Clinical and exercise professional opinion of return-to-running readiness after childbirth: an international Delphi study and consensus statement

Female athletes have identified a lack of guidance as a barrier to successfully returning to running postpartum, and existing guidelines are vague. Our aim was to define the current practice of determining postpartum run-readiness through a consensus survey of international clinicians and exercise professionals in postpartum exercise to assist clinicians and inform sport policy changes.A three-round Delphi approach was used to gain international consensus from clinicians and exercise professionals on run-readiness postpartum. Professionals who work with postpartum runners participated in an online survey to answer open-ended questions about the following postpartum return-to-running topics: definitions (runner and postpartum), key biopsychosocial milestones that runners need to meet, recommended screening, timeline to initiate running, support items, education topics and factors that contribute to advising against running. Consensus was defined as ≥75% participant agreement.One hundred and eighteen professionals participated in round I, 107 participated in round II (response rate 90.6%) and 95 participated in round III (response rate 80.5%). Responses indicated that, following a minimum 3-week period of rest and recovery, an individualised timeline and gradual return to running progression can be considered. Screening for medical and psychological concerns, current physical capacity, and prior training history is recommended prior to a return to running.This study proposes recommendations for the initial guidance on return-to-running postpartum, framed in the context of current research and consensus from professionals. Future research is needed to strengthen and validate specific recommendations and develop guidelines for best practice when returning-to-running after childbirth.

Clinical and exercise professional opinion on designing a postpartum return-to-running training programme: an international Delphi study and consensus statement

Returning to running postpartum presents challenges such as musculoskeletal pain and pelvic floor dysfunction for some females, but there is little guidance on developing and progressing postpartum training programmes. This study aims to establish expert consensus recommendations on designing and modifying a postpartum return-to-running training programme, highlight costs and access to qualified professionals as potential barriers and discuss clinical, research and sports policy implications.A three-round Delphi survey of clinical and exercise professionals working with postpartum runners was conducted. Round I consisted of open-ended questions related to designing the training plan, modifications based on biopsychosocial factors, key muscle groups to train and referral and payment sources. Rounds II and III involved Likert-scale voting to identify consensus (≥75% agreement).118 participants completed Round I, 107 completed Round II (response rate 90.6%) and 95 completed Round III (response rate 80.5%). Consensus was reached in 42/47 (89%) statements, including recommendations for a period of relative rest, gradual increases in duration and intensity, starting with a walk-run protocol and incorporating strength training. Training should be modified based on musculoskeletal or pelvic symptoms, sleep, mental health, lactation or energy availability concerns. Cost and access to experienced postpartum running professionals were identified as potential barriers for runners to receive care.Consensus recommendations for a postpartum return-to-running programme include an individualised exercise prescription, gradual increases in physical activity, walk-run protocols and targeted muscle strengthening. Further research and improved access to clinical and exercise professionals are needed to inform and facilitate best practices.

Embedding Physical Activity Guidance During Pregnancy and in Postpartum Care: 'This Mum Moves' Enhances Professional Practice of Midwives and Health Visitors

INTRODUCTION

The benefits of physical activity during pregnancy and after childbirth are well established, yet many health care professionals do not feel well equipped to provide physical activity guidance to these populations. As such, the objectives of this study were to explore the immediate and longer term effects of training on health care professionals' ability to provide physical activity guidance to pregnant women and new mothers (mums).

METHODS

Midwives and health visitors from 5 locations in the United Kingdom were provided with training on the Chief Medical Officers' physical activity guidelines for pregnancy and after childbirth (n = 393). Midwives and health visitors attended training to become This Mum Moves Ambassadors, then disseminated education to colleagues through a cascade training model. Changes in knowledge, confidence, and professional practice were assessed by survey before and immediately after training (n = 247), and follow-up surveys were completed 3 (n = 35) and 6 (n = 34) months posttraining.

RESULTS

At all posttraining time points, health care professionals reported a significant increase in their confidence to communicate about physical activity (P < .001). The reported frequency of having conversations about physical activity increased significantly 3 and 6 months following training compared with baseline (pregnant women, P = .017; new mums, P = .005). There were changes in the types of advice and resources offered by health care professionals and an overall increase in health care professionals' own reported physical activity levels.

