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1533 Background: At the outset of the COVID-19 pandemic, concerns for the safety of patients receiving anti-cancer treatment coupled with pressures on healthcare services prompted review of standard clinical care pathways in the UK. Revised consensus treatment guidelines were generated. Individual patient-level data regarding actual treatment modifications implemented in clinical practice are lacking. Methods: All anti-cancer treatment plans of patients with breast, lung, renal, hepatopancreatobiliary, CNS cancers and melanoma attending a single academic cancer centre in the UK between 16 March and 31 May 2020 were reviewed and any modifications to standard practice were documented. The effect of patient (age, ECOG performance status [PS], sex) and cancer (site, stage, treatment intent) characteristics on likelihood of treatment modifications were analysed using univariable and multivariable models. Results: Treatment plans for 925 patients were reviewed: median patient age was 63 (range 19-97); 66% were female; 73% were PS 0-1; 45% were on a curative pathway. Overall, 47% of all patients had one or more modifications made to their treatment plans: 53% of surgeries (primarily being delayed); 41% of radiotherapy (primarily reduced fractions delivered); 39% of systemic therapy prescriptions. 96-100% of all systemic therapy modifications resulted in treatment de-escalation, excluding endocrine therapy used as a bridge to defer primary breast cancer surgery. Biological therapy was predominantly interrupted (49%), immunotherapy was mostly omitted entirely (36%), and chemotherapy varied between interruptions (39%) or omissions (31%). Relative to the likelihood of modification to chemotherapy, surgery was significantly more likely to be modified (OR 1.69 95%CI 1.20-2.38). Chemotherapy, radiotherapy, biological therapy and immunotherapy were all modified to a similar degree. Multivariate analysis identified PS ≥2 (OR 1.79, 95% CI 1.18–2.75), but not patient age, as a predictor of treatment modification. Some tumour types were less likely to undergo any modification: stage 1-3 lung (OR 0.13, 95%CI 0.04-0.37), stage 4 lung (OR 0.26 95%CI 0.24–0.60) and stage 4 renal cancer (OR 0.22 95%CI 0.09-0.52). Conclusions: This single centre analysis demonstrated almost half of cancer patients had their treatment modified, the overwhelming majority resulting in treatment de-escalation. The impact of the treatment modifications on overall cancer patient outcomes remains to be determined.

Background Most people with diabetes are not attaining desirable levels of HbA1c (glycated haemoglobin), or of blood pressure and cholesterol, leaving them at risk of developing complications. Aim To identify ways of improving diabetes control by gaining insight into patients’ attitudes/beliefs. Design and setting Questionnaires were offered to patients attending for a diabetes review in the 24 GP practices of North East Hampshire and Farnham Clinical Commissioning Group. Method Infrequent attenders were contacted by post. Volunteers then participated in focus groups. Results Self-reported medication adherence was good with 83% (98/118) of responders recording ≥9 on a 10-point scale. Patients generally accepted they ‘needed’ and ‘could take’ medication. A substantial minority reported ‘not liking’ taking tablets. Focus groups confirmed this and revealed a reluctance to change lifestyle, with medication reported as a way to evade it. A total of 68 out of 112 responders (60.7%) knew their HbA1c value. However, focus groups identified little understanding of HbA1c, with responders perceiving it as medical jargon. Phrases such as ‘stuck-on-sugar’ or ‘sugarload’ were suggested as being semantically easier to understand. The questionnaire revealed trust in clinicians. This was confirmed in focus groups but confounded by frequent reports of healthcare providers giving inadequate/incorrect advice. Conclusion Investment in lifestyle change is needed. Participants were reluctant to change and saw medication as a way of avoiding it. HbA1c needs to be better explained. Intuitive phrases such as ‘stuck-on-sugar’ or ‘sugarload’ could be adopted into common parlance. Inadequate/ incorrect advice seems to be hampering diabetes management and there appears to be a need for more diabetes-trained clinicians.

Research with consumers has revealed limited awareness of the sustainability impact of clothing (Goworek et al., 2012). Semi-structured interviews conducted with a range of experts in sustainable clothing to increase understanding of the challenges for sustainable clothing revealed that a focus on sustainability alone will not drive the necessary changes in consumers’ clothing purchase, care and disposal behaviour for three reasons: (i) clothing sustainability is too complex; (ii) consumers are too diverse in their ethical concerns; and (iii) clothing is not an altruistic purchase. The findings identify the challenges that need to be addressed and the associated barriers for sustainable clothing. Interventions targeting consumers, suppliers, buyers and retailers are proposed that encourage more sustainable clothing production, purchase, care and disposal behaviour. These interventions range from normalising the design of sustainable clothing and increasing the ease of purchase, to shifting clothes washing norms and increasing upcycling, recycling and repair.

