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We investigated (1) the relationship between Type D personality, stress intensity appraisal of a self-selected stressor, coping, and perceived coping effectiveness and (2) the relationship between Type D personality and performance. In study one, 482 athletes completed the Type D personality questionnaire (DS14), stress thermometer and MCOPE in relation to a recently experienced sport stressor. Type D was associated with increased levels of perceived stress and selection of coping strategies (more emotion and avoidance coping) as well as perceptions of their effectiveness. In study two, 32 participants completed a rugby league circuit task and were assessed on pre-performance anxiety, post-performance affect and coping. Type D was associated with poorer performance (reduced distance; more errors), decreases in pre-performance self-confidence and more use of maladaptive resignation/withdrawal coping. Findings suggest that Type D is associated with maladaptive coping and reduced performance. Type D individuals would benefit from interventions related to mood modification or enhancing interpersonal functioning.

BACKGROUND: Poststroke shoulder pain limits stroke survivors' physical functioning, impairs their ability to perform daily activities, and compromises their quality of life. The use of acupuncture to manage shoulder pain after a stroke is believed to free the blockage of energy flow and produce analgesic effects, but the evidence is unclear. We therefore conducted a systematic review to summarize the current evidence on the effects of acupuncture on the recovery outcomes of stroke survivors with shoulder pain. METHODS: Fourteen English and Chinese databases were searched for data from January 2009 to August 2017. The review included adult participants with a clinical diagnosis of ischemic or hemorrhagic stroke who had developed shoulder pain and had undergone conventional acupuncture, electroacupuncture, fire needle acupuncture, or warm needle acupuncture. The participants in the comparison group received the usual stroke care only. RESULTS: Twenty-nine randomized controlled trials were included. Most studies were assessed as having a substantial risk of bias. Moreover, due to the high heterogeneity of the acupuncture therapies examined, pooling the results in a meta-analysis was not appropriate. A narrative summary of the results is thus presented. The review showed that conventional acupuncture can be associated with benefits in reducing pain and edema and improving upper extremity function and physical function. The effects of conventional acupuncture on improving shoulder range of motion (ROM) are in doubt because this outcome was only examined in two trials. Electroacupuncture might be effective in reducing shoulder pain and improving upper extremity function, and conclusions on the effects of electroacupuncture on edema, shoulder ROM, and physical function cannot be drawn due to the limited number of eligible trials. The evidence to support the use of fire needle or warm needle acupuncture in stroke survivors with shoulder pain is also inconclusive due to the

AIM: The aim of this study was to psychometrically evaluate the Heart Failure Screening Tool (Heart-FaST) via: (1) examination of internal construct validity; (2) testing of scale function in accordance with design; and (3) recommendation for change/s, if items are not well adjusted, to improve psychometric credential. BACKGROUND: Self-care is vital to the management of heart failure. The Heart-FaST may provide a prospective assessment of risk, regarding the likelihood that patients with heart failure will engage in self-care. DESIGN: Psychometric validation of the Heart-FaST using Rasch analysis. METHOD: The Heart-FaST was administered to 135 patients (median age = 68, IQR = 59-78 years; 105 males) enrolled in a multidisciplinary heart failure management program. The Heart-FaST is a nurse-administered tool for screening patients with HF at risk of poor self-care. A Rasch analysis of responses was conducted which tested data against Rasch model expectations, including whether items serve as unbiased, non-redundant indicators of risk and measure a single construct and that rating scales operate as intended. RESULTS: The results showed that data met Rasch model expectations after rescoring or deleting items due to poor discrimination, disordered thresholds, differential item functioning, or response dependence. There was no evidence of multidimensionality which supports the use of total scores from Heart-FaST as indicators of risk. CONCLUSION: Aggregate scores from this modified screening tool rank heart failure patients according to their "risk of poor self-care" demonstrating that the Heart-FaST items constitute a meaningful scale to identify heart failure patients at risk of poor engagement in heart failure self-care.

BACKGROUND: Most studies have reported that higher levels (baccalaureate degree) of educational attainment by nurses are associated with lower levels of patient mortality. Researchers working in developed economies (e.g. North America and Europe) have almost exclusively conducted these studies. The value of baccalaureate nurse education has not been tested in countries with a developing economy. METHOD: A retrospective observational study conducted in seven hospitals. Patient mortality was the main outcome of interest. Anonymized data were extracted from nurses and patients from two different administrative sources and linked using the staff identification number that exists in both systems. We used bivariate logistic regression models to test the association between mortality and the educational attainment of the admitting nurse (responsible for assessment and care planning). RESULTS: Data were extracted for 11 918 (12, 830 admissions) patients and 7415 nurses over the first 6 months of 2015. The majority of nurses were educated in South Asia and just over half were educated to at least bachelor degree level. After adjusting for confounding and clustering, nurse education was not found to be associated with mortality. IMPLICATIONS FOR NURSING AND HEALTH POLICY: Our observations may suggest that in a developing economy, the academic level of nurses' education is not associated with a reduction in patient mortality. Findings should be interpreted with considerable caution but do challenge widely held assumptions about the value of baccalaureate-prepared nurses. Further research focused on nursing education in developing economies is required to inform health policy and planning.

