The role of image in the promotion of a region as a visitor destination.

This research examines the role of image in the promotion of a geographical region as a visitor destination. The inter-relationship between tourism and image was focused upon from both the potential visitor's perspective and the viewpoint of the promoter. Using the Grampian region in the North East of Scotland as a case study, visitors and non-visitors to the area were surveyed to ascertain their image of Grampian, how that image was formed and the perceived role of image in destination selection. Although the importance of non-visitors to a destination has previously been recognised, an appropriate methodology has not been developed by other researchers. The significance of image to the promoters of a destination was examined through interviews with members of the industry, analysis of brochures and of policy documents. This revealed a significant lack of co-ordination throughout the industry which hindered effective image promotion. The empirical research was considered against a number of theoretical perspectives, which have been developed to assess tourist motivations and destination selection, but which have previously provided little or no weighting to the role of image. A conceptual framework for the decision-making process of destination selection was developed through the case study. The research suggests that the possession of a clear image is the most significant factor in destination selection due to its inseparable link with other factors, such as past experience of a potential destination and experiences of other destinations. By identifying the significance of experience on image formation, the importance of image promotion is also highlighted. However, there is a lack of significance attached to image in the promotion of a destination, mainly due to problems associated with effectiveness measurement. The research also highlights the problems of developing a promotional image for geographically and economically diverse regions and raises questions regarding the unit areas presently used in the promotion of Scotland

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy

Basic science232. Certolizumab pegol prevents pro-inflammatory alterations in endothelial cell function

Background: Cardiovascular disease is a major comorbidity of rheumatoid arthritis (RA) and a leading cause of death. Chronic systemic inflammation involving tumour necrosis factor alpha (TNF) could contribute to endothelial activation and atherogenesis. A number of anti-TNF therapies are in current use for the treatment of RA, including certolizumab pegol (CZP), (Cimzia ®; UCB, Belgium). Anti-TNF therapy has been associated with reduced clinical cardiovascular disease risk and ameliorated vascular function in RA patients. However, the specific effects of TNF inhibitors on endothelial cell function are largely unknown. Our aim was to investigate the mechanisms underpinning CZP effects on TNF-activated human endothelial cells. Methods: Human aortic endothelial cells (HAoECs) were cultured in vitro and exposed to a) TNF alone, b) TNF plus CZP, or c) neither agent. Microarray analysis was used to examine the transcriptional profile of cells treated for 6 hrs and quantitative polymerase chain reaction (qPCR) analysed gene expression at 1, 3, 6 and 24 hrs. NF-κB localization and IκB degradation were investigated using immunocytochemistry, high content analysis and western blotting. Flow cytometry was conducted to detect microparticle release from HAoECs. Results: Transcriptional profiling revealed that while TNF alone had strong effects on endothelial gene expression, TNF and CZP in combination produced a global gene expression pattern similar to untreated control. The two most highly up-regulated genes in response to TNF treatment were adhesion molecules E-selectin and VCAM-1 (q 0.2 compared to control; p > 0.05 compared to TNF alone). The NF-κB pathway was confirmed as a downstream target of TNF-induced HAoEC activation, via nuclear translocation of NF-κB and degradation of IκB, effects which were abolished by treatment with CZP. In addition, flow cytometry detected an increased production of endothelial microparticles in TNF-activated HAoECs, which was prevented by treatment with CZP. Conclusions: We have found at a cellular level that a clinically available TNF inhibitor, CZP reduces the expression of adhesion molecule expression, and prevents TNF-induced activation of the NF-κB pathway. Furthermore, CZP prevents the production of microparticles by activated endothelial cells. This could be central to the prevention of inflammatory environments underlying these conditions and measurement of microparticles has potential as a novel prognostic marker for future cardiovascular events in this patient group. Disclosure statement: Y.A. received a research grant from UCB. I.B. received a research grant from UCB. S.H. received a research grant from UCB. All other authors have declared no conflicts of interes