Background Between 50% and 80% of people with multiple sclerosis (PwMS) experience neurogenic bowel dysfunction (NBD) (i.e. constipation and faecal incontinence) that affects quality of life and can lead to hospitalisation. Objectives To determine the clinical effectiveness and cost-effectiveness of abdominal massage plus advice on bowel symptoms on PwMS compared with advice only. A process evaluation investigated the factors that affected the clinical effectiveness and possible implementation of the different treatments. Design A randomised controlled trial with process evaluation and health economic components. Outcome analysis was undertaken blind. Setting The trial took place in 12 UK hospitals. Participants PwMS who had ‘bothersome’ NBD. Intervention Following individualised training, abdominal massage was undertaken daily for 6 weeks (intervention group). Advice on good bowel management as per the Multiple Sclerosis Society advice booklet was provided to both groups. All participants received weekly telephone calls from the research nurse. Main outcome measures The primary outcome was the difference between the intervention and control groups in change in the NBD score from baseline to week 24. Secondary outcomes were measured via a bowel diary, adherence diary, the Constipation Scoring System, patient resource questionnaire and the EuroQol-5 Dimensions, five-level version (EQ-5D-5L). Results A total of 191 participants were finalised, 189 of whom were randomised (two participants were finalised in error) (control group, n = 99; intervention group, n = 90) and an intention-to-treat analysis was performed. The mean age was 52 years (standard deviation 10.83 years), 81% (n = 154) were female and 11% (n = 21) were wheelchair dependent. Fifteen participants from the intervention group and five from the control group were lost to follow-up. The change in NBD score by week 24 demonstrated no significant difference between groups [mean difference total score –1.64, 95% confidence interval (CI) –3.32 to 0.04; p = 0.0558]; there was a significant difference between groups in the change in the frequency of stool evacuation per week (mean difference 0.62, 95% CI 0.03 to 1.21; p = 0.039) and in the number of times per week that participants felt that they emptied their bowels completely (mean difference 1.08, 95% CI 0.41 to 1.76; p = 0.002), in favour of the intervention group. Of participant interviewees, 75% reported benefits, for example less difficulty passing stool, more complete evacuations, less bloated, improved appetite, and 85% continued with the massage. A cost–utility analysis conducted from a NHS and patient cost perspective found in the imputed sample with bootstrapping a mean incremental outcome effect of the intervention relative to usual care of –0.002 quality-adjusted life-years (QALYs) (95% CI –0.029 to 0.027 QALYs). In the same imputed sample with bootstrapping, the mean incremental cost effect of the intervention relative to usual care was £56.50 (95% CI –£372.62 to £415.68). No adverse events were reported. Limitations include unequal randomisation, dropout and the possibility of ineffective massage technique. Conclusion The increment in the primary outcome favoured the intervention group, but it was small and not statistically significant. The economic analysis identified that the intervention was dominated by the control group. Given the small improvement in the primary outcome, but not in terms of QALYs, a low-cost version of the intervention might be considered worthwhile by some patients. Future work Research is required to establish possible mechanisms of action and modes of massage delivery. Trial registration Current Controlled Trials ISRCTN85007023 and NCT03166007. Funding This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 58. See the NIHR Journals Library website for further project information.

The 2016 World Health Organization (WHO) classification of primary central nervous system (CNS) tumors includes numerous uncommon (representing ≤1% of tumors) low-grade (grades I-II) brain neoplasms with varying clinical behaviors and outcomes. Generally, gross tumor or maximal safe resection is the primary treatment. Adjuvant treatments, though their exact role is unknown, may be considered individually based on pathological subtypes and a proper assessment of risks and benefits. Targetable mutations such as BRAF (proto-oncogene B-Raf), TRAIL (tumor necrosis factor apoptosis inducing ligand), and PDGFR (platelet derived growth factor receptor) have promising roles in future management.

