UK survey on experiences of men with non-cancer-related lymphoedema: part one

This initial article delves into the methodology, methods and theories, while the subsequent article will centre on the discoveries, discussion and conclusion. The study aimed to address the research question: how do men perceive their engagement in the self-management of non-cancer-related lymphoedema? An interpretivist qualitative methodology was employed, utilising an online survey based on the validated lymphoedema quality of life tool (LYMQoL). The data underwent inductive narrative inquiry. The study incorporated theories such as hegemonic masculinity and the health, illness, men and masculinities (HIMM) framework. The findings will be detailed in the second article in this series. This article has delineated the objective, methodologyand methods, employing a qualitative interpretivist approach through narrative inquiry. The study incorporated masculinity theories, including hegemonic masculinity and HIMM. The second article will present the findings and their significance within the broader literature.

Centre variation in home dialysis uptake: A survey of kidney centre practice in relation to home dialysis organisation and delivery in England

BACKGROUND

Disparities in home dialysis uptake across England suggest inequity and unexplained variation in access. We surveyed staff at all English kidney centres to identify patterns in service organisation/delivery and explore correlations with home therapy uptake, as part of a larger study ('Inter-CEPt'), which aims to identify potentially modifiable factors to address observed variations.

METHODS

Between June and September 2022, staff working at English kidney centres were surveyed and individual responses combined into one centre-level response per question using predetermined data aggregation rules. Descriptive analysis described centre practices and their correlation with home dialysis uptake (proportion of new home dialysis starters) using 2019 UK Renal Registry 12-month home dialysis incidence data.

RESULTS

In total, 180 responses were received (50/51 centres, 98.0%). Despite varied organisation of home dialysis services, most components of service delivery and practice had minimal or weak correlations with home dialysis uptake apart from offering assisted peritoneal dialysis and 'promoting flexible decision-making about dialysis modality'. Moderate to strong correlations were identified between home dialysis uptake and centres reporting supportive clinical leadership (correlation 0.32, 95% Confidence Interval (CI): 0.05-0.55), an organisational culture that values trying new initiatives (0.57, 95% CI: 0.34-0.73); support for reflective practice (0.38, 95% CI: 0.11-0.60), facilitating research engagement (0.39, 95% CI: 0.13-0.61) and promoting continuous quality improvement (0.29, 95% CI: 0.01-0.53).

CONCLUSIONS

Uptake of home dialysis is likely to be driven by organisational culture, leadership and staff attitudes, which provide a supportive clinical environment within which specific components of service organisation and delivery can be effective.

Evaluation of a virtual interprofessional oral-systemic health simulation experience in nursing, dentistry, medicine, and pharmacy education

PURPOSE

The annual teaching oral-systemic health (TOSH) virtual clinical simulation and case study activity exposes interprofessional teams of nurse practitioner, nurse midwifery, dental, medical, and pharmacy students to a virtual clinical simulation experience that uses oral-systemic health as a clinical exemplar for promoting interprofessional core competencies. The present study examines changes in participating students' self-reported interprofessional competencies following participation in virtual TOSH from 2020 to 2022. These findings are also compared to those from in-person TOSH (2019) to examine the equivalence of student outcomes of both the in-person and virtual programs.

METHODS

A pre- and post-test evaluation design was used to examine the effectiveness of exposure to the TOSH program on self-reported attainment of interprofessional competencies for participating students using the interprofessional collaborative competency attainment scale.

RESULTS

Analysis of pre- and post-surveys demonstrated statistically significant improvement in students' self-rated interprofessional experience competencies following the virtual TOSH program, which aligns with results from the in-person cohorts. Similar findings between the in-person and virtual cohorts indicated no statistically significant difference between the two formats.

CONCLUSION

These findings demonstrate the success of TOSH in promoting attainment of interprofessional competencies among future health professionals. We encourage administrators and faculty who lead health professional programs to take advantage of using virtual simulations as an integral component of interprofessional oral health clinical experiences where students from different health professions learn from and about each other in assessing and treating patients across the lifespan.

Gender differences in PTSD severity and pain outcomes: baseline results from the LAMP trial

Background

Post-traumatic stress disorder (PTSD) and chronic pain are highly prevalent comorbid conditions. Veterans dually burdened by PTSD and chronic pain experience more severe outcomes compared to either disorder alone. Few studies have enrolled enough women Veterans to test gender differences in pain outcomes [catastrophizing, intensity, interference] by the severity of PTSD.

Aim

Examine gender differences in the association between PTSD symptoms and pain outcomes among Veterans enrolled in a chronic pain clinical trial.

Methods

Participants were 421 men and 386 women Veterans with chronic pain who provided complete data on PTSD symptoms and pain outcomes. We used hierarchical linear regression models to examine gender differences in pain outcomes by PTSD symptoms.

Results

Adjusted multivariable models indicated that PTSD symptoms were associated with higher levels of pain catastrophizing (0.57, 95% CI [0.51, 0.63]), pain intensity (0.30, 95% CI [0.24, 0.37]), and pain interference (0.46, 95% CI [0.39, 0.52]). No evidence suggesting differences in this association were found in either the crude or adjusted models (all interaction p-values<0.05).

Conclusion

These findings may reflect the underlying mutual maintenance of these conditions whereby the sensation of pain could trigger PTSD symptoms, particularly if the trauma and pain are associated with the same event. Clinical implications and opportunities testing relevant treatments that may benefit both chronic pain and PTSD are discussed.

The Impasse on Gender Differences in Intelligence: a Meta-Analysis on WISC Batteries

This meta-analysis reviews 79 studies (N = 46,605) that examined the existence of gender difference on intelligence in school-aged children. To do so, we limited the literature search to works that assessed the construct of intelligence through the Wechsler Intelligence Scales for Children (WISC) batteries, evaluating eventual gender differences in indices and subtests. The theoretical framework we adopted is the cross-battery approach which locates cognitive abilities into different levels, also considering the possible mediating effect of the version of the WISC being used. As for broad abilities, a notable discrepancy emerged in favour of males for visual and crystallized intelligence, while female/male differences on fluid intelligence were negligible. Conversely, females’ performance on the processing speed factor was superior. Interesting results emerged at the subtest levels, albeit with less pronounced differences in performance. Results generally showed that older versions of WISC batteries displayed larger gender differences compared to the most recent ones.

