Efficacy and safety of dolutegravir/lamivudine in virologically suppressed female participants: week 48 data from the pooled TANGO and SALSA studies

OBJECTIVES

Women represent >50% of people with HIV globally but have historically been underrepresented in clinical trials. We evaluated the efficacy and safety of switching to dolutegravir/lamivudine (DTG/3TC) vs continuing their current antiretroviral regimen (CAR) by sex assigned at birth (female and male) in virologically suppressed adults with HIV-1 without prior virological failure in a pooled analysis of two randomized controlled trials.

METHODS

This analysis included 48-week data from the phase 3 TANGO and SALSA studies. Primary and key secondary endpoints included proportions of participants with HIV-1 RNA ≥50 and <50 copies/mL at week 48, respectively. Safety was also assessed.

RESULTS

Of 1234 participants, 250 (DTG/3TC, n = 133; CAR, n = 117) were female at birth. Week 48 proportions of participants with Snapshot HIV-1 RNA ≥50 copies/mL were similar regardless of sex at birth (DTG/3TC vs CAR: female, <1% [1/133] vs 2% [2/117]; male, <1% [1/482] vs <1% [3/502]). Proportions with HIV-1 RNA <50 copies/mL were high across sexes and treatment groups (DTG/3TC vs CAR: female, 91% [121/133] vs 89% [104/117]; male, 94% [455/482] vs 94% [471/502]). Immunological response with DTG/3TC was slightly higher in female participants. Incidences of adverse events leading to withdrawal and serious adverse events were low and comparable between treatment groups and across sexes. Weight gain was higher with DTG/3TC than with CAR among female participants aged ≥50 years (treatment difference 2.08 kg [95% confidence interval 0.40-3.75]).

CONCLUSIONS

Results confirm the robustness of DTG/3TC as a switch option in virologically suppressed females with HIV-1, with outcomes similar to those in males.

Assessment of online self-testing and self-sampling service providers for sexually transmitted infections against national standards in the UK in 2020

OBJECTIVES

Online testing for STIs may help overcome barriers of traditional face-to-face testing, such as stigma and inconvenience. However, regulation of these online tests is lacking, and the quality of services is variable, with potential short-term and long-term personal, clinical and public health implications. This study aimed to evaluate online self-testing and self-sampling service providers in the UK against national standards.

METHODS

Providers of online STI tests (self-sampling and self-testing) in the UK were identified by an internet search of Google and Amazon (June 2020). Website information on tests and associated services was collected and further information was requested from providers via an online survey, sent twice (July 2020, April 2021). The information obtained was compared with British Association for Sexual Health and HIV and Faculty of Sexual and Reproductive Healthcare guidelines and standards for diagnostics and STI management.

RESULTS

31 providers were identified: 13 self-test, 18 self-sample and 2 laboratories that serviced multiple providers. Seven responded to the online survey. Many conflicts with national guidelines were identified, including: lack of health promotion information, lack of sexual history taking, use of tests licensed for professional-use only marketed for self-testing, inappropriate infections tested for, incorrect specimen type used and lack of advice for postdiagnosis management.

CONCLUSIONS

Very few online providers met the national STI management standards assessed, and there is concern that this will also be the case for service provision aspects that were not covered by this study. For-profit providers were the least compliant, with concerning implications for patient care and public health. Regulatory change is urgently needed to ensure that all online providers are compliant with national guidelines to ensure high-quality patient care, and providers are held to account if non-compliant.

Athena: Speciality Certificate Examination case for psychodermatology - delusional infestation

Athena speciality examination MCQ focused on a presentation of psychodermatologic disease. Explanation includes key teaching points relevant for candidates.

275 “MOVING ON UP”: FEASIBILITY OF A WARD-BASED THERAPY INITIATIVE TO IMPROVE PATIENT ACTIVITY LEVELS IN NEUROLOGICAL REHABILITATION

Background

Patients admitted for neurological rehabilitation are not receiving sufficient dosage of activity to facilitate optimal recovery. Previous research has reported issues with feasibility and patient adherence to intensity programs.

Methods

Mixed methods were employed for this feasibility study. The “Moving On Up” program encompassed “Activitea” structured practice of sit to stands prompted by mealtimes, “Step It Up” a gradual walking program using pedometers and “Weekend Workout” increasing practice of exercise programs. These activities were in addition to daily therapy sessions over a four-week intervention period. Primary feasibility outcomes investigated recruitment, retention, adherence, adverse events, facilitators, barriers and acceptability of the program and preliminarily assessed changes in activity levels using the ActivPAL accelerometer. Functional tests assessed mobility, health-related quality of life and fear of falls. Descriptive statistics were used for analysing quantitative data. Braun and Clarke’s thematic analysis was adopted when reviewing qualitative data.

Results

Ten participants were recruited with zero dropouts. Median age was 72 years and five had a diagnosis of brain tumour excision. Eight participants demonstrated excellent adherence with completion of daily activity logs. There was one participant non-injurious fall, no other adverse events. Clinical outcomes demonstrated improvement in median daily step count, stepping and standing time. The median daily step count for the group increased from 1,375 steps (IQR 2,867, range 82-4,248) to 1,724 steps (IQR 2,914, range 80-8,207). All functional tests improved. Seven participants and three therapists completed semi-structured interviews. Five themes emerged; motivation to move more, empowerment, barriers to increasing activity, weekends long and boring and job satisfaction.

Conclusion

The “Moving On Up” program was feasible to implement without additional staffing and was accepted by key stakeholders. Future research is warranted into the program's effectiveness, incorporating a larger sample and randomised pilot trial. Inclusion of a follow-up of participants after discharge would be desirable to investigate long-term effects on activity.

Protocol for a feasibility study of a cancer symptom awareness campaign to support the rapid diagnostic centre referral pathway in a socioeconomically deprived area: Targeted Intensive Community-based campaign To Optimise Cancer awareness (TIC-TOC)

INTRODUCTION

Rapid diagnostic centres (RDCs) are being implemented across the UK to accelerate the assessment of vague suspected cancer symptoms. Targeted behavioural interventions are needed to augment RDCs that serve socioeconomically deprived populations who are disproportionately affected by cancer, have lower cancer symptom awareness and are less likely to seek help for cancer symptoms. The aim of this study is to assess the feasibility and acceptability of delivering and evaluating a community-based vague cancer symptom awareness intervention in an area of high socioeconomic deprivation.

