A Comparative Account of Institutional Approaches to Addressing Campus-Based Sexual Violence in Australia and Aotearoa New Zealand

Sexual violence is prevalent on university campuses globally. In this article, we report a qualitative insider research study examining practices for addressing sexual violence at four universities across Australia and Aotearoa New Zealand. We collected, analysed, and synthesised descriptive information about the practices at each institution. We found unique institutional approaches that nonetheless share some commonalities, yieldingseveral themes that are central to practice. In reflecting on our findings, we conclude with an outline of critical considerations and a call to action for future efforts to address campus-based sexual violence, particularly as this field remains underdeveloped across Australia and Aotearoa New Zealand.

Evidence for early domestic yak, taurine cattle, and their hybrids on the Tibetan Plateau

Domestic yak, cattle, and their hybrids are fundamental to herder survival at high altitudes on the Tibetan Plateau. However, little is known about their history. Bos remains are uncommon in this region, and ancient domestic yak have not been securely identified. To identify Bos taxa and investigate their initial management, we conducted zooarchaeological analyses of 193 Bos specimens and sequenced five nuclear genomes from recently excavated assemblages at Bangga. Morphological data indicated that more cattle than yak were present. Ancient mitochondrial DNA and nuclear genome sequences identified taurine cattle and provided evidence for domestic yak and yak-cattle hybridization ~2500 years ago. Reliance on diverse Bos species and their hybrid has increased cattle adaptation and herder resilience to plateau conditions. Ancient cattle and yak at Bangga were closely related to contemporary livestock, indicating early herder legacies and the continuity of cattle and yak husbandry on the Tibetan Plateau.

"Crack on": a qualitative study of care home managers experiences and responses to system-led setbacks during the crisis of the COVID-19 Pandemic in England

OBJECTIVES

To explore care home managers' experiences of systems working with various organisations, including statutory, third sector and private, during the second wave of the COVID-19 pandemic from Sept 2020 to April 2021 DESIGN: An exploratory qualitative interview study using a systems theory approach focussing on the intersections of relationship interdependencies with other organisations.

SETTING

Conducted remotely with care home managers and key advisors who had worked since the start of the pandemic in/with care homes for older people across the East Midlands, UK.

PARTICIPANTS

8 care home managers and 2 end-of-life advisors who participated during the second wave of the pandemic from Sept 2020. A total of 18 care home managers participated in the wider study from April 2020 to April 2021 RESULTS: Four organisational relationship interdependencies were identified: care practices, resources governance and wise working. Managers identified changes in their care practices as a shift towards the normalisation of care, with an emphasis on navigating pandemic restrictions to fit the context. Resources such as staffing, clinical reviews, pharmaceutical and equipment supplies were challenged, leading to a sense of precarity and tension. National polices and local guidance were fragmented, complex and disconnected from the reality of managing a care home. As a response a highly pragmatic reflexive style of management was identified which encompassed the use of mastery to navigate and in some cases circumvent official systems and mandates. Managers' experience of persistent and multiple setbacks were viewed as negative and confirmed their views that care homes as a sector ere marginalised by policy makers and statutory bodies.

CONCLUSIONS

Interactions with various organisations shaped the ways in which care home managers responded to and sought to maximise residents and staff well-being. Some relationships dissolved over time, such as when local business and schools returned to normal obligations. Other newly formed relationships became more robust including those with other care home managers, families, and hospices. Significantly, most managers viewed their relationship with local authority and national statutory bodies as detrimental to effective working, leading to a sense of increased mistrust and ambiguity. Respect, recognition and meaningful collaboration with the care home sector should underpin any future attempts to introduce practice change in the sector.

Amyotrophic lateral sclerosis: a neurodegenerative disorder poised for successful therapeutic translation

Amyotrophic lateral sclerosis (ALS) is a devastating disease caused by degeneration of motor neurons. As with all major neurodegenerative disorders, development of disease-modifying therapies has proven challenging for multiple reasons. Nevertheless, ALS is one of the few neurodegenerative diseases for which disease-modifying therapies are approved. Significant discoveries and advances have been made in ALS preclinical models, genetics, pathology, biomarkers, imaging and clinical readouts over the last 10-15 years. At the same time, novel therapeutic paradigms are being applied in areas of high unmet medical need, including neurodegenerative disorders. These developments have evolved our knowledge base, allowing identification of targeted candidate therapies for ALS with diverse mechanisms of action. In this Review, we discuss how this advanced knowledge, aligned with new approaches, can enable effective translation of therapeutic agents from preclinical studies through to clinical benefit for patients with ALS. We anticipate that this approach in ALS will also positively impact the field of drug discovery for neurodegenerative disorders more broadly.

Comparative osteomorphological criteria for differentiating mandibular teeth and post-cranial skeletons of takins (Budorcas taxicolor) from Bovini species on Tibetan Plateau

For centuries, hunting and herding of large bovids were important for human survival at high altitudes on the Tibetan Plateau. However, little is known about past human relations with iconic plateau animals, such as takins (Budorcas taxicolor Hodgson, 1850) or yaks (Bos grunniens Linnaeus, 1766). Takins were widely hunted historically for subsistence and social reasons, but an understanding of ancient relationships has been hampered by the difficulty of distinguishing takins from other large wild or domestic bovids, e.g., gaurs (Bos gaurus), yaks, cattle (Bos taurus), water buffalo (Bubalus bubalis). Through the comparative and systematic study of modern specimens, comprising 80 mandibles and 53–78 skeletons curated across five institutions in China and the United States, this research proposes a new set of osteomorphological criteria for differentiating large bovids from the Tibetan Plateau and tests previously published criteria. The results show that takins can be easily differentiated from yaks, cattle, gaurs, and water buffalos using readily identifiable shape differences, non-metric characteristics, and specific landmarks of mandibular teeth and post-cranial elements. Criteria with especially high-reliability scores include mandibular teeth and 14 postcranial elements: scapula, humerus, femur, tibia, fibula, metapodials, lunate, scaphoid, magnum, unciform, and astragalus. Providing a reproducible field method for distinguishing takins from other large bovids in this region, the osteomorphological criteria established in this study will further archaeological investigations of Holocene hunting on the Tibetan Plateau, as well as early usage of domesticated yaks and cattle. These criteria can also be used in conservation to aid field identification of illegally hunted takins.