A qualitative systematic review and meta-aggregation of the experiences of men diagnosed with chronic lymphoedema

Background

Lymphoedema is a chronic condition that is estimated to affect up to four people per 1000 of the UK population with this increasing with age. Men account for up to 20% of lymphoedema service caseloads with research focussing upon women affected.

Aims

To retrieve primary qualitative research on the experiences of men with chronic lymphoedema.

Methods

A qualitative review was undertaken using the Joanna Briggs Institute (JBI) meta-aggregation method. A search strategy was applied to 12 databases, from inception to February 2021, with 22 studies identified and appraised. The findings were extracted and synthesised via the JBI approach.

Results

Four synthesised findings were identified: (1) The ‘New Norm’, how diagnosis led to men being faced with a ‘new version’ of themselves; (2) ‘Journey into the Unknown’ relates to the unforeseen diagnosis of the condition; (3) ‘Access’ – challenge in receiving a diagnosis, and support; and (4) ‘Personhood’ – the impact of the condition upon external constructs and relationships.

Conclusions

Men are faced with similar challenges as women coupled with societal expectations with respect to gender identity and expression. This leads to those wishing to engage with men to adopt ‘gender-based tailoring’ within healthcare services, information and support.

Modeling Global Carbon Costs of Plant Nitrogen and Phosphorus Acquisition

Most Earth system models (ESMs) do not explicitly represent the carbon (C) costs of plant nutrient acquisition, which leads to uncertainty in predictions of the current and future constraints to the land C sink. We integrate a plant productivity-optimizing nitrogen (N) and phosphorus (P) acquisition model (fixation & uptake of nutrients, FUN) into the energy exascale Earth system (E3SM) land model (ELM). Global plant N and P uptake are dynamically simulated by ELM-FUN based on the C costs of nutrient acquisition from mycorrhizae, direct root uptake, retranslocation from senescing leaves, and biological N fixation. We benchmarked ELM-FUN with three classes of products: ILAMB, a remotely sensed nutrient limitation product, and CMIP6 models; we found significant improvements in C cycle variables, although the lack of more observed nutrient data prevents a comprehensive level of benchmarking. Overall, we found N and P co-limitation for 80% of land area, with the remaining 20% being either predominantly N or P limited. Globally, the new model predicts that plants invested 4.1 Pg C yr-1 to acquire 841.8 Tg N yr-1 and 48.1 Tg P yr-1 (1994-2005), leading to significant downregulation of global net primary production (NPP). Global NPP is reduced by 20% with C costs of N and 50% with C costs of NP. Modeled and observed nutrient limitation agreement increases when N and P are considered together (r 2 from 0.73 to 0.83).

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.

Genomic loci associated with performance limiting equine overriding spinous processes (kissing spines)

Commonly known as "Kissing Spines" (KS), the pathological mechanisms underlying impingement and overriding of spinous processes (ORSPs) in horses are poorly understood. Thoroughbreds, Warmbloods, and stock-type breeds, including Paint Horses and Quarter Horses are at increased risk for developing clinical signs of KS. A total of 155 stock-type and Warmblood horses presented at collaborating veterinary clinics and hospitals were examined using a strict clinical and radiographical phenotyping scheme to grade each horse from 0 for unaffected controls to 4 for severe KS. Following genotyping with the Illumina Equine SNP70 array (Illumina, Inc.) a Genome Wide Association Study (GWAS) using 61,229 filtered individual Single Nucleotide Polymorphisms (SNPs) was performed to the KS grade phenotype. Two significantly associated SNPs (BIEC2-668062 and BIEC2-668013) on chromosome 25 defined a ~1.4 Gb candidate region containing approximately 17 coding genes (EquCab3) and 195 ENSEMBL annotated variants. Investigation of the best associated SNP (BIEC2-668062) on chr25 demonstrates a significant correlation with an increase in one KS grade, on average, per A allele in this population. A significant effect of breed group, age, height or sex was not observed in this population. These preliminary results demonstrate the potential for KS diagnosis and preventative measures for WB/ST individuals supported by increased genetic risk for more severe KS grade. We propose further research including other affected breeds and evaluating causative variants, as well as the effect of BIEC2-668062 in these populations.

Intervening to eliminate the centre-effect variation in home dialysis use: protocol for Inter-CEPt-a sequential mixed-methods study designing an intervention bundle

INTRODUCTION

Use of home dialysis by centres in the UK varies considerably and is decreasing despite attempts to encourage greater use. Knowing what drives this unwarranted variation requires in-depth understanding of centre cultural and organisational factors and how these relate to quantifiable centre performance, accounting for competing treatment options. This knowledge will be used to identify components of a practical and feasible intervention bundle ensuring this is realistic and cost-effective.

METHODS AND ANALYSIS

Underpinned by the non-adoption, abandonment, scale-up, spread and sustainability framework, our research will use an exploratory sequential mixed-methods approach. Insights from multisited focused team ethnographic and qualitative research at four case study sites will inform development of a national survey of 52 centres. Survey results, linked to patient-level data from the UK Renal Registry, will populate a causal graph describing patient and centre-level factors, leading to uptake of home dialysis and multistate models incorporating patient-level treatment modality history and mortality. This will inform a contemporary economic evaluation of modality cost-effectiveness that will quantify how modification of factors facilitating home dialysis, identified from the ethnography and survey, might yield the greatest improvements in costs, quality of life and numbers on home therapies. Selected from these factors, using the capability, opportunity and motivation for behaviour change framework (COM-B) for intervention design, the optimal intervention bundle will be developed through workshops with patients and healthcare professionals to ensure acceptability and feasibility. Patient and public engagement and involvement is embedded throughout the project.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Health Research Authority reference 20-WA-0249. The intervention bundle will comprise components for all stake holder groups: commissioners, provider units, recipients of dialysis, their caregivers and families. To reache all these groups, a variety of knowledge exchange methods will be used: short guides, infographics, case studies, National Institute for Health and Care Excellence guidelines, patient conferences, 'Getting it Right First Time' initiative, Clinical Reference Group (dialysis).

