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Fixed-time AI (FTAI) is a powerful tool for genetic improvement of extensively managed beef cattle. A genomewide association study (GWAS) was conducted to investigate genes and genetic markers associated with the outcome (pregnant or not pregnant) of FTAI in 614 commercial Brahman heifers genotyped for 18,895 SNP and imputed to 51,588 SNP. The likelihood of Brahman heifers becoming pregnant after hormonal treatment to synchronize ovulation followed by FTAI was influenced by the Bos indicuscontent of their genomes, as determined by a principal component analysis. The principal component analysis involved comparisons between the studied heifers and populations of known Bos taurusand B. indicusancestry. The heritability of FTAI outcome was h2= 0.18, which is higher than for most other reproductive outcome traits. The number of SNP associated with FTAI outcome was 101 (P< 0.001, false discovery rate = 0.53). Compared with all SNP tested, associated SNP had a tendency for highly divergent allelic frequencies between B. indicusand B. taurus. Associated SNP were located in nearly all chromosomes, a result that shows a complex genetic architecture that is typical of highly complex traits with low heritability. Considering this and previous GWAS that examined Brahman heifer puberty and postpartum anestrus interval, 3 genomic regions emerge as important for overall Brahman heifer fertility, which mapped to chromosomes 1, 7, and 9. Further analyses, including improved genome annotation, are required to elucidate the link between these regions and heifer fertility. Additional studies are needed to confirm SNP and gene associations reported herein and further elucidate the genetics of FTAI outcome. Future GWAS should target other Braham populations and additional cattle breeds with FTAI records, including breeds with higher B. taurusancestry.

The welfare outcomes for Bos indicuscattle (100 heifers and 50 cows) spayed by either the dropped ovary technique (DOT) or ovariectomy via flank laparotomy (FL) were compared with cattle subjected to physical restraint (PR), restraint by electroimmobilization in conjunction with PR (EIM), and PR and mock AI (MAI). Welfare assessment used measures of morbidity, mortality, BW change, and behavior and physiology indicative of pain and stress. One FL heifer died at d 5 from peritonitis. In the 8-h period postprocedures, plasma bound cortisol concentrations of FL, DOT, and EIM cows were not different and were greater (P< 0.05) than PR and MAI. Similarly, FL and DOT heifers had greater (P< 0.05) concentrations than PR and MAI, with EIM intermediate. Creatine kinase and aspartate aminotransferase concentrations were greater (P< 0.05) in FL and EIM heifers compared with the other treatments, with a similar pattern seen in the cows. Haptoglobin concentrations were significantly (P< 0.05) increased in the FL heifers compared with other treatments in the 8- to 24-h and 24- to 96-h periods postprocedures, and in cows were significantly (P< 0.05) increased in the FL and DOT compared with PR in the 24- to 96-h period. Behavioral responses complemented the physiological responses; standing head down was shown by more (P< 0.05) FL cows and heifers to 3 d postprocedures compared with other treatments, although there was no difference between FL and DOT heifers at the end of the day of procedures. At this same time, fewer (P< 0.05) FL and DOT heifers and cows were observed feeding compared with other treatments, although in cows there was no difference between FL, DOT, and EIM. There were no significant differences (P> 0.05) between treatments in BW changes. For both heifers and cows, FL and DOT spaying caused similar levels of acute pain, but FL had longer-lasting adverse impacts on welfare. Electroimmobilization during FL contributed to the pain and stress of the procedure. We conclude that: i) FL and DOT spaying should not be conducted without measures to manage the associated pain and stress; ii) DOT spaying is preferable to FL spaying; iii) spaying heifers is preferable to spaying cows; and iv) electroimmobilization causes pain and stress and should not be routinely used as a method of restraint.

Despite the importance of congenital viral infections in both veterinary and human medicine, only limited experimental work has been carried out to elucidate the mechanisms involved in transplacental virus infections. To further an understanding of fetal infection with pestiviruses, the distribution of bovine pestivirus in the uterine and fetal tissues of ewes in early pregnancy, following a natural route of infection, was investigated. On the 18th day of pregnancy, nine ewes were inoculated by the intranasal route with 1 X 10550% tissue culture infective doses of an Australian isolate of noncytopathic bovine pestivirus (bovine viral diarrhea virus genotype 1). All ewes were ovariohysterectomized at approximately 100 hours postinfection. Samples from the reproductive tract and conceptus were examined histologically and tested for bovine pestivirus by nested reverse transcription–polymerase chain reaction (RT-PCR) and immunohistochemistry and for interferon-tau mRNA expression by nonnested RT-PCR. Although no histopathologic changes were observed in the maternal or fetal tissues, virus was detected in the reproductive tract of all nine ewes and in all of the conceptuses examined. At the time of surgery, only two of the nine ewes were demonstrably viremic. This study demonstrates that bovine pestivirus can spread from a natural site of infection to the ovine fetus within 4 days in the absence of maternal immunity and despite the presence of interferon expression in the reproductive tract.