We investigated (1) the relationship between Type D personality, stress intensity appraisal of a self-selected stressor, coping, and perceived coping effectiveness and (2) the relationship between Type D personality and performance. In study one, 482 athletes completed the Type D personality questionnaire (DS14), stress thermometer and MCOPE in relation to a recently experienced sport stressor. Type D was associated with increased levels of perceived stress and selection of coping strategies (more emotion and avoidance coping) as well as perceptions of their effectiveness. In study two, 32 participants completed a rugby league circuit task and were assessed on pre-performance anxiety, post-performance affect and coping. Type D was associated with poorer performance (reduced distance; more errors), decreases in pre-performance self-confidence and more use of maladaptive resignation/withdrawal coping. Findings suggest that Type D is associated with maladaptive coping and reduced performance. Type D individuals would benefit from interventions related to mood modification or enhancing interpersonal functioning.

A Group signature protocol is a cryptographic scheme that decouples a user identity and location from verification procedure during authentication. In a group signature scheme, a user is allowed to generate signatures on behalf of other group members but identity and location information of the signer is not known by a verifier. This ensures privacy, authentication and unlinkability of users. Although group signature is expensive to implement, its existential anonymity, non-repudiation and untraceablility properties make it attractive especially for resources-constrained devices in wireless network. A general group signature scheme usually contains six basic phases: setup (or key generation), join, message signing (or signature generation), signature verification, open and user revocation. In this paper, an evaluation of the performance of group signature based on three of the phases mentioned above is considered and its security in wireless networks examined. The key generation, signing and verification algorithms are implemented in Java 8. A proof of security of group signature by implication is also presented.

Purpose: A number of studies, including systematic reviews, show beneficial effects of psychosocial interventions for people with diabetes mellitus; however, they have not been assessed using meta-analysis. The purpose of this meta-analysis of randomized controlled trials is to investigate the effects of psychosocial interventions on depressive and anxiety symptoms, quality of life and self-efficacy in individuals with diabetes mellitus. Methods: The databases Pubmed, MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science and SocINDEX were searched with no year restriction. Eligible studies were randomized controlled trials published in English that included individuals diagnosed with diabetes mellitus, aged 18 years or above, who engaged in a psychosocial intervention, with outcome measures addressing depressive or anxiety symptomology, quality of life or self-efficacy. Eligible studies needed to compare the intervention to usual care. Study selection was completed using Covidence and meta-analysis was undertaken using Comprehensive Meta-Analysis software. Results: Seven studies were included in the meta-analysis. Five studies investigated the effects of psychosocial interventions and showed a medium to large benefit for depressive symptoms (SMD: -0.70; CI: -1.27, -0.13) which persisted at follow up (SMD: -1.54, CI: -2.97, -0.12). Similar results were not seen immediately post-intervention in the three studies that assessed anxiety symptoms (SMD: -0.30; CI: -0.69, 0.10); however, a medium beneficial effect was seen at follow up (SMD = -0.61, CI = -0.92 to -0.31). Small benefits were seen in the three studies assessing quality of life outcomes (SMD: 0.30, CI: 0.06, 0.55). No benefit was seen in the two studies assessing self-efficacy (SMD: 0.23, CI: -0.11, 0.57). Conclusions: The results of the current study provide preliminary evidence that psychosocial interventions, compared to usual care, reduce depressive symptoms, and may improve quality of life in individuals with

AIM: The aim of this study was to evaluate a heart failure education programme developed for patients and carers in Thailand. BACKGROUND: Heart failure is major health problem. This is the first trial of a family-based education programme for heart failure patients and carers residing in rural Thailand. DESIGN: Randomized controlled trial. METHODS: One hundred patient-carer dyads attending cardiac clinics in southern Thailand from April 2014 - March 2015 were randomized to usual care (n = 50) or a family-based education programme (n = 50) comprising face-to-face counselling, a heart failure manual and DVD and telephone support. Assessments of heart failure knowledge, health-related quality of life, self-care behaviours and perceived control were conducted at baseline, three and six months. RESULTS: Linear mixed-effects model revealed that patients and carers who received the education programme had higher knowledge scores at three and six months than those who received usual care. Among those who received the education programme, when compared with those who received usual care, patients had better self-care maintenance and confidence, and health-related quality of life scores at three and six months, and better self-care management scores at six months, whereas carers had higher perceived control scores at three months. CONCLUSION: Addressing a significant service gap in rural Thailand, this family-based heart failure programme improved patient knowledge, self-care behaviours and health-related quality of life and carer knowledge and perceived control.

