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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.

Background: Advanced nurse practitioners (ANPs) within memory services can support prompt diagnoses of dementia. Further understanding of the role is necessary as evidence on its effectiveness is limited. Aim: To assess service user and carer satisfaction with the ANP role within Kirklees memory assessment team. Methods: A cross-sectional survey was undertaken to evaluate carer and patient perceptions of the ANP role in a local memory assessment team. The survey was developed using the Royal College of Nursing's four pillars as a structure: clinical/direct care practice, leadership and collaborative practice, improving quality and developing practice, and developing self and others. Results: One hundred and fifteen surveys were sent out, and 85 were completed, a response rate of 73.9%. Patients expressed significant satisfaction with the ANP, in particular in the areas of direct clinical practice (84%) and quality of care received (87%). Conclusion: Patients and families are highly satisfied with the service provided by the ANP. High-quality research is needed on the cost effectiveness and outcomes of ANP interventions.

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.

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.

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.

The forthcoming birth of a new baby and the life changes that occur can present parents with a range of challenges. While recognised in mothers, postnatal depression is not well researched in fathers; especially considering that up to 25% of men report experiencing depression in the ante and postnatal periods. The aim of this study was to test a self-screening tool and referral pathway pamphlet for expectant women and their partners. We used a single blinded randomised controlled study design. The sample, comprised 70 dyads, was randomised to either care as usual or to the self-screening tool and referral pathway pamphlet intervention. The self-screening tool included the Edinburgh Postnatal Depression Scale (EPDS). Other questionnaires used to survey the dyads were the Kessler Psychological Distress (Kessler-10) and the Maternity Social Support Scale (MSSS). The gender differences in the EPDS, Kessler-10 and MSSS scales are represented by differences of 1.0 points on EPDS, 1.0 points on Kessler-10, fathers were reporting less psychological distress than mothers in all cases. No difference was observed in perceived social support. The attrition between time-points was mostly men. Cultural and socio-demographic factors may affect generalisability of the findings. The self-screening tool and referral pathway pamphlet provided to dyads may have some benefit in assisting couples in the perinatal period to detect and seek help for early symptoms of distress.

Aim: this study examined a brief lifestyle self-management intervention, based on self-determination theory, to manage seizure frequency, and its effects on health-related quality of life and resilience in people with epilepsy aged over 18 years. Background: most people with epilepsy can identify factors that may trigger seizures and may try to avoid these; however, education from clinicians on this varies. Design: a cohort study with control design. Method: sixty participants were purposively sampled and allocated to an intervention or a control group. Results: moderate correlations were found, particularly between: resilience and satisfaction with life; medication adherence and psychological quality of life; and psychological quality of life and satisfaction with life. The mean seizure occurrences between the control and intervention groups were 12.71 (SD 24.55) and 6.76 (SD 13.40) respectively after the intervention. While the study was not powered to assess this, the intervention may be most effective regarding medication adherence and physical health quality of life. Conclusion: the relationship between self-efficacy and seizure management appeared to be strengthened by the programme. This study is the first known to measure resilience in relation to lifestyle self-management for seizure control in people with epilepsy. Relevance to practice: nurses are well placed to work with patients' strengths towards self-efficacy and potentially resilient coping.

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.

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.

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.

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.

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.

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.

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.

Background The majority of breast cancer patients will experience some level of emotional distress, with some patients having long-term psychological maladjustment. Personal and social resources play a role in recovery yet the interplay between these factors warrants further examination. This study aimed to investigate the interaction of psychosocial factors impacting women in their breast cancer trajectory, at 2 years or less following diagnosis (stages I-III). Design A longitudinal cohort study approach was used in this study. Methods The sample consisted of n = 49 participants. Data were collected between June 2013 and October 2013 and followed for 12 months across the trajectory of the disease. Results The mean age was 56.6 years (SD 11.6 years). Most participants had stage I or stage II breast cancer. Time (over three time points—4 weeks, 6 months, and 12 months) after diagnosis was significantly associated with the body image (P = .003) and age (P = .004). Conclusion Older women with breast cancer reported less concern regarding body image than their younger peers. These findings suggest that posttreatment younger women may require access to psychological support posttreatment.

Summary Objective: This study aimed to determine how the abilities of the Charlson Index and Elixhauser comorbidities compared with the chronic health components of the Acute Physiology and Chronic Health Evaluation (APACHE II) to predict in-hospital 30 day mortality among adult critically ill patients treated inside and outside of Intensive Care Unit (ICU). Methods: A total of 701 critically ill patients, identified in a prevalence study design on four randomly selected days in five acute care hospitals, were followed up from the date of becoming critically ill for 30 days or until death, whichever occurred first. Multiple data sources including administrative, clinical, pathology, microbiology and laboratory patient records captured the presence of acute and chronic illnesses. The exponential, Gompertz, Weibull, and log-logistic distributions were assessed as candidate parametric distributions available for the modelling of survival data. Of these, the log-logistic distribution provided the best fit and was used to construct a series of parametric survival models. Results: Of the 701 patients identified in the initial prevalence study, 637 (90.9%) had complete data for all fields used to calculate APACHE II score. Controlling for age, sex and Acute Physiology Score (APS), the chronic health components of the APACHE II score, as a group, were better predictors of survival than Elixhauser comorbidities and Charlson Index. Of the APACHE II chronic health components, only the relatively uncommon conditions of liver failure (3.4%) and immunodeficiency (9.6%) were statistically associated with inferior patient survival with acceleration factors of 0.35 (95% CI 0.17, 0.72) for liver failure, and 0.42 (95% CI 0.26, 0.72) for immunodeficiency. Sensitivity analyses on an imputed dataset that also included the 64 individuals with imputed APACHE II score showed identical results. Conclusion: Our study suggests that, in acute critical illness, most co-existing comorbidities are not major determinants of shortterm survival, indicating that observed variations in ICU patient 30-day mortality may not be confounded by lack of adjustment to pre-existing comorbidities.