Automatic Assessment of the Type and Intensity of Agitated Hand Movements

With increasing numbers of people living with dementia, there is growing interest in the automatic monitoring of agitation. Current assessments rely on carer observations within a framework of behavioural scales. Automatic monitoring of agitation can supplement existing assessments, providing carers and clinicians with a greater understanding of the causes and extent of agitation. Despite agitation frequently manifesting in repetitive hand movements, the automatic assessment of repetitive hand movements remains a sparsely researched field. Monitoring hand movements is problematic due to the subtle differences between different types of hand movements and variations in how they can be carried out; the lack of training data creates additional challenges. This paper proposes a novel approach to assess the type and intensity of repetitive hand movements using skeletal model data derived from video. We introduce a video-based dataset of five repetitive hand movements symptomatic of agitation. Using skeletal keypoint locations extracted from video, we demonstrate a system to recognise repetitive hand movements using discriminative poses. By first learning characteristics of the movement, our system can accurately identify changes in the intensity of repetitive movements. Wide inter-subject variation in agitated behaviours suggests the benefit of personalising the recognition model with some end-user information. Our results suggest that data captured using a single conventional RGB video camera can be used to automatically monitor agitated hand movements of sedentary patients.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

SEeking AnsweRs for Care Homes during the COVID-19 pandemic (COVID SEARCH)

The care and support of older people residing in long-term care facilities during the COVID-19 pandemic has created new and unanticipated uncertainties for staff. In this short report, we present our analyses of the uncertainties of care home managers and staff expressed in a self-formed closed WhatsApp™ discussion group during the first stages of the pandemic in the UK. We categorised their wide-ranging questions to understand what information would address these uncertainties and provide support. We have been able to demonstrate that almost one-third of these uncertainties could have been tackled immediately through timely, responsive and unambiguous fact-based guidance. The other uncertainties require appraisal, synthesis and summary of existing evidence, commissioning or provision of a sector- informed research agenda for medium to long term. The questions represent wider internationally relevant care home pandemic-related uncertainties.

Care homes, their communities, and resilience in the face of the COVID-19 pandemic: interim findings from a qualitative study

BACKGROUND

From late February 2020, English care homes rapidly adapted their practices in response to the COVID-19 pandemic. In addition to accommodating new guidelines and policies, staff had to adjust to rapid reconfiguration of services external to the home that they would normally depend upon for support. This study examined the complex interdependencies of support as staff responded to COVID-19. The aim was to inform more effective responses to the ongoing pandemic, and to improve understanding of how to work with care home staff and organisations after the pandemic has passed.

METHODS

Ten managers of registered care homes in the East Midlands of England were interviewed by videoconference or phone about their experiences of the crisis from a structured organisational perspective. Analysis used an adapted organisational framework analysis approach with a focus on social ties and interdependencies between organisations and individuals.

RESULTS

Three key groups of interdependencies were identified: care processes and practice; resources; and governance. Care home staff had to deliver care in innovative ways, making high stakes decisions in circumstances defined by: fluid ties to organisations outside the care home; multiple, sometimes conflicting, sources of expertise and information; and a sense of deprioritisation by authorities. Organisational responses to the pandemic by central government resulted in resource constraints and additional work, and sometimes impaired the ability of staff and managers to make decisions. Local communities, including businesses, third-sector organisations and individuals, were key in helping care homes overcome challenges. Care homes, rather than competing, were found to work together to provide mutual support. Resilience in the system was a consequence of dedicated and resourceful staff using existing local networks, or forging new ones, to overcome barriers to care.

CONCLUSIONS

This study identified how interdependency between care home organisations, the surrounding community, and key statutory and non-statutory organisations beyond their locality, shaped decision making and care delivery during the pandemic. Recognising these interdependencies, and the expertise shown by care home managers and staff as they navigate them, is key to providing effective healthcare in care homes as the pandemic progresses, and as the sector recovers afterwards.

Analysing interactions among the sustainable development goals: findings and emerging issues from local and global studies

The topic of SDG interactions is a relatively new research area with many knowledge gaps. Some of these gaps are addressed in this summary of a Special Feature of Sustainability Science, including new findings and emerging issues on (1) the characteristics of SDG interactions; (2) methods/methodology to analyse these interactions; and (3) the elaboration of drivers that influence SDG synergies. The importance of scale is clear in two emerging issues. First, there is evidence of a disconnect between national planning for SDGs and their implementation at the local scale which is leading to SDG trade-offs between these scales. Second, the concept of a "critical transition zone" is introduced where SDG trade-offs pose a particular challenge to SDG implementation. These are areas (e.g., peri-urban and forest margin areas in the Global South) undergoing rapid biophysical and/or socio-economic changes and inhabited by populations especially vulnerable to these changes. While trade-offs occur among the SDGs, there are also many examples of synergies which provide opportunities for advancing multiple goals. To distinguish between synergies and the actions that exploit them, the term "synergy driver" is introduced to refer to policies and measures that positively advance two or more goals. Several examples of synergy drivers are presented, including sustainable global supply chains, people-centred early warning systems, and joint conservation-public health programmes. To make synergy drivers relevant to the broader policy community, the research community (working with stakeholders) should first consolidate knowledge about these drivers and then evaluate their effectiveness/applicability to different policy settings.