AIMS AND OBJECTIVES: To examine whether chronic heart failure patient-carer dyads who disagree about the division of illness management tasks (incongruent) experience poorer psychosocial health and self-care, than those who agree (congruent). BACKGROUND: Informal carers often assist patients with chronic heart failure in the complex management of their illness, but little is known about how relationship dynamics may affect psychosocial health. DESIGN: A prospective cross-sectional study was adopted with a purposeful sample of 25 chronic heart failure patient-carer dyads residing in Australia. METHODS: Data were collected via mail-out questionnaires. Dyads were classified as congruent or incongruent using the Heart Failure Care Assessment Scale. Depression, anxiety, stress and quality of life were assessed in patients and carers. Additionally, self-care and relationship quality were assessed in patients; and burden and esteem were assessed in carers. Differences in congruent and incongruent patient and carer outcomes were examined. RESULTS: Dyads were predominantly spousal and around a third demonstrated incongruence. No significant differences were found between congruent (n = 16) and incongruent (n = 9) dyads, although patients in incongruent dyads tended to have been diagnosed more recently. CONCLUSION: In chronic heart failure patient-carer dyads incongruence exists even for patients with relatively mild chronic heart failure symptoms. These findings indicate that dyadic incongruence in illness management might not affect high-functioning chronic heart failure heart failure patients or their carers. RELEVANCE TO CLINICAL PRACTICE: Given the prevalence of dyadic incongruence and the possibility of further negative outcomes with disease progression, it is important to examine factors such as length of time since diagnosis or type of carer relationship. By implementing self-care education and management strategies that focus on the dyad, rather than the individual

BACKGROUND: This paper presents a protocol for a randomised controlled trial of the Cardiac-Diabetes Transcare program which is a transitional care, multi-modal self-management program for patients with acute coronary syndrome comorbid with type 2 diabetes. Prior research has indicated people hospitalised with dual cardiac and diabetes diagnoses are at an elevated risk of hospital readmissions, morbidity and mortality. The primary aim of this study is to evaluate the effectiveness (and cost-effectiveness) of a Cardiac-Diabetes Transcare intervention program on 6-month readmission rate in comparison to usual care. METHODS/DESIGN: A two-armed, randomised controlled trial with blinded outcome assessment will be conducted to evaluate the comparative effectiveness of two modes of care, including a Usual Care Group and a Cardiac-Diabetes Transcare Intervention (in addition to usual care) Group. The primary outcome is 6-month readmission rate, although a range of secondary outcomes will be collected (including self-efficacy) at baseline, 1, 3 and 6 month reassessments. The intervention group will receive in-hospital education tailored for people recovering from an acute coronary syndrome-related hospital admission who have comorbid diabetes, and they will also receive home visits and telephone follow-up by a trained Research Nurse to reinforce and facilitate disease-management-related behaviour change. Both groups will receive usual care interventions offered or referred from participating hospital facilities. A sample size of 432 participants from participating hospitals in the Australian states of Queensland and Victoria will be recruited for 90% power based on the most conservative scenarios modelled for sample size estimates. DISCUSSION: The study outlined in this protocol will provide valuable insight into the effectiveness of a transitional care intervention targeted for people admitted to hospital with cardiac-related presentations commencing in the inpatient hospit

Purpose: Depressive and anxiety symptoms are common amongst individuals with chronic kidney disease and are known to affect quality of life adversely. Psychosocial interventions have been shown to decrease depressive and anxiety symptoms in various chronic diseases, but few studies have examined their efficacy in people with chronic kidney disease and no meta-analysis has been published. Thus, the aim of the present systematic review and meta-analysis was to evaluate the effects of psychosocial interventions on depressive and anxiety symptoms as well as quality of life in individuals diagnosed with chronic kidney disease and/or their carers. Methods: In this systematic review and meta-analysis, we included published randomized controlled trials comparing psychosocial interventions versus usual care for impacting depressive and anxiety symptoms and quality of life. Results: Eight studies were included in the systematic review and six of these were subjected to meta-analysis. Psychosocial interventions were associated with a medium effect size for reduction in depressive symptoms and a small effect size for improved quality of life in the in individuals with chronic-kidney-disease and their carers. Some evidence suggested a reduction in anxiety. Conclusion: Psychosocial interventions appear to reduce depressive symptoms and improve quality of life in patients with chronic-kidney-disease and their carers and to have some beneficial impact on anxiety. However, the small number of identified studies indicates a need for further research in this field.

