The SelfSTarT intervention for low back pain patients presenting to first contact physiotherapists: A mixed methods service evaluation

INTRODUCTION

Globally, back pain is the leading cause of years of disability. In the United Kingdom, over 20 million people live with musculoskeletal (MSK) pain, with low back pain being one of the most common causes. National strategies promote self-management and the use of digital technologies to empower populations.

AIMS

To evaluate the uptake and impact of providing the SelfSTart approach (STarT Back and SelfBACK App) when delivered by a First Contact Physiotherapist (FCP) to people presenting with low back pain in primary care.

METHODS

Patients presenting with a new episode of low back pain underwent routine assessment and completion of a STarT Back questionnaire. Patients with low/medium scores were offered the SelfBACK App. A control population was provided by the MIDAS-GP study. Patient Experience, outcome measures, healthcare utilisation and retention were captured through the app and clinical systems (EMIS). Interviews with five FCPs explored the experiences of using the SelfSTart approach.

RESULTS

SelfSTarT was taken up by almost half (48%) of those to whom it was offered. Compared to MIDAS-GP, users were more likely to be younger, male, in work, and with higher health literacy. SelfSTarT users reported significant improved experiences relating to receiving an agreed care plan and receiving sufficient information. There were no significant differences in treatments offered. FCPs were positive about the app and felt it had value but wanted feedback on patient progress. They recognised that a digital solution would not be suitable for all.

CONCLUSION

This approach offers an opportunity to empower and support self-management, using robustly evaluated digital technology.

University-industry collaboration as a driver of digital transformation: Types, benefits and enablers

University-Industry collaboration as a driver of digital transformation ultimately depends on the engagement and relationship between individual academics and industry practitioners as partners in a trust relationship. This paper describes the personal ('lived') experiences of academics and industry practitioners. The types, benefits, and enablers of the collaboration were investigated during semi-structured face-to-face interviews with industry partners and academic staff from the Science, Technology, Engineering and Mathematics (STEM) unit at the University of Enterprise in Australia. The types of collaboration included research activities, sharing facilities and equipment, innovation and commercialisation, collaboration involving students projects, collaborative teaching and learning, and sharing facilities and equipment. The benefits of the collaboration include access to valuable resources, validation of work, learning and teaching opportunities, financial benefits, improved reputation and career progression. The enablers of collaboration have been clustered into institutional, output, framework, and relationship factors. In this paper we focus on relationship factors and institutional enablers such as stakeholder engagement. The research is represented in a UA-IP Collaboration Model indicating the types (what), benefits (why), and enablers (how) of academic-practitioner collaboration. Universities and businesses from a variety of industries can benefit from the results of the presented research.

522 Early Follow-Up Quality of Life and Mental Health of Patients with Congenital Vascular Malformations Cared for in a Multi-Disciplinary Specialist Center

Aim

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist center

Method

This was a prospective observational study. All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between February 1st 2018 and January 31st 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. P<0.05 were considered significant.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolo-sclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusions

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

518 Efficacy and Safety of Embolo-Sclerotherapy of Low-Flow Vascular Malformations Based on the Experience from a Single Specialist Centre

Aim

To evaluate the efficacy and safety of embolo-sclerotherapy (EST) of low-flow vascular malformations (LFVM) in a specialist vascular anomalies centre.

Method

All patients with LFVM who underwent EST from 01 January 2015–31 December 2019 were retrospectively reviewed. All ESTs were performed with foam STS 3%, ethanol, coils and/or other substances e.g., triamcinolone. LFVMs were grouped according to Puig's classification. The outcome measures were treatment effects and complications. Continuous variables were compared using analysis of variance (ANOVA) F test. Other discrete variables were compared using Chi-squared tests. P<0.05 were considered significant.

Results

A total of 207 patients, with a mean age of 32 years (range 1–71 years) were included. The use of EST with foam STS was significantly lower for type I LFVM (61.8%) compared to others (p<0.001). However, significantly higher type I LFVM (26.5%) were treated with surgery than EST (p<0.001). Overall, outcome categories were significantly different across all types of LFVM (p<0.001), with more discharges for Type I (52.9%) LFVMs but more failure to follow-up in patients with Type II (24.5%) LFVM. EST complications was significantly higher with type I (14.7%) LFVMs (p=0.030). The doses of STS in the first procedure were significantly different across all types of LFVM (p<0.001) with most type I LFVM patients receiving ≤2ml.

Conclusions

EST particularly with foam sclerotherapy is clinically effective and safe for patients with LFVM especially in those with Puig's type I and II lesions. This classification may provide an important guide to volume of sclerosant required and the potential success rate.

