The conversation: developing confidence to provide end of life care in Salford nursing homes

The study was funded by the Burdett Trust for Nursing and partly by Salford Primary Care Trust. A realistic evaluation design was used to collect data using a range of approaches, from before and after surveys of confidence in delivering end of life care, to participant observation and interviews. A total of 43 people were interviewed involving both staff, residents and relatives. Key Messages a) Significant resources are needed to engage staff, residents and relatives/carers with the idea of advance care planning b) Care home staff are optimistic about involving residents and relatives in planning care at the end of life and some relatives become very involved in care c) Clearly registered nurses and other care home workers such as care assistants have different roles, but the overlap between these and the appropriate boundaries would benefit from further work d) Talking to residents and relatives about their feelings and wishes for care at the end of life remains especially difficult, but education and training in key skills and knowledge can engender both ability and motivation e) Care homes need strong and well-informed leadership in order to implement the Gold Standards Framework f) Placing a relative in a care home involves strain and an ability to compromise ‘there’s no perfect place’ g) Advance care planning can reduce the distress and the number of inappropriate hospital admissions, but is challenging in the face of staff rotation and out of hours medical staff being unpredictable h) The principles of the Gold Standards Framework are widely seen as sensible, but clinical challenges include diagnosing and predicting dying trajectories, especially in heart failure, chronic pulmonary disease and dementia i) A particular concern of staff is how to approach nutrition and hydration as frailty and death approach j) Communicating about diagnosis and especially prognosis with residents who lack capacity is an increasing problem k) Natural justice suggests that resources should be allocated to the general standardisation of a good quality of care at the end of life in ALL care homes whatever their Care Quality Commission ratin

Neutrino masses or new interactions

Recent proposals to study the mass of the "electron" neutrino at a sensitivity of 0.3 eV can be used to place limits on the right handed and scalar charged currents at a level which improves on the present experimental limits. Indeed the neglect of the possibility of such interactions can lead to the inference of an incorrect value for the mass, as we illustrate.Comment: 12 pages and 3 figures. Contributed to the XX International Symposium on Lepton and Photon Interactions at High Energies, Rome, July 2001, and to the International Europhysics Conference on High Energy Physics, Budapest, July 2001. Preprint numbers added, misprints correcte

Neutrino clustering and the Z-burst model

The possibility that the observed Ultra High Energy Cosmic Rays are generated by high energy neutrinos creating "Z-bursts" in resonant interactions with the background neutrinos has been proposed, but there are difficulties in generating enough events with reasonable incident neutrino fluxes. We point out that this difficulty is overcome if the background neutrinos have coalesced into "neutrino clouds" --- a possibility previously suggested by some of us in another context. The limitations that this mechanism for the generation of UHECRs places on the high energy neutrino flux, on the masses of the background neutrinos and the characteristics of the neutrino clouds are spelled out.Comment: 13 pages and 3 figures. Contributed to the XX International Symposium on Lepton and Photon Interactions at High Energies, Rome, July 2001, and to the International Europhysics Conference on High Energy Physics, Budapest, July 2001. Preprint numbers added, misprints correcte

The Effects of Additives on the Physical Properties of Electroformed Nickel and on the Stretch of Photoelectroformed Nickel Components

The process of nickel electroforming is becoming increasingly important in the manufacture of MST products, as it has the potential to replicate complex geometries with extremely high fidelity. Electroforming of nickel uses multi-component electrolyte formulations in order to maximise desirable product properties. In addition to nickel sulphamate (the major electrolyte component), formulation additives can also comprise nickel chloride (to increase nickel anode dissolution), sulphamic acid (to control pH), boric acid (to act as a pH buffer), hardening/levelling agents (to increase deposit hardness and lustre) and wetting agents (to aid surface wetting and thus prevent gas bubbles and void formation). This paper investigates the effects of some of these variables on internal stress and stretch as a function of applied current density.Comment: Submitted on behalf of TIMA Editions (http://irevues.inist.fr/tima-editions

Physical therapy and deep brain stimulation in Parkinson’s Disease: Protocol for a pilot randomized controlled trial

