Principal Accompaniment in Australian Faith-Based Schools: A Salutogenesis Approach

A program designed to provide accompaniment reflects a salutogenesis emphasis aimed at sustaining the professional well-being of experienced principals. A mixed methods pilot study focused on participant (N = 12) orientation, principles of accompaniment, mission-aligned processes, leadership agency, structured conversations, and nominated outcomes. Data were collected over twelve months at three stages using online survey. Australian Catholic principals reported a positive orientation experience, professional well-being, the comprehensiveness of the program, and the manageability of its implementation. Discussion confirmed design elements contributed to the wholistic nature of accompaniment linking body, mind, and spirit in conversational processes and the transformative effects of these exchanges on professional practice and well-being.

Pan-European study of genotypes and phenotypes in the Arabidopsis relative Cardamine hirsuta reveals how adaptation, demography, and development shape diversity patterns

We study natural DNA polymorphisms and associated phenotypes in the Arabidopsis relative Cardamine hirsuta. We observed strong genetic differentiation among several ancestry groups and broader distribution of Iberian relict strains in European C. hirsuta compared to Arabidopsis. We found synchronization between vegetative and reproductive development and a pervasive role for heterochronic pathways in shaping C. hirsuta natural variation. A single, fast-cycling ChFRIGIDA allele evolved adaptively allowing range expansion from glacial refugia, unlike Arabidopsis where multiple FRIGIDA haplotypes were involved. The Azores islands, where Arabidopsis is scarce, are a hotspot for C. hirsuta diversity. We identified a quantitative trait locus (QTL) in the heterochronic SPL9 transcription factor as a determinant of an Azorean morphotype. This QTL shows evidence for positive selection, and its distribution mirrors a climate gradient that broadly shaped the Azorean flora. Overall, we establish a framework to explore how the interplay of adaptation, demography, and development shaped diversity patterns of 2 related plant species.

P-508 Why I left my Fertility Clinic for Another ART provider – It’s Not What You Think: A RealTalk patient survey

Study question

To assess with a large number of patients why they chose to switch ART provider[s] before they had exhausted all of their treatment options.

Summary answer

The patient-provider relationship was the most common reason cited for leaving an ART provider, and also the most common reason for staying.

What is known already

A large number of patients drop out of treatment early in the ART treatment process, for many reasons. In previous studies, this was attributed to a negative patient experience. Also, ‘information’, ‘attitude of and relationship with staff’ and ‘competence of clinic and staff’ were noted by patients as three major points. Previous evidence suggests a ‘lack of empathy’, negative interactions with staff, and poorly formulated explanations of healthcare plans[5] are substantially causing discontinuation of treatment. Most research published on the topic available so far, either uses a small sample of patients or only indirectly assesses potential reasons for drop out.

Study design, size, duration

A 12-question online questionnaire was sent to 40 patient advocates of diverse age, race, sexual orientation, and treatment experiences. They were asked to disseminate it to members of their communities who met the criteria of having undergone at least one fertility treatment. In total, 1,060 patients were surveyed (February-April 2019). 89.6% came from the US, the remainder from 21 countries (six continents). Median age of respondents was 33.7. Median months trying to conceive was 48.

Participants/materials, setting, methods

The confidential online survey consisted of four demographic questions, four closed-ended treatment-history questions, and three open-ended questions about experiences with ART providers. The open-ended questions allowed answers of unlimited length.

Long form responses were modeled using Natural Language Processing (NLP) techniques, TF-IDF (Term Frequency-Inverse Document Frequency) combined with NMF (Non-negative Matrix Factorization) and grouped into topics, from which several “themes” emerged.

Methodology, results and conclusions were reviewed and endorsed by a committee of fertility specialists.

Main results and the role of chance

The reasons given for leaving their clinic fell into six clear themes: a treatment/approach not tailored to the patient and their needs (23%); poor bedside manner (communication style, the patient not feeling “heard”) (18%); logistical challenges e.g., doctor, clinic or patient had moved (14%); cost/access issues (9%); lack of efficacy e.g., treatment unsuccessful (8%); provider was “all business” e.g., patient felt like a number (8%). Taken together, 49% left a clinic because of a relationship issue. The remaining responses were too general to classify into a clear theme.