To identify genes that are differentially expressed by Na+, K+-ATPase inhibitors, we used the differential display technique to compare mRNA expression patterns in rat lens. Lenses were treated with 10 microM ouabain, bufalin, or 19-norbufalin derivative for 24 h and were compared with control lenses. Differential display analysis revealed that one of the down-regulated genes was 14-3-3 theta. Down-regulation was confirmed by Northern blot and by reverse transcription-polymerase chain reaction analysis. Reverse transcription-polymerase chain reaction of additional 14-3-3 isoforms revealed that the eta and gamma isoforms of 14-3-3 are also down-regulated by ouabain, bufalin, and 19-norbufalin derivative, whereas the zeta isoform is down-regulated only by bufalin. Down-regulation of the 14-3-3 isoforms occurred without a significant change in gamma-crystallin gene expression. These results demonstrate that one of the consequences of Na+, K+-ATPase inhibition by exogenous or endogenous inhibitors is the down-regulation of mRNA transcripts encoding several isoforms of 14-3-3. Because the 14-3-3 proteins are multifunctional regulatory proteins, the reduction in the abundance of various isoforms will have profound effects on cell function.

Induction of aldose reductase (AR) was observed in human cells treated with tumor necrosis factor-alpha (TNF-alpha). AR protein expression increased severalfold in human liver cells after 1 day of exposure to 100 units/ml TNF-alpha. An increase in AR transcripts was also observed in human liver cells after 3 h of TNF-alpha treatment, reaching a maximum level of 11-fold at 48 h. Among the three inflammatory cytokines: TNF-alpha, interleukin-1, and interferon-gamma, TNF-alpha (100 units/ml) gave the most induction of AR. Differences in the pattern of AR induction were observed in human liver, lens, and retinal pigment epithelial cells with increasing concentrations of TNF-alpha. A similar pattern of AR promoter response was observed between TNF-alpha and osmotically stressed human liver cells. The deletion of the osmotic response element (ORE) abolished the induction by TNF-alpha and osmotic stress. A point mutation that converts ORE to a nuclear factor-kappaB (NF-kappaB) sequence abolished the osmotic response but maintained the TNF-alpha response. Electrophoretic gel mobility shift assays showed two NF-kappaB proteins, p50 and p52, capable of binding ORE sequence, and gel shift Western assay detected NF-kappaB proteins p50 and p65 in the ORE complex. Inhibitors of NF-kappaB signaling, lactacystin, and MG132 abolished the AR promoter response to TNF-alpha.

Initiatives to improve epilepsy care have emphasized the role of specialist nurses. Formal evaluation of these initiatives are scarce. Further evaluative studies are required to ascertain the optimal means of providing epilepsy care. This study aimed to assess the effect of a primary-care-based epilepsy specialist nurse service on patients' reported health status, perceived quality of life, health care use, attitudes to health care, and provision of information. A quasi-experimental follow-up questionnaire survey was sent to all 574 patients aged 16 years or over and receiving antiepileptic drugs for epilepsy, registered in 14 general practices in north-west Bristol. Patients in seven practices who received the new service (intervention patients) were compared with patients in seven practices who did not (control patients). Follow-up comparisons between intervention and control patients were adjusted for baseline differences. Response rates to the first, second and both surveys were 66.2%, 68.6% and 50.9%, respectively. Intervention patients were more likely than control patients to have discussed most epilepsy topics with general practitioners and/or hospital doctors, and were significantly more likely to have categorized general practitioner care as excellent (odds ratio (OR) 2.30, 95% confidence intervals (CI) 1.12–4.70). Intervention patients were significantly less likely than controls to have reported never missing taking their anti-epileptic drugs (OR 0.48, 95% CI 0.24–0.94). There were no significant changes in measures of health status, use of other health care services, and perceived quality of life between intervention and control patients. This study provides evidence of an improvement, after 1 year, in communication and satisfaction but not health status resulting from the introduction of a primary-care-based epilepsy service.