Background Many healthcare services are under considerable pressure to reduce costs while improving quality. This is particularly true in the United Kingdom’s National Health Service where postnatal care is sometimes viewed as having a low priority. There is much debate about the service’s redesign and the reallocation of resources, both along care pathways and between groups of mothers and babies with different needs. The aim of this study was to develop a decision support tool that would encourage a systemic approach to service redesign and that could assess the various quality and financial implications of service change options making the consequent trade-offs explicit. The paper describes the development process and an initial implementation as a preliminary exploration of the possible merits of this approach. Methods Other studies have suggested that combining multicriteria decision analysis with programme budgeting and marginal analysis might offer a suitable basis for resource allocation decisions in healthcare systems. The Postnatal care Resource Allocation Model incorporated this approach in a decision support tool to analyse the consequences of varying design parameters, notably staff contacts and time, on the various quality domains and costs. The initial phase of the study focussed on mapping postnatal care, involving interviews and workshops with a variety of stakeholders. This was supplemented with a literature review and the resultant knowledge base was encoded in the decision support tool. The model was then tested with various stakeholders before being used in an NHS Trust in England. Results The model provides practical support, helping staff explore options and articulate their proposals for the redesign of postnatal care. The integration of cost and quality domains facilitates trade-offs, allowing staff to explore the benefits of reallocating resources between hospital and community-based care, and different patient-categories. Conclusions The main benefits of the model include its structure for assembling the key data, sharing evidence amongst multi-professional teams and encouraging constructive, systemic debate. Although the model was developed in the context of the routine maternity services for mothers and babies in the days following birth it could be adapted for use in other health care services. Electronic supplementary material The online version of this article (10.1186/s12913-018-3430-1) contains supplementary material, which is available to authorized users.

Grade IV glioma is the most common and aggressive primary brain tumour. Gross total resection with 5-aminolevulinic acid (5-ALA) guided surgery combined with local chemotherapy (carmustine wafers) is an attractive treatment strategy in these patients. No previous studies have examined the benefit carmustine wafers in a treatment programme of 5-ALA guided resection followed by a temozolomide-based chemoradiotherapy protocol. The objective of this study was to examine the benefit of carmustine wafers on survival in patients undergoing 5-ALA guided resection. A retrospective cohort study of 260 patients who underwent 5-ALA resection of confirmed WHO 2007 Grade IV glioma between July 2009 and December 2014. Survival curves were calculated using the Kaplan-Meier method from surgery. The log-rank test was used to compare survival curves between groups. Cox regression was performed to identify variables predicting survival. A propensity score matched analysis was used to compare survival between patients who did and did not receive carmustine wafers while controlling for baseline characteristics. Propensity matched analysis showed no significant survival benefit of insertion of carmustine wafers over 5-ALA resection alone (HR 0.97 [0.68-1.26], p = 0.836). There was a trend to higher incidence of wound infection in those who received carmustine wafers (15.4 vs. 7.1%, p = 0.064). The Cox regression analysis showed that intraoperative residual fluorescent tumour and residual enhancing tumour on post-operative MRI were significantly predictive of reduced survival. Carmustine wafers have no added benefit following 5-ALA guided resection. Residual fluorescence and residual enhancing disease following resection have a negative impact on survival.

This study examines the relationship between alcohol marketing and consumer socialization to alcohol brands (assessed here using aided and unaided brand recognition and brand saliency), and the associated relationship between consumer socialization and hazardous alcohol consumption among a cohort of adolescents surveyed in Scotland. The research addresses gaps in the consumer socialization literature, by examining how marketing influences brand consumer socialization, and how brand consumer socialization influences subsequent hazardous consumption behavior over time, using a robust longitudinal design that assesses causal relationships while controlling for a wide range of important confounding variables. The results demonstrate the contribution of marketing to adolescents’ brand socialization to alcohol and the impact of this socialization on subsequent drinking behaviors. Implications for marketing managers, parents, policymakers, and consumer researchers are discussed, together with suggestions for future consumer research.

