Remote medico-legal assessment by telephone during COVID-19: Monitoring safety and quality when documenting evidence of torture for UK asylum applicants

Due to the Covid-19 pandemic, we developed remote assessment to provide interim medicolegal reports, ensuring people could obtain medical evidence to support their asylum claim. The Freedom from Torture research ethics committee approved the project. To audit this new way of working we collected feedback from the doctors, interpreters, individuals being assessed, and senior medical and legal staff who reviewed the reports. This paper presents findings from the first 20 assessments. Individuals reported that the doctors developed good rapport, but in 35% of assessments reported that there were some experiences they felt unable to disclose. In 70% of assessments, doctors felt that rapport was not as good as when face-to-face. In a majority of assessments the doctor was unable to gain a full account of the torture or its impact. Doctors reported feeling cautious about pressing for more information on the telephone, mindful of individuals’ vulnerability and the difficulty of providing support remotely. Nevertheless, in 85% of assessments doctors felt able to assess the consistency of the account of torture that was given with the psychological findings, in accordance with the Istanbul Protocol. The surveys indicated factors that hindered the assessment: inability to observe body language, the person’s ill health, and confidentiality concerns.  The limitations of these assessments underline the need for a follow-up face-to-face assessment to expand the psychological assessment and undertake a physical assessment. This research indicates that psychological medico-legal reports can safely be produced by telephone assessment, but are more likely to be incomplete in terms of both full disclosure of torture experiences and psychological assessment

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society

The "external dimension" of European Union policy on immigration and asylum : readmission, return and protection in the region of origin

This paper outlines the emergence and development of the 'external dimension' of EU policy on immigration and asylum. The external dimension is expected to become of more importance in future years and was recently given a new impetus within the 2004 Hague Programme. Three areas of policy are focused upon in this paper: exporting border controls and readmission agreements, return (and circular) migration and repatriation, and 'protection in the region' (Regional Protection Programmes). The ultimate aim is to ask how policies to reduce unwanted migration into the EU are changing, and whether they can, and are likely, to be reconciled with policies that will benefit developing countries and migrants themselves. Powered by TCPDF (www.tcpdf.org

The role of hydroxamic acids in Gramineae in conferring resistance to the aphids Sitobion avenae and Rhopalosiphum padi

Hydroxamic acids (Hx) occurring in cereal extracts, in particular the compound 2,4-dihydroxy-7-methoxy-1,4-benzoxazin-3-one (DIMBOA), have been shown to be involved in the resistance of cereals to bacteria, fungi and several insects. This investigation screened a wide genetic range of cultivars and species of the genera Triticum and Aegilops for antibiotic resistance to the cereal aphids S. avenae and Rhopalosiphum padi in relation to concentrations of Hx ([Hx]) of seedlings. A significant negative correlation (r &#61; - 0.59) was found between S. avenae intrinsic rate of increase (rm) and [Hx] of 20 lines of tetraploid and hexaploid Triticum. Variation in R. padi rm was very small. Subsequent work assessed [Hx] in whole plants of a variety of ages and individual assessments were made of leaves of different ages in two-, three-, four- and five-leaved plants. [Hx] was found to decline with age but was always highest in newly emerging leaves, including the flag leaves of mature wheat. The effects of varying environmental conditions such as nitrogen and water supply and of damaging plants on subsequent [Hx] and S. avenae mean relative growth rate (RGR) were also studied. Small and relatively short-lived increases in [Hx] were seen following damage or aphid infestation sometimes accompanied by a decrease in mean RGR of S. avenae. Manipulating nutrient availability also affected [Hx] and mean RGR. Finally, a small group of seedling taxa maintained under carefully controlled conditions were re-examined for [Hx] and for aphid antibiosis (mean RGR). The same group of taxa were also assessed as mature plants just coming into ear (growth stage 47) for [Hx] and aphid mean RGR in a field study. The correlation between S. avenae mean RGR and [Hx] in the oldest leaf of seedlings was very strong (r &#61; -0.69; P &#60; 0.05). S. avenae mean RGR and the [Hx] of flag-leaves of the same cultivars were also strongly correlated (r &#61; - 0.80; P &#60; 0.05). The results are discussed in relation to the potential use of hydroxamic acids analysis in plant breeding programs, both as a standard when selecting promising lines for resistance to cereal aphids and also in the isolation of resistant genes.</p

Exploring the clinical decision making used by experienced cardiorespiratory physiotherapists: a mixed method qualitative design of simulation, video recording and think aloud techniques

Background: The ability of physiotherapists to make clinical decisions is a vital component of being an autonomous practitioner, yet this complex phenomenon has been under-researched in cardiorespiratory physiotherapy. The purpose of this study was to explore clinical decision-making (CDM) by experienced physiotherapists in a scenario of a simulated patient experiencing acute deterioration of their respiratory function.Objectives: The main objective of this observational study was to identify the actions, thoughts, and behaviours used by experienced cardiorespiratory physiotherapists in their clinical decision-making processes. Design: A multiple-methods (qualitative) design employing observation and think-aloud, was adopted using a computerised manikin in a simulated environment.Setting: The participants clinically assessed the manikin programmed with the same clinical signs, under standardised conditions in the clinical skills practice suite, which was set up as a ward environment. Participants: Experienced cardiorespiratory physiotherapists, recruited from clinical practice within a 50-mile radius of (*anon for review). Methods: Participants were video-recorded throughout the assessment and treatment and asked to verbalise their thought processes using the ‘think-aloud’ method. The recordings were transcribed verbatim and managed using a Framework approach. Results: Eight cardiorespiratory physiotherapists participated (mean 7 years clinical experience, range 3.5 -16 years). CDM was similar to the collaborative hypothetico-deductive model, five-rights nursing model, reasoning strategies, inductive reasoning and pattern recognition. However, the CDM demonstrated by the physiotherapists was complex, interactive and iterative. Information processing occurred continuously throughout the whole interaction with the patient, and the specific cognitive skills of recognition, matching, implying and predicting were identified as being used sequentially. Conclusions: The findings from this study were used to develop a new conceptual model of clinical decision making for cardiorespiratory physiotherapy. This conceptual model can be used to inform future educational strategies to prepare physiotherapists and nurses for working in acute respiratory care.<br/

