Search

Lymphatic complications following vascular procedures involving the groin require prompt treatment to limit morbidity. Several treatments have been described, including conservative management, aspiration, sclerotherapy, and direct lymphatic ligation with or without a muscle flap have been described. To date, there is no data indicating which treatment results in the shortest time to recovery. We sought to address this gap by conducting a retrospective cohort study.We reviewed all patients who developed a lymphatic complication after undergoing an open revascularization procedure in the groin between 2014 and 2020 in which plastic surgery was involved in the closure. A control group consisted of patients from the same timespan who did not develop a lymphatic complication. Demographics, comorbidities, operative details, and outcomes were compared between these groups. For cases identified with a lymphatic complication, the method of diagnosis, culture data, and treatment details were collected, and outcomes were compared for surgical management versus sclerotherapy.There were 27 lymphatic complications and 60 control patients. The complication group had a higher incidence of aortofemoral bypass (25.8% vs. 8.3%, P = 0.04), and a lower incidence of femoral-to-distal bypass (11.1% vs. 45.0%, P0.01). Daily drain output volume from postoperative days 1-5, and days 6-10, was significantly higher in the complication group than in the controls (194.0 vs. 44.0, P0.01; and 429.5 vs. 35.0, P0.01, respectively). In the lymphatic leak group, 16 patients (59.3%) had surgical treatment and six (22.2%) had sclerotherapy. Of those who had surgery, 71.4% had successful outcomes without the need for an additional intervention, whereas all of the patients analyzed who were treated with sclerotherapy had successful outcomes without further intervention. The average time to resolution was significantly shorter for surgery than for sclerotherapy (38.7 vs. 86.0 days, P = 0.03).Daily postoperative drain volume can assist with early diagnosis of a lymphatic leak in the groin following an open revascularization procedure. Sclerotherapy and surgery were each successful, but surgery resulted in significantly shorter times to resolution. In the appropriate candidates, surgery should be considered first line management of a lymphatic leak.

BACKGROUND Complications following vascular procedures involving the groin can lead to significant morbidity. Achieving stable soft tissue coverage over sites of revascularization can help mitigate complications. Prior evidence supports the use of muscle flaps in reoperative groins and in high risk patient populations to reduce postoperative complications. Data regarding the use of prophylactic muscle flap coverage of the groin is lacking. Therefore, the purpose of this study is to evaluate the effect of immediate prophylactic muscle flap coverage of vascular wounds involving the groin. METHODS A retrospective cohort study was performed on all patients undergoing primary open vascular procedures involving the groin for occlusive, aneurysmal, or oncologic disease between 2014 and 2020 at a single institution where plastic surgery was involved in closure. Patient demographics, comorbidities, surgical details, and postoperative complications were compared between patients who had sartorius muscle flap coverage of the vascular repair versus layered closure alone. RESULTS A total of 133 consecutive groins were included in our analysis. A sartorius flap was used in 115 groins (86.5%) and a layered closure was used in 18 (13.5%). Wound breakdown was similar between groups (25.2% sartorius vs. 38.9% layered closure, P = 0.26). However, the rate of reoperation was significantly higher in the layered closure group (50.0% vs. 12.2%, P < 0.01). Among patients who experienced wound breakdown (N = 36), a larger proportion of layered closure patients required operative intervention (71.4% vs. 20.7%, P = 0.02). Other rates of complications were not statistically different between groups. CONCLUSIONS In patients undergoing primary open vascular procedures involving the groin, patients who underwent prophylactic sartorius muscle flap closure had lower rates of reoperation. Although incisional breakdown was similar between the groups overall, the presence of a vascularized muscle flap overlying the vascular repair was associated with reduced need for reoperation and allowed more wounds to be managed with local wound care alone. Consideration should be given to this low morbidity local muscle flap in patients undergoing vascular procedures involving the groin.

