Recent Submissions

  • Therapist differences in a randomised trial of the outcome of cognitive behaviour therapy for health anxiety in medical patients

    Lisseman-Stones, Yvonne (International Journal of Nursing Studies, 2015-03)
    Background: Health anxiety is common in medical settings and can be treated successfully by cognitive behaviour therapy. However it is not clear who might be best placed to deliver this therapy. Objectives: In a planned secondary analysis of data from a randomised trial of adapted cognitive behaviour therapy for health anxiety we compared outcomes of therapy delivered by nurses and other professional groups. Design: A randomised controlled trial with two treatment arms, 5-10 sessions of cognitive behaviour therapy adapted health anxiety or standard care. Setting: Cardiology, endocrine, gastroenterology, neurological and respiratory clinics in six general hospitals in the UK covering urban, suburban and rural areas. Participants: Medical patients attending the clinics who had pathological health anxiety and also scored for a diagnosis of hypochondriasis. Methods: Patients were randomised to one of two treatment arms, 5-10 sessions of cognitive behaviour therapy adapted health anxiety or standard care delivered by naive therapists (not randomised) who were trained in advance before delivering the treatment. Independent assessment of outcomes by researchers masked to allocation status at 3m, 6m, 12m and 24m. Results: 444 patients were randomised in the trial, 219 to cognitive behaviour therapy adapted health anxiety and 225 to standard care. 373 (84%) completed assessments after two years. Those treated by nurses (n=66) had improvement in health anxiety, generalised anxiety and depression outcomes that were significantly better and twice as great as those of the professional groups of assistant psychologists (n=87) and graduate workers (n=66) (P<0.01 over all time points). The number needed to treat to show superiority of nurse-delivered treatment over other treatment delivery was 4 at 6 months and 6 at one year. Conclusion: General nurses, after suitable training, are very effective therapists for patients with health anxiety in medical clinics and should be the therapists of choice for patients in these settings.
  • Pseudomonas water testing and ISO standards in UK and Germany.

    Weinbren, Michael (Journal of Hospital Infection, 2018-11)
    In the UK, HTM 04-01 recommends microbiological testing of water for Pseudomonas aeruginosa (PA) as part of the strategy to control water supply-related risks in hospitals. The guidance states that ‘All microbiological measurements should be by approved methods and/or be carried out by United Kingdom Accreditation Service (UKAS)-accredited laboratories for the method being used.’
  • Water, Life and Death

    Weinbren, Michael (2019-02)
  • Mini-review: Clostridioides difficile epidemiology in India.

    Ambalkar, Shrikant
    Clostridioides difficile infection (CDI) continues to affect hospitalized patients and community populations worldwide. In contrast to the substantial resources invested in the diagnosis and prevention of CDI in high-income countries, this anaerobic toxigenic bacterium has been largely overlooked in low-and-middle-income countries (LMICs) such as India, where there remains a paucity of epidemiologic data evaluating the burden of CDI. Extensive multi-institutional studies describing C. difficile epidemiology in India have not yet been performed. Given recent economic growth in many Asian countries, with aging populations, increased access to healthcare and widespread inappropriate use of antimicrobials, C. difficile is likely to be highly prevalent and causing significant disease burden. Greater efforts are required to enhance awareness of this neglected pathogen, through educating healthcare practitioners to test for CDI. There is also an urgent need to strengthen laboratory capacity, and ideally establish a national reference laboratory, to help facilitate a greater understanding of the molecular epidemiology of CDI in India and other LMICs. This mini-review aims to summarize the existing research evaluating the burden of CDI in humans and the environment in India.
  • A two-centre study assessing the impact of the COVID-19 pandemic on orthodontic patients in secondary care.

    Flett, Andrew
    Objective: To evaluate the impact of the coronavirus pandemic on patients in active orthodontic treatment. Design: Digital online survey. Setting: Two secondary care orthodontic departments in the United Kingdom. Participants: A prospective convenience sample of 103 patients in active orthodontic treatment. Methods: A 12-item questionnaire developed using the platform SurveyMonkey was used to assess the following: (1) patient's feelings towards attending their orthodontic appointments; (2) their desire to continue with their treatment; (3) how many patients encountered problems with their appliance during the lockdown; (4) how patients sought help during the first national lockdown period; and (5) any other concerns regarding impact on their orthodontic treatment. Results: A total of 103 participants responses were collected over a four-week period across two departments. Of them, 45% required a face-to-face appointment to solve a problem with their appliance; 45% of patients who had problems with their orthodontic appliance were able to resolve the issue through digital means either via telephone/email advice from their provider or from accessing help via the Internet; and 99% of patients wanted to continue with their orthodontic treatment. Conclusion: Our study has shown that a significantly higher percentage of patients are more concerned regarding attending face-to-face appointments after the first national lockdown due to the coronavirus pandemic. Providers of orthodontic care should ensure they support their patients by providing digital support and adopt virtual means of managing emergency cases patients in the event of any further imposed national or local lockdowns. Furthermore, access and availability of emergency face-to-face orthodontic care is necessary for many patients in active orthodontic treatment.
  • Patients' experiences of occupational therapy within a multidisciplinary pain management programme: A qualitative study