Update on the Recommendations on Breast Cancer Screening by the Cancer Expert Working Group on Cancer Prevention and Screening

Breast cancer (BC) is the most common cancer among women in Hong Kong. The Food and Health Bureau commissioned The University of Hong Kong (HKU) to conduct the Hong Kong Breast Cancer Study (HKBCS) with the aim of identifying relevant risk factors for BC in Hong Kong and developing a locally validated BC risk assessment tool for Hong Kong Chinese women. After consideration of the most recent international and local scientific evidence including findings of the HKBCS, the Cancer Expert Working Group on Cancer Prevention and Screening (CEWG) has reviewed and updated its BC screening recommendations. Existing recommendations were preserved for women at high risk and slightly changed for women at moderate risk. The following major updates have been made concerning recommendations for other women in the general population: Women aged 44 to 69 with certain combinations of personalised risk factors (including presence of history of BC among first-degree relative, a prior diagnosis of benign breast disease, nulliparity and late age of first live birth, early age of menarche, high body mass index and physical inactivity) putting them at increased risk of BC are recommended to consider mammography screening every 2 years. They should discuss with their doctors on the potential benefits and harms before undergoing mammography screening. A risk assessment tool for local women (eg, one developed by HKU) is recommended to be used for estimating the risk of developing BC with regard to the personalised risk factors described above.

683 UNDERSTANDING HOW DISCHARGE SERVICES FOR OLDER PATIENTS CAN BRIDGE THE GAP BETWEEN HOSPITAL, COMMUNITY AND SOCIAL CARE

Introduction

UK policy recommends that discharge support is provided by hospital, community and social care staff. However, there is a lack of understanding regarding how these multiagency hospital discharge services work in practice, how they can be sustained and what service stakeholder experiences of them are. This research aimed to understand how integrated discharge services work and the views and experiences of stakeholders.

Method

A qualitative case study of a supported integrated hospital discharge service (SIHDS) for older people was undertaken, which involved interviews with service staff (hospital, community and social care), patients and carers. Staff, patients and carers were interviewed on their experiences of SIHDS. Staff also took part in a process mapping exercise to understand how the service works. Interviews were analysed using thematic analysis. Ethical approval was obtained for this research.

Results

A variety of staff (n = 14) and patients aged over 60 years (n = 11) and their informal carers/family members (n = 4) were interviewed. Three main staff themes emerged from the findings: 1. Preparedness for discharge and impact of discharge service; 2. Integration and impact on patient pathway and 3. Organisational aspects. The three main patient/carer themes were: 1. Support for patients; 2. Patient Outcomes and 3. Information exchange. The findings demonstrated that: SIHDS was seen as important to allow patients to be discharged home in a timely and safe manner; that communication is important at all levels of a SIHDS and SIHDS need to continuously evolve to provide patient centred care.

Conclusion

The findings from this qualitative case study allow the complexities involved in SIHDS to be understood from the experiences and perspectives of multiagency staff, patients and carers. It shows SIHDS are complex, but useful to overcome gaps between services. However, to effectively sustain a patient centred service it is important to regularly review and develop SIHDS.

682 IMPACT OF DISCHARGE INTERVENTIONS FOR OLDER PATIENTS LEAVING HOSPITAL: A SYSTEMATIC REVIEW OF REVIEWS

Introduction

The UK has an aging population and there is an increasing need for additional care and support services for elderly patients discharged from hospital. Despite a large evidence base on different discharge services there is inconsistent findings on their effectiveness. This systematic review of reviews aimed to evaluate the impact of a variety of discharge interventions on older people leaving hospital.

Method

Ten databases were searched (including Medline and The Cochrane Library) using multiple key search terms related to ‘systematic reviews’, ‘older people’ and ‘discharge’. Only systematic reviews of interventions for people aged over 60 years that provided additional support or adapted their discharge processes were included. Outcomes of interest included mortality, readmissions, length of hospital stay, patient health status and costs. Abstract, title and full-text screening was conducted independently by two reviewers. Interventions were categorised by intervention type and a narrative synthesis was conducted on data extracted.

Results

Of the 8,748 title and abstracts reviewed, 859 full texts were assessed for eligibility, of these 91 were taken forward to quality assessment and 66 moderate or high-quality reviews were included in the final synthesis. Interventions were categorised into 10 types and had varying impact on outcomes. A statistically significant positive impact on the outcomes of interest was found for: Interventions providing ‘rehabilitation, therapy or care at home (or in the community) around the time of discharge’ reducing length of stay; ‘primary care interventions’, ‘Discharge planning/coordination or case management’ and ‘patient education’.

Conclusion

This systematic review of reviews shows that different types and configurations of discharge interventions can benefit older patients in multiple ways when compared to usual care and highlights which intervention types make no difference or have negative impacts. These findings will help to inform the development of new discharge interventions and the direction of future research.

Benchmarking physical activity and nutrition policies in Europe: lessons from the CO-CREATE project

Background

Global research shows a strong link between physical activity, nutrition and the risk of developing non-communicable diseases. To increase physical activity and healthy eating, governments must design and implement a comprehensive set of policy actions across a range of areas. The MOVING and NOURISHING benchmarking tools were developed to identify gaps and assess the strength of actions taken by national governments in these complex policy areas.

Methods

The benchmarking tools value the strength of policy design based on policy attributes that are evidence-informed and aspirational. Both tools were applied to five countries participating in CO-CREATE, a European Commission-funded project: Netherlands, Norway, Poland, Portugal and UK. Physical activity and nutrition policies in each of these countries were identified based on a comprehensive country scan, with a set methodology.

Results

The benchmarks assessed the strengths and weaknesses in the design of policies across the NOURISHING and MOVING policy areas. They identified where there was scope for improvement within a policy area. For example, the tools helped evaluate the design of health related-food taxes in Norway, Poland, Portugal, and UK and allowed a cross-country comparison of these policies. When comparing the overall policy environment across all countries, we found an overall lack of policies promoting access to open/green spaces and weaknesses in designing restrictions on marketing unhealthy foods to children.