Limited data is available in the literature on the radiographic results of multilevel posterior lumbar interbody fusion (MPLIF) in the treatment of degenerative scoliosis. The objective of our study was to evaluate the segmental and global correction achieved with MPLIF in the treatment of degenerative scoliosis. Between 2009 and 2014, 42 patients underwent correction of degenerative scoliosis with MPLIF. Several radiological parameters were measured pre- and post-operatively by two independent observers. A statistical analysis was performed to assess the inter-observer reliability of the measurements and to determine the degree of segmental correction achieved at each intervertebral disc. Using sagittal vertical axis (SVA) less than 47 mm; lumbar lordosis (LL) within 11° of pelvic incidence (PI); and pelvic tilt (PT) no more than 22° as radiological criteria for procedural acceptability, we determined predictive factors for a favourable radiological outcome. Forty-two patients (34 female) were included in our study. The average amount of correction per segment was 6.2°. The overall correction achieved with MPLIF was 16.6°. Twenty-six of the 42 patients (61.9 %) had post-operative SVA values less than 47 mm. Nineteen of the 42 patients (45.2 %) had average post-operative LL within 11° of the PI. Sixteen of the 42 patients (38.1 %) had PT less than 22°. Younger age, female gender and a low pre-operative PT were significantly associated with the attainment of a satisfactory sagittal alignment. Our results demonstrate that a satisfactory correction can be achieved in degenerative scoliosis with MPLIF. In addition, our results show that it is significantly more likely to achieve a satisfactory radiological outcome in younger, female patients with low pre-operative PT.

Aims and objectives To explore young adults' knowledge and attitudes of cardiovascular disease and its risk factors. Background Cardiovascular disease morbidity is rising and mortality is declining among young adults. However, the knowledge of cardiovascular disease by young adults is not well known. Design A systematic review with meta‐analysis was used. Methods The databases of CINHAL, MEDLINE Complete, PsycINFO and Psycarticles were searched for all studies published before June 2016. Search terms included cardiovascular disease, young adult, attitude and knowledge. Papers were included if they were published in English and reported quantitative research with a study population between the ages of 18–34 years, with a focus on knowledge and attitudes to cardiovascular disease. Meta‐analyses were conducted to assess the extent of knowledge of risk factors on heart disease. Results Nine risk factors for cardiovascular disease were identified by the respondents; smoking (synthesised estimate of 55% of respondents identifying as a risk factor, 95% confidence interval of synthesised estimate 45%–65%); obesity (27%, 95% CI, 26%–29%); high blood cholesterol (33%, 95% CI, 12%–54%); high blood pressure (25%, 95% CI, 18%–32%); genetic factors (26%, 95% CI, 23%–29%); physical inactivity (39%, 95% CI, 30%–47%); stress (49%, 95% CI, 48%–51%); advancing age (10%, 95% CI, 8%–12%) and diet (55%, 95% CI, 54%–56%). Conclusion Young adults demonstrate limited knowledge and poor attitudes regarding cardiovascular disease and its risk factors. The finding of this review demonstrates that there is an urgent need to build knowledge of cardiovascular risk identification in this population group. Relevance to clinical practice Increasing cardiovascular disease in young adults will put stress in the healthcare system financially and economically. There is a need of awareness of cardiovascular disease in this population group.

Purpose: To evaluate the accuracy of intraocular lens power estimation in eyes having phacovitrectomy for rhegmatogenous retinal detachment.\ud \ud Methods: Retrospective case review of 100 consecutive eyes that underwent phacovitrectomy for rhegmatogenous retinal detachment. Axial lengths were measured using optical biometry and/or ultrasound A-scan. Achieved and predicted refraction were compared to calculate the mean postoperative refractive prediction error and the mean absolute prediction error. Factorial analysis of variance models were developed to assess outcome on the whole and that between the subgroups.\ud \ud Results: Ninety-five eyes had postoperative refraction: 41 macula-on (43%) and 54 macula-off (57%). The mean postoperative prediction error was -0.34 +/- 0.89 diopters. There was no statistical significant difference in the refractive outcomes between macula-on and macula-off groups (P > 0.05). Overall, using mean absolute prediction error as the outcome measure, optical biometry was more accurate than ultrasound (P = 0.040). However, significantly more ultrasound-measured axial lengths were selected for intraocular lens power estimation in macula-off group compared with the macula-on group (P = 0.016).\ud \ud Conclusion: Combined phacovitrectomy in rhegmatogenous retinal detachment included a small biometric error that was within the tolerable range in most cases. Both optical biometry and ultrasound should be used to estimate axial lengths, for macula-off rhegmatogenous retinal detachment cases, to improve the accuracy of intraocular lens power calculation.