Background Context shapes the effectiveness of knowledge implementation and influences health improvement. Successful healthcare quality improvement (QI) initiatives frequently fail to transfer to different settings, with local contextual factors often cited as the cause. Understanding and overcoming contextual barriers is therefore crucial to implementing effective improvement; yet context is still poorly understood. There is a paucity of information on the mechanisms underlying how and why QI projects succeed or fail in given settings. A realist review of empirical studies of healthcare QI initiatives will be undertaken to examine the influence and impact of contextual factors on quality improvement in healthcare settings and explore whether QI initiatives can work in all contexts. Methods The review will explore which contextual factors are important, and how, why, when and for whom they are important, within varied settings. The dynamic nature of context and change over time will be explored by examining which aspects of context impact at key points in the improvement trajectory. The review will also consider the influence of context on improvement outcomes (provider- and patient-level), spread and sustainability. The review process will follow five iterative steps: (1) clarify scope, (2) search for evidence, (3) appraise primary studies and extract data, (4) synthesise evidence and draw conclusions and (5) disseminate findings. The reviewers will consult with experts and stakeholders in the early stages to focus the review and develop a programme theory consisting of explanatory ‘context–mechanism–outcome’ configurations. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. A review advisory group will oversee the review process. Review findings will follow RAMESES guidelines and will be disseminated via a report, presentations and peer-reviewed publications. Discussion The review will update and consolidate evidence on the contextual conditions for effective improvement and distil new knowledge to inform the design and development of context-sensitive QI initiatives. This review ties in with the study of improvement programmes as vehicles of change and the development of an evidence base around healthcare improvement by addressing whether QI initiatives can work in all contexts. Systematic review registration PROSPERO CRD42017062135

BACKGROUND: Brain tumours account for

This study was funded by the Chief Scientist Office, Scotland CZH/4/807. Background Continued smoking after cancer adversely affects quality of life and survival, but one fifth of cancer survivors still smoke. Despite its demands, cancer presents an opportunity for positive behaviour change. Smoking often occurs in social groups, therefore interventions which target families and individuals may be more successful. This qualitative study explored patients, family members and health professionals’ views and experiences of smoking and smoking cessation after cancer, in order to inform future interventions. Methods In-depth qualitative interviews (n=67) with 29 patients, 14 family members and 24 health professionals. Data were analysed using the ‘Framework’ method. Results Few patients and family members had used National Health Service (NHS) smoking cessation services and more than half still smoked. Most recalled little ‘smoking-related’ discussion with clinicians but were receptive to talking openly. Clinicians revealed several barriers to discussion. Participants’ continued smoking was explained by the stress of diagnosis; desire to maintain personal control; and lack of connection between smoking, cancer and health. Conclusions A range of barriers to smoking cessation exist for patients and family members. These are insufficiently assessed and considered by clinicians. Interventions must be more effectively integrated into routine practice. Publisher PDF

Background Multiple sclerosis (MS) is a life-long condition primarily affecting younger adults. Neurogenic bowel dysfunction (NBD) occurs in 50–80% of these patients and is the term used to describe constipation and faecal incontinence, which often co-exist. Data from a pilot study suggested feasibility of using abdominal massage for the relief of constipation, but the effectiveness remains uncertain. Methods/design This is a multi-centred patient randomised superiority trial comparing an experimental strategy of once daily abdominal massage for 6 weeks against a control strategy of no massage in people with MS who have stated that their constipation is bothersome. The primary outcome is the Neurogenic Bowel Dysfunction Score at 24 weeks. Both groups will receive optimised advice plus the MS Society booklet on bowel management in MS, and will continue to receive usual care. Participants and their clinicians will not be blinded to the allocated intervention. Outcome measures are primarily self-reported and submitted anonymously. Central trial staff who will manage and analyse the trial data will be unaware of participant allocations. Analysis will follow intention-to-treat principles. Discussion This pragmatic randomised controlled trial will demonstrate if abdominal massage is an effective, cost-effective and viable addition to the treatment of NBD in people with MS. Trial registration ClinicalTrials.gov, ISRCTN85007023. Registered on 10 June 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1890-y) contains supplementary material, which is available to authorized users.

This article broadens rhetoric’s scope by reclaiming a space for it in drama. It reviews rhetoric’s bodily beginnings in theatre to read contemporary plays, specifically Tony Kushner’s Angels in America, as rhetorical critique. As critique, Angels enacts the relationship among language, bodies, and power via Kushner’s dramatizing of the metaphoric constructions of AIDS and ideology. The play also performs the disruption and resignification of discourses that marginalize peripheral bodies on the sociopolitical stage. Consequently, Angels adopts a sophistic approach to rhetorical critique that demonstrates language’s mutability.

