Perceptions of peritonitis risk, prevention, diagnosis and stigma: Findings from a mixed methods study with patients and relatives using peritoneal dialysis

BACKGROUND

Peritonitis is the main treatment-related complication of peritoneal dialysis and a primary concern for patients and their relatives. Therefore, understanding their perceptions of peritonitis is important.

OBJECTIVES

To explore patients' and relatives' perceptions of peritoneal dialysis-associated peritonitis risk, prevention measures and experiences of diagnosis, and experience of perceived stigma.

DESIGN

A sequential mixed methods study design was used, including a questionnaire and semi-structured interviews.

PARTICIPANTS

Patients using peritoneal dialysis and relatives (n = 75) from six National Health Service organisations from the United Kingdom.

MEASUREMENTS

A structured questionnaire was administered with patients and relatives (n = 75) using peritoneal dialysis; data were analysed using descriptive statistics. Thirty questionnaire respondents were then purposively sampled and interviewed in-depth; data were analysed thematically. Data were collected 2017-2018. Ethical and governance approvals were gained.

RESULTS

Qualitative and quantitative analyses were integrated and three themes presented: • Perceptions of risk: participants assessed their risk of developing peritonitis and possible implications on their health and relatives. Participants felt greatly responsible for preventing infection. • Preventing peritonitis: participants reported similar and some differing measures to minimise their risk of developing peritonitis. Participants wanted to be seen as "clean". • Diagnosis of peritonitis: peritonitis diagnosis was embarrassing and stigmatising for many individuals. This was influenced by the response of healthcare professionals and the cause of peritonitis.

CONCLUSIONS

It is important that healthcare professionals are aware of how responsible patients and relatives feel about preventing peritonitis, the emotional effect of this responsibility and crucially the impact this may have on seeking help.

The use of creative case studies to explore non-verbal and non-ambulant children and young people's well-being

BACKGROUND AND PURPOSE

The aim of this paper is to describe and critically analyse creative research methods, exploring how these can offer ways to enable non-verbal and non-ambulant children and young people with cerebral palsy, to express their views about their well-being. The context of this research explored their choices for recreational activities, seeking to understand how their level of participation impacted upon their well-being.

METHODS

A qualitative comparative case study design was chosen comprising of two interviews, using photographs and diaries to elicit discussion, supported by observations. These observations provided evidence of well-being indicators that were interpreted by the researcher, alongside their parents. Seven participants volunteered, aged nine to sixteen years. Data were analysed utilising Braun and Clark's six stages. Firstly, each case's data sources were coded, themes identified, then across cases comparisons, arriving at three final themes. Triangulation of data sources which made up each case, enhanced the trustworthiness in this study.

RESULTS

Observations were key to providing insight into their well-being. Interpretation of this rich data, supported by their parents, revealed that the participants could self-advocate, as shown by their intentional behaviours, to choose their level of participation.

DISCUSSION

The researcher's ability to be creative in the data collection methods is original in physiotherapy. It was important to work in partnership with parents, to ensure the correct interpretation of their intentional behaviours from the observations. The diaries and photographs added a unique contribution to knowledge, which enabled the non-verbal participants inclusion, empowering them to express their well-being.

STUDY REGISTRATION

This study is registered with the International Study + Clinical Trials Network Register (ISRCTN) Number:42717948. CONTRIBUTION OF PAPER.

A kaleidoscope of well-being to authentically represent the voices of children and young people with complex cerebral palsy: a case study series

PURPOSE

This paper authentically represents the voices of non-verbal children with cerebral palsy using a case study design. Policy suggests that children should have the right to play and leisure opportunities, however non-verbal children with cerebral palsy have fewer choices. Additionally, children with communication, learning and mobility limitations are usually excluded from research. The aim of this research was to capture the voices of non-verbal children by exploring their well-being impact in terms of their experiences and choices about their level of participation in recreational activities.

METHODS

A qualitative case series study included interviews, observations, photographs and diaries. Where possible, the diaries were completed by both caregivers and children. Data were analysed thematically, and the lens of positioning theory applied.

RESULTS

Seven children aged nine to sixteen years participated. The findings showed how equipment, people and environments enabled or hindered the children's participation. The children also advocated as champions for their own well-being. Positioning theory was applied across the data and was adapted offering a way to better understand the children's well-being responses.

CONCLUSION

The findings demonstrate how these children were able to self-advocate, demonstrating their well-being by their intentional behaviours from their level of participation in a recreational activity.

Importance of patient and public involvement in doctoral research involving people living with dementia

BACKGROUND

There is increasing recognition of the need to include patients and the public in the research process. There is extensive literature about patient and public involvement (PPI) in research, but fewer articles report on PPI in doctoral research.

AIM

To reflect on establishing an advisory group for a doctoral study, exploring the opportunities and challenges associated with including patients with dementia in the research process.

DISCUSSION

The authors discuss the practicalities of establishing an advisory group, the challenges of being a novice researcher, long-term commitment to PPI, the overall approach to PPI and ethical considerations.

CONCLUSION

Establishing an advisory group for a doctoral study can facilitate mutual learning and enhance the study's quality.

IMPLICATIONS FOR PRACTICE

Achieving high-quality PPI in health and social care research can ultimately improve its quality and relevance. An important aspect of the doctoral journey is developing knowledge and skills to facilitate PPI as part of a researcher's apprenticeship.

Long-Term Bonding Efficacy of CAD/CAM Hybrid Restorative Materials and Universal Adhesives

OBJECTIVES

In-office and lab milled prostheses are the staple for indirect restorations. It is therefore critical to determine their long-term bonding durability.

METHODS

CAD/ CAM blocks of two classes of restorative materials: 1) a nano-ceramic reinforced polymer matrix (NCPM) and, 2) a polymer-infiltrated ceramic network (PICN) were bonded using four different universal adhesives (UA) and silane systems. A lithium disilicate glassceramic (LDS) was used as a reference. The blocks were bisected and bonded with different UA/resin-cement pairs. Bonded blocks were then cut into 1.0x1.0x12.0 mm bar specimens for microtensile bond testing. Half the bars were subjected to bond strength testing immediately and the other half after aging by 50,000 thermal cycles between 5°C and 55°C. ANOVA and post-hoc tests were used to compare mean bond strength among groups.

RESULTS

NCPM presented consistently high bond strength regardless of bonding techniques, while the bond strength of PICN and LDS were lower when bonded with UA relative to traditional silanes. The more hydrophilic UA produced higher bond strengths.