DISCUSSION

The This Mum Moves cascade approach to delivering training in physical activity guidelines improved reported knowledge, confidence and professional practice of midwives and health visitors, both immediately following and 3 and 6 months after training.

Recommending swimming to people with low back pain: A scoping review

BACKGROUND

It is common practice for health professionals to recommend swimming to people with low back pain (LBP) despite limited evidence. The aim of this review was to gain an understanding of the current evidence base supporting the recommendation of swimming to people with LBP.

METHODS

A scoping review was conducted searching five electronic databases, CINAHL, MEDLINE, PEDro, PubMed, and SPORTdiscus using the keywords back pain AND swim*. The studies were grouped by study design and the following uncertainties were considered; the impact of swimming on the spine and LBP, evidence of swimming increasing or reducing the risk of LBP and the use of swimming in LBP rehabilitation programmes.

RESULTS

25 studies met the eligibility criteria; including sixteen observational studies exploring the relationship between swimming and LBP, three biomechanical studies investigating the impact of swimming on the spine, and five interventional studies of which four integrated swimming into a rehabilitation programme and one used swimming to modify lumbar lordosis.

CONCLUSION

The review confirmed there is limited research and only low-level evidence to support the recommendation of swimming to people with LBP. Observational studies make up the greater proportion of research undertaken in the field; the data indicates that swimming is a low-risk form of exercise but not without risk. The findings from biomechanical research suggest that lumbar lordosis does not increase excessively when swimming breaststroke, but certain swimming techniques could negatively impact LBP and interventional trials illustrate that there are various ways to integrate swimming into a rehabilitation programme.

Whole blood cytokine release assays reveal disparity between capillary blood sampling methods

INTRODUCTION

The use of whole blood in rapid cytokine release assays (CRAs) is becoming an established technique for screening immune responses following natural infection or vaccination, especially in the context of the SARS-CoV-2 pandemic. Establishing an accurate capillary blood sampling method to replace the need for venipuncture could make CRAs more accessible. In this study, capillary blood was collected via two different methods alongside traditional venipuncture to investigate whether the method of blood draw affects cytokine quantification when performing CRAs.

METHODS

Adults previously vaccinated with SARS-CoV-2 vaccines donated three blood samples: one by venipuncture, one by finger prick, and one by a microneedle device. Whole blood was aliquoted and incubated overnight with SARS-CoV-2 peptides or left unstimulated. Cytokine release in plasma was measured by multiplex array.

RESULTS

In unstimulated samples, little to no cytokines were detected in blood collected via venipuncture or by microneedle devices. Conversely, capillary blood collected by finger prick showed detectable levels of all cytokines analysed, with significantly inflated levels of TNFα, IL-10 (p < 0.0001), IL-2, GM-CSF, and IL-13 (p < 0.01), and 53% of these samples were also positive for IFN-γ. Following peptide stimulation, 25% of samples collected via finger prick showed dysregulated production of IFN-γ, TNFα, IL-2, and IL-10, with lower cytokine production than unstimulated controls. Contrastingly, this was seen in just 4% of venous blood samples and in none of the microneedle samples.

CONCLUSIONS

Capillary blood draw via a microneedle device results in highly comparable immune responses to those seen via venipuncture at baseline and following peptide stimulation, suggesting this is a viable method for rapid whole blood CRAs. Conversely, differential cytokine production is observed following capillary blood draw via finger prick.

Differential cellular and humoral immune responses in immunocompromised individuals following multiple SARS-CoV-2 vaccinations

Introduction

The heterogeneity of the immunocompromised population means some individuals may exhibit variable, weak or reduced vaccine-induced immune responses, leaving them poorly protected from COVID-19 disease despite receiving multiple SARS-CoV-2 vaccinations. There is conflicting data on the immunogenicity elicited by multiple vaccinations in immunocompromised groups. The aim of this study was to measure both humoral and cellular vaccine-induced immunity in several immunocompromised cohorts and to compare them to immunocompetent controls.

