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Introduction Concerns exist regarding the suitability of national and international guidance informing third stage of labour care for women at low risk of postpartum haemorrhage. Methods The robustness and appropriateness of the research evidence underpinning third stage of labour care guidance by institutions such as the National Institution for Health and Care Excellence, the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives was assessed and areas for further research to address any gaps in knowledge were identified. Results National and international third stage of labour practice guidance recommend active management for all women. This may not be suitable for women at low risk of postpartum haemorrhage giving birth in a midwife-led unit or a home birth setting. This is because of the reduced reliability, validity and generalisability of the evidence informing this guidance to this group of women. Conclusions Expectant management may be more appropriate for women at low risk of postpartum haemorrhage who choose to birth in a midwife-led unit or home birth setting and want to experience a birth with minimal intervention. However, more research into third stage management practices in these settings is needed.

OBJECTIVE To assess the incidence, risk, and associated factors that contribute to an acquired surgical site infection (SSI) after emergency cesarean section (CS). METHODS This retrospective case-control study was conducted in an acute district general hospital in England with 206 patients (101 SSI patients and 105 non-SSI patients) who had an emergency CS in 2017. Grade of surgeon, smoking status, preoperative vaginal swab status (positive or negative), diabetes status, age, body mass index, membrane rupture to delivery interval, and length of surgery were recorded. Risk factors were identified using simple and multiple logistic regression. RESULTS Body mass index was significantly associated with SSI (odds ratio, 1.17; 95% confidence interval, 1.11 to 1.24; P < .001). Further, substantive nonsignificant associations were recorded between SSI and patient age and vaginal swab status. CONCLUSIONS Body mass index was the only significant risk factor for the development of an SSI after emergency CS, possibly because of the impact of excessive adipose tissue on the immune system and reduced effectiveness of antibiotics. Diabetes status, patient age, and preoperative vaginal swab status were not significantly associated with SSI. Improved guidelines and strategies for managing at-risk patients would enable clinicians to reduce the risk of SSI development. The importance of wound management including frequent wound cleaning, appropriate dressings, dressing changes, and education is highlighted. Future research on larger samples should be conducted to validate these findings.

IntroductionNational Early Warning Score 2 (NEWS2) is widely used to monitor and trigger assessment throughout a patient’s hospital journey. Since the development and role out of NEWS2, its ability to predict mortality has been assessed in several settings, although to date not within an undifferentiated ED population.MethodsWe conducted a retrospective observational study of all adult ED attendees at two EDs in Northern England, between March and November 2019. Multilevel multiple logistic regression analyses were conducted on patient episode data to assess the relationship between mortality at 2, 7 and 30 days from attendances; and maximum NEWS2, adjusting for age, sex, arrival mode and triage priority.ResultsData were collected from 91 871 valid patient episodes associated with 64 760 patients. NEWS2 was a significant predictor of mortality at 2 days (OR 1.75; 95% CI 1.58 to 1.93); at 7 days (OR 1.69; 95% CI 1.59 to 1.80); at 30 days (OR 1.58; 95% CI 1.52 to 1.64). For the analyses of categorised NEWS2, NEWS2 of 2–20 was significantly associated with mortality at 2, 7 and 30 days compared with none assigned: OR 3.54 (95% CI 2.15 to 5.85) at 2 days; OR 6.05 (95% CI 3.92 to 9.34) at 7 days; OR 12.4 (95% CI 7.91 to 19.3) at 30 days. Increasing age, male sex, arrival by ambulance and higher triage categories were also associated with significantly increased mortality. Area under the receiver operating characteristic curve values of 0.963, 0.946 and 0.915, respectively, were recorded for mortality outcomes, with optimum likelihood ratios associated with a trigger of 4 NEWS2 points.ConclusionsNEWS2 is an effective predictor of mortality for patients presenting to the ED. Findings suggest that maximum NEWS2 of 4 and over may be the best trigger point for escalation of treatment. Findings also suggest a NEWS2 of 0–1 can identify a very low-risk group within the ED.

Objective: Episodes of inpatient care-related pressure ulcers (PU) lead to deleterious effects on patient quality of life, and additional costs associated with wound dressings, staff visits and hospitalisation. Accurate prediction of future incidence may be helpful in defining strategies for benchmarking and resource management. Observations of category 2 or above PUs during episodes of care at an NHS Foundation Trust were recorded monthly from 2010 to 2020. Trust-specific interventions designed to reduce PU incidence, such as procurement of specialised staff and equipment, were also recorded. This study aimed to investigate the historical pattern of PU incidence in the Trust to assess intervention effectiveness in reducing PU incidence, and to use historical data to derive estimates of future incidence. Method: Time-series analysis was conducted on monthly PU incidence data to quantify underlying trends, seasonality and effect of interventions, and to derive a suitable model to predict future incidence levels. Results: Mean monthly PU incidence gradually reduced from 20.3 during 2012 to 5.08 during 2019; with a negative linear trend in the presence of concurrent seasonal effects. There was limited evidence that implementation of specific interventions was associated with raised rates of reduction; however, incidence reductions during intervention periods continued from lower baselines. Best estimate predictions revealed that incidence is likely to stay at current levels or below for the foreseeable future. Conclusion: Past data can be used to model future episodes of inpatient care PU occurrence. Interventions may be effective in reducing PU incidence rates.

Background: Nurse shortage is an international issue that has adverse effects on health and the quality of care of whole populations. Aims: The study aimed to explore attrition experienced by return-to-practice students attending higher education institutions in England. Methods: A mixed-methods design, involving questionnaires (n=114) and in-depth interviews (n=20), was used. Findings: Just over half (52%) of respondents left nursing after ≥10 years. Most of these (84%) stayed in alternative employment during their break from nursing. There were two distinct reasons for leaving nursing: the inability to maintain a positive work/life balance and a lack of opportunity for career advancement while retaining nursing registration. Respondents reflected positively on their nursing experience yet frequently reported significant personal or professional incidents prompting their decision to leave. Conclusion: The reasons nurses leave are complex. Professional bodies and managers need to work together to address concerns many nurses have during their careers that lead to them deciding to leave the profession.

