HEALTHY COMMAND ENVIRONMENTS: DEFINITIONS, RISK FACTORS, AND PROTECTIVE FACTORS

This project aims to identify protective and risk factors that contribute to a healthy command environment and the effects of those factors on Sailor behavior. To examine which factors were most impactful for building a healthy command environment, we developed and asked our participants a series of Likert scale questions and open-ended questions. Using their answers, we analyzed any perceived effects upon Sailor behavior. We compared responses from sea vs. shore command experiences as well as responses from different communities within the Navy. Our research shows which command practices, policies, procedures, and processes (P4) contributed to healthier environments. Our research shows that trust, leadership, and communication significantly influence a command’s environment. Our findings indicate that these themes can manifest through a variety of programs, policies, practices, and procedures. As a result, we recommend expanding the current leadership curriculum to include organizational behavior to improve implementation of the P4 throughout the military. We also recommend expanding the data collection effort throughout the Navy to gain a more complete understanding of healthy environments in the fleet and to enhance readiness, foster healthier Sailor behaviors, and encourage higher retention.N17Lieutenant, United States NavyCaptain, United States Marine CorpsLieutenant, United States NavyApproved for public release. Distribution is unlimited

Theorising Disability: Beyond Common Sense

This article seeks to introduce the topic of disability to political theory via a discussion of some of the literature produced by disability theorists. The author argues that these more radical approaches conceptualise disability in ways that conflict with ‘common-sense’ notions of disability that tend to underpin political theoretical considerations of the topic. Furthermore, the author suggests that these more radical conceptualisations have profound implications for current debates on social justice, equality and citizenship that highlight the extent to which these notions are also currently underpinned by ‘common-sense’ notions of ‘normality’

Consumption of cocoa flavanols results in acute improvements in mood and cognitive performance during sustained mental effort

Cocoa flavanols (CF) positively influence physiological processes in ways that suggest their consumption may improve aspects of cognitive function. This study investigated the acute cognitive and subjective effects of CF consumption during sustained mental demand. In this randomized, controlled, double-blinded, balanced, three period crossover trial 30 healthy adults consumed drinks containing 520 mg, 994 mg CF and a matched control, with a three-day washout between drinks. Assessments included the state anxiety inventory and repeated 10-min cycles of a Cognitive Demand Battery comprising of two serial subtraction tasks (Serial Threes and Serial Sevens), a Rapid Visual Information Processing (RVIP) task and a mental fatigue scale, over the course of 1 h. Consumption of both 520 mg and 994 mg CF significantly improved Serial Threes performance. The 994 mg CF beverage significantly speeded RVIP responses but also resulted in more errors during Serial Sevens. Increases in self-reported mental fatigue were significantly attenuated by the consumption of the 520 mg CF beverage only. This is the first report of acute cognitive improvements following CF consumption in healthy adults. While the mechanisms underlying the effects are unknown they may be related to known effects of CF on endothelial function and blood flow

Rapid Evaluation of the Special Measures for Quality and Challenged Provider Regimes: A Mixed-Methods Study