DISCUSSION

Glass-ceramics exhibited lower bond strength with UA than the conventional etch-rinse-silane techniques. However, UAs preserved bonding interface in the long-term.

SIGNIFICANCE

NCPM displayed superior bond strength relative to PICN and LDS regardless of the type of adhesives and bonding techniques.

"Family doctors are also people": a qualitative analysis of how family physicians managed competing personal and professional responsibilities during the COVID-19 pandemic

BACKGROUND

Family physicians (FPs) fill an essential role in public health emergencies yet have frequently been neglected in pandemic response plans. This exclusion harms FPs in their clinical roles and has unintended consequences in the management of concurrent personal responsibilities, many of which were amplified by the pandemic. The objective of our study was to explore the experiences of FPs during the first year of the COVID-19 pandemic to better understand how they managed their competing professional and personal priorities.

METHODS

We conducted semi-structured interviews with FPs from four Canadian regions between October 2020 and June 2021. Employing a maximum variation sampling approach, we recruited participants until we achieved saturation. Interviews explored FPs' personal and professional roles and responsibilities during the pandemic, the facilitators and barriers that they encountered, and any gender-related experiences. Transcribed interviews were thematically analysed.

RESULTS

We interviewed 68 FPs during the pandemic and identified four overarching themes in participants' discussion of their personal experiences: personal caregiving responsibilities, COVID-19 risk navigation to protect family members, personal health concerns, and available and desired personal supports for FPs to manage their competing responsibilities. While FPs expressed a variety of ways in which their personal experiences made their professional responsibilities more complicated, rarely did that affect the extent to which they participated in the pandemic response.

CONCLUSIONS

For FPs to contribute fully to a pandemic response, they must be factored into pandemic plans. Failure to appreciate their unique role and circumstances often leaves FPs feeling unsupported in both their professional and personal lives. Comprehensive planning in anticipation of future pandemics must consider FPs' varied responsibilities, health concerns, and necessary precautions. Having adequate personal and practice supports in place will facilitate the essential role of FPs in responding to a pandemic crisis while continuing to support their patients' primary care needs.

"Technology has allowed us to do a lot more but it's not necessarily the panacea for everybody": Family physician perspectives on virtual care during the COVID-19 pandemic and beyond

INTRODUCTION

Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice.

METHODS

We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach.

RESULTS

We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward.

CONCLUSIONS

The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.

Distinct patterns of incidental exposure to and active selection of radicalizing information indicate varying levels of support for violent extremism

Exposure to radicalizing information has been associated with support for violent extremism. It is, however, unclear whether specific information use behavior, namely, a distinct pattern of incidental exposure (IE) to and active selection (AS) of radicalizing content, indicates stronger violent extremist attitudes and radical action intentions. Drawing on a representative general population sample (N = 1509) and applying latent class analysis, we addressed this gap in the literature. Results highlighted six types of information use behavior. The largest group of participants reported a near to zero probability of both IE to and AS of radicalizing material. Two groups of participants were characterized by high or moderate probabilities of incidental exposure as well as a low probability of active selection of radicalizing content. The remaining groups displayed either low, moderate, or high probabilities of both IE and AS. Importantly, we showed between-group differences regarding violent extremist attitudes and radical behavioral intentions. Individuals reporting near zero or high probabilities for both IE to and AS of radicalizing information expressed the lowest and strongest violent extremist attitudes and willingness to use violence respectively. Groups defined by even moderate probabilities of AS endorsed violent extremism more strongly than those for which the probability for incidental exposure was moderate or high but AS of radicalizing content was unlikely.

Surgical Training Simulators for Rhinoplasty: A Systematic Review

Rhinoplasty training currently follows an apprenticeship model that is largely observational. Trainees have limited experience in performing maneuvers of this complex surgery. Rhinoplasty simulators can address this issue by providing trainees with the opportunity to gain surgical simulator experience that could improve technical competences in the operating room. This review amalgamates the collective understanding of rhinoplasty simulators described to date. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, PubMed, OVID Embase, OVID Medline, and Web of Science databases were all searched for original research on surgical simulators for rhinoplasty education and reviewed by independent reviewers. Articles underwent title and abstract screening, and then relevant articles underwent full-text review to extract simulator data. Seventeen studies, published between 1984 and 2021, were included for final analysis. Study participant numbers ranged from 4 to 24, and included staff surgeons, fellows, residents (postgraduate year 1-6), and medical students. Cadaveric surgical simulators comprised eight studies, of which three were with human cadavers, one study was a live animal simulator, two were virtual simulators, and six were three-dimensional (3D) models. Both animal and human-based simulators increased the confidence of trainees significantly. Significant improvement in various aspects of rhinoplasty knowledge occurred with implementation of a 3D-printed model in rhinoplasty education. Rhinoplasty simulators are limited by a lack of an automated method of evaluation and a large reliance on feedback from experienced rhinoplasty surgeons. Rhinoplasty simulators have the potential to provide trainees with the opportunity for hands-on training to improve skill and develop competencies without putting patients in harm's way. Current literature on rhinoplasty simulators largely focuses on simulator development, with few simulators being validated and assessed for utility. For wider implementation and acceptance, further refinement of simulators, validation, and assessment of outcomes is required.

Arrests and convictions but not sentence length deter terrorism in 28 European Union member states

While countries differ in how they handle terrorism, criminal justice systems in Europe and elsewhere treat terrorism similar to other crime, with police, prosecutors, judges, courts and penal systems carrying out similar functions of investigations, apprehension, charging, convicting and overseeing punishments, respectively. We address a dearth of research on potential deterrent effects against terrorism by analysing data on terrorism offending, arrests, charges, convictions and sentencing over 16 years in 28 European Union member states. Applying both count and dynamic panel data models across multiple specifications, we find that increased probability of apprehension and punishment demonstrate an inverse relationship with terrorism offending, while the rate of charged individuals is associated with a small increase in terrorism. The results for sentence length are less clear but also indicate potential backlash effects. These findings unveil overlaps between crime and terrorism in terms of deterrent effects and have implications for both the research agenda and policy discussion.