Health professionals' views on health literacy issues for culturally and linguistically diverse women in maternity care: barriers, enablers and the need for an integrated approach

Objective To identify health literacy issues when providing maternity care to culturally and linguistically diverse (CALD) women, and the strategies needed for health professionals to collaboratively address these issues. Methods A qualitative case study design was undertaken at one large metropolitan Australian hospital serving a highly CALD population. Semistructured interviews were conducted with a range of maternity healthcare staff. The data were analysed thematically. The study is informed by a framework of cultural competence education interventions for health professionals and a health literacy framework. Results Eighteen clinicians participated in the interviews (seven midwives, five obstetricians, five physiotherapists, one social worker, and one occupational therapist). Emergent themes of health literacy-related issues were: patient-based factors (communication and cultural barriers, access issues); provider-based factors (time constraints, interpreter issues); and enablers (cultural awareness among staff, technology). Conclusions There are significant health literacy and systemic issues affecting the hospital's provision of maternity care for CALD women. These findings, mapped onto the four domains of cultural competence education interventions will inform a technology-delivered health literacy intervention for CALD maternity patients. This approach may be applied to other culturally diverse healthcare settings to foster patient health literacy. What is known about the topic? There are health inequities for pregnant women of culturally and linguistically diverse (CALD) backgrounds. Low health literacy compounded by language and cultural factors contribute to these inequities and access to interpreters in pregnancy care remains an ongoing issue. Pregnancy smart phone applications are a popular source of health information for pregnant women yet these apps are not tailored for CALD women nor are they part of a regulated industry. What does this paper add? This paper provides clinician and language service staff perspectives on key health literacy issues that are both patient-based and provider-based. This research confirms that the complex interplay of social and practical factors contributes to and perpetuates low health literacy, creating barriers to health access; it also highlights several enablers for increasing CALD health literacy and access. These include greater health practitioner awareness and accommodation of CALD women's needs and the provision of culturally and linguistically appropriate eHealth resources. What are the implications for practitioners? eHealth resources are emerging as valuable enabling tools to address the health literacy and information needs of pregnant women. However, these resources need to be used adjunctively with health practitioner communication. Both resource developers and health practitioners need to understand issues affecting CALD patients and their needs. Developers need to consider how the resource addresses these needs. Training of health professionals about culture-specific issues may help to enhance communication with, and therefore health literacy among, individual cultural groups. Further, formalised language and interpreting training of bi- or multilingual health professionals is advised to ensure that they are able to interpret to a professional standard when called on to do so.

An ethnographic study comparing approaches to inter-professional knowledge sharing and learning in discharge planning and care transitions

PURPOSE

The purpose of this paper is to investigate how three communication interventions commonly used during discharge planning and care transitions enable inter-professional knowledge sharing and learning as a foundation for more integrated working. These interventions include information communication systems, dedicated discharge planning roles and group-based planning activities.

DESIGN/METHODOLOGY/APPROACH

A two-year ethnographic study was carried out across two regional health and care systems in the English National Health Service, focussing on the discharge of stroke and hip fracture patients. Data collection involved in-depth observations and 213 semi-structured interviews.

FINDINGS

Information systems (e.g. e-records) represent a relatively stable conduit for routine and standardised forms of syntactic information exchange that can "bridge" time-space knowledge boundaries. Specialist discharge roles (e.g. discharge coordinators) support personalised and dynamic forms of "semantic" knowledge sharing that can "broker" epistemic and cultural boundaries. Group-based activities (e.g. team meetings) provide a basis for more direct "pragmatic" knowledge translation that can support inter-professional "bonding" at the cultural and organisational level, but where inclusion factors complicate exchange.

RESEARCH LIMITATIONS/IMPLICATIONS

The study offers analysis of how professional boundaries complicate discharge planning and care transition, and the potential for different communication interventions to support knowledge sharing and learning.

ORIGINALITY/VALUE

The paper builds upon existing research on inter-professional collaboration and patient safety by focussing on the problems of communication and coordination in the context of discharge planning and care transitions. It suggests that care systems should look to develop multiple complementary approaches to inter-professional communication that offer opportunities for dynamic knowledge sharing and learning.

Carbon and nitrogen isotope variability in the seeds of two African millet species: Pennisetum glaucum and Eleusine coracana

RATIONALE

A range of important small seeded C₄ crops were domesticated in Africa, but little is known about their carbon and nitrogen isotope ratios (δ¹³ C and δ¹⁵ N values). Understanding natural isotopic variability within and among millets has the potential to help us to understand the conditions under which ancient cereals were grown and has significant implications for the interpretation of ancient diets based on stable isotope signatures.

METHODS

We conducted carbon and nitrogen isotope analyses of modern and historical pearl millet (Pennisetum glaucum, n = 108) and finger millet (Eleusine coracana, n = 17) seed samples sourced from the United States Department of Agriculture as well as the Harlan Collection curated at the Crop Evolution Laboratory Herbarium at the University of Illinois.

RESULTS

The millet species have significantly different mean carbon and nitrogen isotope ratios over broad temporal and spatial scales. We also found substantial isotopic variation within species (range of 1.9‰ and 8.5‰ in δ¹³ C and δ¹⁵ N values, respectively). Both water availability and growing season temperature significantly affected the P. glaucum δ¹³ C and δ¹⁵ N values; cumulative annual precipitation was positively correlated with both seed δ¹³ C and δ¹⁵ N values, while temperature was positively correlated with δ¹⁵ N values but negatively correlated with seed δ¹³ C values.

CONCLUSIONS

The importance of both temperature and precipitation as predictors of δ¹³ C and δ¹⁵ N values in millets suggests that C₄ plants may be more sensitive to environmental parameters than previously appreciated. Given the high degree of carbon and nitrogen isotope variability among accessions of these species, it is imperative that site-relevant plant isotope ratios are used for making isotope-based paleo-dietary predictions.