Methods

Cytokine release in peptide-stimulated whole blood, and neutralising antibody and baseline SARS-CoV-2 spike-specific IgG levels in plasma were measured in rheumatology patients (n=29), renal transplant recipients (n=46), people living with HIV (PLWH) (n=27) and immunocompetent participants (n=64) post third or fourth vaccination from just one blood sample. Cytokines were measured by ELISA and multiplex array. Neutralising antibody levels in plasma were determined by a 50% neutralising antibody titre assay and SARS-CoV-2 spike specific IgG levels were quantified by ELISA.

Results

In infection negative donors, IFN-γ, IL-2 and neutralising antibody levels were significantly reduced in rheumatology patients (p=0.0014, p=0.0415, p=0.0319, respectively) and renal transplant recipients (p<0.0001, p=0.0005, p<0.0001, respectively) compared to immunocompetent controls, with IgG antibody responses similarly affected. Conversely, cellular and humoral immune responses were not impaired in PLWH, or between individuals from all groups with previous SARS-CoV-2 infections.

Discussion

These results suggest that specific subgroups within immunocompromised cohorts could benefit from distinct, personalised immunisation or treatment strategies. Identification of vaccine non-responders could be critical to protect those most at risk.

1291 DO PATIENTS UNDERSTAND THEIR RESPECT FORMS? A QI PROJECT REVIEWING PHRASES USED AND WHETHER THEY ARE MEANINGFUL TO PATIENTS

Background

Hospital based Quality Improvement Project focusing on adapting language used on Recommended Summary Plan for Emergency Treatment and Care (ReSPECT) forms to improve patient understanding.

Introduction

ReSPECT forms have been used to document patient wishes and appropriate escalation of treatment in our hospital since 2019. There continues to be a lack of understanding of phrases used amongst both patients and healthcare professionals; the hospital receives regular complaints. This project explored patients’ perceptions of language used and their thoughts on the ReSPECT discussion, to better guide discussions and documentation.

Methods

A questionnaire collecting qualitative and quantitative data was performed with 24 patients aged between 59-95 years old with ReSPECT forms on a medical ward (Geriatrics/ Endocrine).

Results

The phrases ‘DNACPR’ and ‘Not for ITU’ were understood by 5/24 patients (21%), ‘Ward based ceiling of care’ was understood by only 1/24 (4%) and ‘prioritising comfort care’ understood by 8/24 patients (34%). Only 6/24 (25%) of patients said they were a ‘little upset’ by their admission conversation about ReSPECT and no patients surveyed were ‘very upset’.

Conclusions

This first QI cycle found that overall, most patients did not understand the language commonly used on ReSPECT forms, particularly ‘ward-based ceiling of care’. The majority were not upset by the ReSPECT conversation, so a fear of upsetting the patient should not be a barrier to having a clear discussion. The next step in our QI work will be to explore phrases that are better understood by patients and then feedback findings so that we can develop a digital ReSPECT form with drop down options for phrases better understood by patients to describe ceilings of care.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

527 The Challenge to Improve Patient Education for Newly Inserted Urinary Catheters on Discharge from the Emergency Department

Aim

To improve education in patients with new urinary catheters on discharge from the Emergency Department (ED), decreasing the incidence and healthcare burden of subsequent catheter-associated complications.

Method

Qualitative study design was employed to survey all Healthcare Professionals (HCPs) working in the ED and establish the quality and means of information currently provided. A novel trust-endorsed proforma with information leaflet was created with urology team input and uploaded to the ED website. Staff were updated via email, WhatsApp and verbally and re-surveyed after 6 months. Survey responses were evaluated with descriptive statistical analysis.

Results

The majority of HCPs in the department reported nearly always/often providing information verbally to patients, with similar findings on re-surveying. The most commonly discussed topic with patients remained: “Common complications and where to seek advice”. HCPs reported never/rarely offering written information (75%, 74% before and after respectively) and nearly all HCPs surveyed did not know where to find patient information resources (81%, 79% respectively).

Conclusions

Written information provision remained poor despite creation of a proforma with information leaflet. A high departmental turnover of HCPs, alongside varying seasonal Covid burden may have reduced the efficacy of interventions. The findings may also be as a result of HCPs still not knowing where to locate such resources.

