The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England

Background: The REAL (Rehabilitation Effectiveness for Activities for Life) research programme, funded by the National Institute for Heath Research (NIHR) from 2009 to 2015, investigated NHS mental health rehabiliation services across England. The users of these services are people with longer-term, complex mental health problems, such as schizophrenia, who have additional problems that complicate recovery. Although only around 10% of people with severe mental illness require inpatient rehabilitation, because of the severity and complexity of their problems they cost 25–50% of the total mental health budget. Despite this, there has been little research to help clinicians and commissioners to plan and deliver effective treatments and services. This research aimed to address this gap. Methods: The programme had four phases. (1) A national survey, using quantitative and qualitative methods, was used to provide a detailed understanding of the scope and quality of NHS mental health rehabilitation services in England and the characteristics of those who use them. (2) We developed a training intervention for staff of NHS inpatient mental health rehabilitation units to facilitate service users’ activities. (3) The clinical effectiveness and cost-effectiveness of the staff training programme was evaluated through a cluster randomised controlled trial involving 40 units that scored below average on our quality assessment tool in the national survey. A qualitative process evaluation and a realistic evaluation were carried out to inform our findings further. (4) A naturalistic cohort study was carried out involving 349 service users of 50 units that scored above average on our quality assessment tool in the national survey, who were followed up over 12 months. Factors associated with better clinical outcomes were investigated through exploratory analyses. Results: Most NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than that in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective [coefficient 1.44, 95% confidence interval (CI) –1.35 to 4.24]; staff appeared to revert to previous practices once the training team left the unit. Our realistic review suggested that greater supervision and senior staff support could help to address this. Over half of the service users in our cohort study were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels [odds ratio (OR) 1.03, 95% CI 1.01 to 1.05] and social skills (OR 1.13, 95% CI 1.04 to 1.24), and the ‘recovery’ orientation of the unit (OR 1.04, 95% CI 1.00 to 1.08), which includes collaborative care planning with service users and holding hope for their progress. Quality of care was not associated with costs of care. A relatively small investment (£67 per service user per month) was required to achieve the improvement in everyday functioning that we found in our cohort study. Conclusions: People who require inpatient mental health rehabilitation are a ‘low-volume, high-needs’ group. Despite this, these services are able to successfully discharge most to the community within 18 months. Our results suggest that this may be facilitated by recovery-orientated practice that promotes service users’ activities and social skills. Further research is needed to identify effective interventions that enhance such practice to deliver these outcomes. Our research provides evidence that NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports service users with complex needs in their recovery. Main limitation: Our programme included only NHS, non-secure, inpatient mental health rehabilitation services. Trial registration: Current Controlled Trials ISRCTN25898179. Funding: The NIHR Programme Grants for Applied Research programme

Harnessing nonlinear dynamics for applications in high speed information processing

External-cavity lasers (ECLs) are characterized by nonlinear dynamics created when a laser is subjected to optical feedback from a distant reflector. ECLs were studied using comprehensive experiments by simultaneously probing all three dynamic system variables (optical intensity, optical phase, and carrier dynamics) in real-time as the level of light being re-injected into the laser was varied. Specifically, as the level of light increases ECLs transition from constant behavior to deterministic chaos. We characterized the different bifurcation mechanisms which occur during this transition to chaos. We exploited this knowledge to optimize applications (neuromorphic computing, random number generation, microwave oscillation generation, and optical imaging/detection). In practice we observed, faster and more accurate computing, a superior novel entropy source for random number generation, a simple stable X-band tunable microwave oscillator, and a simple compact detector.Ph.D

Parent-collected oropharyngeal swabs in cystic fibrosis

Early detection and treatment of bacterial infection is effective in slowing the progression of lung disease in cystic fibrosis (CF).1 It is recommended that a minimum of 4 samples are collected for bacterial culture annually.2 Approximately two-thirds of children with CF cannot routinely expectorate sputum3 ; therefore, samples, such as oropharyngeal swab (OPS), are used. With reduced hospital visits and increased telehealth consultations secondary to the severe acute respiratory syndrome coronavirus 2 pandemic, the number of samples available for analysis has been severely impacted.4 Therefore, alternative methods of obtaining OPS are needed. One option is parental collection of OPS

Teaching manually assisted cough to caregivers of children with neuromuscular disease