Ancient herders enriched and restructured African grasslands

Grasslands are one of the world's most extensive terrestrial biomes and are central to the survival of herders, their livestock and diverse communities of large wild mammals^1-3. In Africa, tropical soils are predominantly nutrient-limited^4-6 but productive grassy patches in wooded grassland savannah ecosystems^2,4 grow on fertile soils created by geologic and edaphic factors, megafauna, fire and termites^4-6. Mobile pastoralists also create soil-fertility hotspots by penning their herds at night, which concentrates excrement-and thus nutrients-from grazing of the surrounding savannahs^7-11. Historical anthropogenic hotspots produce high-quality forage, attract wildlife and increase spatial heterogeneity in African savannahs^4,12-15. Archaeological research suggests this effect extends back at least 1,000 years^16-19 but little is known about nutrient persistence at millennial scales. Here we use chemical, isotopic and sedimentary analyses to show high nutrient and ¹⁵N enrichment in on-site degraded dung deposits relative to off-site soils at five Pastoral Neolithic²⁰ sites (radiocarbon dated to between 3,700 and 1,550 calibrated years before present (cal. BP)). This study demonstrates the longevity of nutrient hotspots and the long-term legacy of ancient herders, whose settlements enriched and diversified African savannah landscapes over three millennia.

Scaling the Peaks Research Protocol: understanding the barriers and drivers to providing and using dementia-friendly community services in rural areas-a mixed methods study

INTRODUCTION

Scaling the Peaks is a cross-disciplinary research study that draws on medical ethnography, human geography and Geospatial Information Science (GIS) to address the issues surrounding the design and delivery of dementia-friendly services in rural communities. The research question seeks to understand the barriers and drivers to the development of relevant, robust, reliable and accessible services that make a difference among older rural families affected by dementia.

METHODS AND ANALYSIS

This mixed methods study recruits both families affected by dementia who reside within the Peak District National Park, Derbyshire, and their service providers. The study explores the expectations and experiences of rural dementia by adopting a three-part approach ¹ : longitudinal ethnographic enquiry with up to 32 families affected by dementia (aged 70 years plus) who identify themselves as rural residents ² ; ethnographic semistructured interviews and systematic observations of a range of statutory, third sector, private and local community initiatives that seek to support older people living with dementia ³ ; and geospatial visual mapping of the qualitative and quantitative data. The ethnographic data will be used to explore the ideas of belonging in a community, perceptions of place and identity to determine the factors that influence everyday decisions about living well with dementia and, for the providers, working in a rural community. The geospatial component of the study seeks to incorporate quantitative and qualitative data, such as types, locations and allocation of services to produce an interactive web-based map for local communities to determine the future design and delivery of services when considering dementia-friendly services.

ETHICS AND DISSEMINATION

The study is approved by the Leeds and Humberside Health Research Authority 16/YH/0163. The study is also approved by other participating organisations as required by their own governance procedures. The study includes people with dementia and as such adheres to the ethical considerations when including people with dementia. A publicly available interactive visual map of the findings will be produced in relation to current services related to location and, by default, identify gaps in provision. Formal reports and dissemination activities will be undertaken in collaboration with the study advisory group members.

STUDY PROGRESS

The recruitment began in September 2016. The data analysis commenced June 2017, using 59 provider interviews and 27 family participants. Data collection will be completed June 2018.

NOTE ON TERMINOLOGY

Please note that the term 'families affected by dementia' is the preferred term of usage by the family members of the Scaling the Peaks Study Advisory Group. The group wish to emphasise that they consider this term to be more representative of their lives than the term living with dementia.

TRIAL REGISTRATION NUMBER

NIHR IRAS 188103; Pre-results.

The Community In-reach Rehabilitation and Care Transition (CIRACT) clinical and cost-effectiveness randomisation controlled trial in older people admitted to hospital as an acute medical emergency

Objective

to compare the clinical and cost-effectiveness of a Community In-reach Rehabilitation and Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service.

Design

pragmatic randomised controlled trial with an integral health economic study.

Settings

large UK teaching hospital, with community follow-up.

Subjects

frail older people aged 70 years and older admitted to hospital as an acute medical emergency.

Measurements

Primary outcome: hospital length of stay; secondary outcomes: readmission, day 91-super spell bed days, functional ability, co-morbidity and health-related quality of life; cost-effectiveness analysis.

Results

a total of 250 participants were randomised. There was no significant difference in length of stay between the CIRACT and THB-Rehab service (median 8 versus 9 days; geometric mean 7.8 versus 8.7 days, mean ratio 0.90, 95% confidence interval (CI) 0.74–1.10). Of the participants who were discharged from hospital, 17% and 13% were readmitted within 28 days from the CIRACT and THB-Rehab services, respectively (risk difference 3.8%, 95% CI −5.8% to 13.4%). There were no other significant differences in any of the other secondary outcomes between the two groups. The mean costs (including NHS and personal social service) of the CIRACT and THB-Rehab service were £3,744 and £3,603, respectively (mean cost difference £144; 95% CI −1,645 to 1,934).

Conclusion

the CIRACT service does not reduce major hospital length of stay nor reduce short-term readmission rates, compared to the standard THB-Rehab service; however, a modest (<2.3 days) effect cannot be excluded. Further studies are necessary powered with larger sample sizes and cluster randomisation.

Trial registration

ISRCTN 94393315, 25th April 2013

Understanding the occupational and organizational boundaries to safe hospital discharge

OBJECTIVE

Safe hospital discharge relies upon communication and coordination across multiple occupational and organizational boundaries. Our aim was to understand how these boundaries can exacerbate health system complexity and represent latent sociocultural threats to safe discharge.

