Publications

INTRODUCTION: Remote decision-making support (RDMS) systems for on-scene ambulance clinicians aim to improve patient safety, avoid unnecessary admissions and promote appropriate referrals. In the relative absence of previous research, this qualitative study explored the perceived benefits and limitations of a well-established RDMS system in a single NHS ambulance trust. The system described involves advanced paramedic practitioners (APPs) supporting colleagues via an emergency-crew advice telephone line (ECAL).

METHODS: Internally circulated invitations resulted in a convenience sample of 27 participants attending online meetings for data collection. Eight meetings, with a mean duration of 56 minutes, were recorded and anonymised during transcription. A critical realist, experiential approach to thematic analysis was employed on transcripts to produce findings.

RESULTS: Participants reported various patterns of engagement with ECALs, but experienced paramedics were the least involved. ECALs were perceived to benefit patient safety and clinical development, although their influence on appropriate care delivery was considered to be more limited. The information systems, capacity and capability of community care pathways varied considerably across the region, hindering urgent care navigation. Additionally, a cultural shift to normalise collaborative decision making was required, which might be enabled by more proactive intervention, but only if ECAL interactions sustained trust in their effectiveness. Some participants had experience of initiatives where co-located community and emergency department clinicians augmented RDMS provision and perceived that this addressed many of the limitations identified.

CONCLUSION: This study suggests that RDMS is perceived as beneficial to patient safety and appropriate care delivery, and that APPs who are familiar with their region and with the clinicians on scene are well suited to provide this support. Collaborative decision making requires honest and open interaction to be effective and needs to be more widely accepted as standard clinical practice. Improving the consistency and interoperability of community care pathways will maximise their value, and inter-professional collaboration may facilitate this.

INTRODUCTION: Many clinical trials within ambulance services require trained frontline paramedics to directly recruit or enrol eligible patients. Research paramedics may then review study documents and often contact recruiting paramedics to provide feedback or obtain missing data. Using the example of the Paramedic Analgesia Comparing Ketamine and MorphiNe in trauma (PACKMaN) study, we aimed to evaluate the provision of feedback by the Yorkshire Ambulance Service (YAS) research team to recruiting paramedics.

METHODS: This was a service evaluation using a qualitative design. Data collection was conducted in January 2023 and consisted of a focus group and document analysis. The focus group lasted one hour and involved nine YAS research staff involved in feedback provision. Preliminary results were presented to focus group members to facilitate member checking. Reviewed documents included written feedback sent by the local research team and a standard operating procedure on incidental clinical errors. Data were analysed using the framework method.

RESULTS: Research paramedics provided recruiting paramedics with feedback on 'research study activities', such as missing data, (in) eligible patients (not) enrolled or study protocol (not) followed. Feedback on 'clinical practice' not related to research activities, but incidentally discovered, was not considered within the remit of research paramedics. Barriers to effective feedback provision were the lack of awareness in recruiting paramedics that feedback would be provided and a perception that unsolicited feedback is mostly negative. Using different formats to provide feedback and engaging in a dialogue with recruiting paramedics was seen to facilitate more meaningful feedback.

CONCLUSION: Training for recruiting paramedics should highlight that performance and documentation will be scrutinised as part of their involvement in the clinical trial. Although flexibility of local teams regarding feedback format and delivery was important, researchers planning interventional studies in ambulance services may wish to consider the impact of different ways of working with frontline clinicians in their protocol development and study evaluation.

INTRODUCTION: Simulation is considered a mainstay for teaching and assessment in various clinical fields, including paramedicine. Simulation fidelity in educational practice is constantly changing to accommodate the integration of extended realities (XRs), such as augmented, mixed and virtual realities. However, little research has been undertaken to directly compare these newer, technology-enhanced methods, such as 360-degree projection simulation, with the traditional methods used in undergraduate education. The purpose of this research was to provide a direct comparison, exploring their effect on ratings of self-perceived performance in second-year paramedicine students.