Conclusions

The benchmarking tools can inform the development and implementation of policies which promote physical activity and healthy eating. They were developed for the European context but are also being tested on relevant policies in South Africa. They can be used by governments, policymakers, researchers and civil society to identify areas of physical activity and nutrition policy that are weak and require government action.

Key messages

Benchmarking nutrition and physical activity policy can identify gaps and assess the strength of actions taken by national governments in these complex policy areas. The NOURISHING and MOVING benchmarking tools can be used by governments, policymakers, researchers and civil society various to inform policy-making in nutrition and physical activity.

Renal staffs' understanding of patients' experiences of transition from peritoneal dialysis to in-centre haemodialysis and their views on service improvement: A multi-site qualitative study in England and Australia

INTRODUCTION

Many studies have explored patients' experiences of dialysis and other treatments for kidney failure. This is the first qualitative multi-site international study of how staff perceive the process of a patient's transition from peritoneal dialysis to in-centre haemodialysis. Current literature suggests that transitions are poorly coordinated and may result in increased patient morbidity and mortality. This study aimed to understand staff perspectives of transition and to identify areas where clinical practice could be improved.

METHODS

Sixty-one participants (24 UK and 37 Australia), representing a cross-section of kidney care staff, took part in seven focus groups and sixteen interviews. Data were analysed inductively and findings were synthesised across the two countries.

RESULTS

For staff, good clinical practice included: effective communication with patients, well planned care pathways and continuity of care. However, staff felt that how they communicated with patients about the treatment journey could be improved. Staff worried they inadvertently made patients fear haemodialysis when trying to explain to them why going onto peritoneal dialysis first is a good option. Despite staff efforts to make transitions smooth, good continuity of care between modalities was only reported in some of the Australian hospitals where, unlike the UK, patients kept the same consultant. Timely access to an appropriate service, such as a psychologist or social worker, was not always available when staff felt it would be beneficial for the patient. Staff were aware of a disparity in access to kidney care and other healthcare professional services between some patient groups, especially those living in remote areas. This was often put down to the lack of funding and capacity within each hospital.

CONCLUSIONS

This research found that continuity of care between modalities was valued by staff but did not always happen. It also highlighted a number of areas for consideration when developing ways to improve care and provide appropriate support to patients as they transition from peritoneal dialysis to in-centre haemodialysis.

Understanding the impact of systemic lupus erythematosus on work amongst South Asian people in the UK: An explorative qualitative study

SLE has a range of fluctuating symptoms affecting individuals and their ability to work. Although South Asian (SA) patients are at increased risk of developing SLE there is limited knowledge of the impact on employment for these patients in the UK. Understanding ethnicity and disease-specific issues are important to ensure patients are adequately supported at work. Semi-structured interviews were conducted with patients of SA origin to explore how SLE impacted on their employment. Thematic analysis was used to analyse the data which are reported following COREQ guidelines. Ten patients (8 female; 2 male) were recruited from three rheumatology centres in the UK and interviewed between November 2019 and March 2020. Patients were from Indian (n = 8) or Pakistani (n = 2) origin and worked in a range of employment sectors. Four themes emerged from the data: (1) Disease related factors; (2) Employment related factors; (3) Cultural and interpersonal factors impacting on work ability; (4) Recommendations for improvement. Patients’ ability to work was affected by variable work-related support from their hospital clinicians, low awareness of SLE and variable support from their employers, and cultural barriers in their communities that could affect levels of family support received. These findings highlight the need for additional support for SA patients with SLE in the workplace.

P159 Factors associated between SLE and work amongst South Asian people: an explorative qualitative study

Background/Aims 

Systemic lupus erythematosus (SLE) affect patients from minority ethnic backgrounds, with many patients experiencing symptoms that affect their daily lives despite receiving long-term controller medication. Work is a large part of most people’s lives, yet little has been explored into how people from minority ethnic backgrounds cope at work whilst living with SLE. We conducted a study to understand the impact of SLE on working lives of South Asian patients. The aim was to identify and develop support mechanisms that could assist them with remaining at work.

Methods 

Semi-structured interviews were conducted with ten patients of South Asian origin with SLE to explore their work experiences. Patients were recruited from three rheumatology centres in the West Midlands, UK and were interviewed between November 2019 and March 2020. Interviews were audio-recorded and typed by an independent transcribing company. Returned transcripts were analysed using thematic analysis and QSR NVivo 12 software was used to organise and manage the data.

Results 

The majority (n = 8) of patients were female. Eight patients were from an Indian background, and two were from a Pakistani background. Half of all patients were educated to degree level. The age range of patients was 23 - 58 years old (S.D = 10.79), and disease duration varied between 3 months-33 years (S.D = 9.52). All patients had permanent jobs; six were in full-time employment, and four were in part-time employment. Four main themes emerged from the data: 1) Disease related factors; impacting work ability; 2) Employment related factors; impacting work ability; 3) Personal and cultural related factors; impacting work ability; 4) Recommendations for improvement were made by patients.

Conclusion 

In this novel study we highlight patients’ experiences of being at work. This study reports low awareness of SLE and mixed support in the workplace. Patients discussed work to varying degrees with their clinicians and needed further information for employers that was not available nor provided by their clinicians. The study reports cultural barriers in understanding SLE that could lead to lack of family support to remain in employment. Moreover, recommendations made in this study require further investigation and could be used by clinicians and Lupus UK to support patients of South Asian origin at work.

Disclosure 

M. Ubhi: None. S. Dubey: None. J. Reynolds: None. C. Gordon: None. T. Adizie: None. T. Sheeran: None. K. Allen: None. R. Jordan: None. S. Sadhra: None. J. Adams: None. R. Daji: None. K. Kumar: None.

