MiRTLE (Mixed-Reality Teaching and Learning Environment): from prototype to production and implementation

This position paper focuses on our efforts to implement and evaluate a Mixed Reality Teaching and Learning Environment (MiRTLE) in higher education institutions and other organisations, our current technical research to streamline and improve the utility of the system, and potential pedagogical developments for MiRTLE in the future

Survey of the Commissioning Nurse Leaders’ Network membership 2015: summary of results

Executive summary This report presents the findings from the 2015 online survey of nurses working in commissioning roles either as Governing Body nurses (GBNs) and nurses working for Commissioning Support Units (CSUs) which support CCGs. The survey was undertaken in collaboration with the Commissioning Nurse Leaders’ Network (CNLN). We present the results from the online survey in the context of current policy developments and some recommendations. Data collection was carried out using an online survey of all commissioning nurse members of the CNLN between 11th June and 6th July 2015. All of the sample provided by NHS England (n=238) were sent a personalised email (addressed to them by name) which included an information sheet about the survey and a link to the online survey. The response rate was 40.7% (n=97) which was similar to the response rate for the survey of CCG nurses carried out in 2014 by NHS England (41%, n-=69). Findings included in this report refer to all respondents in the survey (GBNs and nurses working in CSUs) unless otherwise indicated. Demographic profile and previous experience 92.8% of respondents worked for one or more CCGs; 7.25% of respondents were employed by a CSU. Respondents were mostly female, over 50 years of age, of White or White British ethnicity, with substantial clinical, managerial and Board experience. Working patterns 75% of the respondents had worked within CCGs or CSUs for more than two years; a relatively small proportion (7.8%) had been in their post for less than one year. 79.7% of respondents worked full-time (37.5 hours a week or more) and the majority (82.2%) worked within one CCG or CSU. Just under 18% of GBNs worked for more than one CCG and a majority of these respondents felt that all their CCGs worked well together (56.3%) but 25% said that only some are working together and 18.8% said that none were working together. A large majority of GBNs (81%) worked in full-time statutory (executive) roles with just 14% working as part- time statutory (executive) roles. Tensions between CSUs and CCGs. Amongst nurses who worked in CSUs, more than half of respondents (57.2%) said that they were fairly or extremely dissatisfied with the impact of their work on the CCG (28.6% in each category). A large minority (42.9%) said that they were fairly satisfied. Comments in open-ended questions suggested that this may be explained by perceptions that CSUs are not respected or valued by CCGs or that CCGs may sometimes make unreasonable demands on CSUs. GBNs‘ motivation, roles and experiences of working in CCGs. The reasons for wanting to be a nurse on a CCG, which GBNs cited most frequently were: having an impact in population health; being an advocate for patient interests and ensuring a nursing influence on commissioning services. GBNs’ perceptions of their influence of their roles on decision-making in CCGs. GBNs were much more satisfied with their impact on CCGs (84% very or fairly satisfied) than were nurses working in CSUs. In addition, more than 90% of GBNs were extremely or fairly satisfied overall with the contribution they made to the work of the CCG. Two-thirds of GBNs said that they chair at least one committee, most commonly the Quality Committee / Quality and Risk Committee or the Safeguarding Committee. Over 90% of GBNs said that their CCG has an executive management board. Of these, 79.7% reported that they were a member of that board. A large majority of GBNs who were on CCG management boards (89.1%) felt that they were extremely or fairly influential on these boards. Amongst those not on executive management boards, the reason most frequently given was that their role was not configured as an executive one and therefore they were not on the board and not able to influence decision making at this level. A large majority of GBNs (85.1%) felt that they were extremely or fairly influential in CCG decision- making generally. Nearly all respondents (92.7%) considered that the statutory nursing role was important (extremely or fairly) to the work of the CCG. GBNs’ views on the perceived purpose of CCGs. Improving the population’s heath was considered to be the most important goal of their CCG by a significant majority of respondents (61.6%); 19.2% felt commissioning was the most important goal of CCG work; 9.6% of respondents believed service redesign and meeting financial targets were the most important goals of their CCG. GBNs’ perceptions of their ability to be leaders in CCGs. 95.8% of respondents felt that that they had a leadership role within their CCG. More than half of respondents (52.9%) said that they were ‘extremely confident’ in carrying out their leadership role and a further 38.2% were fairly confident. Conclusions These are positive, albeit self reported, findings regarding the nursing role in CCGs and CSUs. Some of the findings suggest causes for further investigation: • The open- ended responses show that the influence and impact of the GBN role may in some instances be limited by certain assumptions or ways of working, particularly the perception that the GP is the lead clinician in the CCG. • There is evidence in the findings that GBNs were much more satisfied with their impact on CCGs than were nurses working in supporting commissioning in CSUs. Consequently, achieving the goals of the CCGs, including developing a nursing leadership role in commissioning on CCGs, may therefore be under threat if the contributions of GBNs and other nurses working for CCGS or in CSUs, go unrecognised or are under-utilised