An analysis of policies supporting the roles of family physicians in four regions in Canada during the COVID-19 pandemic

Policy supports are needed to ensure that Family Physicians (FPs) can carry out pandemic-related roles. We conducted a document analysis in four regions in Canada to identify regulation, expenditure, and public ownership policies during the COVID-19 pandemic to support FP pandemic roles. Policies supported FP roles in five areas: FP leadership, Infection Prevention and Control (IPAC), provision of primary care services, COVID-19 vaccination, and redeployment. Public ownership polices were used to operate assessment, testing and vaccination, and influenza-like illness clinics and facilitate access to personal protective equipment. Expenditure policies were used to remunerate FPs for virtual care and carrying out COVID-19-related tasks. Regulatory policies were region-specific and used to enact and facilitate virtual care, build surge capacity, and enforce IPAC requirements. By matching FP roles to policy supports, the findings highlight different policy approaches for FPs in carrying out pandemic roles and will help to inform future pandemic preparedness.

The Impact of a 24-h Low and High Fermentable Oligo- Di- Mono-Saccharides and Polyol (FODMAP) Diet on Plasma Bacterial Profile in Response to Exertional-Heat Stress

Exertional-heat stress (EHS) compromises intestinal epithelial integrity, potentially leading to the translocation of pathogenic agents into circulation. This study aimed to explore the impact of EHS on the systemic circulatory bacterial profile and to determine the impact of a short-term low (LFOD) and high (HFOD) fermentable oligo- di- mono-saccharide and polyol dietary intervention before EHS on this profile. Using a double-blind randomized cross-over design, thirteen endurance runners (n = 8 males, n = 5 females), with a history of exercise-associated gastrointestinal symptoms (Ex-GIS), consumed a 24 h LFOD and HFOD before 2 h running at 60% V.O2max in 35.6 °C. Blood and fecal samples were collected pre-EHS to determine plasma microbial DNA concentration, and sample bacteria and short chain fatty acid (SCFA) profiles by fluorometer quantification, 16S rRNA amplicon gene sequencing, and gas chromatography, respectively. Blood samples were also collected post-EHS to determine changes in plasma bacteria. EHS increased plasma microbial DNA similarly in both FODMAP trials (0.019 ng·μL-1 to 0.082 ng·μL-1) (p < 0.01). Similar pre- to post-EHS increases in plasma Proteobacteria (+1.6%) and Firmicutes (+0.6%) phyla relative abundance were observed in both FODMAP trials. This included increases in several Proteobacteria genus (Delftia and Serratia) groups. LFOD presented higher fecal Firmicutes (74%) and lower Bacteroidota (10%) relative abundance pre-EHS, as a result of an increase in Ruminococcaceae and Lachnospiraceae family and respective genus groups, compared with HFOD (64% and 25%, respectively). Pre-EHS plasma total SCFA (p = 0.040) and acetate (p = 0.036) concentrations were higher for HFOD (188 and 178 μmol·L-1, respectively) vs. LFOD (163 and 153 μmol·L-1, respectively). Pre-EHS total fecal SCFA concentration (119 and 74 μmol·g-1; p < 0.001), including acetate (74 and 45 μmol·g-1; p = 0.001), butyrate (22 and 13 μmol·g-1; p = 0.002), and propionate (20 and 13 μmol·g-1; p = 0.011), were higher on HFOD vs LFOD, respectively. EHS causes the translocation of whole bacteria into systemic circulation and alterations to the plasma bacterial profile, but the FODMAP content of a 24 h diet beforehand does not alter this outcome.

The clinical decision-making process involved in end of life care for people with dementia in primary care: A protocol paper

AIM

This article is a report of a study protocol designed to explore what factors inform healthcare professionals' clinical decision-making when providing end of life care for people with dementia in primary care.

DESIGN

The proposed study will adopt a qualitative study design, utilizing an ethnographic approach.

METHODS

A mixed sample group of registered healthcare professionals, including district nurses, specialist nurses and general practitioners, will be purposively sampled and recruited from one health board in Wales, which will cover three settings in primary care. A multi-method approach will be utilized to provide rich data, including non-participant observation, semi-structured interviews, and review of key documents. Data will be managed using NVivo 12 and analysed thematically. Ethics approval was gained in April 2022.

DISCUSSION

Little is known about the end of life care decision-making process of healthcare professionals caring for people with dementia in primary care settings. This study will therefore address this pertinent gap. The study findings may also be transferable to healthcare professionals working in similar clinical settings across the UK.

IMPACT

It is anticipated that this study will inform the subsequent development of an intervention that can be used by healthcare professionals to support decision making and subsequently the provision of quality end of life care in primary care for people with dementia.

Facilitators and barriers regarding the implementation and interprofessional collaboration of a first contact physiotherapy service in primary care in Wales: a qualitative study

Background/Aims

Future primary care services in Wales are likely to face higher demand for musculoskeletal ailments because of an ageing population and difficulties retaining and recruiting general practitioners. First contact physiotherapists provide specialist musculoskeletal management within primary care and offer a solution to this issue; however, no studies have yet explored first contact physiotherapist services in Wales. Consequently, little is known about the experience of working as a first contact physiotherapist in Wales. The aim of this study was to explore the experiences of first contact physiotherapists in primary care in south east Wales regarding the implementation, interprofessional collaboration and the facilitators and barriers to providing the service.

Methods

A qualitative, Heideggerian hermeneutical phenomenological study was performed. A purposive sample of eleven physiotherapists were recruited for the study from an NHS health board in south east Wales, comprising three different first contact physiotherapist models. Data were collected through individual semi-structured interviews. Data analysis was conducted via a three-step format.

Results

Participants viewed the first contact physiotherapist role as positive as it represented role and career advancement. Adequate training and mentorship were not provided to support the role. Participants perceived that patients and the wider multidisciplinary team did not fully understand the role of the first contact physiotherapist. Inappropriate use of services was common, with first contact physiotherapists often acting as the second contact practitioner, leading to duplication of effort and the development of unnecessary waiting lists. The degree of interprofessional collaboration appeared to influence the clarity of the role of the first contact physiotherapist, with a reduced clarity of role in models where first contact physiotherapists were not often present. Burnout was perceived as a risk for participants with low levels of experience in advanced practice and was dependent on the model worked in. Participants perceived a lack of specific aims for the first contact physiotherapy service and ambiguity over who was responsible for service leadership, leading to inappropriate use of services.

Conclusions

Clear operational leadership and strategies to increase interprofessional collaboration are required to increase the clarity about the roled of the first contact physiotherapist and ensure service efficacy. There is a need in Wales for a professional development, mentorship and governance framework to ensure sustainability and efficacy of first contact physiotherapy services.

