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Background It is reported that the longer-term outcomes for stroke survivors are poor, with a range of unmet needs identified. Objectives The aims were to develop and test a longer-term stroke care strategy focused on improving the quality of life of stroke survivors and their carers by addressing unmet needs, and maintenance and enhancement of participation (i.e. involvement in life situations). Design Five overlapping workstreams were undertaken – (1) refinement of content by semistructured interviews with stroke survivors and their carers and by a review of the literature to inform content and delivery of the care strategy; (2) exploration of service models by national survey and focus groups with purposely selected services; (3) intervention development by interaction with a reference group of stroke survivors, carers, and health and social care professionals; (4) refinement and pilot implementation of the developed intervention in three stroke services (case studies); and (5) a cluster randomised controlled feasibility trial in 10 stroke services across England and Wales. Setting The intervention development work and feasibility trial were in stroke services (inclusive of primary, secondary, community and social care provision) across England and Wales. Participants Participants were stroke survivors resident in the community and their carers, and health and social care professionals in the included stroke services. Data sources Interviews with 28 stroke survivors and their carers at least 9 months post stroke ascertained their needs and the barriers to and facilitators of addressing those needs. Additional literature reviews identified 23 needs. No evidence-based interventions to address these needs were reported; self-management was highlighted as a possible delivery mechanism. In workstream 2, a national survey revealed that the most common model of stroke service provision was care up to 12 months post stroke, reported by 46 (40%) services. Thirty-five (30%) services provided care up to 6 months post stroke and 35 (30%) provided care beyond 12 months, thus identifying 6 months post stroke as an appropriate delivery point for a new intervention. Through focus groups in a range of services, stroke survivors’ perceived unmet needs and the barriers to and enablers of service provision were identified. Intervention Using information obtained in workstreams 1 and 2 and working closely with a stakeholder reference group, we developed an intervention based on the unmet needs prioritised by stroke survivors and their carers (workstream 3). In workstream 4, action groups (clinicians, stroke survivors and researchers) were established in three stroke services that led implementation in their service and contributed to the iterative refinement of the intervention, associated training programme and implementation materials. The intervention (called New Start) was delivered at 6 months post stroke. Key components were problem-solving self-management with survivors and carers, help with obtaining usable information, and helping survivors and their carers build sustainable, flexible support networks. Results A cluster randomised feasibility trial (workstream 5) was successfully implemented in 10 stroke services across England and Wales, with associated process and health economic evaluations. Five services were randomised to provide New Start, while five continued with usual care; 269 participants were recruited. Progression criteria – in terms of our pre-determined (red, amber, green) criteria for progress to a full trial: target stroke survivor recruitment rates were achieved, on average, across sites (24.1 per site over 6 months, green); 216 (80.3%) registered stroke survivors returned follow-up questionnaires at 9 months (84.1% in the intervention arm and 75.8% in the usual care arm, green); according to data reported by sites, overall, 95.2% of registered stroke survivors were offered at least one session of the intervention (green); all five intervention sites had at least two facilitators deemed competent, delivered the New Start intervention and provided it to stroke survivors (green). However, at some sites, there were concerns regarding the number of stroke survivors being offered, accepting and receiving the intervention. Only small differences in outcomes and costs were observed between the New Start and usual care groups, and considerable uncertainty around the cost-effectiveness remains. Conclusions We report a complex programme of work that has described the longer-term needs of stroke survivors and highlighted evidence and service gaps. Working closely with stroke survivors, an intervention was developed that has been refined in three services and feasibility tested in a cluster randomised controlled trial. Further refinement of the target population and optimisation of the intervention materials is required prior to a full randomised controlled trial evaluation. Future work Optimisation of the intervention, and clearer specification of recipients, are required prior to a full trial evaluation. Trial registration Current Controlled Trials ISRCTN38920246. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

The number of people bereaved due to the Covid-19 pandemic is a major health and social care concern. At a time of unprecedented demand on acute and critical care services, restricted family presence to reduce transmission of the disease had a profound impact on the way bereavement support could be provided in the hospital setting. In response, relatively rapid adaptions to practices were required. This paper provides inspiration and guidance on an acute hospital initiative designed to address the emotional needs of the immediately bereaved. The core features of a supported viewing service are presented through the lens of key employees who played a central role in its development and delivery, and with reference to the prevailing literature. Formal evaluation of the service through qualitative inquiry is recommended, complementary to anecdotal evidence of appreciative uptake of the service during the pandemic.

