Development and maturation of the immune system in preterm neonates : results from a whole genome expression study

To expand the knowledge about the consecutive expression of genes involved in the immune system development in preterm neonates and to verify if the environment changes the gene expression after birth we conducted a prospective study that included three cohorts: (A) extremely (gestational age (GA): 23–26 weeks; n=41), (B) very (GA: 27–29 weeks; n=39), and (C) moderately preterm infants (GA: 30–32 weeks; n=33). Blood samples were drawn from the study participants on the 5th and 28th day of life (DOL). The mRNA samples were evaluated for gene expression with the use of GeneChip Human Gene 1.0ST microarrays. Differential expression analysis revealed small subsets of genes that presented positive or negative monotone trends in both the 5th (138 genes) and 28th DOL (308 genes) in the three subgroups of patients. Based on pathway enrichment analysis, we found that most of the pathways that revealed a positive monotone trend were involved in host immunity. The most significantly GA dependent pathways were T-cell receptor signaling pathway and intestinal immune network for IgA production. Overall 4431 genes were differentially expressed between the 5th and 28th DOL. Despite differences in gestational age, patients with the same postconceptional age have a very similar expression of genes

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

Relationship between stereoscopic vision, visual perception, and microstructure changes of corpus callosum and occipital white matter in the 4-year-old very low birth weight children

Aim. To assess the relationship between stereoscopic vision, visual perception, and microstructure of the corpus callosum (CC) and occipital white matter, 61 children born with a mean birth weight of 1024 g (SD 270 g) were subjected to detailed ophthalmologic evaluation, Developmental Test of Visual Perception (DTVP-3), and diffusion tensor imaging (DTI) at the age of 4. Results. Abnormal stereoscopic vision was detected in 16 children. Children with abnormal stereoscopic vision had smaller CC (CC length: 53±6 mm versus 61±4 mm; p<0.01; estimated CC area: 314±106 mm2 versus 446±79 mm2; p<0.01) and lower fractional anisotropy (FA) values in CC (FA value of rostrum/genu: 0.7±0.09 versus 0.79±0.07; p<0.01; FA value of CC body: 0.74±0.13 versus 0.82±0.09; p=0.03). We found a significant correlation between DTVP-3 scores, CC size, and FA values in rostrum and body. This correlation was unrelated to retinopathy of prematurity. Conclusions. Visual perceptive dysfunction in ex-preterm children without major sequelae of prematurity depends on more subtle changes in the brain microstructure, including CC. Role of interhemispheric connections in visual perception might be more complex than previously anticipated

Intervention fidelity in the definitive cluster randomised controlled trial of the Healthy Lifestyles Programme (HeLP) trial: findings from the process evaluation.

BACKGROUND: The Healthy Lifestyles Programme (HeLP) was a novel school-located intervention for 9-10 year olds, designed to prevent obesity by changing patterns of child behaviour through the creation of supportive school and home environments using dynamic and creative delivery methods. This paper reports on both the quantitative and qualitative data regarding the implementation of the HeLP intervention in the definitive cluster randomised controlled trial, which was part of the wider process evaluation. METHODS: Mixed methods were used to collect data on intervention uptake, fidelity of delivery in terms of content and quality of delivery of the intervention, as well as school and child engagement with the programme. Data were collected using registers of attendance, observations and checklists, field notes, focus groups with children and semi-structured interviews with teachers. Qualitative data were analysed thematically and quantitative data were summarized using descriptive statistics. RESULTS: All 16 intervention schools received a complete or near complete programme (94-100%), which was delivered in the spirit in which it had been designed. Of the 676 children in the intervention schools, over 90% of children participated in each phase of HeLP; 92% of children across the socio-economic spectrum were deemed to be engaged with HeLP and qualitative data revealed a high level of enjoyment by all children, particularly to the interactive drama workshops. Further evidence of child engagment with the programme was demonstrated by children's clear understanding of programme messages around marketing, moderation and food labelling. Thirteen of the intervention schools were deemed to be fully engaged with HeLP and qualitative data revealed a high level of teacher 'buy in', due to the programme's compatability with the National Curriculum, level of teacher support and use of innovative and creative delivery methods by external drama practitioners. CONCLUSION: Our trial shows that it is possible to successfully scale up complex school-based interventions, engage schools and children across the socio-economic spectrum and deliver an intervention as designed. As programme integrity was maintained throughout the HeLP trial, across all intervention schools, we can be confident that the trial findings are a true reflection of the effectiveness of the intervention, enabling policy recommendations to be made. TRIAL REGISTRATION: ISRCTN15811706

