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While non-operative treatment has emerged as an alternative to surgery for the treatment of uncomplicated acute appendicitis in children, comparative patient-centred outcomes are not well documented. We investigated these in a feasibility randomised trial. Of 57 randomised participants, data were available for 26. Compared with appendicectomy, children allocated to non-operative treatment reported higher short-term quality of life scores, shorter duration of requiring analgesia, more rapid return to normal activities and shorter parental absence from work. These preliminary data suggest differences exist in recovery profile and quality of life between these treatments that are important to measure in a larger RCT. Trial registration number is ISRCTN15830435.

Background The NHS website gives guidance for pregnant women in England on foods/drinks to avoid or limit because of microbiological, toxicological or teratogenic hazards. These include, for example, some types of soft cheeses, fish/seafood and meat products. This website and midwives are trusted sources of information for pregnant women, but the ways in which midwives can be supported to provide clear and accurate information are unknown. Aims The aims were to: (1) determine midwives’ accuracy of recall of information and confidence in delivering the guidance to women; (2) identify barriers to provision; (3) identify the ways in which midwives provide this information to women. Methods Registered Midwives practicing in England completed an online questionnaire. Questions included those on what information they provided and their confidence in delivering it, the ways they provided information on foods to avoid/limit, and what resources they used. Ethics approval was given by the University of Bristol. Results >10% of midwives (n = 122) were ‘Not at all confident’ in providing advice about seven items, including game meat/gamebirds (38% and 39%, respectively), herbal teas (13%) and cured meats (12%). Only 32% correctly recalled overall advice on eating fish, and only 38% the advice on tinned tuna. The main barriers to provision were lack of time in appointments and lack of training. The most usual methods of disseminating information were verbal (79%) and signposting to websites (55%). Conclusion Midwives were in general knowledgeable about foods and drinks to avoid/limit during pregnancy, but there were some foods for which they were unconfident, and some for which recall was mistaken. Delivery of guidance by midwives on foods to avoid or limit needs to be supported by appropriate training and access to resources. Further research on barriers to the delivery and implementation of the NHS guidance is needed.

Guidance on foods to limit or avoid in pregnancy is provided on the NHS website for England.(1) Advice on fish consumption is related to exposure to mercury, which may have adverse effects on fetal neurodevelopment, as well as to dioxins and polychlorinated biphenyls. The advice includes avoidance of shark/marlin/swordfish, limiting oily fish to two portions per week, and a limit of two tuna steaks or four medium-sized cans of tuna per week. However, the effectiveness of this advice has not been evaluated. There is concern that complexity of the guidance, together with risk aversity, could lead women to avoid eating fish and thereby miss out on the likely beneficial effects of its nutritional content (iodine, vitamin D, long-chain fatty acids, etc.).(2) Our aim was to provide evidence to inform development of the guidance in order to minimise exposure to toxins while preserving nutrient intakes.(3, 4) Postpartum women (≤12 months) resident in England for ≥6 months of pregnancy were invited to complete an online questionnaire. Questions included: (1) demographics; (2) fish consumption before and during pregnancy using food frequency questions; (3) knowledge of the guidance and sources of information. Ethics approval was given by the University of Bristol. The study is part of a larger mixed methods study on dietary exposure to toxic metals (PEAR Study). The questionnaire was completed by 598 women. During pregnancy, 17% (100/598) women never ate fish, of whom 53% (53/100) were vegan/vegetarian without fish/avoided fish for religious reasons. 23% (135/597) ate fish less often in pregnancy and 4% (22/497) ate fish before pregnancy but avoided it completely during pregnancy. The main reason for eating less fish during pregnancy or avoiding it completely was the health of the baby (67% (90/135) and 55% (12/22), respectively). The main sources of information were the NHS website and midwives. 74% (441/598) did not eat ≥2 portions of fish per week and 78% (465/598) did not eat at least one portion of oily fish per week as recommended. 98% (581/593) ate tinned tuna once a week or less, and 92% (537/587) never ate fresh tuna. 99% (595/598) avoided shark/marlin/swordfish. Information provided on the NHS website is a key source of information on fish consumption for pregnant women. There was evidence that some women were more likely to avoid fish altogether or reduce consumption during pregnancy. This is being explored further with in-depth interviews. Although compliance with the message to avoid specific high-mercury/high-pollutant fish species is good, few participants ate at least two portions of fish per week as recommended overall, and fewer still at least one portion of oily fish. These messages need to be shown prominently in NHS guidance to enable benefit from the nutritional content of fish.

