A service evaluation: EllenorLions Hospices Children and Young Peoples Service: Executive Summary

Between January and June 2011, the EllenorLions Hospices commissioned a team from Canterbury Christ Church University to independently review the Children and Young Peoples Service to evaluate the integrated service model which delivers both palliative care and community oncology to children and young people with life threatening and life limiting illnesses. The project brief was conducted in two phases. In Phase 1 an information review was undertaken and in Phase 2 the effectiveness and usability of the service for service users and staff was analysed by qualitative methods (individual and focus group interviews). 10 families, 4 young people, and 12 Professional/ Support Staff were involved. The evaluation team presented the draft report to the EllenorLions Management Team in June 2011 and the final report was presented in August 2011

The timing of benthic copepod emergence

We investigated emergence of marine benthic harpacticoid and cyclopoid copepods from subtidal sediment into the bottom water. Previous studies that used traps in the field found that copepods emerged from the sediment within 2 h of dusk. We examined emergence in 20-min sampling periods over 13 h from 1200 to 0100 h in a laboratory flume under conditions of constant flow speed. The light intensity was adjusted to field conditions every 20 min. We observed a peak in emergence during the 20-min sampling period after the onset of darkness, greatly increasing the accuracy with which the timing of emergence is known. This result will help to set the stage for studies of emergence cues

Calcium channel blockers for acute traumatic brain injury.

BACKGROUND: Acute traumatic brain injury is a major cause of death and disability. Calcium channel blockers (calcium antagonists) have been used in an attempt to prevent cerebral vasospasm after injury, maintain blood flow to the brain, and so prevent further damage. OBJECTIVES: To estimate the effects of calcium channel blockers in patients with acute traumatic brain injury, and in a subgroup of brain injury patients with traumatic subarachnoid haemorrhage. SEARCH STRATEGY: Handsearching and electronic searching for randomised controlled trials. SELECTION CRITERIA: Randomised controlled trials in patients with all levels of severity of clinically diagnosed acute traumatic brain injury. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the identified studies for eligibility and extracted data from each study. Summary odds ratios were calculated using the Mantel-Haenszel method. MAIN RESULTS: Six RCTs were identified as eligible for inclusion in the systematic review. The effect of calcium channel blockers on the risk of death was reported in five of the RCTs. The pooled odds ratio (OR) for the five studies was 0.91 (95% confidence interval [95%CI] 0.70-1.17). For the four RCTs that reported death and severe disability (unfavourable outcome), the pooled odds ratio was 0.85 (95%CI 0.68-1.07). In the two RCTs which reported the risk of death in a subgroup of traumatic subarachnoid haemorrhage patients, the pooled odds ratio was 0.59 (95%CI 0.37-0.94). Three RCTs reported death and severe disability as an outcome in this subgroup, and the pooled odds ratio was 0.67 (95%CI 0.46-0.98). REVIEWER'S CONCLUSIONS: This systematic review of randomised controlled trials of calcium channel blockers in acute traumatic head injury patients shows that considerable uncertainty remains over their effects. The effect of nimodipine in a subgroup of brain injury patients with subarachnoid haemorrhage shows a beneficial effect, though the increase in adverse reactions suffered by the intervention group may mean that the drug is harmful for some patients

A nutrition intervention is effective in improving dietary components linked to cardiometabolic risk in youth with first-episode psychosis

© The Authors 2016. Severe mental illness is characterised by a 20-year mortality gap due to cardiometabolic disease. Poor diet in those with severe mental illness is an important and modifiable risk factor. The present study aimed to (i) examine baseline nutritional intake in youth with first-episode psychosis (FEP), (ii) evaluate the feasibility and acceptability of nutritional intervention early in FEP and (iii) to evaluate the effectiveness of early dietary intervention on key nutritional end points. Participants were recruited over a 12-month period from a community-based programme specifically targeting young people aged 15-25 years with newly diagnosed FEP. Individual dietetic consultations and practical group sessions were offered as part of a broader lifestyle programme. Dietary assessments were conducted before and at the end of the 12-week intervention. Participants exceeded recommended energy and Na intakes at baseline. Retention within the nutrition intervention was 67 %, consistent with other interventions offered to FEP clients. There was a 47 % reduction in discretionary food intake (-94 g/d, P<0·001) and reductions in daily energy (-24 %, P<0·001) and Na (-26 %, P<0·001) intakes. Diet quality significantly improved, and the mean change was 3·6 (95 % CI 0·2, 6·9, P<0·05), although this finding was not significant after Bonferroni's correction. Increased vegetable intake was the main factor contributing to improved diet quality. Nutrition intervention delivered shortly after initiation of antipsychotic medication is feasible, acceptable and effective in youth with FEP. Strategies to prevent weight gain and metabolic decline will contribute to prevent premature cardiometabolic disease in this vulnerable population

The iBRA (implant breast reconstruction evaluation) study: protocol for a prospective multi-centre cohort study to inform the feasibility, design and conduct of a pragmatic randomised clinical trial comparing new techniques of implant-based breast reconstruction.

