Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study

Objective To explore pressure area related pain as a predictor of category ≥2 pressure ulcer (PU) development. Design Multicentre prospective cohort study. Setting UK hospital and community settings. Participants inclusion Consenting acutely ill patients aged ≥18 years, defined as high risk (Braden bedfast/chairfast AND completely immobile/very limited mobility; pressure area related pain or; category 1 PU). Exclusion Patients too unwell, unable to report pain, 2 or more category ≥2 PUs. Follow-up Twice weekly for 30 days. Primary and secondary outcome measures Development and time to development of one or more category ≥2 PUs. Results Of 3819 screened, 1266 were eligible, 634 patients were recruited, 32 lost to follow-up, providing a 602 analysis population. 152 (25.2%) developed one or more category ≥2 PUs. 464 (77.1%) patients reported pressure area related pain on a healthy, altered or category 1 skin site of whom 130 (28.0%) developed a category ≥2 PU compared with 22 (15.9%) of those without pain. Full stepwise variable selection was used throughout the analyses. (1) Multivariable logistic regression model to assess 9 a priori factors: presence of category 1 PU (OR=3.25, 95% CI (2.17 to 4.86), p<0.0001), alterations to intact skin (OR=1.98, 95% CI (1.30 to 3.00), p=0.0014), pressure area related pain (OR=1.56, 95% CI (0.93 to 2.63), p=0.0931). (2) Multivariable logistic regression model to account for overdispersion: presence of category 1 PU (OR=3.20, 95% CI (2.11 to 4.85), p<0.0001), alterations to intact skin (OR=1.90, 95% CI (1.24 to 2.91), p=0.0032), pressure area related pain (OR=1.85, 95% CI (1.07 to 3.20), p=0.0271), pre-existing category 2 PU (OR=2.09, 95% CI (1.35 to 3.23), p=0.0009), presence of chronic wound (OR=1.66, 95% CI (1.06 to 2.62), p=0.0277), Braden activity (p=0.0476). (3) Accelerated failure time model: presence of category 1 PU (AF=2.32, 95% CI (1.73 to 3.12), p<0.0001), pressure area related pain (AF=2.28, 95% CI (1.59 to 3.27), p<0.0001). (4) 2-level random-intercept logistic regression model: skin status which comprised 2 levels (versus healthy skin); alterations to intact skin (OR=4.65, 95% CI (3.01 to 7.18), p<0.0001), presence of category 1 PU (OR=17.30, 95% CI (11.09 to 27.00), p<0.0001) and pressure area related pain (OR=2.25, 95% CI (1.53 to 3.29), p<0.0001). Conclusions This is the first study to assess pain as a predictor of category ≥2 PU development. In all 4 models, pain emerged as a risk factor associated with an increased probability of category ≥2 PU development

Relocating patients from a specialist homeless healthcare centre to general practices: a multi-perspective study.

Background: - The relocation of formerly homeless patients eligible to transfer from a specialist homeless healthcare centre (SHHC) to mainstream general practices is key to patient integration in the local community. Failure to transition patients conferring eligibility for relocation may also negatively impact on SHHC service delivery. Aim: - To explore barriers and facilitators of relocation from the perspectives of formerly homeless patients and healthcare staff involved in their care. Design and setting: - Qualitative semi-structured face-to-face and telephone interviews conducted in the north east of Scotland. Method: - Participants were patients and healthcare staff including GPs, nurses, substance misuse workers, administrative, and local community pharmacy staff recruited from one SHHC, two mainstream general practices, and four community pharmacies. Interview schedules based on the 14 domains of the Theoretical Domains Framework (TDF) were drafted. Transcripts of the interviews were analysed by two independent researchers using a framework approach. Results: - Seventeen patients and 19 staff participated. Key barriers and facilitators aligned to TDF domains included: beliefs about consequences regarding relocation; patient intention to relocate; environmental context and resources in relation to the care of the patients and assessing patient eligibility; patient skills in relation to integration; social and professional role and identity of staff and patients; and emotional attachment to the SHHC. Conclusion: - Implementation of services, which promote relocation and integration, may optimise patient relocation from SHHCs to mainstream general practices. These include peer support networks for patients, better information provision on the relocation process, and supporting patients in the journey of identifying and adjusting to mainstream practices

Pharmacists' training, experiences and behaviours in managing homeless patients.