METHODS AND ANALYSIS

Intervention materials and messages were coproduced with local stakeholders in Cwm Taf Morgannwg, Wales. Cancer champions will be trained to deliver intervention messages and distribute intervention materials using broadcast media (eg, local radio), printed media (eg, branded pharmacy bags, posters, leaflets), social media (eg, Facebook) and attending local community events. A cross-sectional questionnaire will include self-reported patient interval (time between noticing symptoms to contacting the general practitioner), cancer symptom recognition, cancer beliefs and barriers to presentation, awareness of campaign messages, healthcare resource use, generic quality of life and individual and area-level deprivation indicators. Consent rates and proportion of missing data for patient questionnaires (n=189) attending RDCs will be measured. Qualitative interviews and focus groups will assess intervention acceptability and barriers/facilitators to delivery.

ETHICS AND DISSEMINATION

Ethical approval for this study was given by the London-West London & GTAC Research Ethics (21/LO/0402). This project will inform a potential future controlled study to assess intervention effectiveness in reducing the patient interval for vague cancer symptoms. The results will be critical to informing national policy and practice regarding behavioural interventions to support RDCs in highly deprived populations.

POS1503-HPR THE VALUE OF REMOTE CONSULTATIONS WITH A PHYSIOTHERAPIST, SPECIALISED IN AXIAL SPONDYLOARTHRITIS DURING THE COVID 19 PANDEMIC: EVALUATION OF A MEMBER-SUPPORT PROJECT WITH THE NATIONAL AXIAL SPONDYLOARTHRITIS SOCIETY

Background

COVID-19 caused significant disruption to Axial Spondyloarthritis (AxSpA) services during the intial 2020 lockdown1. In response, The National Axial Spondyloarthritis Society (NASS) piloted provision of remote consultations with a physiotherapist specialised in the management of AxSpA to their members in urgent need. This project was funded by the UK National Lottery Fund

Objectives

To provide a total of 130 hrs of remote consultation to members of NASS, unable to access specialist care and in need of self-management advice for their condition

Methods

Remote consultations were offered to NASS members from Sept 2020 to Feb 2021. The preferred format being 1hr assessment and 2 x 30 min at 1 and 3 weeks from assessment. Participants consented to video consultations via Zoom and the inclusion of anonymised outcomes and comments in the project evaluation.

Patient Reported Outcomes (BASDAI and BASFI) were collected immediately prior to assessment, at final consultation and in April 2021, between 8- 16 weeks from final consult

Content was individually tailored, centring on self-management (pacing, sleep management), education (AxSpA pathology, medication) and individualised exercise plans.

Exercise plans were formulated through “Rehab My Patient” software, including links to YouTube video references and daily exercise log sheets.

Results

67 members received online consultations, 63 receiving the full 3 sessions. Missed appointment rate = 2.5%

Participants represented a wide geographical area across England and a spread in time since diagnosis.

Patient Reported Outcomes Measures (PROMs) on assessment:

● Mean BASDAI score (n=55) on assessment = 5.8

● Mean BASFI score on assessment (n=56) = 5.5

24 participants returned PROMS at final consultation, 10 at longer follow-up (8-16 weeks).

Results for complete data set (n=10):

Table 1.PROMSAssessmentFinal consultationFollow-upMean BASDAI5.04.34.0Mean BASFI5.14.04.1

Satisfaction:

60 members completed an online feedback survey provided by NASS:

9 Feedback to questions were asked, with a satisfaction scale of 1-5 (ascending positivity)

99.6% of all scores were 3 or above.

Example responses:

● How would you rate the overall experience: 92% = 5, 100% = 3-5

● To what extent do you feel more confident to manage your condition: 40% = 5, 100% = 3-5

● How useful was it to be in direct contact with a Physiotherapist: 93% = 5, 100% = 3-5

46 members chose to leave additional, overwhelmingly positive comments, with 2 obvious themes arising:

Conclusion

A set of 1-3 sessions per person achieved desirable patient reported outcomes with modest and enduring improvements seen in disease activity and function.

This pilot project enabled those living with Axial SpA across England access to a Physiotherapist highly experienced in treatment of their condition. The majority of participants reported having no previous experience of seeing a therapist with specialised knowledge of their condition. The knowledge and experience of the clinician was a key theme in the positive nature of feedback linking to another key theme of improved confidence to manage their condition. These results highlight the value to patients of specialised knowledge amongst health professionals. Remote consultations may provide access to specialist knowledge “out of area” and may be an efficient method of delivering self-management advice

References

[1]Marzo-Ortega M, et al. COVID-19 in Axial Spondyloarthritis care provision: helping to straighten the long and winding road. Lancet Rheumatology. 2021. Jan 3(1) e11-13

Disclosure of Interests

Emily Clarke Speakers bureau: Has previously received speaker fees from Novartis Pharmaceutical UK, Jill Hamilton: None declared, Sally Dickinson: None declared

Characteristics associated with COVID-19 vaccine uptake among adults aged 50 years and above in England (8 December 2020-17 May 2021): a population-level observational study

OBJECTIVE

To determine characteristics associated with COVID-19 vaccine coverage among individuals aged 50 years and above in England since the beginning of the programme.

DESIGN

Observational cross-sectional study assessed by logistic regression and mean prevalence margins.

SETTING

COVID-19 vaccinations delivered in England from 8 December 2020 to 17 May 2021.

PARTICIPANTS

30 624 257/61 967 781 (49.4%) and 17 360 045/61 967 781 (28.1%) individuals in England were recorded as vaccinated in the National Immunisation Management System with a first dose and a second dose of a COVID-19 vaccine, respectively.

INTERVENTIONS

Vaccination status with COVID-19 vaccinations.

MAIN OUTCOME MEASURES

Proportion, adjusted ORs and mean prevalence margins for individuals not vaccinated with dose 1 among those aged 50-69 years and dose 1 and 2 among those aged 70 years and above.

RESULTS

Of individuals aged 50 years and above, black/African/Caribbean ethnic group was the least likely of all ethnic groups to be vaccinated with dose 1 of the COVID-19 vaccine. However, of those aged 70 years and above, the odds of not having dose 2 was 5.53 (95% CI 5.42 to 5.63) and 5.36 (95% CI 5.29 to 5.43) greater among Pakistani and black/African/Caribbean compared with white British ethnicity, respectively. The odds of not receiving dose 2 was 1.18 (95% CI 1.16 to 1.20) higher among individuals who lived in a care home compared with those who did not. This was the opposite to that observed for dose 1, where the odds of being unvaccinated was significantly higher among those not living in a care home (0.89 (95% CI 0.87 to 0.91)).

CONCLUSIONS

We found that there are characteristics associated with low COVID-19 vaccine coverage. Inequalities, such as ethnicity are a major contributor to suboptimal coverage and tailored interventions are required to improve coverage and protect the population from SARS-CoV-2.