Four clear themes emerged in the reasons provided for staying with their clinic. Patients stayed because of good access/cost/insurance coverage (29%), they were already enrolled in next steps at the clinic (e.g., purchased IVF bundle, embryo storage, etc.) (26%), they had a connection with staff (25%), they were feeling optimistic (20%).

Relationships were also a major theme when respondents were asked to provide further comments about their experiences and/or what they value in a fertility doctor: a good fit (24%); provider has an interest in learning about them and/or exploring tailored treatment options (13%); feels connected and is being treated like a human being (11%); provider communicates and shows compassion (10%).

Limitations, reasons for caution

Respondents were invited to participate by other respondents, rather than recruited centrally.

Wider implications of the findings

This study demonstrates that, unlike patient access to funds or treatment success (over which they have little control), ART clinics can improve their patient retention rates by improving the one aspect of the patient experience over which providers have the most control: the patient-provider relationship.

Trial registration number

NA

OP0160 HLA-DRB1 ASSOCIATIONS WITH AUTOANTIBODY-DEFINED SUBGROUPS IN IDIOPATHIC INFLAMMATORY MYOPATHIES (IIM)

Background

There is a gap between how IIM patients are classified in practice and current validated classification criteria1. Also, different associations with genetic variations in HLA can inform about different T-cell mechanisms involved in disease pathogenesis.

Objectives

We aimed to systematically study associations between HLA-DRB1 alleles, clinical manifestations, and autoantibody-defined IIM subgroups.

Methods

We included 1348 IIM patients from five European countries. An unsupervised cluster analysis was performed using 14 autoantibodies: anti-Jo1, -PL7, -PL12, -EJ, -OJ, -SRP, -U1RNP, -Ro52, -Mi2, -TIF1γ, -MDA5, -PMScl, -SAE1, and -NXP2 to identify patients’ subgroups. Logistic regressions were used to estimate the associations between HLA-DRB1 alleles, clinical manifestations and the identified subgroups.

Results

Eight subgroups were defined by the autoantibody status (Table 1). Three of the subgroups (1, 2 and 6) have overlapping autoantibodies, while four are almost monospecific (3,4,5 and 7), and one (8) has patients negative for tested autoantibodies. Figure 1 represents the significant associations between HLA-DRB1 alleles and the eight subgroups. Heliotrope rash and Gottron’s sign were significantly more frequent in subgroups 3 (OR:2.2 95%CI:[1.1-4.8], OR:2.6 95%CI:[1.3-5.9], respectively), 4 (OR:12 95%CI:[3.6-75], OR:7.8 95%CI:[2.8-33], respectively) and 7 (OR:22 95%CI:[4.5-385], OR:10 95%CI:[3.1-65], respectively), and Raynaud’s phenomenon was significantly more frequent in subgroup 6 (OR:3.3 95%CI:[1.2-11]).

Table 1.

Autoantibody-defined subgroups using an unsupervised cluster analysis.

Subgroups/ MedoidsVariables1 Ro522 U1RNP3 PMScl4 Mi25 Jo16 Jo1/Ro527 TIF18 None*Alln (%)137 (10)183 (14)107 (8)65 (5)119 (9)140 (10)78 (6)519 (39)1348 (100)Female (%)93 (68)116 (63)79 (74)45 (69)76 (64)96 (69)64 (82)313 (60)882 (65)Age at diagnosis, median (IQR)56 (16)51.5 (23)51 (25)57 (22.5)47.5 (23.25)52 (19.5)53.5 (21.75)58 (22)55 (23)AutoantibodiesAnti-Jo106 (3)01 (2)119 (100)140 (100)00266 (20)Anti-PL77 (5)13 (7)00000020 (1.5)Anti-PL125 (4)3 (2)1 (1)01 (1)00010 (0.7)Anti-EJ2 (2)00000002 (0.1)Anti-OJ07 (4)0000007 (0.5)Anti-TIF110 (7)2 (1)2 (2)00078 (100)092 (7)Anti-Mi21 (1)1 (1)1 (1)65 (100)02 (1)0070 (5)Anti-SAE18 (6)23 (13)00000031 (2)Anti-NXP21 (1)23 (13)1 (1)0000025 (2)Anti-MDA59 (7)10 (6)1 (1)1 (2)01 (1)0022 (2)Anti-SRP8 (6)32 (18)00000040 (3)Anti-Ro52137 (100)16 (9)000140 (100)00293 (22)Anti-PMScl11 (8)1 (1)107 (100)00000119 (9)Anti-U1RNP079 (43)0003 (2)0082 (6)

*IIM patients negative for the tested autoantibodies.