Intensity-modulated radiotherapy (IMRT) and image-guided radiotherapy offer significant opportunities to improve outcomes for our patients, although they are not yet as widely used as they might be. IMRT allows better target coverage and lower organ at risk doses than conformal therapy. It also allows inhomogeneous dose plans to be developed, where these can provide benefit, either to dose escalate the tumour or reduce dose to adjacent or overlapping organs at risk. Image guidance adds precision and the possibility of careful reduction in planning target volume margins. The technologies can be valuable both for patients with highly malignant tumours, such as glioblastoma, and those with less malignant or benign tumours. In glioblastoma, temozolomide chemotherapy and surgical developments have improved survival, and developments in radiotherapy techniques should also be used to optimise outcome. Target volume delineation, including calculation of the planning target volume margin is critical. Clear definitions of the gross tumour and clinical target volumes are essential, following established guidelines. Normal tissue volume delineation is also essential for IMRT. The planning organ at risk volume has become a valuable tool to manipulate dose away from organs at risk to avoid toxicities. This is distinct from 'optimising volumes' used to drive the computer optimiser during planning. Hard data on central nervous system (CNS) normal tissue tolerance is surprisingly slight, reflecting the clinical imperative to avoid serious complications in neurological tissues. The effect of chemotherapy on radiotherapy tolerance in the CNS remains obscure, and more needs to be done to develop the knowledge base. IMRT provides better conformation of the high dose treatment to the shape of the target, and reduces the dose to normal tissue structures. Image guidance improves the accuracy of dose delivery, which is particularly important where steep dose gradients are present. These technologies should be regarded as the state-of-the-art for our CNS patients.

Background Improving the quality of healthcare remains central to UK and international policy, practice and research. In 2003, The Institute of Medicine's ‘ Health Professions Education: A Bridge to Quality ', advocated quality improvement as a core competency for all healthcare professionals. As a result, developing capacity and capability of those applying improvement methodologies in the pre-registration population has risen, yet, little is known about the teaching approaches employed for this purpose. Objectives To describe and analyse educational approaches used to teach quality improvement to pre-registration healthcare professionals and identify enabling and impeding factors. Design Integrative review. Data sources CINAHL, PsychINFO, MEDLINE, ERIC, ASSIA, SCOPUS and Google Scholar were accessed for papers published between 2000 and 2016. Review methods Publications where quality improvement education was delivered to pre-registration healthcare professionals were eligible. One author independently screened papers, extracted data using a modified version of the Reporting of Primary Studies in Education Guideline and evaluated methodological quality using the Weight of Evidence Framework. The Kirkpatrick Education Evaluation Model was used to explore the impact of teaching approaches. Enabling and impeding factors were thematically analysed. A narrative synthesis of findings is presented. Results Ten papers were included, representing nursing, pharmacy and medicine from UK, Norway and USA. Studies comprised four quantitative, four mixed method, one qualitative and one cluster randomised trial, all allocated medium Weight of Evidence. Teaching approaches included experiential learning cited in all studies, didactics in seven, group work in four, seminars in three, self-directed learning in three and simulation in one. Most studies measured Level 1 of the Kirkpatrick Model (reaction), all but one measured Level 2 (skills, knowledge or attitudes), none measured Level 3 (behaviour) and one measured Level 4 (patient outcomes). Enabling and impeding themes included: Teaching Approaches, Clinical/Faculty support, Information Provision, Curriculum Balance and Data. Conclusions Evaluating quality improvement education is complex. Experiential learning combined with didactics is the favoured approach; however, attributing causality to educational intervention proves difficult in light of poor methodological rigour, lack of validated tools and complex clinical settings. Clarity regarding which quality improvement competencies are priority for this population would be useful to streamline future educational development and evaluation. Stronger collaboration between educators and clinicians is recommended to explore the multiple components and contextual factors associated with quality improvement education in practice. Ethnographic enquiry may be a logical next step to advance knowledge within the field.

It is astonishing that only a year after The BMJ published Medical Research Council (MRC) guidance on implementing process evaluations within complex interventions that …

Analysis of a diabetes clinical information system in Tayside, Scotland, shows that a significant proportion of insulin-treated patients with diabetes are not self-monitoring blood glucose according to current clinical guidance and recommendations, with some not self-monitoring their blood glucose at all. Although there has been an increase in the number of reagent strips dispensed over the past decade, this increase is mainly accounted for by increased testing frequency among people with diabetes already testing.