Molecular chlamydia and gonorrhoea point of care tests implemented into routine practice: Systematic review and value proposition development

BACKGROUND

Sexually Transmitted Infections, including Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT), continue to be a global health problem. Increased access to point-of-care-tests (POCTs) could help detect infection and lead to appropriate management of cases and contacts, reducing transmission and development of reproductive health sequelae. Yet diagnostics with good clinical effectiveness evidence can fail to be implemented into routine care. Here we assess values beyond clinical effectiveness for molecular CT/NG POCTs implemented across diverse routine practice settings.

METHODS

We conducted a systematic review of peer-reviewed primary research and conference abstract publications in Medline and Embase reporting on molecular CT/NG POCT implementation in routine clinical practice until 16th February 2021. Results were extracted into EndNote software and initially screened by title and abstract by one author according to the inclusion and exclusion criteria. Articles that met the criteria, or were unclear, were included for full-text assessment by all authors. Results were synthesised to assess the tests against guidance criteria and develop a CT/NG POCT value proposition for multiple stakeholders and settings.

FINDINGS

The systematic review search returned 440 articles; 28 were included overall. The Cepheid CT/NG GeneXpert was the only molecular CT/NG POCT implemented and evaluated in routine practice. It did not fulfil all test guidance criteria, however, studies of test implementation showed multiple values for test use across various healthcare settings and locations. Our value proposition highlights that the majority of values are setting-specific. Sexual health services and outreach services have the least overlap, with General Practice and other non-sexual health specialist services serving as a "bridge" between the two.

CONCLUSIONS

Those wishing to improve CT/NG diagnosis should be supported to identify the values most relevant to their settings and context, and prioritise implementation of tests that are most closely aligned with those values.

Impact of COVID-19 vaccination program on seroprevalence in blood donors in England, 2021

The COVID-19 vaccination programme commenced in England on 8th December 2020 primarily based on age; by 7th March 2021 approximately 93% of the English population aged 70+ years had received at least 1 dose of either the Pfizer BioNTech or AstraZeneca vaccines. Using a nucleoprotein assay that detects antibodies following natural infection only and a spike assay that detects infection and vaccine-induced responses, we aim to describe the impact of vaccination on SARS-CoV-2 antibody prevalence in English blood donors.

COVID-19 infection in patients with intestinal failure: UK experience

BACKGROUND

The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described.

METHODS

We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF.

RESULTS

A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected).

CONCLUSION

This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.

Anatomical variations of the superficial ulnar artery: case series observed on historical specimens prepared by Ludwik Karol Teichmann

BACKGROUND

In this report we present a series of cases representing variant origin and course of the ulnar artery, namely the superficial ulnar artery, observed during the review of collection of historical specimens prepared in the 19th century by the prominent Polish anatomist Ludwik Karol Teichmann and his collaborators, exhibited in the Anatomy Museum of Jagiellonian University Medical College.

RESULTS

Three distinct variants of the superficial ulnar artery were found on anatomical specimens of the upper limb with arteries injected by using Teichmann's method. In case No. 1, the superficial ulnar artery originated from the brachial artery slightly above the interepicondylar line of the humerus. This aberrant vessel gave off the common interosseous artery in the upper half of the cubital fossa and then ran superficially to the bicipital aponeurosis and over the muscles arising from the medial epicondyle of the humerus. The cases No. 2 and 3 involved two similar variants of the superficial artery in which the common interosseous artery arose from the radial artery. In the unique case No. 4, the superficial ulnar artery arose from the radial artery.

CONCLUSIONS

The superficial ulnar artery shows diverse anatomy regarding its topography and blood supply territory. Orthopedic, hand, and plastic surgeons should be aware of anatomic variations of the SUA both in planning and in conducting surgeries of the upper limb.

Reducing pain through distraction therapy in small acute paediatric burns

INTRODUCTION

The majority of patients who sustained small (low % total body surface area [TBSA]) burns are assessed in an outpatient setting. This can be a traumatic experience, particularly, for paediatric patients. During the initial assessment pharmacological and non-pharmacological adjuncts, such as distraction therapy, can be employed to provide an environment that may reduce and minimise distress. In this study, we investigated whether distraction therapy reduces objective pain scores during the outpatient assessment of small acute burns in children.

METHODS

Two cohorts of patients were formed. In the first group (group A), the children received analgesia and routine nursing care. In the second group (group B), the children received specialist distraction therapy in addition to the same analgesia and nursing care. We recorded patient demographics, TBSA, anatomical sites and mechanism of burn. The Wong Baker™ visual analogue scale (VAS) was used to convert perceived pain, as reported by the patient or parent, into a numerical value at three set intervals during the consultation.

RESULTS

50 patients were recruited with 32 patients in group A and 18 in group B. A larger TBSA positively correlated with higher pain scores (p < 0.05). At the start of the consultation the mean pain score without distraction therapy was 1.55 and with specialist distraction therapy was 0.33 (p < 0.05). The mean peak pain score during dressing change without distraction therapy was 6.80 and with specialist distraction was 4.47 (p < 0.05). At the end of the procedure, the mean pain score was 2.12 without distraction therapy and with specialist distraction 1.75.

CONCLUSION

This study of pain scores in small acute paediatric burns has shown that distraction therapy provided by a qualified play specialist can reduce maximal pain by over 2 points on the Wong-Baker™ VAS. Consideration should be given to ensure that distraction therapy is available at all times during initial consultations for children who have sustained small burns.

Unusual formation of the musculocutaneous and median nerves: a case report refined by intraneural dissection and literature review

This report presents a detailed anatomical investigation of an upper limb specimen showing an atypical formation of the musculocutaneous (MCN) and median (MN) nerves. The study was refined by intraneural dissection, which supplements earlier descriptions of similar anatomical variations and allows for revision of the accepted classification. The case described in this report was an incidental finding during routine dissection of a fixed isolated upper limb. Intraneural dissection revealed partial fusion between the MCN and aberrant bundles of the MN. Those aberrant bundles joined the main steam of the MN at the level at which the MCN branched off as an independent nerve. The procedure allowed the aberrant fibers of the MN to be differentiated from the MCN. The presence of separate bundles in a territory corresponding to the MCN was confirmed, although those bundles and the aberrant MN bundles were covered by a common epineurium. The aberrant MN bundles running within the MCN did not contribute to innervation of the forearm muscles. They rejoined the main nerve trunk in the arm. A comprehensive understanding of the diverse anatomical variations of the upper limb nerves could be crucial for the safety and success of surgical procedures, especially procedures for reconstructing the brachial plexus or its branches.

Clinical utility of liver biopsies in dogs undergoing splenectomy

OBJECTIVE

To determine the prevalence of neoplasia detected on liver biopsy obtained at the time of splenectomy in dogs with splenic masses.

MATERIALS AND METHODS

Retrospective study of medical records of dogs with splenic masses from which liver biopsies were taken following splenectomy.