Nineteen calves with a clinical history of posterior weakness or ataxia were examined at necropsy. Dorsoventral narrowing of the vertebral canal and myelopathy were found in the thoracic and lumbar areas of the spinal cord; vertebral metaphyseal growth plates had focal areas of premature closure. Malformation of the cranial base and hydrocephalus were also observed. Shortening of lung bones and malformation of long bone epiphyses were prominent findings and were associated with focal premature closure of metaphyseal growth plates. The cause of these lesions is unknown; possible causes, including a maternal deficiency of manganese, are discussed.

Histomorphologic, histochemical, and atomic absorption analysis studies were performed on liver tissue from 623 clinically normal purebred and mixed-breed dogs to assess the range of hepatic copper concentrations, the histologic distribution of copper, and the histomorphologic changes associated with the various copper concentrations that were found. Atomic absorption analysis revealed a continuous numerical spectrum ranging from less than 100 parts per million on a dry weight basis (ppm dw) to more than 2,000. No decisive numerical criterion was found that could be used to separate normal from abnormal copper concentrations because of this continuous array. The threshold for histochemical demonstration of copper-containing granules using rhodanine or rubeanic acid staining was 400 ppm dw. At this concentration the copper-containing granules were located in the centrilobular hepatocytes (zone 3 of Rappaport). Copper-containing granules were found in the midzonal and periportal hepatocytes (zones 2 and 1 of Rappaport) in livers with 1,000 ppm dw and higher copper concentrations. The majority of the 623 livers were normal histomorphologically. Multifocal hepatitis characterized by mixed inflammatory cell accumulation and centrilobular distribution was found to be associated with copper concentrations in the range of 2,000 ppm dw or higher. An appropriate upper limit for normal hepatic copper concentration in the dog was not determined based on the present study.

The two-parameter model In f= a+b ln ?is widely accepted in the literature as providing a good fit to the soil moisture characteristic for a wide variety of soil types. This model is examined and it is shown that the parameters aand bare not independent, and hence that the SMC may be represented by a one-parameter model with little loss of accuracy. Thus it is possible to define the SMC from one paired measurement of soil water content against potential. Because this single paired measurement is all that is required it also avoids the necessity of classification of the soil type–indeed it may provide an additional means of soil identification.

The relationships among functional independence, perceived family functioning and duration of disability were studied in 41 non-institutionalised post-traumatic spinal cord injury (SCI) families. Correlational analyses revealed that SCI subjects with greater self initiation of activities, increased social involvement and higher overall level of independence perceived their family environment as affectively responsive, open in communication and clear in delineation of role responsibilities. The ‘significant other's’ (A ‘significant other’ is designated by the SCI subject as ‘the one most involved with you’. The ‘significant other’ had to be living with or within 25 miles of the SCI subject and in contact at least 3 times a week.) view of the family was unrelated to SCI function. Conversely, for the significant other but not the SCI subject, greater duration of disability predicted more concern for the family's ability to problem solve, delineate roles and maintain standards of behaviour control. Of the functional areas measured, only participation in outside activities increased significantly over time. The results are discussed in terms of the importance of considering the long-term and separate rehabilitation needs of the individual with a SCI and his or her family.

Summary

A new and essential cis-element AEE (aldose reductase enhancer element), necessary for the constitutive activity and the osmotic stress response of rat aldose reductase transcription in a rat liver cell line, has been identified. In transient transfection assays, an increase in promoter activity, up to 3.8-fold, was observed with osmotic stress (600 mosm/kg H2O) using a luciferase reporter gene construct containing aldose reductase promoter sequence from -1,094 base pair (bp) to +23 bp. A deletion between -1,071 and -895 bp reduced the constitutive activity and abolished the osmotic response of the promoter. Exonuclease III mediated in vivo DNA footprinting and dimethyl sulfate in vivo footprinting revealed DNA protection of a 32-bp region and two guanosines (G) within this region protected from methylation, respectively. Electrophoretic gel mobility shift assays using whole liver cell extracts showed protein binding, under both normal and stressed conditions. Deletion of the sequence between the two guanosines protected by in vivo dimethyl sulfate DNA footprinting (GAAGAGTG) in a luciferase construct (-1,094 bp to +23 bp) abolished the constitutive promoter activity. One copy of AEE fused to the thymidine kinase promoter gave a maximum constitutive activity of 7.7-fold and a maximum osmotic response activity of 6. 7-fold.