Purpose\ud \ud To establish whether early vitrectomy for epiretinal membrane (ERM) is preferable to delayed surgery.\ud \ud Methods\ud \ud We carried out a retrospective study of 120 eyes from 120 patients with pre-operative visual acuity (VA) of 6/60 or better. Pre-operative logMAR score was considered to act as an appropriate proxy measure for time of surgical procedure, with scores of 0.3 or less considered to represent early surgery, scores of 0.4 or 0.5 considered to represent medium surgery, and scores of 0.6 or more considered to represent late surgery for ERM. Patients were either pseudophakic at the time of vitrectomy or underwent combined phaco-vitrectomy for symptomatic ERM.\ud \ud Results\ud \ud Evaluation of parameter coefficients indicated that controlling for other factors, a delay of the surgical procedure from a state of early to medium corresponded to an increase (ie, disbenefit) of 0.074 units in post-operative logMAR score (95% confidence interval −0.001–0.15). A delay of the surgical procedure from a state of early to late corresponded to an increase (ie, disbenefit) of 0.21 units in post-operative logMAR score (95% confidence interval 0.13–0.29). Mean post-operative VA for early surgery was 0.16, out of which 36.2% of patients had a LogMAR score of 0.1 or better. This is in comparison to 17.2% in late ERM (those with a pre-operative logMAR score of 0.6 or more).\ud \ud Conclusion\ud \ud We conclude that early surgery is associated with a lower (ie, better) post-operative logMAR score. Vitrectomy for early symptomatic ERM, in carefully selected patients, is beneficial in preserving excellent vision and allows quicker visual rehabilitation.

Purpose The aim of this project was to develop, deliver, and evaluate a brief evidenced-based education package to enhance physical health literacy in mental health nurses. Design and Methods Pre- and post-test survey of knowledge of physical health in serious mental illness, satisfaction with the workshop, and applicability to practice. Findings Participants were motivated to attend and complete the questions. There was statistically significant knowledge gain immediately post workshop and participants described satisfaction with the content and a willingness to apply learning from the session to their practice. Practice Implications If such workshops are provided as a collaborative and relatively inexpensive way of education, they can contribute to building the capacity of mental health nurses to be literate in physical health interventions.

Aim To present the anatomical and visual outcomes of patients with hypo-reflective cystic defects in outer fovea (outer foveal defect; OFD) in macular holes repaired with non-posturing vitrectomy and short term gas tamponade. To identify the incidence and risk factors for developing OFD foveal defect. Method A prospective consecutive case series of 58 patients undergoing macular hole surgery was undertaken. OFD detected on 2-week postoperative Optical coherence tomography (OCT) was measured. In these patients OCT was performed monthly until resolution of OCT. Results 27 eyes (46.6%) had an outer defect at 2 weeks, the presence of which was significantly associated with macular holes with larger base diameters preoperatively (p=0.006). All defects closed spontaneously without further intervention, and the final vision was not affected by the presence of an OFD. Visual recovery was only slightly (and not significantly) delayed by the presence of an outer defect. Conclusions This is the first study of outcomes of OFDs following macular hole surgery in patients who did not posture postoperatively. OFDs are common but do not adversely affect visual outcomes.

Purpose\ud \ud To describe the incidence and features of intraoperative retinal breaks caused by induction of posterior hyaloid face (PHF) separation during 23-gauge pars plana vitrectomy (PPV).\ud \ud Methods\ud \ud A prospective, consecutive, single surgeon, observational study of patients undergoing 23-gauge transconjunctival sutureless vitrectomy for macular pathology or floaters, was carried out between 2009 and 2011 at Calderdale Royal Hospital, UK. PHF separations were categorised as either suction induced or requiring membrane blue (DORC Limited) with suction (adherent). The outcome measure was dichotomised into retinal break or tear and no retinal break or tear. Forced entry and parsimonious multiple logistic regression analyses were conducted, using statistical software, to test for significance of association of the set of recorded factors and covariates with the dichotomised outcome measure.\ud \ud Results\ud \ud Data were collected and analysed from 137 patients. The incidence of iatrogenic retinal breaks associated with PHF separation during 23-gauge PPV was 18.2%. Under both forced entry and parsimonious multiple logistic regression models, the odds of a retinal break or tear reduce by about 3–4% for each increasing year of age. Findings also showed some substantive association in the forced entry model, with the odds of a retinal break or tear for adherent cases being around 3.8 times those for suction-only cases.\ud \ud Conclusions\ud \ud Mechanical detachment of the PHF represents an important risk factor in the formation of retinal breaks. Particular care should be taken to examine intraoperatively for iatrogenic breaks in order to prevent missed breaks and subsequent rhegmatogenous retinal detachments.

Summary Background Patients with metastatic spinal tumours have a limited prognosis. Surgical complications that may result in prolonged hospitalization or readmission are highly undesirable. Surgical site infection (SSI) is one such complication, which can, in extreme cases, lead to death. Aim To assess the impact of SSI on patient survival after surgery for spinal metastases. Methods Demographic, operative, and survival data were collected on 152 patients undergoing surgery for spinal metastasis at a large UK tertiary referral centre. American Society of Anesthesiologists (ASA) grade and the Revised Tokuhashi Score (RTS) were determined as measures of health status and prognosis, respectively, at baseline. A semi-parametric Cox proportional hazards survival analysis was used to assess the relationships between covariates and survival. Findings Seventeen patients (11.2%) experienced SSI. Overall, median survival time from operation was 262 days (95% confidence interval: 190–334 days) and 12-month survival was 42.1%. RTS (hazard ratio: 0.82; 95% confidence interval: 0.76–0.89; P P =0.028) were significantly associated with survival, with better survival found in patients with higher RTS and lower ASA scores. Infection status was of substantive importance, with better survival in those without SSI ( P =0.075). Conclusion Twelve-month survival in patients undergoing surgery for spinal metastasis is ∼42%. RTS and ASA scores may be used as indicators of patient survival either in combination or individually. Whereas SSI has some negative impact on survival, a larger study sample would be needed to confirm whether this is statistically significant.