O064 Early follow-up quality of life and mental health of patients with congenital vascular malformations cared for in a multi-disciplinary specialist center

Introduction

To evaluate the early follow-up quality of life (QoL), pain and mental health of patients with congenital vascular malformation (CVM) receiving care by a single multi-disciplinary specialist centre

Methods

All patients with CVM who received care (supportive treatment only, open surgery, targeted pharmacological therapy, embolosclerotherapy), and had follow-up, between 1 February 2018 and 31 January 2020 were included. The health-related QoL, pain, and mental health were assessed with validated questionnaires: SF-36, VAS-P and HADS. The CVM were categorized into types – low-flow (LFVM) and high-flow (HFVM), and anatomical locations. Paired t-test was used for all analyses. Differences were considered significant at P<0.05.

Results

110 patients (85 LFVM and 25 HFVM) with a mean age of 36.9 years were included. Significant improvement was found in the bodily pain domain of SF-36 and VAS-P (both P = 0.01) in all patients. However, only patients with HFVM reported significant improvement in the bodily pain domain of SF-36 (P=0.002) and VAS-P (P = 0.02). Patients who received supportive treatment only reported significant improvement in mental health (P=0.004) and social functioning (P=0.03) domains of SF-36. Meanwhile, patients treated with embolosclerotherapy reported significant improvement only in VAS-P (P=0.02). Patients who received targeted pharmacological therapy reported no significant early changes.

Conclusion

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Take-home message

The effects of care on early follow-up QoL, pain and mental health of patients with CVM were heterogenous. Future research is required to understand the various factors that affect the QoL and mental health of these patients, as well as the holistic approaches to manage them.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

A reassessment of TBT action levels for determining the fate of dredged sediments in the United Kingdom

As part of reviewing the United Kingdom (UK) action levels (ALs) of contaminants for managing the disposal of dredged marine sediment material, tributyl tin (TBT) has been reassessed. TBT is a banned biocide capable of causing severe harm to the marine environment. Its presence is routinely screened for prior to marine disposal of dredged sediment material. Dredged sediment TBT concentrations have been studied using UK monitoring data obtained between 2000 and 2018. The changes in these TBT concentrations have guided the reassessment of ALs. Recent toxicity studies have also guided the reassessment of TBT ALs. This study, which itself forms part of a larger review by the Department for Environment, Food and Rural Affairs, has concluded that current UK TBT ALs may no longer be fit for purpose. A more environmentally protective approach for controlling release of TBT into the marine environment is recommended.

Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands

Physician assisted death (PAD) for patients with a psychiatric disorder is a controversial topic of increasing relevance, since a growing number of countries are allowing it. General requirements for PAD include that patients possess decision-making capacity to decide on PAD and that their suffering is unbearable and irremediable. In the Netherlands PAD has been eligible for patients with psychiatric disorders since the 1990s, making it one of the few countries that can offer insights on the practice from real life experience. Much of the literature describing these experiences is only available in Dutch. This article aims to make this knowledge more widely available and provide a comprehensive overview of the experience with PAD for psychiatric suffering in the Netherlands. First, the history of PAD for patients suffering from a psychiatric disorder is described. Second, an overview of relevant rules and regulations governing the practice is given. Third, an overview is provided of the scarce epidemiological data. Finally, we will discuss two major clinical challenges; establishing irremediability and decision-making capacity.

875 Using Stress Testing to Identify Vulnerabilities in Artificial Intelligence Models for the Identification of Culprit Carotid Lesions in Cerebrovascular Events

Introduction

Carotid atherosclerosis is a major risk factor for ischaemic stroke, a leading cause of death. Carotid CT angiography (CTA) is commonly performed following a stroke or transient ischaemic attack (TIA) to help guide patient management in secondary prevention of stroke. Deep learning algorithms can help extract greater information from scans.

Method

The dataset comprised CTA scans from 40 culprit and 40 non-culprit carotid arteries of patients with recent stroke/TIA, and 40 carotid arteries of asymptomatic patients without previous stroke/TIA. A 3D convolutional neural network was trained to classify carotid artery type. Each input comprised 14 axial CTA carotid patches (centred around the carotid artery) concatenated together to form a 3D volume (capturing ∼3cm of artery). 75% of the dataset was used for training and 25% for internal validation. Following training, computer vision operations were applied to input images to assess their impact on the model’s classification decisions.

Results

The model achieved 100% accuracy on the training set and 67% on the internal validation set. However, after subjecting input images to image operations, vulnerabilities in the deep learning model were revealed, even when using input images from the training set. For example, using a Gaussian blur filter with sigma 1.0 was sufficient to change classification decisions, as was horizontally flipping the image.