Autoantibodies to thyroid microsomes were more frequent in 102 infertile men with complement-dependent sperm-immobilizing activity (sperm immobilization test [SIT]) in serum (11.8%) than in a control group of 277 men of comparable ages and semen quality without sperm antibodies (4.3%, P< 0.05). Frequencies of organ-specific antibodies (antigastric parietal cell, antithyroglobulin, and antithyroid microsome) in 57 men with genital tract obstructions and positive SIT were similar to those for control subjects, and there were no significant differences in the frequencies of nonorgan-specific autoantibodies (antinuclear antibody, rheumatoid factor, antimitochondrial, and anti-smooth muscle) in the three groups. Because in men without genital tract obstruction antithyroid microsomal autoantibodies were more common with sperm antibodies than without, the possibility of a genetic factor in the causation of sperm autoimmunity should be considered.

When 73 heifers (60 of which were seronegative to pestivirus) were inseminated with pestivirus‐contaminated semen from a transiently infected bull, the conception rate to a single insemination was found to be normal (65 per cent). Only three animals became systemically infected, as determined by viraemia and seroconversion. Pestiviru was isolated from the reproductive tracts of two of these heifers when they were slaughtered 42 or 43 days after insemination. Although the initial incidence of infection was low, a cycle of secondary transmission occurred approximately 29 days after insemination, with a further eight heifers (all seronegative) becoming infected from one group of 11 seronegative and four seropositive animals.

Collection of semen using a modified ovine artificial vagina was attempted on 90 occasions from 25 Queensland koalas (Phascolarctos cinereus adustus). Complete ejaculates consisting of a copulatory plug and sperm fraction were collected on 36 occasions (40%) from 19 animals. Seventeen of the males produced a complete ejaculate on their first or second service. Failure to collect semen (38%) and the collection of partial ejaculates (14.5%) was attributed to lack of sexual interest, aggressive behaviour towards the female by the male, the use of non-compliant teaser females or a distinct dislike of the artificial vagina. Only a few ejaculates were contaminated with urine (4.5%) or obtained after ejaculation behaviour was terminated (3%). The mean (± sem) values for the seminal characteristics of 19 complete ejaculates were: mass of copulatory plug fraction 0.78 ±0.10 g, sperm fraction volume 0.73 ± 0.10 ml, sperm concentration 165.1 ± 26.7 × 106ml−1, pH of sperm fraction 6.7 ± 0.2, osmolarity of sperm fraction 315.0 ± 5.4 mOsm, percentage forward motility 70.7 ± 1.8%, rate of sperm movement 4.0 ±0.1 and percentage of abnormal spermatozoa 26.9 ± 2.5%. Percentages of sperm head morphotypes and tail abnormalities were documented. Although the artificial vagina technique is limited by the need for access to oestrous females, the procedure described has been shown to be a simple, reliable method of collecting semen from captive koalas.

ObjectiveTo determine the proportion and incidence of calves persistently infected with bovine pestivirus in calves (n = 1521) supplied to the Tick Fever Research Centre and to assess the test regime to detect calves persistently infected with bovine pestivirus.

Neurons of the nucleus raphe magnus (NRM) and adjacent nucleus reticularis gigantocellularis pars alpha (NGCp alpha) receive a tonic inhibitory input from gamma-aminobutyric acid (GABA)-ergic neurons that is mediated by GABAA receptors. However, comparatively little is known about the role of GABAB receptors in these nuclei. The present study examined the effects on nociceptive threshold of microinjection of a wide dose range (0.1-150 ng) of the GABAB receptor agonist, baclofen hydrochloride (BAC), in the NRM, NGCp alpha or the nucleus reticularis giganto-cellularis (NGC). Microinjection of low doses of R(+)-BAC (0.1-1.0 ng) in the NRM or the NGCp alpha, but not the NGC increased response latencies in the tail flick test. As the dose of BAC was increased to 30.0 to 50.0 ng, response latencies in the tail flick test diminished to control values. Microinjection of the highest dose, 150 ng, in either the NRM, NGCp alpha or NGC significantly decreased response latencies in the tail flick test. Response latencies in the hot plate test were not increased by microinjection of 0.1 to 5.0 ng of R(+)BAC in the NRM, NGCp alpha or NGC. Although hot plate latency was increased after microinjection of 30.0 to 50.0 ng of R(+)-BAC in these nuclei, the effect was confounded by the occurrence of motor dysfunction. The effects of BAC were stereospecific as nociceptive threshold and motor function were not altered by microinjection of either 0.5 ng or 150 ng of the less active stereoisomer, S(-)-BAC. The biphasic effect of R(+)-BAC suggests the existence of multiple mechanisms by which GABAB receptors modulate the activity of neurons in the ventromedial medulla. It is proposed that the antinociception produced by low doses of R(+)-BAC results from disinhibition (activation) of neurons in the NRM and NGCp alpha as a consequence of the presynaptic inhibition of inhibitory GABAergic and/or noradrenergic inputs. The decrement in antinociceptive effect and hyperalgesia produced by higher doses of R(+)-BAC may result from a presynaptic inhibition of excitatory inputs to the NRM and NGCp alpha, postsynaptic hyperpolarization of neurons in these nuclei or the unmasking of a descending facilitatory pathway originating from the NRM, NGCp alpha and NGC.

