Walking and talking in multiple sclerosis: an investigation of cognitive-motor dual tasking and clinical research portfolio

Problems with walking and attention are known to be prevalent in Multiple Sclerosis (MS), though no studies have reported how these two difficulties might interact. The study aimed to investigate the effects of performing a concurrent cognitive task when walking in MS and determine the effects of task demand on dual-task performance. Eighteen MS participants and 18 healthy controls took part. Participants completed walking and cognitive tasks under single and dual task conditions. MS participants, compared to healthy controls, had greater decrements in dual-task performance; including decrements in cognitive task performance, walking speed and swing time variability. Dual-task decrements were evident in titrated and fixed demand conditions. Dual-task decrements were related to fatigue, cognitive functioning and self-reported cognitive errors, but not to measures of disease severity or duration. MS participants perform differentially poorly on walking and talking dual-tasks compared to healthy controls. This may lead to difficulties in everyday life and increase the risk of falls in MS. Clinicians should independently assess dual-task walking in MS patients. The role of task demand in dual-tasking decrements remains unclear and needs further investigation. Future studies should replicate the current findings and develop practical clinical tools to assess walking and talking ability

Evaluating the impact of financial incentives on inequalities in smoking cessation in primary care

Background: Smoking cessation interventions are underprovided in primary care. This thesis examines the impact of financial incentives on the provision of smoking cessation interventions, and inequalities in provision, in primary care. Methods: • Systematic review of financial incentives for smoking cessation in healthcare. • Cross sectional study using general practice data from Wandsworth, London, using logistic regression to examine associations between ethnicity and disease group with ascertainment of smoking status and provision of cessation advice following the introduction of the UK’s Quality and Outcomes Framework (QOF). • Before-and-after studies using general practice data from Hammersmith & Fulham, London, looking at the impact of a local financial incentive scheme (QOF+) on smoking outcomes for patients without smoking-related diseases (primary prevention), and antenatal patients, using logistic regression to examine inequalities. Results: Introduction of financial incentives was associated with increased recording of smoking status and advice to smokers, most evident for patients with smoking-related diseases compared with patients without smoking-related diseases, for whom there were much smaller incentives for recording smoking status and none for offering stop smoking advice. However, when specific incentives were provided for primary prevention large improvements in smoking outcomes were seen. The youngest and oldest groups of patients were less likely to be asked about smoking. White British patients were more likely to smoke than other ethnic groups, except Black Caribbean men with depression, 62% of whom smoked. Smoking advice was provided relatively equitably, but Black Caribbean men with depression were less likely to receive advice than White British men with depression (59% vs 81%). Disparities in smoking outcomes with respect to age and ethnicity persisted after the financial incentives were introduced. Conclusions: Introduction of financial incentives was associated with increases in recording smoking status and largely equitable provision of cessation advice, but variations in smoking outcomes between groups persisted. Extending financial incentives to include recording of ethnicity and rewarding quit rates may further improve smoking outcomes in primary care.Open Acces

Flow Cytometric Analysis of Uveal Melanoma

Uveal melanoma, although a comparatively rare tumour of man, is the commonest malignant tumour of the eye. The tumours can be composed of varying cell types; pure spindle, pure epithelioid and a mixture of spindle and epithelioid cells, with a worse prognosis being associated with the pure epithelioid cells. Fow cytometry is a modem method of studying cell surface marker expression which makes use of fluorescently labelled antibodies specific for these molecules. It gives quantitative analysis of a large number of cells from a substantial section of the sample in a short period of time and allows small changes in fluorescence to be quantified

Alternative, more sustainable, wall construction techniques than brick and block, for new housing in England and Wales