Conclusions

Deep learning has exceptional capabilities for learning, however the risk with such high-capacity models is failure to learn relevant features from the data. Stress testing provides a viable method to further evaluate deep learning models before clinical deployment.

The experience of using prompting technology from the perspective of people with Dementia and their primary carers

OBJECTIVES

People who are living with dementia typically experience difficulties in completing multi-step, everyday tasks. However, digital technology such as touchscreen tablets provide a means of delivering concise personalised prompts that combine audio, text and pictures. This study was one component of a broader, mixed methods study that tested how an application (app) -based prompter running on a touchscreen tablet computer could support everyday activities in individuals with mild to moderate dementia. In this study we set out to understand the experiences of people living with dementia and their primary carer in using the prompter over a four-week period.

METHOD

We collected qualitative data using semi-structured interviews from 26 dyads, composed of a person living with dementia and their carer. Dyads were interviewed at the start and end of this period. Transcripts were then analysed using thematic analysis.

RESULTS

The study identified three overarching themes related to: participants' attitudes towards the technology; their judgements about how useful the prompter would be; and the emotional impact of using it.

CONCLUSION

Consistent with the Technology Acceptance Model, carers and participants were influenced by their approaches to technology and determined the usefulness of the prompter according to whether it worked for them and fitted into their routines. In addition, participants' decisions about using the prompter were also determined by the extent to which doing so would impact on their self-identity.

Environmental sustainability disclosures in annual reports of mining companies listed on the Australian Stock Exchange (ASX)

Mining companies use environmental sustainability reporting to inform their stakeholders about their position in relation to environmental sustainability. This paper explores how these companies include topics related to the environment and its protection in their annual reports. The 100 largest mining companies listed on the Australian Stock Exchange (ASX) were included in the research sample, using market capitalisation as the size indicator. The investigation was performed by means of quantitative and qualitative content analysis of annual reports to identify relevant keyword occurrences. Results revealed that topics related to protection of the environment, emissions, carbon footprint, and climate change are addressed in companies’ annual reports. In line with research in other industries, this study confirmed that the intensity of communication about these topics varies with company size. A new methodology was developed to assess the extent to which mining companies inform the stakeholders about their environmental protection initiatives and to address the limited applicability of the GRI G3 disclosure checklist for sustainability reporting, thereby enhancing the theory of social licence to operate.

Communicating knowledge-focus through websites of higher education institutions

Although higher education institutions (HEIs) are expected to be the leaders in knowledge generation and dissemination, it is often not clear whether they are knowledge-aware, that is, have a knowledge focus. In this article, the communication with stakeholders through HEI websites is examined to determine to what extent these institutions communicate about their knowledge initiatives and projects. This is done through an investigative study involving all HEIs and their faculties in Slovakia. Using content analysis, the study examines whether the publicly available resources on HEIs’ websites contain knowledge-related keywords, indicating the existence of a knowledge-focus. The results reveal that the websites of some HEIs contain hundreds of these resources, whereas others have none. Statistical evidence confirms that the intensity of communication about knowledge terms increases with the age and size of the HEI and is also dependent on the type of HEI (public, private state, foreign). Other dependencies between the examined factors have also been revealed, for example, HEIs that rank higher in Webometrics indicators are more intensive in their knowledge communications.

O75: SINGLE CENTRE EXPERIENCE OF SIROLIMUS THERAPY IN HEAD AND NECK VASCULAR MALFORMATIONS

Introduction

To assess the efficacy and safety of Sirolimus in the treatment of low-flow head and neck (H&N) vascular malformations

Method

Patients who presented to our tertiary referral clinic were assessed for eligibility. Suitable patients were commenced on Sirolimus at 0.8 mg/m2, administered orally twice daily, which was approved by our trust Drug and Therapeutic Committee. Patients were reviewed on a monthly basis for a total of six months with an additional one-month review to check for effects upon ceasing treatment. Efficacy and safety were measured through functional and radiological response, laboratory investigations and quality of life questionnaire (36-Item Short Form Health Survey (SF-36), Hospital Anxiety and Depression Scale (HADS) and Visual Analogue Score for Pain (VAS-P)).

Result

Seven patients (mean age 39 years, range 23-65 years) were recruited. One patient did not complete treatment due to intolerable side effects. All patients had a partial response with no patients showing disease progression or complete response. All post-treatment MRI scans showed stable disease with five patients demonstrating a decrease in lesion volume. Five patients reported return of symptoms at one-month post review upon discontinuation of treatment. No statistical significance (P>0.05) in all eight domains of SF-36, HADS, VAS-P and radiological vascular lesion volume between pre- and post-treatment. Most common reported side effects were mouth ulcers (n=2) and metabolic/laboratory abnormality (n=2)

Conclusion

Sirolimus is an effective and safe treatment for patients with complicated low-flow H&N vascular malformations. This provides an alternative treatment where interventional therapy is considered to be limited or challenging.