An enzyme-linked immunosorbent assay (ELISA) was developed for the detection of Streptococcus pneumoniae polysaccharide antigen in cerebrospinal fluid and serum. Sensitivity and specificity were determined for purified antigen preparations. Specificity was also evaluated in the rabbit meningitis model, and the sensitivity was compared to counterimmunoelectrophoresis, using the infected rabbits' cerebrospinal fluid and serum. The ELISA was a specific technique for detecting S. pneumoniae antigen. ELISA was 25 times more sensitive than counterimmunoelectrophoresis for purified antigen and resulted in an increased positivity of the cerebrospinal fluid and serum from infected rabbits. ELISA should prove very useful in the diagnosis of pneumococcal infections.

The aim of this study was to assess the severity of epilepsy and its effect on patients lives, and to describe patients' use of and attitudes to health care.

Introduction:Mastery learning, which deconstructs a complex task into sequential sub-steps combined with deliberate practice to achieve each step in sequence, represents an important method to enhance simulation-based procedural skills training. However, the evidence to support the effectiveness of this theory to improve learning is lacking. This study compared mastery learning using deliberate practice with self-guided practice on skill performance of a rarely performed, life-saving procedure, a bougie-assisted cricothyroidotomy (BAC). Methods:In this multi-centre, randomized study at five North American emergency medicine (EM) residency training programs, we assigned 166 EM postgraduate trainees to either mastery learning and deliberate practice (ML + DP) or self-guided practice for BAC. Three blinded airway experts independently evaluated BAC skill performance by video review before (pre-test) and after (post-test) each training session. The primary outcome was post-test skill performance using a 5-point global rating score (GRS). A secondary outcome, defined a priori, was performance time to complete the BAC skill (chronometry). Results:There was no significant difference in post-test BAC performance after ML + DP or self-guided practice. Performance scores improved for both groups by 13% from the pre-test to post-test (F (1,138) = 43, p < 0.001). Overall, time to complete the BAC improved significantly from pre-test (87.6 seconds) to posttest (54.1 seconds), (F, 1,149) = 122, p < 0.001). At post-test, the ML + DP group performed the skill 7.4 seconds faster than the self-guided practice group (F (1,150) = 6.77, p < 0.01). Conclusion:Mastery learning coupled with deliberate practice provides systematic and focused feedback during skill acquisition. However, it is resource intensive and its efficacy is not fully defined. In this study, MP + DP did not result in improved global performance; it did result in faster performance times, a relevant finding for time-sensitive procedures. These results are important for educators who seek to optimize technical skills training in a competency-based model of medical education. Our findings suggest that time-sensitive procedures might benefit from ML + DP teaching strategies to enhance time to procedural performance.