BACKGROUND: Implant-based breast reconstruction (IBBR) is the most commonly performed reconstructive procedure in the UK. The introduction of techniques to augment the subpectoral pocket has revolutionised the procedure, but there is a lack of high-quality outcome data to describe the safety or effectiveness of these techniques. Randomised controlled trials (RCTs) are the best way of comparing treatments, but surgical RCTs are challenging. The iBRA (implant breast reconstruction evaluation) study aims to determine the feasibility, design and conduct of a pragmatic RCT to examine the effectiveness of approaches to IBBR. METHODS/DESIGN: The iBRA study is a trainee-led research collaborative project with four phases:Phase 1 - a national practice questionnaire (NPQ) to survey current practicePhase 2 - a multi-centre prospective cohort study of patients undergoing IBBR to evaluate the clinical and patient-reported outcomesPhase 3- an IBBR-RCT acceptability survey and qualitative work to explore patients' and surgeons' views of proposed trial designs and candidate outcomes.Phase 4 - phases 1 to 3 will inform the design and conduct of the future RCT All centres offering IBBR will be encouraged to participate by the breast and plastic surgical professional associations (Association of Breast Surgery and British Association of Plastic Reconstructive and Aesthetic Surgeons). Data collected will inform the feasibility of undertaking an RCT by defining current practice and exploring issues surrounding recruitment, selection of comparator arms, choice of primary outcome, sample size, selection criteria, trial conduct, methods of data collection and feasibility of using the trainee collaborative model to recruit patients and collect data. DISCUSSION: The preliminary work undertaken within the iBRA study will determine the feasibility, design and conduct of a definitive RCT in IBBR. It will work with the trainee collaborative to build capacity by creating an infrastructure of research-active breast and plastic surgeons which will facilitate future high-quality research that will ultimately improve outcomes for all women seeking reconstructive surgery. TRIAL REGISTRATION: ISRCTN37664281

Views and experiences of managing eczema:systematic review and thematic synthesis of qualitative studies*

Background: The number of qualitative studies on eczema has increased rapidly in recent years. Systematically reviewing these can provide greater understandings of people’s perceptions of eczema and eczema treatments. Objectives: We sought to systematically review and thematically synthesize qualitative studies exploring views and experiences of people with eczema and parents/carers of children with eczema. Methods: We searched MEDLINE, EMBASE, PsycINFO and CINAHL from the earliest date available to February 2019. We selected papers focusing on views and experiences of eczema and eczema treatments, and barriers/facilitators to eczema self-management. We excluded papers focusing on health service provision models or health professionals’ views. Results: We synthesized 39 papers (reporting 32 studies) from 13 countries. We developed four analytical themes: (1) Eczema not viewed as a long-term condition; (2) Significant psychosocial impact not acknowledged by others; (3) Hesitancy (patient/carer uncertainty) about eczema treatments; and (4) Insufficient information and advice. Our findings suggest that people with eczema and their carers experience frustration at having to manage a condition that is often seen by others as mundane but has significant psychosocial impact and is difficult to manage due to concerns about, and burden of, treatment. This frustration can be exacerbated by experiences of conflicting and/or insufficient information and advice from health professionals, family and others. Conclusions: Effective self-management of eczema could be supported by addressing beliefs and concerns about treatments; seeking positive ways to promote a ‘control not cure’ message; acknowledging psychosocial impacts of eczema and treatment burden; and providing clear consistent advice or signposting towards reliable information.</p

The stroke oxygen pilot study: a randomized control trial of the effects of routine oxygen supplementation early after acute stroke--effect on key outcomes at six months

Introduction: Post-stroke hypoxia is common, and may adversely affect outcome. We have recently shown that oxygen supplementation may improve early neurological recovery. Here, we report the six-month outcomes of this pilot study. Methods: Patients with a clinical diagnosis of acute stroke were randomized within 24 h of admission to oxygen supplementation at 2 or 3 L/min for 72 h or to control treatment (room air). Outcomes (see below) were assessed by postal questionnaire at 6 months. Analysis was by intention-to-treat, and statistical significance was set at p#0.05. Results: Out of 301 patients randomized two refused/withdrew consent and 289 (148 in the oxygen and 141 in the control group) were included in the analysis: males 44%, 51%; mean (SD) age 73 (12), 71 (12); median (IQR) National Institutes of Health Stroke Scale score 6 (3, 10), 5 (3, 10) for the two groups respectively. At six months 22 (15%) patients in the oxygen group and 20 (14%) in the control group had died; mean survival in both groups was 162 days (p= 0.99). Median (IQR) scores for the primary outcome, the modified Rankin Scale, were 3 (1, 5) and 3 (1, 4) for the oxygen and control groups respectively. The covariate-adjusted odds ratio was 1.04 (95% CI 0.67, 1.60), indicating that the odds of a lower (i.e. better) score were non-significantly higher in the oxygen group (p= 0.86). The mean differences in the ability to perform basic (Barthel Index) and extended activities of daily living (NEADL), and quality of life (EuroQol) were also non-significant. Conclusions: None of the key outcomes differed at 6 months between the groups. Although not statistically significant and generally of small magnitude, the effects were predominantly in favour of the oxygen group; a larger trial, powered to show differences in longer-term functional outcomes, is now on-going. Trial Registration: Controlled-Trials.com ISRCTN12362720; Eudract.ema.europa.eu 2004-001866-4