Background People with haemophilia A and inhibitors (PwHi) suffer more orthopaedic complications, bleeding and pain than those without inhibitors. The advent of emicizumab as a prophylactic treatment has led to a reduction in bleed frequency and a significant improvement in overall quality of life. No research to date has examined the nature of this improvement on treated individuals and their families. Aims The Emi & Me study aims to capture the real‐life experience of using emicizumab for PwHi and their families. Methods Participants were recruited through treatment centres, social media and by word of mouth. Each participant and a family member, if available, took part in a semistructured qualitative interview. All interviews were recorded, transcribed verbatim and analysed thematically. All elements of the study were reviewed by local statutory authorities and informed consent was sought from all participants. Results Fifteen PwHi, mean age 27.2 years (range 8–63 years), most with a family member, participated in a single qualitative interview online (n = 13), by telephone (n = 1) or in person (n = 1). Mean time on emicizumab was 2.26 years (range 1–5 years). Six major themes emerged: bleeds; pain; treatment burden; control; freedom (for both PwHi and family members) and missed potential. Emicizumab prophylaxis has delivered significant improvements in the lives of the participants. Despite these improvements, some participants felt that their pre‐existing physical disabilities and the lack of physiotherapy provision had prevented them achieving similar improvements in their functional ability. Conclusion This study shows that in reducing bleeds, pain and treatment burden, emicizumab had given PwHi greater control over their condition, allowing a sense of freedom they had not experienced with factor VIII or bypassing agent prophylaxis. However, for emicizumab to be truly effective, there is a need to ensure the continued availability and accessibility of robust multidisciplinary support services. Without this, it is unlikely that PwHi will realize the life‐changing potential offered either by emicizumab or any other novel treatment approach. Patient or Public Contribution A patient participant (who did not wish to be included as an author of the paper) was involved in the design of the study protocol and interview guide.

Acute pain after mastectomy is increased with concurrent breast reconstruction. One postulated advantage of prepectoral breast reconstruction is less postoperative pain; however, no comparisons to partial submuscular reconstruction have been made to date. Here, we examined the postoperative pain experienced between patients with prepectoral and subpectoral breast reconstruction after mastectomy.We performed a retrospective chart review of all patients undergoing immediate breast reconstruction with tissue expanders from 2012 to 2019 by a single plastic surgeon. Patient demographics, surgical details, and anesthetic techniques were evaluated, and our primary outcome compared postoperative opioid usage between prepectoral and subpectoral reconstructions. Our secondary outcome compared pain scores between techniques.A total of 211 subpectoral and 117 prepectoral reconstruction patients were included for analysis. Patients with subpectoral reconstructions had higher postoperative opioid usage (80.0 vs 45.0 oral morphine equivalents, P0.001). Subpectoral patients also recorded higher maximum pain scores compared with prepectoral reconstructions while admitted (7 of 10 vs 5 of 10, P0.004). Multivariable linear regression suggests that mastectomy type and subpectoral reconstruction were significant contributors to postoperative opioid use (P0.05).Prepectoral breast reconstruction was associated with less postoperative opioid consumption and lower postoperative pain scores as compared with subpectoral reconstruction, when controlling for other surgical and anesthesia factors. Future randomized controlled trials are warranted to study how postoperative pain and chronic pain are influenced by the location of prosthesis placement in implant-based postmastectomy breast reconstruction.

The music that was produced in Dunedin, New Zealand, during the 1980's occupies a unique place in the global indie music canon. In writing about this supposed ‘Dunedin sound,' critics and scholars alike have fixated on the city's remoteness: it is believed to be distant from metropolitan centres of music industry power and influence, and consequently supported a subversive and democratised local music scene. This article explores the implications of the ongoing historicisation of Dunedin's popular music scene along these lines, and highlights the ways in which the valorisation of the city’s musical heritage obstructs problematic power dynamics that impact the way young musicians in the city express place and musical identity. Our research applies an embedded participatory ethnography to unpack the ideological positions occupied by contemporary local musicians, and to critique factions within the contemporary musical scene in the city.

A particular problem arises for the translator when a word has no equivalent in the target language, because what it refers to is something that the speakers of that language simply do not think. The French term mouvement is a case in point. All French dictionaries give prominence to a definition of the term which relates it to impulse, sentiment and passion and characterizes it positively as a ‘sign of life’. By contrast, although the OED records that movement may refer to ‘a “moving” of the mind’, ‘an impulse of desire or aversion’, it defines this usage as now obsolete. The article begins by tracing the problem as it arose during the translation of some of Maurice Blanchot's early writings, before going on to show that, in Blanchot's use of it, the term mouvement eventually parts company with all of its received meaning in French, and refers to the movement whereby language itself becomes writing when image is allowed priority over rational thought. From having been a problem, therefore, the interruption of exchange between French and English for the translator of mouvement foregrounds translation itself as the site of an original mode of writing.