Background Context\ud \ud Corrective surgery for adolescent idiopathic scoliosis (AIS) leads to vertical growth arrest of the instrumented spine. This might be offset by the immediate gain in spinal height (SH) as a result of correction of the curvature.\ud \ud Purpose\ud \ud This study aimed to identify predictors of gain in SH following corrective surgery for AIS. We present a unique model to predict postoperative height prior to intervention, which could contribute to the preoperative counseling and consenting process.\ud \ud Study Design\ud \ud This was a retrospective case series. All surgeries were performed by one of four substantive pediatric spinal surgeons within a single regional center over a 3.5-year period.\ud \ud Patient Sample\ud \ud There were 104 patients who had instrumented posterior spinal fusion for AIS included. There were 93 females, and the age range was from 11 to 17 years. All patients had posterior instrumented fusion using rods and anchors (pedicle screws±hooks).\ud \ud Outcome Measures\ud \ud Postoperative SH was the primary outcome measure. The SH (C7–L5) and Cobb angles were measured from a pre- and postoperative standing X-ray of each patient.\ud \ud Methods\ud \ud Variables associated with patients (demographic and radiological) and the surgical constructs were analyzed for predictability of height gain. A model was derived including only significant predictors of substantive importance using hierarchical regression methods. Cross-validation procedures verified the adequacy of the model fit. Analysis was performed using IBM SPSS Statistics for Windows version 20.0 (IBM Corp. Armonk, NY, USA).\ud \ud Results\ud \ud The major curve was thoracic in 90% of cases. The number of vertebrae fused ranged from 5 to 15. The average preoperative Cobb angle was 66°, with an average correction of 45°. The average change in SH was 4.66 cm (SD 2.13 cm). The model presented included preoperative height, preoperative Cobb angle, and number of vertebrae within the construct, with coefficients of 1.00 (95% CI: 0.90, 1.09), 0.067 (95% CI: 0.039, 0.095), and 0.26 (95% CI: 0.11, 0.41), respectively. This model had an adjusted-R2 value of 0.83 and a R2 for prediction of 0.79, and can be shown to have similar predictive capability as a model comprising a wider range of predictors.\ud \ud Conclusion\ud \ud The greatest postoperative height values following posterior spinal fusion for AIS could be expected from a patient with greater preoperative height and Cobb angle, and whose construct spans a large number of vertebrae.

Caring for a person with a mental illness can have adverse effects on caregivers; however, little is known about how best to help such caregivers. The aim of the present study was to examine the efficacy of a cognitive behaviour therapy-guided self-help manual in increasing resilience in caregivers of individuals with depression, in comparison to caregivers who receive routine support only. A randomized, controlled trial was conducted, following CONSORT guidelines, with 54 caregivers allocated to parallel intervention (self-help manual) (n = 27) or control (standard support) (n = 27) groups. Resilience was assessed at baseline, post-test (week 8), and follow up (week 12). Intention-to-treat analyses were undertaken. Repeated-measures ANOVA indicated a significant difference in resilience scores between the three time points, showing a large effect. Pairwise comparisons between intervention and control groups indicated resilience to be significantly different between baseline and post-test, and between baseline and follow up, but not between post-test and follow up. Overall, the intervention group showed a slightly greater increase in resilience over time than the control group; however, the time-group interaction was not significant. Guided self-help is helpful in improving caregivers' resilience and could be used as an adjunct to the limited support provided to carers by mental health nurses and other clinicians.

Background\ud Percutaneous coronary intervention (PCI) is a very common revascularisation procedure for coronary artery disease (CAD). The purpose of this study was to evaluate cardiac outcomes, health related quality of life (HRQoL), resilience and adherence behaviours in patients who have undergone a PCI at two time points (6 and 12 months) following their procedure.\ud \ud Methods\ud A longitudinal pilot study was conducted to observe the cardiac outcomes across a cohort of patients who had undergone a percutaneous coronary intervention (PCI). Participants who had undergone PCI 6 months prior were invited. Those participants who met the inclusion criteria and provided consent then completed a telephone survey (time point 1). These participants were then contacted 6 months later (i.e. 12 months post-intervention, time point 2) and the measures were repeated.\ud \ud Results\ud All patients (n = 51) were recorded as being alive at time point 1. The multiple model indicated that controlling for other factors, gender was significantly associated with a linear combination of outcome measures (p = 0.004). The effect was moderate in magnitude (partial-η2 = 0.303), where males performed significantly better than females 6 months after the PCI procedure physically and with mood. Follow-up univariate ANOVAs indicated that gender differences were grounded in the scale measuring depression (PHQ9) (p = 0.005) and the physical component score of the short form measuring HRQoL (SF12-PCS) (p = 0.003). Thirteen patients were lost to follow-up between time points 1 and 2. One patient was confirmed to have passed away. The pattern of correlations between outcome measures at time point 2 revealed statistically significant negative correlation between the PHQ instrument and the resilience scale (CD-RISC) (r = -0.611; p

It has been claimed that King James VI/I, an antecedent of King George III, suffered from acute porphyria, and that the disease was passed on to George III through his grand-daughter Sophie, mother of George I. The life of James is reviewed and previously-proposed diagnoses are considered. James’s medical history is discussed in detail and, where possible, examined with validated symptom scales. Using an online database of neurological diseases, the authors show that James’s symptomatology is compatible with a diagnosis of Attenuated (mild) Lesch-Nyhan disease; no evidence was found to support a diagnosis of acute porphyria. In addition, there is evidence of associated Asperger traits which may explain some of the King’s unusual behavioural and psycho-social features.

