 16 years (IQR 10 to 19), between April 1971 and April 2023. The median follow-up for the assessment of survival in the whole cohort was 4.6 years (IQR 1.4 to 8.9). The cumulative incidence of revision was 10.0% (95% CI 0.0 to 20.8) at ten years, 29.1% (95% CI 4.1 to 47.5) at 15 years, 36.2% (95% CI 8.0 to 55.7) at 20 years, and 45.3% (95% CI 12.1 to 65.9) at 30 years. The mean index value derived from the EQ-5D-3L, which was available in 15 patients (21 THAs), improved from -0.35 (SD 0.28) to 0.71 (SD 0.33) at a median follow-up of 1.5 years (IQR 0.5 to 2.0). The median OHS improved from 10 (IQR 7 to 16) preoperatively to 45 (IQR 37 to 48), and the median mHHS improved from 28 (IQR 16.25 to 32.75) to 84 (IQR 63 to 91), at a median follow-up of 1.3 years (IQR 0.5 to 2.3). Conclusion Adolescent patients with severe symptoms from the hip have some of the worst possible states of health which are encountered in orthopaedic surgery. THA is an effective form of treatment for hip conditions in children, with a higher than normal incidence of revision surgery. The socioeconomic benefits of THA need further investigation to establish guidelines for the treatment of children with severe symptoms from the hip. Cite this article: Bone Joint J 2025;107-B(5 Supple A):9–15.

Background Postpartum pelvic girdle pain (PGP), experienced by approximately 10% of women, is typically refractory to conservative management. Customised dynamic elastomeric fabric orthoses (DEFOs) are one novel option to address this. We assessed the feasibility and acceptability of a randomised controlled trial comparing a DEFO plus standardised advice/exercises (intervention) versus standardised advice/exercise alone (control). Methods A multicentre randomised controlled feasibility trial with embedded qualitative study and economic evaluation. Participants were randomised to either intervention or control group. All received two remote physiotherapy sessions via videoconferencing separated by 14 days. Primary feasibility outcomes were related to the feasibility and acceptability of methods and interventions, recruitment, intervention fidelity, outcome measure performance and completion. The proposed primary outcome measure for the definitive trial was the Numerical Pain Rating Scale (NPRS) which assessed pain intensity fortnightly over 24 weeks. Secondary outcome measures assessed kinesiophobia, continence, function, health-related quality of life, depression and health/care resource use at baseline, 12 and 24 weeks. Adverse events were recorded. Pre-defined progression criteria were set to decide whether, and how, to proceed with a future definitive trial: (1) Target sample size (60 from 3 centres over a 7-month recruitment period), (2) outcome measure completion (> 60% at 24 weeks), (3) orthosis wear-time compliance (> 70% for 6 h/day) as measured by the Orthotimer, and (4) evidence suggesting efficacy. Results Of 180 participants sent information sheets, 40 were screened and 24 randomised. At 24 weeks, 95% completed NPRS and 89–95% the secondary outcome measures. Wear-time adherence appeared below the set target of 42 h per week. Outcomes were broadly comparable between groups. Recruitment was insufficient to estimate a signal of efficacy with confidence. Two intervention participants experienced Candida infections, considered possibly due to the DEFO. Conclusions Trial procedures and interventions were acceptable to participants. Technical Orthotimer issues are resolvable through modification of recording parameters. Recruitment of participants was a major challenge. Work to understand how best to engage women in this research is needed before moving to a definitive trial. Trial registration ISCRTN, ISRCTN67232113. Registered 08/05/2021, https://www.isrctn.com/ISRCTN67232113.

Background Stimulation‐induced dyskinesia (SID) is a poorly studied and usually transient manifestation of subthalamic deep brain stimulation (STN DBS) for Parkinson's disease (PD), which can be troubling for patients. Objectives The aim of our study was to describe the features and management of SID in PD patients undergoing STN DBS. Methods We conducted a retrospective study among 86 STN DBS patients. Clinical features and volume of tissue activated (VTA) were correlated to SID occurrence. Results SID was identified in 28 (32.6%) patients and persisted for 6 months in six patients (7.0%). VTA overlap with the right motor STN was associated ( P < 0.02) with SID. Weaning dopaminergic drugs and reducing the DBS amplitude were the most used strategies to control SID. Conclusions SID is a relatively common complication of STN DBS and can be persistent. It often requires specific postoperative management strategies.