Purpose The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand developed candidate quality measures for potential inclusion in the Merit-Based Incentive Program and National Quality Forum in the hope that hand surgeons could report specialty-specific data. The following measures regarding the management of carpal tunnel syndrome (CTS) were developed using a Delphi consensus process: (1) use of magnetic resonance imaging (MRI) for diagnosis of CTS, (2) use of adjunctive surgical procedures during carpal tunnel release (CTR), and (3) use of formal occupational and/or physical therapy after CTR. This study simulated attempts to identify outlier regions in an insurance claims database, which is an important step in establishing feasibility of these measures. Methods Using the Truven Health MarketScan, we identified 643,357 patients who were given a diagnosis of CTS between 2012 and 2014. We reported the percentage of metropolitan statistical areas (MSA) with one or more claims for MRI within 90 days of CTS diagnosis, one or more adjunctive surgical procedures, and one or more formal referrals for physical and/or occupational therapy within 6 weeks of CTR, and we calculated the rate of use for each of these diagnostic or treatment modalities. In addition, we report the precision ratio (signal to noise), SD, and 95% confidence interval. Results A high percentage of patients given a diagnosis of CTS did not have MRI (99%), and the precision ratio was considered high (0.99). Over 30% of all observed MSAs had at least one claim for MRI as a diagnostic modality in CTS. Most patients (98%) did not have adjunctive surgical procedures. For the observed years, over 28% of MSAs had at least one insurance claim for an adjunctive procedure. A total of 86% of patients did not receive formal occupational or physical therapy after CTR. In addition, 92% of MSAs had at least one claim for therapy. The precision ratio was considered high (approximately 0.85). Conclusions There is regional variation in the utilization rate of diagnostic MRI for CTS, adjunctive surgical procedures, and formal referral for physical and occupational therapy. For the proposed quality measures, outlier regions can be detected in insurance claims data. Clinical relevance Use of MRI in diagnosis, adjunctive surgical procedures, and formal therapy after surgery are feasible quality measures for the Merit-Based Incentive Program and National Quality Forum.

Physical activities that involve muscle strengthening, balance and coordination skills such as ballroom dancing are encouraged for older adults to assist with the maintenance of functional autonomy and prevention of falls. Twenty-three community-dwelling older adults engaged in regular ballroom dancing completed a 12-month study assessing well-being, falls risk and balance using a set of clinical outcome measures. Those attending ballroom dancing classes were more likely to be active older adults, with lower levels of BMI and obesity compared to the general population. Participants scored lower in the falls risk tests than normative values. Some of the results suggest a possible substantive finding for clinical practice and indicate ballroom dancing is an activity with good attrition and adherence rates among community-dwelling older adults that can improve well-being, balance and reduce falls risk as part of an active lifestyle.

Objective: The burden of wound care within the NHS is estimated at a cost of £5.3 billion per year and is set to rise annually by 30%. This case series describes the results of using polyhexanide (PHMB) and betaine wound irrigation solution and gels (Prontosan, B.Braun Medical Ltd., UK) across the UK in hard-to-heal (also described as chronic) wounds up to 20 years' duration, with an observation period of greater than one month. Over half of the hard-to-heal wounds were healed and vast improvements to all other wounds were observed. Improvements to wound bed condition were reported as early as two days after commencing initial treatment, with decreases in malodour, exudate, slough and pain reported across the case series. In addition to wound bed improvements, a reduction in dressing change frequency of 55% was observed in hard-to-heal wounds under the new treatment regime.

The aim of this systematic review and meta-analysis was to examine the effectiveness of e-health interventions for the treatment of children and adolescents with overweight or obesity. Databases were searched up to November 2020. Studies were randomized controlled trials where interventions were delivered via e-health (e.g., computers, tablets, and smartphones, but not phone calls). Studies should target the treatment of overweight or obesity in children or their agent of changes and report body mass index (BMI) or BMI z-score. A meta-analysis using a random-effects model was conducted. Nineteen studies met the inclusion criteria, and 60% were of high quality. The narrative review revealed variation in behavior change strategies and modes of delivery. The pooled mean reduction in BMI or BMI z-score showed evidence for a nonzero effect (standardized mean difference = -0.31, 95% confidence interval -0.49 to -0.13), with moderately high heterogeneity between studies (I-2 = 74%, p < 0.001). Subgroup analysis revealed high heterogeneity in studies with a high or unclear risk of bias. E-health interventions can be effective in treating children and adolescents with overweight and obesity and should be considered by practitioners and policymakers. However, an understanding of the most effective and acceptable intervention components, long-term benefits, and sustainability should be further studied.

Background The relationship between obesity and health-related quality of life (HRQoL) may be confounded by factors such as multimorbidity. The aim of the study was to explore this relationship, controlling for long-term conditions and other health, lifestyle and demographic factors in a general adult population. There was specific interest in the impact of high weight status, measured by body mass index (BMI) levels (obesity, morbid obesity) compared with individuals of normal weight. Methods Health, lifestyle and demographic data were collected from 64,631 individuals aged 16 years and over registered in the Yorkshire Health Study; a long-term cohort study. Data were collected in 2 waves: from patients attending GP surgeries in the South Yorkshire region; and using online recruitment across the entire Yorkshire and Humber area. Univariable and multivariable regression methods were utilised to identify factors associated with HRQoL as measured by the EQ-5D summary score. Long-term conditions were tested as both covariates and mediating factors on the causal pathway between obesity and HRQoL. Results Increasing levels of obesity are associated with reduced HRQoL, although this difference is negligible between those of normal weight and those who are overweight. Individuals with obesity and morbid obesity score 4.9 and 11.3 percentage points less on the EQ-5D summary scale respectively than those of normal weight. Concurrent physical, and particularly mental health-related long-term conditions are substantively related to HRQoL: those with 3 or more reported mental or physical health conditions score 29.8 and 14.6 percentage points less on the EQ-5D summary scale respectively than those with fewer conditions. Long-term conditions can be conceptualised as lying on the causal path between obesity and HRQoL, but there is weak evidence for a partial mediating relationship only. Conclusions To conclude, in agreement with the established literature we have found a clear inverse relationship between increasing weight status and decreasing HRQoL and confirmed the mediating role of long-term conditions in the reduction of HRQoL in people with obesity. Nevertheless, a high BMI remains independently related to HRQoL, suggesting that ‘healthy people with obesity’ may be in transition to an unhealthy future.

Background Over the past 20 years, Nepal has seen major improvements in childhood and maternal survival. In 2015, the Nepalese government introduced a new federal political structure. It is unclear how this has affected the health system, and particularly, maternal and child health care. Hence, this study aims to describe and analyse health facility preparedness in the light of the federalization process with regards to providing appropriate and timely maternal and neonatal health services. Methods A descriptive cross-sectional study was conducted in Jumla district, Nepal in 2019 covering all 31 state health facilities (HF) to assess the availability of maternal and neonatal health services including appropriate workforce and access to essential medicines. Tests of association between demographic factors and the probability of a facility experiencing a shortage of essential medicine within the last 3 months were also conducted as exploratory procedures. Results Out ot 31 HFs, more than 90% of them had all their staff positions filled. Most facilities (n = 21) had experienced shortages of essential medicines within the past 3 months. The most common out of stock medicine were: Amoxicillin (n = 10); paracetamol (n = 10); Vitamin A (n = 7); and Metronidazole (n = 5). Twenty-two HFs had referred maternal and newborn cases to a higher centre within the past 12 months. However, more worryingly, twenty HFs or their catchment communities did not have emergency ambulance transport for women and newborns. Conclusion HFs reported better staffing levels than levels of available drugs. HFs should be supported to meet required minimal standards such as availability of essential medicines and the provision of emergency ambulance transport for women and newborns.