‘Nudge theory’ through placing leaflets next to catheter supplies, combined with improved education of new staff rotating through the department at individual inductions and the introduction of checklists are changes that have been since actioned and due to be re-surveyed in February 2022.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Oral health-related self-efficacy and fatalism in a regional South Australian Aboriginal population

OBJECTIVES

To assess the psychometric properties, including face, content, criterion and known-groups validity and reliability, of scales to measure oral health-related self-efficacy and fatalism in a regional Aboriginal adult population in Australia.

METHODS

Four hundred Aboriginal adults (aged 18-82 years, 67% female) completed a self-report questionnaire including items pertaining to oral health-related self-efficacy and fatalism. Structural validity was determined in exploratory factor analysis (EFA) with principal components analysis for each scale. Criterion validity was assessed between the instruments and theoretically related variables. Known-groups validity was investigated by comparing the scores in different population groups according to age, sex, education and employment. Reliability of the scales was assessed through internal consistency.

RESULTS

The EFA confirmed a single factor structure for self-efficacy and fatalism scales, with Cronbach's alphas of 0.93 and 0.89 respectively. The two scales were not correlated. Oral health-related self-efficacy was associated with toothbrush ownership and brushing the previous day supporting criterion validity. Oral health-related fatalism was associated with previous extractions and perceived need for extractions also supporting criterion validity. Both measures were associated with social impact of oral health as measured by the OHIP-14, supporting their criterion validity. Mixed findings were observed in terms of known-groups validity.

CONCLUSIONS

There was initial evidence that measures of oral health-related self-efficacy and fatalism displayed adequate psychometric properties in this Aboriginal community. These constructs could have implications for approaches for improving oral health among Aboriginal people.

The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC): International consensus statement and user guide

Effective physical activity messaging plays an important role in the pathway towards changing physical activity behaviour at a population level. The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC) are outputs from a recent modified Delphi study. This sought consensus from an international expert panel on how to aid the creation and evaluation of physical activity messages. In this paper, we (1) present an overview of the various concepts within the PAMF and PAMC, (2) discuss in detail how the PAMF and PAMC can be used to create physical activity messages, plan evaluation of messages, and aid understanding and categorisation of existing messages, and (3) highlight areas for future development and research. If adopted, we propose that the PAMF and PAMC could improve physical activity messaging practice by encouraging evidence-based and target population-focused messages with clearly stated aims and consideration of potential working pathways. They could also enhance the physical activity messaging research base by harmonising key messaging terminologies, improving quality of reporting, and aiding collation and synthesis of the evidence.

Encouraging Physical Activity during and after Pregnancy in the COVID-19 Era, and beyond

Physical activity is known to decline during pregnancy and the postnatal period, yet physical activity is recommended during this time due to the significant health benefits for mothers and their offspring. As a result of the COVID-19 pandemic and the restrictions imposed to reduce infection rates, pregnant and postnatal women have experienced disruption not just to their daily lives but also to their pregnancy healthcare experience and their motherhood journey with their new infant. This has included substantial changes in how, when and why they have engaged with physical activity. While some of these changes undoubtedly increased the challenge of being sufficiently active as a pregnant or postnatal woman, they have also revealed new opportunities to reach and support women and their families. This commentary details these challenges and opportunities, and highlights how researchers and practitioners can, and arguably must, harness these short-term changes for long-term benefit. This includes a call for a fresh focus on how we can engage and support those individuals and groups who are both hardest hit by COVID-19 and have previously been under-represented and under-served by antenatal and postnatal physical activity research and interventions.

Proteus mirabilis - a rare cause of non-HACEK Gram-negative infective endocarditis

Infective endocarditis caused by Proteus mirabilis is strikingly rare. Here, we describe the case of an 86-year old man with five recurrent septic episodes over a period of three months associated with Proteus mirabilis bacteraemia secondary to underlying Proteus endocarditis. The final diagnosis was made based on clinical findings, blood culture results and transoesophageal echocardiogram. The patient was treated medically with 6 weeks of ceftriaxone and long-term oral ciprofloxacin. On completion of intravenous therapy the patient remained well. We performed a literature review and found this to be only the fourth confirmed case of Proteus mirabilis endocarditis successfully treated with antibiotic therapy alone. This case highlights an important but rare cause of endocarditis, reinforcing the need to consider this diagnosis in recurrent Gram-negative bacteraemia even if by an atypical organism.

