Improving the health of people with multimorbidity: the need for prospective cohort studies

The dramatic rise in long-term conditions (LTCs) represents a major challenge for individuals, families, and health care systems worldwide. Due to the scale of this rise, the management of patients with LTCs largely falls within the domain of primary rather than secondary care, at least in countries with well-developed primary care systems. For example, in the UK, which has a comprehensive primary care system based around general practice (trained family physicians working in multidisciplinary teams) and funded by the National Health Service (NHS), primary care contacts account for around 90% of the total activity of the NHS, and patients with LTCs account for 80% of general practice consultations. Effective primary care and community-based management of people with LTCs is thus a top priority

Accentuate the negative

A survey of mean inequalities with real weights is given.Comment: 16 pages 3 figure

Arcuate nucleus homeostatic systems reflect blood leptin concentration but not feeding behaviour during scheduled feeding on a high-fat diet in mice

Acknowledgements T.B. was funded by a CASE studentship from the BBSRC and AstraZeneca. J.B. was a summer student from Bordeaux Sciences Agro and funded by student laboratory experience grant from the British Society of Neuroendocrinology. The authors are also grateful for funding from the Scottish Government, and from the European Union Seventh Framework Programme (FP7/2007-2013) under grant agreements 266408 (Full4Health) and 245009 (NeuroFAST).Peer reviewedPublisher PD

Patient enablement requires physician empathy: a cross-sectional study of general practice consultations in areas of high and low socioeconomic deprivation in Scotland

<b>Background</b> Patient 'enablement' is a term closely aligned with 'empowerment' and its measurement in a general practice consultation has been operationalised in the widely used patient enablement instrument (PEI), a patient-rated measure of consultation outcome. However, there is limited knowledge regarding the factors that influence enablement, particularly the effect of socio-economic deprivation. The aim of the study is to assess the factors influencing patient enablement in GP consultations in areas of high and low deprivation.<p></p> <b>Methods</b> A questionnaire study was carried out on 3,044 patients attending 26 GPs (16 in areas of high socio-economic deprivation and 10 in low deprivation areas, in the west of Scotland). Patient expectation (confidence that the doctor would be able to help) was recorded prior to the consultation. PEI, GP empathy (measured by the CARE Measure), and a range of other measures and variables were recorded after the consultation. Data analysis employed multi-level modelling and multivariate analyses with the PEI as the dependant variable.<p></p> <b>Results</b> Although numerous variables showed a univariate association with patient enablement, only four factors were independently predictive after multilevel multivariate analysis; patients with multimorbidity of 3 or more long-term conditions (reflecting poor chronic general health), and those consulting about a long-standing problem had reduced enablement scores in both affluent and deprived areas. In deprived areas, emotional distress (GHQ-caseness) had an additional negative effect on enablement. Perceived GP empathy had a positive effect on enablement in both affluent and deprived areas. Maximal patient enablement was never found with low empathy.<p></p> <b>Conclusions</b> Although other factors influence patient enablement, the patients' perceptions of the doctors' empathy is of key importance in patient enablement in general practice consultations in both high and low deprivation settings

Collaborative Epistemic Discourse in Classroom Information Seeking Tasks

We discuss the relationship between information seeking, and epistemic beliefs – beliefs about the source, structure, complexity, and stability of knowledge – in the context of collaborative information seeking discourses. We further suggest that both information seeking, and epistemic cognition research agendas have suffered from a lack of attention to how information seeking as a collaborative activity is mediated by talk between partners – an area we seek to address in this paper. A small-scale observational study using sociocultural discourse analysis was conducted with eight eleven year old pupils who carried out search engine tasks in small groups. Qualitative and quantitative analysis were performed on their discussions using sociocultural discourse analytic techniques. Extracts of the dialogue are reported, informed by concordance analysis and quantitative coding of dialogue duration. We find that 1) discourse which could be characterised as ‘epistemic’ is identifiable in student talk, 2) that it is possible to identify talk which is more or less productive, and 3) that epistemic talk is associated with positive learning outcomes