Take-home message

Sirolimus is an effective and safe treatment option for patients with complicated low-flow head and neck vascular malformations where interventional therapy is limited or challenging.

Reaching out to stakeholders: The use of knowledge terminology on the websites of Australian public hospitals

Background

The objective of the study described in this article was to examine whether, and to what extent, Australian public hospitals use knowledge terminology, i.e. a body of knowledge-related terms, on their websites. The paper also discusses the difference in the level of such communication between large and small hospitals, the factors affecting the use of the knowledge-related terms in the communication and the similarities/differences between the use of knowledge terms in Australian public hospitals and large/small companies in Australia.

Methods

151 Australian public hospitals were included in the research sample: 51 large and 100 small hospitals. Using the method of content analysis, websites mentioning knowledge creation, knowledge sharing, knowledge implementation, and knowledge retention were identified, along with the number of these mentions. Descriptive statistics and chi square test of independence were used to provide answers to four research questions.

Results

Of the 151 hospitals included in the sample, 30 had no website and 62 (50 small and 12 large) had a single page website. The study found that there are differences between Australian public hospitals regarding the level of their knowledge communication on their websites, both between small and large hospitals and between the individual hospitals within the large and small hospital groups.

Conclusions

A well-known saying goes “For the mouth speaks what the heart is full of”. Effective communication of knowledge-related terminologies to both internal and external stakeholders, i.e. the parties who access the websites, is therefore an indication of a knowledge focus in the public hospitals. Large hospitals are generally more active in communicating knowledge terms, although there are some exceptions. Some of the small hospitals can lead by example, but most of them do not include knowledge terminology in their communication on websites.

The transcription factor scleraxis differentially regulates gene expression in tenocytes isolated at different developmental stages

The transcription factor scleraxis (SCX) is expressed throughout tendon development and plays a key role in directing tendon wound healing. However, little is known regarding its role in fetal or young postnatal tendons, stages in development that are known for their enhanced regenerative capabilities. Here we used RNA-sequencing to compare the transcriptome of adult and fetal tenocytes following SCX knockdown. SCX knockdown had a larger effect on gene expression in fetal tenocytes, affecting 477 genes in comparison to the 183 genes affected in adult tenocytes, indicating that scleraxis-dependent processes may differ in these two developmental stages. Gene ontology, network and pathway analysis revealed an overrepresentation of extracellular matrix (ECM) remodelling processes within both comparisons. These included several matrix metalloproteinases, proteoglycans and collagens, some of which were also investigated in SCX knockdown tenocytes from young postnatal foals. Using chromatin immunoprecipitation, we also identified novel genes that SCX differentially interacts with in adult and fetal tenocytes. These results indicate a role for SCX in modulating ECM synthesis and breakdown and provide a useful dataset for further study into SCX gene regulation.

PARE0018 WEBSITE FOR PARENTS OF CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS REDUCES PARENTING STRESS

Background:

Having a child with JIA presents many challenges. Many parents experience considerable stress. Parental distress and functioning have been found to be related to child outcomes (Cousino, 2013), therefore interventions that help parents to manage their child’s illness are important for both parents and child. We developed a website for parents of children with newly diagnosed JIA to help increase parental confidence in managing their child’s arthritis and reduce parenting stress.

Objectives:

To evaluate the efficacy of a web-based tool ‘WebParC’ for parents of children with JIA.

Methods:

Design:Multi-centre randomised controlled trial conducted in 16 tertiary paediatric rheumatology centres in England.

Participants:Parent(s) of children aged ≤12 years, diagnosed with JIA within the previous six months.

Procedures:Parents were enrolled when they attended the rheumatology service and were randomised by household to either the intervention arm (I) who were given access to the website in addition to their child’s standard care or the control arm (C) who received standard care alone.

The primary outcome was parenting stress, measured with the Pediatric Inventory for Parents (PIP) (Streisand, 2001), which parents completed prior to randomisation and at 4-months and 12-months post randomisation.

Website content was developed by a multidisciplinary team including rheumatology, physiotherapy, ophthalmology, social work, podiatry, occupational therapy, clinical and health psychology along with parents of children with JIA. It includes information about JIA and its treatment plus a ‘toolkit’ for parents. The toolkit is based on cognitive-behavioural principles to develop skills for managing JIA-related issues.

Analysis:We conducted linear mixed models to examine the main effect of trial arm (I vs C), main effect of time (between 4M and 12M scores), and interaction between trial arm and time on PIP scores, after controlling for baseline scores.