Reliability of pathophysiological markers reflective of exercise-induced gastrointestinal syndrome (EIGS) in response to 2-h high-intensity interval exercise: A comprehensive methodological efficacy exploration

The study aimed to determine the test-retest reliability of exercise-induced gastrointestinal syndrome (EIGS) biomarkers, and assess the association of pre-exercise short chain fatty acid (SCFA) concentration with these biomarkers in response to prolonged strenuous exercise. Thirty-four participants completed 2 h of high-intensity interval training (HIIT) on two separate occasions with at least 5-days washout. Blood samples were collected pre- and post-exercise, and analysed for biomarkers associated with EIGS [i.e., cortisol, intestinal fatty-acid binding protein (I-FABP), sCD14, lipopolysaccharide binding protein (LBP), leukocyte counts, in-vitro neutrophil function, and systemic inflammatory cytokine profile]. Fecal samples were collected pre-exercise on both occasions. In plasma and fecal samples, bacterial DNA concentration was determined by fluorometer quantification, microbial taxonomy by 16S rRNA amplicon sequencing, and SCFA concentration by gas-chromatography. In response to exercise, 2 h of HIIT modestly perturbed biomarkers indicative of EIGS, including inducing bacteremia (i.e., quantity and diversity). Reliability analysis using comparative tests, Cohen's d, two-tailed correlation, and intraclass correlation coefficient (ICC) of resting biomarkers presented good-to-excellent for IL-1ra (r = 0.710, ICC = 0.92), IL-10 (r = 0.665, ICC = 0.73), cortisol (r = 0.870, ICC = 0.87), and LBP (r = 0.813, ICC = 0.76); moderate for total (r = 0.839, ICC = 0.44) and per cell (r = 0.749, ICC = 0.54) bacterially-stimulated elastase release, IL-1β (r = 0.625, ICC = 0.64), TNF-α (r = 0.523, ICC = 0.56), I-FABP (r = 0.411, ICC = 0.21), and sCD14 (r = 0.409, ICC = 0.38), plus fecal bacterial α-diversity; and poor for leukocyte (r = 0.327, ICC = 0.33) and neutrophil (r = 0.352, ICC = 0.32) counts. In addition, a medium negative correlation was observed between plasma butyrate and I-FABP (r = -0.390). The current data suggest a suite of biomarkers should be used to determine the incidence and severity of EIGS. Moreover, determination of plasma and/or fecal SCFA may provide some insight into the mechanistic aspects of EIGS instigation and magnitude in response to exercise.

"It was horrible for that community, but not for the way we had imagined": A qualitative study of family physicians' experiences of caring for communities experiencing marginalisation during COVID-19

The COVID-19 response required family physicians (FPs) to adapt their practice to minimise transmission risks. Policy guidance to facilitate enacting public health measures has been generic and difficult to apply, particularly for FPs working with communities that experience marginalisation. Our objective was to explore the experiences of FPs serving communities experiencing marginalisation during COVID-19, and the impact the pandemic and pandemic response have had on physicians' ability to provide care. We conducted semi-structured qualitative interviews with FPs from four Canadian regions, October 2020 through June 2021. We employed maximum variation sampling and continued recruitment until we reached saturation. Interviews explored participants' roles/experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support communities experiencing marginalisation throughout. We used a thematic approach to analyse the data. FPs working with communities experiencing marginalisation expressed the need to continue providing in-person care throughout the pandemic, often requiring them to devise innovative adaptations to their clinical settings and practice. Physicians noted the health implications for their patients, particularly where services were limited or deferred, and that pandemic response policies frequently ignored the unique needs of their patient populations. Pandemic-related precautionary measures that sought to minimise viral transmission and prevent overwhelming acute care settings may have undermined pre-existing services and superseded the ongoing harms that are disproportionately experienced by communities experiencing marginalisation. FPs are well placed to support the development of pandemic response plans that appreciate competing risks amongst their communities and must be included in pandemic planning in the future.

Family physicians' perspectives on the impact of COVID-19 on preventative care in primary care: findings from a qualitative study

INTRODUCTION

Health system disruptions, caused by unexpected emergencies such as disease outbreaks, natural disasters, and cybercrimes, impact the delivery of routine preventative care. As comprehensive care providers, family physicians (FPs) devote significant time to prevention. However, without emergency and pandemic plans in place in primary care, FPs face added barriers to prioritizing and sustaining preventative care when health systems are strained, which was evident during the COVID-19 pandemic. This study aims to describe FPs' experiences providing preventative care during the COVID-19 pandemic and their perceptions of the impacts of disrupted preventative care in primary care settings.

METHODS

Using a qualitative descriptive approach, we conducted semistructured interviews with FPs across 4 provinces in Canada (i.e. Newfoundland and Labrador, Nova Scotia, Ontario, British Columbia) between October 2020 and June 2021 as part of a larger multiple case study. These interviews broadly explored the roles and responsibilities of FPs during the COVID-19 pandemic. Interviews were coded thematically and codes from the larger study were analysed further using an iterative, phased process of thematic analysis.

RESULTS

Interviews averaged 58 min in length (range 17-97 min) and FPs had a mean of 16.9 years of experience. We identified 4 major themes from interviews with FPs (n = 68): (i) lack of capacity and coordination across health systems, (ii) patient fear, (iii) impacts on patient care, and (iv) negative impacts on FPs. Physicians voiced concerns with managing patients' prevention needs when testing availability and coordination of services was limited. Early in the pandemic, patients were also missing or postponing their own primary care appointments. Change in the provision and coordination of routine preventative care had negative impacts on both patients and physicians, affecting disease incidence/progression, physician workload, and psychological wellbeing.

CONCLUSION

During the COVID-19 pandemic, upstream care efforts were impacted, and FPs were forced to reduce their provision of preventative care. FPs contribute direct insight to primary care delivery that can support pandemic planning to ensure preventative care is sustained during future emergencies.