The prevalence of complex health and social needs in primary care patients is growing. Furthermore, recent research suggests that the impact of psychosocial distress on the significantly poorer health outcomes in this population may have been underestimated. The potential of social work in primary care settings has been extensively discussed in both health and social work literature and there is evidence that social work interventions in other settings are particularly effective in addressing psychosocial needs. However, the evidence base for specific improved health outcomes related to primary care social work is minimal. This review aimed to identify and synthesise the available evidence on the health benefits of social work interventions in primary care settings. Nine electronic databases were searched from 1990 to 2015 and seven primary research studies were retrieved. Due to the heterogeneity of studies, a narrative synthesis was conducted. Although there is no definitive evidence for effectiveness, results suggest a promising role for primary care social work interventions in improving health outcomes. These include subjective health measures and self-management of long-term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance. Although few rigorous study designs were found, the contextual detail and clinical settings of studies provide evidence of the practice applicability of social work intervention. Emerging policy on the integration of health and social care may provide an opportunity to develop this model of care.

T h r o u g h m o s T o f T h e m i d d l e A g e s , childbirth was an event attended and controlled largely by women. Men, while they might wait anxiously outside the birthing chamber and sometimes conveyed their wishes to the women inside, were rarely present at births and had little direct impact on the birth process. Nevertheless, male contemporaries could not and did not ignore entirely something as vital to society as childbirth. An examination of French and English law codes written before 1325 shows that secular authorities throughout the Middle Ages wrote laws concerning pregnancy and childbirth and that these laws became more prevalent and more intrusive in the late twelfth and thirteenth centuries. Although these forms of intervention were limited in scope and would have had little real effect on most women, it can be argued that they represent part of the “thin end of the opening wedge” of male control of pregnancy and childbirth and helped pave the way for the greater loss of female hegemony in later centuries. still, the development of such laws should not be seen merely as

PurposeThe complexity of customer relationships has been recognized in the relationship marketing literature. Yet, the understanding of how this complexity impacts on the formation and development of different relationship forms is limited. Focusing on the development of customer‐service provider relationships in a financial services context, this paper aims to critically examine the nature and formation of business‐to‐consumer service relationships.Design/methodology/approachQualitative methods were employed, with in‐depth interviews undertaken with a sample of UK bank customers.FindingsThe complexity of customer relationships was documented by approaching relationships as multidimensional, dynamic and contextual. A relationship typology based on four key relationship components (trust, commitment, buyer‐seller bonds, and relationship benefits) is proposed. This typology suggests that for a relationship to exist it does not necessarily have to encompass an emotional dimension. Moreover, the paper demonstrates the importance of the fit between customers' relational expectations and their experiences with service providers in developing long‐term committed relationships.Research limitations/implicationsThe study was limited to the UK context. The extension of this study to other sectors or financial institutions operating in different regulatory and technological environments needs to be tested.Practical implicationsIt is crucial that relationships are viewed as multidimensional, taking into account various relationship components. Since different relationship components influence relationships differently, organisations need to develop different relationship marketing strategies for each consumer segment according to consumers' relational expectations.Originality/valueBuilding on preceding research, this paper broadens understanding of the complexity of customer‐firm relationships by presenting insight into the affective element of relationships and highlighting the role of the fit between customers' relational expectations and their experiences in relationship development.

BACKGROUND: In the United Kingdom, general practitioner (GP) involvement in maternity care has declined significantly over the past decade. This is particularly so in remote and rural areas where midwives have stepped up and taken over units to ensure that women in these areas continue to have a service. A recent report by the King’s Fund argues for a greater role for the GP in maternity care provision; however, this raises questions about whether GPs have the skills and training to provide such care.AIM: To explore the views of GPs on the skills and training required to deliver safe and appropriate local intrapartum services in remote and rural settings.METHODS: Mixed-method study consisting of qualitative interviews with a purposive sample of GPs in six remote and rural sites. To triangulate the interview findings and identify features that might have been missed in the interviews, a questionnaire was developed using initial key themes identified.FINDINGS: Maternity care accounted for less than 10% of most remote and rural GPs’ workload, yet interviewees reported that their role required them to be competent in a wide range of procedures. This was seen as a major barrier to recruitment and retention in rural areas. Although self-reported competence and confidence was high, several GPs felt de-skilled and felt that they were fighting a losing battle to maintain skills. GPs regarded isolation, need for comprehensive expertise, limited resources, and transportation difficulties as factors affecting the decline in their contribution to remote and rural maternity care.CONCLUSION: Although rural GPs and midwives might traditionally have been in competition, providing a woman-centered service in remote areas may be easier to achieve through collaborative working. However, if GPs are to play a greater role, then they will need to be prepared to make a strategic commitment to the maintenance of remote and rural maternity care. This will require innovative methods of training, special consideration of educational needs, and incentives for practitioners to settle in rural areas, but it may already be too late for GPs to have a substantial input into maternity care.