A new tract scoring system for age at puberty (RTSCORE) has been proposed for application in Northern Australian beef herds. RTSCORE is an indirect measure of age at first corpus luteum (AGECL), which is an accurate, intensively collected phenotype but has limited feasibility for large scale commercial application. When measurements are taken in unrelated herds it is possible to use multivariate genomic prediction to compare RTSCORE to other puberty related traits, such as AGECL. Here we use this methodology to evaluate the ability of RTSCORE to accurately predict genomic estimated breeding values (GEBV) for age at puberty. We also evaluate the effect of including AGECL phenotypes on GEBV accuracy for RTSCORE. Multi-trait best linear unbiased prediction with a multi-breed, across-population genomic relationship matrix derived from 728,000 imputed SNP markers was used to compare AGECL in a population of 894 Brahman and 1088 Tropical Composite heifers and RTSCORE in a population of 979 Brahman, 1803 Santa Gertrudis, and 914 Droughtmaster heifers. GEBV accuracy from within-herd predictions of puberty were compared to GEBV accuracies from a combined reference population containing both measures of puberty. The inclusion of heifers with RTSCORE and corresponding genotypes improved the accuracy of genomic evaluations for AGECL compared to within-herd predictions. Although across-herd prediction of puberty using RTSCORE for training resulted in accuracies that were low, this was expected given a correlation between RTSCORE and AGECL of -0.66. These results suggest that RTSCORE is an appropriate measure of puberty and can be used to accurately predict age at puberty. Including both populations in the reference herd for prediction of RTSCORE resulted in either no change or slight improvement in accuracy. As RTSCORE is not an exact measure of puberty, AGECL should be included with RTSCORE when predicting genomic breeding values for puberty in a commercial setting.

The effects of recombinant interleukin-1β (rIL-1β), recombinant tumor necrosis factor (rTNFα) and two growth factors, basic fibroblast growth factor (bFGF) and epidermal growth factor (EGF) on PLA2 activity and prostaglandin E2 (PGE2) release were investigated using rabbit chondrocytes. Cellular PLA2 activity increased 2–10×above controls in the presence of 8×10−12M (5 U) rIL-1β or 5×10−9M rTNFα after 20 hr incubation. PLA2 activity remained constant with 1–50 ng/ml of either growth factor. PGE2 release significantly increased (p<0.05) when the chondrocytes were incubated with rIL-1β, bFGF and EGF alone, but not with rTNFα above. These data suggest PLA2 activity and PGE2 release are not coordinately regulated in rabbit chondrocytes.

Introduction:Hospital shootings are rare events that pose extreme and immediate risk to staff, patients and visitors. In 2015, the Ontario Hospital Association mandated all hospitals devise an armed assailant Code Silver protocol, an alert issued to mitigate risk and manage casualties. We describe the design and implementation of ASSIST (Active Shooter Simulation In-Situ Training), an institutional, full-scale hybrid simulation exercise to test hospital-wide response and readiness for an active shooter event, and identify latent safety threats (LSTs) related to the high-stakes alert and transport of internal trauma patients. Methods:A hospital-wide in-situ simulation was conducted at a Level 1 trauma centre in downtown Toronto. The two-hour exercise tested a draft Code Silver policy created by the hospital’s disaster planning committee, to identify missing elements and challenges with protocol implementation. The scenario consisted of a shooting during a hospital meeting with three casualties: a manikin with life-threatening head and abdomen gunshot wounds (GSWs), a standardized patient (SP) with hypotension from an abdominal GSW, and a second SP with minor injuries and significant psychological distress. The exercise piloted the use of a novel emergency department (ED)-based medical exfiltration team to transport internal victims to the trauma bay. The on-call trauma team provided medical care. Ethnographic observation of response by municipal police, hospital security, logistics and medical personnel was completed. LSTs were evaluated and categorized using video framework analysis. Feasibility was measured through debriefings and impact on ED workflow. Results:Seventy-six multidisciplinary medical and logistical staff and learners participated in this exercise. Using a framework analysis, the following LSTs were identified: 1) Significant communication difficulties within the shooting area, 2) Safe access and transport for internal casualties, 3) Difficulty accessing hospital resources (blood bank) 4) Challenges coordinating response with external agencies (police, EMS) and 5) Delay in setting up an off-site command centre. Conclusion:In situ simulation represents a novel approach to the development of Code Silver alert processes. Findings from ethnographic observations and a video-based analysis form a framework to address safety, logistical and medical response considerations.