Assessing the relationship between terrorist attacks against ingroup or outgroup members and public support for terrorism

Terrorist groups rely on constituency support for their long-term survival. Here, we examined the extent to which terrorists’ own activities are related with public opinion on terrorism. Specifically, we assessed whether more frequent and more costly terrorist attacks against the ingroup are associated with war weariness or retaliatory sentiments, thus, either weaker or stronger approval of terrorism. We further investigated if more frequent and costly attacks that target an outgroup predict higher levels of justification of terrorism. Lastly, we identified the timeframe during which domestic and outgroup terrorist attacks correlate with (lower or higher) public support. The analyses focused on Jordan (ingroup) and Israel (outgroup), over an 8-year period (2004–2011), drawing on data from the Pew Global Attitudes Survey and the Global Terrorism Database. Results showed that support for terrorism in Jordan decreased in 2005 and, again, in 2008. The frequency of terrorist attacks and fatality/injury rates in Jordan did not vary significantly during the study period. The number of attacks and fatalities/people injured in Israel, however, changed between 2004 and 2011. Cross-correlations of the time-series further demonstrated that the number of attacks and fatalities/people injured in Jordan was not related with the level of public approval of terrorism in the country. Importantly, and in line with the literature, the casualty rate in Israel was positively associated with support for terrorism in Jordan, in the next year. That is, there is evidence that more/less costly terrorist attacks on an outgroup can predict stronger/weaker public support for the tactic relatively quickly. Those findings provide insights for counter-terrorism measures.

Association Between the Gut Microbiome and Their Metabolites With Human Blood Pressure Variability

BACKGROUND

Blood pressure (BP) variability is an independent risk factor for cardiovascular events. Recent evidence supports a role for the gut microbiota in BP regulation. However, whether the gut microbiome is associated with BP variability is yet to be determined. Here, we aimed to investigate the interplay between the gut microbiome and their metabolites in relation to BP variability.

METHODS

Ambulatory BP monitoring was performed in 69 participants from Australia (55.1% women; mean±SD, 59.8±7.26 years; body mass index, 25.2±2.83 kg/m²). These data were used to determine nighttime dipping, morning BP surge (MBPS) and BP variability as SD. The gut microbiome was determined by 16S ribosomal RNA (rRNA) sequencing and metabolite levels by gas chromatography.

RESULTS

We identified specific taxa associated with systolic BP variability, nighttime dipping, and MBPS. Notably, Alistipesfinegoldii and Lactobacillus spp. were only present in participants within the normal ranges of BP variability, MBPS and dipping, while Prevotella spp. and Clostridium spp., were found to be present in extreme dippers and the highest quartiles of BP SD and MBPS. There was a negative association between MBPS and microbial α-diversity (r=-0.244, P=0.046). MBPS was also negatively associated with plasma levels of microbial metabolites called short-chain fatty acids (r=-0.305, P=0.020), particularly acetate (r=-0.311, P=0.017).

CONCLUSIONS

Gut microbiome diversity, levels of microbial metabolites, and the bacteria Alistipesfinegoldii and Lactobacillus were associated with lower BP variability and Clostridium and Prevotella with higher BP variability. Thus, our findings suggest the gut microbiome and metabolites may be involved in the regulation of BP variability.

The Moderating Effects of “Dark” Personality Traits and Message Vividness on the Persuasiveness of Terrorist Narrative Propaganda

Terrorism researchers have long discussed the role of psychology in the radicalization process. This work has included research on the respective roles of individual psychological traits and responses to terrorist propaganda. Unfortunately, much of this work has looked at psychological traits and responses to propaganda individually and has not considered how these factors may interact. This study redresses this gap in the literature. In this experiment (N = 268), participants were measured in terms of their narcissism, Machiavellianism, subclinical psychopathy, and everyday sadism—collectively called the Dark Tetrad. Participants were then exposed to a vivid or nonvivid terrorist narrative (or a control message). Results indicate that Machiavellianism interacts with both narrative exposure and narrative vividness to amplify the persuasive effect of terrorist narratives. Neither narcissism, subclinical psychopathy, nor everyday sadism had such an effect. These results highlight the importance of considering the psychological traits of audiences when evaluating proclivity for radicalization via persuasion by terrorist narratives.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

British Journal of Surgery Society.

Dialysis, Distress, and Difficult Conversations: Living with a Kidney Transplant

Background: Providing holistic care to kidney patients is important; however, without full consideration of the perspectives of people living with a kidney transplant, the provision of truly ‘holistic healthcare’ cannot be possible. It is imperative to understand patient experiences by including kidney patients in key strategies and future renal service planning. Ignoring these important patient views means that there is a significant risk of inappropriate renal service provision and lack of adequate support, impacting overall health. The aim of this study was to develop an in-depth understanding of the lived experiences of kidney transplant recipients. Methods: A total of 23 participants were recruited between two regional nephrology units within the United Kingdom via clinical gatekeepers. In-depth interviews were undertaken. Interviews were digitally recorded, transcribed verbatim, and subjected to interpretative phenomenological analysis. Results: Two themes emerged: “managing ongoing fears of dialysis, distress, and COVID-19” and “dealing with difficult conversations”. Conclusions: Renal healthcare professionals need to understand more than the biological impact of receiving a kidney transplant. Understanding the holistic and multidomain experiences that these participants experience will help healthcare professionals to recognize the needs of this group and ensure more responsive psychosocial care.

Individual Differences in Personality Moderate the Effects of Perceived Group Deprivation on Violent Extremism: Evidence From a United Kingdom Nationally Representative Survey

Numerous studies argue that perceived group deprivation is a risk factor for radicalization and violent extremism. Yet, the vast majority of individuals, who experience such circumstances do not become radicalized. By utilizing models with several interacting risk and protective factors, the present analysis specifies this relationship more concretely. In a large United Kingdom nationally representative survey (n = 1,500), we examine the effects of group-based relative deprivation on violent extremist attitudes and violent extremist intentions, and we test whether this relationship is contingent upon several individual differences in personality. The results show that stronger group-based injustices lead to increased support for and intentions to engage in violent extremism. However, some of the effects are much stronger for individuals who exhibit a stronger need for uniqueness and for status and who demonstrate higher levels of trait entitlement. Conversely, several effects are lessened for those individuals high in trait forgiveness, demonstrating a strong capacity for self-control and for those who are exerting critical as well as open-minded thinking styles, thus constituting buffering protective factors, which dampen the adverse effects of perceived group injustice on violent extremism. The results highlight the importance of considering (a) the interaction between individual dispositions and perceptions of contextual factors (b) the conditional and cumulative effects of various risk and protective factors and (c) the functional role of protective factors when risk factors are present. Collectively, these findings bring us one step closer to understanding who might be more vulnerable to violent extremism as well as how. Overall, the study suggests that preventing and countering violent extremism (P/CVE) programs must take account of the constellation of multiple factors that interact with (and sometimes enable or disable) one another and which can be targeted in preventions strategies.

