The experiences and impact of the COVID-19 pandemic on young carers: practice implications and planning for future health emergencies

BACKGROUND

Young carers are children or young people aged up to 25 years old who undertake unpaid caring responsibilities for a friend or family member. Young carers faced significant challenges brought on by the COVID-19 pandemic. We explored the impact of the pandemic and associated restrictions on mental health, wellbeing and access to support in young carers in the United Kingdom (UK) to understand how to improve services, as well as support this population in future health emergencies.

METHOD

We conducted 22 qualitative semi-structured interviews from May to November 2021 with 14 young carers and eight staff working in organisations that supported them. Interviews took place remotely over video or telephone call and explored participant experiences of the pandemic and its impact on their health, wellbeing and caring responsibilities. We used reflexive thematic analysis to analyse interview transcripts.

RESULTS

We identified four overarching themes pertaining to the impact of the pandemic and associated restrictions on mental health, wellbeing and access to support in young carers in the UK: (1) challenges in protecting loved ones from the virus, (2) changes to and loss of routine, (3) reduced access to pre-pandemic informal and formal support structures and (4) better understanding of inner resilience and goals. Many participants struggled with their mental health and wellbeing as a result of pandemic related restrictions which impacted on support structures for themselves and the individual they cared for. However, positive impacts pertained to additional support provided by local authority and third sector organisations.

CONCLUSIONS

Our findings highlight some of the changes that affected young carers during the COVID-19 pandemic. The impact of changes to routine and a reduction in pre-pandemic support were the greatest concerns reported by participants in this study. The additional support provided by local authority and third sector organisations during social restrictions suggests such organisations could play a greater role in supporting this population going forward and that schools and Governments may wish to put in additional strategies and provisions to protect young carers in the future.

Exploring the Use of an Electronic Competency Assessment Document Using iPad Minis to Assess Clinical Practice Competency in a Preregistration Nursing Program: A Cross-sectional Feasibility Study

The aim of this study was to explore the feasibility of using iPad minis as a method of completing competency assessment in clinical practice. Digital technology helps to revolutionize all aspects of our lives. The use of digital technologies in clinical practice can facilitate a move toward a more flexible learning environment and enable students to adapt in a rapidly changing, interconnected world. The introduction of electronic clinical booklets in practice placements could facilitate the sharing of clinical information through connected healthcare systems, thus improving the student experience. A cross-sectional design was used in this study. A sample of BSc nursing students (n = 53) and clinically based healthcare professionals (n = 27) (preceptors and clinical placement coordinators) participated in this study. Data were collected using a modified version of Garrett and colleagues' instrument, the System Usability Scale, a demographics questionnaire, and three open-ended questions. There was a significant difference between the students and preceptors/clinical placement coordinators across all items with higher proportions of students (ranging from 66% to 75.5%), indicating that they agreed or strongly agreed with the reliability, ease of use, and effectiveness of the device in assessing their clinical competency (ranging from 11.1% to 40.7%). In addition, the iPad minis were found to be smaller, lighter, and easier to carry than paper-based booklets and encouraged students to access timely online learning resources during placement to help augment their learning. The use of iPad mini to complete the electronic competency assessment document as a replacement for a paper-based system to assess clinical practice is feasible. The introduction of electronic assessment documents should incorporate a robust training plan and standard operating procedures.

How did UK social distancing restrictions affect the lives of women experiencing intimate partner violence during the COVID-19 pandemic? A qualitative exploration of survivor views

BACKGROUND

Increased numbers of domestic abuse cases were reported at the start of the COVID-19 pandemic. Many people experiencing abuse faced barriers to seeking support with service closures affecting the sector. Available evidence suggests women are overrepresented in the reported cases of intimate partner violence (IPV) and we aimed to learn more about how their lives were impacted by social distancing restrictions.

METHODS

We conducted an online qualitative interview study, using reflexive thematic analysis. Interviews were conducted between April 2021 and March 2022. 18 women in the UK with past experiences of IPV provided informed consent and participated in this study.

RESULTS

During the analysis, we identified five themes relating to the impact of lockdown restrictions on participants' lives, including: (1) Lockdown meant being confined to a place where abuse was escalating, (2) Barriers to accessing support, including "cancelled" services and missed opportunities to intervene during interactions in lockdown with frontline workers. (3) Increased feelings of fear, isolation, and loss of control, particularly during the early stages of the pandemic from the combination of abuse and pandemic-related changes to daily life. (4) Some forms of support were more accessible during the pandemic, such as provision of online psychological support and social groups. Participants also accessed new forms of support for the first time during the pandemic, in some cases sparked by posts and content on social media about abuse awareness. (5) For some, psychosocial wellbeing transformed during the pandemic, with several participants using the word "freedom" when reflecting on their experience of simultaneously escaping abuse and living through the COVID-19 pandemic.

CONCLUSIONS

In this study, we explored the views of female survivors of IPV in the UK during the COVID-19 pandemic. Our results highlight the importance of combined public awareness campaigns and community intervention points for victims to safely seek help during social distancing restrictions. Having the time and space to reflect on healing after escaping abuse was described by women in our study as a benefit from their lives in lockdown, which is a factor that could be incorporated into future initiatives developed to support people subjected to violence and abuse.

The APPLE Tree programme: Active Prevention in People at risk of dementia through Lifestyle, bEhaviour change and Technology to build REsiliEnce-randomised controlled trial

BACKGROUND

Large-scale trials of multidomain interventions show that modifying lifestyle and psychological risk factors can slow cognitive decline. We aim to determine if a lower intensity, personally tailored secondary dementia prevention programme for older people with subjective or mild objective memory decline, informed by behaviour change theory, reduces cognitive decline over 2 years.