Herein, we subject formamidinium lead iodide films to oxygen-containing gases (flowing O

Quality improvement (QI) in healthcare is a cultural transformation process. We explored how routine reporting could be developed to aid visibility of the process for QI governance.A retrospective evaluation of QI projects in a large healthcare organisation was conducted. We used an online survey so that the data accrual process resembled routine reporting to help identify implementation challenges. A purposive sample of QI projects was targeted to maximise contrast between projects that were or were not successful as determined by the resident QI team. To hone strategic focus in what should be reported, we also compared factors that might affect project outcomes.Out of 52 QI projects, 10 led to a change in routine practice ('adoption'). Details of project outcomes were limited. Project team outcomes, indicative of capacity building, were not systematically documented. Service user involvement, quality of measurement plan, fidelity of plan-do-study-act (PDSA) cycles had a major impact on adoption.Designing a routine reporting framework requires an iterative process to navigate data accrual demands. A retrospective evaluation, as in this study, can yield empirical insights to support development of QI governance, thereby honing the implementation science of QI in a healthcare organisation.

Aesthetic science is a rapidly growing discipline that involves plastic surgery as much or more than other disciplines of science. Fortunately, how and why the human brain responds to the visual world is better understood now than ever before. Of necessity plastic surgery is a part of that aesthetic science movement because it deals directly with the application of aesthetic principles. Therefore, it behooves the surgeon to be familiar with the principles of aesthetic science so as to both delineate and attain the aesthetic goal at the same time any functional goal is part of the operation. There are three important principles for rhinoplasty: (1) symmetry, (2) continuity and (3) persistence. This study provides examples of how they apply in the preop, intraop and postop phase of performing aesthetic rhinoplasty. A firm understanding of these principles can then guide the surgeon through the difficult maze of decision making, operative planning and surgical execution that arguably makes aesthetic rhinoplasty the most difficult aesthetic operation in plastic surgery. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background Gene therapy has the potential to change the life experience of people with haemophilia and family members. Few studies have sought to explore the impact of gene therapy on both individuals and families. The aim of this study was to capture real-life experiences of gene therapy in People with haemophilia and their families. Results Sixteen participants with severe haemophilia (11 haemophilia A, five haemophilia B), mean age 41.4 years (range 23–75 years), took part in a single qualitative interview; ten were accompanied by a family member. Mean time since transfection was 3.56 years (range 1–10 years). Participants saw their involvement in gene therapy as a positive experience, freeing them from the personal burden of haemophilia and furthering treatment options for the wider haemophilia community. However, participants reported being unprepared for the side effects of immunosuppression. Some also reported feeling unsupported and having little control over what was happening as their factor levels became the focus of the process. Conclusion The results suggest that strategies need to be put into place to enable PwH fully to understand the process of gene therapy, and thereby make an informed choice as to whether it is a treatment they might wish for themselves. These include early and ongoing education, increased provision of psychosocial support and ongoing qualitative research.

Background The majority of older people (> 65 years) in hospital have frailty and are at increased risk of readmission or death following discharge home. In the UK, following acute hospitalisation, around one third of older people with frailty are referred on for rehabilitation, termed ‘intermediate care’ services. Although this rehabilitation can reduce early readmission to hospital ( Methods A multi-centre individually randomised controlled trial, to evaluate the clinical and cost-effectiveness of the HOPE programme. This individualised, graded and progressive 24-week exercise programme is delivered by NHS physiotherapy teams to people aged 65 and older with frailty, identified using the Clinical Frailty Scale, following discharge from acute hospitalisation and linked intermediate care rehabilitation pathways. The primary outcome is physical health-related quality of life, measured using the physical component summary score of the modified Short Form 36- item health questionnaire (SF36) at 12 months. Secondary outcomes include self-reported physical and mental health, functional independence, death, hospitalisations, care home admissions. Plans include health economic analyses and an embedded process evaluation. Discussion This trial seeks to determine if extended rehabilitation, via the HOPE programme, can improve physical health-related quality of life for older people with frailty following acute hospitalisation. Results will improve awareness of the rehabilitation needs of older people with frailty, and provide evidence on the clinical and cost-effectiveness of the targeted exercise intervention. There is potential for considerable benefit for health and social care services through widespread implementation of trial findings if clinical and cost-effectiveness is demonstrated. Trial registration ISRCTN 13927531. Registered on April 19, 2017.