Assessing the Quality of Goal Setting in Behavioural Support for Smoking Cessation and its Association with Outcomes

BACKGROUND: Smoking cessation behavioural support can be effective but practitioners differ markedly in effectiveness, possibly due to variation in the quality of delivery of key behaviour change techniques, such as goal setting (i.e. setting a quit date). OBJECTIVES: This study aimed to (i) develop a reliable method for assessing the quality of practitioners' support in setting quit dates and (ii) assess whether quality predicts initiation of abstinence as a first step to quitting. METHODS: A scale for scoring the quality of goal setting was developed from national guidance documents and applied to 85 transcribed behavioural support sessions. Inter-rater reliability was assessed. Associations between quality scores and quit attempts were assessed. RESULTS: The 10-item scale produced had good inter-rater reliability (Kappa = 0.68). Higher quality goal setting was associated with increased self-reported quit attempts (p < .001; OR = 2.60, 95 % CI 1.54-4.40). The scale components 'set a clear quit date' (χ (2) (2, N = 85) = 22.3, p < .001) and 'within an appropriate timeframe' (χ (2) (2, N = 85) = 15.5, p < .001) were independently associated with quit attempts. CONCLUSIONS: It is possible to reliably assess the quality of goal setting in smoking cessation behavioural support. Higher quality of goal setting is associated with greater likelihood of initiating quit attempts

Head Position in Stroke Trial (HeadPoST)- sitting-up vs lying-flat positioning of patients with acute stroke: study protocol for a cluster randomised controlled trial

Background Positioning a patient lying-flat in the acute phase of ischaemic stroke may improve recovery and reduce disability, but such a possibility has not been formally tested in a randomised trial. We therefore initiated the Head Position in Stroke Trial (HeadPoST) to determine the effects of lying-flat (0°) compared with sitting-up (≥30°) head positioning in the first 24 hours of hospital admission for patients with acute stroke. Methods/Design We plan to conduct an international, cluster randomised, crossover, open, blinded outcome-assessed clinical trial involving 140 study hospitals (clusters) with established acute stroke care programs. Each hospital will be randomly assigned to sequential policies of lying-flat (0°) or sitting-up (≥30°) head position as a ‘business as usual’ stroke care policy during the first 24 hours of admittance. Each hospital is required to recruit 60 consecutive patients with acute ischaemic stroke (AIS), and all patients with acute intracerebral haemorrhage (ICH) (an estimated average of 10), in the first randomised head position policy before crossing over to the second head position policy with a similar recruitment target. After collection of in-hospital clinical and management data and 7-day outcomes, central trained blinded assessors will conduct a telephone disability assessment with the modified Rankin Scale at 90 days. The primary outcome for analysis is a shift (defined as improvement) in death or disability on this scale. For a cluster size of 60 patients with AIS per intervention and with various assumptions including an intracluster correlation coefficient of 0.03, a sample size of 16,800 patients at 140 centres will provide 90 % power (α 0.05) to detect at least a 16 % relative improvement (shift) in an ordinal logistic regression analysis of the primary outcome. The treatment effect will also be assessed in all patients with ICH who are recruited during each treatment study period. Discussion HeadPoST is a large international clinical trial in which we will rigorously evaluate the effects of different head positioning in patients with acute stroke. Trial registration ClinicalTrials.gov identifier: NCT02162017 (date of registration: 27 April 2014); ANZCTR identifier: ACTRN12614000483651 (date of registration: 9 May 2014). Protocol version and date: version 2.2, 19 June 2014

Physically active academic lessons; Acceptance, barriers and facilitators for implementation

