Minor head injury in the Republic of Ireland : evaluation of written information given at discharge from emergency departments

Most patients presenting to the emergency department with minor head injuries are discharged with written information. Here the quality of minor head injury discharge leaflets in the Republic of Ireland is evaluated against a nationally accepted template. There was great variability in leaflet content. Most provided minimal information on emergency symptoms but 60% contained no information on post-concussional symptoms. No leaflet was available in audio-format or languages other than English. Information provided in minor head injury leaflets should be improved and standardised across Ireland

Patients’ perceptions and experiences of cardiovascular disease and diabetes prevention programmes:a systematic review and framework synthesis using the Theoretical Domains Framework

Background - This review provides a worked example of ‘best fit’ framework synthesis using the Theoretical Domains Framework (TDF) of health psychology theories as an a priori framework in the synthesis of qualitative evidence. Framework synthesis works best with ‘policy urgent’ questions. Objective - The review question selected was: what are patients’ experiences of prevention programmes for cardiovascular disease (CVD) and diabetes? The significance of these conditions is clear: CVD claims more deaths worldwide than any other; diabetes is a risk factor for CVD and leading cause of death. Method - A systematic review and framework synthesis were conducted. This novel method for synthesizing qualitative evidence aims to make health psychology theory accessible to implementation science and advance the application of qualitative research findings in evidence-based healthcare. Results - Findings from 14 original studies were coded deductively into the TDF and subsequently an inductive thematic analysis was conducted. Synthesized findings produced six themes relating to: knowledge, beliefs, cues to (in)action, social influences, role and identity, and context. A conceptual model was generated illustrating combinations of factors that produce cues to (in)action. This model demonstrated interrelationships between individual (beliefs and knowledge) and societal (social influences, role and identity, context) factors. Conclusion - Several intervention points were highlighted where factors could be manipulated to produce favourable cues to action. However, a lack of transparency of behavioural components of published interventions needs to be corrected and further evaluations of acceptability in relation to patient experience are required. Further work is needed to test the comprehensiveness of the TDF as an a priori framework for ‘policy urgent’ questions using ‘best fit’ framework synthesis

Effectiveness and uptake of screening programmes for coronary heart disease and diabetes:a realist review of design components used in interventions

Objective - To evaluate behavioural components and strategies associated with increased uptake and effectiveness of screening for coronary heart disease and diabetes with an implementation science focus. Design - Realist review. Data sources - PubMed, Web of Knowledge, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register and reference chaining. Searches limited to English language studies published since 1990. Eligibility criteria - Eligible studies evaluated interventions designed to increase the uptake of cardiovascular disease (CVD) and diabetes screening and examined behavioural and/or strategic designs. Studies were excluded if they evaluated changes in risk factors or cost-effectiveness only. Results - In 12 eligible studies, several different intervention designs and evidence-based strategies were evaluated. Salient themes were effects of feedback on behaviour change or benefits of health dialogues over simple feedback. Studies provide mixed evidence about the benefits of these intervention constituents, which are suggested to be situation and design specific, broadly supporting their use, but highlighting concerns about the fidelity of intervention delivery, raising implementation science issues. Three studies examined the effects of informed choice or loss versus gain frame invitations, finding no effect on screening uptake but highlighting opportunistic screening as being more successful for recruiting higher CVD and diabetes risk patients than an invitation letter, with no differences in outcomes once recruited. Two studies examined differences between attenders and non-attenders, finding higher risk factors among non-attenders and higher diagnosed CVD and diabetes among those who later dropped out of longitudinal studies. Conclusions - If the risk and prevalence of these diseases are to be reduced, interventions must take into account what we know about effective health behaviour change mechanisms, monitor delivery by trained professionals and examine the possibility of tailoring programmes according to contexts such as risk level to reach those most in need. Further research is needed to determine the best strategies for lifelong approaches to screening

GPs' perspectives on managing the NHS Health Check in primary care:a qualitative evaluation of implementation in one area of England