OBJECTIVE: To explore the psychosocial determinants and interhospital variability on a major acute cardiovascular event (MACE), during follow-up of a multicenter cohort of patients hospitalised with heart disease, participating in a nurse-led secondary prevention programme. METHODS: Outcome data were retrospectively analysed from 602 cardiac inpatients randomised to postdischarge standard care (n=296), or home-based intervention (n=306), with prolonged follow-up of individualised multidisciplinary support. Baseline psychosocial profiling comprised depressive status, health-related quality of life (HRQoL), social isolation and mild cognitive impairment (MCI). Multivariate analyses examined the independent correlates of a composite 2-year MACE rate of all-cause mortality and unplanned cardiovascular-related hospitalisation, according to gender. RESULTS: Participants were aged 70±10 years, 431 (72%) were men and 377 (63%) had coronary artery disease. During 2-year follow-up, 165 (27%) participants (114 men, 51 women; p=0.431) experienced a MACE. Independent correlates of a MACE in men were depressive status (OR 1.95, 95% CI 1.06 to 3.58; p=0.032), low physical HRQoL (OR 0.98, 95% CI 0.96 to 1.00; p=0.027) and increasing comorbidity (OR 1.14, 95% CI 1.04 to 1.25; p=0.004). In women, age (OR 1.06, 95% CI 1.02 to 1.12; p=0.008), MCI (OR 2.38, 95% CI 1.09 to 5.18; p=0.029) and hospital site predicted a MACE (OR 2.32, 95% CI 1.09 to 4.93; p=0.029). CONCLUSIONS: Psychological determinants, cognitive impairment and responses to secondary prevention are different for men and women with heart disease and appear to modulate cardiovascular-specific outcomes. Early detection of psychosocial factors through routine screening and gender-specific secondary prevention is encouraged. TRIAL REGISTRATION NUMBER: 12608000014358.

Family interventions for first-episode psychosis (FEP) are an integral component of treatment, with positive effects mainly on patients' mental state and relapse rate. However, comparatively little attention has been paid to the effects of family interventions on caregivers' stress coping and well-being, especially in non-Western countries. We aimed to test the effects of a 5-month clinician-supported problem-solving bibliotherapy (CSPSB) for Chinese family caregivers of people with FEP in improving family burden and carers' problem-solving and caregiving experience, and in reducing psychotic symptoms and duration of re-hospitalizations, compared with those only received usual outpatient family support (UOFS). A randomized controlled trial was conducted across 2 early psychosis clinics in Hong Kong, where there might be inadequate usual family support services for FEP patients. A total of 116 caregivers were randomly selected, and after baseline measurement, randomly assigned to the CSPSB or UOFS. They were also assessed at 1-week and 6- and 12-month post-intervention. Intention-to-treat analyses were applied and indicated that the CSPSB group reported significantly greater improvements in family burden and caregiving experience, and reductions in severity of psychotic symptoms and duration of re-hospitalizations, than the UOFS group at 6- and 12-month follow-up. CSPSB produces moderate long-term benefits to caregivers and FEP patients, and is a low-cost adjunct to UOFS.

BACKGROUND: After a diagnosis of diabetes mellitus, people not only have to cope with the physical aspects and common complications that require daily self-management, they are also faced with ongoing psychosocial challenges. Subsequently they find themselves having to navigate the health system to engage multidisciplinary supports; the combination of these factors often resulting in reduced health-related quality of life. To maintain optimal diabetes control, interventions need to incorporate psychosocial supports and a skill base for disease management. Therefore, our aim was to evaluate an 'Optimal Health Program' that adopts a person-centred approach and engages collaborative therapy to educate and support the psychosocial health of people diagnosed with type I or II diabetes. METHODS: This prospective randomised controlled trial will include 166 people diagnosed with diabetes: 83 in the intervention (Optimal Health Program) and 83 in the control (usual care) group. Participants with type diabetes mellitus will be recruited through hospital outpatient clinics and diabetes community organisations. Participants in the intervention group will receive nine (8 + 1 booster session) sequential sessions, based on a structured treatment manual emphasising educational and psychosocial support self-efficacy and skills building. The primary outcome measures will be generalised self-efficacy (GSE) and health-related quality of life (AQoL-6D and EQ-5D). Secondary measures will be anxiety and depression (HADS), social and workplace functioning (WSAS), diabetes-related quality of life (DQoL), diabetes-related distress (PAID), and type of coping strategies (Brief COPE). In addition, a health economic cost analysis and process evaluations will be performed to assess the economic cost and efficacy of the program's operations, implementation and service delivery. DISCUSSION: We envisage that the Optimal Health Program's emphasis on self-efficacy and self-management will provide par