RESULTS

Malignant splenic neoplasia was detected in 50 of 113 (44.2%) of the dogs undergoing splenectomy. Neoplastic liver disease was detected on biopsy from 1 of 40 (2.5%) dogs with a grossly normal liver and from 20 of 69 (28.9%) dogs with a grossly abnormal liver. Dogs with a grossly abnormal liver had a ~ 16 times (95% CI: 2.5-170) higher chance of being diagnosed with liver neoplasia on biopsy. Haemoabdomen was also associated with an increased likelihood of liver neoplasia on biopsy at the time of splenectomy.

CLINICAL SIGNIFICANCE

A liver biopsy taken from grossly normal liver is a low-yield diagnostic test but liver biopsy is recommended following splenectomy if the liver appears abnormal at surgery.

Restricted bowel loop contouring: Improving efficiency in radiotherapy contouring for abdomino-pelvic Stereotactic Ablative Radiotherapy (SABR)

We present a time-saving alternative to individual bowel loop delineation for abdomino-pelvic Stereotactic Ablative Radiotherapy. Here, individual bowel loop contouring is only performed within a 3 cm circumferential and 2 cm superio-inferior expansion of the PTV. A bowel bag structure represents distal bowel. No relevant doses are 'missed' with this time-saving strategy.

Potential cost-effectiveness of a maternal Group B streptococcal vaccine in The Gambia

OBJECTIVE

To estimate neonatal health benefits and healthcare provider costs of a theoretical Group B streptococcal (GBS) hexavalent maternal vaccination programme in The Gambia, a low-income setting in West Africa.

METHODS

A static decision analytic cost-effectiveness model was developed from the healthcare provider perspective. Demographic data and acute care costs were available from studies in The Gambia undertaken in 2012-2015. Further model parameters were taken from United Nations and World Health Organisation sources, supplemented by data from a global systematic review of GBS and literature searches. As vaccine efficacy is not known, we simulated vaccine efficacy estimates of 50-90%. Costs are reported in US dollars. Cost-effectiveness thresholds of one (US$473, very cost effective) and three (US$1420, cost effective) times Gambian GDP were used.

RESULTS

Vaccination with a hexavalent vaccine would avert 24 GBS disease cases (55%) and 768 disability adjusted life years compared to current standard of care (no interventions to prevent GBS disease). At vaccine efficacy of 70%, the programme is cost-effective at a maximum vaccine price per dose of 12 US$ (2016 US$), and very cost-effective at a maximum of $3/dose. The total costs of vaccination at $12 is $1,056,962 for one annual cohort of Gambian pregnant women. One-way sensitivity analysis showed that GBS incidence was the most influential parameter on the cost effectiveness ratio.

CONCLUSION

The introduction of a hexavalent vaccine would considerably reduce the current burden of GBS disease in The Gambia but to be cost-effective, the vaccine price per dose would need to be $12/dose or less.

Adherence to the 2012 European gonorrhoea guideline in the WHO European Region according to the 2018-19 International Union against Sexually Transmitted Infections European Collaborative Clinical Group gonorrhoea survey

Gonorrhoea is a major public health problem globally. Increasing incidence in many particularly developed countries and the emergence of resistance to the extended-spectrum cephalosporin ceftriaxone, the last option for empiric first-line monotherapy, are of serious concern. This paper evaluates the results of the 2018–19 International Union against Sexually Transmitted Infections European Collaborative Clinical Group survey on the diagnosis and treatment of gonorrhoea in Europe. Although high quality clinical care was reported in many European settings, in several countries the testing, diagnostics, antimicrobial treatment, and follow-up of gonorrhoea patients were evidently suboptimal. Increased adherence to evidence-based European and/or nationally-adapted management guidelines is essential in controlling the increasing incidence of gonorrhoea in many European settings and the spread of ceftriaxone-resistant, multidrug-resistant, and extensively drug-resistant gonorrhoea.

The 2018-19 International Union against Sexually Transmitted Infections European Collaborative Clinical Group report on the diagnosis and treatment of gonorrhoea in Europe

The European Collaborative Clinical Group (ECCG) has been surveying clinical management of sexually transmitted infections (STIs) in Europe since its inauguration in 2011. The ECCG is a network of nearly 130 STI specialists from 34 European countries who conduct questionnaire-based research across the European region. The research of ECCG focuses on providing data regarding clinical practice to inform European STI guideline development and revisions. The present paper describes the results of the 2018–19 ECCG survey regarding diagnosis and treatment of gonorrhoea in Europe.

Age-related neurochemical and behavioural changes in D409V/WT GBA1 mouse: Relevance to lewy body dementia

Heterozygous mutations in GBA1, the gene which encodes the lysosomal enzyme glucocerebrosidase (GCase), are a strong genetic risk factor for the development of Lewy body dementia (LBD). Until this point however, recapitulation of the symptoms and pathology of LBD has been limited to a homozygous GBA1 mouse model which genetically and enzymatically reflects the lysosomal storage disorder Gaucher's disease. This study reports for the first time cognitive impairment by two independent behavioural tests in heterozygous GBA1 mutant mice (D409V/WT) which demonstrate significant cognitive impairment by the age of 12 months. Furthermore, reductions in GBA1 GCase enzyme activity within the brain reflects levels seen in sporadic and GBA1 mutant LBD patients. While there is no overt deposition of Lewy bodies within the hippocampus, alterations to cholinergic machinery and glial proliferation are evident, both pathological features of LBD. Interestingly, we also describe the novel finding of significantly reduced GBA2 GCase enzyme activity specifically within the hippocampus. This suggests that reduced GBA1 GCase enzyme activity dis-equilibrates the finely balanced glycosphingolipid metabolism pathway and that reductions in GBA2 GCase enzyme could contribute to the pathological and behavioural effects seen. Overall, this study presents evidence to suggest that pathological hallmarks associated with LBD specifically affecting brain regions intrinsically linked with cognition are present in the D409V/WT mice. In the absence of Lewy body deposition, the D409V/WT mice could be considered an early pre-clinical model of LBD with potential for drug discovery. Since few robust pre-clinical models of LBD currently exist, with further characterization, the mouse model described here may contribute significantly to developments in the LBD field.

Efficacy of repetitive transcranial magnetic stimulation in the treatment of depression with comorbid anxiety disorders

BACKGROUND

The presence of comorbid anxiety is generally associated with poorer treatment outcomes in people with depression. Repetitive transcranial magnetic stimulation (rTMS) has been shown to be effective for treatment resistant depression, but there has been little research examining rTMS in depressed patients with comorbid anxiety disorders. This study aimed to investigate the efficacy of rTMS in patients with treatment resistant Major Depressive Disorder (MDD) and comorbid anxiety disorders.

METHODS

This study included 248 patients with treatment resistant MDD who were treated with rTMS. Of these, 172 patients had one or more comorbid anxiety disorders, so their outcomes were compared with patients who did not have comorbid anxiety.