OBJECTIVES: To evaluate the implementation of the National Health Service (NHS) Health Check programme in one area of England from the perspective of general practitioners (GPs). DESIGN: A qualitative exploratory study was conducted with GPs and other healthcare professionals involved in delivering the NHS Health Check and with patients. This paper reports the experience of GPs and focuses on the management of the Heath Check programme in primary care. SETTING: Primary care surgeries in the Heart of Birmingham region (now under the auspices of the Birmingham Cross City Clinical Commissioning Group) were invited to take part in the larger scale evaluation. This study focuses on a subset of those surgeries whose GPs were willing to participate. PARTICIPANTS: 9 GPs from different practices volunteered. GPs served an ethnically diverse region with areas of socioeconomic deprivation. Ethnicities of participant GPs included South Asian, South Asian British, white, black British and Chinese. METHODS: Individual semistructured interviews were conducted with GPs face to face or via telephone. Thematic analysis was used to analyse verbatim transcripts. RESULTS: Themes were generated which represent GPs' experiences of managing the NHS Health Check: primary care as a commercial enterprise; 'buy in' to concordance in preventive healthcare; following protocol and support provision. These themes represent the key issues raised by GPs. They reveal variability in the implementation of NHS Health Checks. GPs also need support in allocating resources to the Health Check including training on how to conduct checks in a concordant (or collaborative) way. CONCLUSIONS: The variability observed in this small-scale evaluation corroborates existing findings suggesting a need for more standardisation. Further large-scale research is needed to determine how that could be achieved. Work needs to be done to further develop a concordant approach to lifestyle advice which involves tailored individual goal setting rather than a paternalistic advice-giving model

A transcendental geometry

Art and life should not be divorced. Art objects are objects in the real world. Yet, I cannot agree with recent artists, like Frank Stella, who believe that in a painting, "Only what can be seen there is there."1 A painting can have transcendent content, but not in the sense of something "other." The content must be "in", and "between", and in relation to the viewer. Therefore, in my own painting, I attempt a synthesis between the empirical and the transcendent. In this synthesis, I meld the subjective and objective. Building on the Slavic mysticism of Malevich and the French rationalism of Duchamp, I mitigate strict geometry with atmospheric automatism. I accept the art object as object but transcend that objecthood. First, the objecthood is emphasized by maintaining the surface skin of the board, riding the surface, articulating its literalness. Then an ambience is created with bivalent indeterminate grounds. This ambience is created specifically by switching transitivity of ground and shape. Ground becomes shape and moves to the front, yet retains a possible reading of ground. In some of my work, this reading goes both ways and forms a continuum. In a few works, the change is in one direction,primarily. Close value, chromatic equality, or perceptual ambiguity related to geometry effect these changes. Whatever the method, the result is energy change, and the inert physical object is transcended

Evaluating recall of key safety messages, and attitudes and perceptions of a patient safety initiative at a pediatric hospital

Involving inpatients in their safety and well-being is becoming increasingly common. Interventions have been developed to encourage patients to be active in their own safety, but published evaluations are scarce. The Patient Safety Ambassador (PSA) program was developed to increase patient and parent/guardian engagement and knowledge in patient safety. This study aimed to determine recall ability of key safety messages and explore attitudes and perceptions towards the PSA program, hence obtaining feedback for program improvements. Participants were pediatric inpatients and parents of inpatients. Face-to-face semi-structured interviews were conducted. Cued and non-cued recall ability was determined using questions with and without specific cues, while attitudes and perceptions were explored using open-ended questions regarding patient safety. QSR NVivo 10 software was used to analyze interviews for recall ability and major themes. 95% of parents could remember all safety messages with cues, but could only remember one (35%) or two (32.5%) messages without cues. Inpatient participants could remember up to 4 messages with cues, no messages without cues, and, unlike parents, were unable to discuss their attitudes and perceptions towards safety. Five major themes emerged from analysis of interviews with parents: the importance of medication knowledge, parental involvement in care, having trust in healthcare team, asking questions, and advocacy. Use of cues appears beneficial in facilitating recall of safety messages. Parents had varied attitudes and perceptions to safety. Future research can explore methods to engage pediatric inpatients, integrate cues to increase recall, and examine resulting behavioural changes

Transition from community dwelling to retirement village in older adults:cognitive functioning and psychological health outcomes

Supported living and retirement villages are becoming a significant option for older adults with impairments, with independence concerns or for forward planning in older age, but evidence as to psychological benefits for residents is sparse. This study examined the hypothesis that the multi-component advantages of moving into a supported and physically and socially accessible ‘extra-care’ independent living environment will impact on psychological and functioning measures. Using an observational longitudinal design, 161 new residents were assessed initially and three months later, in comparison to 33 older adults staying in their original homes. Initial group differences were apparent but some reduced after three months. Residents showed improvement in depression, perceived health, aspects of cognitive function and reduced functional limitations, while controls showed increased functional limitations (worsening). Ability to recall specific autobiographical memories, known to be related to social problem solving, depression and functioning in social relationships, predicted change in communication limitations, and cognitive change predicted changes in recreational limitations. Change in anxiety and memory predicted change in depression. Findings suggest that older adults with independent living concerns who move to an independent but supported environment can show significant benefits in psychological outcomes and reduction in perceived impact of health on functional limitations in a short period. Targets for focused rehabilitation are indicated, but findings also validate development of untargeted general supportive environments