Community pharmacists are well-situated to offer proactive and opportunistic support and advice to the homeless. The aim of this research was to investigate pharmacists' training, experiences and behaviours in managing homeless patients. A questionnaire using both open and closed questions was developed, based on existing literature, researcher expertise and the Theoretical Domains Framework (TDF) - a synthesis of behaviour change theory. The TDF outlines fourteen individual domains perceived to influence behaviour, including knowledge, skills, beliefs about capabilities and social influences. The questionnaire was reviewed and piloted with fifty pharmacists, and NHS R&D approval was obtained. The questionnaire was then sent to a random sample of 1,951 community pharmacies in England and Scotland, with two follow-up reminders. Results were analysed using descriptive statistics. 321 responses (response rate 16.5%) were received. The mean (SD) age of respondents was 39 (plus or minus 12) years with a third (n=94, 29.3%) having been qualified as a pharmacist for fewer than five years. Many respondents (n = 187) reported having managed a homeless patient in their pharmacy, with approximately 17% (n=53) saying that this was a daily activity. The majority (n=242, 75.4%) of participants said that homelessness was not included in their undergraduate, postgraduate or continuous professional development (CPD) pharmacy training (n=225, 70.1%). Only a third (n=100, 31.1%) agreed or strongly agreed that they knew to whom they should refer a homeless patient for social support. Approximately 42% (n=137) indicated they would discuss homelessness only if raised by the patient. Only one fifth (n=71, 22.1%) felt comfortable advising homeless patients on how to minimise the impact of homelessness on their medication use, and the vast majority of respondents reported a lack of clear guidelines (n=294, 94.2%). The results of this study suggest lack of appropriate opportunities - at undergraduate, postgraduate and CPD level - for training on how to manage homeless patients. There is a need to develop guidelines that will enable community pharmacists to better support homeless patients in alleviating the impact of homelessness; these guidelines should include advice on the pharmacist's role in supporting homeless medicine management and providing signposting to appropriate social services

Effectiveness and cost-effectiveness of basic versus biofeedback-mediated intensive pelvic floor muscle training for female stress or mixed urinary incontinence: protocol for the OPAL randomised trial

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordIntroduction Accidental urine leakage is a distressing problem that affects around one in three women. The main types of urinary incontinence (UI) are stress, urgency and mixed, with stress being most common. Current UK guidelines recommend that women with UI are offered at least 3 months of pelvic floor muscle training (PFMT). There is evidence that PFMT is effective in treating UI, however it is not clear how intensively women have to exercise to give the maximum sustained improvement in symptoms, and how we enable women to achieve this. Biofeedback is an adjunct to PFMT that may help women exercise more intensively for longer, and thus may improve continence outcomes when compared with PFMT alone. A Cochrane review was inconclusive about the benefit of biofeedback, indicating the need for further evidence. Methods and analysis This multicentre randomised controlled trial will compare the effectiveness and cost-effectiveness of PFMT versus biofeedback-mediated PFMT for women with stress UI or mixed UI. The primary outcome is UI severity at 24 months after randomisation. The primary economic outcome measure is incremental cost per quality-adjusted life-year at 24 months. Six hundred women from UK community, outpatient and primary care settings will be randomised and followed up via questionnaires, diaries and pelvic floor assessment. All participants are offered six PFMT appointments over 16 weeks. The use of clinic and home biofeedback is added to PFMT for participants in the biofeedback group. Group allocation could not be masked from participants and healthcare staff. An intention-to-treat analysis of the primary outcome will estimate the mean difference between the trial groups at 24 months using a general linear mixed model adjusting for minimisation covariates and other important prognostic covariates, including the baseline score. Ethics and dissemination Approval granted by the West of Scotland Research Ethics Committee 4 (16/LO/0990). Written informed consent will be obtained from participants by the local research team. Serious adverse events will be reported to the data monitoring and ethics committee, the ethics committee and trial centres as required. A Standard Protocol Items: Recommendations for Interventional Trials checklist and figure are available for this protocol. The results will be published in international journals and included in the relevant Cochrane review. Trial registration number ISRCTN57746448; Pre-results.National Institute for Health Research (NIHR