"They turn to you first for everything": insights into midwives' perspectives of providing physical activity advice and guidance to pregnant women

Background

The antenatal period is associated with a decline in physical activity among women. Midwives are viewed central to the dissemination of information during pregnancy, however, there is little research relating to their promotion of physical activity. The purpose of this study was to gain insight into midwives’ perspectives of providing physical activity advice and guidance to pregnant women

Methods

Community midwives (N = 10) from ten randomly selected antenatal clinics in England took part in semi-structured interviews which were audio recorded, transcribed and analysed thematically

Results

In relation to perceived role and responsibilities in providing physical activity advice and guidance, midwives emphasised the extent to which their profession has evolved, the perceived burden of responsibility, and the tick box approach to physical activity discussion. Midwives identified a lack of training, knowledge, confidence, time, resources, and perceptions of vulnerability as barriers to effective physical activity promotion. Despite these issues midwives proposed eight opportunities to facilitate pregnant women’s physical activity engagement: (1) recognising and addressing barriers in the uptake and maintenance of physical activities, (2) professional development, (3) inter-professional collaboration, (4) communicating effectively through simple, reliable resources, (5) improved access, availability, and awareness of suitable activities in the local community, (6) encouraging a support network, (7) “selling” physical activity by challenging misconceptions and focusing on benefits, and (8) suitable motivation, incentives and reward.

Conclusions

These opportunities identified by midwives provide foundations from which improvements in practice can result. Whilst midwives are ideally placed to promote physical activity as part of a healthy pregnancy, this is likely to be most effective as part of a wider network of practitioners that share consistent and confident messages regarding physical activity engagement. This notion has far reaching implications for practice, policy, research and the normalisation of active pregnancies in the wider population.

Assessing the psychosocial factors associated with adherence to exercise referral schemes: A systematic review

This paper aimed to systematically review the evidence base to uncover the key psychosocial factors that underpin adherence to an exercise referral scheme (ERS). Databases PsycINFO, MEDLINE, SPORTDiscus, Web of Science, PubMed, PsycARTICLES, Open Grey, and PsycEXTRA were systematically searched. A parallel results-based convergent synthesis was performed by identifying key themes from quantitative and qualitative studies separately. After applying inclusion and exclusion criteria, the review included 24 eligible studies. Key findings showed intrinsic motivation, psychological need satisfaction, social support, and self-efficacy to be the prominent psychosocial factors associated with ERS adherence. In addition, lower expectations for change when entering the scheme was associated with ERS adherence. This review should serve as a catalyst to provide evidence-based ERS and as such ERS providers should seek to place an emphasis on participants' expectations and beliefs when entering the scheme. Moreover, targeting the key factors of intrinsic motivation, psychological need satisfaction, social support, and self-efficacy throughout the duration of an ERS should serve to facilitate adherence.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Experiences of physical activity during pregnancy resulting from in vitro fertilisation: an interpretative phenomenological analysis

OBJECTIVE

To explore the qualitative experiences and decision-making processes surrounding physical activity (PA) for women who have undergone IVF treatment.

BACKGROUND

PA during pregnancy is safe for both mother and fetus in the majority of cases, including for women who have undergone in vitro fertilisation (IVF) treatment; however, there is a paucity of research into decision-making and PA in this population.

METHODS

Eight women, who had undergone successful IVF treatment and were currently pregnant or had given birth within the last two years, participated in semi-structured interviews about their experiences of infertility and PA during pregnancy. Interview transcripts were analysed using interpretative phenomenological analysis.

RESULTS

Three superordinate themes emerged from the data: 'navigating away from childlessness and towards motherhood', 'negotiating a safe passage' and 'balancing the challenges of pregnancy with the needs of the self'. Ten subthemes indicated the processes adopted to navigate experiences of infertility, the IVF process, and subsequent decision-making about PA during pregnancy.