Background: Healthcare organisations in England rated as inadequate for leadership and one other domain enter Special Measures for Quality (SMQ) to receive support and oversight. A ‘watch list’ of challenged providers (CPs) at risk of entering SMQ also receive support. Knowledge is limited about whether the support interventions drive improvements in quality, their costs, and whether they strike the right balance between support and scrutiny. Objective: Analyse trust responses to the implementation of a) interventions for SMQ trusts and b) interventions for CP trusts to determine their impact on these organisations' capacity to achieve and sustain quality improvements. Design: Rapid research comprising five inter-related workstreams: 1. Literature review using systematic methods. 2. Analysis of policy documents and interviews at national level. 3. Eight multi-site, mixed method trust case studies. 4. Analysis of national performance and workforce indicators. 5. Economic analysis. Results: SMQ/CP were intended to be “support” programmes. SMQ/CP had an emotional impact on staff. Perceptions of NHSI interventions were mixed overall. Senior leadership teams were a key driver of change, with strong clinical input vital. Local systems have a role in improvement. Trusts focus efforts to improve across multiple domains. Internal and external factors contribute to positive performance trajectories. Nationally, only 15.8% of SMQ trusts exited within 24 months. Relative to national trends, entry into SMQ/CP corresponded to positive changes in 4-hour waits in Emergency Departments, mortality and delayed transfers of care. Trends in staff sickness and absence improved after trusts left SMQ/CP. There was some evidence that staff survey results improve. No association was found between SMQ/CP and referral to treatment times or cancer waiting times. The largest components of NHSI spending in case studies were interventions directed at 'training on cultural change' (33.6%), 'workforce quality and safety' (21.7%) and 'governance and assurance' (18.4%). Impact of SMQ on financial stability was equivocal; most trusts exiting SMQ experienced the same financial stability before and after exiting. Limitations: The rapid research design and one-year timeframe precludes longitudinal observations of trusts and local systems. The small number of indicators limited the quantitative analysis of impact. Measuring workforce effects was limited by data availability. Conclusions: Empirical evidence of positive impacts from SMQ/CP were identified, however, perceptions were mixed. Key lessons: • Time is needed to implement and embed changes. • Ways to mitigate emotional costs and stigma are needed. • Support strategies should be more trust specific. • Poor organisational performance needs to be addressed within local systems. • Senior leadership teams with stability, strong clinical input and previous SMQ experience helped enact change. • Organisation-wide quality improvement strategies and capabilities are needed. • Staff engagement and an open listening culture promote continuous learning and a quality improvement ‘mindset’, critical for sustainable improvement. • Need to consider level of sustainable funds required to improve patients’ outcomes. Future work: Evaluating recent changes to the regimes; role of local systems; longitudinal approaches. Study registration: Review protocol registered with PROSPERO (CRD: 42019131024). Funding: The National Institute for Health Research Health Services and Delivery Research programme (16/138/17 – Rapid Service Evaluation Research Team)

MRI for assessment of anal fistula

Magnetic resonance imaging (MRI) is the best imaging modality for preoperative assessment of patients with anal fistula. MRI helps to accurately demonstrate disease extension and predict prognosis. This in turn helps make therapy decisions and monitor therapy. The pertinent anatomy, fistula classification and MRI findings will be discussed

Is a Priming Dose of Insulin Necessary in a Low-Dose Insulin Protocol for the Treatment of Diabetic Ketoacidosis?

OBJECTIVE—The purpose of this study was to assess the efficacy of an insulin priming dose with a continuous insulin infusion versus two continuous infusions without a priming dose

Increasing Adipocyte Lipoprotein Lipase Improves Glucose Metabolism in High Fat Diet-Induced Obesity

Lipid accumulation in liver and skeletal muscle contributes to co-morbidities associated with diabetes and obesity. We made a transgenic mouse in which the adiponectin (Adipoq) promoter drives expression of lipoprotein lipase (LPL) in adipocytes to potentially increase adipose tissue lipid storage. These mice (Adipoq-LPL) have improved glucose and insulin tolerance as well as increased energy expenditure when challenged with a high fat diet (HFD). To identify the mechanism(s) involved, we determined whether the Adipoq-LPL mice diverted dietary lipid to adipose tissue to reduce peripheral lipotoxicity, but we found no evidence for this. Instead, characterization of the adipose tissue of the male mice after HFD challenge revealed that the mRNA levels of peroxisome proliferator-activated receptor-γ (PPARγ) and a number of PPARγ-regulated genes were higher in the epididymal fat pads of Adipoq-LPL mice than control mice. This included adiponectin, whose mRNA levels were increased, leading to increased adiponectin serum levels in the Adipoq-LPL mice. In many respects, the adipose phenotype of these animals resembles thiazolidinedione treatment except for one important difference, the Adipoq-LPL mice did not gain more fat mass on HFD than control mice and did not have increased expression of genes in adipose such as glycerol kinase, which are induced by high affinity PPAR agonists. Rather, there was selective induction of PPARγ-regulated genes such as adiponectin in the adipose of the Adipoq-LPL mice, suggesting that increasing adipose tissue LPL improves glucose metabolism in diet-induced obesity by improving the adipose tissue phenotype. Adipoq-LPL mice also have increased energy expenditure

