Advocacy for looked after children and children in need: achievements and challenges

This briefing paper offers a summary of the key findings of ‘Advocacy for looked after children and children in need: achievements and challenges’, the first national study of children’s advocacy in England. The study was prepared for the Department of Health and the DfES. The study was undertaken for a number of reasons: despite the relatively rapid increase in the number of advocacy services for children and young people over the last decade or so, relatively little is known about the extent to which advocacy makes a positive difference to the lives of individual children or to developments in children’s services more generally. Evidence also suggests that, in order to reduce the scope for conflict or confusion, there is a need to raise awareness about the principles and practices of advocacy among practitioners and policy makers working in the field of children’s health and social care. This study sought to address these gaps in knowledge and to create a platform for an evidence-based debate about the future of advocacy for children and young people

Chronicles of Oklahoma

Article discusses the history of the Cherokees in colonial North America. Oliver Knight explores their agricultural process and development, discovery of gold, adoption of the practice of slavery, and trade system. Knight then discusses their settlement in the west after removal, the establishment of their political parties, and relations with the U. S. government

Chronicles of Oklahoma

Article discusses the laws made by the constitutional government of the Choctaw Nation from 1834 to 1884. Oliver Knight explains the phases of the institution of the government and its leaders, the construction of public roads and railroads, criminal law, and internal and external relations, and other sections of laws

Chronicles of Oklahoma

Article discusses the history of the Cherokees and eventually the division they experienced during the period of removal by the United States government. Oliver Knight discusses white influence on Cherokee society, diet, family life, traditions, education, and the injustices they suffered during this time

Leukoencephalopathy and cerebral edema as the presenting manifestations of SLE in an ANA-negative adolescent female: a case report and review of literature

Background: Systemic lupus erythematosus (SLE) is an autoimmune disease with various clinical manifestations involving multiple organ systems. Neuropsychiatric manifestations of SLE have been associated with increased morbidity and mortality, thus it is important to recognize and diagnose the disease entity and treat early. When neuropsychiatric symptoms are involved, typically there are many other systemic features to aid in the diagnosis of SLE. Many autoantibodies have been discovered and are used to help diagnose SLE. The antibody present in most cases of pediatric SLE, as well as in many other rheumatic diseases, is the nonspecific antinuclear antibody (ANA). The ANA is a commonly used screening tool by primary care physicians when evaluating a patient with a possible rheumatic disorder. However, a small subset of SLE patients, 1-5%, present with a negative ANA, and it is important to keep SLE on the differential diagnosis in specific instances when a thorough infectious, metabolic and neurological workup has been completed and proven to be inconclusive. Case presentation: This case involves a Hispanic adolescent female with a negative ANA who presented with diffuse cerebral edema secondary to leukoencephalopathy due to SLE with central nervous system involvement. She was normotensive on presentation and relatively symptom free aside from headache. She had an extensive workup while inpatient involving metabolic, infectious disease, rheumatology, and neurology prior to obtaining the diagnosis of SLE. She was treated with cyclophosphamide and rituximab with appropriate disease response. Conclusions: A review of the literature revealed 12 cases with SLE presenting with or developing diffuse cerebral edema and/or leukoencephalopathy. Our patient's case differs in that she was also ANA negative despite other autoantibody positivity. While she did have low complements and transient leukopenia, she did not present with other signs of organ involvement, which made the diagnosis of SLE with neuropsychiatric involvement quite challenging. We discuss the importance of keeping SLE on the differential diagnosis despite a negative ANA in complex cases after thorough workup has been unrevealing, and to consider initial screening with not only the ANA but also dsDNA and complements to avoid missed diagnoses

The PodPAD project: a podiatry-led integrated pathway for people with peripheral arterial disease in the UK – a pilot study

Background: Peripheral arterial disease affects the lower limb and is associated with diabetes, high cholesterol, smoking and obesity. It increases the risk of cardiovascular morbidity and mortality. It can be symptomatic causing intermittent claudication, but often there are few clinical signs. Podiatrists are able to detect the presence of peripheral arterial disease as part of their lower limb assessment and are well placed to give advice on lifestyle changes to help reduce disease progression. This is important to improve health outcomes and is offered as a prevention/public health intervention. Method: We describe the clinical and patient-centred outcomes of patients attending a podiatry-led integrated care pathway in a multi-use clinic situated in a venue supported by the National Centre for Sports and Exercise Medicine in the UK. At the baseline appointment, patients were given a full assessment where symptoms of intermittent claudication using the Edinburgh Intermittent Claudication Questionnaire, foot pulses, Doppler sounds, Ankle Brachial Pressure Indices, glycated haemoglobin (HbA1c) and cholesterol levels, and smoking status were recorded. A tailored treatment plan was devised, including referral to an exercise referral service, smoking cessation programmes (if applicable) and each participant was also seen by a dietician for nutritional advice. Participants were followed up at 3 and 6 months to assess any improvement in vascular status and with each completing the EQ-5D quality of life questionnaire and a simple satisfaction questionnaire at the end of the study. As this was a complex intervention a pilot study design was adopted to evaluate if the method and outcomes were suitable and acceptable to participants the results of which will then inform the design of a larger study. Results: Data was collected on 21 individuals; 15 men (71.4%) and 6 women (28.6%) across the 6-month study period. Eleven participants were referred onto the exercise referral service; 16 participants saw the dietician for nutritional advice at baseline and had one-to-one or telephone follow-up at 3 months. Five out of 14 participants had reduced scores from baseline of intermittent claudication during the study period. No evidence for substantive changes in Doppler sounds or ABPI measurements was revealed. Quality of life scores with the EQ-5D improved in 15 participants; this was statistically significant (p = 0.007) with 14 participants who completed the simple satisfaction questionnaire expressing a positive view of the programme. Of the four people who were smokers, two stopped smoking cigarettes and moved to e-cigarettes as part of smoking cessation advice. Conclusion: As this was a pilot study the sample size was low, but some statistically significant improvements with some measures were observed over the 6-month study. Podiatrists are able to provide a comprehensive vascular assessment of the lower limb and accompanying tailored advice on lifestyle changes including smoking cessation and exercise. Locating clinics in National Centres for Sports and Exercise Medicine enables easy access to exercise facilities to encourage the adoption of increased activity levels, though the long term sustainability of exercise programmes still requires evaluation