Introduction Provision of care for care home residents with complex needs is challenging. Physiotherapists can play a major role in enhancing the confidence, skills and abilities of care home staff. The Skilful Care Training Package (SCTP) aims to provide staff with an understanding of good posture and training in skilled facilitation of movement. This process evaluation explored barriers and facilitators to delivery and uptake of the SCTP within the context of a feasibility cluster randomised controlled trial (cRCT) in 10 care homes. Methods A mixed methods process evaluation, incorporating non-participant observations and interviews, conducted in the five care homes receiving the SCTP intervention. Interviews were audio recorded and transcribed verbatim; resident conversations were captured via a Dictaphone and/or field-notes. Data analysis used the Framework approach. Results Fourteen staff training sessions were observed. Interviews with 22 staff and four trainers, and 13 conversations with residents were completed. Five factors influenced delivery and uptake of the SCTP:Organisational factors: strategies to publicise and facilitate access to training improved attendance; a convenient training location and trainer flexibility encouraged attendance and staff engagement.Intervention delivery: a practical participatory element to the training was highly valued; adapting the training to meet the needs of the homes was well-received.Engagement and interaction: relating training to workplace and residents’ experiences engaged staff; high levels of engagement and positive interaction within the training sessions were reported; challenges relating to staff hierarchy affected training delivery in some homes.Intervention content: posture and mobility elements were seen as important; however, some repetition with prior training was highlighted.Training impact: there were indications that staff adopted SCTP techniques. Staff reported an increase in their wellbeing and confidence in movement facilitation; cascade training was reported in some homes. Conclusions Training was well-received, and feedback on its impact was largely positive. Practical elements were viewed favourably over classroom-based learning. Intervention content should be revised to optimise focus and avoid overlap with other training.

Two polymorphs of ammonium trifluorooxovanadate (NH4VOF3) were synthesized as single crystals by the reaction of ammonium metavanadate with vanadium in hydrofluoric acid. The two phases crystalize in the same space group (Pbam), have similar unit cell volumes (α-NH4VOF3:371 A3, β-NH4VOF3:375 A3 at 100 K), and similar total energies (difference of ∼2.2 meV per formula unit at 0 K). Both structures contain the [VOF3]nn− ladder motif that has been reported in phases such as KVOF3 and RbVOF3. The polymorphs are differentiated by the angle between two neighboring ladder motifs. Although the two polymorphs are structurally similar, selective synthesis is possible as longer reaction times favor β-NH4VOF3.

The potential to capture additional air pollutants by introducing more vegetation or changing existing short vegetation to woodland on first sight provides an attractive route for lowering urban pollution. Here, an atmospheric chemistry and transport model was run with a range of landcover scenarios to quantify pollutant removal by the existing total UK vegetation as well as the UK urban vegetation and to quantify the effect of large-scale urban tree planting on urban air pollution. UK vegetation as a whole reduces area (population)-weighted concentrations significantly, by 10% (9%) for PM 2.5 , 30% (22%) for SO 2 , 24% (19%) for NH 3 and 15% (13%) for O 3 , compared with a desert scenario. By contrast, urban vegetation reduces average urban PM 2.5 by only approximately 1%. Even large-scale conversion of half of existing open urban greenspace to forest would lower urban PM 2.5 by only another 1%, suggesting that the effect on air quality needs to be considered in the context of the wider benefits of urban tree planting, e.g. on physical and mental health. The net benefits of UK vegetation for NO 2 are small, and urban tree planting is even forecast to increase urban NO 2 and NO x concentrations, due to the chemical interaction with changes in BVOC emissions and O 3 , but the details depend on tree species selection. By extrapolation, green infrastructure projects focusing on non-greenspace (roadside trees, green walls, roof-top gardens) would have to be implemented at very large scales to match this effect. Downscaling of the results to micro-interventions solely aimed at pollutant removal suggests that their impact is too limited for their cost–benefit analysis to compare favourably with emission abatement measures. Urban vegetation planting is less effective for lowering pollution than measures to reduce emissions at source. The results highlight interactions that cannot be captured if benefits are quantified via deposition models using prescribed concentrations, and emission damage costs. This article is part of a discussion meeting issue ‘Air quality, past present and future’.