RESULTS

Patients both with and without comorbid anxiety disorders showed improvement in depression ratings after rTMS treatment, with no significant difference in remission rates between groups. In those with comorbid anxiety disorders, 23.3% met criteria for remission and 39.5% met response criteria. For each anxiety disorder diagnosis, there was a significant reduction in HAM-A, HAM-D21, MADRS and ZUNG scores (p = <0.001 for all).

LIMITATIONS

This was not a sham-controlled study, so placebo response rates are not known. Patients were referred by private psychiatrists so are not representative of all patients with depression.

CONCLUSION

Our study indicates that rTMS is an effective treatment for Major Depressive Disorder in people who have comorbid anxiety disorders.

Tunable Photon Statistics Exploiting the Fano Effect in a Waveguide

A strong optical nonlinearity arises when coherent light is scattered by a semiconductor quantum dot coupled to a nanophotonic waveguide. We exploit the Fano effect in such a waveguide to control the phase of the quantum interference underpinning the nonlinearity, experimentally demonstrating a tunable quantum optical filter which converts a coherent input state into either a bunched or an antibunched nonclassical output state. We show theoretically that the generation of nonclassical light is predicated on the formation of a two-photon bound state due to the interaction of the input coherent state with the quantum dot. Our model demonstrates that the tunable photon statistics arise from the dependence of the sign of two-photon interference (either constructive or destructive) on the detuning of the input relative to the Fano resonance.

Quantum interface of an electron and a nuclear ensemble

Coherent excitation of an ensemble of quantum objects underpins quantum many-body phenomena and offers the opportunity to realize a memory that stores quantum information. Thus far, a deterministic and coherent interface between a spin qubit and such an ensemble has remained elusive. In this study, we first used an electron to cool the mesoscopic nuclear spin ensemble of a semiconductor quantum dot to the nuclear sideband–resolved regime. We then implemented an all-optical approach to access individual quantized electronic-nuclear spin transitions. Lastly, we performed coherent optical rotations of a single collective nuclear spin excitation—a spin wave. These results constitute the building blocks of a dedicated local memory per quantum-dot spin qubit and promise a solid-state platform for quantum-state engineering of isolated many-body systems.

Th17 responses to pneumococcus in blood and adenoidal cells in children

Pneumococcal infections cause a large global health burden, and the search for serotype-independent vaccines continues. Existing conjugate vaccines reduce nasopharyngeal colonization by target serotypes. Such mucosal effects of novel antigens may similarly be important. CD4+ Th17 cell-dependent, antibody-independent reductions in colonization and enhanced clearance have been described in mice. Here we describe the evaluation of T helper type 17 (Th17) cytokine responses to candidate pneumococcal protein vaccine antigens in human cell culture, using adenoidal and peripheral blood mononuclear cells. Optimal detection of interleukin (IL)-17A was at day 7, and of IL-22 at day 11, in these primary cell cultures. Removal of CD45RO+ memory T cells abolished these responses. Age-associated increases in magnitude of responses were evident for IL-17A, but not IL-22, in adenoidal cells. There was a strong correlation between individual IL-17A and IL-22 responses after pneumococcal antigen stimulation (P < 0·015). Intracellular cytokine staining following phorbol myristate acetate (PMA)/ionomycin stimulation demonstrated that  > 30% CD4+ T cells positive for IL-22 express the innate markers γδT cell receptor and/or CD56, with much lower proportions for IL-17A+ cells (P < 0·001). Responses to several vaccine candidate antigens were observed but were consistently absent, particularly in blood, to PhtD (P < 0·0001), an antigen recently shown not to impact colonization in a clinical trial of a PhtD-containing conjugate vaccine in infants. The data presented and approach discussed have the potential to assist in the identification of novel vaccine antigens aimed at reducing pneumococcal carriage and transmission, thus improving the design of empirical clinical trials.

Klingler's method of brain dissection: review of the technique including its usefulness in practical neuroanatomy teaching, neurosurgery and neuroimaging

Klingler's technique was discovered in the 1930s. It is a modified method of brain fixation and dissection, based on freezing and thawing of the brain tissue, subsequent peeling away of white matter fibres and the gradual exposure of white matter tracts. The added value of this technique is that it is carried out in a stratigraphic manner. This fact makes it an invaluable tool for an in-depth understanding of the complex anatomical organisation of the cerebral hemispheres. The purpose of this paper is to provide a review of Klingler's method while taking into account the original description of the technique and its value for medical training. The historical background, the concise outline of white matter organisation, as well as our own experience in using this procedure for research and teaching activities were also included. The fibre dissection technique may still be considered an excellent complementary research tool for neuroanatomical studies. Numerous detailed observations about the white matter topography and spatial organisation have been recently made by applying this method. Using this technique may also improve understanding of the three-dimensional intrinsic structure of the brain, which is particularly important both in under- and postgraduate training in the field of neuroanatomy.

Nonreciprocal Transmission and Reflection of a Chirally Coupled Quantum Dot

We report strongly nonreciprocal behavior for quantum dot exciton spins coupled to nanophotonic waveguides under resonant laser excitation. A clear dependence of the transmission spectrum on the propagation direction is found for a chirally coupled quantum dot, with spin up and spin down exciton spins coupling to the left and right propagation directions, respectively. The reflection signal shows an opposite trend to the transmission, which a numerical model indicates is due to direction-selective saturation of the quantum dot. The chiral spin-photon interface we demonstrate breaks reciprocity of the system and opens the way to spin-based quantum optical components such as optical diodes and circulators in a chip-based solid-state environment.

Increased Alcohol Seeking in Mice Lacking Gpr88 Involves Dysfunctional Mesocorticolimbic Networks

BACKGOUND

Alcohol use disorder (AUD) is devastating and poorly treated, and innovative targets are actively sought for prevention and treatment. The orphan G protein-coupled receptor GPR88 is enriched in mesocorticolimbic pathways, and Gpr88 knockout mice show hyperactivity and risk-taking behavior, but a potential role for this receptor in drug abuse has not been examined.

METHODS

We tested Gpr88 knockout mice for alcohol-drinking and -seeking behaviors. To gain system-level understanding of their alcohol endophenotype, we also analyzed whole-brain functional connectivity in naïve mice using resting-state functional magnetic resonance imaging.

RESULTS

Gpr88 knockout mice showed increased voluntary alcohol drinking at both moderate and excessive levels, with intact alcohol sedation and metabolism. Mutant mice also showed increased operant responding and motivation for alcohol, while food and chocolate operant self-administration were unchanged. Alcohol place conditioning and alcohol-induced dopamine release in the nucleus accumbens were decreased, suggesting reduced alcohol reward in mutant mice that may partly explain enhanced alcohol drinking. Seed-based voxelwise functional connectivity analysis revealed significant remodeling of mesocorticolimbic centers, whose hallmark was predominant weakening of prefrontal cortex, ventral tegmental area, and amygdala connectional patterns. Also, effective connectivity from the ventral tegmental area to the nucleus accumbens and amygdala was reduced.