There is a need to reduce the emissions of the country as a whole, to limit the risk of climate change due to Global warming and to meet targets set by the Kyoto agreement and the Climate Change Act. The large number of houses constructed annually in England and Wales have an important role to play in this. By reducing emissions, resulting from both the manufacture of construction materials and the energy used by house occupants, housing can help achieve the necessary emissions reductions. Alternative construction methods can contribute to this, either by having a lower embodied energy or by demonstrating good thermal properties to limit heat loss and hence operational energy. However, it is essential that both the construction industry and the public accept the alternative construction methods for them to be economically viable. In addition, there should be no loss of performance as a result of using alternative construction methods. Six methods of construction were studied in depth, including generating embodied and operational energy requirements and identifying their performance in terms of airtightness, wall thickness, and fire resistance. Public and industry acceptability were examined by use of questionnaires. A comparison of the data collected showed that identifying the best, or optimal, option visually is a challenging task as no single method of construction is best in all areas. A methodology was created to aid the selection of a wall construction method. The methodology is capable of examining multiple variables, in this work it is demonstrated with construction method and front building dimension. To identify the optimal method, optimisation by genetic algorithms is used. Use of the methodology was demonstrated with a case study based on the most frequently constructed housing type for England and Wales. The importance of weighting was demonstrated with the use of weightings based on concerns held by different parties. It was found that minimising the external wall area gives the optimal solution as less material is needed and there is less opportunity for heat loss. For the situation examined in the case study, Structural Insulated Panels (SIPs) were identified as having the potential to reduce the environmental impact of housing construction in England and Wales without impacting saleability or performance

Impact of Argument Type and Concerns in Argumentation with a Chatbot

Conversational agents, also known as chatbots, are versatile tools that have the potential of being used in dialogical argumentation. They could possibly be deployed in tasks such as persuasion for behaviour change (e.g. persuading people to eat more fruit, to take regular exercise, etc.) However, to achieve this, there is a need to develop methods for acquiring appropriate arguments and counterargument that reflect both sides of the discussion. For instance, to persuade someone to do regular exercise, the chatbot needs to know counterarguments that the user might have for not doing exercise. To address this need, we present methods for acquiring arguments and counterarguments, and importantly, meta-level information that can be useful for deciding when arguments can be used during an argumentation dialogue. We evaluate these methods in studies with participants and show how harnessing these methods in a chatbot can make it more persuasive

Preferences for cancer investigation:a vignette-based study of primary-care attendees

SummaryBackgroundThe UK lags behind many European countries in terms of cancer survival. Initiatives to address this disparity have focused on barriers to presentation, symptom recognition, and referral for specialist investigation. Selection of patients for further investigation has come under particular scrutiny, although preferences for referral thresholds in the UK population have not been studied. We investigated preferences for diagnostic testing for colorectal, lung, and pancreatic cancers in primary-care attendees.MethodsIn a vignette-based study, researchers recruited individuals aged at least 40 years attending 26 general practices in three areas of England between Dec 6, 2011, and Aug 1, 2012. Participants completed up to three of 12 vignettes (four for each of lung, pancreatic, and colorectal cancers), which were randomly assigned. The vignettes outlined a set of symptoms, the risk that these symptoms might indicate cancer (1%, 2%, 5%, or 10%), the relevant testing process, probable treatment, possible alternative diagnoses, and prognosis if cancer were identified. Participants were asked whether they would opt for diagnostic testing on the basis of the information in the vignette.Findings3469 participants completed 6930 vignettes. 3052 individuals (88%) opted for investigation in their first vignette. We recorded no strong evidence that participants were more likely to opt for investigation with a 1% increase in risk of cancer (odds ratio [OR] 1·02, 95% CI 0·99–1·06; p=0·189), although the association between risk and opting for investigation was strong when colorectal cancer was analysed alone (1·08, 1·03–1·13; p=0·0001). In multivariable analysis, age had an effect in all three cancer models: participants aged 60–69 years were significantly more likely to opt for investigation than were those aged 40–59 years, and those aged 70 years or older were less likely. Other variables associated with increased likelihood of opting for investigation were shorter travel times to testing centre (colorectal and lung cancers), a family history of cancer (colorectal and lung cancers), and higher household income (colorectal and pancreatic cancers).InterpretationParticipants in our sample expressed a clear preference for diagnostic testing at all risk levels, and individuals want to be tested at risk levels well below those stipulated by UK guidelines. This willingness should be considered during design of cancer pathways, particularly in primary care. The public engagement with our study should encourage general practitioners to involve patients in referral decision making.FundingThe National Institute for Health Research Programme Grants for Applied Research programme