Background Daytime urinary incontinence (UI) is common in childhood and often persists into adolescence. UI in adolescence is associated with a range of adverse outcomes, including depressive symptoms, peer victimization, poor self-image, and problems with peer relationships. The first-line conservative treatment for UI is bladder training (standard urotherapy) that aims to establish a regular fluid intake and a timed schedule for toilet visits. The success of bladder training is strongly dependent on good concordance, which can be challenging for young people. Objective This paper aims to describe the development of a smartphone app (URApp) that aims to improve concordance with bladder training in young people aged 11 to 19 years. Methods URApp was designed by using participatory co-design methods and was guided by the person-based approach to intervention design. The core app functions were based on clinical guidance and included setting a daily drinking goal that records fluid intake and toilet visits, setting reminders to drink fluids and go to the toilet, and recording progress toward drinking goals. The development of URApp comprised the following four stages: a review of current smartphone apps for UI, participatory co-design workshops with young people with UI for gathering user requirements and developing wireframes, the development of a URApp prototype, and the user testing of the prototype through qualitative interviews with 23 young people with UI or urgency aged 10 to 19 years and 8 clinicians. The app functions and additional functionalities for supporting concordance and behavior change were iteratively optimized throughout the app development process. Results Young people who tested URApp judged it to be a helpful way of supporting their concordance with a timed schedule for toilet visits and drinking. They reported high levels of acceptability and engagement. Preliminary findings indicated that some young people experienced improvements in their bladder symptoms, including a reduction in UI. Clinicians reported that URApp was clinically appropriate and aligned with the best practice guidelines for bladder training. URApp was deemed age appropriate, with all clinicians reporting that they would use it within their own clinics. Clinicians felt URApp would be of particular benefit to patients whose symptoms were not improving or those who were not engaging with their treatment plans. Conclusions The next stage is to evaluate URApp in a range of settings, including pediatric continence clinics, primary care, and schools. This research is needed to test whether URApp is an effective (and cost-effective) solution for improving concordance with bladder training, reducing bladder symptoms, and improving the quality of life.

Additional file 1.

Background: Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in adolescents is common and disabling. Teenagers in the United Kingdom (UK) are more likely to recover if they access specialist care, but most do not have access to a local specialist CFS/ME service. Delivering treatment remotely via the internet could improve access to treatment.Objective: This study aimed to assess (1) the feasibility of recruitment and retention into a trial of internet-delivered specialist treatment for adolescents with CFS/ME and (2) the acceptability of trial processes and 2 web-based treatments (to inform continuation to full trial).Methods: This study was an internal pilot for the initial 12 months of a full randomized controlled trial (RCT), with integrated qualitative methods (analysis of recruitment consultations and participant and clinician interviews). Recruitment and treatment were delivered remotely from a specialist pediatric CFS/ME treatment service within a hospital in South West UK. Adolescents (aged 11-17 years) from across the United Kingdom with a diagnosis of CFS/ME and no access to local specialist treatment were referred by their general practitioner to the treatment center. Eligibility assessment and recruitment were conducted via remote methods (telephone and on the web), and participants were randomized (via a computer-automated system) to 1 of 2 web-based treatments. The trial intervention was Fatigue in Teenagers on the InterNET in the National Health Service, a web-based modular CFS/ME-specific cognitive behavioral therapy program (designed to be used by young people and their parents/caregivers) supported by individualized clinical psychologist e-consultations (regular, scheduled therapeutic message exchanges between participants and therapist within the platform). The comparator was Skype-delivered activity management with a CFS/ME clinician (mainly a physiotherapist/occupational therapist). Both treatments were intended to last for up to 6 months. The primary outcomes were (1) the number of participants recruited (per out-of-area referrals received between November 1, 2016, to October 31, 2017) and the proportion providing 6-month outcome data (web-based self-report questionnaire assessing functioning) and (2) the qualitative outcomes indicating acceptability of trial processes and treatments.Results: A total of 89 out of 150 (59% of potentially eligible referrals) young people and their parents/caregivers were recruited, with 75 out of 89 (84%) providing 6-month outcome data. Overall, web-based treatment was acceptable; however, participants and clinicians described both the advantages and disadvantages of remote methods. No serious adverse events were reported.Conclusions: Recruiting young people (and their parents/caregivers) into an RCT of web-based treatment via remote methods is feasible and acceptable. Delivering specialist treatment at home via the internet is feasible and acceptable, although some families prefer to travel across the UK for face-to-face treatment.Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 18020851; http://www.isrctn.com/ISRCTN18020851.

IntroductionThe clinical effectiveness of a “rule-out” strategy for emergency department patients with chest pain, incorporating a single undetectable high-sensitivity troponin (hs-cTn) taken at presentation, together with a non-ischaemic electrocardiogram (ECG), remains unknown.MethodsThis randomised controlled trial, across eight hospitals in the UK, aimed to establish the clinical effectiveness of an undetectable hs-cTn and ECG (LoDED) discharge strategy. Eligible patients presented with chest pain, were adults, the treating clinician intended to perform investigations to rule out an acute coronary syndrome, the initial ECG was non-ischaemic and peak symptoms occurred ResultsBetween June 2018 and March 2019, 632 patients were randomised, three were later withdrawn. Of 629 patients (age 53.8 [SD 16.1] years, 41% women), 7% had a MACE within 30 days. For the LoDED strategy 141 of 309 [46%] patients were discharged within four hours, without MACE within 30 days, and for usual care 114 of 311 [37%]; pooled adjusted odds ratio 1.58 (95% CI 0.84-2.98). No patient with an initial undetectable hs-cTn had a MACE within 30 days.ConclusionThe LoDED strategy facilitates safe early discharge in >40% of chest pain patients. Clinical effectiveness is variable when compared to existing rule-out strategies and influenced by wider system factors.

Additional file 1. Patients coded TATT between 1st April 2012- 30th June 2013. Estimate of prevalence of fatigue in general practice during the period of the study.

Additional file 2. CONSORT 2010 checklist of information to include when reporting a pilot or feasibility trial.