BACKGROUND: Chronic kidney disease (CKD) and end-stage kidney disease (ESKD) are serious and growing health problems with enormous impact on psychological and social functioning. Despite high rates of comorbid depression and anxiety in these patient populations, and the adverse impact these have upon treatment adherence, quality of life, social connectedness and healthcare costs there has been little attention focused on the prevention or management of these problems. Thus, our aim was to evaluate the Dialysis Optimal Health Program (DOHP) that adopts a person-centred approach and engages collaborative therapy to educate and support those diagnosed with ESKD who are commencing dialysis. METHODS: The study design is a randomised controlled trial. Ninety-six adult patients initiating haemodialysis or peritoneal dialysis will be randomly allocated to either the intervention (DOHP) or usual care group. Participants receiving the intervention will receive nine (8 + 1 booster session) sequential sessions based on a structured information/workbook, psychosocial and educational supports and skills building. The primary outcome measures are depression and anxiety (assessed by the Hospital Anxiety and Depression Scale; HADS). Secondary outcomes include health-related quality of life (assessed by the Kidney Disease Quality of Life instrument; KDQOL), self-efficacy (assessed by General Self-Efficacy Scale) and clinical indices (e.g. albumin and haemoglobin levels). Cost-effectiveness analysis and process evaluation will also be performed to assess the economic value and efficacy of the DOHP. Primary and secondary measures will be collected at baseline and at 3-, 6-, and 12-month follow-up time points. DISCUSSION: We believe that this innovative trial will enhance knowledge of interventions aimed at supporting patients in the process of starting dialysis, and will broaden the focus from physical symptoms to include psychosocial factors such as depression, anxiety, self-efficacy

Background: Stroke is a leading cause of disability and distress, and often profoundly affects the quality of life of stroke survivors and their carers. With the support of carers, many stroke survivors are returning to live in the community despite the presence of disability and ongoing challenges. The sudden and catastrophic changes caused by stroke affects the mental, emotional and social health of both stroke survivors and carers. The aim of this study is to evaluate a Stroke and Carer Optimal Health Program (SCOHP) that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of stroke survivors and their carers. Methods: This study is a prospective randomised controlled trial. It will include a total of 168 stroke survivors and carers randomly allocated into an intervention group (SCOHP) or a control group (usual care). Participants randomised to the intervention group will receive nine (8 + 1 booster) sessions guided by a structured workbook. The primary outcome measures for stroke survivors and carers will be health-related quality of life (AQoL-6D and EQ-5D) and self-efficacy (GSE). Secondary outcome measures will include: anxiety and depression (HADS); coping (Brief COPE); work and social adjustment (WSAS); carer strain (MCSI); carer satisfaction (CASI); and treatment evaluation (TEI-SF and CEQ). Process evaluation and a health economic cost analysis will also be conducted. Discussion: We believe that this is an innovative intervention that engages the stroke survivor and carer and will be significant in improving the psychosocial health, increasing independence and reducing treatment-related costs in this vulnerable patient-carer dyad. In addition, we expect that the intervention will assist carers and stroke survivors to negotiate the complexity of health services across the trajectory of care and provide practical skills to improve self-management.

BACKGROUND: Multimorbidity in heart failure (HF), defined as HF of any aetiology and multiple concurrent conditions that require active management, represents an emerging problem within the ageing HF patient population worldwide. METHODS: To inform this position paper, we performed: 1) an initial review of the literature identifying the ten most common conditions, other than hypertension and ischaemic heart disease, complicating the management of HF (anaemia, arrhythmias, cognitive dysfunction, depression, diabetes, musculoskeletal disorders, renal dysfunction, respiratory disease, sleep disorders and thyroid disease) and then 2) a review of the published literature describing the association between HF with each of the ten conditions. From these data we describe a clinical framework, comprising five key steps, to potentially improve historically poor health outcomes in this patient population. RESULTS: We identified five key steps (ARISE-HF) that could potentially improve clinical outcomes if applied in a systematic manner: 1) Acknowledge multimorbidity as a clinical syndrome that is associated with poor health outcomes, 2) Routinely profile (using a standardised protocol - adapted to the local health care system) all patients hospitalised with HF to determine the extent of concurrent multimorbidity, 3) Identify individualised priorities and person-centred goals based on the extent and nature of multimorbidity, 4) Support individualised, home-based, multidisciplinary, case management to supplement standard HF management, and 5) Evaluate health outcomes well beyond acute hospitalisation and encompass all-cause events and a person-centred perspective in affected individuals. CONCLUSIONS: We propose ARISE-HF as a framework for improving typically poor health outcomes in those affected by multimorbidity in HF.