BackgroundQuality improvement (QI) in healthcare is a cultural transformation process that requires long-term commitment from the executive board, a critical theme in emerging accounts of QI success in the UK National Health Service (NHS). To help sustain long-term commitment from the executive board, an organisation-wide picture of QI applications and their impact needs to be made routinely visible.MethodWe developed a retrospective evaluation drawing inputs from the resident QI team of a healthcare organisation and academic colleagues in the field of implementation and improvement science, as well as peer-reviewed and grey literature on what constitutes success for QI in healthcare. Formative feedback on content relevance, acceptability, and feasibility issues were used to guide evaluation design. The evaluation was conducted as an online survey so that the data accrual process resembles routine reporting to help surface implementation challenges. A purposive sample of QI projects was identified to maximise contrast between projects that were or were not successful as determined by the resident QI team. To hone strategic focus in what should be reported, we also compared factors that might affect project outcomes. For understanding implementation issues, we reviewed data quality to surface challenges in the design and sustainability of routine reporting for the executive board.ResultsOut of 52 QI projects, 10 led to a change in routine practice (henceforth referred to as adoption). Details of project outcomes were limited. Project team outcomes, indicative of capacity building, were not systematically documented. Service user involvement, quality of measurement plan, fidelity and documentation of plan-do-study-act (PDSA) cycles had a major impact on adoption. The proximal impact of these process factors on adoption was consistently more apparent than the distal impact of input and contextual factors.ConclusionsDesigning a routine reporting framework is an iterative process involving continual dialogue with frontline staff and improvement specialists to navigate data accrual demands. A retrospective evaluation, as in this study, can yield empirical insights for dialogue about the routine visibility of QI applications and their organisation-wide impact, thereby honing the implementation science of QI in a healthcare organisation.

Vaccines and immunotherapies depend on the ability of antibodies to sensitively and specifically recognize particular antigens and specific epitopes on those antigens. As such, detailed characterization of antibody&ndash, antigen binding provides important information to guide development. Due to the time and expense required, high-resolution structural characterization techniques are typically used sparingly and late in a development process. Here, we show that antibody&ndash, antigen binding can be characterized early in a process for whole panels of antibodies by combining experimental and computational analyses of competition between monoclonal antibodies for binding to an antigen. Experimental &ldquo, epitope binning&rdquo, of monoclonal antibodies uses high-throughput surface plasmon resonance to reveal which antibodies compete, while a new complementary computational analysis that we call &ldquo, dock binning&rdquo, evaluates antibody&ndash, antigen docking models to identify why and where they might compete, in terms of possible binding sites on the antigen. Experimental and computational characterization of the identified antigenic hotspots then enables the refinement of the competitors and their associated epitope binding regions on the antigen. While not performed at atomic resolution, this approach allows for the group-level identification of functionally related monoclonal antibodies (i.e., communities) and identification of their general binding regions on the antigen. By leveraging extensive epitope characterization data that can be readily generated both experimentally and computationally, researchers can gain broad insights into the basis for antibody&ndash, antigen recognition in wide-ranging vaccine and immunotherapy discovery and development programs.

BACKGROUND Immediate tissue expander placement remains a preferred method for breast reconstruction after mastectomy. The use of prophylactic postoperative antibiotic administration is thought to reduce rates of surgical site infection and reconstructive failure, but has not been studied in patients undergoing reconstruction in the prepectoral plane. METHODS We retrospectively identified all patients undergoing immediate prepectoral tissue expander placement after mastectomy by a single plastic surgeon from 2015 to 2018. We identified 2 cohorts of patients: one group that received prophylactic antibiotics at the time of discharge and one group that did not. We collected treatment and outcomes data to compare rates of postoperative complications between cohorts. RESULTS We identified 69 patients with 115 breasts who received discharge antibiotics and 63 patients with 106 breasts who did not. The antibiotic cohort had significantly lower rates of tissue expander loss (4.3% vs 17.0%, P = 0.003), unplanned operation (10.4% vs 24.5%, P = 0.007), and infection (7.0% vs 24.5, P < 0.001). CONCLUSIONS The use of prophylactic postoperative antibiotics in prepectoral breast reconstruction is associated with significantly lower rates of postoperative complications. Further randomized controlled studies are warranted to explore the effect of antibiotic therapy on outcomes and to determine what the optimal duration of antibiotic therapy may be.