Acetyl-leucine slows disease progression in lysosomal storage disorders

Acetyl-DL-leucine is a derivative of the branched chain amino acid leucine. In observational clinical studies acetyl-DL-leucine improved symptoms of ataxia, in particular in patients with the lysosomal storage disorder, Niemann-Pick disease type C1. Here, we investigated acetyl-DL-leucine and its enantiomers acetyl-L-leucine and acetyl-D-leucine in symptomatic Npc1-/- mice and observed improvement in ataxia with both individual enantiomers and acetyl-DL-leucine. When acetyl-DL-leucine and acetyl-L-leucine were administered pre-symptomatically to Npc1-/- mice, both treatments delayed disease progression and extended life span, whereas acetyl-D-leucine did not. These data are consistent with acetyl-L-leucine being the neuroprotective enantiomer. Altered glucose and antioxidant metabolism were implicated as one of the potential mechanisms of action of the L enantiomer in Npc1-/- mice. When the standard of care drug miglustat and acetyl-DL-leucine were used in combination significant synergy resulted. In agreement with these pre-clinical data, when Niemann-Pick disease type C1 patients were evaluated after 12 months of acetyl-DL-leucine treatment, rates of disease progression were slowed, with stabilisation or improvement in multiple neurological domains. A beneficial effect of acetyl-DL-leucine on gait was also observed in this study in a mouse model of GM2 gangliosidosis (Sandhoff disease) and in Tay-Sachs and Sandhoff disease patients in individual cases of off-label-use. Taken together, we have identified an unanticipated neuroprotective effect of acetyl-L-leucine and underlying mechanisms of action in lysosomal storage diseases, supporting its further evaluation in clinical trials in lysosomal disorders

Evaluation of non-invasive prenatal testing (NIPT) for aneuploidy in an NHS setting: a reliable accurate prenatal non-invasive diagnosis (RAPID) protocol

This is the final version of the article. Available from BioMed Central via the DOI in this record.BACKGROUND: Non-invasive prenatal testing (NIPT) for aneuploidies is now available through commercial companies in many countries, including through private practice in the United Kingdom (UK). Thorough evaluation of service delivery requirements are needed to facilitate NIPT being offered more widely within state funded healthcare systems such as the UK's National Health Service (NHS). Successful implementation will require the development of laboratory standards, consideration of stakeholder views, an analysis of costs and development of patient and health professional educational materials. METHODS/DESIGN: NIPT will be offered in an NHS setting as a contingent screening test. Pregnant woman will be recruited through six maternity units in England and Scotland. Women eligible for Down's syndrome screening (DSS) will be informed about the study at the time of booking. Women that choose routine DSS will be offered NIPT if they have a screening risk ≥ 1:1000. NIPT results for trisomy 21, 18, 13 will be reported within 7-10 working days. Data on DSS, NIPT and invasive testing uptake, pregnancy outcomes and test efficacy will be collected. Additional data will be gathered though questionnaires to a) determine acceptability to patients and health professionals, b) evaluate patient and health professional education, c) assess informed choice in women accepting or declining testing and d) gauge family expenses. Qualitative interviews will also be conducted with a sub-set of participating women and health professionals. DISCUSSION: The results of this study will make a significant contribution to policy decisions around the implementation of NIPT for aneuploidies within the UK NHS. The laboratory standards for testing and reporting, education materials and counselling strategies developed as part of the study are likely to underpin the introduction of NIPT into NHS practice. NIHR PORTFOLIO NUMBER: 13865.This manuscript presents independent research funded by the National Institute for Health Research (NIHR) under the Programme Grants for Applied Research programme (RP-PG-0707-10107) (the "RAPID" project). LSC is partially funded by the Great Ormond Street Hospital Children’s Charity and the NIHR Biomedical Research Centre at Great Ormond Street Hospital. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health