AIM: To investigate the relationship between patient mortality and the educational preparation (graduateness) of the nurses who cared for them. BACKGROUND: There have been 18 studies over the last two decades examining the effect of nurses' educational qualifications on mortality. All but three have used mortality data aggregated at the hospital level that has been combined with surveys of nurses to estimate the level of graduateness in the population. Data collection and extraction generally has been done at different points in time. DESIGN: A retrospective, cross-sectional study. METHOD: Routine administrative patient data were extracted (May-August 2015). The primary outcome was all-cause patient mortality at discharge. We were able to identify the individual nurses who provided care during patients inpatient stay using an identification number. We were then able to calculate the 'graduateness' of the nursing care patients received by dividing the number of recorded episodes of care provided by baccalaureate prepared nurses with the total number of care episodes. RESULTS: After adjusting for confounding, we observed a significant association between patient mortality and nurse graduateness. Our observations suggest an optimum level of baccalaureate prepared nurses of approximately 70%. Above this level, there appears to be no additional decrease in mortality rates. CONCLUSION: This study represents an important methodological step forward over previous approaches. Our observations are generally consistent with existing literature and confirm the importance of baccalaureate nurse education.

Population ageing is a worldwide phenomenon, most advanced in developed countries and expected to continue over the next few decades. As people are surviving longer with age-associated disease and disability, there is an imperative to identify innovative solutions for an already overburdened health care system. Such innovations need to be focused on disease management, taking into consideration the strong associations that have been established between psychosocial factors and pathophysiological mechanisms associated with chronic disease. Aside from personal and community costs, chronic diseases produce a significant economic burden due to the culmination of health care costs and lost productivity. This commentary reports on a programme of research, Translating Research, Integrated Public Health Outcomes and Delivery, which will evaluate an optimal health programme that adopts a person-centred approach and engages collaborative therapy to educate, support and improve the psychosocial health of those with chronic disease. The effectiveness of the optimal health programme will be evaluated across three of the most significant contributors to disease burden: diabetes mellitus, chronic kidney disease and stroke. Cost-effectiveness will also be evaluated. The findings derived from this series of randomised controlled trials will also provide evidence attesting to the potential applicability of the optimal health programme in other chronic conditions.

BACKGROUND: We sought to determine the overall impact of a nurse-led, multidisciplinary home-based intervention (HBI) adapted to hospitalized patients with chronic forms of heart disease of varying types. METHODS AND RESULTS: Prospectively planned, combined, secondary analysis of 3 randomized trials (1226 patients) of HBI were compared with standard management. Hospitalized patients presenting with heart disease but not heart failure, atrial fibrillation but not heart failure, and heart failure, as well, were recruited. Overall, 612 and 614 patients, respectively, were allocated to a home visit 7 to 14 days postdischarge by a cardiac nurse with follow-up and multidisciplinary support according to clinical need or standard management. The primary outcome of days-alive and out-of-hospital was examined on an intention-to-treat basis. During 1371 days (interquartile range, 1112-1605) of follow-up, 218 patients died and 17 917 days of hospital stay were recorded. In comparison with standard management, HBI patients achieved significantly prolonged event-free survival (90.1% [95% confidence interval, 88.2-92.0] versus 87.2% [95% confidence interval, 85.1-89.3] days-alive and out-of-hospital; P=0.020). This reflected less all-cause mortality (adjusted hazard ratio, 0.67; 95% confidence interval, 0.50-0.88; P=0.005) and unplanned hospital stay (median, 0.22 [interquartile range, 0-1.3] versus 0.36 [0-2.1] days/100 days follow-up; P=0.011). Analyses of the differential impact of HBI on all-cause mortality showed significant interactions (characterized by U-shaped relationships) with age (P=0.005) and comorbidity (P=0.041); HBI was most effective for those aged 60 to 82 years (59%-65% of individual trial cohorts) and with a Charlson Comorbidity Index Score of 5 to 8 (36%-61%). CONCLUSIONS: These data provide further support for the application of postdischarge HBI across the full spectrum of patients being hospitalized for chronic forms of heart disease. CLINICAL TRIAL REGIST

There is evidence that older Canadians have a higher incidence of presenting to the emergency department (ED) than any other age group. These visits may be made more complex if individuals are also cognitively impaired or have dementia. The purpose of this study was to explore ED nurses’ experiences of caring for adults with dementia in the ED. Using an interpretive descriptive approach, 12 registered nurses working in different EDs in an urban setting in Western Canada were interviewed about these experiences. Using the thematic analysis process described by Braun and Clarke, four themes were identified: 1) not a priority; 2) not the right place; 3) get them in, get them out; and 4) getting it wrong. The nurses identified that challenges in the care of persons with dementia in the ED are created by the fast-paced and chaotic environment of the ED, staffing, issues with disposition, and safety concerns. Suggestions for improving the care of persons with dementia were provided by the nurses.