METHODS: Using a single-site, parallel randomised controlled, non-blinded trial, participants were randomly allocated to a three-day intensive 360-degree projection (intervention) or traditional (control) simulation programme. Ratings of self-perceived performance were collected using the Seattle University Simulation Evaluation tool at three different time points: after participants' first simulation as 'lead paramedic' on Day 1 of the intensive programme (Rating 1), after their final simulation on Day 3 of the intensive programme (Rating 2) and after their final simulation in a follow-up programme after a nine-week washout period (Rating 3).

RESULTS: Out of the 37 participants randomly allocated, 20 fulfilled the study requirements, with 11 in the 360-degree projection group and nine in the traditional simulation group. Participants consistently reported higher ratings of self-perceived performance in the traditional simulation group, in comparison to the 360-degree projection simulation group (p = 0.04). While no difference was seen between groups after the intensive programme (Rating 2), a notable difference was observed between groups at Rating 3 in favour of the traditional simulation group (p = 0.02).

CONCLUSION: This pilot study suggested that measures of self-perceived performance were lower when using 360-degree projection simulation spaces. While there may be some benefit to this form of simulation as an adjunct to current traditional methods used, further research, including studies that are appropriately powered and include objective outcome measures, is needed to understand the measure of effectiveness in a practical setting and to inform future educational interventions.

INTRODUCTION: Often women will experience the menopause and its associated symptoms during their working lives, and there is now an increased focus on improving menopause support offerings in the workplace. The main aim of this study was to explore the menopause transition experiences of ambulance staff and identify workplace interventions that may offer improved support to menopausal staff within the ambulance sector.

METHODS: A purpose-designed, online survey was disseminated to UK ambulance services for voluntary completion between December 2021 and February 2022. Topics that were covered included participant age and role, menopause transition phase, symptoms experienced and their severity, expectation and effect of symptoms, work pattern, need for work leave and policy awareness. An opportunity for additional menopause-related comments was included. Quantitative data analysis was performed using descriptive and exploratory statistics; qualitative data were analysed using content analysis.

RESULTS: A convenience sample of 1896 survey responses was obtained; the majority of participants self-reported to be in the menopause transition. Pre- and peri-menopausal participants were more likely to undertake shift-based work; menopausal and post-menopausal participants were more prevalent in office-based roles. Shift-working participants reported more severe tiredness or low energy levels, hot flushes, night sweats and gastric problems; office-working staff reported more severe issues with vaginal health, weight, skin changes and oral health. There were significant associations between role type, severity of symptom impact and need for leave from work. Recommended areas for organisational improvement to support menopausal women in the ambulance workplace are alternative work opportunities, menopause education and training, appropriate menopause policies and guidance, expert resources and support and access to improved physical work environments.

CONCLUSION: Women can experience menopausal symptoms that impact their working lives; their work role and setting can influence their menopause experiences. Workplace interventions for improved menopause awareness, support and staff well-being are warranted.

INTRODUCTION: The incidence of pulseless electrical activity (PEA) as a presenting rhythm in out-of-hospital cardiac arrest is rising in comparison with other rhythms. Prompt recognition of the cause of PEA can improve outcomes. The assessment of electrocardiogram (ECG) characteristics during resuscitation has been suggested as a source of diagnostic information for clinicians. The aim of this systematic review was to identify literature evaluating the use of ECG characteristics as indicators of the aetiology of PEA and to consider how their findings may be utilised in clinical practice.

METHODS: Case series, observational studies, randomised controlled trials and empirical research investigating the ECG characteristics of adult patients and reporting the aetiology of PEA were searched for via a systematic literature search of the MEDLINE, CINAHL Plus and EMBASE databases. Searches for grey literature were performed, as well as reference screening. A risk-of-bias assessment was undertaken for each included study.

RESULTS: A total of four articles were selected for final inclusion. One study reported a statistically significant correlation between the presence of wide QRS complexes and hyperkalaemia. No further associations between ECG characteristics and the aetiology of cardiac arrest were reported. Three studies were found to be at moderate risk of bias due to incomplete inclusion of patients. Studies often assessed groups of aetiologies, rather than specific causes. Consequently, this limits their application in clinical practice.