METHODS

A multi-site, single-blind randomised controlled trial recruiting 704 older adults at high dementia risk due to mild cognitive impairment (MCI) or subjective cognitive decline (SCD). Participants are randomised using 1:1 allocation ratio to the APPLE Tree intervention versus control arm (dementia prevention information), stratified by site. The intervention explores and implements strategies to promote healthy lifestyle, increase pleasurable activities and social connections and improve long-term condition self-management. Two facilitators trained and supervised by a clinical psychologist deliver ten, 1-h group video call sessions over 6 months (approximately every fortnight), video-call 'tea breaks' (less structured, facilitated social sessions) in intervening weeks and individual goal-setting phone calls every 2 weeks. From 6 to 12 months, participants meet monthly for 'tea breaks', with those not attending receiving monthly goal-setting phone calls. Participants receive a food delivery, pedometer and website access to cognitive training and information about lifestyle modification. Follow-ups for all outcome measures are at 12 and 24 months. The primary outcome is cognition (Neuropsychological Test Battery (NTB) score) at 24 months. Secondary outcomes are quality of life, cost per quality-adjusted life year (QALY) and wellbeing and lifestyle factors the intervention targets (diet, vascular risk, body weight, activity, sleep, anxiety, depression, social networks and loneliness, alcohol intake and smoking). Participants from purposively selected sites participate in qualitative process evaluation interviews, which will be analysed using thematic analytic methods.

DISCUSSION

If effective, the intervention design, involving remote delivery and non-clinical facilitators, would facilitate intervention roll-out to older people with memory concerns.

TRIAL REGISTRATION

ISRCTN17325135 . Registration date 27 November 2019.

Factors affecting the mental health of pregnant women using UK maternity services during the COVID-19 pandemic: a qualitative interview study

Background

People using maternity services in the United Kingdom (UK) have faced significant changes brought on by the COVID-19 pandemic and social distancing regulations. We focused on the experiences of pregnant women using UK maternity services during the pandemic and the impact of social distancing rules on their mental health and wellbeing.

Methods

We conducted 23 qualitative semi-structured interviews from June 2020 to August 2021, with women from across the UK who experienced a pregnancy during the pandemic. Nineteen participants in the study carried their pregnancy to term and four had experienced a miscarriage during the pandemic. Interviews took place remotely over video or telephone call, discussing topics such as mental health during pregnancy and use of UK maternity services. We used reflexive thematic analysis to analyse interview transcripts.

Results

We generated six higher order themes: [1] Some pregnancy discomforts alleviated by social distancing measures, [2] The importance of relationships that support coping and adjustment, [3] Missed pregnancy and parenthood experiences, [4] The mental health consequences of birth partner and visitor restrictions, [5] Maternity services under pressure, and [6] Lack of connection with staff. Many participants felt a sense of loss over a pregnancy experience that differed so remarkably to what they had expected because of the pandemic. Supportive relationships were important to help cope with pregnancy and pandemic-related changes; but feelings of isolation were compounded for some participants because opportunities to build social connections through face-to-face parent groups were unavailable. Participants also described feeling alone due to restrictions on their partners being present when accessing UK maternity services.

Conclusions

Our findings highlight some of the changes that may have affected pregnant women’s mental health during the COVID-19 pandemic. Reduced social support and being unable to have a partner or support person present during maternity service use were the greatest concerns reported by participants in this study. Absence of birth partners removed a protective buffer in times of uncertainty and distress. This suggests that the availability of a birth partner or support person must be prioritised wherever possible in times of pandemics to protect the mental health of people experiencing pregnancy and miscarriage.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04602-5.

The impact of the COVID-19 pandemic on mental health and well-being of people living with a long-term physical health condition: a qualitative study

BACKGROUND

The COVID-19 pandemic and associated restrictions caused major global disruption. Individuals with long-term physical health conditions (LTCs) are at higher risk of severe illness and often subject to the strictest pandemic guidance, so may be disproportionally affected. The aim of this study was to qualitatively explore how living with a LTC during the COVID-19 pandemic affected people's mental health and wellbeing.

METHODS

Participants were people living with LTCs who participated in telephone/video call interviews based on a semi-structured topic guide. Key themes and subthemes were determined using deductive and inductive thematic analysis.

RESULTS

The sample included 32 participants with LTCs (most commonly cancer, respiratory conditions or cardiovascular diseases), mean age 57 (SD 13) years, 66% female and 72% white British. There were four overarching themes specific to living with a LTC. These were 1) high levels of fear and anxiety related to perceived consequences of catching COVID-19, 2) impact of shielding/isolation on mental health and wellbeing, 3) experience of healthcare during the pandemic and 4) anxiety created by uncertainty about the future. Fourteen subthemes were identified, including concerns about accessing essential supplies and the importance of social support. Individuals who lived alone and were advised to shield could be profoundly negatively affected.

CONCLUSIONS

This study found that there were a number of aspects of living with a LTC during the pandemic that had a significant impact on mental health and well-being. There should be focus on how best to provide practical and social support to people with LTCs during a pandemic, particularly if they have to shield or isolate.

A qualitative study about the mental health and wellbeing of older adults in the UK during the COVID-19 pandemic

OBJECTIVES

The objective of this study was to examine factors that threatened and protected the wellbeing of older adults living in the UK during social distancing restrictions due to the COVID-19 pandemic.

METHODS

Semi-structured telephone or video interviews with 20 adults aged over 70. Purposive sampling methods were used to increase diversity within the group. Transcripts were analysed using reflexive thematic analysis.