Viral testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), particularly early in the COVID-19 pandemic, was limited by supply of reagents. We pooled nasopharyngeal samples from patients at low risk of SARS-CoV-2 infection in groups of 3 for testing. Three weeks of testing using this strategy resulted in 530 patient tests in 179 cartridges; 4 positive test groups required the use of 11 additional cartridges with an overall positive rate of 0.8% in a low-risk population. This strategy resulted in the use of 340 fewer cartridges than if each test were performed on one patient sample. Pooled testing of lowrisk populations allows for continued testing even when supplies are relatively scarce. Journal of Hospital Medicine 2020;15:538-539. © Society of Hospital Medicine

BackgroundDissemination of clinical guidelines is necessary but seldom sufficient by itself to ensure the reliable uptake of evidence-based practice. There are further challenges in implementing multiple clinical guidelines and clinical practice recommendations in the pressurised environment of general practice.ObjectivesWe aimed to develop and evaluate an implementation package that could be adapted to support the uptake of a range of clinical guideline recommendations and be sustainably integrated within general practice systems and resources. Over five linked work packages, we developed ‘high-impact’ quality indicators to show where a measurable change in clinical practice can improve patient outcomes (work package 1), analysed adherence to selected indicators (work package 2), developed an adaptable implementation package (work package 3), evaluated the effects and cost-effectiveness of adapted implementation packages targeting four indicators (work package 4) and examined intervention fidelity and mechanisms of action (work package 5).Setting and participantsHealth-care professionals and patients from general practices in West Yorkshire, UK.DesignWe reviewed recommendations from existing National Institute for Health and Care Excellence clinical guidance and used a multistage consensus process, including 11 professionals and patients, to derive a set of ‘high-impact’ evidence-based indicators that could be measured using routinely collected data (work package 1). In 89 general practices that shared data, we found marked variations and scope for improvement in adherence to several indicators (work package 2). Interviews with 60 general practitioners, practice nurses and practice managers explored perceived determinants of adherence to selected indicators and suggested the feasibility of adapting an implementation package to target different indicators (work package 3). We worked with professional and patient panels to develop four adapted implementation packages. These targeted risky prescribing involving non-steroidal anti-inflammatory and antiplatelet drugs, type 2 diabetes control, blood pressure control and anticoagulation for atrial fibrillation. The implementation packages embedded behaviour change techniques within audit and feedback, educational outreach and (for risky prescribing) computerised prompts. We randomised 178 practices to implementation packages targeting either diabetes control or risky prescribing (trial 1), or blood pressure control or anticoagulation (trial 2), or to a further control (non-intervention) group, and undertook economic modelling (work package 4). In trials 1 and 2, practices randomised to the implementation package for one indicator acted as control practices for the other package, and vice versa. A parallel process evaluation included a further eight practices (work package 5).Main outcome measuresTrial primary end points at 11 months comprised achievement of all recommended levels of glycated haemoglobin, blood pressure and cholesterol; risky prescribing levels; achievement of recommended blood pressure; and anticoagulation prescribing.ResultsWe recruited 178 (73%) out of 243 eligible general practices. We randomised 80 practices to trial 1 (40 per arm) and 64 to trial 2 (32 per arm), with 34 non-intervention controls. The risky prescribing implementation package reduced risky prescribing (odds ratio 0.82, 97.5% confidence interval 0.67 to 0.99;p = 0.017) with an incremental cost-effectiveness ratio of £2337 per quality-adjusted life-year. The other three packages had no effect on primary end points. The process evaluation suggested that trial outcomes were influenced by losses in fidelity throughout intervention delivery and enactment, and by the nature of the targeted clinical and patient behaviours.LimitationsOur programme was conducted in one geographical area; however, practice and patient population characteristics are otherwise likely to be sufficiently diverse and typical to enhance generalisability to the UK. We used an ‘opt-out’ approach to recruit general practices to the randomised trials. Subsequently, our trial practices may have engaged with the implementation package less than if they had actively volunteered. However, this approach increases confidence in the wider applicability of trial findings as it replicates guideline implementation activities under standard conditions.ConclusionsThis pragmatic, rigorous evaluation indicates the value of an implementation package targeting risky prescribing. In broad terms, an adapted ‘one-size-fits-all’ approach did not consistently work, with no improvement for other targeted indicators.Future workThere are challenges in designing ‘one-size-fits-all’ implementation strategies that are sufficiently robust to bring about change in the face of difficult clinical contexts and fidelity losses. We recommend maximising feasibility and ‘stress testing’ prior to rolling out interventions within a definitive evaluation. Our programme has led on to other work, adapting audit and feedback for other priorities and evaluating different ways of delivering feedback to improve patient care.Trial registrationCurrent Controlled Trials ISRCTN91989345.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 8, No. 4. See the NIHR Journals Library website for further project information.