BACKGROUND: Cognitive impairment is seen in up to three quarters of heart failure (HF) patients and has a significant negative impact on patients' health outcomes. Prospective memory, which is defined as memory to carry out future intentions, is important for functional independence in older adults and involves application of multiple cognitive processes that are often impaired in HF patients. The objective of this study is to examine the effects of prospective memory training on patients' engagement in HF self-care and health outcomes, carer strain and quality of life. METHODS/DESIGN: The proposed study is a randomised, controlled trial in which 200 patients diagnosed with HF, and their carers will be recruited from 3 major hospitals across Melbourne. Eligible patients with HF will be randomised to receive either: 1) The Virtual Week Training Program - a computerised prospective memory (PM) training program (intervention) or 2) non-adaptive computer-based word puzzles (active control). HF patients' baseline cognitive function will be compared to a healthy control group (n = 60) living independently in the community. Patients will undergo a comprehensive assessment of PM, neuropsychological functioning, self-care, physical, and emotional functioning. Assessments will take place at baseline, 4 weeks and 12 months following intervention. Carers will complete measures assessing quality of life, strain, perceived control in the management of the patients' HF symptoms, and ratings of the patients' level of engagement in HF self-care behaviours. DISCUSSION: If the Virtual Week Training Program is effective in improving: 1) prospective memory; 2) self-care behaviours, and 3) wellbeing in HF patients, this study will enhance our understanding of impaired cognitive processes in HF and potentially is a mechanism to reduce healthcare costs. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry #366376; 27 May 2014. https://www.anzctr.org.au/Trial/Registration/Tri

BACKGROUND: A number of factors have been identified which might influence the variation observed in climacteric symptoms in peri- and post-menopausal women. We examined the role of the distressed or Type-D personality and mode of physical activity or exercise on the climacteric symptoms experienced by peri- or post-menopausal women. METHODS: 213 Women (M age 52.2 years, SD = 5.9), 58% classified as peri- and 42% as post-menopausal completed a questionnaire pack consisting of demographic questions, the DS14 (Type-D personality), Kaiser Physical Activity Survey (assessing household care giving, occupational, active living and sport and exercise index) and the Greene Climacteric Scale (Psychological, somatic/physical, vasomotor and sexual symptoms). RESULTS: Type-D personality and increased levels of household care-giving physical activity were both associated with increased bothersomness for all four climacteric factors. Increased levels of sport and exercise participation on the other hand resulted in less psychological, somatic/physical and sexual functioning problems whereas the active living index was inversely related to somatic/physical climacteric symptoms. Finally, lower income was associated with more psychological and somatic/physical symptoms and being peri-menopausal resulted in more vasomotor symptoms. CONCLUSIONS: The results suggest that mode of physical activity is an important moderator in alleviating climacteric symptoms. In addition, our results support previous findings in that Type-D personality is associated with negative health outcomes. In particular menopausal women with Type-D personality would benefit from interventions (coping, mindfulness training) and regular sport and exercise participation to reduce climacteric symptomology.

OBJECTIVES: Cognitive deficits are common in patients with chronic heart failure (CHF), but no study has investigated whether these deficits extend to social cognition. The present study provided the first empirical assessment of emotion recognition and theory of mind (ToM) in patients with CHF. In addition, it assessed whether each of these social cognitive constructs was associated with more general cognitive impairment. METHODS: A group comparison design was used, with 31 CHF patients compared to 38 demographically matched controls. The Ekman Faces test was used to assess emotion recognition, and the Mind in the Eyes test to measure ToM. Measures assessing global cognition, executive functions, and verbal memory were also administered. RESULTS: There were no differences between groups on emotion recognition or ToM. The CHF group's performance was poorer on some executive measures, but memory was relatively preserved. In the CHF group, both emotion recognition performance and ToM ability correlated moderately with global cognition (r = .38, p = .034; r = .49, p = .005, respectively), but not with executive function or verbal memory. CONCLUSION: CHF patients with lower cognitive ability were more likely to have difficulty recognizing emotions and inferring the mental states of others. Clinical implications of these findings are discussed.