Prescribing issues experienced by people living with Phenylketonuria in the UK

Background: Foods for Special Medical purposes (Phe-free protein substitutes [PS] and low protein foods [LPFs]) are central to successful dietary management of patients with phenylketonuria (PKU). In the UK, PS and LPFs are prescribed by primary care general practitioners (GPs) and dispensed by high street pharmacists or via home delivery companies. As patients and carers commonly reported access issues with PS and LPFs through the National Society for PKU (NSPKU) helpline, the NSPKU collected more information about the extent of prescriptions issues via a questionnaire. Methods: A cross sectional online survey was carried out (consisting of 7 multiple choice and 3 open questions). The questionnaire was available via the NSPKU website over a nine-month period (15th May 2018 to 31st January 2019). Carers or patients with PKU were invited to participate if they had any problems accessing PS and LPF over a 9-month period. Results: There were 252 responses. 65% for children and 35% for adults, aged ≥18y with PKU. 59% (n=146/246) of responses described difficulties accessing basic LPF (bread, pasta) and 33% (n=81/248) PS. 36% (n=88/248) said problems had re-occurred during >1y, and 40% (n=99/248) for < 3 months. 59% (n= 146/246) had supply issues with LPF and 33% (n= 81/246) with PS. 18% (n=42/234) reported that the local NHS authority had refused, restricted or had a policy to block treatment access; 27% (n=63/234) cited GPs declining requests or restricting prescription amounts. 21% (n=49/234) could not access all their products via a pharmacy, 40% (n=93/234) said their home delivery system failed, and 15% (n=34/234) of the dispensed prescribed products were out of date, incorrect, damaged or poor quality. For patients and carers these issues caused: stress (87%, n=210/241); they considered PKU was not taken seriously by professionals (66%, n=160/241); they reduced patient access to LPF and PS (53%, n=128/241); and affected the patients’ health (53%, n=128/241)

Living with Phenylketonuria: lessons from the PKU community

Introduction: We report the practical, social and psychological issues of living with phenylketonuria (PKU) from one of the largest surveys that has been completed by both adults with PKU and parents/caregivers of children. Methods: In the UK, parents/caregivers of children and adults with PKU were invited to complete an online survey between November 2017 to January 2018 by the NSPKU (National Society for Phenylketonuria). Results: 631 participants (adults, n=338; parents/caregivers of children, n=293) with PKU completed the questionnaire. Problems experienced by children with PKU were: difficulty with maintaining focus (48%,n=114/236), educational difficulties (28%, n=67/236), anxiety or depression (29%, n=68/236), and gastrointestinal symptoms (34%, n=97/282). Fifty one per cent (n=120/236) described social exclusion; 17% (n=41/236) had relationship issues with friends or family. Problems experienced by adults were: depression or anxiety (52%, n=148/286), difficulty maintaining focus (54%, n=154/286), and low mood (54%, n=180/334). Difficulties were experienced with relationships (34%, n=96/286); social exclusion (44%, n=126/286); and gastrointestinal issues (n=34%, n=112/334). Common medications used included antidepressants (40%, n=131/331) and anxiolytics (18%, n=60/334). Discussions: Adults with PKU or caregivers/parents of children identified significant neurocognitive, mental health and general health issues. Limits on socialisation, perception of social isolation and dietary stigma are major obstacles which are difficult to overcome with conventional dietary management

Reproductive experience of women living with phenylketonuria

Introduction: Many women with PKU are well-informed about the risks of maternal PKU but there are several barriers to achieving satisfactory metabolic control before and during pregnancy. Many studies have documented the outcome of maternal PKU infants, but very little has been reported about the experiences of women of reproductive age with PKU, particularly about their psychosexual development, pre-conception, pregnancy and postnatal experience. Methods: In the UK, in a subsection of an online questionnaire conducted by the National Society for PKU (NSPKU) about living with PKU, women aged 18 years and over completed 9 closed questions about their pre-conception, pregnancy and post-natal experiences and an open-ended question on their reproductive health. Results: 300 women aged 18 years and over with PKU completed this questionnaire with 37% (n= 111/300) of women already having children. 56% (n= 71/128) of pregnancies were planned and a further 18% (n= 23/128) of women had both planned and unplanned pregnancies. Most women (73%, n=200/273) expressed concerns, fears and distress about pregnancy and two thirds of women who had at least one pregnancy stated that having PKU made pregnancy more stressful and difficult. 60% (n= 164/273) were concerned that they may cause harm to a baby, 58% (n= 159/273) worried about their ability to manage a strict diet during pregnancy, 54% (n= 147/273) had anxiety about their ability to maintain blood Phe within target range, and 48% (n= 132/273) feared having an unplanned pregnancy. Postnatally, 48% (n= 45/93) had low mood or sadness, 42% (n= 38/93) were depressed, 34% (n= 32/93) felt unable to cope, 33% (n= 31/93) said they could not manage their PKU and care for their baby, 14% (n= 13/93) struggled with child care needs and 4% (n= 4/94) worried they might hurt themselves or their baby through being unable to manage their diet. Conclusions: Many women with PKU have unmet sexual and reproductive health needs Pregnancy fears are prominent from adolescence onwards and for some women overarching concerns about their ability to cope with pregnancy led to a decision not to have children. Interventions are needed to reduce the psychological impact of the risk of maternal PKU syndrome and assist with safe pregnancies. Post-natal experiences of women with PKU give rise to concern