End-of-life care for people with severe mental illness: mixed methods systematic review and thematic synthesis of published case studies (the MENLOC study)

OBJECTIVES

People with severe mental illness (SMI) have significant comorbidities and reduced life expectancy. The objective of the review reported in this paper was to synthesise material from case studies relating to the organisation, provision and receipt of care for people with SMI who have an end-of-life (EoL) diagnosis.

DESIGN

Systematic review and thematic synthesis.

DATA SOURCES

MEDLINE, PsycINFO, EMBASE, HMIC, AMED, CINAHL, CENTRAL, ASSIA, DARE and Web of Science from inception to December 2019. Supplementary searching for additional material including grey literature along with 62 organisational websites.

RESULTS

Of the 11 904 citations retrieved, 42 papers reporting 51 case studies were identified and are reported here. Twenty-five of the forty-two case study papers met seven, or more quality criteria, with eight meeting half or less. Attributes of case study subjects included that just over half were men, had a mean age of 55 years, psychotic illnesses dominated and the EoL condition was in most cases a cancer. Analysis generated themes as follows diagnostic delay and overshadowing, decision capacity and dilemmas, medical futility, individuals and their networks, care provision.

CONCLUSIONS

In the absence of high-quality intervention studies, this evidence synthesis indicates that cross disciplinary care is supported within the context of established therapeutic relationships. Attention to potential delay and diagnostic overshadowing is required in care provision. The values and preferences of individuals with severe mental illness experiencing an end-of-life condition should be recognised.

PROSPERO REGISTRATION NUMBER

CRD42018108988.

The patient perspective, experience and satisfaction of day case unicompartmental knee arthroplasty: A short-term mixed-methods study

BACKGROUND

Day case unicompartmental knee arthroplasty (UKA) is increasingly being performed worldwide. When performed in the appropriate patient, day case UKA has been demonstrated to be safe, cost effective and improve resource allocation. Limited evidence highlights increased patient satisfaction of day case UKA when compared with inpatient UKA. A detailed study of the patient perspective, experience and satisfaction following day case UKA has not been described before.

METHODS

A retrospective case series review of 21 consecutive patients (19 unilateral, 2 bilateral) undergoing day case UKA in an elective orthopaedic centre was undertaken. A qualitative and quantitative patient assessment of the day case UKA experience was administered. A five-point Likert scale satisfaction questionnaire, Oxford Knee Score (OKS) and open-ended interview was undertaken. The qualitative responses underwent thematic analysis.

RESULTS

One hundred percent of patients expressed satisfaction (76.2% completely satisfied, 33.8% moderately satisfied) with day case UKA. The majority of patients (90.5%) reported that if they had to undergo UKA again they would prefer a day case over an inpatient procedure. Patients consider surgical outcome, physiotherapy provision, discharge planning, postoperative medications and follow up as key aspects of day case UKA care. One patient was re-admitted following discharge.

CONCLUSIONS

The present study demonstrates a high level of patient satisfaction with day case UKA. The results reported herein are subject to the study limitations of sample size, recall bias and inclusion criteria. We recommend that the themes identified by patients are addressed through a multidisciplinary approach with well-defined clinical pathways for a high-quality patient-centred experience.

End of life care for people with severe mental illness: Mixed methods systematic review and thematic synthesis (the MENLOC study)

BACKGROUND

Parity of esteem means that end-of-life care for people with severe mental illness should be of equal quality to that experienced by all.

AIM

To synthesise international, English language, research and UK policy and guidance relating to the organisation, provision, and receipt of end-of-life care for people with severe mental illness.

DESIGN

A mixed methods systematic review was conducted following the Evidence for Policy and Practice Information and Co-ordinating Centre approach and informed by a stakeholder group. We employed thematic synthesis to bring together data from both qualitative and quantitative studies, and from non-research material. We assessed the strength of synthesised findings using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches.

DATA SOURCES

Ten electronic databases were searched from inception to December 2019, along with 62 organisational websites. Quality appraisal was conducted using Critical Appraisal Skills Programme checklists or other study design-specific alternatives as necessary.

RESULTS

Of the 11,904 citations retrieved, 34 research publications were included plus 28 non-research items. The majority of research was of high or acceptable quality. An overarching synthesis including 52 summary statements, with assessments of confidence in the underpinning evidence, was produced using four themes: Structure of the system; Professional issues; Contexts of care; and Living with severe mental illness.

CONCLUSIONS

Implications for services and practice reflect evidence in which there is a high degree of confidence. Partnership should be developed across the mental health and end-of-life systems, and ways found to support people to die where they choose. Staff caring for people with severe mental illness at the end-of-life need education, support and supervision. End-of-life care for people with severe mental illness requires a team approach, including advocacy. Proactive physical health care for people with severe mental illness is needed to tackle problems of delayed diagnosis.

Psychological distress and terrorist engagement: Measuring, correlating, and sequencing its onset with negative life events, social factors, and protective factors

This article employs probability-based modelling to unpack the complex and multifaceted individual, social, and psychological processes that may provide psychological protection for individuals engaged with terrorist groups. We outline the predictors of the onset of psychological distress across two phases of terrorist involvement (pre-engagement and engagement). Using a dataset of 96 terrorist autobiographies, we conduct sequence analyses to pinpoint the onset of psychological problems and the experiences that preceded and followed this onset. The results demonstrate a complexity in the relationship between mental disorders and terrorist engagement, as well as the heterogeneity of the lived experience of "being" a terrorist. The experience of psychological distress was mediated by numerous factors and the combination of these factors. The evidence suggests that, in certain cases, individual and group resilience may be a protective factor when an individual faces negative experiences. The presence of protective factors may not be sufficient to explain why group-actor terrorists present with a lower than expected prevalence of mental disorder. Future work should examine whether experiences commonly viewed as risk factors may be more useful in examining the occurrence of psychopathology in terrorists.