RESULTS

Participants described potential threats to their wellbeing during the pandemic, including fears for mortality, grieving normal life, and concerns for the future. Participants also described activities and behaviours that helped to protect their mental health, including adopting a slower pace of life, maintaining routine, socialising, and using past coping skills. Many participants drew on their resilience and life experience to self-manage fear and uncertainty associated with the pandemic, using their time during lockdown to reflect or organise end-of-life affairs.

DISCUSSION

This study provides UK-based evidence that while some older adults experienced challenges during the first wave of COVID-19, many were resilient throughout social distancing restrictions despite early reported concerns of mental health consequences among the older adult population. Our findings highlight the importance of maintaining access to essentials to promote feelings of normality and use of social support to help reduce uncertainty in times of pandemics.

Challenges of living with and managing inflammatory bowel disease: A meta-synthesis of patients' experiences

AIMS AND OBJECTIVES

To examine qualitative studies which reported on patients' challenges of living with and managing inflammatory bowel disease (IBD).

BACKGROUND

There is a growing body of qualitative research focusing on the subjective experiences of patients with IBD. This research points to the daily challenges that patients experience which can relate to their physical and psychological health, as well as their social well-being, and may impact negatively on their lives. To date, there has been little attempt to synthesise these studies, and little is known about how patients manage the challenges they experience.

DESIGN

A meta-synthesis was conducted, based on guidelines developed by Sandelowski and Barroso (Handbook for synthesizing qualitative research, Springer, New York, NY, 2007) and PRISMA (Int J Surg, 8, 2009, 336).

METHODS

Searches were conducted within the CINAHL, MEDLINE, PsycINFO, Psychology and Behavioural Sciences Collection and SocINDEX databases to locate qualitative and mixed methodology studies. The retrieved articles were screened against predetermined inclusion criteria. Quality appraisal was assessed using the Joanna Briggs Institute critical appraisal tool for qualitative research (Int J Evid Based Healthc, 13, 2015, 179).

RESULTS

Thematic analysis resulted in three themes: the unpredictability of living with IBD, the emotional turmoil of living with IBD and striving to maintain a normal life in managing IBD.

CONCLUSION

The greatest challenges for patients identified in this meta-synthesis were the physical symptoms associated with IBD. These impacted negatively on their psychological and social well-being and reduced their quality of life. There is a notable gap in research on patient experiences of managing the challenges identified in everyday life and to what extent they receive support from healthcare professionals.

RELEVANCE TO CLINICAL PRACTICE

The results of this meta-synthesis offer insights into how the physical challenges of living with IBD, particularly in relation to symptoms, impact adversely on patients' psychological and social well-being. These insights are clinically relevant to healthcare professionals as a basis for supporting patients to manage their challenges.

Se and I status in pregnant ewes from a pastoral system and the effect of supplementation with Se and I or only Se on wool quality of lambs

Australian Merino ewes and lambs producing fine fibre wool for export are raised in the north-west of Uruguay in pasture-based systems. We studied the status of selenium and iodine in pregnant Merino ewes (10 per treatment) grazing in natural pasture, in natural pasture and supplemented with Se (0.1 mg Se/kg dry matter intake) and I (1 mg I/kg dry matter intake), or in natural pasture and supplemented with Se alone (0.1 mg Se/kg dry matter intake), during the last 30 days of gestation. Further, we evaluated the performance and wool quality of their offspring. Content of Se and I in natural pasture, in the sera of pregnant ewes, and in the wool of their offspring and levels of thyroidal hormones—TSH, T4, and free T3 (FT3)—in the sera of pregnant ewes were determined. The performance of lambs and the commercial parameters of fine fibre wool produced were measured. Results showed normal Se levels in serum (0.12–0.15 mg/l) in the ewes grazing in natural pasture (0.07–0.09 mg/kg DM) during late pregnancy. The observed increase in Se content in the pasture at lambing (0.11–0.16 mg/kg DM) improved serum Se levels (0.216 mg/l); however, the serum levels were not affected by the supplementation.

I content in pasture showed adequate levels (0.50–0.60 mg/kg DM), which were reflected in the blood serum values 30 days prior to lambing (0.197–0.208 mg/l). However, at lambing, the I content in blood serum decreased (0.150 mg/l). Further, the supplementation did not modify the serum I levels (0.163–0.175 mg/l). An increase in FT3 levels in ewes at lambing could be associated with the increase in Se content in pasture and/or the adequate I content in pasture. No effect of supplementation was observed. Lambs showed good results regarding the quality of fine fibre wool and performance after supplementation with Se and I or Se alone and exhibited slightly improved Se and I content in wool. In conclusion, natural pasture provides adequate status in Se and I for the Merino ewes and their offspring without any additional beneficial effects of supplementation with Se and I or only Se.

Ethnographic study using Normalization Process Theory to understand the implementation process of infection prevention and control guidelines in Ireland

OBJECTIVE

The aim of this study was to explore how infection prevention and control (IPC) guidelines are used and understood by healthcare professionals, patients and families.

DESIGN

Ethnographic study with 59 hours of non-participant observation and 57 conversational interviews. Data analysis was underpinned by the Normalization Process Theory (NPT) as a theoretical framework.

SETTING

Four hospitals in Ireland.

PARTICIPANTS

Healthcare professionals, patient and families.