CONCLUSIONS

Gpr88 deletion disrupts executive, reward, and emotional networks in a configuration that reduces alcohol reward and promotes alcohol seeking and drinking. The functional connectivity signature is reminiscent of alterations observed in individuals at risk for AUD. The Gpr88 gene, therefore, may represent a vulnerability/resilience factor for AUD, and a potential drug target for AUD treatment.

Electro-mechanical control of an on-chip optical beam splitter containing an embedded quantum emitter

We demonstrate electro-mechanical control of an on-chip GaAs optical beam splitter containing a quantum dot single-photon source. The beam splitter consists of two nanobeam waveguides, which form a directional coupler (DC). The splitting ratio of the DC is controlled by varying the out-of-plane separation of the two waveguides using electromechanical actuation. We reversibly tune the beam splitter between an initial state, with emission into both output arms, and a final state with photons emitted into a single output arm. The device represents a compact and scalable tuning approach for use in III-V semiconductor integrated quantum optical circuits.

Pilot feasibility randomized clinical trial of negative-pressure wound therapy versus usual care in patients with surgical wounds healing by secondary intention

Background

Surgical wounds healing by secondary intention (SWHSI) are increasingly being treated with negative-pressure wound therapy (NPWT) despite a lack of high-quality research evidence regarding its clinical and cost-effectiveness. This pilot feasibility RCT aimed to assess the methods for and feasibility of conducting a future definitive RCT of NPWT for the treatment of SWHSI.

Methods

Eligible consenting adult patients receiving care at the study sites (2 acute and 1 community) and with a SWHSI appropriate for NPWT or wound dressing treatment were randomized 1 : 1 centrally to receive NPWT or usual care (no NPWT). Participants were followed up every 1-2 weeks for 3 months. Feasibility (recruitment rate, time to intervention delivery) and clinical (time to wound healing) outcomes were assessed.

Results

A total of 248 participants were screened for eligibility; 40 (16·1 per cent) were randomized, 19 to NPWT and 21 to usual care. Twenty-four of the 40 wounds were located on the foot. Participants received NPWT for a median of 18 (range 0-72) days. Two participants in the NPWT group never received the intervention and 14 received NPWT within 48 h of randomization. Five participants in the usual care group received NPWT during the study. Ten of the 40 wounds were deemed to have healed during the study.

Conclusion

A full-scale RCT to investigate the clinical and cost-effectiveness of NPWT for SWHSI is feasible. This study identified crucial information on recruitment rates and data collection methods to consider during the design of a definitive RCT. Registration number: ISRCTN12761776 (http://www.iscrtn.com).

Transition from Propagating Polariton Solitons to a Standing Wave Condensate Induced by Interactions

We explore phase transitions of polariton wave packets, first, to a soliton and then to a standing wave polariton condensate in a multimode microwire system, mediated by nonlinear polariton interactions. At low excitation density, we observe ballistic propagation of the multimode polariton wave packets arising from the interference between different transverse modes. With increasing excitation density, the wave packets transform into single-mode bright solitons due to effects of both intermodal and intramodal polariton-polariton scattering. Further increase of the excitation density increases thermalization speed, leading to relaxation of the polariton density from a solitonic spectrum distribution in momentum space down to low momenta, with the resultant formation of a nonequilibrium condensate manifested by a standing wave pattern across the whole sample.

Exciton Polaritons in a Two-Dimensional Lieb Lattice with Spin-Orbit Coupling

We study exciton polaritons in a two-dimensional Lieb lattice of micropillars. The energy spectrum of the system features two flat bands formed from S and P_{x,y} photonic orbitals, into which we trigger bosonic condensation under high power excitation. The symmetry of the orbital wave functions combined with photonic spin-orbit coupling gives rise to emission patterns with pseudospin texture in the flat band condensates. Our Letter shows the potential of polariton lattices for emulating flat band Hamiltonians with spin-orbit coupling, orbital degrees of freedom, and interactions.

Improving a Solid-State Qubit through an Engineered Mesoscopic Environment

A controlled quantum system can alter its environment by feedback, leading to reduced-entropy states of the environment and to improved system coherence. Here, using a quantum-dot electron spin as a control and probe, we prepare the quantum-dot nuclei under the feedback of coherent population trapping and observe their evolution from a thermal to a reduced-entropy state, with the immediate consequence of extended qubit coherence. Via Ramsey interferometry on the electron spin, we directly access the nuclear distribution following its preparation and measure the emergence and decay of correlations within the nuclear ensemble. Under optimal feedback, the inhomogeneous dephasing time of the electron, T_{2}^{*}, is extended by an order of magnitude to 39 ns. Our results can be readily exploited in quantum information protocols utilizing spin-photon entanglement and represent a step towards creating quantum many-body states in a mesoscopic nuclear-spin ensemble.

Phase-Tuned Entangled State Generation between Distant Spin Qubits

Quantum entanglement between distant qubits is an important feature of quantum networks. Distribution of entanglement over long distances can be enabled through coherently interfacing qubit pairs via photonic channels. Here, we report the realization of optically generated quantum entanglement between electron spin qubits confined in two distant semiconductor quantum dots. The protocol relies on spin-photon entanglement in the trionic Λ system and quantum erasure of the Raman-photon path information. The measurement of a single Raman photon is used to project the spin qubits into a joint quantum state with an interferometrically stabilized and tunable relative phase. We report an average Bell-state fidelity for |ψ^{(+)}⟩ and |ψ^{(-)}⟩ states of 61.6±2.3% and a record-high entanglement generation rate of 7.3 kHz between distant qubits.

Publisher's Note: Spin Textures of Exciton-Polaritons in a Tunable Microcavity with Large TE-TM Splitting [Phys. Rev. Lett. 115, 246401 (2015)]

This corrects the article DOI: 10.1103/PhysRevLett.115.246401.

Spatial regularity of InAs-GaAs quantum dots: quantifying the dependence of lateral ordering on growth rate

The lateral ordering of arrays of self-assembled InAs-GaAs quantum dots (QDs) has been quantified as a function of growth rate, using the Hopkins-Skellam index (HSI). Coherent QD arrays have a spatial distribution which is neither random nor ordered, but intermediate. The lateral ordering improves as the growth rate is increased and can be explained by more spatially regular nucleation as the QD density increases. By contrast, large and irregular 3D islands are distributed randomly on the surface. This is consistent with a random selection of the mature QDs relaxing by dislocation nucleation at a later stage in the growth, independently of each QD’s surroundings. In addition we explore the statistical variability of the HSI as a function of the number N of spatial points analysed, and we recommend N > 10³ to reliably distinguish random from ordered arrays.

Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study

BACKGROUND

Clinical decision-making is the vehicle of health care provision, and level of involvement predicts implementation and satisfaction. The aim of this study was to investigate the impact of decision-making experience on recovery.

METHODS

Data derived from an observational cohort study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR). Adults (aged 18-60) meeting standardised criteria for severe mental illness were recruited from caseloads of outpatient and community mental health services in six European countries. After consenting, they were assessed using standardised measures of decision-making, clinical outcome and stage of recovery at baseline and 1 year later. Latent class analysis was used to identify course of recovery, and proportional odds models to investigate predictors of recovery stage and change.

RESULTS

Participants (n = 581) clustered into three stages of recovery at baseline: Moratorium (N = 115; 19.8%), Awareness/Preparation (N = 145; 25.0%) and Rebuilding/Growth (N = 321; 55.2%). Higher stage was cross-sectionally associated with being male, married, living alone or with parents, and having better patient-rated therapeutic alliance and fewer symptoms. The model accounted for 40% of the variance in stage of recovery. An increased chance of worse outcome (change over 1 year to lower stage of recovery) was found for patients with active involvement compared with either shared (OR = 1.84, 95% CI 1.15-2.94) or passive (OR = 1.71, 95% CI = 1.00-2.95) involvement. Overall, both process (therapeutic relationship) and outcome (symptomatology) are cross-sectionally associated with stage of recovery.

CONCLUSIONS

Patient-rated decision-making involvement and change in stage of recovery are associated. Joint consideration of decision practise within the recovery process between patient and clinician is supposed to be a useful strategy to improve clinical practice (ISRCTN registry: ISRCTN75841675. Retrospectively registered 15 September 2010).

Predictors of older drivers' involvement in rapid deceleration events

Rapid deceleration occurs when substantial force slows the speed of a vehicle. Rapid deceleration events (RDEs) have been proposed as a surrogate safety measure. As there is concern about crash involvement of older drivers and the effect of age-related declining visual and cognitive function on driving performance, we examined the relationship between RDEs and older driver's vision, cognitive function and driving confidence, using naturalistic driving measures. Participants aged 75 to 94 years had their vehicle instrumented for 12 months. To minimise the chance of identifying false positives, accelerometer data was processed to identify RDEs with a substantial deceleration of >750 milli-g (7.35m/s²). We examined the incidence of RDEs amongst older drivers, and how this behaviour is affected by differences in age; sex; visual function, cognitive function; driving confidence; and declines over the 12 months. Almost two-thirds (64%) of participants were involved in at least one RDE, and 22% of these participants experienced a meaningful decline in contrast sensitivity during the 12 months. We conducted regression modelling to examine associations between RDEs and predictive measures adjusted for (i) duration of monitoring and (ii) distance driven. We found the rate of RDEs per distance increased with age; although, this did not remain in the multivariate model. In the multivariate model, we found older drivers who experienced a decline in contrast sensitivity over the 12 months and those with lower baseline driving confidence were at increased risk of involvement in RDEs adjusted for distance driven. In other studies, contrast sensitivity has been associated with increased crash involvement for older drivers. These findings lend support for the use of RDEs as a surrogate safety measure, and demonstrate an association between a surrogate safety measure and a decline in contrast sensitivity of older drivers.

Recovery practice in community mental health teams: national survey

BACKGROUND

There is consensus about the importance of 'recovery' in mental health services, but the link between recovery orientation of mental health teams and personal recovery of individuals has been underresearched.

AIMS

To investigate differences in team leader, clinician and service user perspectives of recovery orientation of community adult mental health teams in England.

METHOD

In six English mental health National Health Service (NHS) trusts, randomly chosen community adult mental health teams were surveyed. A random sample of ten patients, one team leader and a convenience sample of five clinicians were surveyed from each team. All respondents rated the recovery orientation of their team using parallel versions of the Recovery Self Assessment (RSA). In addition, service users also rated their own personal recovery using the Questionnaire about Processes of Recovery (QPR).

RESULTS

Team leaders (n = 22) rated recovery orientation higher than clinicians (n = 109) or patients (n = 120) (Wald(2) = 7.0, P = 0.03), and both NHS trust and team type influenced RSA ratings. Patient-rated recovery orientation was a predictor of personal recovery (b = 0.58, 95% CI 0.31-0.85, P<0.001). Team leaders and clinicians with experience of mental illness (39%) or supporting a family member or friend with mental illness (76%) did not differ in their RSA ratings from other team leaders or clinicians.

CONCLUSIONS

Compared with team leaders, frontline clinicians and service users have less positive views on recovery orientation. Increasing recovery orientation may support personal recovery.

Quantum dot spin coherence governed by a strained nuclear environment

The interaction between a confined electron and the nuclei of an optically active quantum dot provides a uniquely rich manifestation of the central spin problem. Coherent qubit control combines with an ultrafast spin–photon interface to make these confined spins attractive candidates for quantum optical networks. Reaching the full potential of spin coherence has been hindered by the lack of knowledge of the key irreversible environment dynamics. Through all-optical Hahn echo decoupling we now recover the intrinsic coherence time set by the interaction with the inhomogeneously strained nuclear bath. The high-frequency nuclear dynamics are directly imprinted on the electron spin coherence, resulting in a dramatic jump of coherence times from few tens of nanoseconds to the microsecond regime between 2 and 3 T magnetic field and an exponential decay of coherence at high fields. These results reveal spin coherence can be improved by applying large magnetic fields and reducing strain inhomogeneity.

Spins confined to quantum dots are a possible qubit, but the mechanism that limits their coherence is unclear. Here, the authors use an all-optical Hahn-echo technique to determine the intrinsic coherence time of such spins set by its interaction with the inhomogeneously strained nuclear bath.

Participation in medical decision-making across Europe: An international longitudinal multicenter study

BACKGROUND

The purpose of this paper was to examine national differences in the desire to participate in decision-making of people with severe mental illness in six European countries.

METHODS

The data was taken from a European longitudinal observational study (CEDAR; ISRCTN75841675). A sample of 514 patients with severe mental illness from the study centers in Ulm, Germany, London, England, Naples, Italy, Debrecen, Hungary, Aalborg, Denmark and Zurich, Switzerland were assessed as to desire to participate in medical decision-making. Associations between desire for participation in decision-making and center location were analyzed with generalized estimating equations.