Background In March 2020, Austria was among the first European countries to declare a national lockdown, responding to SARS-CoV-2 infections with a stringent ringfencing policy for inpatient beds. These interventions altered access to the Austrian healthcare system. This study aims to understand demand- and supply-side factors influencing Austrian Primary Care Physicians’ (PCPs’) assessment of their care quality during the first ten months of the COVID-19 pandemic. Methods The study deployed a cross-section design based on stratified random sampling, where all Austrian PCPs (split into three disjointed random samples) were invited to participate in an online questionnaire (in May, September and November 2020, respectively). A multinomial logit model was used to analyse the three sets of cross-sectional survey data. The study subjects are all 6,679 Austrian PCP (2020) with a registered practice. The total sample size was 403 (corresponding to a net response rate of 6.3%). Results The primary outcome was the PCPs’ evaluation of their care quality. Secondary outcomes were “patient behaviour and wellbeing” (five questions), with Cronbach’s alpha of 0.74, and the PCPs’ “pandemic preparedness” (five questions) with a smaller internal consistency (0.69). 47% of the PCPs rated their care quality during the first ten months of the pandemic as worse than before the outbreak of COVID-19. The overall assessment correlates to the pandemic stage, lack of preventive care and mediocre information exchange/cooperation within the medical profession. Towards the end of the first lockdown, PCPs’ care quality perception was exclusively shaped by the availability of SARS-CoV-2 tests at the practice. Conclusions PCP quality assessments can serve as a real-time indicator, helping to anticipate the need for epidemiologic and diagnostic procedures. In Austria, supply-side factors, such as protective equipment and tests, were generally provided quickly by the public authorities. Findings suggest that perceptions of quality have changed considerably over time. Our results show that the understanding of quality changes during the first year. At the beginning, lack of resources or supply-side factors are the main driver for the assessment, while at the end of the first year, demand-side factors drive the quality assessment. In particular, the strong silo mentality and the separation between the care sectors have impacted the quality assessment of PCP.

Cowden Syndrome is a rare genetic condition that can be extremely difficult to diagnose. Jenna takes us through her journey of getting her diagnosis with Cowden syndrome which has been a rollercoaster. She also tells us how the diagnosis has affected her life and how to bring hope to patients.

Aims Functional alignment (FA) and adjusted mechanical alignment (aMA) are recognized techniques for performing total knee arthroplasty (TKA). The native femur rolls back further on the lateral tibial plateau than the medial side during flexion, resulting in a medial pivot pattern of movement. We have assessed whether an individualized alignment technique affects the kinematic pattern observed and the clinical outcomes, when compared to a systematic alignment technique in TKA. Methods A total of 60 consecutive patients were randomized to a robotically assisted TKA with either FA (n = 29) or aMA (n = 31), using a cruciate-retaining (CR) implant. After definitive implantation of the prostheses, a trial pressure monitor was inserted recording contact points between the femoral component and monitor in the medial and lateral compartments as the knee was taken through a range of motion. The kinematic pattern was observed, contact pressures measured, and patient-reported outcome measures (PROMs) assessed at 12 months. Results The FA-TKA group produced a medial pivot in 58.6% of cases (17/29), symmetrical rollback in 37.9% (11/29), and a lateral pivot in 3.4% (1/29). The aMA-TKA group produced a medial pivot in 19.4% of cases (6/31), symmetrical rollback in 45.2% (14/31), and a lateral pivot in 35.5% (11/31) (p < 0.001). No differences in knee balance were recorded between the two alignment groups at any flexion point. Patients with a medial pivot kinematic pattern had superior one-year PROMs in some measures. Patients producing a lateral pivot had lower Kujala scores. Conclusion FA CR-TKA generates an intraoperative medial pivot kinematic pattern through soft-tissue balance more often than those that use aMA. Lateral pivot kinematic patterns are more commonly found with aMA. These intraoperative kinematic patterns are related to clinical outcomes, with knees producing a medial pivot performing better than those with lateral pivot. Cite this article: Bone Joint J 2025;107-B(4):423–431.