CONCLUSION

PA during pregnancy was experienced as a way to soothe the self and control the experience of pregnancy; however, this was mediated by concerns about safety and physical limitations on PA. Limitations of the study are considered, as well as implications for clinical practice and directions for future research.

A comparison of airborne bacterial fallout between orthopaedic and vascular surgery

INTRODUCTION The objective of the study was to compare bacterial fallout during vascular prosthesis insertion and orthopaedic major joint replacement performed in conventional and laminar flow ventilation, respectively. MATERIALS AND METHODS A prospective single-centre case control study of 21 consecutive elective vascular procedures involving prosthetic graft insertion and 24 consecutive elective orthopaedic major joint replacements were tested for degree of bacterial fallout using agar settle plates. Preparation time, waiting time and total procedure duration were collected at the time of surgery, and bacterial colony counts on the agar settle plates from airborne bacterial fallout were counted after an incubation period. RESULTS Bacterial fallout count in vascular prosthetic graft insertion was 15-fold greater than in orthopaedic prosthetic joint insertion (15, (IQR 15) vs 1, (IQR 3) respectively, P < 0.0001, Wilcoxon). Waiting time and patient transfer did not significantly increase bacterial fallout counts during the procedure (P = 0.9). CONCLUSIONS Vascular surgical theatres have significantly higher bacterial fallout compared with orthopaedic theatres. This may be partly explained by orthopaedic surgery being routinely performed in laminar flow ventilation, a practice which has not been widely adopted for vascular surgery, in which prosthetic infection may also result in significant mortality and morbidity.

Oral Papillomas Associated With Felis catus Papillomavirus Type 1 in 2 Domestic Cats

Multiple small sessile raised lesions were detected on the ventral surface of the tongue in two 13-year-old domestic cats. The lesions were incidental in both cats. Lesions from both cats appeared histologically as well-demarcated foci of markedly thickened folded epithelium that formed keratin-filled shallow cuplike structures. Large keratinocytes that contained a swollen nucleus surrounded by a clear cytoplasmic halo (koilocytes) were common, suggesting a diagnosis of a papillomavirus-induced papillomas, and papillomavirus antigen was demonstrated by immunohistochemistry. The papillomas exhibited diffuse intense cytoplasmic and nuclear immunoreactivity against cyclin-dependent kinase inhibitor 2A protein (also known as p16 or INK4a protein). Felis catus papillomavirus type 1 DNA sequences were amplified from both papillomas. The papillomas resolved in 1 cat within 3 months of diagnosis, while the papillomas were still visible 4 months after diagnosis in the other cat. This is the first evidence that these papillomas are caused by F. catus papillomavirus type 1.

Development and psychometric validation of a Health Literacy in Dentistry scale (HeLD)

BACKGROUND

Oral health literacy is emerging as a new public health challenge and poor oral health literacy is increasingly seen as an important predictor of poor oral health outcomes. Within Indigenous populations, there may be benefits to research in using a culturally acceptable, internally consistent and valid instrument to assess oral health literacy. We translated a general health literacy measure, the Health Literacy Management (HeLM) scale to make a dentally relevant scale; Health Literacy in Dentistry (HeLD).

OBJECTIVE

This study describes the development and assessment of the reliability and validity of the HeLD in an Indigenous Australian population.

DESIGN AND METHODS

The 29 item HeLD scale assesses the components of oral health literacy. The reliability and validity of the seven HeLD subscales were evaluated in a convenience sample of 209 Indigenous Australians with mean age 35 years (range 17-81) and of which 139 were female.

RESULTS

The scale was supported by exploratory factor analysis and established seven distinct and internally consistent domains of oral health literacy: Communication, Access, Receptivity, Understanding, Utilisation, Support and Economic Barriers (Cronbach's alpha = 0.91). Discriminative ability was confirmed by HeLD associations with socio-demographic variables and self-reported health ratings in the expected direction. The convergent validity and predictive validity were confirmed by HeLD scores being significantly associated with toothbrush ownership, use of a toothbrush, time since last dental visit and knowledge of the effect of cordial on the teeth.

