Use of a patient-centred educational exchange (PCEE) to improve patient's self-management of medicines after a stroke: a randomised controlled trial study protocol

Introduction: National and international guidelines make recommendations for secondary prevention of stroke including the use of medications. A strategy which engages patients in a conversation to personalise evidence-based educational material (patient-centred educational exchange; PCEE) may empower patients to better manage their medications. Methods and analysis: This protocol outlines a non-blinded randomised controlled trial. Consenting patients admitted with a diagnosis of stroke or transient ischaemic attack will be randomised 1:1 to receive either a PCEE composed of two sessions, one at the bedside before discharge and one by telephone at least 10 days after discharge from hospital in addition to usual care (intervention) or usual care alone (control). The primary aim of this study is to determine whether a PCEE improves adherence to antithrombotic, antihypertensive and lipid-lowering medications prescribed for secondary prevention of stroke over the 3 months after discharge, measured using prescription-refill data. Secondary aims include investigation of the impact of the PCEE on adherence over 12 months using prescription-refill data, self-reported medication taking behaviour, self-reported clinical outcomes (blood pressure, cholesterol, adverse medication events and readmission), quality of life, the cost utility of the intervention and changes in beliefs towards medicines and illness. Ethics and dissemination: Communication of the trial results will provide evidence to aid clinicians in conversations with patients about medication taking behaviour related to stroke prevention. The targeted audiences will be health practitioners and consumers interested in medication taking behaviour in chronic diseases and in particular those interested in secondary prevention of stroke. The trial has ethics approval from Metro South Human Research Ethics Committee (HREC/15/QPAH/531) and The University of Queensland Institutional Human Research Ethics (2015001612). Trial registration number: ACTRN12615000888561; Pre-results

Testing the relative sensitivity of 102 ecological variables as indicators of woodland condition in the New Forest, UK.

Forests globally are facing an increasing number of threats from modified disturbance regimes, novel stressors and changing environmental conditions. This has ultimately resulted in declines in the ecological condition of many forest and woodland ecosystems, leading to widespread tree mortality and stand dieback. Effective indicators of overall woodland ecological condition are therefore needed for environmental monitoring and to support management responses. To test the effectiveness of different variables that could potentially be used as indicators of woodland condition, 102 variables that describe woodland structure, composition, functioning, edaphic conditions and disturbance regimes were assessed along 12 replicate gradients of beech stand dieback. Results indicated that 35 variables differed significantly between at least two stages of the dieback gradient, indicating their sensitivity to stand dieback. Seven of these indicators related to woodland species composition, two to functional processes, 20 to structural features, four to edaphic conditions, and two to disturbance regimes. These results demonstrate that effective indicators can potentially be identified for each of the ecological categories. Effective composition indicators included species richness of ectomycorrhizal fungi, ground flora and epiphytic lichens; functional indicators were soil respiration rate and net nitrification rate; edaphic conditions included soil Na:Ca ratio, exchangeable sodium, total carbon, Ca:Al ratio; structural indicators included canopy openness, litter cover, sward height, and volume of deadwood, and for disturbance the indicator was Equus dung density. Other measures, such as shrub cover and species richness of carabid beetles and spiders, were not found to vary significantly along the dieback gradients, and were therefore not identified as effective indicators. These results demonstrate the value of gradient analysis for evaluating indicators of woodland condition, but also highlight the need for multi-site studies to identify indicators with widescale applicability

Cultural distance, mindfulness and passive xenophobia: Using Integrated Threat Theory to explore home higher education students' perspectives on 'internationalisation at home'

This paper addresses the question of interaction between home and international students using qualitative data from 100 home students at two 'teaching intensive' universities in the southwest of England. Stephan and Stephan's Integrated Threat Theory is used to analyse the data, finding evidence for all four types of threat that they predict when outgroups interact. It is found that home students perceive threats to their academic success and group identity from the presence of international students on the campus and in the classroom. These are linked to anxieties around 'mindful' forms of interaction and a taboo around the discussion of difference, leading to a 'passive xenophobia' for the majority. The paper concludes that Integrated Threat Theory is a useful tool in critiquing the 'internationalisation at home' agenda, making suggestions for policies and practices that may alleviate perceived threats, thereby improving the quality and outcomes of intercultural interaction. © 2010 British Educational Research Association

Investigation of hospital discharge cases and SARS-CoV-2 introduction into Lothian care homes