How do patients and their family members experience the transition from peritoneal dialysis to incentre haemodialysis? A multisite qualitative study in England and Australia

BACKGROUND

While numerous studies have explored the patient experience of dialysis or other end-stage kidney disease (ESKD) treatments, few have explored the process of transitioning between dialysis modalities. This study aimed to develop an in-depth understanding of patient and caregiver perceptions and experiences of the transition from peritoneal to haemodialysis (HD) and to identify ways in which transitions can be optimised.

METHODS

Fifty-four in-depth, semi-structured interviews were undertaken at six study sites across the West Midlands, UK (n = 23), and Queensland, Australia (n = 31). Thirty-nine participants were patients with ESKD; the remainder were family members. An inductive analytical approach was employed, with findings synthesised across sites to identify themes that transcended country differences.

RESULTS

Of the 39 patient transitions, only 4 patients reported a wholly negative transition experience. Three cross-cutting themes identified common transition experiences and areas perceived to make a difference to the treatment transition: resistance to change and fear of HD; transition experience shared with family; and bodily adjustment and sense of self.

CONCLUSION

Although each transition is unique to the individual and their circumstances, kidney care services could optimise the process by recognising these patient-led themes and developing strategies that engage with them. Kidney care services should consider ways to keep patients aware of potential future treatment options and present them objectively. There is potential value in integrating expert support before and during treatment transitions to identify and address patient and family concerns.

Delay in seeking medical help in patients with rheumatoid arthritis in India: A qualitative study

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disease with varied articular and extra-articular manifestations. In developing countries such as India patients with RA often delay seeking medical advice which may impact prognosis and disease burden.

AIM

To explore perceptions and experiences of patients living in India in seeking medical help for their RA symptoms.

METHODS

Clinician-diagnosed RA participants from different socioeconomic backgrounds were interviewed using a semi-structured topic guide. Participants were purposively selected and interviewed following an iterative approach. All interviews were recorded and transcribed by an independent company and analyzed using a thematic framework. Findings were reported in accordance with consolidated criteria for reporting qualitative research guidelines.

RESULTS

Twenty participants (13 male, 7 female) with median age 40 years (35.7-46.5) were recruited. Three overarching themes demonstrating participants' experiences and reasons for delay in seeking medical help were identified. (1) "Symptoms perspectives and delay in participants' journey" narrated participants' experiences of having RA symptoms, how these were perceived, rationalized and led to delay. (2) "Participants' experience of the healthcare system" illustrated delay in referral, reaching diagnosis and treatment initiation highlighting their experiences with the health system. (3) "Recommendations for improving care" where participants made recommendations for reducing the delay at local and national levels.

CONCLUSION

This is the first qualitative study which explored perceptions and experiences of RA patients in India resulting in delay. Improved provision of rheumatology care, effective referral system and greater involvement of government at local and national levels are needed to improve the delay in seeking medical help for Indian patients.

Variation in the strength of allometry drives rates of evolution in primate brain shape

Large brains are a defining feature of primates, as is a clear allometric trend between body mass and brain size. However, important questions on the macroevolution of brain shape in primates remain unanswered. Here we address two: (i), does the relationship between the brain size and its shape follow allometric trends and (ii), is this relationship consistent over evolutionary time? We employ three-dimensional geometric morphometrics and phylogenetic comparative methods to answer these questions, based on a large sample representing 151 species and most primate families. We found two distinct trends regarding the relationship between brain shape and brain size. Hominoidea and Cercopithecinae showed significant evolutionary allometry, whereas no allometric trends were discernible for Strepsirrhini, Colobinae or Platyrrhini. Furthermore, we found that in the taxa characterized by significant allometry, brain shape evolution accelerated, whereas for taxa in which such allometry was absent, the evolution of brain shape decelerated. We conclude that although primates in general are typically described as large-brained, strong allometric effects on brain shape are largely confined to the order's representatives that display more complex behavioural repertoires.

'You have got a foreign body in there': renal transplantation, unexpected mild-to-moderate distress and patients' support needs: a qualitative study

OBJECTIVE

To explore why transplant patients experience unexpected mild-to-moderate distress and what support they may need.

DESIGN

Qualitative study using individual in-depth interviews.

SETTING

Four National Health Service (NHS) Trusts in the Midlands, UK.

PARTICIPANTS

Fifteen renal transplant patients meeting the criteria for mild-to-moderate distress from their responses to emotion thermometers.

MAIN OUTCOME MEASURES

Identification of the reasons for distress and support options acceptable to renal transplant patients.

RESULTS

Three themes were interpreted from the data: 'I am living with a "foreign body" inside me', 'why am I distressed?' and 'different patients want different support'. Following their transplant, participants felt that they should be happy and content, but this was often not the case. They described a range of feelings about their transplant, such as uncertainty about the lifespan of their new kidney, fear of transplant failure or fear of the donor having health conditions that may transfer to them. A few experienced survivors' guilt when others they had met at the dialysis unit had not received a transplant or because someone had died to enable them to receive the transplant. No longer having regular contact with the renal unit made participants feel isolated. Some participants did not initially attribute the source of their distress to their transplant. Participants' preferred support for their distress and their preferences about who should deliver it varied from peer support to seeing a psychologist.

CONCLUSIONS

Raising the issue of post-transplant mild-to-moderate distress with patients and encouraging them to think about and plan coping strategies pretransplant may prove beneficial for the patient and healthcare provider. Patients should be able to choose from a variety of support options.

Distress in patients with end-stage renal disease: Staff perceptions of barriers to the identification of mild-moderate distress and the provision of emotional support

OBJECTIVES

To explore staff perceptions of barriers to the identification of mild to moderate distress and the provision of emotional support in patients with end-stage renal disease.

METHODS

Qualitative semi-structured interviews with staff in two hospitals (n = 31), with data analysed using a hybrid approach combining thematic analysis with aspects of grounded theory.