Background Care after death includes supporting the bereaved. Evidence suggests that opportunity to view the deceased person is helpful to grieving families. During the COVID-19 pandemic, imposed restrictions to family presence challenged viewing arrangements. Some funeral firms also had essential health and safety policies in place which restricted visiting in a Chapel of Rest. Methods To help meet the needs of grieving families whose relative died in an acute hospital setting, bereavement, chaplaincy and mortuary teams, together with essential administrative, portering and housekeeping staff implemented a service of COVID-secure supported viewing. Viewing the deceased person was facilitated in accordance with the family preference to be accompanied by the hospital bereavement nurse or by a male or female member of the hospital chaplaincy team of a specific faith, and included the option of prayer with or without family presence. Each family was offered a prayer booklet which was personalised with the name of the deceased. This was presented at the end of the viewing or sent by post. Results In the period 14th April to 31st July 2020, 560 families were offered the service, and the uptake was 404 (72%). Of the 404 families: Just over half (51%, n=205) required accompanied viewings, of which: 128 (62.4%) requested/received prayer/faith–based support. 77 (37.6%) requested/received bereavement nurse support only. The majority (81%, n=327) opted for chaplaincy team involvement. This comprised: 128 (39.1%) viewings with prayer. 199 (60.9%) prayers without the family present. A total of 840 personalised prayer booklets were produced. Several families requested and received multiple copies. Conclusion Our supported viewing service serves as an example of the extraordinary caring creativity in the wake of COVID-19. It has been a real privilege to create something very precious and meaningful at such a challenging time in peoples’ lives.

Online learning readiness is fundamental to student successful participation, presence, and interaction in online courses. Effective facilitation of these key components depends on sound instructional design. In self-directed online environments, learner-content interaction and scaffolding self-regulated learning have been found of primary importance to generate meaningful learning. To provide a solution to the challenges of interoperability of various functions in synchronous online learning environments, this chapter presents a case study about the design and development of a self-paced orientation to help students acquire online learning readiness. Learner-content interaction is strategically utilized in the design to scaffold self-regulated learning. The results of the case study demonstrate that this orientation positively prepares students to be ready for learning in a synchronous online environment. The approach can be of practical use to individuals and groups.

The 2000-mile border between the United States and Mexico has been the subject of much discourse in relation to economics, immigration, and human rights issues. Home health care professionals who choose to practice in the 42 km border region are faced with a uniquely diverse practice setting. As persons of different cultures in the border area experience daily contact due to the ease of border crossing, challenges arise in providing culturally congruent care to the millions of people who live in this unique, multicultural area. Annually, an estimated 200 million persons cross the border to work, shop, visit relatives, and partake in other experiences on either side of the border, leading some to refer to the area as “Amexica.” This cultural mix has implications for providers of health care in the border communities. Understanding the complexities of the border region will enable international health care professionals to provide culturally congruent care to the residents of this dynamic area. This article explores the implications of providing culturally congruent care to residents of the area along the border area between the United States and Mexico.

Objectives This study aims to evaluate the effectiveness and acceptability of a pharmacist-led antimicrobial stewardship intervention, consisting of consultant performance audit and feedback, on antimicrobial prescribing quality. Methods From October 2010 to September 2012, the prescribing performance of medical consultant teams rotating on the acute medical admissions unit was measured against four quality indicators. Measurements were taken at baseline then at quarterly intervals during which time consultants received feedback. Proportion of prescriptions adhering to each indicator was compared with baseline using paired sample z-test (significance level P < 0.01, Bonferroni corrected). Consultants’ views were explored using anonymous questionnaires. Key findings Overall, 2609 antimicrobial prescriptions were reviewed. Improvement from baseline was statistically significant in all follow-up periods for two indicators: ‘antimicrobials should have a documented indication in the medical notes’ and ‘antimicrobials should adhere to guideline choice or have a justification for deviation’, reaching 6.0% (95% CI 2.5, 9.6) and 8.7% (95% CI 3.7, 13.7), respectively. Adherence to the indicator ‘antimicrobials should have a documented stop/review prompt’ improved significantly in all but the first follow-up period. For the indicator: ‘antimicrobial assessed by antimicrobial specialists as unnecessary’, improvement was statistically significant in the first (−4.7%, 95% CI −8.0, −1.4) and fourth (−4.2%, 95% CI −7.7%, −0.8%) periods. Service evaluation showed support for the pharmacist-led stewardship activities. Conclusions There were significant and sustained improvements in prescribing quality as a result of the intervention. Consultants’ engagement and acceptance of stewardship activities were demonstrated.

Pallister-Hall syndrome (PHS) is a rare condition characterised by anomalies including hypothalamic hamartoma, bifid epiglottis and postaxial polydactyly. Hearing loss has been recognised in this condition. Cochlear abnormalities have been described in mouse models of PHS, but there are no reports of similar findings in humans to date. This report describes a case of PHS with bilateral cochlear hypoplasia as seen on MRI.

The program of synthesis for the soluble cuticular proteins of Tenebrio molitor was determined by following the incorporation of labeled leucine after a 4-hr pulse in vivo. Soluble proteins were extracted from labeled cuticles and separated on SDS-polyacrylamide slab gels; individual gel slices were counted. The synthetic patterns of larvae and pupae were similar to one another but distinct from the adult pattern. At each stage, the preecdysial pattern was unlike that of postecdysial animals. Distinct periods of synthesis were detected for different proteins. One protein was synthesized and deposited throughout cuticle formation in all three metamorphic stages. One group was synthesized only after ecdysis, while synthesis and secretion of other proteins were restricted to the preecdysial period. Some cuticular proteins never acquired detectable label.