Effectiveness of the interventions in preventing the progression of pre-frailty and frailty in older adults:a systematic review protocol

REVIEW QUESTION / OBJECTIVE : The objective of this review is to identify the effectiveness of the interventions in preventing progression of pre-frailty and frailty in older adults. More specifically, the review questions are: - What is the effectiveness of interventions in preventing or reducing frailty in older adults? - How does effectiveness vary with degree of frailty? - Are there factors that influence the effectiveness of interventions? - What is the economic feasibility of interventions for pre-frailty and frailty? INCLUSION CRITERIA : Types of participants This review will consider studies that include older adults (female and male) aged 65 years and over, explicitly identified as pre-frail or frail by the researchers or associated medical professionals according to a pre-specified scale or index, and who have received health care and support services in any type of setting (primary care, nursing homes, hospitals). This review will exclude studies that: - Include participants who have been selected because they have one specific illness - Consider people with a terminal diagnosis only. - Types of intervention(s)/phenomena of interest: The clinical/medical component of the review will consider studies that evaluate any type of interventions to prevent the progression of pre-frailty and frailty in older adults. These interventions will include, but will not be limited to, physical activity, multifactorial intervention, psychosocial intervention, health and social care provision, and cognitive, nutrition or medication/medical maintenance and adherence focused interventions. The economic component of the review will consider studies that have performed any type of health economic analysis of ..

Predicting risk and outcomes for frail older adults:a protocol for an umbrella review of available frailty screening tools