Background provision of care for care home residents with complex needs is challenging. Physiotherapy and activity interventions can improve well-being but are often time-limited and resource intensive. A sustainable approach is to enhance the confidence and skills of staff who provide care. This trial assessed the feasibility of undertaking a definitive evaluation of a posture and mobility training programme for care staff. Design and setting a cluster randomised controlled feasibility trial with embedded process evaluation. Ten care homes in Yorkshire, United Kingdom, were randomised (1:1) to the skilful care training package (SCTP) or usual care (UC). Participants residents who were not independently mobile. Intervention SCTP—delivered by physiotherapists to care staff. Objectives and measurements key objectives informed progression to a definitive trial. Recruitment, retention and intervention uptake were monitored. Data, collected by a blinded researcher, included pain, posture, mobility, hospitalisations and falls. This informed data collection feasibility and participant safety. Results a total of 348 residents were screened; 146 were registered (71 UC, 75 SCTP). Forty two were lost by 6 months, largely due to deaths. While data collection from proxy informants was good (>95% expected data), attrition meant that data completion rates did not meet target. Data collection from residents was poor due to high levels of dementia. Intervention uptake was variable—staff attendance at all sessions ranged from 12.5 to 65.8%. There were no safety concerns. Conclusion care home and resident recruitment are feasible, but refinement of data collection approaches and intervention delivery are needed for this trial and care home research more widely.

BACKGROUND Animation deformity is an undesirable outcome of subpectoral breast reconstruction that results in abnormal breast contraction with activity, breast pain, and increased implant visibility. Surgical correction requires implant removal and conversion of the reconstruction to a prepectoral plane. The authors present their institutional experience with their preferred surgical technique to treat this challenging problem and outline solutions for increased success in these patients. METHODS A retrospective review was performed of all patients undergoing conversion of their subpectoral breast reconstruction to a prepectoral plane at the authors' institution. Patient demographics and surgical details were analyzed, and postoperative outcomes and morbidity were assessed. The effects of changing operative strategies on enhanced success are also reported. RESULTS A total of 80 breast conversions were performed over a 2.5-year period. All patients demonstrated resolution of animation deformity at a mean follow-up of 15.2 months. Two reconstructions (2.5 percent) required an unplanned return to the operating room, and 11 reconstructions (13.8 percent) were treated for infection. Preconversion fat grafting and the use of acellular dermal matrix were both associated with a reduced incidence of postoperative asymmetry and capsular contracture (p < 0.05). There were no reconstructive failures associated with conversion to a prepectoral pocket. CONCLUSIONS Treatment of animation deformity in the reconstructed patient can be safely performed by surgical conversion to a prepectoral plane. The use of acellular dermal matrix, and preconversion fat grafting, in appropriate patients can improve results. The authors promote this operative algorithm for all reconstructive patients experiencing symptomatic animation deformity with subpectoral breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