Figure 1.

Forest plot of significant associations of HLA. *DRB1 alleles with autoantibody-defined subgroups. Scandinavia includes patients from Denmark, Norway, and Sweden.

Conclusion

Our study reveals that certain subgroups of IIM patients are characterized by overlap of myositis -specific and -associated autoantibodies, which in turn are associated with different HLA-DRB1 alleles including potential novel associations. These results point to different disease mechanisms in the subgroups, as well as suggest that IIM classification could be improved by integrating broader serological and genetic data.

References

[1]Parker MJS, Oldroyd A, Roberts ME, et al. The performance of the European League Against Rheumatism/American College of Rheumatology idiopathic inflammatory myopathies classification criteria in an expert-defined 10 year incident cohort. Rheumatology (Oxford). 2019;58(3):468-475.

Acknowledgements

We thank all the patients who participated in the study.

Disclosure of Interests

Valerie Leclair: None declared, Angeles Shunashy Galindo-Feria: None declared, Simon Rothwell: None declared, Olga Kryštůfková: None declared, Heřman Mann: None declared, Louise Pyndt Diederichsen: None declared, helena andersson: None declared, Martin Klein: None declared, Sarah Tansley: None declared, Neil McHugh: None declared, Janine Lamb: None declared, Jiří Vencovský Speakers bureau: Abbvie, Biogen, Boehringer, Eli Lilly, Gilead, MSD, Novartis, Pfizer, Roche, Sanofi, UCB, Werfen, Consultant of: Abbvie, Argenx, Boehringer, Eli Lilly, Gilead, Octapharma, Pfizer, UCB, Grant/research support from: Abbvie, Hector Chinoy: None declared, Marie Holmqvist: None declared, Leonid Padyukov: None declared, Ingrid E. Lundberg Shareholder of: Roche and Novartis, Consultant of: Corbus Pharmaceuticals Inc, Astra Zeneca, Bristol Myer´s Squibb, Corbus Pharmaceutical, EMD Serono Research & Development Institute, Argenx, Octapharma, Kezaar, Orphazyme, and Janssen, Grant/research support from: Astra Zeneca, Lina M. Diaz-Gallo: None declared

Service evaluation of the efficiency of moving discharge medicine request screening from the dispensary to hospital wards over a two-year period

Introduction

It is a common patient perception that their discharge from hospital is delayed by waiting for medicines (1). However, it is important to consider the entire discharge process when addressing this problem (2). In our large tertiary referral hospital, clinical pharmacy services were moved from wards to the dispensary following a staffing crisis during 2018. Ward-based services were reintroduced in 2020, but doubts remained over the practicality and benefits of doing this.

Aim

To compare the efficiency of ward and dispensary based clinical pharmacy services in our hospital in terms of interventions made and time taken.

Methods

We completed an observational service evaluation. Data on the time taken to process discharge medication requests with the dispensary-based service were collected retrospectively from the hospital electronic discharge system for 12 months (2018) for five medical wards. Equivalent data for the ward-based service were collected prospectively over three days (2020) by pharmacists delivering the service to seven medical wards, as this was considered more accurate, and several process steps did not exist in the ward-based model. For example, prescriber sending request to pharmacy and pharmacy acknowledging receipt of a request. The prospective data collection period was curtailed by Covid-19. Descriptive statistics were produced using Excel.

Results

Using the dispensary-based service (2018), 4459 medicine requests were processed from 5 medical wards, during a 12-month period. The mean time between prescribing and reaching the screening pharmacist was 175 minutes [95%CI ± 25.4]. It took an estimated time of 62 minutes [95%CI ± 2.99] to screen and resolve an intervention, with a mean of 3 interventions/ward/day. In 2020, using the ward-based approach to clinical pharmacy which screened medicine requests on the ward, 142 requests were screened over three days from seven wards, with no delay between prescribing and clinical screening. It took a mean of 17 minutes [95%CI ± 10.63] to screen and resolve an intervention, with a mean of 15 interventions/ward/day.