RESULTS

Staff appeared very aware that many patients with end-stage renal disease experience distress, and most thought distressed patients should be helped as part of routine care. However, practice was variable and looking for and addressing distress was not embedded in care pathways. Interviews identified six themes: i) staff perceptions about how distress is manifested and what causes distress were variable; ii) staff perceptions of patients could lead to distress being overlooked because patients were thought to hide their distress whilst some groups were assumed to be more prone to distress than others; iii) role perceptions varied, with many staff believing it to be their role but not feeling comfortable with it, with doctors being particularly ambivalent; iv) fears held back some staff, who were concerned about what might happen when talking about distress, or who found the emotional load for themselves to be too high; v) staff felt they lacked skills, confidence and training, vi) capacity to respond may be limited, as staff perceive there to be insufficient time, with little or no specialist support services to refer patients to.

CONCLUSIONS

Staff perceived significant barriers in identifying and responding to patient distress. Barriers related to skills and knowledge could be addressed through training, with training ideally targeted at staff with positive attitudes, but who currently lack skills and confidence. Barriers related to role perceptions would be harder to address. The study is relevant internationally as part of improving long-term condition pathways.

Work productivity loss among rheumatoid arthritis patients in India: a qualitative study

Objective

The aim was to explore the extent to which RA impacts work productivity in patients living with RA in India.

Methods

Face-to-face semi-structured interviews took place with 13 male and seven female patients attending outpatient clinics at Sanjay Gandhi Postgraduate Institute of Medical Sciences, India, living with RA. Patients who were currently working were recruited. Data were audio recorded, transcribed by an independent translation company and analysed using the framework method of thematic analysis.

Results

Four themes that explained patients’ experiences of coping with work whilst having RA were identified. These were as follows: balancing act of work and RA, in which participants expressed their day-to-day struggle of living with RA and coping at work; workplace adaptation after RA, in which participants shared insights into communicating with employers and their efforts to adapt at the workplace; support from others and information to manage RA and work, in which participants considered seeking support from different sources that would help them cope at work and understand RA; and wanting a better support mechanism, in which participants made recommendations that could help them to cope at work.

Conclusion

This is the first study to explore the impact of RA on patients’ work productivity in India. Patients might have different support needs compared with previous studies in other countries. Patients seem to be adopting additional coping strategies not addressed by current interventions or country systems, which might not be sufficient to support patients in remaining employed. Patients made future recommendations.

PP30 Investigating the use and effect of a patient outcome feedback intervention (POFI) on ambulance staff

Background

Feedback and audit are ways of reflecting upon professional practice (Ivers et al, 2012). Opportunities for feedback have been cited as one of the mechanisms which ambulance staff develop their decision-making skills and reflect on their practice (Ivers et al, 2014).

Methods

A digital patient outcome feedback intervention (POFI) was designed and tested. POFI reported patient outcomes, clinical investigations and treatment after conveyance to hospital. A data sharing agreement between one hospital and ambulance service was secured. Ambulance staff were surveyed and interviewed regarding its desirability, impact and usability. Descriptive and thematic data analysis was performed.

Results

Respondents were enthusiastic about feedback, reflected in a good response rate to the first survey (N=186). This was not matched by high POFI usage or the second survey (N=28). This may be because it is not yet easily accessible or well known. Respondents indicated feedback is likely to improve decision-making confidence, enhance self-efficacy and patient safety. They felt it would contribute to learning through self-reflection, enhancing knowledge and skills and thus continue professional development. Feedback provides an opportunity to clear up mysteries and support wellbeing.

Conclusions

Feedback is desirable, but requires a commitment by ambulance services and hospital sites to share data and then feedback system with staff. There are pockets of interest, nationally, in giving feedback to ambulance staff. This project is the only one known, using a digital mechanism. Other projects give personalised feedback through ‘post-boxes’ or other written requests. Further study could be carried out in collaboration with these similar projects. It is important to work out the best mechanism of sharing data, to suit information governance requirements, whilst also contributing to ambulance confidence, learning and wellbeing.

Reports of rationing from the neglected realm of capital investment: Responses to resource constraint in the English National Health Service

Health systems around the world face financial pressures that can affect sustainability and patient outcomes, and there is a vast literature devoted to the allocation of scarce health care resources. Capital spending - for example on estates, equipment and information technology - is an important but often neglected area of this literature. This study explores the constraints on the allocation of capital budgets in health care, before addressing the question: what is the role of priority setting and rationing in responses to these constraints? The paper presents findings from interviews conducted with senior finance professionals in 30 National Health Service local provider organisations across England. Findings suggest a pervasive sense of impending crisis, with capital restrictions limiting investment in buildings, infrastructure and equipment. The paper applies a conceptual classification scheme from the classic rationing literature (the forms of rationing framework) and identifies widespread practices of 'selection', 'dilution' and 'delay', with 'denial' and 'termination' comparatively rare. Practices of 'deflection' and 'deterrence' are ascribed to national actors as a means of restricting the flow of capital resources to the system. The study suggests that there is little by way of tailored support for priority setting in capital spending, and a perception that decisions are often reactive and short term. It also suggests that wider system features and dynamics can preclude or constrain priority setting at the organisational level. The authors use these findings to suggest future conceptual development of the forms of rationing framework and make recommendations for research and practice in this area.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Abstract P3-10-06: What is the latest evidence on diet, nutrition, physical activity and cancer – key findings from the WCRF/AICR continuous update project

Introduction:

Since 1997, World Cancer Research Fund (WCRF) International and the American Institute for Cancer Research (AICR) have been at the forefront of synthesizing and interpreting the accumulated scientific literature on the link between diet, nutrition, physical activity and cancer, and deriving evidence-based Cancer Prevention Recommendations. The 2007 WCRF/AICR 2nd Expert Report, using a robust method and systematic literature reviews, was a landmark in the analysis of evidence linking diet, body weight and physical activity to cancer and led to the establishment of the Continuous Update Project (CUP). New findings from the CUP systematic review have been released for 12 cancers, and updated findings for breast cancer have just been released. The 2018 WCRF/AICR 3rd Expert Report, to be published in 2018, will include a new review of the WCRF/AICR Cancer Prevention Recommendations.

Methods:

The review was conducted as part of the Continuous Update Project (CUP).

The research team at Imperial College London searched PubMed for relevant prospective studies up to April 30, 2015.