METHODS

An ethnographic study was conducted in two local health and social care systems (health economies) in England, focusing on two clinical areas: stroke and hip fracture patients. Data collection involved 345 hours of observations and 220 semi-structured interviews with health and social care professionals, patients and their lay carers.

RESULTS

Hospital discharge involves a dynamic network of interactions between heterogeneous health and social care actors, each characterized by divergent ways of organizing discharge activities; cultures of collaboration and interaction and understanding of what discharge involves and how it contributes to patient recovery. These interrelated dimensions elaborate the occupational and organisational boundaries that can influence communication and coordination in hospital discharge.

CONCLUSIONS

Hospital discharge relies upon the coordination of multiple actors working across occupational and organizational boundaries. Attention to the sociocultural boundaries that influence communication and coordination can help inform interventions that might support enhanced discharge safety.

Substance use and misuse: A public health perspective

Drug, alcohol and tobacco misuse (generically known as substance misuse) is a universal phenomenon that affects all levels of society. Increasing drug use generally has caused a host of social, behavioural, psychological and physical problems among populations. Substance use and misuse impinges on the five key areas for health promotion outlined in the Health of the Nation document (DoH, 1992): coronary heart disease and stroke, prevention of accidents, cancer, sexual health, mental health. The widespread misuse of psychoactive substances in the general population demands a healthcare workforce that can offer nursing interventions; is capable of providing effective preventive strategies; can offer counselling; and is qualified to give specialist care when necessary to substance misusers and their families.

The care of substance misusers is not the domain of any one profession or organisation, although professionals in both primary healthcare and hospital settings are usually the first point of contact for clients who have potential or even early substance use problems. From the late '80s, prevention and treatment have become much higher on the political and service agendas. Public health campaigns have been introduced that maximise awareness of the risks of tobacco smoking, of drink driving, and of the misuse of over-the-counter drugs, alcohol, prescribed and illicit drugs. As a result, the public health triangular model, which involves interaction between the host (the individual), the agent and the environment, has become more prominent. The increase in substance misuse means that research that identifies why nurses and other healthcare workers are unable to identify the factors that lead to substance misuse is of paramount importance. If nurses and other healthcare professionals are to respond to substance misusers, there need to be new models of care from those that have traditionally guided the work of generic healthcare professionals. This paper considers substance misuse in general, but concentrates particularly on drug misuse.

A qualitative study of professional and carer perceptions of the threats to safe hospital discharge for stroke and hip fracture patients in the English National Health Service

Background

Hospital discharge is a vulnerable transitional stage in patient care. This qualitative study investigated the views of healthcare professionals and patients about the threats to safe hospital discharge with aim of identifying contributory and latent factors. The study was undertaken in two regional health and social care systems in the English National Health Service, each comprising three acute hospitals, community and primary care providers and municipal social care services. The study focused on the threats to safe discharge for hip fracture and stroke patients as exemplars of complex care transitions.

Methods

A qualitative study involving narrative interviews with 213 representative stakeholders and professionals involved in discharge planning and care transition activities. Narratives were analysed in line with ‘systems’ thinking to identify proximal (active) and distal (latent) factors, and the relationships between them.

Results

Three linked categories of commonly and consistently identified threat to safe discharge were identified: (1) ‘direct’ patient harms comprising falls, infection, sores and ulceration, medicines-related issues, and relapse; (2) proximal ‘contributing’ factors including completion of tests, assessment of patient, management of equipment and medicines, care plan, follow-up care and patient education; and distal ‘latent’ factors including discharge planning, referral processes, discharge timing, resources constraints, and organisational demands.

Conclusion

From the perspective of stakeholders, the study elaborates the relationship between patient harms and systemic factors in the context of hospital discharge. It supports the importance of communication and collaboration across occupational and organisational boundaries, but also the challenges to supporting such communication with the inherent complexity of the care system.

Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study

Background

Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater.

Objective

To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years.

Methods

A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients.

Results

In total, 250 participants were randomised (n = 125 CIRACT service,n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services.

Conclusions

The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team.

Trial registration

Current Controlled Trials ISRCTN94393315.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Pharmacology and physiology of gastrointestinal enteroendocrine cells

Gastrointestinal (GI) polypeptides are secreted from enteroendocrine cells (EECs). Recent technical advances and the identification of endogenous and synthetic ligands have enabled exploration of the pharmacology and physiology of EECs. Enteroendocrine signaling pathways stimulating hormone secretion involve multiple nutrient transporters and G protein-coupled receptors (GPCRs), which are activated simultaneously under prevailing nutrient conditions in the intestine following a meal. The majority of studies investigate hormone secretion from EECs in response to single ligands and although the mechanisms behind how individual signaling pathways generate a hormonal output have been well characterized, our understanding of how these signaling pathways converge to generate a single hormone secretory response is still in its infancy. However, a picture is beginning to emerge of how nutrients and full, partial, or allosteric GPCR ligands differentially regulate the enteroendocrine system and its interaction with the enteric and central nervous system. So far, activation of multiple pathways underlies drug discovery efforts to harness the therapeutic potential of the enteroendocrine system to mimic the phenotypic changes observed in patients who have undergone Roux-en-Y gastric surgery. Typically obese patients exhibit ∼30% weight loss and greater than 80% of obese diabetics show remission of diabetes. Targeting combinations of enteroendocrine signaling pathways that work synergistically may manifest with significant, differentiated EEC secretory efficacy. Furthermore, allosteric modulators with their increased selectivity, self-limiting activity, and structural novelty may translate into more promising enteroendocrine drugs. Together with the potential to bias enteroendocrine GPCR signaling and/or to activate multiple divergent signaling pathways highlights the considerable range of therapeutic possibilities available. Here, we review the pharmacology and physiology of the EEC system.