A single gene mutation in cauliflower resulted in the production of an orange coloured curd when heterozygous, and a stunted orange curd when homozygous. The orange heterozygote has commercial potential.

The binding of juvenile hormone (JH) by components from hemolymph of adult female Locusta migratoria was characterized to establish whether hemolymph JH-binding proteins could be distinguished from a protein of fat body (BP-1) that may be a JH receptor. Hemolymph was analyzed by the hydroxyapatite assay, gel separation chromatography, polyacrylamide gel electrophoresis, and density gradient centrifugation. Three fractions that bound JH were separated from whole hemolymph by DEAE cellulose column chromatography, and these differed from all three cytosol-binding components. The major hemolymph component (H-A) showed relatively stable binding of JH, a slight loss of binding capacity after delipidation, and a Kd for JH-I of 16 nM. The Kds for JH-l and JH-lll with unfractionated hemolymph were 26 and 42 nM respectively. The order of effectiveness of competitors for binding of [3H]JH-l was JH-lll > JH-l ≫ methoprene > hydroprene ≫ acids of methoprene and hydroprene. The data indicated that unlabeled JH-lll was bound more effectively than its radioactive counterpart. The sedimentation values determined by sucrose density gradient ultracentrifugation were 13-14 S for hemolymph, and the sedimentation value was not altered by the inclusion of 0.4 M KCl throughout the gradient. The data indicated that H-A resembled the specific JH carriers and differed from the putative receptor of fat body cytosol by several criteria.

In the analysis of insect juvenile hormone (JH) function, metamorphosis is complicated by ecdysone and JH acting concurrently. Although JH stimulation of vitellogenin synthesis by the fat body is by no means simple, it is possible to focus on the events leading to selective transcription of a single gene. The two-striped grasshopper Melanoplus bivittatus was used to study nuclear binding of JH during vitellogenesis and to investigate proteins binding JH that have been found in hemolymph and fat body. M. bivittatus reproduction is regulated by JH. The fat body nuclei increased in ploidy with time after eclosion, and, because the antiallatotropin precocene completely inhibited vitellogenin production, we assume that this grasshopper differs little from Locusta migratoria in which JH stimulates transcription of the vitellogenin gene. Proteins that bind JH with high affinity were identified with the hydroxyapatite assay. Characterization of the JH-binding proteins included ion exchange chromatography, gel filtration, and polyacrylamide gel electrophoresis. Four proteins of hemolymph and three proteins of fat body bound JH with high affinity, and binding was competitively inhibited by JHIII. Short-term tissue culture was used to follow [3H]JH-III uptake by fat body and to determine the intracellular distribution of the hormone. Proteins that bound JH were extracted from nuclei with KCI, and they increased in number from the time of adult emergence to the time of maximum vitellogenin secretion. The JH-binding proteins from nuclei might be receptors that help regulate the selective expression of genes for vitellogenin and for other proteins induced by JH.

Juvenile hormone (JH), ecdysterone and some antibiotics cause Tenebrio molitor to form a second pupa or pupal-adult intermediate. Incorporation of labelled leucine into the cuticular proteins of JH-induced second pupae did not differ from incorporation in normal pupae, and the soluble cuticular proteins from these young second pupae were identical to those extracted from normal pupal exocuticle when analysed by SDS-polyacry lamide gel electrophoresis. However, as these second pupae aged, the major early bands did not undergo a normal decrease in staining intensity, indicating a JH effect on protein insolubilization (sclerotization). The transport of protein into the cuticle may also have been altered by JH; electrophoretic analysis of the new cuticle of treated animals showed intense staining of bands with RF’s similar to those of blood proteins. The new exocuticle produced after treatment of pupae with ecdysterone had soluble proteins which were typical of normal pupae, but extracts from such animals aged prior to cuticle removal yielded bands characteristic of normal adults. Pupae treated with actinomycin D occasionally form new abdominal cuticle with characteristic pupal morphology. These cuticles yielded soluble proteins which, upon analysis, had pupal, pupal and adult, or adult banding patterns. Animals treated with mitomycin C, although retaining vestiges of pupal abdominal characters, had adult cuticular proteins.

Several chemical agents have been identified which block interaction of the avian progesterone receptor with isolated nuclei, ATP-Sepharose, DNA-cellulose or phosphocellulose. Four of these inhibitors, rifamycin AF/013, o-phenanthroline, aurintricarboxylic acid and pyridoxal 5-phosphate appear to block directly binding of the activated receptor complex to the above “acceptors.” Another inhibitor, sodium molybdate, only blocks receptor interactions when added before receptor activation and therefore appears to interfere with the activation process. When nuclear receptor complexes were formed in vivo and labeled by nuclear exchange with [3H]progesterone in vitro these complexes could not be disrupted by incubation of the nuclei with inhibitors. Therefore, the receptor complex bound in nuclei appears to be modified or masked in a way which resists the action of these chemical agents. These results indicate the value of inhibitors as chemical probes for the analysis of steroid receptors.