Introduction:Discharge from the Emergency Department (ED) is a high-risk period for communication failures. Clear verbal and written discharge instructions at patient-level health literacy are fundamental to a safe discharge process. As part of a hospital-wide quality initiative to measure and improve discharge processes, and in response to patient feedback, the St. Michael’s Hospital ED and patient advisors co-designed and implemented patient-centred discharge handouts. Methods:The design and implementation of discharge handouts was based on a collaborative and iterative approach, including stakeholder engagement and patient co-design. Discharge topics were based on the 10 most common historical ED diagnoses. ED patient advisors and the hospital’s plain language review team co-designed and edited materials for readability and comprehension. Process mapping of ED workflow identified opportunities for interventions. Multidisciplinary ED stakeholders co-led implementation, including staff education, training and huddles for feedback. Patient telephone surveys to every 25thpatient presenting to the ED meeting the study inclusion criteria (16 years of age or older, directly discharged from the ED, speaks English, has a valid telephone number, and has capacity to consent) were conducted both pre- (June-Sept 2016) and post- (Oct-Dec 2016) implementation. Results:Stakeholder engagement and co-design took place over 10 months. Education was provided across one MD staff meeting, four RN inservices, and at monthly learner orientation. 44846 patients presented to the ED and 25600 met the study inclusion criteria. 935 surveys (response rate=97%; declined n=30) were completed to date. Pre-implementation (n=467), 9.2% (n=43) of patients received printed discharge materials and 71% (n=330) understood symptoms to look for after leaving the ED. Post-implementation (n=468), 44% (n=207) of patients received printed discharge materials with 97% (n=200) finding the handouts helpful and 82% (n=385) understanding symptoms to look for after leaving the ED. Conclusion:Through the introduction of patient co-designed and patient-centred discharge handouts, we have found a marked improvement in patient understanding, and consequently safer discharge practices. Future efforts will focus on optimizing discharge communication, both verbal and written, tailored to individual patient preferences.

The transition from paediatric to adult neurodisability services can be a challenging time for young people and their families. This vulnerable group have complex needs encompassing healthcare, social care and education sectors. A new transition clinic for young people with complex neurodisability was established in 2015. Our aim was to ensure a patient-centred approach in developing and improving the current transition service in accordance with NICE guidelines on transition (2016) and cerebral palsy (2017).The patient cohort was derived from young people referred from the paediatric neurodisability service to the transition ‘spasticity’ clinic since its establishment in 2015. We used a two pronged apporach in the form of audit and telephone interviews. The audit criteria were derived from NICE guidelines and involved reviewing patients‘ notes and clinic letters. The structured telephone interviews with patients and parents enabled us to get qualitative feedback on the existing service.Our cohort of 8 patients were transitioned from paediatric to adult services at a mean age of 17.2 years. As well as the adult neurologist, a paediatrician was present in the transition clinic in 7 of 8 cases. An adult physiotherapist was present in 6, but a paediatric physiotherapist was only present in 2. Strengths demonstrated during the clinic included discussing communication and learning needs (7 out of 8). Weaknesses included discussing emotional health and planning future involvement of parents/carers. Communication with GPs was present in 5 out of 8 (formal transition letter with GP CC’d). 6 families gave us qualitative feedback.Based on our results and responses, we co-produced a leaflet with young people and their families on what to expect from the transition process including information about the transition clinic and possible discussion topics, practical information such as new contact details and where to seek emergency care. We also produced a matching ‘Patient Passport’ to be used as a checklist in the transition clinic to ensure that all aspects of care are covered in the discussion. We hope these interventions will encourage autonomy and informed decision making in the transition process.

Background and aimsThere is a high burden of mental health (MH) problems among children with epilepsy. The relationship between MH problems and epilepsy is bidirectional with shared risk factors. Our key aims were:To determine the prevalence of MH difficulties among the patients of our Secondary Paediatric Epilepsy Service.To ascertain if more input from MH services is required within the Secondary Paediatric Epilepsy Service.To demonstrate the use of a standardised behavioural screening questionnaire in assessing MH difficulties.MethodsThe Strengths and Difficulites Questionnaire (SDQ) was used to screen for those at risk of, or currently experiencing MH problems. We received 86 replies and, following exclusions, 64 patients data was analysed. The patient’s electronic notes were used to determine diagnoses and medications.Results56% of patients scored high or very high risk for having or developing MH difficulties. A chi- square test indicated a significant difference (p<0.001) in the proportion of children with epilepsy with clinically significant scores versus the proportion in the community samples. Peer and pro-social subdomains scored in the ‘high’ risk category whilst the other subdomains scored in ‘close to average’ risk. Patients not on anti-epileptic drugs have close to average scores. There is trend towards those on more than 1 Antiepileptic drug having higher scores. Developmental disorder increases that risk of having a high or very high score from 43% to 68%.ConclusionsOur results reflect similar prevalence to that demonstrated in the literature; children with epilepsy have a high risk of developing MH disorders. Our data highlights the need to improve identification, diagnosis, prevention and management of MH problems in children with epilepsy on both a national and local level.