GBM is the most frequent primary CNS tumor. RT + TMZ represents first-line therapy. ErbB pathway dysregulation contributes to GBM pathogenesis; EGFR activation is associated with RT resistance. This 3 + 3 dose-escalation study assessed afatinib, an irreversible ErbB family blocker, with RT ± TMZ in newly diagnosed GBM. Patients with MGMT promoter methylation received afatinib (20, 30, 40 mg/day) + RT + TMZ for 6 weeks (RT period), then afatinib 40 mg/day + TMZ for 6 months, then afatinib 40 mg/day until progression/undue adverse events (AEs; Regimen M). Those with unmethylated MGMT promoter received RT + afatinib then afatinib (Regimen U). Primary endpoint was maximum tolerated dose (MTD) of afatinib + RT ± TMZ; secondary endpoints were safety, pharmacokinetics and antitumor activity. Thirty-six patients were enrolled (M, 20; U, 16). In regimen M, 1/6 (20 mg), 0/6 (30 mg) and 2/5 (40 mg) evaluable patients had dose-limiting toxicities (DLTs) in the RT period (two Grade 4 thrombocytopenia, one Grade 3 vomiting); MTD of afatinib + RT + TMZ was 30 mg/day. In regimen U, 0/3 (20 mg) and 1/6 (40 mg) evaluable patients had DLTs (Grade 3 diarrhea); MTD of afatinib + RT was 40 mg/day. Common treatment-related AEs were diarrhea, rash, fatigue, nausea and thrombocytopenia; 80% and 75% had Grade 3 AEs in M and U. Pharmacokinetic evaluation suggested that afatinib with RT ± TMZ had no influence on afatinib exposure. Five patients in M and one in U had an objective response. Five patients (M, 4; U, 1) were long-term responders to afatinib (>12 months treatment); two had available tumor samples. Both had MGMT promoter methylation; one had a PTPN11 mutation, the other focal EGFR amplification with concomitant EGFRvIII allele amplification. Afatinib + RT ± TMZ appears tolerable; preliminary biomarker analysis may indicate patients likely to have long-term responses.

BACKGROUND: Patients (pts) with recurrent HGGs are usually managed with alkylating chemotherapy +/- bevacizumab. However, prognosis remains poor with an overall survival (OS) of 7–9 months. Preclinically, we showed that HGGs are a target for arginine depletion with Pegargiminase (ADI-PEG20) due to epimutations of argininosuccinate synthetase (ASS1) and argininosuccinate lyase (ASL). Moreover, ADI-PEG20 disrupts pyrimidine pools in ASS1-ve HGGs, thereby impacting sensitivity to the antifolate, pemetrexed. METHODS: We expanded a phase 1 trial of ADI-PEG20 with pemetrexed and cisplatin (ADIPEMCIS), which noted activity in aggressive thoracic cancers, to pts with relapsed HGGs (clinicaltrials.gov NCT02029690). Pts with ASS1-ve recurrent HGGs were enrolled (01/16 – 06/17) to receive ADI-PEG20 weekly at the maximum tolerated dose of 36 mg/m(2) i.m. plus PEM 500 mg/m(2) and CIS 75 mg/m(2) i.v. every 3 weeks for up to 6 cycles. Pts with disease control were allowed ADI-PEG20 maintenance. The primary endpoints were safety, tolerability and preliminary estimates of activity. Additional endpoints included pharmacodynamics, immunogenicity, OS, and ASS1/ASL epimutations. RESULTS: 10/19 ASS1-ve heavily pre-treated pts were enrolled onto ADIPEMCIS therapy. Treatment was well tolerated with the majority of adverse events (AEs) being CTCAE v4.03 grade 1–2; 7 pts (70%) had at least one grade 3 or 4 AE with neutropenia (40%) and thrombocytopenia (30%). The best response was stable disease by RECIST 1.1 and partial response (n=1; 10%) by RANO criteria. The median (95% CI) OS was 6.5 (1.8, 9.7) months. Two pts are alive and one continues 16 months on ADI-PEG20 as 3rd-line therapy for a de novo IDH-wildtype glioblastoma multiforme. Epimutations in ASS1 and/or ASL were detectable in pts’ tumours consistent with prior studies. CONCLUSIONS: ADIPEMCIS was well tolerated and compares favourably to historical controls in recurrent HGG. A randomised, phase II trial comparing ADIPEMCIS with alkylating drugs at first relapse is planned (ATOMIC-G).