Conclusion

Ward based pharmacy yielded five times more interventions, took an average of 45 minutes less to screen and resolve issues per request and removed 175 minutes of process time. The additional time required to resolve issues identified in the dispensary-based screening process was thought to be the delay in contacting either the appropriate member of the ward staff referencing a particular patient for information or identifying and contacting the prescriber, or a combination of both. This study is limited by the long delay between data collection periods and the small sample size in 2020, but the differences between the two systems were large and there had been few other changes to hospital systems. Other limitations include changes related to Covid-19 and the lack of a control group, so it is not possible to establish a causal relationship between the type of pharmacy service and study outcomes.

References

(1) Wright S, Morecroft CW, Mullen R, Ewing AB. UK hospital patient discharge: the patient perspective. Eur J Hosp Pharm. 2017 Nov;24(6):338-342.

(2) Green CF, Hunter L, Jones L, Morris K. The TTO Journey: How much of it is actually in pharmacy? Pharm Man. 2015 Oct;31(4):16-20.

pyconsFold: a fast and easy tool for modeling and docking using distance predictions

MOTIVATION

Contact predictions within a protein have recently become a viable method for accurate prediction of protein structure. Using predicted distance distributions has been shown in many cases to be superior to only using a binary contact annotation. Using predicted interprotein distances has also been shown to be able to dock some protein dimers.

RESULTS

Here, we present pyconsFold. Using CNS as its underlying folding mechanism and predicted contact distance it outperforms regular contact prediction-based modeling on our dataset of 210 proteins. It performs marginally worse than the state-of-the-art pyRosetta folding pipeline but is on average about 20 times faster per model. More importantly pyconsFold can also be used as a fold-and-dock protocol by using predicted interprotein contacts/distances to simultaneously fold and dock two protein chains.

AVAILABILITY AND IMPLEMENTATION

pyconsFold is implemented in Python 3 with a strong focus on using as few dependencies as possible for longevity. It is available both as a pip package in Python 3 and as source code on GitHub and is published under the GPLv3 license. The data underlying this article together with source code are available on github, at https://github.com/johnlamb/pyconsfold.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

Risk factors influencing fracture characteristics in postoperative periprosthetic femoral fractures around cemented stems in total hip arthroplasty : a multicentre observational cohort study on 584 fractures

Aims

This study evaluates risk factors influencing fracture characteristics for postoperative periprosthetic femoral fractures (PFFs) around cemented stems in total hip arthroplasty.

Methods

Data were collected for PFF patients admitted to eight UK centres between 25 May 2006 and 1 March 2020. Radiographs were assessed for Unified Classification System (UCS) grade and AO/OTA type. Statistical comparisons investigated relationships by age, gender, and stem fixation philosophy (polished taper-slip (PTS) vs composite beam (CB)). The effect of multiple variables was estimated using multinomial logistic regression to estimate odds ratios (ORs) with 95% confidence intervals (CIs). Surgical treatment (revision vs fixation) was compared by UCS grade and AO/OTA type.

Results

A total of 584 cases were included. Median age was 79.1 years (interquartile range 72.0 to 86.0), 312 (53.6%) patients were female, and 495 (85.1%) stems were PTS. The commonest UCS grade was type B1 (278, 47.6%). The most common AO/OTA type was spiral (352, 60.3%). Metaphyseal split fractures occurred only with PTS stems with an incidence of 10.1%. Male sex was associated with a five-fold reduction in odds of a type C fracture (OR 0.22 (95% CI 0.12 to 0.41); p < 0.001) compared to a type B fracture. CB stems were associated with significantly increased odds of transverse fracture (OR 9.51 (95% CI 3.72 to 24.34); p < 0.001) and wedge fracture (OR 3.72 (95% CI 1.16 to 11.95); p = 0.027) compared to PTS stems. Both UCS grade and AO/OTA type differed significantly (p < 0.001 and p = 0.001, respectively) between the revision and fixation groups but a similar proportion of B1 fractures underwent revision compared to fixation (45.3% vs 50.6%).