RESULTS

Five themes emerged through the analysis. Four themes provided evidence of the NPT elements (coherence, cognitive participation, collective action and reflexive monitoring). Our findings revealed the existence of a 'dissonance between IPC guidelines and the reality of clinical practice' (theme 1) and 'Challenges to legitimatize guidelines' recommendations in practice' (theme 3). These elements contributed to 'Symbolic implementation of IPC guidelines' (theme 2), which was also determined by a 'Lack of shared reflection upon IPC practices' (theme 4) and a clinical context of 'Workforce fragmentation, time pressure and lack of prioritization of IPC' (theme 5).

CONCLUSIONS

Our analysis identified themes that provide a comprehensive understanding of elements needed for the successful or unsuccessful implementation of IPC guidelines. Our findings suggest that implementation of IPC guidelines is regularly operationalised through the reproduction of IPC symbols, rather than through adherence to performance of the evidence-based recommendations. Our findings also provide insights into changes to make IPC guidelines that align with clinical work.

Leadership perspective on the implementation of guidelines on healthcare-associated infections

Background

Leadership is a key component for infection prevention and control and plays an important role in the implementation of guidelines on healthcare-associated infections. A body of literature exists on healthcare workers’ perspectives on implementing these types of guidelines; however, there is a paucity of data on the leadership perspectives on implementation. This study aims to contribute to the evidence base of leadership perspectives.

Objective

To explore the implementation of National Clinical Guidelines pertaining to methicillin-resistant Staphylococcus aureus and Clostridium difficile from the leadership angle.

Setting

Healthcare organisations.

Participants

Clinical and non-clinical leaders.

Design

This research used a mixed-methods approach comprising qualitative individual interviews (n=16) and quantitative surveys (n=51) underpinned by the integrated Promoting Action on Research Implementation in Health Services framework.

Results

Leaders recognise the value and innovation of guidelines to support clinical practice. However, they describe barriers to implementation that prevent the full uptake of guidelines, for example, guidelines may present an ideological approach to care which differs from the contextual reality of clinical practice where resources and time are not always available.

Conclusion

This research highlighted that guidelines are complex interventions in complex organisations, perhaps leadership could help overcome the challenges posed by this complexity. Leadership may allow a systematic approach to all aspects of implementation despite the variety of challenges faced at different stages of implementation and sustainability of uptake of guidelines over time.

Patient involvement in the implementation of infection prevention and control guidelines and associated interventions: a scoping review

OBJECTIVE

To explore patient involvement in the implementation of infection prevention and control (IPC) guidelines and associated interventions.

DESIGN

Scoping review.

METHODS

A methodological framework was followed to identify recent publications on patient involvement in the implementation of IPC guidelines and interventions. Initially, relevant databases were searched to identify pertinent publications (published 2013-2018). Reflecting the scarcity of included studies from these databases, a bidirectional citation chasing approach was used as a second search step. The reference list and citations of all identified papers from databases were searched to generate a full list of relevant references. A grey literature search of Google Scholar was also conducted.

RESULTS

From an identified 2078 papers, 14 papers were included in this review. Our findings provide insights into the need for a fundamental change to IPC, from being solely the healthcare professionals (HCPs) responsibility to one that involves a collaborative relationship between HCPs and patients. This change should be underpinned by a clear understanding of patient roles, potential levels of patient involvement in IPC and strategies to overcome barriers to patient involvement focusing on the professional-patient relationship (eg, patient encouragement through multimodal educational strategies and efforts to disperse professional's power).

CONCLUSIONS

There is limited evidence regarding the best strategies to promote patient involvement in the implementation of IPC interventions and guidelines. The findings of this review endorse the need for targeted strategies to overcome the lack of role clarity of patients in IPC and the power imbalances between patients and HCPs.

A low cost virtual reality system for home based rehabilitation of the arm following stroke: a randomised controlled feasibility trial

Objective:

To assess the feasibility of conducting a randomised controlled trial of a home-based virtual reality system for rehabilitation of the arm following stroke.

Design:

Two group feasibility randomised controlled trial of intervention versus usual care.

Setting:

Patients’ homes.

Participants:

Patients aged 18 or over, with residual arm dysfunction following stroke and no longer receiving any other intensive rehabilitation.

Interventions:

Eight weeks’ use of a low cost home-based virtual reality system employing infra-red capture to translate the position of the hand into game play or usual care.

Main measures:

The primary objective was to collect information on the feasibility of a trial, including recruitment, collection of outcome measures and staff support required. Patients were assessed at three time points using the Wolf Motor Function Test, Nine-Hole Peg Test, Motor Activity Log and Nottingham Extended Activities of Daily Living.

Results:

Over 15 months only 47 people were referred to the team. Twenty seven were randomised and 18 (67%) of those completed final outcome measures. Sample size calculation based on data from the Wolf Motor Function Test indicated a requirement for 38 per group. There was a significantly greater change from baseline in the intervention group on midpoint Wolf Grip strength and two subscales of the final Motor Activity Log. Training in the use of the equipment took a median of 230 minutes per patient.

Conclusions:

To achieve the required sample size, a definitive home-based trial would require additional strategies to boost recruitment rates and adequate resources for patient support.

Effectiveness and cost-effectiveness of a cardiovascular risk prediction algorithm for people with severe mental illness

Introduction

Cardiovascular risk prediction tools are important for cardiovascular disease (CVD) prevention, however, which algorithms are appropriate for people with severe mental illness (SMI) is unclear.

Objectives/aims

To determine the cost-effectiveness using the net monetary benefit (NMB) approach of two bespoke SMI-specific risk algorithms compared to standard risk algorithms for primary CVD prevention in those with SMI, from an NHS perspective.