Results:

A total of 220 parents (183 mothers, 37 fathers) of 203 children were randomised, 106 intervention and 114 controls. Parents mean (SD) age was 36.5 (6.5). Their children with JIA were mostly female (137/203, 67.5%), mean (SD) age of 6.1 (3.4) years. There were 107 (52.7%) with oligoarthritis, 65 (32%) polyarthritis, 8 (3.9%) systemic and 23 (11.3%) other JIA subtypes. Seventy (34.5%) were prescribed methotrexate.

Trial arms did not differ significantly at baseline except for parent education, which was higher in the intervention group and was controlled for in the analysis.

Follow-up assessments were completed by 133 (I60, C73) at 4M and 124 (I58, C66) at 12M.

We found significant main effects of trial arm on PIP Difficulty (p=0.022, Control (Mean=93.62, SE=2.717) > Intervention (Mean=84.23, SE=3.025)) and PIP Frequency (p= 0.008, Control (Mean=95.78, SE=2.400) > Intervention (Mean=86.23, SE=2.622), with Controls reporting significantly greater frequency and difficulty of stressful events than the Intervention group (Fig 1).

Conclusion:

This trial found that a website for parents of children with JIA can help to reduce parenting stress.

References:

[1]Cousino MK, Hazen RA. J Pediatr Psychol 2013; 38(8):809-28

[2]Streisand R, Braniecki S, Tercyak KP, Kazak AE. J Pediatr Psychol 2001; 26(3):155-62.

Acknowledgments:

We thank all parent participants, the health professionals and parents who developed website content and the clinical teams who supported recruitment.

Funded by NIHR RfPB.

Disclosure of Interests:

Kathleen Mulligan: None declared, Shashivadan Hirani: None declared, Sally Clarke: None declared, Neil Evans: None declared, Chris Flood: None declared, Jo Taylor: None declared, Lucy Wedderburn Speakers bureau: Pfizer, Stanton Newman Grant/research support from: Yes Baxter Healthcare Educational Grants not in relation to rheumatology, Speakers bureau: Yes Baxter Healthcare and Merke Sharp and Dome

A preliminary evaluation of a client-centred prompting tool for supporting everyday activities in individuals with mild to moderate levels of cognitive impairment due to dementia

Objectives

Technology-based prompting has the potential to support people with dementia to complete multistep tasks in the home. However, these devices can be complex to use. This paper reports a feasibility trial of a personalised touchscreen digital prompter designed for home use.

Methodology: A tablet-based prompter suitable for people living with dementia was developed, along with a detailed guidance manual. Carers loaded instructions for completing the task onto the prompter, and the person with dementia then used the tablet independently to complete a task. Eleven couples used the prompter ‘out-of-the-box’ with no support other than a guidance manual.

Results

The majority of participants with dementia could follow the steps on the prompter, and carers were able to breakdown and load tasks onto the prompter. Eight couples used the prompter successfully to complete goals that they had identified in advance. These included preparing simple snacks and using a TV remote control. Successfully achieving goals was associated with more frequent use of the prompting screen on more days, but not higher levels of editing or previewing of tasks.

Conclusion

The study provides the preliminary evidence that family caregivers can use a touchscreen tablet, software and manual package to identify specific tasks and break these down into steps and that people living with dementia can then follow the prompts to complete the tasks. This potentially represents an important advance in dementia care. Further testing is required to establish efficacy and to identify any factors that impact on outcomes.

Developing a decision-making dependency (DMD) model for nurse managers

Decision making is an inherent, complex and vital component of the work of managers. Its importance and role in operationalizing the activities of an organisation are well-evidenced in management literature. Yet, there is a dearth of literature about the processes used by nurse managers to make decisions. The principal aim of this paper is to identify the different types of decisions made by nurse managers and explore the related decision-making processes. A ‘dependency model’ is proposed, which illustrates the factors affecting the art of decision making. Structured interviews were conducted to identify types of decisions made by nurse managers in different health-care settings and the factors underpinning these decisions. The research focused on an intensive study of a small group of nurse managers working in rural and regional health institutions in South Australia. The sample included nurse unit managers, after-hours coordinators and directors of nursing. Hermeneutic principles and interpretive research were used to conduct interviews with nurse managers who make numerous and varied types of decisions, though often without following a step-by-step approach. The study identified dependency factors that influence how decisions are made, and developed a model based on eight key variables: (1) the situation to be addressed; (2) the time period in which the decision has to be made; (3) required inputs from colleagues; (4) complexity of the task and the environment, (5) the duration and time it takes to make a decision, (6) availability of resources, (7) the decision-making environment, and (8) personal characteristics. These eight variables are interrelated and have both direct and indirect impacts on how decisions are made. Nurse managers make pragmatic decisions reflecting the complexity of their roles and responsibilities. Awareness of the factors on which decisions depend helps understanding of how they navigate through decision-making processes. The findings are presented as a model that can be used to support decision making by nurse managers in various health settings.