Background: Research has consistently demonstrated that preventive cardiology programs have limited success, and healthy practices among high-risk individuals remain suboptimal. Furthermore, there are no current programmes in Malta that offer support to first-degree relatives of patients with premature coronary heart disease. This internal pilot study will determine the feasibility, acceptability, and potential effectiveness of a preventative intervention., Methods/design: We are conducting a 12-month single-centre, two-armed group randomised controlled trial (RCT), recruiting a sample of 100 asymptomatic first-degree relatives of patients with premature coronary heart disease (CHD). The study seeks to test an evidence-based intervention to reduce modifiable risk and determine its feasibility and acceptability. The Intervention will be delivered at an outpatient office based in a large acute academic hospital. It will comprise risk communication using an online risk calculator, a counselling style adapted from motivational interviewing, and 12 weekly telephone goal reinforcement calls (3 months). Control subjects will receive verbal lifestyle advice only. Feasibility will be assessed through recruitment and retention. Qualitative evaluation interviews will be conducted with a subsample of 24 purposefully selected participants at 12 months. Assessment for risk factor changes will be measured at pre-intervention and 6 and 12 months. Associations between variables will also be assessed descriptively, Discussion: Preventive cardiology guidelines highlighted the importance of lifestyle interventions, and lifestyle intervention adherence was proven to reduce atherosclerotic cardiovascular disease (ASCVD) risk, regardless of the individual's genetic risk. Preventive cardiology programmes may fail to adequately support persons in modifying risky behaviours, and research demonstrates that healthy practices among high-risk individuals can remain suboptimal. Siblings and offspring of patients with premature CHD are at increased risk of ASCVD. Despite this, there is no process in place for routine screening and support to modify risk. It is hypothesised that participants assigned to the intervention arm will show more cardio-protective lifestyle-related improvement from the baseline than those in the control group. To date, this is the first trial being conducted amongst Maltese first-degree relatives. This study addresses the needed research, and the results will inform a definitive trial. The funding institution is the University of Malta., peer-reviewed

Introduction Intermittent claudication (IC) is the most common symptom of peripheral arterial disease. Previous research has suggested that cycloidal vibration therapy (CVT) may induce angiogenesis and improvements in circulation. The objective of this feasibility study was to explore trial design and acceptability of the protocol to provide data to estimate the parameters required to design a definitive randomised control trial. This feasibility study specifically aimed to assess recruitment rate; attendance rates at baseline and follow-up; and safety, tolerability, and compliance with therapy device and additionally, to consider the potential efficacy of CVT as a novel treatment for intermittent claudication. Methods Patients with intermittent claudication (IC) were recruited and CVT was applied at home for 30 min twice a day for a period of 12 weeks. Primary outcomes were pain-free walking time (PFWT) and maximum walking time (MWT) after 12 weeks of treatment. Secondary outcomes included the ankle-brachial index and ankle systolic blood pressure. Participants were assessed during active therapy phase at baseline, week 4, week 8, and week 12. Results Thirty-four participants with IC were recruited: 30 (88%) male and 4 (12%) female. The rate of recruitment was 2.4 participants per month from a standard-size district general hospital. No participants left the study during the activity therapy stage, and no participant failed to attend their follow-up appointment. The general compliance with CVT was high. No participants dropped out during the treatment phase. The mean age of all participants was 68 years (IQR 60–75 years). Substantive improvements were seen in a comparison of differences in times to PFWT and MWT, in ABPI, and in systolic leg pressure in the treated leg. There was no evidence of a substantive difference from baseline in systolic leg pressure in the untreated leg. There were no immediate or delated treatment safety concerns of documented adverse effects with the treatment, all patients completed the required 12-week course indicated a high degree of patient acceptability. Conclusion The statistically significant and substantive improvements from baseline after 12 weeks observed in PFWT and MWT in participants experiencing IC are comparable to improvements seen from other treatment options such as supervised exercise as reported by Stewart et al. (N Engl J Med 347:1941–1951, 2002). The substantive improvement in systolic leg pressure in the treated leg and the concurrent absence of a substantive change in systolic leg pressure in the untreated leg over the same period suggests a causative effect. This study has provided novel information relating to the number of potential eligible participants for a further research trial and potential association between CVT and improved symptoms. Additionally, it has established that CVT treatment is highly acceptable, as indicated by no participant drop-out in the treatment phase, and may potentially offer an alternative treatment option for patients experiencing IC. Furthermore, this study has assessed the variability of the primary outcome measure which provides vital information needed to calculate sample sizes for any future studies. In conclusion, this study has established the feasibility of using CVT to improve patients’ symptoms of IC and provides essential information which will contribute to the design of future research investigating whether the improvements seen are directly related to CVT.

Wound assessment and treatment are essential aspects of nursing care. Dressing-associated complications can delay wound healing, causing unnecessary patient distress. Despite evidence suggesting that dressings should be changed infrequently, there still remains a tendency for healthcare professionals to remove dressings regularly, increasing the risk of complications and the cost of wound care.To understand the experiences and current practices of tissue viability nurses (TVNs) involved in wound care and dressing wear time in the acute and community settings.This quality improvement project used a mixed-methods design. A retrospective audit was undertaken to establish nurse rationale for the renewal of foam dressings on patients with acute/chronic wounds. Semistructured qualitative interviews were conducted with registered TVNs (n = 12) working in acute and community care settings and focused on their experiences with all dressing types.The analysis identified several key themes, including Training and Education (including the subthemes of TVN Experience and TVN Training), Knowledge and Information, Lack of Confidence (including the subthemes Reasons for Dressing Change and Ritualistic Practice), and Dressing Choice.Fundamental changes in staff attitudes and beliefs about dressing wear time are essential to optimizing dressing performance and increasing patient quality of care. Flexible community services that are reflective of the needs of the service are central to changing practice and increasing dressing wear time in these settings.

Community nursing caseloads are vast, with differing complexities. The Sheffield Caseload Classification Tool (SCCT) was co-produced with community nurses and nurse managers to help assign patients on a community caseload according to nursing need and complexity of care. The tool comprises 12 packages of care and three complexities. The present study aimed to test the inter-rater reliability of the tool. This was a table top validation exercise conducted in one city in South Yorkshire. A purposive sample of six community nurses assessed 69 case studies using the tool and assigned a package of care and complexity of need to each. These were compared with pre-determined answers. Cronbach's alpha for the care package was 0.979, indicating very good reliability, with individual nurse reliability values also being high. Fleiss's kappa coefficient for the care packages was 0.771, indicating substantial agreement among nurses; it was 0.423 for complexity ratings, indicating moderate agreement. The SCCT can reliably assign patients to the appropriate skilled nurse and care package. It helps prioritise and plan a community nursing caseload, ensuring efficient use of staff time to deliver appropriate care to patients with differing needs.