Methods

A microsimulation model was populated with 1000 individuals with SMI from The Health Improvement Network Database, aged 30–74 years without CVD. Four cardiovascular risk algorithms were assessed; (1) general population lipid, (2) general population BMI, (3) SMI-specific lipid and (4) SMI-specific BMI, compared against no algorithm. At baseline, each cardiovascular risk algorithm was applied and those high-risk (> 10%) were assumed to be prescribed statin therapy, others received usual care. Individuals entered the model in a ‘healthy’ free of CVD health state and with each year could retain their current health state, have cardiovascular events (non-fatal/fatal) or die from other causes according to transition probabilities.

Results

The SMI-specific BMI and general population lipid algorithms had the highest NMB of the four algorithms resulting in 12 additional QALYs and a cost saving of approximately £37,000 (US$ 58,000) per 1000 patients with SMI over 10 years.

Conclusions

The general population lipid and SMI-specific BMI algorithms performed equally well. The ease and acceptability of use of a SMI-specific BMI algorithm (blood tests not required) makes it an attractive algorithm to implement in clinical settings.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Biochemical and physiological processes associated with the differential ozone response in ozone-tolerant and sensitive soybean genotypes

Biochemical and physiological traits of two soybean [Glycine max (L.) Merr.] genotypes differing in sensitivity to ozone (O3 ) were investigated to determine the possible basis for the differential response. Fiskeby III (O3 -tolerant) and Mandarin (Ottawa) (O3 -sensitive) were grown in a greenhouse with charcoal-filtered air for 4 weeks, then treated with O3 for 7 h·day(-1) in greenhouse chambers. Mandarin (Ottawa) showed significantly more leaf injury and hydrogen peroxide (H2 O2 ) and superoxide (O2 (-) ) production compared with Fiskeby III. Peroxidase activity in Mandarin (Ottawa) was 31% higher with O3 but was not significantly different in Fiskeby III. Ozone did not affect superoxide dismutase or glutathione reductase activities, or leaf concentrations of glutathione or ascorbic acid. Thus, variation in O3 response between Fiskeby III and Mandarin (Ottawa) was not explained by differences in antioxidant enzymes and metabolites tested. Ethylene emission from leaves declined in Fiskeby III following O3 exposure but not in Mandarin (Ottawa). Ozone exposure reduced quantum yield (ΦPSII ), electron transport rate (ETR) and photochemical quenching (qp ) in Mandarin (Ottawa) more than in Fiskeby III, indicating that efficiency of energy conversion of PSII and photosynthetic electron transport was altered differently in the two genotypes. Short-term exposure to O3 had minimal effects on net carbon exchange rates of both soybean cultivars. A trend toward higher stomatal conductance in Mandarin (Ottawa) suggested stomatal exclusion might contribute to differential O3 sensitivity of the two genotypes. Increased sensitivity of Mandarin (Ottawa) to O3 was associated with higher H2 O2 and O2 (-) production compared with Fiskeby III, possibly associated with genotype differences in stomatal function or regulation of ethylene during the initial phases of O3 response.

10 Mb/s visible light transmission system using a polymer light-emitting diode with orthogonal frequency division multiplexing

We present a newly designed polymer light-emitting diode with a bandwidth of ~350  kHz for high-speed visible light communications. Using this new polymer light-emitting diode as a transmitter, we have achieved a record transmission speed of 10  Mb/s for a polymer light-emitting diode-based optical communication system with an orthogonal frequency division multiplexing technique, matching the performance of single carrier formats using multitap equalization. For achieving such a high data-rate, a power pre-emphasis technique was adopted.

Raised levels of metal ions in the blood in patients who have undergone uncemented metal-on-polyethylene Trident-Accolade total hip replacement

The issues surrounding raised levels of metal ions in the blood following large head metal-on-metal total hip replacement (THR), such as cobalt and chromium, have been well documented. Despite the national popularity of uncemented metal-on-polyethylene (MoP) THR using a large-diameter femoral head, few papers have reported the levels of metal ions in the blood following this combination. Following an isolated failure of a 44 mm Trident-Accolade uncemented THR associated with severe wear between the femoral head and the trunnion in the presence of markedly elevated levels of cobalt ions in the blood, we investigated the relationship between modular femoral head diameter and the levels of cobalt and chromium ions in the blood following this THR. A total of 69 patients received an uncemented Trident-Accolade MoP THR in 2009. Of these, 43 patients (23 men and 20 women, mean age 67.0 years) were recruited and had levels of cobalt and chromium ions in the blood measured between May and June 2012. The patients were then divided into three groups according to the diameter of the femoral head used: 12 patients in the 28 mm group (controls), 18 patients in the 36 mm group and 13 patients in the 40 mm group. A total of four patients had identical bilateral prostheses in situ at phlebotomy: one each in the 28 mm and 36 mm groups and two in the 40 mm group. There was a significant increase in the mean levels of cobalt ions in the blood in those with a 36 mm diameter femoral head compared with those with a 28 mm diameter head (p = 0.013). The levels of cobalt ions in the blood were raised in those with a 40 mm diameter head but there was no statistically significant difference between this group and the control group (p = 0.152). The levels of chromium ions in the blood were normal in all patients. The clinical significance of this finding is unclear, but we have stopped using femoral heads with a diameter of ≤ 36 mm, and await further larger studies to clarify whether, for instance, this issue particularly affects this combination of components.

Unvaccinated children in years of increasing coverage: how many and who are they? Evidence from 96 low- and middle-income countries

OBJECTIVE

While childhood immunisation coverage levels have increased since the 70s, inequities in coverage between and within countries have been widely reported. Unvaccinated children remain undetected by routine monitoring systems and strikingly unreported. The objective of this study was to provide evidence on the magnitude of the problem and to describe predictors associated with non-vaccination.