An exploration of the experience of using calendar reminders for people with dementia and family carers

People with dementia and family carers often use calendars to support time orientation to maintain routine. However, little is known about the use of calendars as a compensatory strategy. This study examines the experience and practicalities of using calendar reminders from the perspective of people with dementia and family carers. Six dyads were recruited and interviewed at home. Interpretative Phenomenological Analysis was used to develop a narrative interpreted from an occupational therapy perspective. The themes were reflected on during two subsequent focus groups. Findings suggested that calendars are used either intensively as external memory records or more casually and randomly for reassurance. The familiarity and location of the calendar and its utility to the person with dementia and carer, all contribute to its efficacy. For carers the experience of supporting calendar reminders encompasses practical, cognitive and emotional effort. There was little awareness amongst participants of electronic assistive technology.

Home Testing of a Digital Prompter for People with Dementia

This technology evaluation study assessed a personalised digital prompter designed for people with dementia, by trialling its use in the home by people with dementia and their carers. Technology based prompting may be used to support people with dementia to complete multi-step tasks in the home, provided that suitable tasks can be chosen and that a carer is able to load appropriate task steps onto the prompter. A prompter was developed specifically for this purpose, along with a detailed guidance manual. Twelve participants with mild or moderate dementia carried out cognitive tests and their carers completed carer burden and carer competence scales. Each pair attended a training session with a researcher and were provided with the prompter and instruction manual. The prompter was trialled at home for four weeks after a one-week familiarisation period, for use with a simple set task and one or two tasks chosen by the participants. Semi-structured interviews were used to capture the views of the participants at the start and end of the home testing, and to set and evaluate goals. Chosen tasks included preparing simple food and drinks, and using home appliances including coffee machines and television remote controls. There was a weak correlation between greater goal success for the participants and the carer goal success, number letter switching within the D-KEFS and ACE-III score. A thematic analysis of the interviews revealed three core themes relating to familiarity with technology, utility of the prompter and the cost versus benefit in terms of the effort required to set up the prompter. Factors influencing success could be grouped into: participants' motivation and capability; the design of the prompter; and the details of the task being carried out. Barriers to success included the difficulty of choosing a suitable task and the effort required to break down a task in to appropriate steps. All of the participants with dementia could follow the steps on the prompter, and all of the carers were able to choose, breakdown and load at least one task onto the prompter during the training session, but successful use in the home was varied because of the increased complexity of the home context. Changes to the hardware, software and manual were made in response to the data gathered during the study, in readiness for the planned further testing.

Equipment: Is it the Answer? An Audit of Equipment Provision

The provision of equipment and adaptations is a major part of the social services occupational therapist's role and is, therefore, an area that needs investigation to ensure that assessed needs are being met effectively and cost-efficiently. This study was an audit that investigated the longer-term usefulness of equipment and adaptations, provided by social services occupational therapists, in enabling service users to perform daily living tasks. The focus of the audit was whether the service users were still using the equipment and/or adaptations provided, and how useful they were finding them, 18 months to 2 years after provision.

This was a retrospective audit of a random sample of 100 service users during a specified time scale, using a telephone survey for data collection. Fifty-seven telephone questionnaires were completed.

The clearest finding was that the majority (83%) of the equipment and adaptations issued between 18 months and 2 years previously were still being used at the time of this audit, with 69% being used on a daily basis. This suggested that the equipment and adaptations provided were being used as an integral part of daily life and that they had been prescribed appropriately. It was also interesting to note that the satisfaction with the equipment and adaptations being used independently was higher than the satisfaction with the equipment and adaptations used with help from others.

Conclusion

The audit found that 83% of the equipment and adaptations were still being used 18 months after provision, which suggests accurate and appropriate prescription by the occupational therapy service. Small low-cost items, such as grab rails, were seen by the service users to be very useful in helping them to perform activities of daily living, frequently on their own. The audit suggests that people rate equipment or an adaptation as more useful if they are able to use it alone. This link between independent use and satisfaction is an area for further study, because it suggests that equipment can be very important to a person's sense of independence and wellbeing in the community.

The reasons for non-use of equipment were mainly changes in functional ability or personal circumstances, not poor instruction or fitting. This suggests a more appropriate assessment process or more suitable equipment being issued than in the studies reviewed by Mountain (2000).

There was a very high proportion of respondents who would recommend the occupational therapy service to others with similar difficulties; however, most needed prompting to remember that it was occupational therapy staff who had provided the equipment and/or adaptations. Even when prompted, they could remember the staff member but not the name of the service; publicity and clearer information provided to service users at the point of contact may resolve this issue.