Background \ud Patients undergoing surgery for basal and early squamous cell carcinomas are rarely offered psychological support as their malignancies have a low mortality. Nonetheless, 80 % of non-melanoma skin cancers occur in the head and neck, rendering both the malignancy and subsequent surgical scar clearly visible. This study was designed to quantify the social and emotional impact of facial skin malignancies pre- and postoperatively and to identify vulnerable groups who may benefit from increased support irrespective of tumour severity.\ud \ud Methods \ud Fifty-three patients with facial skin malignancies were prospectively evaluated before and 3 months after surgery using the Skin Cancer Index (SCI); a 15-item, validated, disease-specific quality-of-life (QOL) assessment tool with emotion, social and appearance subscales. Higher scores reflect improvements in QOL.\ud \ud Results \ud Surgical excision of the malignancy led to a significant increase in SCI (p

Background/Aims To compare several methods of macular hole measurement using optical coherence tomography (OCT), and to assess their predictive capability against anatomical and visual outcomes in a single cohort of patients. Methods A retrospective study of 50 eyes undergoing standardised macular hole surgery. All patients underwent preoperative OCT scanning with measurement of macular hole inner opening diameter, minimum linear diameter, base diameter and macular hole height. Values were calculated for the macular hole index and the tractional hole index. Results Logistic regression analyses indicated that the preoperative base diameter, macular hole inner opening and minimum linear diameter were associated with both anatomical and visual success. Derived parameters as alternatives to these basic ophthalmic parameters add little to the modelling of either anatomical or visual success. Conclusion Base diameter, macular hole inner opening and minimum linear diameter can each be used to predict anatomical and/or functional success in macular hole surgery. Preoperative base diameter is the most useful variable in this regard, as it holds the strongest association with anatomical and visual outcome and is easily measured on a OCT scan.

Background: Intravenous cannulation enables administration of fluids or drugs by paramedics in prehospital settings. Inappropriate use and poor technique carry risks for patients, including pain and infection. We aimed to investigate the effect of an educational intervention designed to reduce the rate of inappropriate cannulation and to improve cannulation technique. Method: We used a non-randomised control group design, comparing two counties in the East Midlands (UK)as intervention and control areas. The educational intervention was based on Joint Royal Colleges Ambulance Liaison Committee guidance and delivered to paramedic team leaders who cascaded it to their teams. We analysed rates of inappropriate cannulation before and after the intervention using routine clinical data. We also assessed overall cannulation rates before and after the intervention. A sample of paramedics was assessed post-intervention on cannulation technique with a ‘‘model’’ arm using a predesigned checklist. Results: There was a non-significant reduction in inappropriate (no intravenous fluids or drugs given) cannulation rates in the intervention area (1.0% to 0%) compared with the control area (2.5% to 2.6%). There was a significant (p,0.001) reduction in cannulation rates in the intervention area (9.1% to 6.5%; OR 0.7, 95% CI 0.48 to 1.03) compared with an increase in the control area (13.8% to 19.1%; OR 1.47, 95% CI 1.15 to 1.90), a significant difference (p,0.001). Paramedics in the intervention area were significantly more likely to use correct hand-washing techniques post-intervention (74.5% vs. 14.9%; p,0.001). Conclusion: The educational intervention was effective in bringing about changes leading to enhanced quality and safety in some aspects of prehospital cannulation.

As impaired insulin signalling (IIS) is a risk factor for Alzheimer's disease we crossed mice (Tg2576) over-expressing human amyloid precursor protein (APP), with insulin receptor substrate 2 null (Irs2(-/-)) mice which develop insulin resistance. The resulting Tg2576/Irs2(-/-) animals had increased tau phosphorylation but a paradoxical amelioration of Abeta pathology. An increase of the Abeta binding protein transthyretin suggests that increased clearance of Abeta underlies the reduction in plaques. Increased tau phosphorylation correlated with reduced tau-phosphatase PP2A, despite an inhibition of the tau-kinase glycogen synthase kinase-3. Our findings demonstrate that disruption of IIS in Tg2576 mice has divergent effects on pathological processes-a reduction in aggregated Abeta but an increase in tau phosphorylation. However, as these effects are accompanied by improvement in behavioural deficits, our findings suggest a novel protective effect of disrupting IRS2 signalling in AD which may be a useful therapeutic strategy for this condition., Journal Article, Research Support, Non-U.S. Gov't, info:eu-repo/semantics/published

Alzheimer's disease (AD) is characterized by the presence of neurofibrillary tangles of hyperphosphorylated, aggregated tau protein and extracellular deposits of beta-amyloid peptide. Increased beta-amyloid levels are thought to precede tangle formation, but tau pathology is more closely related to neuronal death. Minocycline, a tetracycline derivative, has potent antiinflammatory, antiapoptotic, and neuroprotective effects in several models of neurodegenerative disease, including models of AD with amyloid pathology. We have used both in vitro and in vivo models of AD to determine whether minocycline may have therapeutic efficacy against tau pathology. In primary cortical neurons, minocycline prevents beta-amyloid-induced neuronal death, reduces caspase-3 activation, and lowers generation of caspase-3-cleaved tau fragments. Treatment of tangle-forming transgenic mice (htau line) with minocycline results in reduced levels of tau phosphorylation and insoluble tau aggregates. The in vivo effects of minocycline are also associated with reduced caspase-3 activation and lowered tau cleavage by caspase-3. In tau mice, we find that conformational changes in tau are susceptible to minocycline treatment, but are not directly associated with the amount of tau fragments produced, highlighting a dissociation between the development of these pathological tau species. These results suggest a possible novel therapeutic role for minocycline in the treatment of AD and related tauopathies.