Preparing allied health students for placement: a contrast of learning modalities for foundational skill development

Background: with increasing pressure on placement capacity for allied health students, a need for novel and creative means through which students can develop foundational skills and prepare for practice-based learning opportunities has arisen. This study aimed to explore the experiences of domestic and international first-year students completing pre-clinical preparation programs, contrasting between in-person simulation and online options to contribute to best practice evidence for program design and delivery.Methods: first-year students from physiotherapy, podiatry and occupational therapy self-selected to either a one-weeklong in-person simulation program or an online preparation for placement program. An integrative mixed-methods approach was employed. Qualitative findings from student focus groups were analyzed by reflexive thematic analysis and complemented by quantitative pre-post questionnaires which were examined for patterns of findings.Results: there were 53 student participants in the study (simulation n = 29; online n = 24). Self-selecting, international students disproportionately opted for the simulation program while older students disproportionately selected the online program. Students appeared to benefit more from the simulation program than the online program, with alignment of focus group findings to the quantitative questionnaire data. The in-person simulation allowed students to apply their learning and practice patient communication. All simulation students reported asubsequent increase in confidence, although this seemed particularly marked for the international students. By contrast, the online program was most effective at developing students' clinical reasoning and proficiency with documentation. Both programs faced minor challenges to student perceived relevance and skill development.Conclusion: both online and in-person simulation preparation programs were perceived to enhance readiness and foundational skills development for novice allied health students, with the practical nature of simulation generating more advantageous findings. This study provides useful information on the benefits and challenges of both types of delivery for foundational skills development and/or clinical preparation of allied health students.</p

Innovations in preparing students for placement: student perceptions of an interprofessional simulation week

Purpose and aims: the COVID pandemic and the growing number of institutions offering allied health professions courses has increased the pressure on placement capacity (Clarke et al 2021). Consequently, institutions must explore innovative ways to ensure students complete placement hours and develop their professional and communication skills. One solution is simulation-based learning (Salter et al 2020, Imms et al 2018). Understanding student experience of this learning modality can inform future programme design, ensuring student learning needs are met (Aguilera- Hermida 2020). This research evaluates how a simulation programme prepared occupational therapy, physiotherapy and podiatry students at the University of Southampton for their first clinical placement.Design and methods: a mixed-methods design was used, with only qualitative findings with a focus on communication, confidence and interpersonal skill development presented here. A self-selected group of 29 students completed the week-long simulation programme with actor role players as patients and carers in three inter-professional multidisciplinary case studies. Of these students, 11 participated across two focus groups mid-way through a five-week placement. These were transcribed verbatim and thematically analysed. The project was funded by Health Education England.Results: students reported improved communication as the simulations enabled them to practise building rapport, trial using different phrases and tailor their communication. Although some students found taking a turn stressful, particularly initially, they felt their confidence grew, with several students finding the week particularly transformative.Conclusion: a week-long simulation-based programme can increase students’ perceived confidence and improve their communication before their first clinical placement.<br/

Preparing allied health students with foundational placement skills through a multi-disciplinary simulation week

Background:The COVID-19 pandemic has led to an increased demand for clinical placements for Allied Health Professional (AHP) students. Consequently, we have needed to be creative to explore other ways to ensure students complete their 1,000 hours of clinical experience across the programme. A potential option is to use simulation to replace a portion of clinical hours. Evidence confirms that up to 25% of authentic physical practice with standardized simulated patients results in comparable student competency as assessed by an educator and that a 1-week period of simulation is effective in building students’ confidence before continuing with a placement in the clinical setting [1,2].Aim:Our aim was to design, develop, implement and evaluate a multi-disciplinary simulation programme to prepare students with foundational placement skills. We sought to therefore reduce the burden on NHS staff. We also sought to determine the effect of the programme on student readiness for placement, student confidence, investigate stakeholder perceptions of the programme and determine the suitability of simulation in contributing to clinical hours.Method/design:Simulation-based educational (SBE) pedagogy and principles guided the programme design and included: pre-brief, simulation with regular time outs to enable rehearsal of an activity and debriefing for reflection. We employed actor role players to act as the patient, relative or carer and clinical educators to guide the students as they would on a traditional placement. We developed three generic patient case studies designed specifically to focus on the development of the key programme learning outcomes: developing patient-centred communication skills and professional behaviours. We adopted a mixed-methods approach in our research design, collecting quantitative data from student self-report pre–post questionnaires, clinical educator questionnaires and qualitative data from focus groups to address our research questions and aims.Implementation outline:A total of 29 Allied Health Professional students (from physiotherapy, occupational therapy and podiatry) completed a 5-day intensive simulation programme. The programme included an inter-professional ‘fishbowl simulation’ followed by 3 days of profession-specific clinical scenarios with profession-specific learning outcomes ending on the final day in six simulated multi-disciplinary team meetings. The sessions were interactive with simulated patients and their relative/carers giving authentic patient feedback from a patient perspective. We observed rich transformational learning observing students improve their communication skills and becoming more patient-centred in their approach. Preliminary student feedback indicates that they found the simulation programme challenging but extremely rewarding. Formal data analysis is continuing