    Goodall, Jacqueline
    Background Occupational problems are common for adults experiencing chronic pain, but occupational therapists are not always accessed as part of the multidisciplinary team. Despite evidence of benefit for work-focused interventions, there is limited evidence for broader benefit from occupational therapy interventions within the context of multidisciplinary pain management. The aim of this study was to explore the experiences of programme attendees who received structured intervention from an occupational therapist as part of a multidisciplinary pain management programme, and gain an understanding as to how they felt it influenced changes they made to occupational participation. Method A qualitative approach was undertaken with 9 individual patients recruited from a group pain management programme for adults with chronic low back pain. Semi-structured interviews were carried out, recorded and transcribed. Thematic analysis was used to identify themes in the data. Results Three key themes were identified: 1) the helpfulness of activity pacing techniques 2) the value of participating in a therapeutic activity-based session and 3) an increased understanding of the importance of leisure and creative activities in the context of their lives. Conclusion Participants perceived the specific occupational therapy content of the programme to be helpful in a number of different ways. The findings suggest that occupational therapy can be important in facilitating patients to apply theoretical techniques in the real world, thereby increasing the likelihood of long term benefit.
  • Drains and the periphery of the water system - what do you do when the guidance is outdated?.

    Weinbren, Michael
    Summary The periphery of the water system (defined as the last 2 m of pipework from an outlet and ensuing devices including drainage), is the juncture of multiple inherent risks: the necessity to use materials with higher risk of biofilm formation, difficulty in maintaining safe water temperatures, a human interface with drainage systems, poor design, poor layout and use by staff. Add to this risk a large new healthcare facility capital build programme in England, outdated guidance and bacteria emanating from drainage systems containing highly mobile genetic elements (threatening the end of the antibiotic era), and the scene is set for the perfect storm.There is an urgent need for the re-evaluation of the periphery of the water system and drainage systems. Consequently, in this article we examine the requirement and placement of hand wash stations (HWSs), design of showers, kitchens and the dirty utility with respect to water services. Lastly, we discuss the provision of safe water to high-risk patient groups. The purpose of this article is to stimulate debate and provide infection control and design teams with support in deviating from the outdated existing guidance and to challenge conventional thinking until new advice is forthcoming.
  • Prevalence of Clostridioides difficile infection in Central India: a prospective observational cohort study

    Ambalkar, Shrikant (GUT, 2021)
    ntroduction The true burden of Clostridioides difficile infection (CDI) in India remains poorly understood. Prolifigate, unregulated antibiotic use and inappropriate prescribing suggest that CDI could be widespread in India. Our aim was to establish and compare baselines rates of CDI in both in-and outpatient settings in Nagpur city district and rural Melghat, Central India. Methods We recruited adult participants aged ≥18 years of age who could provide written or thumb-print informed consent. A diagnosis of diarrhoea was defined as 3 or more loose stools in a 24-hour period. Immunosuppression was defined as those on prednisolone (>5mg/day), immunomodulators or biologics. Baseline characteristics were also collected and included: demographics, symptomatology, antibiotics exposure, duration of diarrhoea, hospitalisation status at recruitment, and duration, BMI, animal exposure, housing conditions, toilet access, and seasonality. All diarrhoeal samples were tested for CDI using the C. DIFF QUIK CHEK COMPLETE-enzyme immunoassay in accordance with the manufacturers’ instructions. Results C. difficile testing was performed on 1223 patients with acute diarrhoea. A total of 36 patients (2.9%) tested positive for both GDH antigen and toxin expression. A higher% of urban inpatient diarrheal samples tested positive for toxigenic C. difficile (26 cases; 8%) compared to that seen for urban outpatients (9 cases; 3%) and the rural diarrhoeal group (1 outpatient case). Of those testing positive for toxigenic C. difficile, 63.9% were immunosuppressed and almost all (94.4%) were on antibiotics at the time of recruitment. The majority of the toxigenic CDI cases were detected during the monsoon season, lived in very good or good housing conditions, had access to good toilet facilities and reported no co-habitation with animals. Non-toxigenic C. difficile was detected in 6.2%, 4.8%, and 0.5% in the urban inpatient, urban outpatient, and rural populations tested, respectively. Conclusions Toxigenic C. difficile is an important but neglected aetiologic cause of infective diarrhoea in Central India. The higher prevalence within the urban inpatient setting likely reflects greater exposure to antibiotics and hospitalisation. Our findings underscore the need to enhance awareness of and testing of patients with diarrhoea in India, particularly in high-risk individuals with recent or ongoing antibiotic exposure or hospitalisation.
  • Multiplex PCR for determining aetiology of infectious diarrhoea in rural and urban central Indian populations