Glycogen synthase kinase-3 (GSK-3) is a serine ⁄threonine kinase regulating diverse cellular functions including metabolism, transcription and cell survival. Numerous intracellular signalling pathways converge on GSK-3 and regulate its activity via inhibitory serine-phosphorylation. Recently, GSK-3 has been involved in learning and memory and in neurodegeneration. Here, we present evidence that implicates GSK-3 in synaptic plasticity. We show that phosphorylation at the inhibitory Ser9 site on GSK-3b is increased upon induction of long-term potentiation (LTP) in both hippocampal subregions CA1 and the dentate gyrus (DG) in vivo. The increase in inhibitory GSK-3b phosphorylation is robust and persists for at least one hour postinduction. Furthermore, we find that LTP is impaired in transgenic mice conditionally overexpressing GSK-3b. The LTP deficits can be attenuated ⁄rescued by chronic treatment with lithium, a GSK-3 inhibitor. These results suggest that the inhibition of GSK-3 facilitates the induction of LTP and this might explain some of the negative effects of GSK-3 on learning and memory. It follows that this role of GSK-3b in LTP might underlie some of the cognitive dysfunction in diseases where GSK-3 dysfunction has been implicated, including Alzheimer’s and other dementias.

Objective: The AeroChamber Plus (AC) valved holding chamber has been enhanced to include the Flow-Vu (FV) inspiratory flow indicator that provides visual inhalation feedback during use. We have investigated if FV alters asthma control and whether parents accept it. Methods: At visit 1, children with asthma, age 1–5 years, used an AC with their pressurised metered dose inhaler and 2 weeks later (visit 2) they were randomised to use either AC or FV. Subjects returned 6 (visit 3) and 12 (visit 4) weeks later. The Asthma Control (ACQ) and Paediatric Asthma Caregiver’s Quality of Life (PACQLQ) questionnaires were scored at each visit, and their peak inhalation flow (PIF) when they used their spacer was measured. Results: Forty participants in each group completed the study. There was no difference in the ACQ scores from visits 2 to 4 between the two groups. The improvements in the PACQLQ scores were greater in the FV group (p = 0.029). The mean difference (95% confidence interval) for the change from visits 2 to 4 between FV and AC groups was 0.05 (−0.33, 0.43) and 0.39 (0.035, 0.737) for the ACQ and PACQLQ, respectively. Most parents preferred the FV (p

The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have recently published, in both the Journal of the American College of Cardiology (JACC) and Circulation, a Scientific Statement on the Evaluation of Syncope ('Statement'). This Scientific Statement was commissioned to provide guidance for clinicians regarding the evaluation of patients who present with 'syncope'. The Statement was not intended to be a formal set of practice guidelines. However, in the absence of generally accepted practice guidelines in North America, the Statement's potential impact on clinical care may be more far-reaching than expected; it may erroneously be considered to be the authoritative 'de-facto' guideline document. This commentary, submitted by a multidisciplinary consortium of more than 60 physicians with expertise in the management of transient loss of consciousness (TLOC), points out that in many respects the ACCF/AHA Syncope Statement fails to address long-standing clinical errors associated with the evaluation of episodes of apparent TLOC, including syncope. If not appropriately revised, the current Statement may lead to both inadequate patient care as well as a potentially damaging legal environment for physicians undertaking evaluation of patients who present with transient loss of consciousness.

Following transection of peripheral nerve, rats exhibit autotomy, which is considered to be the animal model of postdenervation pain syndrome. It has been suggested that phantom limb pain is a result of peripheral denervation leading to reorganization of somatosensory pathways, particularly in the cerebral cortex, which is shown to depend upon central noradrenergic activity. In this study, sciatic and saphenous nerves were sectioned in the left hindpaw of 30 adult rats resulting in complete loss of pain sensation in the hindpaw. A group of rats received normal saline, compared to another group which received N-(2-) Chloroethyl-N-ethyl-2-bromobenzylamine (DSP4) injection 24 h prior to transection. The latter group was also compared to a third group whose central noradrenergic system were also blocked by bilateral injection of 6-OHDA into the ascending noradrenergic bundle 1 week prior to transection. A fourth group received contralateral cortical ablation in addition to peripheral nerve transection and was compared to the first group whose cortex remained intact. The animals were observed daily for 60 days and autotomy was scored in accordance to the system of Wall et al. [42]. After 1 week, control animals began to exhibit autotomy. In contrast, autotomy was absent in rats treated with DSP4, similar to rats which received 6-OHDA. Rats which had contralateral cortical ablation showed a considerably delayed onset of autotomy and a reduction in final autotomy scores. We conclude that autotomy, as a model of postdenervation pain syndrome, can be prevented by blockade of noradrenergically mediated cortical reorganization. The clinical implications of this finding are discussed.

Background: Patients often experience problems using metered dose inhalers (MDIs), particularly poor coordination between inhalation start and dose actuation (TsIn: time difference between the start of an inhalation and the actuation of a dose), and fast peak inspiratory flow (PIF). We investigated if a coordination cap (CAP), with instruction to prolong inhalation, solved these problems. Methods: Inhalation profiles [PIF, TsIn, inhalation volume (Vi), inhalation time (Ti)] of patients with stable asthma prescribed an MDI were measured using their real-life technique (MDI). Inhalation profiles were then measured with the cap fitted (MDI+CAP). These patients were then instructed to inhale through the MDI+CAP for 5 sec, and inhalation profiles measured (MDI+CAP+TRAIN). TsIn was only measured for the MDI. Results: Resistances of MDI and MDI+CAP were 0.0135 and 0.0243 (cm H2O)½/(L/min), respectively. Seventy-one patients were evaluated, with mean [standard deviation (SD)] forced expiratory volume over 1 sec % predicted normal of 78.3% (21.0). Following MDI, MDI+CAP, and MDI+CAP+TRAIN: mean (SD) PIF was 155.6 (61.5), 112.3 (48.4), and 73.8 (34.9) L/min, respectively (p