Purpose: As advances are made in smaller-gauge vitrectomy, it is important to characterize the associated risks. This allows the surgeon to anticipate complications and appropriately counsel patients. The incidence of iatrogenic retinal breaks in 25- and 23-gauge (G) vitrectomy is known, but no studies exist looking at the incidence in 27G vitrectomy with an attached posterior hyaloid face (PHF). This study set out to characterize the incidence. Methods: A retrospective, consecutive, observational study of patients undergoing 27G transconjunctival sutureless vitrectomy for macular pathology or floaters was conducted. This was a single-surgeon series conducted between 2015 and 2017 at Calderdale Royal Hospital, United Kingdom. Inclusion criteria included only those with an attached PHF at the disc, identified intraoperatively. Results: Data were collected and analyzed in 94 patients. Preoperative diagnosis frequency was as follows: epiretinal membrane 24 (25.5%), macular hole 47 (50.0%), vitreomacular traction 11 (11.7%), and floaters 12 (12.8%). In 82 out of 94 patients (89.1%), 27G vitrectomy was combined with 2.2 mm microincisional phacoemulsification with lens implantation. The incidence of iatrogenic retinal breaks associated with PHF separation during 27G PPV was 17% (16 cases). Conclusions: This is the first study to report the incidence of peripheral retinal breaks induced by PHF separation during 27G vitrectomy. Our single-surgeon case series of 27G PPV for all elective vitreoretinal indications, in eyes with attached vitreous, yielded an iatrogenic break rate of 17%. However, no postoperative retinal detachments followed. Statistical analysis revealed no specific risk factors to be significantly associated with outcome (incidence of retinal tear).

In this study, we recruited 50 chronic pain (neuropathic and nociceptive) and 43 pain-free controls to identify specific blood biomarkers of chronic neuropathic pain (CNP). Affymetrix microarray was carried out on a subset of samples selected 10 CNP and 10 pain-free control participants. The most significant genes were cross-validated using the entire dataset by quantitative real-time PCR (qRT-PCR). In comparative analysis of controls and CNP patients, WLS (P = 4.80 × 10–7), CHPT1 (P = 7.74 × 10–7) and CASP5 (P = 2.30 × 10–5) were highly significant, whilst FGFBP2 (P = 0.00162), STAT1 (P = 0.00223), FCRL6 (P = 0.00335), MYC (P = 0.00335), XCL2 (P = 0.0144) and GZMA (P = 0.0168) were significant in all CNP patients. A three-arm comparative analysis was also carried out with control as the reference group and CNP samples differentiated into two groups of high and low S-LANSS score using a cut-off of 12. STAT1, XCL2 and GZMA were not significant but KIR3DL2 (P = 0.00838), SH2D1B (P = 0.00295) and CXCR31 (P = 0.0136) were significant in CNP high S-LANSS group (S-LANSS score > 12), along with WLS (P = 8.40 × 10–5), CHPT1 (P = 7.89 × 10–4), CASP5 (P = 0.00393), FGFBP2 (P = 8.70 × 10–4) and FCRL6 (P = 0.00199), suggesting involvement of immune pathways in CNP mechanisms. None of the genes was significant in CNP samples with low (MYC, STAT1, TLR4, CASP5 and WLS gene expression could be potentially used as a biomarker signature of CNP (AUROC − 0.852, (0.773, 0.931 95% CI)).

Complex foot infections involving bone and soft tissue in patients with co-morbidities such as diabetes and peripheral arterial disease (PAD) are a cause of significant hospital admission. They are associated with substantial economic costs to health services worldwide. Historically, severe foot infection has been treated with surgical debridement and prolonged courses of systemic antibiotics. Prolonged systemic antibiotic use increases the risk of drug side effects, antimicrobial resistance and Clostridium difficile infection. The purpose of this study was to investigate whether surgical debridement and implantation of antibiotic loaded calcium sulfate is effective in the resolution of foot infection and wound healing. A retrospective cohort study of 137 consecutive cases of osteomyelitis (127) or significant soft tissue infection (10) over 62 months from 02/2013 to 04/2018 was conducted following local ethical approval. All cases of infection were treated with surgical debridement and local antibiotic-loaded calcium sulfate. The primary outcomes of infection resolution, time to healing and duration of postoperative antibiotics were measured. In 137 cases, 88.3% of infections resolved. Infection was eradicated in 22 patients without postoperative systemic antibiotics. About 82.5% of wounds healed, with an average healing time of 11.3 weeks. Healing time was significantly increased for the co-morbidities of diabetes and PAD (p =< .05) and for those requiring prolonged systemic postoperative antibiotics. Conservative surgical debridement and implantation of local antibiotic impregnated calcium sulfate is safe and effective in managing complex foot infections. We advocate early surgical intervention before deeper tissue involvement to help preserve lower limb structure and function.

The aims of this study were to investigate the influence of reduced-exertion, high-intensity interval training (REHIT), comparing a novel shortened-sprint protocol (SSREHIT) against a traditional protocol (TREHIT), on perceptual responses and to determine if changes in peak oxygen uptake (V˙O2peak) are attenuated with shorter sprints. Twenty-four healthy men undertook 15 sessions of SSREHIT or TREHIT. V˙O2peak was determined at baseline and after completion of each exercise condition. Affective (pleasure-displeasure) responses and perceived exertion were assessed during exercise to capture peak responses. Enjoyment was recorded 5-min after cessation of exercise. Compared to baseline, V˙O2peak increased in both groups (6% for SSREHIT [d=− 0.36] and 9% for TREHIT [d=− 0.53], p=0.01). Affective responses were more favourable for SSREHIT (p=0.001, d=1.62), but both protocols avoided large negative peaks of displeasure. Peak ratings of perceived exertion were lower for SSREHIT (p=0.001, d=− 1.71), although there were no differences in enjoyment (d=0.25). The results demonstrate both exercise conditions can increase V˙O2peak without overly compromising perceptual responses. Decreased sprint duration might further circumvent negative perceptual responses but might also attenuate physiological adaptations.

Insertion of partial monolayers of oxygen during silicon epitaxy (OI) has been shown experimentally and by simulation to facilitate the blocking interstitials during oxidation and thus to enable precision engineering of dopant profiles. This invited paper describes examples of recent OI advances, including the engineering of improved 5V NMOS power devices and RF-SOI switches.

Background: Percutaneous coronary intervention is a common revascularisation technique. Serious complications are uncommon, but death is one of them. Seeking informed consent in advance of percutaneous coronary intervention is mandatory. Research shows that percutaneous coronary intervention patients have inaccurate perceptions of risks, benefits and alternative treatments. Aim: To assess cardiologists’ and patients’ views about the informed consent process and anticipated treatment benefits. Methods: Two cross-sectional, anonymous surveys were distributed in England: an electronic version to a sample of cardiologists and a paper-based version to patients recruited from 10 centres. Results: A sample of 118 cardiologists and 326 patients completed the surveys. Cardiologists and patients shared similar views on the purpose of informed consent; however, over 40% of patients and over a third of cardiologists agreed with statements that patients do not understand, or remember, the information given to them. Patients placed less value than cardiologists on the consent process and over 60% agreed that patients depended on their doctor to make the decision for them. Patients’ and cardiologists’ views on the benefits of percutaneous coronary intervention were significantly different; notably, 60% of patients mistakenly believed that percutaneous coronary intervention was curative. Conclusions: The percutaneous coronary intervention informed consent process requires improvement to ensure that patients are more involved and accurately understand treatment benefits to make an informed decision. Redesign of the patient pathway is recommended to allow protected time for health professionals to engage in discussions using evidence-based approaches such as ‘teach back’ and decision support which improve patient comprehension.