Cross-Cultural Applicability of the Montreal Cognitive Assessment (MoCA): A Systematic Review

The Montreal Cognitive Assessment (MoCA) is widely used to screen for mild cognitive impairment (MCI). While there are many available versions, the cross-cultural validity of the assessment has not been explored sufficiently. We aimed to interrogate the validity of the MoCA in a cross-cultural context: in differentiating MCI from normal controls (NC); and identifying cut-offs and adjustments for age and education where possible. This review sourced a wide range of studies including case-control studies. In addition, we report findings for differentiating dementias from NC and MCI from dementias, however, these were not considered to be an appropriate use of the MoCA. The subject of the review assumes heterogeneity and therefore meta-analyses was not conducted. Quality ratings, forest plots of validated studies (sensitivity and specificity) with covariates (suggested cut-offs, age, education and country), and summary receiver operating characteristic curve are presented. The results showed a wide range in suggested cutoffs for MCI cross-culturally, with variability in levels of sensitivity and specificity ranging from low to high. Poor methodological rigor appears to have affected reported accuracy and validity of the MoCA. The review highlights the necessity for cross-cultural considerations when using the MoCA, and recognizing it as a screen and not a diagnostic tool. Appropriate cutoffs and point adjustments for education are suggested

Geometric View of Measurement Errors

The slope of the best fit line from minimizing the sum of the squared oblique errors is the root of a polynomial of degree four. This geometric view of measurement errors is used to give insight into the performance of various slope estimators for the measurement error model including an adjusted fourth moment estimator introduced by Gillard and Iles (2005) to remove the jump discontinuity in the estimator of Copas (1972). The polynomial of degree four is associated with a minimun deviation estimator. A simulation study compares these estimators showing improvement in bias and mean squared error

Structure variation and evolution in microphase-separated grafted diblock copolymer films

The phase behavior of grafted d-polystyrene-block-poly(methyl methacrylate) diblock copolymer films is examined, with particular focus on the effect of solvent and annealing time. It was observed that the films undergo a two-step transformation from an initially disordered state, through an ordered metastable state, to the final equilibrium configuration. It was also found that altering the solvent used to wash the films, or complete removal of the solvent prior to thermal annealing using supercritical CO2, could influence the structure of the films in the metastable state, though the final equilibrium state was unaffected. To aid in the understanding to these experimental results, a series of self-consistent field theory calculations were done on a model diblock copolymer brush containing solvent. Of the different models examined, those which contained a solvent selective for the grafted polymer block most accurately matched the observed experimental behavior. We hypothesize that the structure of the films in the metastable state results from solvent enrichment of the film near the film/substrate interface in the case of films washed with solvent or faster relaxation of the nongrafted block for supercritical CO2 treated (solvent free) films. The persistence of the metastable structures was attributed to the slow reorganization of the polymer chains in the absence of solvent

Characteristics of torque production of the lower limb are significantly altered after 2 hours of treadmill load carriage

Load carriage is seldom completed in isolation, meaning load bearers need to be physically capable of physical activity after the load carriage task. This study aims to examine changes in lower limb muscle strength, as measured by torque production across a range of joint angles as a result of prolonged load carriage. Thirty-four healthy participants underwent two hours of loaded or unloaded treadmill load carriage, with lower limb muscle function variables assessed pre and post activity. The loaded group had a mass of (Mean(range)) 76.45 (27.12)kg, stature: 178.56 (17.63)cm, age: 23(6)yrs, and comprised of 13 males and 3 females. While the unloaded group had a body mass of 73.69(24.19)kg, stature: 178.89(18.49)cm, age: 22(5)yrs and comprised of 14 males and 4 females. Significant reductions across a range of parameters were observed. Characterised by reductions at the optimum muscle length for torque output, with all aspects demonstrating large (knee extension at 180˚·s-1: 0.51 Standardised SD, knee extnsion at 60˚·s-1: 0.98 standardised SD) or extremely large individual differences (knee flexion at 180˚·s-1: 2.17 standardised SD). These findings suggest after the completion of the load carriage task participants are in a significantly reduced physical state, which may have implications for secondary tasks