    Ambalkar, Shrikant (Gut, 2021)
    Introduction Infectious diarrhoea is a major cause of morbidity and mortality in Central India. There is an urgent unmet need to implement rapid point-of-care tests to deliver effective and targeted treatment plans. The aim of this exploratory study was to assess the performance of the FilmArray Gastrointestinal Panel for the detection of enteric pathogens directly from stool specimens collected from diarrhoeal and non-diarrhoeal control populations in Central India. Methods Faecal samples were collected from participants with and without acute diarrhoea presenting to an inpatient or outpatient setting in Nagpur city district and rural Melghat. Each stool sample was stored at 4°C and preserved in Cary-Blair enteric transport medium for multiplex PCR using the FilmArray GI Panel according to the manufacturer’s instructions. This panel allows for the simultaneous detection of 22 common diarrhoeal agents, including bacteria, viruses and protozoa. Baseline characteristics were also recorded and included: demographics, symptomatology, antibiotics exposure, duration of diarrhoea, hospitalisation status at recruitment, and duration, BMI, animal exposure, housing conditions, toilet access, and seasonality. Results 179 participants provided stool samples for analysis on the FilmArray GI Panel. 70 and 109 participants were from rural Melghat and Nagpur urban district, respectively. Of these, 138 were from mainly non-hospitalised participants with acute diarrhoea from urban (n=89) and rural areas (n=49). In the urban cohort, 81% (88/109) of all diarrhoeal and non-diarrhoeal samples tested positive for one (27%) or more (54%) pathogens. In the rural cohort, a striking 97% (68/70) of samples yielded positivity to one (14%) or multiple organisms (83%). The most prevalent pathogen detected in both the diarrhoeal and control cohorts was Enterohaemorrhagic E. coli (51% vs 59%, respectively). However, other pathotypes of diarrhoeagenic E. coli were highly prevalent in both cohorts, including ETEC, EPEC, Shigella/EIEC, and STEC. A higher proportion of diarrhoeal samples tested positive to Campylobacter (12%) compared to the non-diarrhoeal control group (5%). Unlike the diarrhoeal samples, no control samples yielded positivity to Vibrio cholerae, Cyclospora cayetanensis, Astrovirus, Rotavirus A or Sapovirus Conclusions Detection of high levels of polymicrobial enteric infections are prevalent in Central Indian symptomatic and asymptomatic populations. E. coli pathotypes predominate in both urban and rural settings. Further studies are required to understand the clinical significance of these mixed infections, as well as how best to manage them.
  • What do senior genitourinary medicine physicians think of the future of the speciality? A national survey.

    Carlin, Elizabeth (International Journal of STD & AIDS, 2021-10)
    Genitourinary Medicine (GUM) is a specialty that has undergone significant change over the past decade. Multiple factors have contributed to this including changes in service models and commissioning landscapes, health service leadership, medical education and changes in the spectrum of our clinical work. The Joint Specialist Committee for GUM at the Royal College of Physicians (RCP) conducted a national survey in December 2019 - January 2020 to understand the changing scope of work for GUM consultants. The survey indicated an increase in clinical complexity alongside a decline in registrar recruitment, staff shortages and service fragmentation. Funding cuts have impacted many services and the majority of consultants feel a return to an NHS commissioning model would be preferable. Despite the many challenges, GUM physicians consider the specialty 'unique, dynamic, friendly and open-minded'. It is clear that senior doctors value the wider clinical, academic and educational opportunities within the specialty.
  • Role of the kitchen environment

    Weinbren, Michael (2021-06)
  • British Association of Sexual Health and HIV national guideline on the management of sexually acquired reactive arthritis 2021

    Carlin, Elizabeth
    These guidelines update the 2008 UK guideline for the management of sexually acquired reactive arthritis. The guideline is aimed at those over the age of 16 years, presenting to healthcare professionals working in sexual health services. The recommendations are primarily aimed at services offering level 3 care in sexually transmitted infection management within the United Kingdom. However, the principles will apply to those presenting to level 1 and 2 services, and appropriate local referral pathways will need to be developed.
  • Water springing to life the fungal desert

    Weinbren, Michael (2021-05)
    Immunosuppressed patients are at increased risk of developing hospital-acquired fungal infections. The risk of fungal infection from construction is well established, but water ingress also presents a risk if it is not dealt with promptly. This article describes four such scenarios and the learning points from each. Water ingress may go under-reported and, as such, may be an underestimated source of fungal healthcare-associated infections.
  • Introducing artificial intelligence tools into clinical and non-clinical workflows, Evidence from the NHS Breast Screening Programme of staff and general population perceptions of and trust in the use of AI in this context and the implications for further testing and implementation.