Background Peripheral arterial disease affects the lower limb and is associated with diabetes, high cholesterol, smoking and obesity. It increases the risk of cardiovascular morbidity and mortality. It can be symptomatic causing intermittent claudication, but often there are few clinical signs. Podiatrists are able to detect the presence of peripheral arterial disease as part of their lower limb assessment and are well placed to give advice on lifestyle changes to help reduce disease progression. This is important to improve health outcomes and is offered as a prevention/public health intervention. Method We describe the clinical and patient-centred outcomes of patients attending a podiatry-led integrated care pathway in a multi-use clinic situated in a venue supported by the National Centre for Sports and Exercise Medicine in the UK. At the baseline appointment, patients were given a full assessment where symptoms of intermittent claudication using the Edinburgh Intermittent Claudication Questionnaire, foot pulses, Doppler sounds, Ankle Brachial Pressure Indices, glycated haemoglobin (HbA1c) and cholesterol levels, and smoking status were recorded. A tailored treatment plan was devised, including referral to an exercise referral service, smoking cessation programmes (if applicable) and each participant was also seen by a dietician for nutritional advice. Participants were followed up at 3 and 6 months to assess any improvement in vascular status and with each completing the EQ-5D quality of life questionnaire and a simple satisfaction questionnaire at the end of the study. As this was a complex intervention a pilot study design was adopted to evaluate if the method and outcomes were suitable and acceptable to participants the results of which will then inform the design of a larger study. Results Data was collected on 21 individuals; 15 men (71.4%) and 6 women (28.6%) across the 6-month study period. Eleven participants were referred onto the exercise referral service; 16 participants saw the dietician for nutritional advice at baseline and had one-to-one or telephone follow-up at 3 months. Five out of 14 participants had reduced scores from baseline of intermittent claudication during the study period. No evidence for substantive changes in Doppler sounds or ABPI measurements was revealed. Quality of life scores with the EQ-5D improved in 15 participants; this was statistically significant (p = 0.007) with 14 participants who completed the simple satisfaction questionnaire expressing a positive view of the programme. Of the four people who were smokers, two stopped smoking cigarettes and moved to e-cigarettes as part of smoking cessation advice. Conclusion As this was a pilot study the sample size was low, but some statistically significant improvements with some measures were observed over the 6-month study. Podiatrists are able to provide a comprehensive vascular assessment of the lower limb and accompanying tailored advice on lifestyle changes including smoking cessation and exercise. Locating clinics in National Centres for Sports and Exercise Medicine enables easy access to exercise facilities to encourage the adoption of increased activity levels, though the long term sustainability of exercise programmes still requires evaluation. This study was reviewed and approved by London Brent Ethics Committee IRAS ID 204611 and received research governance approval from the sponsor, Sheffield Teaching Hospitals NHS Foundation Trust Research and Innovation Office STH19410.

Background This study aims to assess the quantity and quality of available literature on surgical treatment outcomes of spinal stenosis in adult and paediatric achondroplasia patients through a systematic review of literature and to investigate the suitability of conducting a meta-analysis on outcomes of surgical treatment. Methods Online databases were searched according to PRISMA guidelines. No restrictions regarding study design, sample size, previous treatment, or publication date were implemented. The following terms: “Spinal stenosis”, “Spinal Decompression”, “Spinal fusion”, each term separately combined with the term “Achondroplasia” were used. Quality of the included studies were assessed used the Modified Coleman method. Results Five adult and four paediatric single-sample non-comparative studies were identified for inclusion (176 adult and 102 paediatric patients). Meta-analyses assessed the proportion of patients achieving full resolution of symptoms to be 0.51 (95% CI 0.00 to 1.00); the proportion of patients achieving full or partial resolution of symptoms to be 0.90 (95% CI 0.84 to 0.97); the proportion of procedures requiring re-operation to be 0.42 (95% CI 0.34 to 0.50; and the proportion of procedures involving dural tears to be 0.20 (95% CI 0.02 to 0.39). Statistical heterogeneity was very high for full resolution of symptoms and requirement for dural repair; and very low for other outcomes. Conclusions The available literature on this population and condition is sparse, highly heterogenous, and is generally of low quality limiting the value of meta-analysis. Overall, outcomes of surgical decompression of symptomatic spinal stenosis in achondroplasia patients show consistent degree of resolution of symptoms. Duration of symptoms prior to surgical treatment appears to play an important role in the overall outcome of treatment. Therefore, a delay in diagnosis and treatment can potentially be detrimental in achieving a better outcome.

Interstitial trapping by oxygen-inserted silicon channel results in blocking of boron and phosphorus transient enhanced diffusion as well as retention of channel boron profiles during the gate oxidation process. The enhanced doping profile control capability is applicable to punch-through stop of advanced CMOS devices and its benefits to 28nm planar CMOS and 20nm bulk FinFET devices projected by TCAD have been discussed.

Oxygen-Inserted (OI) layers are shown to shield a buried boron profile from oxidation enhanced diffusion. A TCAD model for the OI layer, including point defect and dopant trapping, as implemented in Sentaurus Process is shown to match experimental results, demonstrating the retention of steeper boron profiles after oxidation. Incorporation of the oxygen insertion layers into a CMOS process increases on-current and reduces threshold variability and mismatch.

Purpose: To ascertain whether posterior hyaloid face (PHF) status (attached vs detached) affects the risk of intraoperative retinal breaks and number of operations in patients undergoing vitrectomy for floaters. Methods: Consecutive, comparative single-surgeon case series. All patients undergoing vitrectomy for visually disabling floaters between July 2003 and June 2016 were included in this study. Data were collected prospectively into a vitreoretinal database and reviewed retrospectively for the purpose of the study.The following data were collected on each patient: age in years, sex, axial length (mm), presence of myopia, pre- and postoperative visual acuity in logarithm of the minimal angle of resolution. The status of the PHF was ascertained using preoperative clinical and optical coherence tomography assessment that was confirmed intraoperatively. The presence or absence of a retinal break was considered the primary outcome measure. Significant visual loss (reduction in ≥2 log units visual acuity), number of operations, and time from surgery to discharge were considered the secondary outcomes. Sequential multiple logistic and Cox regression analyses were conducted. Results: Data were collected from 97 patients (55 males and 42 females). Indications for surgery were Fuchs heterochromic cyclitis (9 patients), asteroid hyalosis (12 patients), and vitreous syneresis (76 patients). Twenty-one patients were pseudophakic on presentation, while 76 underwent combined phacovitrectomy. Vitreous status was significantly associated with retinal breaks ( P = .010). Controlling for other parameters, the odds of a retinal break in patients with PHF attached were about 5.5 times those in patients with PHF detached (95% confidence interval [CI], 1.52 -20.4). Number of operations was also significantly associated with this outcome ( P = .027); the odds of a retinal break increase by 6.28 times (95% CI, 1.23 -32.1). A substantive difference in the proportion of patients with retinal breaks was observed between the 2 groups, with a 50% prevalence rate in the attached group and a 9.1% prevalence rate in the detached group. Vitreous status was not associated with either secondary outcome measures. Number of operations was also significantly associated with time to discharge ( P = .008; hazard ratio, 2.78; 95% CI, 1.30 -5.91) in a multiple Cox model. Hence an increasing number of operations is associated with longer time to discharge. Conclusion: The analysis has found evidence to link vitreous status with the primary outcome of the presence of a retinal break. Particular care should be taken in, cases with vitreous attached status, to prevent missed breaks and subsequent rhegmatogenous retinal detachment.