OBJECTIVES In patients with acute hypoxemic respiratory failure (AHRF), the use of lower tidal volume ventilation facilitated by veno-venous extracorporeal C O 2 removal (vv-ECCO 2 R) does not improve clinical outcomes. The primary objective of this analysis was to evaluate for differences in indices of systemic inflammation and ventilator-induced lung injury between patients treated with lower tidal volume ventilation facilitated by vv-ECCO 2 R and standard care. Secondary objectives included an evaluation for heterogeneity of treatment effect. DESIGN Substudy of a randomized clinical trial. SETTING Nine U.K. ICUs. PATIENTS Moderate-to-severe AHRF (Pa o 2 : F io 2 < 150mmHg [20ka]). INTERVENTION Plasma samples obtained at baseline and day 3. MEASUREMENTS AND MAIN RESULTS The primary outcome was day 3 C-reactive protein (CRP). Clinical outcomes included 90-day mortality and ventilator-free days (VFD) until day 28. Exploratory analyses included an evaluation of plasma indices of lung injury, inflammation, and heterogeneity of treatment effect (HTE). Seventy-nine patients were enrolled, and 69 patients had paired plasma samples taken at baseline and day 3. There was no difference in day 3 plasma CRP (intervention 138.6 [70.4, 189.4] vs. standard care 113.0 [62.7, 233.8] mg/L; p = 0.72). Between baseline and day 3, there was a greater increase in plasma interleukin-18 in patients that received intervention compared with those that received standard care (Δ 337.7 [–128.9, 738.9] vs. 6.4 [–457.2, 6.4] pg/mL p = 0.05). In patients with high interleukin-18, allocation to intervention was associated with increased VFDs ( p = 0.03). Similarly in patients with a hyperinflammatory phenotype, the intervention was independently associated with increased VFDs ( p < 0.01) and decreased 90-day mortality ( p = 0.01). CONCLUSIONS In patients with moderate-to-severe AHRF, lower tidal volume ventilation, facilitated by vv-ECCO 2 R, was not associated with a difference in day 3 plasma CRP, but was associated with an increase in plasma interleukin-18 between baseline and day 3. Baseline plasma interleukin-18 and inflammatory phenotypes may identify subgroups of patients with moderate-to-severe AHRF that benefit from lower tidal volume ventilation facilitated by vv-ECCO 2 R. TRIAL REGISTRATION NCT02654327

Cognitive behavioural therapists and practitioners often feel uncertain about how to treat post-traumatic stress disorder (PTSD) following rape and sexual assault. There are many myths and rumours about what you should and should not do. All too frequently, this uncertainty results in therapists avoiding doing trauma-focused work with these clients. Whilst understandable, this means that the survivor continues to re-experience the rape as flashbacks and/or nightmares. This article outlines an evidence-based cognitive behavioural therapy (CBT) approach to treating PTSD following a rape in adulthood. It aims to be a practical, ‘how to’ guide for therapists, drawing on the authors’ decades of experience in this area. We have included film links to demonstrate how to undertake each step of the treatment pathway. Our aim is for CBT practitioners to feel more confident in delivering effective trauma-focused therapy to this client group. We consider how to assess and formulate PTSD following a rape in adulthood, then how to deliver cognitive therapy for PTSD (CT-PTSD; Ehlers and Clark, 2000). We will cover both client and therapist factors when working with memories of rape, as well as legal, social, cultural and interpersonal considerations. Key learning aims (1) To understand the importance of providing effective, trauma-focused therapy for survivors of rape in adulthood who are experiencing symptoms of PTSD. (2) To be able to assess, formulate and treat PTSD following a rape in adulthood. (3) How to manage the dissociation common in this client group. (4) To be able to select and choose appropriate cognitive, behavioural and imagery techniques to help with feelings of shame, responsibility, anger, disgust, contamination and mistrust. (5) For therapists to learn how best to support their own ability to cope with working in a trauma-focused way with survivors of rape and sexual violence.

Research on supervisee disclosure in clinical supervision has predominantly focused on supervisees' tendency to withhold important information (e.g., negative feelings, perceived power differentials, clinical mistakes, personal issues and countertransference), highlighting a significant gap in understanding the factors that influence supervisees' self‐disclosure. Self‐disclosure, which is considered essential for supervisors to provide personalised feedback and tailored guidance, plays a critical role in effective supervision but remains underexplored in terms of its facilitators and barriers. This study addresses this gap by systematically exploring the contributory factors affecting supervisee self‐disclosure within the context of clinical supervision. Using the principles of meta‐ethnography, this systematic review synthesised findings from eight qualitative studies involving 180 participants (the sample ranging from 3 to 110). Through a thorough process of data extraction, translation, and synthesis, a conceptual framework was developed, positioning self‐disclosure as a dynamic process shaped by the interplay between supervisory dynamics, contextual factors, and supervisees' internal experiences. Key factors influencing self‐disclosure included the quality of the supervisory relationship, supervisees' perception of supervisors' personal characteristics, the emotional impact of self‐disclosure on supervisees and power differentials. These findings highlight the relational and systemic factors shaping supervisee self‐disclosure. Implications include strategies to improve supervisory relationships, reduce power imbalances and foster supportive environments. The study informs future research, enhances supervisory practice and guides training programmes to improve clinical supervision effectiveness.