The Community In-Reach and Care Transition (CIRACT) clinical and cost-effectiveness study: study protocol for a randomised controlled trial

BACKGROUND

Older people represent a significant proportion of patients admitted to hospital. Their care compared to younger patients is more challenging, length of stay is longer, risk of hospital-acquired problems higher and the risk of being re-admitted within 28 days greater. This study aims to compare a Community In-Reach and Care Transition (CIRACT) service with Traditional Hospital Based rehabilitation (THB-Rehab) provided to the older person. The CIRACT service differs from the THB-rehab service in that they are able to provide more intensive hospital rehabilitation, visiting patients daily, and are able to continue with the patient's rehabilitation following discharge allowing a seamless, integrated discharge working alongside community providers. A pilot comparing the two services showed that the CIRACT service demonstrated reduced length of stay and reduced re-admission rates when analysed over a four-month period.

METHODS/DESIGN

This trial will evaluate the clinical and cost-effectiveness of the CIRACT service, conducted as a randomised controlled trial (RCT) with an integral qualitative mechanism and action study designed to provide the explanatory and theoretical components on how the CIRACT service compares to current practice. The RCT element consists of 240 patients over 70 years of age, being randomised to either the THB therapy group or the CIRACT service following an unplanned hospital admission. The primary outcome will be hospital length of stay from admission to discharge from the general medical elderly care ward. Additional outcome measures including the Barthel Index, Charlson Co-morbidity Scale, EuroQoL-5D and the modified Client Service Receipt Inventory will be assessed at the time of recruitment and repeated at 91 days post-discharge. The qualitative mechanism and action study will involve a systematic programme of organisational profiling, observations of work processes, interviews with key informants and care providers and tracking of participants. In addition, a within-trial economic evaluation will be undertaken comparing the CIRACT and THB-rehab services to determine cost-effectiveness.

DISCUSSION

The outcome of the study will inform clinical decision-making, with respect to allocation of resources linked to hospital discharge planning and re-admissions, in a resource intensive and growing group of patients.

TRIAL REGISTRATION

Registered with the ISRCTN registry ( ISCRCTN94393315 ) on 25 April 2013 (version 3.1, 11 September 2014).

Implications of metabotropic glutamate receptor structures for drug discovery in neurotherapeutics

Recent technological advances in the field of membrane protein structural biology have led to significantly improved success rates in the structure resolution of G protein-coupled receptors. Apart from gaining insight into the mechanics of receptor biology, these technical advances facilitate the application of structure-based drug discovery to G protein-coupled receptors. Structure-based drug discovery has the potential to significantly increase the efficiency and success rate of drug discovery campaigns against this important family of drug targets. Recently, structures of mGlu1 and mGlu5 transmembrane domains were reported in complex with negative allosteric modulators. Analysis of these structures reveals a fascinating insight into the historical difficulties associated with the drug discovery efforts for these receptors and provides an important novel template for structure-based drug discovery approaches to identify more diverse and better quality chemotypes.

An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge

Background

Hospital discharge is a vulnerable stage in the patient pathway. Research highlights communication failures and the problems of co-ordination as resulting in delayed, poorly timed and unsafe discharges. The complexity of hospital discharge exemplifies the threats to patient safety found ‘between’ care processes and organisations. In developing this perspective, safe discharge is seen as relying upon enhanced knowledge sharing and collaboration between stakeholders, which can mitigate system complexity and promote safety.

Aim

To identify interventions and practices that support knowledge sharing and collaboration in the processes of discharge planning and care transition.

Setting

The study was undertaken between 2011 and 2013 in two English health-care systems, each comprising an acute health-care provider, community and primary care providers, local authority social services and social care agencies. The study sites were selected to reflect known variations in local population demographics as well as in the size and composition of the care systems. The study compared the experiences of stroke and hip fracture patients as exemplars of acute care with complex discharge pathways.

Design

The study involved in-depth ethnographic research in the two sites. This combined (a) over 180 hours of observations of discharge processes and knowledge-sharing activities in various care settings; (b) focused ‘patient tracking’ to trace and understand discharge activities across the entire patient journey; and (c) qualitative interviews with 169 individuals working in health, social and voluntary care sectors.

Findings

The study reinforces the view of hospital discharge as a complex system involving dynamic and multidirectional patterns of knowledge sharing between multiple groups. The study shows that discharge planning and care transitions develop through a series of linked ‘situations’ or opportunities for knowledge sharing. It also shows variations in these situations, in terms of the range of actors, forms of knowledge shared, and media and resources used, and the wider culture and organisation of discharge. The study also describes the threats to patient safety associated with hospital discharge, as perceived by participants and stakeholders. These related to falls, medicines, infection, clinical procedures, equipment, timing and scheduling of discharge, and communication. Each of these identified risks are analysed and explained with reference to the observed patterns of knowledge sharing to elaborate how variations in knowledge sharing can hinder or promote safe discharge.