Abstract Background Subthalamic nucleus deep brain stimulation (STN-DBS) reduces tremor, muscle stiffness, and bradykinesia in people with Parkinson’s Disease (PD). Walking speed, known to be reduced in PD, typically improves after surgery; however, other important aspects of gait may not improve. Furthermore, balance may worsen and falls may increase after STN-DBS. Thus, interventions to improve balance and gait could reduce morbidity and improve quality of life following STN-DBS. Physical therapy (PT) effectively improves balance and gait in people with PD, but studies on the effects of PT have not been extended to those treated with STN-DBS. As such, the efficacy, safety, and feasibility of PT in this population remain to be determined. The purpose of this pilot study is to address these unmet needs. We hypothesize that PT designed to target balance and gait impairment will be effective, safe, and feasible in this population. Methods/design Participants with PD treated with STN-DBS will be randomly assigned to either a PT or control group. Participants assigned to PT will complete an 8-week, twice-weekly PT program consisting of exercises designed to improve balance and gait. Control group participants will receive the current standard of care following STN-DBS, which does not include prescription of PT. The primary aim is to assess preliminary efficacy of PT on balance (Balance Evaluation Systems Test). A secondary aim is to assess efficacy of PT on gait (GAITRite instrumented walkway). Participants will be assessed OFF medication/OFF stimulation and ON medication/ON stimulation at baseline and at 8 and 12 weeks after baseline. Adverse events will be measured over the duration of the study, and adherence to PT will be measured to determine feasibility. Discussion To our knowledge, this will be the first study to explore the preliminary efficacy, safety, and feasibility of PT for individuals with PD with STN-DBS. If the study suggests potential efficacy, then this would justify larger trials to test effectiveness and safety of PT for those with PD with STN-DBS. Trial registration NCT03181282 (clinicaltrials.gov). Registered on 7 June 2017

Barriers and facilitators to HPV vaccination in primary care practices: A mixed methods study using the Consolidated Framework for Implementation Research

Abstract Background In the United States, the effective, safe huma papilloma virus (HPV) vaccine is underused and opportunities to prevent cancer continue to be missed. National guidelines recommend completing the 2–3 dose HPV vaccine series by age 13, well before exposure to the sexually transmitted virus. Accurate characterization of the facilitators and barriers to full implementation of HPV vaccine recommendations in the primary care setting could inform effective implementation strategies. Methods We used the Consolidated Framework for Implementation Research (CFIR) to systematically investigate and characterize factors that influence HPV vaccine use in 10 primary care practices (16 providers) using a concurrent mixed methods design. The CFIR was used to guide collection and analysis of qualitative data collected through in-person semi-structured interviews with the primary care providers. We analyzed HPV vaccine use with data abstracted from medical charts. Constructs that most strongly influenced vaccine use were identified by integrating the qualitative and quantitative data. Results Of the 72 CFIR constructs assessed, seven strongly distinguished and seven weakly distinguished between providers with higher versus lower HPV vaccine coverage. The majority of strongly distinguishing constructs were facilitators and were related to characteristics of the providers (knowledge and beliefs; self-efficacy; readiness for change), their perception of the intervention (relative advantage of vaccinating younger vs. older adolescents), and their process to deliver the vaccine (executing). Additional weakly distinguishing constructs that were facilitators were from outer setting (peer pressure; financial incentives), inner setting (networks and communications and readiness for implementation) and process (planning; engaging, and reflecting and evaluating). Two strongly distinguishing constructs were barriers to use, one from the intervention (adaptability of the age of initiation) and the other from outer setting (patient needs and resources). Conclusions Using CFIR to systematically examine the use of this vaccine in independent primary care practices enabled us to identify facilitators and barriers at the provider, interpersonal and practice level that need to be addressed in future efforts to increase vaccine use in such settings. Our findings suggest that implementation strategies that target the provider and help them to address multi-level barriers to HPV vaccine use merit further investigation

The simulation of a propulsive jet and force measurement using a magnetically suspended wind tunnel model

Models featuring the simulation of exhaust jets were developed for magnetic levitation in a wind tunnel. The exhaust gas was stored internally producing a discharge of sufficient duration to allow nominal steady state to be reached. The gas was stored in the form of compressed gas or a solid rocket propellant. Testing was performed with the levitated models although deficiencies prevented the detection of jet-induced aerodynamic effects. Difficulties with data reduction led to the development of a new force calibration technique, used in conjunction with an exhaust simulator and also in separate high incidence aerodynamic tests