How to design and evaluate interventions to improve outcomes for patients with multimorbidity

Multimorbidity is a major challenge for patients and healthcare providers. The limited evidence of the effectiveness of interventions for people with multimorbidity means that there is a need for much more research and trials of potential interventions. Here we present a consensus view from a group of international researchers working to improve care for people with multimorbidity to guide future studies of interventions. We suggest that there is a need for careful consideration of whom to include, how to target interventions that address specific problems and that do not add to treatment burden, and selecting outcomes that matter both to patients and the healthcare system. Innovative design of these interventions will be necessary as many will be introduced in service settings and it will be important to ensure methodological rigour, relevance to service delivery, and generalizability across healthcare systems

Developing and testing accelerated partner therapy for partner notification for people with genital Chlamydia trachomatis diagnosed in primary care: a pilot randomised controlled trial

Background Accelerated partner therapy (APT) is a promising partner notification (PN) intervention in specialist sexual health clinic attenders. To address its applicability in primary care, we undertook a pilot randomised controlled trial (RCT) of two APT models in community settings. Methods Three-arm pilot RCT of two adjunct APT interventions: APTHotline (telephone assessment of partner(s) plus standard PN) and APTPharmacy (community pharmacist assessment of partner(s) plus routine PN), versus standard PN alone (patient referral). Index patients were women diagnosed with genital chlamydia in 12 general practices and three community contraception and sexual health (CASH) services in London and south coast of England, randomised between 1 September 2011 and 31 July 2013. Results 199 women described 339 male partners, of whom 313 were reported by the index as contactable. The proportions of contactable partners considered treated within 6 weeks of index diagnosis were APTHotline 39/111 (35%), APTPharmacy 46/100 (46%), standard patient referral 46/102 (45%). Among treated partners, 8/39 (21%) in APTHotline arm were treated via hotline and 14/46 (30%) in APTPharmacy arm were treated via pharmacy. Conclusions The two novel primary care APT models were acceptable, feasible, compliant with regulations and capable of achieving acceptable outcomes within a pilot RCT but intervention uptake was low. Although addition of these interventions to standard PN did not result in a difference between arms, overall PN uptake was higher than previously reported in similar settings, probably as a result of introducing a formal evaluation. Recruitment to an individually randomised trial proved challenging and full evaluation will likely require service-level randomisation

Extracellular vesicle signalling in atherosclerosis

Atherosclerosis is a major cardiovascular disease and in 2016, the World Health Organisation (WHO) estimated 17.5 million global deaths, corresponding to 31% of all global deaths, were driven by inflammation and deposition of lipids into the arterial wall. This leads to the development of plaques which narrow the vessel lumen, particularly in the coronary and carotid arteries. Atherosclerotic plaques can become unstable and rupture, leading to myocardial infarction or stroke. Extracellular vesicles (EVs) are a heterogeneous population of vesicles secreted from cells with a wide range of biological functions. EVs participate in cell-cell communication and signalling via transport of cargo including enzymes, DNA, RNA and microRNA in both physiological and patholophysiological settings. EVs are present in atherosclerotic plaques and have been implicated in cellular signalling processes in atherosclerosis development, including immune responses, inflammation, cell proliferation and migration, cell death and vascular remodeling during progression of the disease. In this review, we summarise the current knowledge regarding EV signalling in atherosclerosis progression and the potential of utilising EV signatures as biomarkers of disease

Selective cooling of the brain in reindeer

Selective cooling of the brain during hyper-thermia has been demonstrated in several species of mammals (Baker 1979, 1982). Such cooling is achieved by heat exchange between the cooled venous blood returning from the nasal mucosa and the warmer arterial blood entering the brain via the carotid rete. Spot measurements of brain temperature (Tbr) and carotid blood temperature (TCar) were made within 1 min. of death in 40 wild reindeer (Rangifer tarandus tarandus). At Tear lower than 40.5°C Tbr was higher than T c a r. With increasing Tear above 40.5°C Tbr remained at approxima-tely 40.5°C, indicating that selective cooling of the brain had occurred