Conclusions

The study supports the view of hospital discharge as a complex system involving tightly coupled and interdependent patterns of interaction between multiple health and social care agencies. Knowledge sharing can help to mitigate system complexity through supporting collaboration and co-ordination. The study suggests four areas of change that might enhance knowledge sharing, reduce system complexity and promote safety. First, knowledge brokers in the form of discharge co-ordinators can facilitate knowledge sharing and co-ordination; second, colocation and functional proximity of stakeholders can support knowledge sharing and mutual appreciation and alignment of divergent practices; third, local cultures should prioritise and value collaboration; and finally, organisational resources, procedures and leadership should be aligned to fostering knowledge sharing and collaborative working. These learning points provide insight for future interventions to enhance discharge planning and care transition. Future research might consider the implementation of interviews to mediate system complexity through fostering enhanced knowledge sharing across occupational and organisational boundaries. Research might also consider in more detail the underlying complexity of both health and social care systems and how opportunities for knowledge sharing might be engendered to promote patient safety in other areas.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Policy Transformations and Translations: Lessons for Sustainable Water Management in Peri-Urban Delhi, India

This paper explores the complex interactions that occur as formal policies are interpreted and utilised to develop water management plans in peri-urban Delhi. With an emphasis on people's participation in decision making, the paper examines some of the disjunctures between formal assumptions about water management in peri-urban areas and practices on the ground. In doing so it attempts to reveal some of the key processes responsible for social fragmentation of services. The paper describes informal coping strategies adopted by poor and marginalised peri-urban communities with little or no access to formal provision. Within this, the role of ‘hidden’ interactions with the formal system are highlighted in the context of failures of formal participatory platforms. The paper argues that enhanced understanding of the policy process, and the alternative arrangements that emerge in response to its shortfalls, could be important contributory factors in identifying realistic intervention strategies for enhanced, more socially just, water management in peri-urban situations.

The epileptic singers of belle époque Paris

In late 19th century Paris, people with epilepsy were treated alongside those with hysteria in the now famous Salpêtrière Hospital, where both conditions were deemed to have a neurological basis. When Jean Martin Charcot became chief physician at the Salpêtrière Hospital in 1862, he described himself 'in possession of a kind of museum of living pathology whose holdings were virtually inexhaustible'. He opened the doors of his 'living museum' and exhibited his prize specimens to all of Paris. By putting his patients on display, Charcot introduced a vogue for pathology that permeated well beyond the world of medical enquiry and into the public psyche and vernacular. Not only did Charcot's demonstrations provide the inspiration for high culture in the form of operas, plays and novels, they also provided the inspiration for the 'gommeuses epileptiques' (epileptic singers), who entertained the masses at the café concerts. This paper explores the foundations of our current medical approaches to mental illness and epilepsy, with a particular focus on the boundaries that emerged between hysteria and epilepsy in 19th century Paris. These clinical boundaries were both shaped by and reflected in the popular entertainments in the city.

Clinical vignettes in Parkinson's disease: a collection of unusual medication-induced hallucinations, delusions, and compulsive behaviours

Hallucinations, delusions, and compulsive behaviors are frequent iatrogenic complications of the treatment of motor dysfunction in Parkinson's disease (PD). Although these have been studied, and the phenomenology described, there are few detailed descriptions of the various psychiatric problems our treated PD patients live with that allow physicians who do not have a great deal of experience with PD patients to appreciate the extent of their altered lives. This report is a compilation of vignettes describing these behavioral problems that the treating neurologist or psychiatrist attributed to the medications used for treating PD.

Biacore analysis with stabilized G-protein-coupled receptors

Using stabilized forms of β₁ adrenergic and A₂(A) adenosine G-protein-coupled receptors, we applied Biacore to monitor receptor activity and characterize binding constants of small-molecule antagonists spanning more than 20,000-fold in affinity. We also illustrate an improved method for tethering His-tagged receptors on NTA (carboxymethylated dextran preimmobilized with nitrilotriacetic acid) chips to yield stable, high-capacity, high-activity surfaces as well as a novel approach to regenerate receptor binding sites. Based on our success with this approach, we expect that the combination of stabilized receptors with biosensor technology will become a common method for characterizing members of this receptor family.

The impact of GPCR structures on pharmacology and structure-based drug design

After many years of effort, recent technical breakthroughs have enabled the X-ray crystal structures of three G-protein-coupled receptors (GPCRs) (beta1 and beta2 adrenergic and adenosine A(2a)) to be solved in addition to rhodopsin. GPCRs, like other membrane proteins, have lagged behind soluble drug targets such as kinases and proteases in the number of structures available and the level of understanding of these targets and their interaction with drugs. The availability of increasing numbers of structures of GPCRs is set to greatly increase our understanding of some of the key issues in GPCR biology. In particular, what constitutes the different receptor conformations that are involved in signalling and the molecular changes which occur upon receptor activation. How future GPCR structures might alter our views on areas such as agonist-directed signalling and allosteric regulation as well as dimerization is discussed. Knowledge of crystal structures in complex with small molecules will enable techniques in drug discovery and design, which have previously only been applied to soluble targets, to now be used for GPCR targets. These methods include structure-based drug design, virtual screening and fragment screening. This review considers how these methods have been used to address problems in drug discovery for kinase and protease targets and therefore how such methods are likely to impact GPCR drug discovery in the future.

Monoenergetic-proton-radiography measurements of implosion dynamics in direct-drive inertial-confinement fusion

Time-gated, monoenergetic radiography with 15-MeV protons provides unique measurements of implosion dynamics in direct-drive inertial-confinement fusion. Images obtained during acceleration, coasting, deceleration, and stagnation display a comprehensive picture of spherical implosions. Critical information inferred from such images, hitherto unavailable, characterizes the spatial structure and temporal evolution of self-generated fields and plasma areal density. Results include the first observation of a radial electric field inside the imploding capsule. It is initially directed inward (at approximately 10(9) V/m), eventually reverses direction ( approximately 10(8) V/m), and is the probable consequence of the evolution of the electron pressure gradient.

Differential effects of the D- and L- isomers of amphetamine on pharmacological MRI BOLD contrast in the rat

RATIONALE

The D - and L-amphetamine sulphate isomers are used in the formulation of Adderall XR(R), which is effective in the treatment of attention-deficit hyperactivity disorder (ADHD). The effects of these isomers on brain activity has not been examined using neuroimaging.

OBJECTIVES

This study determines the pharmacological magnetic resonance imaging blood-oxygenation-level-dependent (BOLD) response in rat brain regions after administration of each isomer.