CONCLUSIONS

The HeLD appears to be an internally valid and reliable instrument and can be used for measuring oral health literacy among rural Indigenous Australian adults.

Exploring the perceptions of success in an exercise referral scheme: a mixed method investigation

BACKGROUND

Exercise referral schemes feature as one of the prevalent primary care physical activity interventions in the United Kingdom, without extensive understanding of how those involved in providing and participating view success. The present research explores and reveals the constituents of "success," through comparison, contradiction, and integration of qualitative and quantitative research findings.

METHOD

A population-based cohort design formed the basis for a mixed method approach to the research. The quantitative component used a three-stage binary logistic regression to identify patient sociodemographic characteristics and referral reasons associated with three outcomes (n=1,315). The qualitative component (n=28) comprised four focus groups with patients (n=17), individual interviews with exercise providers (n=4), and referring health professionals (n=7). The research components were compared at discussion stage to offer insights into the concept of "success."

RESULTS

The integrated findings highlighted the multidimensional nature of the concept of success, containing a wide range of concepts such as empowerment, inclusion, and confidence. The traditional notions of success such as, attendance, weight loss, and blood pressure reduction featured amid a more holistic view which incorporated psychological and social aspects as both influences and outcomes.

CONCLUSION

These findings can enable future development of more representative evaluations of the benefits of exercise referral. This mixed methods research approach can facilitate the development of sophisticated, tailored, evidence-based interventions in the future.

Immunomodulatory effects of vitamin D: implications for GVHD

GVHD remains a major source of morbidity and mortality after allogeneic BMT. GVHD is mediated by alloreactive T cells derived from the hematopoietic graft that target host tissues. Pre-clinical models have shown that presentation of alloantigens by host DCs results in the activation of donor-derived T cells that mediate GVHD. Strategies that interfere with the Ag-presenting capacity of DCs after allogeneic transplantation may decrease the risk of developing GVHD. Vitamin D is a hormone essential for calcium metabolism that shows immunomodulatory properties. We showed that correction of vitamin D deficiency appeared to mitigate manifestations of GVHD. In pre-clinical studies, we have shown that vitamin D inhibits DC maturation, polarizes T-cell populations toward the expression of Th2 as compared with Th1 cytokines, and blunts allogeneic T-cell proliferation in response to DC stimulation. Exposure to vitamin D resulted in increased expression of IDO, an enzyme responsible for tryptophan metabolism that is upregulated in tolerizing DCs. These data suggest that exposure to vitamin D results in immature DC populations that bias toward tolerizing rather than stimulatory T-cell populations. Vitamin D may therefore have a role in the prevention of GVHD.

Factors associated with physical activity referral completion and health outcomes

Participant socio-demographic characteristics and referral reason were investigated in relation to completion and health outcomes in a Primary Care Physical Activity Referral Scheme using a prospective population-based longitudinal design. Participants (n = 1735) were recruited over a 2-year period. A three-stage binary logistic regression analysis identified the factors associated with the outcomes of completion (model 1), body mass reduction (model 2) and blood pressure reduction (model 3). Participant's age, gender, ethnicity, occupation and referral reason were the independent variables for model 1, with the variables of completion added in model 2 and completion and body mass reduction added in model 3. Logistic regression analysis revealed that increasing age is associated with the likelihood of completion (Odds Ratio, OR = 1.019; Confidence Interval, CI = 1.008-1.030; P = 0.001). Participants with a pulmonary condition are less likely to complete (OR = 0.546; CI = 0.346-0.860; P < 0.01) compared to those referred for cardiovascular conditions. For ethnicity, in comparison to the white category, patients in the mixed category are significantly more likely to achieve a reduction in body mass (OR = 3.991; CI = 1.191-13.373; P < 0.05). Those who complete are more likely to achieve a reduction in body mass (OR = 3.541; CI = 2.721-4.608; P < 0.001). When compared to the unemployed category, the skilled manual category had an increased likelihood of achieving a reduction in blood pressure (OR = 1.875; CI = 1.044-3.227; P < 0.05). Participants who completed also demonstrated an increased likelihood of a reduction in blood pressure (OR = 1.680; CI = 1.250-2.003; P < 0.001). Furthermore, those participants who achieved a reduction in body mass had an increased likelihood of achieving a reduction in blood pressure (OR = 1.292; CI = 1.008-1.641; P < 0.05). Completion is associated with health outcomes of reduced body mass and blood pressure.