Introduction Myeloproliferative neoplasms (MPNs), such as polycythaemia vera (PV), essential thrombocythemia (ET) and myelofibrosis (MF), are primarily treated by managing blood counts to reduce the thrombotic risk using cytoreductive agents. Busulphan, an oral alkylating agent, has been historically used for MPN management due to its myelosuppressive effects, but concerns about its risk of leukaemic transformation have limited its use. Methods This real‐world retrospective study evaluated the safety and efficacy of busulphan in 115 MPN patients across 13 UK hospitals. Responses in patients with ET and PV only were assessed using European LeukemiaNet (ELN) criteria. Results With a median age of 78 years, the overall response rate was 78.1%, with 29% of PV and 18% of ET patients achieving complete responses. Dosing regimens were similarly distributed between repeated single doses of busulphan (31%), courses of treatment lasting 1–4 weeks (30%) and continuous therapy for more than 4 weeks (35%). No cases of disease progression to acute leukaemia or myelofibrosis were recorded during the median follow‐up of 23 months. Adverse events were infrequent, with fatigue and cytopaenia being the most common (4% each). Conclusion Busulphan demonstrated a favourable safety profile and is a viable cytoreductive option, particularly for elderly patients who are intolerant to hydroxycarbamide. Trial Registration The authors have confirmed clinical trial registration is not needed for this submission

Background Asthma and chronic obstructive pulmonary disease (COPD) outcomes vary by sex. We investigated whether males and females with asthma or COPD are managed differently in-hospital when admitted for an exacerbation. Methods Data from the National Asthma and COPD Audit Programme were used to determine three cohorts of people hospitalised for an exacerbation: (1) adults with asthma, (2) children and young people (CYP) with asthma, and (3) adults with COPD. Outcomes included the following in-hospital interventional measures: spirometry recording, respiratory specialist review, respiratory medication administration and discharge bundle recording. Linked hospital data were used to determine 30-day and 90-day readmissions and Office for National Statistics data for 90-day mortality. Random effects logistic regression was used to investigate the association between sex and in-hospital outcomes, readmission and mortality. Results 16 370 adults with asthma, 7156 CYP with asthma and 28 354 adults with COPD were included. Female adults with asthma had higher odds of being seen by a respiratory specialist ( a OR 0.1.13, 1.02-1.26) and higher odds of readmission within 30 and 90 days ( a OR 1.22, 1.10–1.37, a OR 1.34, 1.23–1.46) compared with males. Female adults with COPD had higher odds of being seen by a respiratory specialist, ( a OR 1.10,1.02–1.19), being administered non-invasive ventilation ( a OR 1.18, 1.09–1.29), and receiving a discharge bundle ( a OR 1.07, 1.00–1.14), and lower odds of readmission within 90 days ( a OR 0.95, 0.90–1.01), or mortality within 90 days ( a OR 0.88, 0.81–0.96). Lastly, female CYP had higher odds of steroids administered within 1 hour ( a OR 1.13, 1.00–1.28) and higher 30-day and 90-day readmission compared with males ( a OR 1.21, 1.00–1.44 and 1.17, 1.03–1.34). Interpretation Sex differences in in-hospital care exist in adults COPD, which may impact readmissions and mortality; however, little to no sex differences in in-hospital care were seen in people with asthma yet females were more likely to be readmitted to hospital.

Background We assessed the healthcare and economic burden of sepsis in adult hospitalised patients in Wales, UK. Methods We analysed hospital admissions to all acute hospitals in Wales via the Secure Anonymised Information Linkage Databank. We included all adult patients, 2006–2018, with an inpatient admission including one or more explicit sepsis codes. Results 38,564 patients had at least one admission for sepsis between 2006 and 2018. Most persons (86.7%) had just one admission. 3398 patients (8.4%) were admitted to ICU. The number of admissions increased yearly over the study period from 1548 in 2006 to 8708 in 2018. The largest annual increase (141.7% compared to the previous year) occurred in 2017. Admission numbers increased disproportionately amongst patients with high levels of comorbidities, but changes were consistent across all age groups, areas of deprivation and ICU admissions. Estimated inpatient sepsis costs were £340.34 million in total during the study period. The average cost per hospital spell was £7270. Patients readmitted to the hospital for sepsis amassed estimated treatment costs of over £72 million during the study period. Out of the 38,564 persons, 21,275 (55.2%) died within 3 years of their first admission. Inpatient mortality halved from 40.5% to 19.5%, and there was a trend towards reduced mortality at 6 months, 1 and 3 years post hospital discharge. Conclusion Sepsis related hospital admissions are increasing over time and still likely to be underreported. Although mortality appears to have fallen, prolonged hospitalisation and readmissions place a significant burden on healthcare system resources and costs.