Background The question of whether quality improvement (QI) actually improves quality in a large healthcare organisation requires overview of a diverse range of QI projects. To-date, an organisational overview remains elusive due to heterogeneity across project- specific outcomes. Where organisational-level assessments of QI success have been offered, the extent to which they could be attributed to QI activity remains unclear. Reporting on a retrospective evaluation of return on investment of QI in a UK National Health Service (NHS) Trust, we discuss the development of a reporting methodology for providing board-level insights on organisational needs and achievements in QI. Methods A researcher-in-residence worked with a resident QI team to develop and conduct a retrospective evaluation of QI projects in a large healthcare organisation in the UK that specialises in mental health. Using a survey, we assessed QI project outcomes and explored costs and benefits, as well as contextual, input and process factors that might be associated with whether QI projects led to a change in routine practice. Findings Out of 52 QI projects, 10 led to a change in routine practice. Across a diverse range of projects, time invested by staff is an opportunity cost that could serve as a common denominator for return on investment. Retrospective data accrual proved problematic for measuring benefits. Odds ratios from logistic regressions show that process factors had more apparent impact on project outcomes than contextual and input factors. Service user engagement and implementation of measurement plan showed major impact on project outcome. Of note, if QI projects had documentation for Plan-Do-Study-Act (PDSA) cycles, the odds of effecting a change in routine practice were much higher. Conclusions To inform organisational-level decision making and optimise return on investment from QI in large healthcare organisations, systematic monitoring of QI activity needs prospective data accrual, consistent measurement and coherent iterations. We recommend that this be undertaken by a resident QI unit with the data categories explored in this study. Developing a reporting methodology for routine organisational-level monitoring can be an asset for improving practice, one that is pivotal for a learning healthcare system.

Michael Holland presents an early and little-known article by Maurice Blanchot, whose subject is the memorial concert in honour of Claude Debussy which took place in Paris in June 1932, following t...

The main purpose of this paper is to analyse the socio-economic justification of implementing a Nitrogen Emission Control Area (NECA), starting 2021, for ships in the Baltic Sea and/or the North Sea and English Channel. We analyse the potential for emission reduction, emission control costs, and monetised benefits following the introduction of a NECA. Costs and benefits are compared for 2030. We compile new data on emission control costs for shipping, use the GAINS model for calculations of emission dispersion, and the Alpha-RiskPoll model for estimating monetary values of health impacts. The model results show that costs to conform to the NOX regulations of a NECA in the Baltic Sea, North Sea or both sea regions would be 111 (100–123), 181 (157–209), and 230 (195–273) million € per year, respectively. Corresponding benefits from reduced emissions are estimated to be 139 (56–294), 869 (335–1882), and 1007 (392–2177) million € per year, respectively. Calculated benefits surpass costs for most scenarios, but less convincingly for a Baltic Sea NECA. Conforming to the NECA regulations by using Liquefied Natural Gas (LNG) propulsion engines is estimated to give the highest net benefits but also the largest variation (costs: 153 (88–238), benefits: 1556 (49–3795) million €/year). The variations are mainly due to uncertainties in the valuation of avoided fatalities and climate impacts. It is concluded that the NECAs for the Baltic and North Seas can be justified using CBA under all but extreme assumptions.

Air pollution presents a major risk to human health, resulting in premature deaths and reduced quality of life. Quantifying the role of vegetation in reducing air pollution concentrations is an important contribution to urban natural capital accounting. However, most current methods to calculate pollution removal are static, and do not represent atmospheric transport of pollutants, or interactions among pollutants and meteorology. An additional challenge is defining urban extent in a way that captures the green and blue infrastructure providing the service in a consistent way. We developed a refined urban morphology layer which incorporates urban green and blue space. We then applied an atmospheric chemistry transport model (EMEP4UK) to calculate pollutant removal by urban natural capital for pollutants including PM2.5, NO2, SO2, O3. We calculated health benefits directly from the change in pollutant concentrations (i.e. exposure) rather than from tonnes of pollutant removed. Urban natural capital across Britain removes 28,700 tonnes of PM2.5, NO2, SO2, O3. The economic value of the health benefits are substantial: £136 million in 2015, resulting from 900 fewer respiratory hospital admissions, 220 fewer cardiovascular hospital admissions, 240 fewer deaths and 3600 fewer Life Years Lost.