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme

Your child is dead

OBJECTIVE: To determine parent's views on how death of their children should have been handled. DESIGN: Retrospective questionnaire survey of parents who had experienced death of their child. SETTING: Charitable organisation of bereaved parents. SUBJECTS: 150 bereaved parents, all members of the organisation, of whom 120 (80%) participated voluntarily in the study. MAIN OUTCOME MEASURES: Child's age; date and cause of death; details of person breaking the news and handling of the interview; time parents spent with dead child, their attitude to requests for organ donation, and follow up support received. RESULTS: 122 children's deaths were described; the largest single group was due to road traffic accidents, 16 were suicides, and eight were murders. Twice as many interviews were rated as sympathetically or reasonably handled as badly or offensively handled (68 v 34). The interview ratings depended on the sensitivity and personal skills of the interviewers rather than on their previous contact or professional position; police were rated as more sympathetic than doctors and nurses. Of 109 respondents, 81 had seen their child's body, 44 of whom thought that sufficient time had been denied. Of the 28 parents who did not see the body, 17 subsequently stated their regret. In 82 parents organ donation had not been discussed. Only 16 parents recorded any follow up support from hospital staff and very few support at the time. CONCLUSIONS: The consistency of the responses suggests a serious need to revise the in service training and education of the police and health professionals in their approach to informing of death; organ donation should be discussed sensitively and parents allowed time with their dead child with fewer restrictions

Planning palliative care services

An audit was conducted to assess the use of, and satisfaction with, local services for the care of the dying, which have developed over the past seven years in South Glamorgan. These services include hospice inpatient, outpatient and day care facilities, home care specialist nursing, volunteer services and domiciliary medical consultations. All general practitioners in the district were surveyed about the services by postal questionnaire; respondents represented most of the practices in the district. The results show a variable level of uptake of services for those well established (excluding paediatric oncology), including a high level of satisfaction with the available services. The results identify a lack of provision for patients dying from a non-malignant disease

The assessment of communication skills in palliative medicine: a comparison of the scores of examiners and simulated patients

The Diploma in Palliative Medicine was established in 1991 and included communication skills as a major part of the curriculum. In order to assess the efficacy of doctors' communication skills in the Diploma examination, an assessment tool was developed based on the modified Prevara Score. Simulated (actor) patients are used for the consultation in the examination; the doctors' performance is assessed independently by the examiner and by the actor. This provides an opportunity to consider the methods used for describing agreement between raters. There was high correlation between examiners' and actors' scores and high acceptability of the scoring method. However, satisfactory agreement in terms of the mean differences between scores and their standard deviation between examiners' and actors' scores was not achieved. We have found the simulated patient interview to be a useful teaching and assessment tool. The good correlation between the observer's (examiner) and the recipient's (actor-patient) perception of the doctor's interviewing skills provides evidence of the validity of the assessment. However the actor-patients' ratings tended to be higher and the two groups of assessors could not be used interchangeably. We conclude that actor-patients are of value in teaching and in assessing the communication skills of doctors but produce different scores to clinical examiners

The effect of topical 0.75% metronidazole gel on malodorous cutaneous ulcers

The unpleasant smell of infected fungating tumors and benign cutaneous ulcers is a distressing clinical problem, known to be associated with anaerobic infection. Topical metronidazole 0.8% gel has been shown to decrease smell from fungating malodorous tumors. This study was conducted to assess prospectively the subjective and bacteriological response to 0.75% metronidazole gel to decrease smell from these lesions and to assess whether bacterial contamination of the tubes of gel occurs during use. Forty-seven patients with benign or malignant cutaneous lesions associated with a foul smell were assessed for smell, pain, appearance, and bacteriological profile before entry and at 7 and 14 days. Forty-one (95%) of the 43 patients assessed at 14 days reported decreased smell. Anaerobic infection was initially found in 25 (53%) of patients and was eliminated in 21 (84%) of these. At review after 7 days, patients reported less pain from the lesions. Discharge and associated cellulitis were also observed to decrease significantly