Background To improve health and academic learning in schoolchildren, the Active School programme in Stavanger, Norway has introduced physically active academic lessons. This is a teaching method combining physical activity with academic content. The purpose of this paper was to evaluate the response to the physically active lessons and identify facilitators and barriers for implementation of such an intervention. Methods Five school leaders (principals or vice-principals), 13 teachers and 30 children from the five intervention schools were interviewed about their experiences with the 10-month intervention, which consisted of weekly minimum 2 × 45 minutes of physically active academic lessons, and the factors affecting its implementation. All interviews were transcribed and analysed using the qualitative data analysis program NVivo 10 (QSR international, London, UK). In addition, weekly teacher’s intervention delivery logs were collected and analysed. Results On average, the physically active academic lessons in 18 of the 34 weeks (53%) were reported in the teacher logs. The number of delivered physically active academic lessons covered 73% of the schools’ planned activity. Physically active lessons were well received among school leaders, teachers and children. The main facilitators for implementation of the physically active lessons were active leadership and teacher support, high self-efficacy regarding mastering the intervention, ease of organizing physically active lessons, inclusion of physically active lessons into the lesson curricula, and children’s positive reception of the intervention. The main barriers were unclear expectations, lack of knowledge and time to plan the physiclly active lessons, and the length of the physically active lessons (15–20 min lessons were preferred over the 45 min lessons). Conclusion Physically active academic lessons were considered an appropriate pedagogical method for creating positive variation, and were highly appreciated among both teachers and children. Both the principal and the teachers should be actively involved the implementation, which could be strengthened by including physical activity into the school’s strategy. Barriers for implementing physically active lessons in schools could be lowered by increasing implementation clarity and introducing the teachers to high quality and easily organized lessons.publishedVersio

How healthcare providers’ own death anxiety influences their communication with patients in end-of-life care: A thematic analysis

Healthcare providers’ own death anxiety can influence end-of-life communication. We interviewed nine palliative care health providers about their experiences of providing end-of-life care. Participants also completed the Revised Death Anxiety Scale. A thematic analysis of the interview transcripts identified one theme labelled ‘avoidant coping’ and another labelled ‘death anxiety awareness’, which are presented in the context of the participants’ own Revised Death Anxiety Scale scores. The findings show that avoidant death anxiety coping can compromise end-of-life communication, but that greater awareness of death anxiety can help overcome avoidant coping. The findings can inform potential improvements in healthcare practice and training.N/

Facilitators and barriers of implementing and delivering social prescribing services: a systematic review

BACKGROUND: Social Prescribing is a service in primary care that involves the referral of patients with non-clinical needs to local services and activities provided by the third sector (community, voluntary, and social enterprise sector). Social Prescribing aims to promote partnership working between the health and the social sector to address the wider determinants of health. To date, there is a weak evidence base for Social Prescribing services. The objective of the review was to identify factors that facilitate and hinder the implementation and delivery of SP services based in general practice involving a navigator. METHODS: We searched eleven databases, the grey literature, and the reference lists of relevant studies to identify the barriers and facilitators to the implementation and delivery of Social Prescribing services in June and July 2016. Searches were limited to literature written in English. No date restrictions were applied. Findings were synthesised narratively, employing thematic analysis. The Mixed Methods Appraisal Tool Version 2011 was used to evaluate the methodological quality of included studies. RESULTS: Eight studies were included in the review. The synthesis identified a range of factors that facilitate and hinder the implementation and delivery of SP services. Facilitators and barriers were related to: the implementation approach, legal agreements, leadership, management and organisation, staff turnover, staff engagement, relationships and communication between partners and stakeholders, characteristics of general practices, and the local infrastructure. The quality of most included studies was poor and the review identified a lack of published literature on factors that facilitate and hinder the implementation and delivery of Social Prescribing services. CONCLUSION: The review identified a range of factors that facilitate and hinder the implementation and delivery of Social Prescribing services. Findings of this review provide an insight for commissioners, managers, and providers to guide the implementation and delivery of future Social Prescribing services. More high quality research and transparent reporting of findings is needed in this fiel