Dose-response meta-analyses were conducted and summary relative risks (RR) were calculated using a random effects model. Analyses comparing the highest versus the lower categories were also conducted. An international panel of experts (CUP Panel) reviewed the evidence and drew conclusions.

Results:

The updated Breast Cancer Report included 119 studies from around the world, comprising more than 12 million women and over 260,000 cases of breast cancer.

The latest evidence suggests that vigorous physical exercise reduces your risk of breast cancer before menopause by 17%. In addition, the report reconfirms the link between physical activity and decreased risk of breast cancer after menopause. Taking at least 30 minutes of moderate physical activity, such as brisk walking, or 15 minutes of vigorous physical activity each day can reduce your risk of breast cancer after menopause by 10%.

Greater body fatness and weight gain as an adult does increase the risk of breast cancer after menopause. However, in contrast we observed greater body fatness in young adulthood may reduce breast cancer risk both before and after menopause.

The report found strong evidence that drinking just the equivalent of a small glass of wine or half a pint of beer a day (about 10g alcohol content), could increase your pre-menopausal breast cancer risk by 5% and your post-menopausal breast cancer risk by 9%.

Conclusions:

Recent evidence has resulted in new findings and changes to the CUP Panel's conclusions from the 2010 Breast Cancer Report with regard to physical activity and body fatness at different life periods. In addition, new evidence confirmed their judgements on alcohol.

The CUP provides a unique resource synthesizing epidemiological and other evidence on diet, nutrition, physical activity and cancer, to facilitate related research, and underpin advice to the public and policy-makers.

Evidence is accumulating that the degree of adherence to WCRF/AICR recommendations is associated with lower mortality of cancer overall, of specific cancers and of all-cause mortality.

Citation Format: Thune I, Allen K, Thompson RL, Wiseman MJ, Mitrou P, McGinley-Gieser D. What is the latest evidence on diet, nutrition, physical activity and cancer – key findings from the WCRF/AICR continuous update project [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-10-06.

Kinematic Gait Analysis of the Trot in Healthy Mixed Breed Dogs

Computer aided kinematic and synchronized force plate gait analysis were used to characterize joint movement in 14 large mixed breed dogs at a trot. A curvilinear relationship of joint angle to time was described, for three forelimb and three hindlimb joints. Two peaks of maximum extension, one preceding the onset and at the end of stance phase were observed for the femorotibial, tarsus and cubital joints. The carpus, scapulohumeral and coxofemoral joint exhibited one peak of maximum extension. The variance in joint angle measurement was calculated for repeated trials for a given dog and for differences between dogs using a 2-factor repeated measures ANOVA. The mean variance for all joints except the carpal joint for trial repetition was 12.6 (degrees)2 (range, 2.6-23.9) and for differences between dogs 6.2 (degrees)2 (range, 1.0-11.3). The carpal joint exhibited greater variation with a mean variance, attributable to trial repetition, of 42.5 (degrees)2 (range, 39.4-44.3) and a variance between dogs of 52.4 (degrees)2 (range, 18.5-89.4).

The results obtained would suggest that computer assisted kinematics is an accurate means of assessing joint angle movement in large mixed breed dogs with a low level of variance attributable to trial repetition and to differences between dogs, with the exception of the carpal joint. The sample of mixed breed dogs in this study is similar to dogs that would be seen in a clinical sample population. Our results suggest that computer assisted kinematics could be an important tool in providing objective information on gait, in clinical and research studies, using mixed breed dogs.

This study describes the trot in 14 large mixed breed dogs using computer aided kinematic and force plate gait analysis techniques. Variances in fore and hindlimb joint angle measurements were deter-mined, for a given dog, by repeated trials and for differences between dogs. The measured variances were low in all joints except the corpus, despite diverse dog conformation in the study.

The association between higher maternal pre-pregnancy body mass index and increased birth weight, adiposity and inflammation in the newborn

BACKGROUND

Excess adiposity and adiposity-related inflammation are known risk factors for cardiovascular disease in adults; however, little is known regarding the determinants of adiposity-related inflammation at birth.

OBJECTIVES

The aim of this study was to investigate the association between maternal pre-pregnancy BMI and newborn adiposity and inflammation.

METHODS

Paired maternal (28-week gestation) and infant (umbilical cord) blood samples were collected from a population-derived birth cohort (Barwon Infant Study, n = 1074). Data on maternal comorbidities and infant birth anthropomorphic measures were compiled, and infant aortic intima-media thickness was measured by trans-abdominal ultrasound. In a selected subgroup of term infants (n = 161), matched maternal and cord lipids, high-sensitivity C-reactive protein (hsCRP) and maternal soluble CD14 were measured. Analysis was completed by using pairwise correlation and linear regression. Because of their non-normal distribution, pathology blood measures were log transformed prior to analysis.

RESULTS

Maternal pre-pregnancy BMI was positively associated with increased birth weight (mean difference 17.8 g per kg m^-2 , 95% CI 6.6 to 28.9; p = 0.002), newborn mean skin-fold thickness (mean difference 0.1 mm per kg m^-2 , 95% CI 0.0 to 0.1; p < 0.001) and cord blood hsCRP (mean difference of 4.2% increase in hsCRP per kg m^-2 increase in pre-pregnancy BMI, 95% CI 0.6 to 7.7%, p = 0.02), but not cord blood soluble CD14. Inclusion of maternal hsCRP as a covariate attenuated the associations between pre-pregnancy BMI and both newborn skin-fold thickness and cord blood hsCRP.

CONCLUSION

Higher maternal pre-pregnancy BMI is associated with increased newborn adiposity and inflammation. These associations may be partially mediated by maternal inflammation during pregnancy.

A randomised controlled trial of three psychological treatments for anorexia nervosa

BACKGROUND

There is a lack of evidence pointing to the efficacy of any specific psychotherapy for adults with anorexia nervosa (AN). The aim of this study was to compare three psychological treatments for AN: Specialist Supportive Clinical Management, Maudsley Model Anorexia Nervosa Treatment for Adults and Enhanced Cognitive Behavioural Therapy.