METHODS

Two hundred and forty-one nationally representative household surveys in 96 countries were analysed. Proportions and changes in time of 'unvaccinated' (children having not received a single dose of vaccine), 'partially vaccinated' and 'fully vaccinated' children were estimated. Predictors of non-vaccination were explored.

RESULTS

The percentage of unvaccinated children was 9.9% across all surveys. 66 countries had more than one survey: 38 showed statistically significant reductions in the proportion of unvaccinated children between the first and last survey, 10 countries showed increases and the rest showed no significant changes. However, while 18 of the 38 countries also improved in terms of partially and fully vaccinated, in the other 20 the proportion of fully vaccinated decreased. The predictors more strongly associated with being unvaccinated were education of the caregiver, education of caregiver's partner, caregiver's tetanus toxoid (TT) status, wealth index and type of family member participation in decision-making when the child is ill. Multivariable logistic regression identified the TT status of the caregiver as the strongest predictors of unvaccinated children. Country-specific summaries were produced and sent to countries.

CONCLUSION

The number of unvaccinated children is not negligible and their proportion and the predictors of non-vaccination have to be drawn from specific surveys. Specific vaccine indicators cannot properly describe the performance of immunisation programmes in certain situations. National immunisation programmes and national and international immunisation stakeholders should also consider monitoring the proportion of unvaccinated children (i.e. those who have received no vaccines at all) and draw specific plans on the determinants of non-vaccination.

Clinician and service user perceptions of implementing contingency management: a focus group study

BACKGROUND

Contingency management (CM), despite the evidence base for its effectiveness, remains controversial, with sub-optimal implementation. In 2007, UK guidelines recommended the use of CM in publicly funded services, but uptake has also been minimal. Previous surveys of service providers suggest differences in opinions about CM, but to date there has been no published involvement of service users in this debate.

METHOD

Focus group methodology was used to explore systematically the attitudes, concerns and opinions of staff and service users about the use of CM, in publicly funded substance misuse services, to identify the key areas that may be influential in terms of implementation and outcome. Data were analysed thematically using the constant comparative method.

RESULTS

70 staff and service users participated in 9 focus groups. 15 themes of discussion around CM were identified, grouped into four categories: how CM was aligned to the philosophy of substance misuse services; the practicalities of implementation; wider ethical concerns; and how participants perceived the evidence for effectiveness.

CONCLUSIONS

Robust process evaluation in different treatment systems is needed to define the active components of CM for implementation. Involvement of service users in this process is essential and is likely to provide valuable insights into the mechanism of action of CM and its effectiveness and uptake within complex treatment systems.

The effect of contact stress on cartilage friction, deformation and wear

Following hip hemiarthroplasty, a metal femoral head articulates against natural acetabular cartilage. Cartilage friction and wear may be influenced by variables including loading time, contact stress, contact area, sliding distance, and sliding speed. The aim of this study was to investigate the effect of these variables on cartilage friction, deformation and wear in a simulation using idealized geometry model. Bovine cartilage pins were reciprocated against metal plates to mimic a hemiarthroplasty articulation under static loading. The effective coefficient of friction (µeff) under contact stresses (0.5 to 16 MPa), contact areas (12 and 64 mm2), stroke lengths (4 and 8 mm), sliding velocities (4 and 8 mm/s), and loading time (1 and 24 hours) were studied. The permanent deformation of cartilage (after 24 hours of recovery) with and without motion was recorded to assess cartilage linear wear.

The µeff was found to remain < 0.35 with contact stresses ≤ 4 MPa. Severe damage to the cartilage occurred at contact stresses > 8 MPa and significantly increased µeff after 12 hours of reciprocation. In long-term, contact area had no significant effect on µeff, and sliding distance and velocity only affected µeff under low contact stresses. The cartilage linear wear increased with contact stress, sliding distance and velocity.

An analysis of the existing resources in relation to education and treatment of diabetes in four European countries: Estonia, Finland, Ireland, and Lithuania

Diabetes has reached pandemic proportions worldwide. To address and assist health care professionals in maintaining and updating their knowledge base on diabetes care, a multilateral project within the framework of the Lifelong Learning Programme and the Erasmus Curriculum Development - sub programme was initiated in 2008. Four European countries are involved in the project - Estonia, Finland, Ireland and Lithuania. Across all four countries the prevalence of diabetes is rising rapidly. The project's (DIPRA - Counselling for Practice - a pilot of improving counselling quality of diabetes) main product will be an on-line study module on patient education and counselling for health care professionals. The management of diabetes demands a broad range of skills which include, communication, leadership, counselling, teaching and research to name but a few. While it is acknowledged that nurses can incorporate these skills into practice and so benefit the care of the patient there is no uniformity across the four countries studied as to what constitutes a specialist diabetes nurse. The study module and all the materials (databank, on-line lectures, and interactive exercises) will be developed in English and translated into partners' national languages (Estonian, Finnish, Lithuanian) to maximize the accessibility of all professionals in partner countries.