Smartphone-based technology for nanomolecular detection of aflatoxin B1 by aptamer-conjugated magnetic nanoparticles

The need for a healthy market in the rapid and accurate screening of a variety of pathogenic agents and toxins in the environment and food has led to an increase in the development of new biosensors, which have ideal characteristics, such as high sensitivity and specificity with rapid detection and simple preparation of the sample. Among the food contaminants, mycotoxins have been identified as a major challenge for the food industry, and rapid and accurate detection has attracted the attention of food inspection and monitoring organisations. In this study, a nanomolecular detection method is described using aflatoxin B1 (AFB1)-specific aptamers attached to streptavidin-coated magnetic nanoparticles. A prominent feature of the AFB1-specific aptamers is a guanine-rich (G-rich) sequence with a G-quadruplex structure after capturing AFB1 molecules and mimicking peroxidase activity. The enzymatic reaction evaluated in the presence of chromogenic substrate and measurement is done by a smartphone-specific application for colorimetric measurement. The results indicated that the assay could measure AFB1 in rice, flour, seed, maize, and pistachio. In addition, the application of hybrid nanomaterial technology resulting from the binding of biotin-labelled aptamers to the surface of streptavidin-coated magnetic nanoparticles minimises preparation and treatment of samples, improves results, and consequently reduces false negative and positive responses in the detection field. This study may eventually lead to the design and development of a fast, sensitive, specific, and on-site AFB1-based nanomolecular colorimetric detection system via a smartphone-based application that can be readily accessible to all applicants, from professionals to manufacturers of foodstuffs.

Essential Hypertension Is Associated With Changes in Gut Microbial Metabolic Pathways: A Multisite Analysis of Ambulatory Blood Pressure

[Figure: see text].

Seeking help for peritoneal dialysis-associated peritonitis: Patients' and families' intentions and actions. A mixed methods study

AIMS

To examine patients' and families' help-seeking intentions and actions when suspecting peritoneal dialysis-associated peritonitis.

DESIGN

A sequential explanatory mixed methods design was used, comprising a questionnaire and semi-structured interviews.

METHODS

A questionnaire was designed, piloted and used with patients and family members (n=75) using peritoneal dialysis from six hospital sites in Wales and England. Questionnaire data were analysed using descriptive statistics. A purposive sample of questionnaire participants (n=30) then took part in telephone or face-to-face semi-structured interviews. Interview data were analysed thematically. Data were collected between September 2017 and August 2018. Ethical and governance approvals were obtained; the study was reported on national research portfolios.

RESULTS

The quantitative data highlighted differences between participants' knowledge of when they should seek help for suspected peritonitis and their actions when they subsequently experienced peritonitis. The interview data revealed the complexities involved with recognizing peritonitis, making the decision to seek help and accessing healthcare. Some participants struggled to recognize peritonitis when signs/symptoms started, leading to delays in deciding to seek help. Furthermore, some participants reported that they accessed help from renal or generic out-of-hours and were misadvised or misdiagnosed, delaying diagnosis and treatment. The data were integrated using conceptual analyses of help-seeking behaviour and access to healthcare, which informs understanding of the complexity of seeking help in this context.

CONCLUSIONS

This study revealed differences between participants' help-seeking intentions and actions. Using the conceptual analyses of help-seeking behaviour and access to healthcare informs understanding of the complexity of the help-seeking process in this context. To safely use a home therapy, it is imperative that individuals recognize signs/symptoms of peritonitis, seek help promptly and are appropriately supported when they access healthcare. Further work is needed to examine how these individual and system changes can be enacted.

Similar crimes, similar behaviors? Comparing lone-actor terrorists and public mass murderers

This article adds to the growth in data-driven analyses seeking to compare samples of violent extremists with other violent populations of interest. While lone-actor terrorists and public mass murderers are frequently treated as distinct offender types, both engage (or attempt to engage) in largely public and highly publicized acts of violence and often use similar weapons. This article investigates the (dis)similarities between both offender types. We use a series of bivariate and multivariate statistical analyses to compare demographic, psychologic and behavioral variables across 71 lone-actor terrorists and 115 public mass murderers. The results show little distinction in sociodemographic profiles, but significant differences in (a) the degree to which they interact with co-ideologues (b) antecedent event behaviors and (c) the degree to which they leak information before the attack. Overall, our data inform the emerging idea that lone-actor terrorists and public mass shooters are not distinct offender types. There is more that unites them than divides them. Although the over-arching focus of our results are on the few variables that distinguish them, the vast majority (80%+), of the 180+ variables showed no significant difference. We discuss implications for threat assessment and management in the context of these results.

Predictors of varying levels of risks posed by fixated individuals to British public figures

Concerning approaches and communications to the Royal Family and other British public figures are relatively numerous. This paper examines over 2000 such cases logged over a three-year period in the United Kingdom. Using police and health data, the paper conducts a series of bivariate and multivariate analyses to demonstrate the predictors of what types of risk are posed by an individual case (e.g., communicate only, approach, security breach). The results showed that (a) the rates of serious mental disorders are higher among this sample than the general population base rate, (b) approachers were significantly more likely than communicators to suffer from serious mental disorders, (c) approachers were significantly more likely than communicators to have a history of substance use and abuse problems, (d) approachers were significantly more likely than communicators to have a history of violent behavior against property and persons, and (e) the motivations of approachers and communicators significantly differ. The paper concludes with a consideration of the implications for threat assessment and management.

Imposter syndrome- why is it so common among nurse researchers and is it really a problem?

BACKGROUND

Imposter syndrome is common among early career nurse researchers and often has a considerable impact on those affected. It can cause various problems, including anxiety, self-doubt and feelings of inadequacy, and therefore has significant potential to adversely affect personal and professional development.

AIM

To critically explore the concept of imposter syndrome among early-to-mid career nurse researchers.

DISCUSSION

There may be several reasons why imposter syndrome is common among nurse researchers. Evidence suggests it is ubiquitous in other academic disciplines across the higher education sector, particularly in early-to-mid career researchers. It is unclear how or why nurse researchers are affected by this phenomenon, and whether feeling like an imposter is problematic in this context.

CONCLUSION

Imposter syndrome can be deeply unsettling, particularly at times of specific exposure or peer review. It is relatively normal for even the most experienced, successful researchers to feel like this. Related feelings of self-doubt and critical self-reflection are essential in appropriate measures to research and can reduce researchers' potential for making significant mistakes.

IMPLICATIONS FOR PRACTICE

When managed appropriately, imposter syndrome can be important in scholarly activity and ongoing personal and professional development. Recognising this is an important first step in mitigating related feelings of inadequacy.