CONCLUSION: ECG characteristics should not be used in isolation as an indicator of the aetiology of cardiac arrest in patients with PEA. The included studies often employed broad categorisations of aetiologies, limiting their ability to identify specific characteristics associated with individual causes. Future research should include analysis of specific aetiologies and the evaluation of ECG characteristics to augment other diagnostic tools.

INTRODUCTION: Communication is essential in healthcare, but language barriers between patients and clinicians can hinder care quality, especially as the UK sees an increasing number of non-native English speakers. The 2021 UK census revealed that 5.1 million people do not speak English as a first language, with many having limited or no proficiency. Despite these trends, little research has been carried out to explore the experiences of these individuals in pre-hospital care, where language challenges often arise. UK paramedic education includes communication training, but foreign-language learning is not part of most curricula. Some universities offer optional language modules, yet there is no data on how many paramedics or student paramedics speak additional languages. Clinicians with foreign-language skills could enhance patient satisfaction and reduce communication barriers, but there is a lack of pre-hospital evidence in this area. This exploratory study aimed to capture the foreign-language skills of student paramedics in the UK, addressing a gap in the literature and laying the groundwork for future research.

METHODS: This exploratory study employed a quantitative, cross-sectional design using an online survey distributed to student paramedics across 24 higher education institutions in the UK during April and May 2024. The survey captured demographic data and language competencies, with descriptive statistics used for analysis.

RESULTS: Out of 105 respondents, 73 were female (69.5%), and the mean age was 23.65 (± 8.25). Over half (53.3%) reported proficiency in at least one foreign language, predominantly languages spoken in Europe, such as French (48.2%), Spanish (35.7%) and German (21.4%). Most respondents had beginner-level skills (64.3%), with no formal language training in their programmes. However, 57.7% expressed interest in studying an optional foreign-language module.

CONCLUSION: This study found that over half of student paramedics possess foreign-language proficiency. The majority of the sample indicated a desire to study a foreign language if given the opportunity during their paramedic training. Given the increasing linguistic diversity in the UK, integrating language modules into paramedic education could enhance patient care and satisfaction. Further research is needed to explore the feasibility of such training and its impact on pre-hospital care outcomes for non-native English speakers.

Genitourinary-Rhabdomyosarcomas (GU-RMS) are challenging to treat due to the probable lifelong sequelae of local therapy. Western-world data show 3-year event-free survival (EFS) and overall survival (OS) of 77% and 86%, respectively, for localised disease, with dismal outcomes for metastatic disease. We studied the clinical profile, outcomes and prognostic factors of GU-RMS treated with a multimodal protocol. Treatment-naïve children ≤ 15years with biopsy-proven GU-RMS treated from January 2013 to June 2022 were retrospectively analysed. Local therapy performed at 10-12 weeks of induction was radiotherapy (RT) and/or surgery. Fifty-two patients with a median tumour size of 5.5 cm (range, 3.4-9.2 cm) were analysed. Four patients (7.8%) had alveolar histology. The bladder was the commonest site of primary (36.5%). Group distribution: I-7 (13.4), II-1 (1.9%), III-35 (67.3%) and IV-9 (17.3%). Local therapy was surgery in 11 (21.5%), RT in 25 (49%) or both in 14 (26.9%) patients. With a median follow-up of 56 months (95% confidence interval (CI): 49.1%-63.1%), 4-year EFS for groups I-IV, were 100%, 50% (95% CI: 41%-59%) and 33.3% (95% CI: 2.6%-64%) (p = 0.01), respectively. The corresponding 4-year OS were 100%, 72% (95% CI: 56.4%-87.6%) and 33.3% (95% CI: 2.6%-64%) (p = 0.007), respectively. Relapses were locoregional-4 (7.7%), metastatic-5 (9.6%) and combined-4 (7.7%). Tumour size > 6.45 cm significantly affected outcomes in the localised cohort (hazard ratio = 4.1, 95% CI: 1.38-12.1, p = 0.01). Outcomes of group III GU-RMS in children treated on a multimodal protocol in our study are suboptimal compared to those from co-operative group trials, probably affected by large tumours at presentation, warranting alternative strategies for optimisation of survival.