Conclusion

The commonest fracture types are B1 and spiral fractures. PTS stems are exclusively associated with metaphyseal split fractures, but their incidence is low. Males have lower odds of UCS grade C fractures compared to females. CB stems have higher odds of bending type fractures (transverse and wedge) compared to PTS stems. There is considerable variation in practice when treating B1 fractures around cemented stems.

Cite this article: Bone Jt Open 2021;2(7):466–475.

POS0288 A KEY TIF1γ EPITOPE MAY FACILITATE THE IDENTIFICATION OF PATIENTS AT HIGHEST RISK OF CANCER ASSOCIATED MYOSITIS

Background:

The myositis specific autoantibody anti-TIF1γ targets TRIM33, a TRIM family proetin with a PHDBromo domain at the C terminal end. Anti-TIF1γ is strongly associated with malignancy in adult patients with idiopathic inflammatory myopathies (IIM). Intriguingly, anti-TIF1γ is also the most common autoantibody in juvenile-onset IIM but younger patients with anti-TIF1γ do not have an increased risk of cancer (1-3). Genetic studies have consistently shown human leukocyte antigen (HLA) to be the strongest risk factor for IIM. Adult and juvenile-onset patients with anti-TIF1γ have recently been shown to have different associations at the HLA-DQB1 locus (4). This could be due to differences in the key TIF1γ epitopes and may relate to differences in aetiology, such as malignancy in adults versus other environmental factors in juvenile onset disease.

Objectives:

To identify key epitopes targeted by anti-TIF1γ antibody in patients with IIM and establish if different TIF1γ epitopes are targeted in patients with and without malignancy.

Methods:

Patient plasma/serum samples were obtained from UK Juvenile Dermatomyositis Cohort and Biomarker and UKMyoNet studies. Autoantibody status had previously been determined by immunoprecipitation. Cancer data was collated from the UK Health and Social Care Information Centre and cancer associated IIM (CAM) defined as that occurring within 3 years of IIM diagnosis.

An in house ELISA was developed using a purified TIF1γ fragment comprising residues 882-1090, produced in E.coli, corresponding to the PHDBromo protein domain. An ELISA cut-off of 5SD above the mean of 38 healthy control samples was used.

Results:

38 healthy controls, and 117 anti-TIF1γ IIM patient sera (60 juvenile onset) were analysed for reactivity to the TIF1γ PHDbromo domain.

No healthy controls were positive. Anti-TIF1γPHDbromo was more common in JDM: 18 (30%) juvenile patients and 6 (10.5%) adult patients were positive, p=0.01.

Additional data was available for 39 adult patients (82% female, median age 52 (IQR 38-64)). Anti-TIF1γPHDbromo was only found in CAM patients plus one young adult non-CAM patient aged 27 years at disease onset, p =0.07 (p=0.02 for patients >30 years at disease onset), see Table 1. No juvenile patients had a history of malignancy.

Table 1.

Anti-TIF1γPHDbromo in 39 adult patients with cancer data available

anti-TIF1γPHDbromo positiveanti-TIF1γPHDbromo negativeCancer associated myositis n(%)5a (83)12(36)Myositis not associated with cancer n(%)1b(17)21(64)Total633

a. Median age 64 yearsb. Age 27 years

Conclusion:

The TIF1γ PHDBromo domain is an important epitope and autoantibody reactivity is more common in patients with juvenile-onset disease and adults with CAM. The distinction between adult and juvenile-onset IIM is arbitrary and it is relevant that the only adult with anti-TIF1γPHDbromo not to have malignancy was just 27 years old. Our numbers are small and further work is needed to establish if anti-TIF1γPHDbromo, and indeed other TIF1γ epitopes, could help identify patients at highest risk of malignancy, and how this relates to our understanding of IIM aetiopathogenesis. Our findings may add weight to the theory that the development of IIM in younger patients occurs after immune-mediated resolution of a pre-cancer event.

