An exploration of the use of devices for the prevention of heel pressure ulcers in secondary care: A realist evaluation

Background The heel is a particularly high-risk and problematic area for pressure ulcers (PU) to develop. The effectiveness of devices and the factors that lead to their use for the prevention of heel PUs is poorly understood. Aims 1. To assess the effectiveness of devices used for the prevention of heel PUs. 2. Explore what factors influence the implementation, and how heel-specific devices are used (or not used) in secondary care. Methods To address aim 1: Systematic review of the evidence of effectiveness for devices in the prevention of heel PU. Aim 2: Realist evaluation, including Phase 1 - theory elicitation through stakeholder interviews with Tissue Viability Nurse Specialists (TVNS) from across the UK and Phase 2 - testing theories using ethnography in three orthopaedic wards in the North of England. Results Systematic review: identified 29 trials with fifteen comparisons and eight meta-analyses conducted. Offloading devices were found to be effective in the prevention of ≥Category 1 and ≥Category 2 heel PUs when compared to standard care, but this is based on low to moderate quality evidence and intervention compliance was found to be an issue. Realist evaluation Phase 1: Interviews with eight TVNS elicited thirteen candidate theories into three program theories, regarding the proactive and reactive use of offloading devices, along with patient factors that influenced their use. Phase 2: Ethnography found that heel-specific devices are used in practice. Leadership, protocols, identification of high-risk patient groups, and access to devices influenced staff knowledge but did not necessarily increase device use. Conclusion Exploring the perceptions and realities of how offloading and heel-specific devices are used in practice can not only influence their use, but also inform how future device trials are designed and conducted to improve protocol compliance and reduce withdrawals and attritions

Garnet–monazite rare earth element relationships in sub-solidus metapelites: a case study from Bhutan

A key aim of modern metamorphic geochronology is to constrain precise and accurate rates and timescales of tectonic processes. One promising approach in amphibolite and granulite-facies rocks links the geochronological information recorded in zoned accessory phases such as monazite to the pressure–temperature information recorded in zoned major rock-forming minerals such as garnet. Both phases incorporate rare earth elements (REE) as they crystallize and their equilibrium partitioning behaviour potentially provides a useful way of linking time to temperature. We report REE data from sub-solidus amphibolite-facies metapelites from Bhutan, where overlapping ages, inclusion relationships and Gd/Lu ratios suggest that garnet and monazite co-crystallized. The garnet–monazite REE relationships in these samples show a steeper pattern across the heavy (H)REE than previously reported. The difference between our dataset and the previously reported data may be due to a temperature-dependence on the partition coefficients, disequilibrium in either dataset, differences in monazite chemistry or the presence or absence of a third phase that competed for the available REE during growth. We urge caution against using empirically-derived partition coefficients from natural samples as evidence for, or against, equilibrium of REE-bearing phases until monazite–garnet partitioning behaviour is better constrained

Pilot study on the reliability of the coach\u27s eye: Identifying talent throughout a 4-day cadet judo campp

A typical assumption found in talent identification literature is that different coaches, given the same athletes and circumstances, will identify the same subset of athletes as “talented”. However, while coaches play a major role during talent identification in practical sport settings, there is limited empirical research exploring the processes which underpin this. The purpose of this study was to explore the reliability of “the coach\u27s eye” during the assessment of talent in a group of athletes. Specifically, this project compared inter-coach agreement between nine judo coaches (ages 35.8 ± 10.6 years) with varying levels of experience (12.9 ± 8.9 years) in the evaluation of 24 talented cadet judo athletes (13–15 years) at seven timepoints throughout a 4-day development training camp. Without discussion of their scores with other coaches, coaches provided a single score representing each athlete\u27s “potential for future performance” on an 11-point Likert scale at each timepoint. Scores from each coach were converted into rankings from 1 to 24 to create a normalized scale to facilitate comparison of athletes. Based on their rankings at each timepoint, athletes were placed into one of three evenly distributed groups (high, medium, and low rank). Inter-coach agreement at each timepoint was determined by the number of coaches who ranked each athlete in the same group, categorized at three levels: 50, 75 or 100% agreement. Overall results showed that at completion of the camp, coaches reached 100% agreement on only two athletes, both of whom were in the high rank group. When inter-coach agreement was set at 50%, 15 athletes (62.5%) were placed into like groups. The first timepoint at which coaches were able to differentiate between the majority of athletes was Timepoint 3 (end of day 2). The findings suggest that, in isolation, coaches do not agree on the talent or potential of athletes. This indicates that the “coach\u27s eye” is subjective and variable, and, given the same context, there is poor inter-coach agreement in the identification of talented athletes. In turn, these findings may have significant implications for both future talent identification research and athlete selection processes by sport organizations

Offloading devices for the prevention of heel pressure ulcers: a realist evaluation