Cancer burden is expected to increase in the next decades, especially in low- and middle-income countries (LMICs). There, including in Portuguese-speaking African countries, cancer care remains fragile and highly centralised. Global ONCOlogy Initiative (GONCO) is a pragmatic initiative launched in Portugal to support the development of decentralised oncology services through short, targeted interventions. This paper presents its conceptual design and the first two pilot projects, implemented in Lubango (Angola) and Mindelo (Cape Verde). GONCO follows a three-step model: digital planning, fieldwork and digital follow-up. In both sites, the program was co-developed with local teams and focused on establishing multidisciplinary tumour boards, improving service coordination and building capacity in clinical management, protocols and research. In Lubango, GONCO helped launch the oncology unit and research group. In Mindelo, it supported service restructure planning and the creation of a breast cancer working group. Remote collaboration sustained momentum after field visits. Challenges included hierarchical barriers, unreliable digital infrastructure and non-sustainable funding. Despite these, GONCO demonstrated that focused and adaptable models can catalyse oncology development in resource-constrained hospitals. GONCO provides a replicable, light-footprint model for early oncology development in LMICs.

Anxiety and depression are common in prostate cancer (PCa) patients and negatively impact the quality of life, treatment outcome, survival and overall well-being, thus, requiring interventions to meet the psychosocial needs of PCa patients across treatment stages. However, there is not enough information to guide the design of these interventions, as there are still areas of lack of clarity regarding the prevalence and predictors of anxiety and depression in PCa patients. Therefore, this review was conducted to examine the literature to identify the overall prevalence of anxiety and depression across treatment stages in PCa patients and to identify the predictors of anxiety and depression in this population. A literature search was conducted from the Cochrane library, Ovid Medline and APA PsycINFO databases. Eighteen eligible studies were included in the final review. The findings were analysed using a narrative synthesis. The study quality was assessed using the Joanna Briggs Institute critical appraisal checklist. The prevalence of anxiety and depression was found to be between 6% to 44.8% and 10% to 48%, respectively. Notably, the prevalence of depression was higher in the post-treatment phase than in the treatment phase. Finally, the result demonstrates that socio-economic/demographic, clinical and lifestyle factors determine patients' predisposition to anxiety and depression. These demonstrate that the prevalence of anxiety and depression is high across the PCa disease trajectory and that some patients are more likely to experience anxiety and depression than others. Therefore, we recommend periodic assessment to identify at risk patients and those with clinically significant or worsening levels of anxiety and depression for timely interventions to mitigate the risks or ameliorate the symptoms of anxiety and depression.

BACKGROUND: Colorectal cancer (CRC) is a major global health issue, ranking fourth in incidence and third in cancer-related deaths. In 2022, it was most prevalent in Asia, Europe and North America. Although rates in Latin America, including Mexico, are lower, they still represent a substantial public health concern. However, CRC data in Mexico are limited and outdated.

AIM: This study aimed to assess the incidence trends of CRC in a secondary-level hospital in Mexico from 2011 to 2023.

METHODS: A retrospective analysis was conducted on 819 individuals with CRC at Regional General Hospital 251 (Mexican Social Security Institute) in Metepec, Mexico. Incidence rates were calculated per 100,000 inhabitants and stratified by sex, age group, tumour site and body mass index. Trend analysis was performed using Joinpoint regression models to estimate annual percent change (APC).

RESULTS: CRC incidence showed a significant upward trend (APC = 8.81%; p = 0.01) from 2011 to 2023. A one-joinpoint model revealed an increase from 2011 to 2021 (APC = 17.90%; < 0.01), followed by a sharp decrease from 2021 to 2023 (APC = -41.34%; p = 0.03). Males had slightly higher incidence rates than females; the ≥50 age group showed the highest burden. Over half of the individuals were diagnosed at advanced stages (III-IV), with similar trends observed across the sexes.

CONCLUSION: CRC incidence increased significantly over the last decade, with a recent drop likely influenced by the COVID-19 pandemic. Despite some limitations, this is the first study of CRC trends at a secondary-level hospital in Mexico that underscores the need for enhanced screening and timely diagnosis strategies.