Comparison of wear of ultra-high molecular weight polyethylene acetabular cups against surface-engineered femoral heads

Alumina ceramic heads have been previously shown to reduce polyethylene wear in comparison to cobalt chrome (CoCr) heads in artificial hip joints. However, there are concerns about the brittle nature of ceramics. It is therefore of interest to investigate ceramic-like coatings on metallic heads. The aim of this study was to compare the friction and wear of ultra-high molecular weight polyethylene (UHMWPE) against alumina ceramic, CoCr, and surface-engineered ceramic-like coatings in a friction simulator and a hip joint simulator. All femoral heads tested were 28 mm diameter and included: Biolox Forte alumina, CoCr, arc evaporative physical vapour deposition (AEPVD) chromium nitride (CrN) coated CoCr, plasma-assisted chemical vapour deposition (PACVD) amorphous diamond-like carbon (aDLC) coated CoCr, sputter CrN coated CoCr, reactive gas controlled arc (RGCA) AEPVD titanium nitride (TiN) coated CoCr, and Graphit-iC coated CoCr. These were articulated against UHMWPE acetabular cups in a friction simulator and a hip joint simulator. Alumina and CoCr gave the lowest wear volumes whereas the sputter coated CrN gave the highest. Alumina also had the lowest friction factor. There was an association between surface parameters and wear. This study indicates that surface topography of surface-engineered femoral heads is more important than friction and wettability in controlling UHMWPE wear.

Post anaesthetic care units in the Republic of Ireland: a survey of discharge criteria

Discharge readiness of patients from the post anaesthetic care unit (PACU) is often determined by specific discharge criteria. This quantitative, descriptive national study aimed to survey discharge criteria used in the PACU. Data from 45 hospitals nationally with a response rate of 77.8% (n = 35) was gathered. Specific discharge criteria were used by 71.4% (n = 25) of the PACUs in the determination of fitness of patients for discharge from the PACU.

Percutaneous vertebroplasty and/or kyphoplasty is an effective and safe treatment for painful vertebral compression fractures in multiple myeloma (MM)

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Background: Painful vertebral compression fractures are a major source of morbidity in MM. Vertebroplasty involves percutaneous injection of polymethylmethacrylate (PMMA) into a vertebral body, while kyphoplasty involves inflation of a balloon for painful kyphotic deformity prior to stabilization with PMMA. Methods: We assessed safety and efficacy of 100 vertebroplasties and/or kyphoplasties in 81 consecutive myeloma patients between 12/2000 and 2/2005. Results: Median age was 63 (range 32–84), with 29% having prior radiotherapy to the vertebra treated. Contraindications included epidural compression of neural elements and failure to localize a symptomatic level. Kyphoplasty was preferred if kyphosis of > 20 degrees contributed to pain, or if the posterior vertebral cortex was disrupted so that controlled delivery of bone cement was difficult. Vertebroplasty was performed when vertebral collapse was either slight or so severe that insertion of balloon device was not possible, or if patient could not tolerate the general anesthesia required for kyphoplasty. The median preoperative visual analog pain score (0–10) was 8(range 2–10); the median postoperative pain score was 3 (range 0–10) (p < 0.01). There were no significant complications . Conclusions: Percutaneous vertebroplasty and kyphoplasty provided rapid and marked pain relief. These procedures are safe and feasible and represent the treatment of choice in selected MM patients with severe refractory pain due to pathologic compression fractures.

No significant financial relationships to disclose.

Delaying Radiotherapy for the Delivery of Adjuvant Chemotherapy in the Combined Modality Treatment of Early Breast Cancer: Is It Disadvantageous and Could Combined Treatment be the Answer?

Women with early stage breast cancer are increasingly being treated with both adjuvant chemotherapy and radiotherapy. The optimal sequence of these two treatment modalities is yet to be defined. It remains controversial whether delaying radiotherapy in order to deliver chemotherapy compromises local disease control and survival. Consequently, clinical practice in the UK is divided, with a number of different combination schedules being used in an effort to bring forward the start of radiotherapy. In practice, however, any benefit in local control must be balanced against a potential increase in toxicity. A review of the current literature on the effect of radiotherapy delay is presented, together with data on the toxicity of combined chemo-radiotherapy schedules and recent data from clinical trials designed to determine the optimal sequencing of chemotherapy and radiotherapy.

Electrocardiographic changes during cesarean section: a review

Recently, various authors have noticed and studied the phenomenon of ST segment depression during cesarean section. We have undertaken a review of the various postulated etiologies including venous air emboli, hormonal influences, autonomic nervous system influences tachycardia, postural influences, hypokalemia, hyperventilation, and myocardial ischemia. It appears that ST segment depression during cesarean section is almost certainly a multifactorial phenomenon. There is evidence that some myocardial dysfunction occurs during these episodes. Additionally, the hormonal milieu, tachycardia, and the postural component probably contribute to the phenomenon. Venous air emboli, hypokalemia, and hyperventilation probably have a minimal role. The sympatholysis produced by regional anesthesia is of unclear significance. It is important to note the apparent lack of morbidity associated with these changes.

Missing covariate data within cancer prognostic studies: a review of current reporting and proposed guidelines

Prognostic models play a crucial role in the clinical decision-making process. Unfortunately, missing covariate data impede the construction of valid and reliable models, potentially introducing bias, if handled inappropriately. The extent of missing covariate data within reported cancer prognostic studies, the current handling and the quality of reporting this missing covariate data are unknown. Therefore, a review was conducted of 100 articles reporting multivariate survival analyses to assess potential prognostic factors, published within seven cancer journals in 2002. Missing covariate data is a common occurrence in studies performing multivariate survival analyses, being apparent in 81 of the 100 articles reviewed. The percentage of eligible cases with complete data was obtainable in 39 articles, and was <90% in 17 of these articles. The methods used to handle incomplete covariates were obtainable in 32 of the 81 articles with known missing data and the most commonly reported approaches were complete case and available case analysis. This review has highlighted deficiencies in the reporting of missing covariate data. Guidelines for presenting prognostic studies with missing covariate data are proposed, which if followed should clarify and standardise the reporting in future articles.