METHOD

A multi-centre randomised controlled trial was conducted with outcomes assessed at pre-, mid- and post-treatment, and 6- and 12-month follow-up by researchers blind to treatment allocation. All analyses were intention-to-treat. One hundred and twenty individuals meeting diagnostic criteria for AN were recruited from outpatient treatment settings in three Australian cities and offered 25-40 sessions over a 10-month period. Primary outcomes were body mass index (BMI) and eating disorder psychopathology. Secondary outcomes included depression, anxiety, stress and psychosocial impairment.

RESULTS

Treatment was completed by 60% of participants and 52.5% of the total sample completed 12-month follow-up. Completion rates did not differ between treatments. There were no significant differences between treatments on continuous outcomes; all resulted in clinically significant improvements in BMI, eating disorder psychopathology, general psychopathology and psychosocial impairment that were maintained over follow-up. There were no significant differences between treatments with regard to the achievement of a healthy weight (mean = 50%) or remission (mean = 28.3%) at 12-month follow-up.

CONCLUSION

The findings add to the evidence base for these three psychological treatments for adults with AN, but the results underscore the need for continued efforts to improve outpatient treatments for this disorder. Trial Registration Australian New Zealand Clinical Trials Registry (ACTRN 12611000725965) http://www.anzctr.org.au/.

How does pre-dialysis education need to change? Findings from a qualitative study with staff and patients

BACKGROUND

Pre-dialysis education (PDE) is provided to thousands of patients every year, helping them decide which renal replacement therapy (RRT) to choose. However, its effectiveness is largely unknown, with relatively little previous research into patients' views about PDE, and no research into staff views. This study reports findings relevant to PDE from a larger mixed methods study, providing insights into what staff and patients think needs to improve.

METHODS

Semi-structured interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients, exploring experiences of and views about PDE, and analysed using thematic framework analysis.

RESULTS

Most patients found PDE helpful and staff valued its role in supporting patient decision-making. However, patients wanted to see teaching methods and materials improve and biases eliminated. Staff were less aware than patients of how informal staff-patient conversations can influence patients' treatment decision-making. Many staff felt ill equipped to talk about all treatment options in a balanced and unbiased way. Patient decision-making was found to be complex and patients' abilities to make treatment decisions were adversely affected in the pre-dialysis period by emotional distress.

CONCLUSIONS

Suggested improvements to teaching methods and educational materials are in line with previous studies and current clinical guidelines. All staff, irrespective of their role, need to be trained about all treatment options so that informal conversations with patients are not biased. The study argues for a more individualised approach to PDE which is more like counselling than education and would demand a higher level of skill and training for specialist PDE staff. The study concludes that even if these improvements are made to PDE, not all patients will benefit, because some find decision-making in the pre-dialysis period too complex or are unable to engage with education due to illness or emotional distress. It is therefore recommended that pre-dialysis treatment decisions are temporary, and that PDE is replaced with on-going RRT education which provides opportunities for personalised education and on-going review of patients' treatment choices. Emotional support to help overcome the distress of the transition to end-stage renal disease will also be essential to ensure all patients can benefit from RRT education.

Examining the psychological and social impact of relative age in primary school children: a cross-sectional survey

BACKGROUND

A number of studies demonstrate that children who are younger within their school year have poorer academic attainment and are more likely to have special educational needs. Few, however, have considered the impact relative age may have on child mental health, behaviour and happiness in school.

METHODS

This paper utilized data from the Supporting Teachers and Children in Schools study (2075 pupils aged 5 to 9 years from 80 primary schools) to explore the relationship among relative age, behaviour and happiness in school. Behavioural and emotional development was assessed by using the teacher-reported and parent-reported Strengths and Difficulties Questionnaire and the Pupil Behaviour Questionnaire. Children's happiness within school was assessed by using the How I Feel About My School Questionnaire.

RESULTS

Relatively younger children had higher Total Difficulties scores on the Strengths and Difficulties Questionnaire than their peers. There was a mean increase per 30-day decrease in relative age of 0.09 (95% CI: 0.03 to 0.16; p = 0.007) in teacher-reported and 0.08 (0.001 to 0.16; p = 0.05) in parent-reported scores. There was little evidence of a relationship between relative age and children's behaviour and happiness in school.

CONCLUSIONS

For children with complex difficulties, being relatively young for their school year may be an additional stressor that may undermine mental health.

Novel outreach settings to enhance sexually transmitted infection/HIV awareness, diagnosis and treatment in hard-to-reach populations

Despite recent rises in the number of cases of sexually transmitted infections (STIs) such as syphilis and gonorrhoea in England and increasing rates of HIV diagnosis among several men who have sex with men populations, many individuals are still not engaging with sexual health services. The John Hunter Clinic for Sexual Health, Chelsea and Westminster Hospital, London set up outreach clinics at the two world's largest adult lifestyle exhibitions in 2013 and 2015. This was the first time that a sexual health screening and promotion service was available at these large-scale (over 10,000 attendees at each) adult lifestyle events. A total of 381 individuals underwent STI screening across the two events. Nineteen (5.0%) patients were diagnosed with an infection. Twelve (3.1%) patients with Chlamydia trachomatis, three (0.8%) patients with syphilis, one (0.3%) patient with Neisseria gonorrhoeae, one (0.3%) patient with HIV, one (0.3%) patient with hepatitis B and one (0.3%) patient with hepatitis C. All 19 patients were promptly contacted with their results and had arrangements made for treatment or were referred for specialist follow up. Where possible, contact tracing was also performed. Implementing such outreach-based projects is challenged by lack of on-site laboratory support, high staffing demands and potentially high costs. However, we achieved a total HIV screening uptake rate of 94.5% amongst our outreach clinic attendees (versus 67% nationally in conventional sexual health clinic attendees) with an HIV positivity rate of 0.3% (versus 0.2% nationally in high HIV prevalence band populations). Additionally, 30.7% had never been tested for HIV previously (versus 20.7% nationally). Our work demonstrates that these strategies can help to address issues related to lack of STI/HIV screening in hard-to-reach populations and promote risk reduction behaviour.