    Sherwood Forest Hospitals NHS Foundation Trust; The East Midlands Radiology Consortium (EMRAD) (, 2020-06)
    Background: The East Midlands Radiology Consortium (EMRAD) is a partnership of seven NHS trusts spread over 11 hospitals, covering more than five million patients in the East Midlands of England. In 2018, EMRAD formed a partnership with two UK-based Artificial Intelligence (AI) companies, Faculty and Kheiron Medical, to help develop, test and - ultimately - deploy AI tools in the breast cancer screening programme in the East Midlands as part of wave two NHS Test Beds programme. The project aims to improve and optimise clinical service capacity, to enhance patient care at significant scale and to increase NHS confidence in the utilisation of innovative machine learning tools. The successful implementation of the technology rests not only on its clinical effectiveness but also on the attitudes of key adopters and organisational readiness (Greenhalgh et al, 2017).
  • Metagenomics reveals impact of geography and acute diarrheal disease on the Central Indian human gut microbiome.

    Ambalkar, Shrikant (2020-05)
    Background: The Central Indian gut microbiome remains grossly understudied. Herein, we sought to investigate the burden of antimicrobial resistance and diarrheal diseases, particularly Clostridioides difficile , in rural-agricultural and urban populations in Central India, where there is widespread unregulated antibiotic use. We utilized shotgun metagenomics to comprehensively characterize the bacterial and viral fractions of the gut microbiome and their encoded functions in 105 participants. Results: We observed distinct rural-urban differences in bacterial and viral populations, with geography exhibiting a greater influence than diarrheal status. Clostridioides difficile disease was more commonly observed in urban subjects, and their microbiomes were enriched in metabolic pathways relating to the metabolism of industrial compounds and genes encoding resistance to 3 rd generation cephalosporins and carbapenems. By linking phages present in the microbiome to their bacterial hosts through CRISPR spacers, phage variation could be directly related to shifts in bacterial populations, with the auxiliary metabolic potential of rural-associated phages enriched for carbon and amino acid energy metabolism. Conclusions: We report distinct differences in antimicrobial resistance gene profiles, enrichment of metabolic pathways and phage composition between rural and urban populations, as well as a higher burden of Clostridioides difficile disease in the urban population. Our results reveal that geography is the key driver of variation in urban and rural Indian microbiomes, with acute diarrheal disease, including C. difficile disease exerting a lesser impact. Future studies will be required to understand the potential role of dietary, cultural, and genetic factors in contributing to microbiome differences between rural and urban populations.
  • Dissemination of antibiotic resistance and other healthcare waterborne pathogens. The price of poor design, construction, usage and maintenance of modern water/sanitation services.

    Weinbren, Michael (, 2020-03)
    Summary Classical waterborne pathogens (cholera/typhoid) drove the development of safe water and sanitation during the industrial revolution. Whilst effective against these organisms, other bacteria exploited the potential to form biofilm in the narrow pipes of buildings. Legionella was discovered in 1976. Despite evidence dating back to 1967 (including paediatric deaths in Manchester in 1995 from splashes from a sink contaminating parenteral nutrition) it required the deaths of four neonates and the might of the news media in 2011 for the UK medical services to accept waterborne transmission of other opportunistic plumbing premise pathogens (OPPPs). Human nature, a healthcare construction industry largely devoid of interest in water safety, and failures in recognizing transmission are major forces hindering progress in preventing infection/deaths from waterborne infections. The advent of highly resistant Gram-negative bacteria is highlighting further deficiencies in modern drainage systems. These bacteria are not thought to have special adaptations promoting their dispersal but purely attract our attention to the well-trodden routes used by susceptible organisms, which go undetected. The O'Neill report warns of the bleak future without effective antibiotics. This review examines the evidence as to why modern water services/sanitation continue to present a risk to patient safety (and the general public) and suggests that their designs may be flawed if they are to stem the modern equivalent of cholera, the dissemination of antibiotic resistance.

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