The efficacy of a commercial ELISA as an alternative to virus neutralisation test for the detection of antibodies to EAV

Infection with equine arteritis virus is a notifiable disease with sporadic occurrence in the UK. As stallions may harbour the virus after infection, horses are screened for exposure by serological testing prior to breeding. The virus neutralisation test is considered the 'gold standard' serological screening test, but it is time-consuming and labour intensive; consequently there is a move towards more rapid screening methodology. In this study, a commercially available EVA antibody ELISA is assessed. The ELISA performed poorly with a specificity [corrected] of 26% and a sensitivity [corrected] of 96% in the samples analysed. It was concluded that this ELISA would be of little value for reducing sample turnaround time. The study emphasises the need for in-house validation of commercially available kits.

Reproduction and Captive Breeding as a Tool for Mammal Conservation: The Role of Modem Zoos

There is a growing awareness in the scientific research community of the role that zoological institutions can play in the conservation of threatened or endangered species. Zoos themselves have changed and become more focussed on the contributions they can make to regional conservation objectives, driven in part by the "World Zoo Conservation Strategy" published in 1993. Perth Zoo has committed itself to this strategy and established a collaborative scientific research program with Conservation and Land Management (CALM), WA, to develop captive breeding techniques for a number of Western Australian native species. To achieve this objective, the zoo has established a sub-program known as the Native Species Breeding Program. This consists of 6 specialist keepers who are charged with developing specialised skills in captive husbandry of selected species, and the implementation of research projects. All of the species under study are part of recovery plans, and many of the species are being produced for release under the objectives of those plans and as part of CALM&apos;s "Western Shield Project". Mammal species under study are the Numbat, Chuditch, Dibbler, Djoongari (Shark Bay Mouse) and the Wopilkara (Greater Stick Nest Rat). Currently, Chuditch, Numbats and Djoongari bred in captivity have been the subject of re-introduction programs. The results of these breeding programs and the subsequent releases of selected species into different habitats in Western Australia will be presented, along with a discussion of the issues which relate to the limitations of captive breeding as a conservation tool.

Growth and Sexual Dimorphism in the Dibbler, Parantechinus apicalis (Marsupialia, Dasyuridae)

Sexual dimorphism in animals has been recognised as being associated with particular breeding strategies or mating systems since Darwin&apos;s Origin of Species. Frequently, in polygamous situations, females express a variety of attributes to attract males, and males compete with each other for access to females. This produces different selective pressures in each sex, which in tum produces differing morphologies (Leigh 1995). Thus, the emphasis of morphological studies of sexual differences tends to focus on adults and not the growth patterns that generate those differences. Growth patterns in marsupials have been shown to be variable between species (Gemmell and Hendrikz 1993). Previous studies of dasyurid species in captivity concluded that the onset of dimorphism occurs prior to or during weaning (Whitford, Fanning and White 1982; Williams and Williams 1982), but wild animals are not sexually dimorphic until after weaning (Soderquist 1995). These studies have generally examined the growth rates of males and females and the timing of the onset of sexual dimorphism, but little attention has been focussed on how the differences between the sexes are generated.

Implementing the Agency for Health Care Policy and Research pain management pediatric guideline in a multicultural practice setting

This article describes the implementation, monitoring, and evaluation of a clinical practice guideline for managing pediatric patient pain. The standard of care used was the Agency for Health Care Policy and Research acute pain management guideline. It was used to assess current levels of care and to make recommendations for improvements. Information was gathered from a sample of 240 pediatric patients aged 1 week to 14 years. Recommendations for improving care are given. The guideline was found to be clinically useful as a general standard of care, but more work needs to be done to individualize care for specific populations, age groups, and cultures.