RESULTS

We found large cross-national differences in patients' desire to participate in decision-making, with the center explaining 47.2% of total variance in the desire for participation (P<0.001). Averaged over time and independent of patient characteristics, London (mean=2.27), Ulm (mean=2.13) and Zurich (mean=2.14) showed significantly higher scores in desire for participation, followed by Aalborg (mean=1.97), where scores were in turn significantly higher than in Debrecen (mean=1.56). The lowest scores were reported in Naples (mean=1.14). Over time, the desire for participation in decision-making increased significantly in Zurich (b=0.23) and decreased in Naples (b=-0.14). In all other centers, values remained stable.

CONCLUSIONS

This study demonstrates that patients' desire for participation in decision-making varies by location. We suggest that more research attention be focused on identifying specific cultural and social factors in each country to further explain observed differences across Europe.

Exuberant granulation tissue response associated with Neobenedenia sp. (Monogenea: Capsalidae) infestation in two cobia, Rachycentron canadum (Linnaeus)

Monogenean parasite infestations are common in captive marine teleosts, and are generally found on the skin and gills. This report describes an unusual pathological presentation of exuberant granulation tissue of the gills, suspected to be related to Neobenedenia infestation in two cobia housed together at a North Carolina aquarium.

Spin Textures of Exciton-Polaritons in a Tunable Microcavity with Large TE-TM Splitting

We report an extended family of spin textures of zero-dimensional exciton-polaritons spatially confined in tunable open microcavity structures. The transverse-electric-transverse-magnetic (TE-TM) splitting, which is enhanced in the open cavity structures, leads to polariton eigenstates carrying quantized spin vortices. Depending on the strength and anisotropy of the cavity confining potential and of the TE-TM induced splitting, which can be tuned via the excitonic or photonic fractions, the exciton-polariton emissions exhibit either spin-vortex-like patterns or linear polarization, in good agreement with theoretical modeling.

International students' experience of a western medical school: a mixed methods study exploring the early years in the context of cultural and social adjustment compared to students from the host country

BACKGROUND

Few studies have addressed the challenges associated with international students as they adapt to studying medicine in a new host country. Higher level institutions have increasing numbers of international students commencing programmes. This paper explores the experiences of a cohort of students in the early years of medical school in Ireland, where a considerable cohort are from an international background.

METHODS

A mixed exploratory sequential study design was carried out with medical students in the preclinical component of a five year undergraduate programme. Data for the qualitative phase was collected through 29 semi-structured interviews using the peer interview method. Thematic analysis from this phase was incorporated to develop an online questionnaire combined with components of the Student Adaptation to College Questionnaire and Student Integration Questionnaire. First year students were anonymously surveyed online. The Mokken Scaling procedure was used to investigate the students' experiences, both positive and negative.

RESULTS

Three main themes are identified; social adjustment, social alienation and cultural alienation. The response rate for the survey was 49% (467 Respondents). The Mokken Scaling method identified the following scales (i) Positive experience of student life; (ii) Social alienation, which comprised of negative items about feeling lonely, not fitting in, being homesick and (iii) Cultural alienation, which included the items of being uncomfortable around cultural norms of dress and contact between the sexes. With the threshold set to H = 0.4. Subscales of the positive experiences of student life scale are explored further.

CONCLUSIONS

Overall student adjustment to a western third level college was good. Students from regions where cultural distance is greatest reported more difficulties in adjusting. Students from these regions also demonstrate very good adaptation. Some students from the host country and more similar cultural backgrounds were also struggling. Acculturation is more complex than being associated with cultural distance and worthy of further exploration.

Prodromal symptoms in knee osteoarthritis: a nested case-control study using data from the Osteoarthritis Initiative

OBJECTIVE

In order to gain a better understanding of the timing of emergent symptoms of osteoarthritis, we sought to investigate the existence, duration and nature of a prodromal symptomatic phase preceding incident radiographic knee osteoarthritis (ROA).

DESIGN

Data were from the incidence cohort of the Osteoarthritis Initiative (OAI) public use datasets. Imposing a nested case-control design, ten control knees were selected for each case of incident tibiofemoral ROA between 2004 and 2010 from participants aged 45-79 years. Candidate prodromal symptoms were Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) and Knee injury and Osteoarthritis Outcome Score (KOOS) subscale scores and individual items, available up to 4 years prior to the time of incident ROA. Multi-level models were used to estimate the length of the prodromal phases.

RESULTS

The prodromal phase for subscale scores ranged from 29 months (KOOS Other Symptoms) to 37 months (WOMAC Pain). Pain and difficulty on activities associated with higher dynamic knee loading were associated with longer prodromal phases (e.g., pain on twisting/pivoting (39 months, 95% confidence interval: 13, 64) vs pain on standing (25 months: 7, 42)).

CONCLUSIONS

Our analysis found that incident ROA is preceded by prodromal symptoms lasting at least 2-3 years. This has potential implications for understanding phasic development and progression of osteoarthritis and for early recognition and management.

Supporting recovery in patients with psychosis through care by community-based adult mental health teams (REFOCUS): a multisite, cluster, randomised, controlled trial

BACKGROUND

Mental health policy in many countries is oriented around recovery, but the evidence base for service-level recovery-promotion interventions is lacking.

METHODS

We did a cluster, randomised, controlled trial in two National Health Service Trusts in England. REFOCUS is a 1-year team-level intervention targeting staff behaviour to increase focus on values, preferences, strengths, and goals of patients with psychosis, and staff-patient relationships, through coaching and partnership. Between April, 2011, and May, 2012, community-based adult mental health teams were randomly allocated to provide usual treatment plus REFOCUS or usual treatment alone (control). Baseline and 1-year follow-up outcomes were assessed in randomly selected patients. The primary outcome was recovery and was assessed with the Questionnaire about Processes of Recovery (QPR). We also calculated overall service costs. We used multiple imputation to estimate missing data, and the imputation model captured clustering at the team level. Analysis was by intention to treat. This trial is registered, number ISRCTN02507940.

FINDINGS

14 teams were included in the REFOCUS group and 13 in the control group. Outcomes were assessed in 403 patients (88% of the target sample) at baseline and in 297 at 1 year. Mean QPR total scores did not differ between the two groups (REFOCUS group 40·6 [SD 10·1] vs control 40·0 [10·2], adjusted difference 0·68, 95% CI -1·7 to 3·1, p=0·58). High team participation was associated with higher staff-rated scores for recovery-promotion behaviour change (adjusted difference -0·4, 95% CI -0·7 to -0·2, p=0·001) and patient-rated QPR interpersonal scores (-1·6, -2·7 to -0·5, p=0·005) at follow-up than low participation. Patients treated in the REFOCUS group incurred £1062 (95% CI -1103 to 3017) lower adjusted costs than those in the control group.

INTERPRETATION

Although the primary endpoint was negative, supporting recovery might, from the staff perspective, improve functioning and reduce needs. Implementation of REFOCUS could increase staff recovery-promotion behaviours and improve patient-rated recovery.

FUNDING

National Institute for Health Research.