Objective: Surgical site infection (SSI) is a common cause of postoperative morbidity. Perioperative hypothermia may contribute to surgical complications including increased risk of SSI. In this systematic review and meta-analysis, the effectiveness of active and passive perioperative warming interventions to prevent SSI was compared with standard (non-warming) care. Method: Ovid MEDLINE; Ovid EMBASE; EBSCO CINAHL Plus; The Cochrane Wounds Specialised Register, and The Cochrane Central Register of Controlled Trials were searched, with no restrictions on language, publication date or study setting for randomised controlled trials (RCTs) and cluster RCTs. Adult patients undergoing elective or emergency surgery under general anaesthesia, receiving any active or passive warming intervention perioperatively were included. Selection, risk of bias assessment and data extraction were performed by two review authors, independently. Outcomes studied were SSI (primary outcome), inpatient mortality, hospital length of stay and pain (secondary outcomes). Results: We identified four studies, including 769 patients. The risk ratio (RR) for SSI in warming groups was 0.36 [95% confidence interval (CI): 0.23, 0.56; pConclusion: This review provides evidence in favour of active warming to prevent SSI, but insufficient evidence of active warming to reduce length of hospital stay and mortality. Benefits of passive warming remain unclear and warrant further research.

Purpose: To assess the relationship between day 1 postoperative intraocular pressure (IOP) and patient demographic information, indication for vitrectomy, lens status, tamponade medium (air, perfluoroethane, sulfur hexafluoride), and laser treatment. Methods: A prospective observational study of all patients undergoing pars plana vitrectomy (PPV) by a single surgeon within 1 case study. All patients had IOP recorded 1 day after surgery. None of the patients had postoperative antiglaucoma medications. All patients undergoing PPV were previously pseudophakic or underwent combined surgery. Results: Of a final cohort of 161 patients, 6% had raised IOP (defined as >30 mm Hg). A parsimonious regression model showed no strong correlation between raised IOP and type of gas tamponade ( P = .028 for C2F6, P = .067 for SF6, air was the reference category) and a moderate association with the number of laser burns ( P = .067). Conclusion: The use of gas tamponade, in particular C2F6, does not constitute justification for pre/postoperative antiglaucoma prophylactic treatment. In addition, we postulate that careful consideration should be given to the frequency of laser burns during PPV.

Purpose: To investigate the usefulness of Oxane HD for nonposturing surgery on persistent (redo) macular holes by reporting visual and anatomical outcomes as well as complications in a consecutive case series. Methods: Eighteen consecutive patients with a persistent macular hole were recruited from 2008 to 2016. Pre- and postoperative visual acuity and optical coherence tomography data were recorded. Anatomical success was defined as complete circumferential neurosensory reattachment. Postoperative complications were actively looked for and noted. Results: Eighteen (100%) of the 18 persistent holes were closed on the first postoperative day. Visual acuity improved significantly in 15 (83.4%) of the 18 patients from baseline, mean change 0.62 log units (range, 0-1.72). Two (11.1%) of the 18 patients maintained their vision while 1 (5.5%) of the 18 patients lost more than 2 lines. No pre- or postoperative complications were noted. Conclusion: This is the largest prospective study on the use of heavier than water silicone oil to close persistent macular holes without the need for prone posturing. Oxane HD may be successfully used where conventional techniques have already failed and can be associated with functional recovery. Patients’ inability to posture need not preclude redo macular surgery.

Contains fulltext : 175853.pdf (Publisher’s version ) (Open Access) The changing retirement landscape calls on employers to develop practices that respond to individuals’ retirement needs. Line managers are a key stakeholder in managing retirement and this study focuses on how they respond to employee retirement scenarios. This empirical work examines manager openness to involvement in retirement, focusing on three sets of explanatory variables: manager psycho-social characteristics (experience of managing older workers, intention to work past 65), their decision-making environment (influence, discretion and decision-making support) and older employee situational factors (performance, ease of replacement, retirement affect and attitude to work). Data were collected from 129 managers in the United Kingdom's university sector using survey items and a factorial vignette design. The multi-level analysis found support for each category of variables in predicting manager openness to involvement in employee retirement. Managers with more experience of managing older workers were more likely to be open to involvement although managers’ own retirement intentions were not significant as a predictor. Decision-making environment variables were significant predictors of manager openness to involvement. The only older employee situational factor that was associated with manager openness to involvement was employee performance. Practically, organisations need to recognise the potential influence that managers have on employee retirement decisions and this study's findings show that managers may need training to help them understand their own role in supporting older employee retirement. 23 maart 2017

Objective To investigate the clinical effectiveness of silver nitrate (95%) for the treatment of verruca pedis comparing professional and self-application treatments. Methods A single-centre, two-armed randomized evaluation was conducted at a University podiatry clinic. A total of 113 participants (101 analysed) with verruca pedis were included. Participants were randomized to either a clinical group, where silver nitrate was applied by a healthcare professional or a home group, where silver nitrate was self-applied. The main outcome measure was post-treatment pain, controlling for pre-treatment pain, and resolution of the verruca. Secondary outcome measures were participant satisfaction, partial reduction in the verruca and ease of use of the product. Key findings The study showed no significant difference between home treatment and clinically applied treatment for the treatment of verruca pedis in either primary outcome; however, a substantive difference in resolution between groups was recorded, with 34.0% full resolution and 26.4% partial resolution in the clinical treatment group, and 18.8% full resolution and 37.5% partial resolution in the home treatment group. Participants widely reported general ease of use of the product. All participants reported a reduction in pain as a result of the intervention. Conclusion Silver nitrate has been shown to be a safe and effective treatment for verruca pedis, with equal success rates when compared between home and clinical applications.