Understanding the holistic experiences of living with a kidney transplant: an interpretative phenomenological study (protocol)

Background

Currently very little is known about the perceptions and experiences of kidney transplant recipients from a qualitative perspective. As highlighted by the European Kidney Health Alliance recommendations, providing holistic care to kidney patients is important however this is currently an unmet care need in renal disease. It is imperative to understand patient experiences to ensure that they are included in key strategies and future renal service planning. Ignoring these important patient views means that there is a significant risk of inappropriate renal service provision and lack of adequate support impacting on overall health.

Method

A purposive sampling strategy will recruit individuals currently living with a kidney transplant, 6 months to 5 years post-transplant. A maximum of 30 patients will be recruited between two Regional Nephrology units within the United Kingdom via clinical gatekeepers. In-depth interviews will be undertaken with participants living with a kidney transplant across the two sites. Interviews will be digitally-recorded, transcribed verbatim and subjected to interpretative phenomenological analysis.

Discussion

Renal healthcare professionals need to understand more than the biological impact of receiving a kidney transplant. Understanding the holistic and multi-domain experiences that these patients experience will help healthcare professionals to recognize the needs of this group and ensure more responsive care.

The Base Rate Study: Developing Base Rates for Risk Factors and Indicators for Engagement in Violent Extremism

Improvements have been made in identifying the prevalence of risk factors/indicators for violent extremism. A consistent problem is the lack of base rates. How to develop base rates is of equal concern. This study has two aims: (i) compare two methods for developing base rates; the Unmatched Count Technique (UCT) and direct questioning, (ii) generate base rates in a general population sample and compare these to a sample of lone-actor terrorists (n = 125). We surveyed 2108 subjects from the general population. Participants were recruited from an online access panel and randomly assigned to one of three conditions; direct survey, control, or UCT. Survey items were based on a lone-actor terrorist codebook developed from the wider literature. Direct questioning was more suitable under our study conditions where UCT resulted in deflation effects. Comparing the base rates identified a number of significant differences: (i) lone-actor terrorists demonstrated propensity indicators related to a cognitive susceptibility, and a crime- and/or violence-supportive morality more often; the general sample demonstrated protective factors more often, (ii) lone-actor terrorists demonstrated situational indicators related to a crime- and/or violence-supportive morality more often, whereas the general sample experienced situational stressors more often, (iii) lone-actor terrorists demonstrated indicators related to exposure to extremism more often. Results suggest there are measurable differences in the prevalence of risk factors between lone-actor terrorists and the general population. However, no single factor "predicts" violent extremism. This bears implications for our understanding of the interrelation of risk and protective factors, and for the risk assessment of violent extremism.

Nurse managed patient focused assessment and care: A grounded theory of qualified nurses in acute and critical care settings assessing the mental capacity of adult patients

AIMS

To explore processes used by qualified nurses in assessing mental capacity of acutely and critically ill hospitalised adult patients.

BACKGROUND

Mental capacity is the ability to understand, reason and make decisions. Acute and critical illness may impact upon the decision-making abilities of hospitalised adult patients but little is known about how qualified nurses across a range of acute settings assess the capacity of such patients in their care.

DESIGN

A qualitative grounded theory approach informed by the Corbin and Strauss (Basics of Qualitative Research (Third Edition). London, UK: Sage, 2008) methodological pathway.

METHODS

Data were collected through digitally recorded, semi-structured interviews to explore assessment of capacity processes used by 13 registered nurses employed in acute and critical care environments in a district general hospital in South Wales, UK. Data were analysed using iterative constant comparative processes leading to a core category and grounded theory. The study is presented in accordance with the COREQ checklist.

RESULTS

Informal, intuitive, holistic nurse-led processes were used to assess the mental capacity of patients which combined processes for the assessment of their physiological and mental capacity status, recognising the need to support their rights, dignity and autonomy. The assessment of mental capacity was not a lone process but one that contributed to a cyclical process in which multi-professional assessment was necessary and ongoing, and in which qualified nurses had a co-ordinating role. This led to the development of the theory, Nurse Managed Patient Focused Assessment and Care.

CONCLUSION

This theory provides a framework to explain processes and strategies used by qualified nurses in assessing mental capacity of, and caring for, adult patients with acute and/or critical illness.

RELEVANCE TO CLINICAL PRACTICE

This framework may inform related clinical practice and can serve as a basis of an assessment tool in what has been identified as a fundamental role of the qualified nurse.

Chaos in a ring circuit

A ring-shaped logic circuit is proposed here as a robust design for a True Random Number Generator (TRNG). Most existing TRNGs rely on physical noise as a source of randomness, where the underlying idealized deterministic system is simply oscillatory. The design proposed here is based on chaotic dynamics and therefore intrinsically displays random behavior, even in the ideal noise-free situation. The paper presents several mathematical models for the circuit having different levels of detail. They take the form of differential equations using steep sigmoid terms for the transfer functions of logic gates. A large part of the analysis is concerned with the hard step-function limit, leading to a model known in mathematical biology as a Glass network. In this framework, an underlying discrete structure (a state space diagram) is used to describe the likely structure of the global attractor for this system. The latter takes the form of intertwined periodic paths, along which trajectories alternate unpredictably. It is also invariant under the action of the cyclic group. A combination of analytical results and numerical investigations confirms the occurrence of symmetric chaos in this system, which when implemented in (noisy) hardware, should therefore serve as a robust TRNG.

Compact laser system for a laser-cooled ytterbium ion microwave frequency standard

The development of a transportable microwave frequency standard based on the ground-state transition of ¹⁷¹Yb⁺ at ∼12.6 GHz requires a compact laser system for cooling the ions, clearing out of long-lived states and also for photoionisation. In this paper, we describe the development of a suitable compact laser system based on a 6U height rack-mounted arrangement with overall dimensions 260 × 194 × 335 mm. Laser outputs at 369 nm (for cooling), 399 nm (photoionisation), 935 nm (repumping), and 760 nm (state clearout) are combined in a fiber arrangement for delivery to our linear ion trap and we demonstrate this system by cooling of ¹⁷¹Yb⁺ ions. Additionally, we demonstrate that the lasers at 935 nm and 760 nm are close in frequency to water vapor and oxygen absorption lines, respectively; specifically, at 760 nm, we show that one ¹⁷¹Yb⁺ transition is within the pressure broadened profile of an oxygen line. These molecular transitions form convenient wavelength references for the stabilization of lasers for a ¹⁷¹Yb⁺ frequency standard.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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