The aim of this systematic review is to comprehensively search the available literature and to summarize the best available evidence from systematic reviews in relation to published screening tools to identify pre-frailty and frailty in older adults, that is: (i) to determine their psychometric proprieties; (ii) to assess their capacity to detect pre-frail and frail conditions against established methods; and (iii) to evaluate their predictive ability. More specifically, the review will focus on the following questions: Frailty is an age-related state of vulnerability resulting from a balance between the maintenance of health and the deficits threatening it.1,2 This clinical condition compromises the ability to cope with daily or acute stressors and, further, increases the risk of adverse outcomes, predisposing those involved to disability and dependency on others for daily life activities, and leading to hospitalization and institutional placement.3,4 It is also a predictor of higher mortality rates.4-7 In the absence of biological markers, an operational definition of frailty has been proposed.2,8 This definition is based on physical markers, including weakness with low muscle strength (e.g. poor grip strength), overall slowness (particularly of gait), decreased balance and mobility, fatigability or exhaustion, low physical activity and involuntary weight loss. For diagnostic purposes, at least three of these symptoms must be observed.8 The presence of only one or two of them indicates the earlier stage of frailty, namely, pre-frailty. Despite high predictive validity of this operational definition, and despite its common use in clinical settings, many researchers believe it is insufficient, asserting that it should also include cognitive and mental health domains, and possibly also social domains such as living alone.9-12 Other dimensions recognized as important for identifying frailty are the ability to deal with activities of daily living and quality of life, as for individuals with this clinical condition both of these areas tend to be decreased.9,13 This lack of consensus on the definition of frailty (based on physical markers as opposed to a broader multidimensional approach) is also reflected in divergences related to the prevalence data obtained from epidemiological studies. Systematic comparison of these data14 shows that frailty prevalence differs from 4% to 17% in the population aged 65 and over, and in case of pre-frailty, prevalence varies from 19% to 53% of the same age group, with average values of 10.7% and 41.6%, respectively. The divergences between estimates are also conditioned by demographic variables such as age and gender. Namely, for elders aged 80-84 the prevalence of frailty is estimated as 15.7%, and for elders over the age of 84, 26.1%. Additionally, women tend to have higher rates of frailty than men. Although the condition of frailty has been studied for years, there is no consensus on its pathophysiologic mechanism. According to some authors2,8,15, this state of increased vulnerability is due to accumulation of subthreshold decrements in physiologic reserves that affects multiple physiologic systems. Other authors16,17 have described frailty in terms of progressive dysregulation in a number of main physiologic systems and their complex interconnected network, and subsequent depletion of homeostatic reserve and resiliency. Recently, discussion on the psychopathological mechanism of this clinical condition has been enriched by new theoretical proposals associating frailty to reduced capacity to compensate ageing-related molecular and cellular damage.13,18 In all these approaches it is assumed that the development of frailty may be modulated by disease. In other words, it can be precipitated or exacerbated by the occurrence of comorbid pathological conditions.19-21 It is also suggested that increased vulnerability for adverse health outcomes can precede the onset of chronic diseases.19,20 However, according to Bergman et al19, it is probable that in this case, frailty is just a manifestation of subclinical and undiagnosed stages of such diseases. Because of the high prevalence and the severity of adverse outcomes of frailty, its screening should be a priority in appropriate components of primary care networks (including general practice, geriatrics, psychology, etc.), as well as in institutional or community care settings. Early diagnosis of this clinical condition can help improve care for older adults, making possible the minimization of the risk of pre-frail states developing into frail states (primary prevention), and implementation of therapeutic measures in order to attenuate or delay underlying conditions and symptoms, or to ameliorate the impact on independence or healthy and engaged lifestyles (loss of which would in turn have a further impact on frailty development, i.e. secondary prevention).2,4 In more advanced stages, frailty assessment provides valuable data necessary to plan and implement intervention strategies oriented to the preservation of functional status or to control the progression of adverse outcomes, such as recurrent hospitalizations, institutionalization or death (tertiary prevention).2,4 The evidence obtained from the implementation of various types of interventions for frailty indicates that the frailty condition can be managed and reduced.22-25 Screening for frailty can also provide information on populations at high risk of disability and poor prognosis, and help to identify reversible risk factors.2 These data are especially important for determining variables that make specific interventions more beneficial to specific patients. In order to identify individuals at risk of frailty, several assessment tools have been developed. The most widely cited focus on physical markers of frailty2,8 or are based on the accumulation of deficits from physical, cognitive, mental health and functional domains.13,26 However, both types of measures seem to be insufficient. The first one does not cover all dimensions of frailty and consequently does not provide indications useful to treatment choice and care planning, and the last one is time consuming and thus is difficult to integrate into day-to-day health care practice.27 In more recent approaches, the indices created for frailty assessment integrate demographic, medical, social and functional information, and demonstrate their usefulness either for diagnostic purposes or to predict adverse health outcomes.28 According to the literature, there are more than 20 different measures being used for frailty screening. Nonetheless, it is still unknown how their characteristics match different samples within the frail/pre-frail condition and robust populations, and what is the best fit between these measures, purposes (e.g. to predict need for care, mortality or potential response to intervention) and contexts/populations to assess frailty in older age. Also, the reliability and validity of these measures need to be clarified, as well as the comparative sensitivity and specificity in identifying patients at risk of a poor prognosis. A scoping search identified a large number of relevant systematic reviews; however in most cases they are confined to specific assessment measures related to a specific clinical model (phenotype model8, cumulative deficits model13 and predictive model28). For a clear view and objective evaluation of existing tools, this set of evidence needs to be systematized, compared and synthesized. In other words, it is essential to conduct an umbrella review. A preliminary search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, Prospero, CINAHL and Medline has revealed that there is currently no overview of reviews or umbrella review (neither published nor in progress) on this topic of sufficient reliability, validity and capacity to detect pre-frail and frail conditions, and with predictive accuracy of available screening tools for frailty in older adults29 The main goal of this umbrella review is to consolidate the available evidence regarding screening for pre-frailty and frailty from the published literature. More specifically, reviews will be summarized in order to determine the quality of screening tools in terms of frailty diagnosis and frailty prognosis

Perceptions and experiences of frailty interventions:quantitative and qualitative results from a survey of partners within the European Innovation Partnership on Active and Healthy Ageing (EIP-AHA)

The European Innovation Partnership on Active and Healthy Ageing (EIP-AHA) was launched by the European Commission in 2011 to promote innovation in ageing research. This paper explores the experiences of partners delivering frailty interventions within Europe, registering their programmes with the EIP-AHA. Data were collected using an online survey from 21 partners in seven countries. A mixed-method approach was used with inductive thematic analysis of free-text responses to improve data richness. Responses indicated that there was a lack of consistency between EIP-AHA partners in methods of defining, screening and measuring for frailty and pre-frailty. Open responses to survey questions about intervention facilitators, moderators and barriers were coded into two themes: working with stakeholders and project management. We concluded that EIP-AHA partners are providing interventions addressing physical, cognitive and wellbeing elements of frailty. However, there needs to be an increase in the proportion of interventions that consistently apply valid methods of screening and/or measuring frailty and pre-frailty. Most, but not all projects are targeting pre-frail older adults, suggesting an appropriate balance of prevention in a useful ‘intervention window’ but also a growing understanding that frailty at later stages is amenable to intervention. Findings suggest design manipulations to improve outcomes and adherence to interventions, specifically inclusion of a perceived benefit/reward for older adults, e.g. a social aspect or health-care promotion