Background The first epidemic wave of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Scotland resulted in high case numbers and mortality in care homes. In Lothian, over one-third of care homes reported an outbreak, while there was limited testing of hospital patients discharged to care homes. Aim To investigate patients discharged from hospitals as a source of SARS-CoV-2 introduction into care homes during the first epidemic wave. Methods A clinical review was performed for all patients discharges from hospitals to care homes from 1st March 2020 to 31st May 2020. Episodes were ruled out based on coronavirus disease 2019 (COVID-19) test history, clinical assessment at discharge, whole-genome sequencing (WGS) data and an infectious period of 14 days. Clinical samples were processed for WGS, and consensus genomes generated were used for analysis using Cluster Investigation and Virus Epidemiological Tool software. Patient timelines were obtained using electronic hospital records. Findings In total, 787 patients discharged from hospitals to care homes were identified. Of these, 776 (99%) were ruled out for subsequent introduction of SARS-CoV-2 into care homes. However, for 10 episodes, the results were inconclusive as there was low genomic diversity in consensus genomes or no sequencing data were available. Only one discharge episode had a genomic, time and location link to positive cases during hospital admission, leading to 10 positive cases in their care home. Conclusion The majority of patients discharged from hospitals were ruled out for introduction of SARS-CoV-2 into care homes, highlighting the importance of screening all new admissions when faced with a novel emerging virus and no available vaccine

SARS-CoV-2 Omicron is an immune escape variant with an altered cell entry pathway

Vaccines based on the spike protein of SARS-CoV-2 are a cornerstone of the public health response to COVID-19. The emergence of hypermutated, increasingly transmissible variants of concern (VOCs) threaten this strategy. Omicron (B.1.1.529), the fifth VOC to be described, harbours multiple amino acid mutations in spike, half of which lie within the receptor-binding domain. Here we demonstrate substantial evasion of neutralization by Omicron BA.1 and BA.2 variants in vitro using sera from individuals vaccinated with ChAdOx1, BNT162b2 and mRNA-1273. These data were mirrored by a substantial reduction in real-world vaccine effectiveness that was partially restored by booster vaccination. The Omicron variants BA.1 and BA.2 did not induce cell syncytia in vitro and favoured a TMPRSS2-independent endosomal entry pathway, these phenotypes mapping to distinct regions of the spike protein. Impaired cell fusion was determined by the receptor-binding domain, while endosomal entry mapped to the S2 domain. Such marked changes in antigenicity and replicative biology may underlie the rapid global spread and altered pathogenicity of the Omicron variant

What proportion of unplanned re-presentations to an emergency department are medication related and preventable?

Background: Australian data suggest that one-fifth of emergency department (ED) presentations are re-presentations within 28\ua0days of discharge, with early re-presentations common. The contribution of medication misadventure to re-presentations has been poorly defined to date, but has been reported previously as medication-related readmission rates of 23%, of which 90% are considered preventable. Aims: This study identified and categorised medication-related 28-day ED re-presentations after discharge, associated medication-related problems (MRPs) and differences in demographics between medication-related and -unrelated ED re-presentations. Methods: A retrospective medical record review was conducted for every third adult 28-day ED re-presentation between 1 July and 31 December 2016. Re-presentations were examined for potential medication-related causes. The MRPs identified were categorised using causality, contribution and preventability criteria. Results: Of 631 eligible re-presentations, 196 were sampled. Re-presentations were potentially medication related in 41 (21%) cases; in 24 (59%) re-presentations, preventable MRPs were considered the main cause of re-presentation. Early medication-related re-presentations were common: 49% occurred within 7\ua0days of discharge, and 20% on Day 1. Patients re-presenting with an MRP were, on average, 10.3\ua0years older and prescribed 3.4 more medications on the index discharge than those re-presenting with a non-MRP. Cardiovascular medications (n\ua0=\ua014) were most commonly implicated in MRPs, with toxicity or adverse reaction (n\ua0=\ua016) and undertreated (n\ua0=\ua015) the most common MRP categories. Conclusions: One-fifth of the 28-day ED re-presentations observed were considered potentially medication related, with 59% of these associated with MRPs considered preventable. MRPs most frequently involved cardiovascular medications, adverse reactions and undertreatment. Early individualised pharmaceutical review after discharge may help reduce the MRPs observed

"Just working in a team was a great experience..." - Student perspectives on the learning experiences of an interprofessional education program

Interprofessional education (IPE) programs aim to improve collaboration between health- and social-care professionals and to optimize clinical outcomes. Such programs are complex to design, and evaluation of effectiveness is difficult. Combining qualitative and quantitative data may provide greater understanding of how a program affects participants and what aspects are influential on attitudes and behavior. This qualitative study used semi-structured interviews and interpretative phenomenological analysis to explore undergraduate student perspectives on what attributes of a 4-week IPE program they considered contributed to a successful learning experience. Due to the fact that the students were not formally assessed, the realistic context of the activities and the quality of the facilitators created an environment where the students felt empowered to interact freely without fear of reproach. Learning the roles of other professions and their contribution to a healthcare team broadened the students' perspectives on healthcare and increased their sense of self-worth and pride in their professions. In addition, being able to identify the relevance of the learning experience to their future practice motivated the students. This information can be used to create optimal learning environments for facilitating the development of successful future healthcare teams