Background\ud Breast reconstruction is safe and improves quality of life. Despite this, many women do not undergo breast reconstruction and the reasons for this are poorly understood. This study aims to identify the factors that influence a woman's decision whether or not to have breast reconstruction and to better understand their attitudes toward reconstruction.\ud \ud Methodology\ud An online survey was distributed to breast cancer patients from Breast Cancer Network Australia. Results were tabulated, described qualitatively and analyzed for significance using a multiple logistic regression model.\ud \ud Results\ud 501 mastectomy patients completed surveys, of which 62% had undergone breast reconstruction. Factors that positively influenced likelihood of reconstruction included lower age, bilateral mastectomy, access to private hospitals, decreased home/work responsibilities, increased level of home support and early discussion of reconstructive options. Most common reasons for avoiding reconstruction included “I don't feel the need” and “I don't want more surgery”. The most commonly sited sources of reconstruction information came from the breast surgeon followed by the plastic surgeon then the breast cancer nurse and the most influential of these was the plastic surgeon.\ud \ud Conclusions\ud A model using factors easily obtained on clinical history can be used to understand likelihood of reconstruction. This knowledge may help identify barriers to reconstruction, ultimately improving the clinicians' ability to appropriately educate mastectomy patients and ensure effective decision making around breast reconstruction.

Purpose\ud The purpose of this study was to validate the Oswestry Spinal Risk Index (OSRI) in an external population. The OSRI predicts survival in patients with metastatic spinal cord compression (MSCC).\ud \ud Methods\ud We analysed the data of 100 patients undergoing surgical intervention for MSCC at a tertiary spinal unit and recorded the primary tumour pathology and Karnofsky performance status to calculate the OSRI. Logistic regression models and survival plots were applied to the data in accordance with the original paper.\ud \ud Results\ud Lower OSRI scores predicted longer survival. The OSRI score predicted survival accurately in 74% of cases (p = 0.004).\ud \ud Conclusions\ud Our study has found that the OSRI is a significant predictor of survival at levels similar to those of the original authors and is a useful and simple tool in aiding complex decision making in patients presenting with MSCC

Background: The characteristics of each inhalation maneuver when patients use dry powder inhalers (DPIs) are important, because they control the quality of the emitted dose.\ud \ud Methods: We have measured the inhalation profiles of asthmatic children [CHILD; n=16, mean forced expiratory volume in 1 sec (FEV1) 79% predicted], asthmatic adults (ADULT; n=53, mean predicted FEV1 72%), and chronic obstructive pulmonary disease (COPD; n=29, mean predicted FEV1 42%) patients when they inhaled through an Aerolizer, Diskus, Turbuhaler, and Easyhaler using their “real-life” DPI inhalation technique. These are low-, medium-, medium/high-, and high-resistance DPIs, respectively. The inhalation flow against time was recorded to provide the peak inhalation flow (PIF; in L/min), the maximum pressure change (ΔP; in kPa), acceleration rates (ACCEL; in kPa/sec), time to maximum inhalation, the length of each inhalation (in sec), and the inhalation volume (IV; in liters) of each inhalation maneuver.\ud \ud Results: PIF, ΔP, and ACCEL values were consistent with the order of the inhaler's resistance. For each device, the inhalation characteristics were in the order ADULT>COPD>CHILD for PIF, ΔP, and ACCEL (p4 L and ΔP >4 kPa.\ud \ud Conclusion: The large variability of these inhalation characteristics and their range highlights that if inhalation profiles were used with compendial in vitro dose emission measurements, then the results would provide useful information about the dose patients inhale during routine use. The inhalation characteristics highlight that adults with asthma have greater inspiratory capacity than patients with COPD, whereas children with asthma have the lowest. The significance of the inhaled volume to empty doses from each device requires investigation.

Aim\ud The aim of this project was to develop and deliver an evidence-based educational package with a physical and mental health focus to clinicians and other health care workers in mental health settings.\ud \ud Background\ud For individuals who experience mental disorders, pharmacotherapy is often considered as a first line of treatment. However, owing to adverse drug reactions and pre-existing physical conditions, outcomes for clients/service users may be compromised. Mortality and morbidity rates of people diagnosed with a serious mental illness caused by physical health conditions do not compare favourably with the general population. This paper reports on a physical skills project that was developed in collaboration between the University of Huddersfield and South West Yorkshire Partnership Foundation Trust.\ud \ud Method\ud Pre–post study design: five workshops were conducted in the fields of intramuscular injections, diabetes, health improvement, oral health and wound care. A total of 180 pairs of questionnaires to assess practitioner and student skills and knowledge were administered to participants before and after workshops. All workshops resulted in a statistically significant improvement in subject skills and knowledge scores (P < 0.001 in all cases). Questionnaires also elicited participant satisfaction with the workshops: over 99% of participants reported being ‘satisfied’ or ‘very satisfied’ with the workshops.\ud \ud Implications for nursing management\ud Mental health nurses are the largest group of registered practitioners working in the mental health setting and thus need to be harnessed to make a positive contribution to the improvement of the physical health status of service users with a serious mental illness.