pH-responsive and antibacterial PANI-PEDOT:PSS fibres for wearable applications

With the emergence of wearable electronics for health and the prevalence of chronic wounds, there is demand for an effective wearable pH sensor. A simple method of solvent treating wet-spun poly(3,4-ethylenedioxythiophene)-poly(styrenesulfonate) (PEDOT:PSS) fibres proved effective in the development of highly conductive fibre substrates. With an optimised polyaniline coating, these fibres displayed a Nernstian response to changes in pH in the solid-state vs. a fabricated pseudoreference electrode across a wide pH range of 3.0 to 9.0. In addition, these biocompatible fibre electrodes displayed antibacterial properties. The fibre electrodes offer significant opportunities for future wearable textile-based sensors as well as the realisation of a real-time, on-body pH sensing device for monitoring skin and wound healing

Circulating αKlotho influences phosphate handling by controlling FGF23 production

The FGF23 coreceptor αKlotho (αKL) is expressed as a membrane-bound protein (mKL) that forms heteromeric complexes with FGF receptors (FGFRs) to initiate intracellular signaling. It also circulates as an endoproteolytic cleavage product of mKL (cKL). Previously, a patient with increased plasma cKL as the result of a translocation [t(9;13)] in the αKLOTHO (KL) gene presented with rickets and a complex endocrine profile, including paradoxically elevated plasma FGF23, despite hypophosphatemia. The goal of this study was to test whether cKL regulates phosphate handling through control of FGF23 expression. To increase cKL levels, mice were treated with an adeno-associated virus producing cKL. The treated groups exhibited dose-dependent hypophosphatemia and hypocalcemia, with markedly elevated FGF23 (38 to 456 fold). The animals also manifested fractures, reduced bone mineral content, expanded growth plates, and severe osteomalacia, with highly increased bone Fgf23 mRNA (>150 fold). cKL activity in vitro was specific for interactions with FGF23 and was FGFR dependent. These results demonstrate that cKL potently stimulates FGF23 production in vivo, which phenocopies the KL translocation patient and metabolic bone syndromes associated with elevated FGF23. These findings have important implications for the regulation of αKL and FGF23 in disorders of phosphate handling and biomineralization

Forests for the New Millennium - MAKING FORESTS WORK FOR PEOPLE AND NATURE

THE WAYS IN WHICH FORESTS ARE PERCEIVED AND USED HAVE CHANGED DRAMATICALLY OVER RECENT YEARS. FORESTS ARE NO LONGER SEEN SIMPLY AS A SOURCE OF TIMBER, BUT AS COMPLEX ECOSYSTEMS WHICH SUSTAIN LIVELIHOODS AND PROVIDE A RANGE OF PRODUCTS AND ENVIRONMENTAL SERVICES. IT IS NOW WIDELY RECOGNISED THAT FORESTS CAN CONTRIBUTE TO RURAL DEVELOPMENT AND POVERTY ALLEVIATION.Forest, economics, livelihoods

Hsp90 orchestrates transcriptional regulation by Hsf1 and cell wall remodelling by MAPK signalling during thermal adaptation in a pathogenic yeast

Acknowledgments We thank Rebecca Shapiro for creating CaLC1819, CaLC1855 and CaLC1875, Gillian Milne for help with EM, Aaron Mitchell for generously providing the transposon insertion mutant library, Jesus Pla for generously providing the hog1 hst7 mutant, and Cathy Collins for technical assistance.Peer reviewedPublisher PD