Recommendations

Further study is needed to provide more evidence that the provision of equipment and/or adaptations can be effective in enabling independent living in the community. The expertise of community occupational therapists in enabling people to perform daily living tasks is not widely recognised because there has been little or no research in this specialist field. The process of issuing equipment follows a holistic assessment and a practical step-by-step analysis of the problems identified by users and carers. It continues with training and support to use the equipment, with constant re-evaluation of the whole process.

It is interesting to note that although there was a high level of satisfaction with the service provided, there was a lack of clarity over who had provided it. This suggests that more signposting is needed to help service users and the general public to identify occupational therapy as a profession working within social services.

Following on from this audit, there will be a review of systems to ensure that service users and carers are competent in using the equipment issued to them and are aware of how to contact the service if reassessment, repair or return of equipment is needed. This will complement the standard equipment review systems and ensure that as much unused equipment as possible is recovered for recycling. More investigation is also needed to find out how service users are using the equipment and adaptations: are they following the instructions and using them safely? There is some anecdotal evidence that whilst a service user may be using a piece of equipment to perform daily living tasks, this might not be in the manner intended by the manufacturer or demonstrated by occupational therapy staff.

It would be invaluable to introduce a standardised outcome measure for social services occupational therapy staff to use with all service users. Heaton and Bamford (2001) stated that outcomes are increasingly important in the current policy context, with emphasis on quality, national standards, best value and evidence-based practice. If information could be routinely collected and analysed, it would provide continual statistical data to ensure a strong evidence base to the service. The appraisal of existing outcome measures and their suitability to be used as a tool for community occupational therapy will be a continuing task for the service.

A future audit using the same methodology would enable performance to be measured and reviewed again, ensuring that standards are maintained, and would ascertain whether improvements in service provision have been achieved. The results of this and subsequent audits are vital to ensure that the occupational therapy service meets the challenge of using evidence to underpin practice.

Who's Carrying the Baby?

Parents who are wheelchair users face the practical problem of manoeuvring a wheelchair at the same time as pushing a pushchair. The Bath Institute of Medical Engineering (BIME) has designed a pushchair to attach to a manual wheelchair. This paper describes the rationale behind the project and how disabled parents have been integral to the design process. The process and findings of the evaluation programme are reported.

Evaluation is important to designers to understand the outcomes of their work. ‘It's as simple as needing to know whether assistive technology works’ (Smith 1998, p20). This process also provides insights to occupational therapists to guide them in their professional judgements about whether an equipment solution can meet user requirements.

Personal message cards: An evaluation of an alternative method of delivering simulated presence therapy

Simulated presence therapy is a technique which utilises a familiar recorded voice to calm and reassure people with dementia who are agitated or anxious. Although simulated presence therapy has shown potential benefits in small-scale studies, practical limitations in making and playing the recordings have restricted its use. An alternative method of delivering a message from an attachment figure is through a personal message card. This was one of seven products used within the Bath Memory Technology Library which was made available free of charge to people affected by dementia and their carers. This paper provides an evaluation of the personal message cards. Although feedback was received on only 10 of the 24 cards that were distributed, for nine people there was evidence that the cards met the goals that had been set either fully or in part, and that people affected by even quite severe levels of dementia could benefit from them.

Disrupted seasonal biology impacts health, food security and ecosystems

The rhythm of life on earth is shaped by seasonal changes in the environment. Plants and animals show profound annual cycles in physiology, health, morphology, behaviour and demography in response to environmental cues. Seasonal biology impacts ecosystems and agriculture, with consequences for humans and biodiversity. Human populations show robust annual rhythms in health and well-being, and the birth month can have lasting effects that persist throughout life. This review emphasizes the need for a better understanding of seasonal biology against the backdrop of its rapidly progressing disruption through climate change, human lifestyles and other anthropogenic impact. Climate change is modifying annual rhythms to which numerous organisms have adapted, with potential consequences for industries relating to health, ecosystems and food security. Disconcertingly, human lifestyles under artificial conditions of eternal summer provide the most extreme example for disconnect from natural seasons, making humans vulnerable to increased morbidity and mortality. In this review, we introduce scenarios of seasonal disruption, highlight key aspects of seasonal biology and summarize from biomedical, anthropological, veterinary, agricultural and environmental perspectives the recent evidence for seasonal desynchronization between environmental factors and internal rhythms. Because annual rhythms are pervasive across biological systems, they provide a common framework for trans-disciplinary research.