MATERIALS AND METHODS

Rats were individually placed into a 2.35 T Bruker magnet for 60 min to achieve basal recording of variation in signal intensity. Either saline (n = 9), D-amphetamine sulphate (2 mg/kg, i.p.; n = 9) or L: -amphetamine sulphate (4 mg/kg, i.p.; n = 9) were administered, and recording continued for a further 90 min. Data were analysed for BOLD effects using statistical parametric maps. Blood pressure, blood gases and respiratory rate were monitored during scanning.

RESULTS

The isomers show overlapping effects on the BOLD responses in areas including nucleus accumbens, medial entorhinal cortex, colliculi, field CA1 of hippocampus and thalamic nuclei. The L-isomer produced greater global changes in the positive BOLD response than the D-isomer, including the somatosensory and motor cortices and frontal brain regions such as the orbitofrontal cortices, prelimbic and infralimbic cortex which were not observed with the D-isomer.

CONCLUSIONS

The amphetamine isomers produce different BOLD responses in brain areas related to cognition, pleasure, pain processing and motor control probably because of variations on brain amine systems such as dopamine and noradrenaline. The isomers may, therefore, have distinct actions on brain regions affected in ADHD patients.

Heavy metal contamination of soil and vegetables in suburban areas of Varanasi, India

Heavy metal contamination of soil resulting from wastewater irrigation is a cause of serious concern due to the potential health impacts of consuming contaminated produce. In this study an assessment is made of the impact of wastewater irrigation on heavy metal contamination of Beta vulgaris (palak); this is a highly nutritious leafy vegetable that is widely cultivated and consumed in urban India, particularly by the poor. A field study was conducted at three major sites that were irrigated by either treated or untreated wastewater in the suburban areas of Varanasi, India according to normal practice. Samples of irrigation water, soil, and the edible portion of the palak (Beta vulgaris L. var All green H1) were collected monthly during the summer and winter seasons and were analyzed for Cd, Cu, Zn, Pb, Cr, Mn, and Ni. Heavy metals in irrigation water were below the internationally recommended (WHO) maximum permissible limits set for agricultural use for all heavy metals except Cd at all the sites. Similarly, the mean heavy metal concentrations in soil were below the Indian standards for all heavy metals, but the maximum value of Cd recorded during January was higher than the standard. However, in the edible portion of B. vulgaris, the Cd concentration was higher than the permissible limits of the Indian standard during summer, whereas Pb and Ni concentrations were higher in both summer and winter seasons. Results of linear regression analysis computed to assess the relationship between individual heavy metal concentration in the vegetable samples and in soil showed that Zn in soil had a positive significant relationship with vegetable contamination during winter. Concentrations of Cd, Cu, and Mn in soil and plant showed significant positive relationships only during summer. Concentration of Cr and Pb during winter season and Zn and Ni during summer season showed significant negative relationships between soil and plant contamination. The study concludes that the use of treated and untreated wastewater for irrigation has increased the contamination of Cd, Pb, and Ni in edible portion of vegetables causing potential health risk in the long term from this practice. The study also points to the fact that adherence to standards for heavy metal contamination of soil and irrigation water does not ensure safe food.

Atomoxetine produces changes in cortico-basal thalamic loop circuits: assessed by phMRI BOLD contrast

Atomoxetine is a selective noradrenaline reuptake inhibitor used in the treatment of attention deficit hyperactivity disorder (ADHD) which has not yet been assessed using pharmacological neuroimaging for its effects on rat brain activity. The pharmacological magnetic resonance imaging (phMRI) blood oxygenation level dependent (BOLD) response was determined in rat brain regions following administration of atomoxetine. Rats were individually placed into a 2.35T Bruker magnet for 60min to achieve basal recording of changes in signal intensity. Either saline (n=9) or atomoxetine hydrochloride (2mg/kg; i.p.; n=10) was then administered and recording continued for a further 90min. Data were analysed for BOLD random effects using statistical parametric maps and time course analysis. The main changes observed were widespread negative BOLD responses in the caudate putamen and changes in brain regions associated with the cortico-basal thalamic loop circuits. BOLD changes in the basal ganglia help explain its efficacy in reducing hyperactivity observed in ADHD patients. Although positive BOLD changes in the prefrontal cortex were limited to the ventral orbital cortex this is an area associated with behavioral control and may be of relevance to the use of the drug in ADHD.

Effects of amphetamine isomers, methylphenidate and atomoxetine on synaptosomal and synaptic vesicle accumulation and release of dopamine and noradrenaline in vitro in the rat brain

D- and L-amphetamine sulphate isomers, methylphenidate and atomoxetine, are effective treatments for attention-deficit hyperactivity disorder (ADHD). This study provides a detailed comparison of their effects on the synaptosomal and vesicular accumulation of dopamine (DA) and noradrenaline (NA) and release in vitro in rat prefrontal cortex and striatum. D-amphetamine was more potent than L-amphetamine at inhibiting accumulation of DA or NA in synaptosomes and vesicles. All drugs were weaker at inhibiting the accumulation of vesicular DA and NA compared to synaptosomal accumulation and more potently inhibited NA accumulation than DA. Methylphenidate was weak at inhibiting vesicular accumulation of DA and NA compared to its potent synaptosomal effects. The D-isomer had greater potency than the L-isomer on basal and electrically stimulated striatal DA release; however the L-isomer was 2-fold more potent than the D-isomer on basal fronto-cortical NA release. The selective DA reuptake inhibitor, GBR-12909 and NA reuptake inhibitors, maprotiline and atomoxetine, had different release profiles both on the potency and magnitude of basal and stimulated DA and NA release compared to the amphetamine isomers. These results identify distinct pharmacological action by the amphetamine isomers on dopaminergic and noradrenergic neurotransmission, which may impact on their therapeutic effects in the treatment of ADHD.