Dysfunction in the dopaminergic and serotonergic neurotransmitter systems has been demonstrated to be important in the etiology of borderline personality disorder (BPD). We investigated the relationship of two BPD risk factors, the HTR1A promoter polymorphism -1019C > G (rs6295) and the dopamine transporter (DAT1) repeat allele, with BPD in a major depressive disorder cohort of 367 patients. Out-patients with major depressive disorder were recruited for two treatment trials and assessed for personality disorders, including BPD. DNA samples were collected and the rs6295 polymorphism was detected with a TaqMan® assay. The DAT1 repeat allele was genotyped using a modified PCR method. The impact of polymorphisms on BPD was statistically analyzed using uncontrolled logistic and multiple logistic regression models. BPD patients had higher frequencies of the DAT1 9,9 (OR = 2.67) and 9,10 (OR = 3.67) genotypes and also those homozygous HTR1A G allele (OR = 2.03). No significant interactions between HTR1A and DAT1 genotypes, were observed; however, an increased risk of BPD was observed for those patients who were either 9,10; G,G (OR = 6.64) and 9,9; C,G (OR = 5.42). Furthermore, the odds of BPD in patients exhibiting high-risk variants of these two genes differed from those of patients in low-risk groups by up to a factor of 9. Our study provides evidence implicating the importance of the serotonergic and dopaminergic systems in BPD and that the interaction between genes from different neurotransmitters may play a role in the susceptibility to BPD.

Episodic ataxia type 1 (EA1) is an autosomal dominant central nervous system potassium channelopathy characterized by brief attacks of cerebellar ataxia and continuous interictal myokymia. Point mutations in the voltage-gated potassium channel gene KCNA1 on chromosome 12p associate with EA1. We have studied 4 families and identified three new and one previously reported heterozygous point mutations in this gene. Affected members in Family A (KCNA1 G724C) exhibit partial epilepsy and myokymia but no ataxic episodes, supporting the suggestion that there is an association between mutations of KCNA1 and epilepsy. Affected members in Family B (KCNA1 C731A) exhibit myokymia alone, suggesting a new phenotype of isolated myokymia. Family C harbors the first truncation to be reported in KCNA1 (C1249T) and exhibits remarkably drug-resistant EA1. Affected members in Family D (KCNA1 G1210A) exhibit attacks typical of EA1. This mutation has recently been reported in an apparently unrelated family, although no functional studies were attempted. Heterologous expression of the proteins encoded by the mutant KCNA1 genes suggest that the four point mutations impair delayed-rectifier type potassium currents by different mechanisms. Increased neuronal excitability is likely to be the common pathophysiological basis for the disease in these families. The degree and nature of the potassium channel dysfunction may be relevant to the new phenotypic observations reported in this study.

This paper presents the pre- and post-test results of the outcomes of a workshop designed to increase learning disability and mental health nurses' knowledge and skill to undertake interventions for service users at risk of, or with a diagnosis of, type 2 diabetes. Health literacy is also discussed as a way of explaining why such nurses may lack expertise in physical health care. Findings from the workshop show that learning disability and mental health nurses have the motivation to increase their health literacy (skills and knowledge) in diabetes care. The potential of such workshops, and how organisations looking forward to the future can build health literacy, is discussed.

Background context\ud Previous studies have shown that modern intraoperative blood-saving techniques dramatically reduce the allogeneic transfusion requirements in surgery for adolescent idiopathic scoliosis (AIS). No studies have looked at the pattern of postoperative hemoglobin (Hb) in AIS patients undergoing corrective spinal surgery and correlated this with the timing of allogeneic transfusion.\ud Purpose\ud To describe the pattern of perioperative blood loss in instrumented surgery for AIS. We look at the recommendations regarding an ideal preoperative Hb, the need for preoperative cross-matching, and the timing of postoperative Hb analysis.\ud \ud Study design\ud This was a retrospective case series. Surgeries were performed by one of four substantive pediatric spinal surgeons within a single regional center over a 3-year period.\ud \ud Patient sample\ud A consecutive series of 86 patients who underwent posterior instrumented fusion for AIS were included: 10 males and 76 females. Mean age was 14 years (range 10–17 years). All patients had posterior instrumented fusion using various blood-saving techniques (eg, cell-saver). All patients were cross-matched preoperatively, and our transfusion trigger value (TTV) was 7 g/dL.\ud \ud Outcome measures\ud Hemoglobin level was the outcome measure. Hemoglobin readings were obtained preoperatively, within 2 hours of surgery, and daily up to 5 days after surgery. This physiologic measure was assessed using routine blood sampling techniques and standardized laboratory processing.\ud \ud Methods\ud Patient predictor variables (demographic and surgical) were assessed for association with Hb levels in a hierarchical model, with repeated Hb readings at the lower level being clustered within an individual patient at the upper level of the structure. The variation of Hb levels within individuals was compared with mean levels in different individuals via the variance partition coefficient of the model structure.\ud \ud Results\ud No patients required intraoperative allogeneic transfusion. Only four patients (4.65%) received allogeneic transfusion, all within 2 days of surgery. A clinically important drop in Hb occurred within the first 2 postoperative days, rising thereafter. The average postoperative drop in Hb was 4.1 g/dL. Young males had lower postoperative Hb values. Neither the preoperative curve magnitude (Cobb angle of major curve) nor the number of vertebrae/levels fused significantly affected the blood loss.\ud \ud Conclusions\ud We recommend setting a minimum preoperative Hb value that is 5 g/dL higher than your TTV. Because no patients required an intraoperative transfusion when using modern blood-saving techniques, preoperative cross-matching is unnecessary and potentially wasteful of blood reserves. Hemoglobin analysis beyond the second postoperative day is unnecessary unless clinically indicated