Background Programmes using motivational interviewing show potential in facilitating lifestyle change, however this has not been well established and explored in individuals at risk of, yet without symptomatic pre-existent cardiovascular disease. The objective of this systematic review and meta-analysis was to determine the effectiveness of motivational interviewing in supporting modifiable risk factor change in individuals at an increased risk of cardiovascular disease., Methods Systematic review and meta-analysis with results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-related databases were searched for randomised controlled trials from 1980 to March 2020. Criteria for inclusion included; preventive programmes, motivational interviewing principles, modification of cardiovascular risk factors in adults of both genders, different ethnicities and employment status, and having at least 1 or more modifiable cardiovascular risk factor/s. Two reviewers independently extracted data and conducted a quality appraisal of eligible studies using an adapted Cochrane framework. The Cochrane framework supports to systematically identify, appraise and synthesize all the empirical evidence that meets the pre-specified eligibility criteria to answer a specific question., Findings A total of 12 studies met the inclusion criteria. While completeness of intervention reporting was found to be adequate, the application of motivational interviewing was found to be insufficiently reported across all studies (mean overall reporting rate; 68%, 26% respectively). No statistical difference between groups in smoking status and physical activity was reported. A random effects analysis from 4 studies was conducted, this determined a synthesized estimate for standardised mean difference in weight of -2.00kg (95% CI -3.31 to -0.69 kg; p = 0.003), with high statistical heterogeneity. Pooled results from 4 studies determined a mean difference in LDL-c of -0.14mmol/l (5.414mg/dl), which was non-significant. The characteristics of interventions more likely to be effective were identified as: use of a blended approach delivered by a nurse expert in motivational interviewing from an outpatient-clinic. The application of affirmation, compassion and evocation, use of open questions, summarising, listening, supporting and raising ambivalence, combining education and barrier change identification with goal setting are also important intervention characteristics., Conclusions While motivational interviewing may support individuals to modify their cardiovascular risk through lifestyle change, the effectiveness of this approach remains uncertain. The strengths and limitations of motivational interviewing need to be further explored through robust studies., peer-reviewed

This article reports on an evaluation of a prescribing workshop to increase ‘sharedlearning’ between registered practitioners undertaking a non-medicalprescribing (NMP) course (midwifery, nursing, physiotherapy, and podiatry) andundergraduate pharmacy students to increase awareness of, and understanding of theroles. The focus was on three domains ofsafe prescribing: Knowledge (of commonly prescribed medicines and theirsuitability for individual patients); Process (of legal requirements and supplyof medicines and associated patient information); and Relationships (betweenprescribers and pharmacists). A cross-sectional evaluation was utilized with6-point Likert-style items and a free text section, completed by 337participants. Participants reported positivelyabout the workshop content and their learning experience, although somedifferences between pharmacy and NMP participants were noted in the knowledgedomain. Quantitative analysis revealed significant differences (p

Background Percutaneous Coronary Intervention (PCI) is the commonest invasive procedure in cardiology. Before treatment consent must be given. As part of this communication process patients receive information about the risks and benefits of PCI and alternative treatments. Published studies tell us that the amount and quality of the information received by patients undergoing PCI is variable; benefits are often overestimated, risks forgotten and alternative treatments not always considered. Very little is known about patients' preferences for PCI risk information. Aim: To describe patients' preferences for formation about PCI treatment risk as part of the informed consent process Methods: A cross-sectional survey was distributed to 350 participants treated with PCI across 10 PCI centres in England. Results Three hundred and twenty six participants completed the survey. Thirty percent of the sample reported needing help to understand written medical information. Fifty-one percent were treated with elective PCI, 75% were male, average age of 66.5 years. Recall and comprehension of PCI information given during the consent process was generally limited; 47% and 61% agreed that patients do not usually understand, or remember, the information given to them respectively. Eighty-eight percent of urgent PCI patients wanted to know about all possible risks compared to 90% of elective cases. Most participants (88% urgent and 94% elective) believed that PCI would reduce their risk of a future heart attack. Conclusion A significant proportion of PCI patients find it difficult to recall or understand information about treatment risks. It is recommended that patients are given health-related information designed to accommodate different health literacy levels in advance of their treatment. Acknowledgement/Funding National Institute for Health Research Research for Patient Benefit Programme Grant Reference Number PB-PG-0712-28089

Dysphagia is a debilitating condition with significant consequences in terms of physical and mental health. This study demonstrates that it is feasible to provide an intensive therapy program combining neuromuscular electrical stimulation (NMES) with exercise against resistance in the treatment of dysphagia in a public healthcare setting. Thirty-one patients (17 stroke, 14 non-stroke) who experienced dysphagia with reduced laryngeal elevation completed the therapy program. After checking the data sets for comparability, it was deemed appropriate for the outcome data from these patients to be combined with that of 12 stroke patients previously reported to enable statistical analysis on a larger data set (n = 43). A repeated-measures ANOVA revealed a statistically significant increase in amount and variety of food a patient was able to take orally (FOIS) following completion of treatment (p &lt, 0.001). There was no significant between-subject effect of stroke status (p = 0.43), or interaction between treatment and stroke status (p = 0.68). There was a significant improvement in secondary outcome measures of swallow safety with fluids (PAS) (p &lt, 0.001) and swallow-related quality of life (Swal-Qol (p &lt, 0.001). These findings indicate that the therapy program may be associated with reduced impairment in a subset of patients with dysphagia resulting from stroke and non-stroke atiologies, and the data will inform the design of future research to address unanswered questions.

In the light of the increasing recognition of the relevance of spirituality in person-centred, holistic care, this study examines the attitudes of a convenience sample of mental health practitioners, including nurses, to the concepts of spirituality in general and in clinical practice. A series of 5-point Likert-style items assessed two key domains of spirituality in everyday life (SEDL) and spirituality in practice (SIP). The questionnaire was derived from one previously used with healthcare educators (including nurses). Each item was scored from 1 point (strongly disagree) to 5 points (strongly agree). Additional information about how far practitioners believed spirituality had been integrated in their education and how much they believed that spirituality related to religion was also ascertained. Three further items, not part of the main questionnaire, dealt with respondents' views of spirituality competent practice, in the light of a description provided as part of the questionnaire. Data were collected from 104 respondents. Standard statistical procedures, including reliability analyses, were applied to the data. Respondents who viewed spirituality to be distinct from religion, or a place of worship, were likely to place a higher value on spirituality in everyday life, while respondents who experienced the integration of spirituality within their preregistration training and/or clinical education were likely to place a higher value on the place of spirituality in practice. The possible reasons for these associations are discussed in the light of the importance of spiritual care as a part of person-centred, holistic practice.

Objective: This study aimed to determine the rate of surgical site infection (SSI) in patients undergoing surgery for spinal metastases, and identify key risk factors for SSI among this patient group. Method: A retrospective case note review was undertaken in adult patients being treated at a single specialist centre for spinal surgery. Results: There were 152 patients identified for inclusion. Overall SSI rate was 11.2 per 100 patients (9.7 per 100 procedures). An increase in the risk of SSI was observed when surgery involved a greater number of vertebral levels (odds ratio 1.26, p=0.019) when controlling for primary spinal region. Controlling for the number of spinal levels, the odds of SSI increased by a factor of 5.6 (p=0.103) when the primary surgical region was thoracic, as opposed to cervical or lumbar. Conclusion: In conclusion, surgery associated with multiple vertebral levels for treatment of spinal metastases, particularly of the thoracic spine, is associated with increased risk of SSI.