BACKGROUND: A cross-sectional study was conducted to provide a snapshot of smoking behavior among staff and patients at a major metropolitan hospital in Melbourne. METHODS: Patients and staff were surveyed using a questionnaire exploring demographics, nicotine dependence (Fagerstrom test), readiness to quit, and preference for smoking cessation options. RESULTS: A total of 1496 people were screened within 2 hours; 1,301 participated (1,100 staff, 199 patients). Mean age was 42 years, 68% were female. There were 113 (9%) current smokers and 326 (25%) ex-smokers. Seven percent of the staff were current smokers compared with 19% of the patients. The Fagerstrom test showed that 47% of patients who smoked were moderately nicotine dependent compared with 21% of staff. A third of the staff who smoked did not anticipate health problems related to smoking. Most patients (79%) who smoked disagreed that their current health problems were related to smoking. Although more than half of the current smokers preferred pharmacotherapy, one in two of them did not prefer behavior counseling; with consistent results among staff and patients. Multivariate analyses showed that patients were three times more likely (odds ratio 3.0, 95% confidence interval 1.9-4.7) to smoke than staff. CONCLUSION: This study reports lower prevalence of smoking among hospital staff compared with national data. It also indicates an under-appreciation of health effects of smoking, and a preference not to use conventional methods of quitting.

BACKGROUND: Previous work using Mokken scaling analysis with the SF-36 has found subscales appearing to show excellent Mokken scaling properties. However, the values of scalability of the subscales are very large, raising the possibility that these are artificially high and this may result from violations of local stochastic independence between items. OBJECTIVES: To analyse selected items from the Chinese Mandarin form of the SF-36 scale using Mokken scaling and to investigate if violations of local stochastic independence exaggerate scalability. METHODS: Exploratory Mokken scaling analysis was run using the online public domain software R by entering 19 items from the Chinese Mandarin form of the SF-36 items into the analysis. The items in the resulting scales, judged by the size of Loevinger's coefficient, were analysed for violations of monotony, 95% confidence intervals and invariant item ordering, including inspection of item pair plots. RESULTS: Two Mokken scales were obtained, one including items from the Physical Functioning subscale, and one including items from the Mental Health subscale of the Chinese Mandarin form of the SF-36. The Physical Functioning scale was very strong according to Loevinger's coefficient with high invariant item ordering; the Mental Health scale was moderately strong with weak invariant item ordering. CONCLUSION: The strength of the Physical Functioning Mokken scale derived from the Chinese Mandarin form of the SF-36 is probably the result of an item chain and item overlap which violate local stochastic independence. This is due to the nature of the items in the Physical Functioning subscale, all of which relate to physical ability and some of which can only be achieved if previous items in the subscale have been achieved.

BACKGROUND: Health care provider experiences of the carer have been researched, but little is written about how these can inform development of support programs. OBJECTIVES: This study aimed to (1) explore health care provider perceptions of stroke carer roles and support needs and (2) examine carer needs across the stroke care trajectory to assist with development of an Optimal Health Program (OHP) to support carers. This study is part of a staged program of research that will evaluate and refine the OHP. METHODS: Four dual-moderated semi-structured focus groups of stroke health care providers across acute, subacute, and community rehabilitation services were conducted. Facilitators used a semi-structured focus group schedule to guide discussion. Sessions were recorded, transcribed, and analyzed using thematic and content analysis. RESULTS: Three key themes emerged: transition, information, and impact of stroke. A number of subthemes highlighted the distinct roles of health care providers and carers. Specific elements of the OHP were identified as having the potential to advance support for carers across the stroke care trajectory. DISCUSSION: Findings support the integration of an OHP for carers within existing stroke care services in Australian public hospital and community settings. CONCLUSION: This study suggests how health care provider experiences could inform a self-management OHP to assist carers in navigating stroke services and to address their health-related concerns.

BACKGROUND: Heart failure (HF) significantly impacts on the daily lives of patients and their carers. In Western society HF education programs have increased patient and carer knowledge and improved health-related quality of life. However, there is a paucity of such evidence in Asia. For example, to date no studies have been conducted in Thailand to investigate the potential benefits of a family-based education program on the health outcomes of HF patients and carers. METHODS: This randomised controlled trial will evaluate the effectiveness of an education program on knowledge, self-care and health-related quality of life of Thai HF patients and their carers. Assessments will be conducted at baseline, three and six months. Participants will be assigned by independent random allocation to an intervention (family-based education plus usual care) or a control (usual care) group. Analyses will be conducted on an intention-to-treat basis. DISCUSSION: This trial will be the first to evaluate the effectiveness of family-based education for HF patients and carers residing in rural Thailand. It attempts to advance understanding of family-based HF education and address the gap in service provision. TRIAL REGISTRATION: Thai Clinical Trial Registry TCTR20140506003.