BACKGROUND: Cough augmentation techniques are taught by health-care providers to improve secretion clearance and to help prevent respiratory infections in children with neuromuscular disease. There is some evidence of the effectiveness of a manually assisted cough when applied by health-care providers. However, it is unknown whether parents and caregivers may also be effective in applying manually assisted cough. The aim of this study was to evaluate whether parents and caregivers are effective at applying a manually assisted cough to a child with neuromuscular disease after being taught by a health-care provider. METHODS: For this prospective cohort study, children and their parents or caregivers were recruited from neuromuscular clinics in the Sydney Children's Hospitals Network. Cough peak flow was the outcome measure for the strength of the child's cough. Children were eligible to participate if their unassisted cough peak flow at baseline was <270 L/min. Parents and caregivers were taught a manually assisted cough by a physiotherapist before being measured. The cough peak flow was measured in the following order: (1) during an unassisted cough as baseline, (2) during a manually assisted cough performed by a physiotherapist, (3) during a manually assisted cough performed by a parent or caregiver, and (4) during an unassisted cough after intervention. RESULTS: Twenty-eight children (24 boys, 4 girls; mean ± SD age, 12 ± 3 y) completed the study. No clinically or statistically significant changes were found in the cough peak flow after the application of a manually assisted cough by parents or caregivers (95% CI −11 to 11 L/min) or by physiotherapists (95% CI −6 to 14 L/min). CONCLUSIONS: Parents and caregivers and health-care providers were ineffective at increasing cough peak flow in children with neuromuscular weakness when applying a manually assisted cough. A single training session was insufficient for a parent or caregiver to be able to apply a manually assisted cough effectively on his or her child with neuromuscular weakness. Further research is warranted to guide recommendations on how best to equip parents and caregivers with the skills to help manage children with neuromuscular disease

[In Press] The protective role of resilience in the reporting of post-concussive symptoms within a non-clinical sample

Objective: Despite being common following a brain injury, post-concussive symptoms (PCS) are highly prevalent in healthy and non-concussed individuals. Psychosocial factors likely subserve the maintenance of symptoms, and numerous studies have identified prominent risk factors associated with post-concussive symptom reporting (e.g. history of depression). However, few studies have investigated protective factors in this context. The aim of the current study was to examine the relationship between resilience and PCS, and to identify the factors subserving resilience within this relationship. Method: Healthy and non-concussed participants (n = 283, Mage = 22.70 years) completed questionnaires examining PCS (Rivermead Post-Concussion Symptom Questionnaire) and resilience (Resilience Scale for Adults), together with a screener of background demographic/clinical factors. Results: Resilience negatively predicted PCS above and beyond the effect of demographic and clinical factors previously implicated in the reporting of PCS. Interestingly, heightened “perception of self” was the resilience factor uniquely associated with PCS symptoms. The final model accounted for 33% of the variance in PCS. Overall, female gender, a history of headaches, and diagnoses of ADHD and depression, and reduced “perception of self” were all predictive of greater PCS (ps < .05). Conclusion: Resilience, particularly perception of self, is a positive protective factor in the reporting of PCS. These findings highlight the importance of early identification of less resilient individuals following trauma—such as an mTBI and provide a potential rationale for the incorporation of resilience-based rehabilitation programs into the recovery process, particularly those that promote greater self-efficacy and self-competency

Parent, Child and Physiotherapist Perceptions of Effectiveness of Parent Performed Manually Assisted Cough on Children With Neuromuscular Disease

Published research exploring confidence and perceptions of effectiveness in performing a manually assisted cough on children with neuromuscular disease is not available. This descriptive study aimed to describe confidence and perceived effectiveness of parents, children, and therapists in parent performed manually assisted cough. A total of 28 children with neuromuscular disease, one of their parents, and physiotherapist participated. Overall, 40% of parents, 52% of children, and 46% of therapists were very confident in parents’ ability to perform effective manually assisted coughs. Parents, children, and therapists largely perceived the parental manually assisted coughs as somewhat effective (68%, 60%, and 57%, respectively). Approximately, half of parents (48%), children (52%), and therapists (50%) felt very confident in parents’ ability to retain the technique between clinic visits. Interestingly, percentage agreement statistics indicate that a reasonable proportion (30%) of pairs of respondents did not agree in their ratings. Overall, high percentages of favourable ratings were noted for all questions