Systems Pharmacology Approach for Prediction of Pulmonary and Systemic Pharmacokinetics and Receptor Occupancy of Inhaled Drugs

Pulmonary drug disposition after inhalation is complex involving mechanisms, such as regional drug deposition, dissolution, and mucociliary clearance. This study aimed to develop a systems pharmacology approach to mechanistically describe lung disposition in rats and thereby provide an integrated understanding of the system. When drug‐ and formulation‐specific properties for the poorly soluble drug fluticasone propionate were fed into the model, it proved predictive of the pharmacokinetics and receptor occupancy after intravenous administration and nose‐only inhalation. As the model clearly distinguishes among drug‐specific, formulation‐specific, and system‐specific properties, it was possible to identify key determinants of pulmonary selectivity of receptor occupancy of inhaled drugs: slow particle dissolution and slow drug‐receptor dissociation. Hence, it enables assessment of factors for lung targeting, including molecular properties, formulation, as well as the physiology of the animal species, thereby providing a general framework for rational drug design and facilitated translation of lung targeting from animal to man.

Admission blood glucose helps predict 1 year, but not 2 years, mortality in an unselected cohort of acute general medical admissions

AIM

We previously showed that hyperglycaemia in newly hospitalised medical inpatients is associated with longer length of hospital stay, higher 28-day readmission rates and increased 28-day mortality. We aimed to assess whether a single blood glucose measurement taken at the time of admission could help to predict 1 and 2 years mortality.

METHODS

We retrospectively reviewed data from all 1502 patients admitted to our Acute Medical Unit during February 2010.

RESULTS

By using a blood glucose range of 6.5-7.0 mmol/l as the comparator, an admission blood glucose between 9.1 and 20 mmol/l was associated with an increased risk of death at 1 year (p < 0.05). In addition, those people with admission glucose readings of < 6.5 mmol/l showed a strong trend towards a higher mortality (p = 0.053) at 1 year.

CONCLUSION

Thus admission blood glucose can be used to help predict the risk of 1 year mortality in an unselected cohort of general medical admissions.

Deterrents to knowledge-sharing in the pharmaceutical industry: a case study

Purpose

– This study aims to explore deterrents to knowledge-sharing in pharmaceutical manufacturing. Effective knowledge-sharing is fundamental to stimulation of the process of knowledge absorption. The limited proximal communication between the employees in the pharmaceutical industry stifles their knowledge-sharing behaviour significantly.

Design/methodology/approach

– A cross-sectional case study, consisting of semi-structured interviews with managers and scientists, was conducted in a multinational pharmaceutical company in Australia. Respondents were asked to answer questions regarding their current knowledge-sharing practices and to identify organisational deterrents to knowledge-sharing. The data were condensed into themes according to the thematic analysis method.

Findings

– The pharmaceutical industry is extensively regulated and its excessive competitiveness is cultivating organisational reticence towards the development of a knowledge-sharing culture. Nine categories of deterrents to intra- (within) and inter-organisational (between organisations) knowledge-sharing have been identified. These categories include high cost of sharing knowledge, information technology limitations, knowledge-hiding, lack of socialisation, lack of trust culture, non-educational mindset, organisational politics, poor leadership and time pressure.

Research limitations/implications

– The population of this study consists of managers and practitioners working for a pharmaceutical company. Hence, the generalisability of the findings to other health-care settings is unknown.

Practical implications

– The findings have implications for leaders and managers who should be aware of these professional diversities, instigators as well as the ripple effects of limited knowledge-sharing to guide the organisation towards developing an optimal knowledge-sharing culture.

Originality/value

– A focussed investigation of knowledge-sharing behaviour within the pharmaceutical industry in Australia, considering the pressure applied to this industry over the past decade. This case study specifically focusses on the diversity of deterrents to knowledge-sharing in the pharmaceutical manufacturing industry.

Tumours and tumour mimics in the olecranon

Lesions in the olecranon are rare and may be identified during the investigation of a clinically suspected abnormality or as an incidental finding. This review describes the spectrum of tumours and tumour-like lesions that can involve the olecranon and illustrates the radiographic, CT, and MRI appearances that may facilitate diagnosis. A variety of pathological processes affecting the olecranon are presented and discussed including the epidemiology and imaging features.

Modeling and Simulation Approaches for Cardiovascular Function and Their Role in Safety Assessment

Systems pharmacology modeling and pharmacokinetic-pharmacodynamic (PK/PD) analysis of drug-induced effects on cardiovascular (CV) function plays a crucial role in understanding the safety risk of new drugs. The aim of this review is to outline the current modeling and simulation (M&S) approaches to describe and translate drug-induced CV effects, with an emphasis on how this impacts drug safety assessment. Current limitations are highlighted and recommendations are made for future effort in this vital area of drug research.