Biochemical, physiological and psychological changes during endurance exercise in people with type 1 diabetes.

BACKGROUND: Increasing numbers of people with diabetes are adopting exercise programs. Fear of hypoglycemia, hypoglycemia itself, and injuries are major issues for many people with diabetes undertaking physical activity. The purpose of this study was to investigate the effects of type 1 diabetes mellitus on the risk of hypoglycemia, glycemic variability, exercise performance, changes in body composition, changes in insulin dosage, and psychosocial well-being during a multiday endurance exercise event. METHODS: Eleven participants (7 with type 1 diabetes, 4 with normal glucose tolerance) undertook a 15-day, 2300 km cycling tour from Barcelona to Vienna. Data were prospectively collected using bike computers, continuous glucose monitors, body composition analyzers, and mood questionnaires. RESULTS: Mean blood glucose in riders with and without diabetes significantly reduced as the event progressed. Glycemic variability and time spent in hypoglycemia did not change throughout the ride for either set of riders. Riders with diabetes in the lowest quartile of sensor glucose values had significantly reduced power output. Percentage body fat also significantly fell. Hypo- and hyperglycemia provoked feelings of anxiety and worry. CONCLUSIONS: This is the first study to describe a real-time endurance event in type 1 diabetes, and provides important new data that cannot be studied in laboratory conditions. Hypoglycemia continues to occurs in spite of peer support and large reductions in insulin dose. Glycemic variability is shown as a potential barrier to participation in physical activity through effects on mood and psychological well-being

Medical decision making using knowledge of patient identification as Aboriginal or Torres Strait Islander: what do medical students think?

Objective Best-practices guidelines require Australian health practitioners to ask all patients “are you [is the person] of Aboriginal and/or Torres Strait Islander origin?”. The present study investigated medical student attitudes regarding medical decisions made after asking this standard status question. Methods A hypothetical interaction between a doctor and an Aboriginal patient was presented in a pen-and-paper questionnaire in which: (1) the doctor considered (or did not consider) the patient’s Indigenous status relevant to make a medical diagnosis, and (2) the doctor registered (or did not register) the patient for the Closing the Gap PBS co-payment. Participants were first- and second-year medical students at the Australian National University who evaluated the doctor’s decisions against 20 attributes characterising professionalism and prejudice. Results Students evaluated the doctor more favourably when the doctor registered the patient for the co-payment and when the doctor did not consider Indigenous status relevant to making a medical diagnosis. Conclusions Encouragingly, medical students recognise that withholding registration for the co-payment is unprofessional. At the same time, medical students clearly do not think medical diagnoses should be made using the knowledge a patient identifies as Aboriginal. Implications With the continual development of policy and guidelines (and the prospect of diagnostic guidelines) to improve Aboriginal and Torres Strait Islander health, students and practitioners must understand how to use this knowledge of a patient’s status to benefit health outcomes

Stereodivergent cyclopropanation of unactivated alkenes with heme proteins

Cyclopropyl motifs are present in a variety of compounds important to pharmaceutical, agrochemical, and fragrance industries. The asymmetric synthesis of cyclopropanes is often performed under harsh conditions with toxic, precious metal chiral catalysts. In 2013, the first example of biocatalytic alkene cyclopropanation was reported, using an engineered cytochrome P450 enzyme [1]. Since then, several heme proteins were reported to cyclopropanate a variety of styrenyl alkenes [2], but none have been shown to asymmetrically cyclopropanate more challenging substrates such as unactivated, aliphatic alkenes using the native iron-heme cofactor. Here we report that heme proteins can cyclopropanate unactivated alkenes and that stereoselectivity and activity can be tuned by directed evolution. A few rounds of site-saturation mutagenesis and screening yielded four protein variants with high enantio- and diastereoselectivity for complementary isomers, enabling stereodivergent synthesis of aliphatic cyclopropanes. These iron-porphyrin proteins are fully genetically encoded, and the reactions can be performed under mild, aqueous conditions with whole cells or purified protein. The protein enhances the activity of the native iron-heme cofactor, giving access to a broad array of cyclopropanated products. This example showcases the ability to quickly and efficiently engineer proteins for non-natural biocatalytic function. [1] P.S. Coelho, E.M. Brustad, A. Kannan, F.H. Arnold, Olefin cyclopropanation via carbene transfer catalyzed by engineered cytochrome P450 enzymes., Science. 339 (2013) 307–10. [2] O.F. Brandenberg, R. Fasan, F.H. Arnold, Exploiting and engineering hemoproteins for abiological carbene and nitrene transfer reactions, Curr. Opin. Biotechnol. 38 (2017) in press