The calculation of embodied energy in new build UK housing

Reducing CO2 emissions to mitigate the impacts of climate change is now an international imperative. The built environment is responsible for nearly half of all CO2 emissions in the UK. Therefore, the reduction of carbon emissions from the products and processes involved in a building’s lifecycle are of paramount importance in meeting national and global emissions reduction targets. The energy used and consequent carbon emissions associated with construction materials and processes are usually calculated using the concept of embodied energy, albeit with significant variations in methodology. In general, the embodied energy of a building is considered to account for less than one-fifth of its whole-life energy use. However, as energy efficiency for new-build improves towards the zero carbon target in 2016, the embodied energy will assume an increasingly greater proportion, approaching 100% of the lifetime energy use and emissions. The research reported here is aimed at achieving a better understanding of the aspects of embodied energy of new-build UK houses (in particular, the focus is on the accuracy of various calculation procedures) that are often simplified to a few building types via a generalised and frequently non- UK, representation of the construction process. The need for a more standardised calculation method for embodied energy and resulting CO2 emissions is therefore discussed. Although considered in relation to the house building industry, this research is also applicable to the wider construction industry, as well as manufacturing

Acceptability of a digital healthintervention alongside physiotherapy to support patients following anterior cruciateligament reconstruction

Background: Physiotherapy rehabilitation following surgical reconstruction to the Anterior Cruciate Ligament (ACL) can take up to 12 months to complete. Given the lengthy rehabilitation process, a blended intervention can be used to compliment face-to-face physiotherapy with a digital exercise intervention. In this study, we used TRAK, a web–based tool that has been developed to support knee rehabilitation, which provides individually tailored exercise programs with videos, instructions and progress logs for each exercise, relevant health information and a contact option that allows a patient to email a physiotherapist for additional support. The aim of this study was to evaluate the acceptability of TRAK–based blended intervention in post ACL reconstruction rehabilitation. Methods: A qualitative research design using semi-structured interviews was used on a convenience sample of participants following an ACL reconstruction, and their treating physiotherapists, in a London NHS hospital. Participants were asked to use TRAK alongside face-to-face physiotherapy for 16 weeks. Interviews were carried out, audio recorded, transcribed verbatim and coded by two researchers independently. Data were analyzed using thematic analysis. Results: Of the 25 individuals that were approached to be part of the study, 24 consented, comprising 8 females and 16 males, mean age 30 years. 17 individuals used TRAK for 16 weeks and were available for interview. Four physiotherapists were also interviewed. The six main themes identified from patients were: the experience of TRAK rehabilitation, personal characteristics for engagement, strengths and weaknesses of the intervention, TRAK in the future and attitudes to digital healthcare. The main themes from the physiotherapist interviews were: potential benefits, availability of resources and service organization to support use of TRAK. Conclusions: TRAK was found to be an acceptable method of delivering ACL rehabilitation alongside face-to-face physiotherapy. Patients reported that TRAK, specifically the videos, increased their confidence and motivation with their rehabilitation. They identified ways in which TRAK could be developed in the future to meet technological expectations and further support rehabilitation. For Physiotherapists time and availability of computers affected acceptability. Organization of care to support integration of digital exercise interventions such as TRAK into a blended approach to rehabilitation is required

A scoping review of the resources needed to deliver anterior cruciate ligament physiotherapy rehabilitation in randomised controlled trials

Background: The Anterior Cruciate Ligament (ACL) stabilises the knee and is commonly injured in sport. Surgical repair and rehabilitation are common. However, rehabilitation randomised controlled trials do not always report the resources used to deliver ACL rehabilitation. This may lead to suboptimal availability of resources for evidence based care. Objective: To identify the resources used to deliver multimodal ACL rehabilitation in randomised controlled trials Methods: Comprehensive searches, combining ‘anterior cruciate ligament’, and ‘rehabilitation’ with the Cochrane RCT filter, were conducted of Medline, Embase, Cinahl, PeDro, Sports Discus and the Cochrane Library. Adults post ACL reconstruction were included. The intervention and comparator were physiotherapy for post-operative rehabilitation. Outcomes were the resources required to deliver rehabilitation, and study type was randomised controlled trials. Papers were screened against the criteria; data were charted and narrative synthesis applied. Results: Fourteen studies reported on 599 patients. The interventions ranged from 4 to 36 weeks. Physiotherapy was typically an hour and ranged from 1 to 5 sessions/week. Resources included a gym environment with rehabilitation equipment such as resistance machines, free weights, cardiovascular and neuromuscular control equipment, and an experienced physiotherapist. Conclusions: Implications for future studies include the need for a more detailed report of the resources used in RCTs. Accurate reporting would help healthcare decision makers to effectively manage resources when implementing evidence based care. Findings can be considered as criteria against which to audit resource provision