Purpose To evaluate the accuracy of user-adjusted axial length (AL) measured by optical biometry for intraocular lens (IOL) calculations in eyes having combined phacovitrectomy for macula-off rhegmatogenous retinal detachment (RRD). Setting Ophthalmology Department, Calderdale Royal Hospital, Halifax, United Kingdom. Design Retrospective case series. Methods Consecutive eyes having phacovitrectomy for macula-off RRD were evaluated. The ALs were measured using optical biometry with user adjustment to identify a posterior peak corresponding to the eye's AL and ultrasound (US). These were compared with each other and with the postoperative optical biometry and analyzed for accuracy as an indication of the eye's AL. Results The study comprised 22 eyes of 22 patients. There was no statistically significant difference between the mean AL measurements derived from user-adjusted optical biometry and US AL ( P = .964). The user-adjusted optical biometry was not statistically significantly different from the postoperative optical biometry ( P = .242). Compared with the postoperative optical biometry, the IOL power was within ±0.5 diopter in 12 (92%) of 13 cases (95% confidence interval [CI], 77.8 to 100.0) for user-adjusted optical biometry and in 10 (77%) of 13 cases (95% CI, 54.0 to 99.8) for US measurements. Conclusions User-adjusted optical biometry could be used as an alternative method for measuring AL in macula-off RRD with combined phacovitrectomy. However, optical biometry would require assessment of agreement with US AL in cases in which a posterior peak is not easily identifiable. User-adjusted optical biometry might outperform US AL when calculating IOL power; however, a larger study should be performed to confirm this. Financial Disclosure None of the authors has a financial or proprietary interest in any material or method mentioned.

The elements of visual culture preserved in late Roman houses confirm an intense interest in dramatic visual display. This study employs an interpretive lens of spectacle to examine a new form of banquet space amd furnishings in the period, as well as a new style of ‘dinner-theatre’ they served. By considering ancient art as inseparable from active contexts and ephemeral events, a more sophisticated understanding of a society's self-definition through art emerges. Rather than being epiphenomenal to the poliltical culture of late antiquity, spectacle is argued to be central to the creation and contestation of power structures: performance is politics.

Aim: To determine if co-morbidities have an effect on mood in a cohort of morbidly obese patients.

In cold climates, special consideration needs to be given to the design and construction of segmental post-tensioned concrete girder bridges. This article presents the special considerations that e...

Background\ud Prophylactic antibiotics are commonly prescribed intra-operatively after caesarean section birth, often at high doses. Even so, wound infections are not uncommon and obesity increases the risk. Currently, no independent wound assessment technology is available to stratify women to low or high risk of surgical site infection (SSI).\ud \ud Study Aim: to investigate the potential of non-invasive infrared thermography (IRT), performed at short times after surgery, to predict later SSI.\ud \ud Methods\ud IRT was undertaken in hospital on day 2 with community follow up (days 7, 15, 30) after surgery. Thermal maps of wound site and abdomen were accompanied by digital photographs, the latter used for wound assessment by six experienced healthcare professionals. Confirmatory diagnosis of SSI was made on the basis of antibiotic prescribing by the woman’s community physician with logistic regression models derived to model dichotomous outcomes.\ud \ud Results\ud Fifty-three women aged 21–44 years with BMI 30.1–43.9 Kg.m− 2 were recruited. SSI rate (within 30 days) was 28%. Inter-rater variability for ‘professional’ opinion of wound appearance showed poor levels of agreement. Two regions of interest were interrogated; wound site and abdomen. Wound site temperature was consistently elevated (1.5 °C) above abdominal temperature with similar values at days 2,7,15 in those who did and did not, develop SSI. Mean abdominal temperature was lower in women who subsequently developed SSI; significantly so at day 7. A unit (1 °C) reduction in abdominal temperature was associated with a 3-fold raised odds of infection. The difference between the sites (wound minus abdomen temperature) was significantly associated with odds of infection; with a 1 °C widening in temperature associated with an odds ratio for SSI of 2.25 (day 2) and 2.5 (day 7). Correct predictions for wound outcome using logistic regression models ranged from 70 to 79%;\ud \ud Conclusions\ud IRT imaging of wound and abdomen in obese women undergoing c-section improves upon visual (subjective) wound assessment. The proportion of cases correctly classified using the wound-abdominal temperature differences holds promise for precision and performance of IRT as an independent SSI prognostic tool and future technology to aid decision making in antibiotic prescribing.

Designers of online learning, the review reveals, should pay considerable attention to learner control, dialogue, learner support and opportunities for direct learner involvement. The chapter explores the implications of these different modes for the design, structure and management of online learning and proposes a framework to help practitioners locate their own practice and construct appropriate programmes and systems based on lessons from the review. It is based on a systematic review of such reports. Web-based online learning is too recent a medium to have been the subject of a systematic and comprehensive research programme to test its overall educational effectiveness. Each of the dialogue, involvement, support, control features had different characteristics in each of the paradigms, with implications for the structuring and design of good practice. The learner-managed element of the north-east sector is structured and controlled by the teacher with freedom for the learner to explore.

AimsTo assess the ‘Okay to Stay’ plan to investigate if this reduces visits to emergency departments, unplanned admissions and elective admission to hospital in elderly patients with long-term health conditions.BackgroundThe incidence of long-term conditions is rising as the elderly population increases, resulting in more people from this group attending emergency departments and being admitted to hospital. Okay to Stay is a simple plan for people with long-term conditions to help them remain in their own home if they suffer an acute exacerbation in their health. It was co-designed with professional and patient representatives with the aim of empowering patients and their carers to more effectively manage their long-term conditions.MethodsData from 50 patients (20 males, 30 females, mean baseline age 77.5 years) were compared 12 months before implementation of the plan and in the subsequent 12 months, with the significance of effects assessed at the 5 per cent significance level using t-tests.FindingsVisits to emergency departments were reduced by 1.86; unplanned emergency admissions were reduced by 1.28 and planned elective admissions were raised by 0.22 admissions per annum. The reduction in visits to the emergency department was significant (p = 0.009) and the reduction in emergency admissions was significant (p = 0.015). The change in elective admissions was not significant (p = 0.855). The Okay to Stay plan is effective in reducing visits to the emergency department and unplanned hospital admissions in people with long-term conditions. This is a positive step to supporting vulnerable and complex patients who are cared for at home, and facilitates the recognition by the individual of the possibility to stay at home with the support of health professionals. There are potential cost benefits to the investment of initiating an Okay to Stay plan through the avoidance of visits to the emergency department and non-elective admissions to hospital.