Reduced level of arousal and increased mortality in adult acute medical admissions: a systematic review and meta-analysis

Abstract Background Reduced level of arousal is commonly observed in medical admissions and may predict in-hospital mortality. Delirium and reduced level of arousal are closely related. We systematically reviewed and conducted a meta-analysis of studies in adult acute medical patients of the relationship between reduced level of arousal on admission and in-hospital mortality. Methods We conducted a systematic review (PROSPERO: CRD42016022048), searching MEDLINE and EMBASE. We included studies of adult patients admitted with acute medical illness with level of arousal assessed on admission and mortality rates reported. We performed meta-analysis using a random effects model. Results From 23,941 studies we included 21 with 14 included in the meta-analysis. Mean age range was 33.4 - 83.8 years. Studies considered unselected general medical admissions (8 studies, n=13,039) or specific medical conditions (13 studies, n=38,882). Methods of evaluating level of arousal varied. The prevalence of reduced level of arousal was 3.1%-76.9% (median 13.5%). Mortality rates were 1.7%-58% (median 15.9%). Reduced level of arousal was associated with higher in-hospital mortality (pooled OR 5.71; 95% CI 4.21-7.74; low quality evidence: high risk of bias, clinical heterogeneity and possible publication bias). Conclusions Reduced level of arousal on hospital admission may be a strong predictor of in-hospital mortality. Most evidence was of low quality. Reduced level of arousal is highly specific to delirium, better formal detection of hypoactive delirium and implementation of care pathways may improve outcomes. Future studies to assess the impact of interventions on in-hospital mortality should use validated assessments of both level of arousal and delirium

Mindfulness-Based Cognitive Therapy (MBCT) For Health Anxiety (Hypochondriasis): Rationale, Implementation and Case Illustration.

Recent research has shown that mindfulness-based cognitive therapy (MBCT) could be a useful alternative approach to the treatment of health anxiety and deserves further investigation. In this paper, we outline the rationale for using MBCT in the treatment of this condition, namely its hypothesised impact on the underlying mechanisms which maintain health anxiety, such as rumination and avoidance, hypervigilance to body sensations and misinterpretation of such sensations. We also describe some of the adaptations which were made to the MBCT protocol for recurrent depression in this trial and discuss the rationale for these adaptations. We use a case example from the trial to illustrate how MBCT was implemented and outline the experience of one of the participants who took part in an 8-week MBCT course. Finally, we detail some of the more general experiences of participants and discuss the advantages and possible limitations of this approach for this population, as well as considering what might be useful avenues to explore in future research

The tactical mimicry of social enterprise strategies: acting ‘as if’ in the everyday life of third sector organizations

Using England as a paradigmatic case of the „enterprising up ‟ of the third sector through social enterprise policies and programs, this article sheds light on resistance as enacted through dramaturgical identification with government strategies. Drawing from a longitudinal qualitative research study, which is interpreted via Michel de Certeau‟s theory of the everyday, we present the case study of Teak, a charitable regeneration company, to illustrate how its Chief Executive Liam „acted as ‟ a social entrepreneur in order to gain access to important resources. We establish „tactical mimicry ‟ as a sensitizing concept to suggest that third sector practitioners ‟ identification with the normative premises of „social enterprise ‟ is part of a parasitical prosaics geared toward appropriating public money. While tactical mimicry conforms to strategies only in order to exploit them, its ultimate aim is to increase potentials of collective agency outside the direct influence of power. The contribution we make is threefold: first, we extend the recent debate on productive resistance by highlighting how „playing the game ‟ without changing existing relations of power can nevertheless produce largely favorable outcomes. Second, we suggest that recognition of the productive potential of tactical mimicry requires methodologies which pay attention to the spatial and temporal dynamics of resistance. And third, we argue that explaining „social enterprise‟ without consideration of the non-discursive, mainly financial resources made available to those who identify with it, necessarily risks overlooking a crucial element of the dramaturgical dynamic of discourse