Background Heel pressure ulcers can cause pain, reduce mobility, lead to longer hospital stays and in severe cases can lead to sepsis, amputation, and death. Offloading boots are marketed as heel pressure ulcer prevention devices, working by removing pressure to the heel, yet there is little good quality evidence about their clinical effectiveness. Given that evidence is not guiding use of these devices, this study aims to explore, how, when, and why these devices are used in hospital settings. Objective To explore how offloading devices are used to prevent heel pressure ulcers, for whom and in what circumstances. Methods A realist evaluation was undertaken to explore the contexts, mechanisms, and outcomes that might influence how offloading devices are implemented and used in clinical practice for the prevention of heel pressure ulcers in hospitals. Eight Tissue Viability Nurse Specialists from across the UK (England, Wales, and Northern Ireland) were interviewed. Questions sought to elicit whether, and in what ways, initial theories about the use of heel pressure ulcers fitted with interviewee's experiences. Results Thirteen initial theories were refined into three programme theories about how offloading devices are used by nurses ‘proactively’ to prevent heel pressure ulcers, ‘reactively’ to treat and minimise deterioration of early-stage pressure ulcers, and patient factors that influence how these devices are used. Conclusions Offloading devices were used in clinical practice by all the interviewees. It was viewed that they were not suitable to be used by every patient, at every point in their inpatient journey, nor was it financially viable. However, the interviewees thought that identifying suitable ‘at risk’ patient groups that can maintain use of the devices could lead to proactive and cost-effective use of the devices. This understanding of the contexts and mechanisms that influence the effective use of offloading devices has implications for clinical practice and design of clinical trials of offloading devices. Tweetable abstract How, for whom, and in what circumstances do offloading devices work to prevent heel pressure ulcers? Tissue viability nurses' perspectives

Comparative effectiveness of heel-specific medical devices for the prevention of heel pressure ulcers: a systematic review

Background Pressure ulcers (PUs) impact on patient's quality of life and are costly for healthcare providers. Heels are a particular concern due to specific risk factors. Relative effectiveness of medical devices, e.g., dressings, off-loading devices, heel cushioning devices, to reduce PU development is unknown. Methods Systematic review of the effectiveness of heel-specific medical devices for the prevention of heel PU (HPU)s. Database searches were performed from inception to June 2021 for RCTs. The primary outcome was incidence of new HPUs. Trials were assessed for risk of bias and data analysed with risk ratios, mean difference or hazard ratios as appropriate. Results Fifteen RCTs (4724 participants) were identified. Dressings, as constant low pressure (CLP) devices vs standard care: eight trials (very low quality) showed no-significant difference in effectiveness (RR 0.31, 95%CI 0.10 to 1.01). Off-loading devices vs standard care: three trials (low quality), showed significant reduction in development of Category≥1 HPUs (RR 0.20, 95%CI 0.05 to 0.80) two trials (medium quality), showed significant reduction in development of Category≥2 HPUs (RR 0.08, 95%CI 0.01 to 0.67). Comparisons between off-loading devices: two trials (low quality) showed no clear difference in HPU incidence. In a paediatric post-surgical population, one trial of off-loading device and one of a dressing (CLP device), both versus standard care, showed no clear difference in HPU incidence (RR 0.19 95%CI 0.02 to 1.55 and RR 0.89 95%CI 0.56 to 1.42 respectively). Conclusions Off-loading devices may reduce HPU incidence, from low-quality evidence. There is insufficient evidence to suggest that dressings reduce HPU incidence

Understanding the “gut instinct” of expert coaches during talent identification

Coaches are an integral part of talent identification in sport and are often used as the “gold standard” against which scientific methods of talent identification are compared. However, their decision-making during this process is not well understood. In this article, we use an ecological approach to explore talent identification in combat sports. We interviewed twenty-four expert, international-level coaches from the Olympic disciplines of boxing, judo, and taekwondo (age: 48.7 + 7.5 years; experience: 20.8 + 8.3 years). Findings indicated that when coaches identify talent they rely on “gut instinct”: intuitive judgements made without conscious thought, used to direct attention to particular athletes or characteristics. Our analysis revealed four major contributors to coaches’ intuition: experiential knowledge, temporal factors, seeing athletes in context, and what can be worked with. Our findings demonstrate that i) athlete selections may be influenced by the coaches’ perceived ability to improve certain athletes (rather than solely on athlete ability); and ii) “instinctual” decisions are the result of years of experience, time spent with the athlete, and the context surrounding the decision. Based on these findings, we recommend that future research focuses on the duration and conditions that are required for coaches to confidently and reliably identify talented athletes

Carbon dioxide and ocean acidification observations in UK waters. Synthesis report with a focus on 2010–2015

Key messages: 1.1 The process of ocean acidification is now relatively well-documented at the global scale as a long-term trend in the open ocean. However, short-term and spatial variability can be high. 1.2 New datasets made available since Charting Progress 2 make it possible to greatly improve the characterisation of CO2 and ocean acidification in UK waters. 3.1 Recent UK cruise data contribute to large gaps in national and global datasets. 3.2 The new UK measurements confirm that pH is highly variable, therefore it is important to measure consistently to determine any long term trends. 3.3 Over the past 30 years, North Sea pH has decreased at 0.0035±0.0014 pH units per year. 3.4 Upper ocean pH values are highest in spring, lowest in autumn. These changes reflect the seasonal cycles in photosynthesis, respiration (decomposition) and water mixing. 3.5 Carbonate saturation states are minimal in the winter, and lower in 7 more northerly, colder waters. This temperature-dependence could have implications for future warming of the seas. 3.6 Over the annual cycle, North-west European seas are net sinks of CO2. However, during late summer to autumn months, some coastal waters may be significant sources. 3.7 In seasonally-stratified waters, sea-floor organisms naturally experience lower pH and saturation states; they may therefore be more vulnerable to threshold changes. 3.8 Large pH changes (0.5 - 1.0 units) can occur in the top 1 cm of sediment; however, such effects are not well-documented. 3.9 A coupled forecast model estimates the decrease in pH trend within the North Sea to be -0.0036±0.00034 pH units per year, under a high greenhouse gas emissions scenario (RCP 8.5). 3.10 Seasonal estimates from the forecast model demonstrate areas of the North Sea that are particularly vulnerable to aragonite undersaturation

Effectiveness of structured patient-clinician communication with a solution focused approach (DIALOG+) in community treatment of patients with psychosis - a cluster randomised controlled trial

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