ObjectiveTo explore how and why self-monitoring of blood glucose (SMBG) is carried out in a real-world context.Research design and methodsWe conducted a multicase study among ten people with type 1 and insulin-treated type 2 diabetes mellitus in Scotland, alongside seven nominated support people and four healthcare professionals. All participants were interviewed in depth and six participants provided SMBG diaries. Stones’ version of structuration theory informed the analysis.ResultsPeople with diabetes were able to provide immediate motives for SMBG at particular times, often having different motives on different occasions. We identified six such motives, including routine, in response to symptoms, associated with a diabetes review, to facilitate lifestyle, when a ‘good’ result was expected, and higher level motives for longer term glycemic control. These motives were influenced by underlying attitudes toward diabetes that included level of engagement and responsibility for diabetes, a desire not to be controlled by diabetes, resistance to diabetes, diabetes education and relationship with the health service, fear of hypoglycemia, and prevention of diabetes complications. Five responses to test results were identified, depending on the immediate motive and underlying attitudes.ConclusionsPeople with insulin-treated diabetes do not necessarily self-monitor with an explicit goal of improving long-term glycemic control, but may have other motives that are important to them. An individualized understanding is therefore needed to advise people with diabetes how SMBG can be optimized for them.

As alcohol marketing remains a highly debated and politically charged issue, we examine the cumulative impact of alcohol marketing on alcohol initiation and drinking behaviour among youth (12–14 years). Cross-sectional data come from a cohort of 920 second year school pupils from Scotland. Regression models, with multiple control variables, were employed to examine the relationship between awareness of, and involvement with, a range of alcohol marketing communications, and drinking behaviour and intentions. Marketing variables were constructed for 15 different types of alcohol marketing, including marketing in new media. Drinking behaviour measures included drinking status and future drinking intentions. Significant associations were found between awareness of, and involvement with, alcohol marketing and drinking behaviour and intentions to drink alcohol in the next year. Given these associations, our study suggests the need for a revision of alcohol policy: one limiting youth exposure to these seemingly ...

Aims Radiotherapy is an important treatment option for paraganglioma in the head and neck region. It seems to be highly effective and avoids important surgical morbidity, which can impair quality of life. The aim of this study was to evaluate the outcomes of radiotherapy for paraganglioma of the head and neck region in order to inform our future practice. Materials and methods The cohort of patients for the present study comprised 21 patients who received radiotherapy between 1998 and 2008. Follow-up ranged from 6 to 132 months, median 55 months. The mean age was 48.7 years, range 20–78 years. The female:male ratio was 2 : 1. Two patients had confirmed familial tumour syndromes. The gross tumour volume in 20 cases ranged from 1.3 to 74cm 3 , mean 23.2cm 3 , median 14.7cm 3 . Five patients were treated with intensity-modulated radiotherapy. The median dose was 50Gy in 30 fractions. Results The crude 5-year local control rate was 95% (20/21), although the 5-year actuarial local control rate was 87%. The one patient who relapsed, at 45 months after radiotherapy, had a comparatively small tumour of 10.8cm 3 . A relationship between tumour volume and local control seems unlikely. It was possible to obtain details of side-effects from electronic records for 11 patients. Grade 3 headache, which resolved, was the most serious acute side-effect. One patient had three teeth extracted due to exacerbation of dental caries, and one had deterioration of hearing thought to be due to a combination of tumour and radiotherapy. There were two serious complications in patients who had embolisation, which we no longer use. Conclusions Our results show a high level of efficacy for fractionated external beam radiotherapy, with minimal toxicity, in keeping with other series. This should encourage the use of radiotherapy as primary treatment for paragangliomas of the head and neck region.

2036Background: GB is a malignant primary incurable CNS tumor with poor prognosis. RT + TMZ is standard treatment for newly diagnosed GB suitable for radical treatment. ErbB pathway dysregulation h...

e14085Background: Patients (pts) with recurrent HGGs are usually managed with alkylating chemotherapy +/- bevacizumab. However, prognosis remains poor with an overall survival (OS) of 7-9 months. P...