A randomised multicentre trial of modified CHOP versus MCOP in patients aged 65 years and over with aggressive non-Hodgkin's lymphoma

BACKGROUND

The aim of this study was to determine in a randomised trial whether there is any significant difference in toxicity between modified CHOP and MCOP chemotherapy in elderly patients with aggressive non-Hodgkin's lymphoma (NHL) and to determine whether this reduced dose chemotherapy can be administered with full dose intensity, low toxicity and produce acceptable survival.

PATIENTS AND METHODS

Between 1993 and 2000, 155 eligible patients were randomised into this trial mainly from three centres (Nottingham, Birmingham and Leeds, UK). The patients were newly diagnosed with aggressive NHL and had a median age of 74 years (range 65-91 years). Ninety-six patients (62%) had bulky stage I or II disease; 59 patients (38%) had either stage III or IV disease; 77% had one or more extranodal sites involved at presentation; and 31% showed B symptoms. Seventy-seven patients were randomised to receive six cycles of modified CHOP (cyclophosphamide 600 mg/m(2) i.v., doxorubicin 30 mg/m(2) i.v., vincristine 1 mg i.v. all on day 1 with prednisolone 20 mg bd for days 1-5) every 21 days and 78 patients to MCOP (mitozantrone 10 mg/m(2) i.v. substituted for doxorubicin). Growth factors were not used routinely. After completion of chemotherapy, 39 patients received involved field radiotherapy (35-40 Gy) in 20 fractions.

RESULTS

One hundred and one patients (65%) completed all six cycles of chemotherapy. The median course dose intensity was 97%. The median follow-up for 53 surviving patients was 51 months. The median survival was 19 months (95% confidence interval 10-36 months) with an actuarial survival of 47% at 2 years and 42% at 3 years (CHOP versus MCOP, P = 0.79). There was no significant difference in any of the toxicities experienced with either CHOP or MCOP, except for white cell count (46 patients on MCOP and 27 patients on CHOP had grade 3 or 4 toxicity, P = 0.002) and red cell transfusion (37 patients, MCOP; 17 patients, CHOP; P = 0.001). Grade 3 or 4 neutropenia was documented in 75 patients (50%). One patient died from toxicity whilst in remission and seven patients died with septicaemia and persistent NHL.

CONCLUSION

This multicentre randomised trial provides further information on the dose intensity achievable with CHOP or MCOP regimens in elderly patients (median age 74 years) with aggressive NHL. These dose-reduced regimens can be given with nearly 100% dose intensity with 65% of patients completing all the treatment. Survival is comparable to that observed with the more intensive regimens given in this age group.

Patterns, costs and cost-effectiveness of care in a trial of chemotherapy for advanced non-small cell lung cancer

In a recently published randomised trial of chemotherapy versus palliative care in advanced non-small cell lung cancer (the MIC2 trial), chemotherapy was shown to prolong survival without compromising quality of life. The study presented here examines patterns of care and their associated costs within a representative subgroup of patients from the MIC2 trial. The study consisted of 116 patients from the South Birmingham Health Authority area. The total health service cost for each patient from entry to trial to death or last follow-up was calculated by combining the resources used with their associated unit costs. The mean cost for patients with complete data on the chemotherapy arm was 6999 pounds sterling (standard deviation (S.D.) 4194 pounds sterling) compared to 4076 pounds sterling (S.D. 3078 pounds sterling) for those with complete data on the palliative care arm. Non-parametric bootstrapping gave a difference between treatment arms in mean cost of 2924 pounds sterling(95% CI 1234 pounds sterling - 4323 pounds sterling). With a difference in mean survival of 2.4 months, this translates to an incremental cost-effectiveness ratio of 14,620 pounds sterling per life year gained. Chemotherapy was found to be more costly than standard palliative care, mainly due to the increased number of hospital in-patient days.

Prospective randomized comparison of dacarbazine (DTIC) versus DTIC plus interferon-alpha (IFN-alpha) in metastatic melanoma

Dacarbazine (DTIC) has been the mainstay of chemotherapy for metastatic melanoma for over two decades, but only 15%-20% of patients respond and benefit is usually transient. Randomized studies combining DTIC with interferon-alpha (IFN-alpha) in advanced disease have so far been inconclusive in terms of response and survival. We report a randomized prospective pilot Phase III trial of DTIC +IFN-alpha in patients with metastatic melanoma. The primary endpoint was death. A total of 61 patients were randomized between April 1995 and April 1998. Differences in survival between groups were assessed using log-rank analysis. Quality of life was measured using the European Organization for Research on Treatment of Cancer QLQ C30 (+3) questionnaire. Fifty-seven patients died during the study. The median survival for patients receiving DTIC was 7.2 months (95% confidence interval (CI) 4.4-9.0); it was 4.8 months for DTIC + IFN-alpha (95% CI 2.0-8.0). There was no significant difference in survival between the two treatment arms (chi2 unadjusted = 0.15, P = 0.70; chi2 adjusted = 0.01, P = 0.91). The 6-month survival of those patients randomized to DTIC alone was 58% compared with 40% for those patients randomized to DTIC + IFN-alpha. There were no differences in quality of life between treatment groups. This study failed to demonstrate a survival benefit for patients receiving IFN-alpha in combination with DTIC. These results are inconclusive primarily owing to the small size of the trial. A meta-analysis is required to determine whether there is a role for the addition of IFN-alpha to DTIC in the treatment of this disease.