References:

[1]Oldroyd A, Sergeant JC, New P et al. The temporal relationship between cancer and adult onset anti-transcriptional intermediary factor 1 antibody-positive dermatomyositis. Rheumatology. 2019;58(4):650-655

[2]Tansley SL, Simou S, Shaddick G et al. Autoantibodies in juvenile-onset myositis: Their diagnostic value and associated clinical phenotype in a large UK cohort. J Autoimmun. 2017;84:55-64

[3]Fujimoto M, Hamaguchi Y, Kaji K et al. Myositis-specific anti-155/140 autoantibodies target transcription intermediary factor 1 family proteins. Arthritis Rheum. 2012;64(2):513-22.

[4]Rothwell S, Chinoy H, Lamb JA et al. Focused HLA analysis in Caucasians with myositis identifies significant associations with autoantibody subgroups. Ann Rheum Dis. 2019;78(7):996-1002.

Disclosure of Interests:

None declared

Detection of Salmonella in Fresh Cheese, Poultry Products, and Dried Egg Products by the ISO 6579 Salmonella Culture Procedure and the AOAC Official Method: Collaborative Study

Three food types were analyzed for the presence of Salmonella by the AOAC culture method and by the International Organization for Standardization (ISO 6579:2002) culture method. Paired test portions of each food type were simultaneously analyzed by both methods. A total of 21 laboratories representing federal government agencies and private industry, in the United States and Europe, participated in this interlaboratory study. Foods were artificially contaminated with Salmonella and competing microflora if naturally contaminated sources were not available. No statistical differences (p &lt; 0.05) were observed between the AOAC and ISO culture methods for fresh cheese and dried egg products. A statistically significant difference was observed for one of the 2 lots of poultry from the first trial. The poultry meat used in this run was radiation sterilized, artificially contaminated with Salmonella and competitive flora, and then lyophilized. A second trial was conducted with 2 separate lots of raw ground chicken that were naturally contaminated. The results from the second trial showed no statistical difference between the 2 culture methods. A third trial involving 4 laboratories was conducted on 2 separate lots of naturally contaminated raw poultry. Again, no statistically significant differences occurred. It is recommended that ISO 6579:2002 culture method for Salmonella be adopted Official First Action for the analysis of fresh cheese, fresh chilled and frozen poultry, and dried egg products.

Enumeration of Total Aerobic Microorganisms in Foods by SimPlate® Total Plate Count–Color Indicator Methods and Conventional Culture Methods: Collaborative Study

The relative efficacy of the SimPlate® Total Plate Count–Color Indicator (TPC–CI) method (SimPlate 35°C) was compared with the AOAC Official Method 966.23 (AOAC 35°C) for enumeration of total aerobic microorganisms in foods. The SimPlate TPC–CI method, incubated at 30°C (SimPlate 30°C), was also compared with the International Organization for Standardization (ISO) 4833 method (ISO 30°C). Six food types were analyzed: ground black pepper, flour, nut meats, frozen hamburger patties, frozen fruits, and fresh vegetables. All foods tested were naturally contaminated. Nineteen laboratories throughout North America and Europe participated in the study. Three method comparisons were conducted. In general, there was &lt;0.3 mean log count difference in recovery among the SimPlate methods and their corresponding reference methods. Mean log counts between the 2 reference methods were also very similar. Repeatability (sr) and reproducibility (sR) standard deviations were similar among the 3 method comparisons. The SimPlate method (35°C) and the AOAC method were comparable for enumerating total aerobic microorganisms in foods. Similarly, the SimPlate method (30°C) was comparable to the ISO method when samples were prepared and incubated according to the ISO method.

Is Knee Joint Distraction a Viable Treatment Option for Knee OA?-A Literature Review and Meta-Analysis

Knee joint distraction (KJD) is a new application of an established technique to regenerate native cartilage using an external fixator. The purpose of this study is to perform a systematic review and meta-analysis of the literature to determine whether KJD is beneficial for knee osteoarthritis and how results compare with established treatments. Studies assessing the outcomes of KJD were retrieved, with three studies (one cohort and two randomized controlled trials), 62 knees, meeting the inclusion criteria. The primary outcome was functional outcome, assessed using a validated outcome score, at 1 year. Secondary outcomes included pain scores, structural assessment of the joint, and adverse events. KJD is associated with improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from baseline to 1 year as well as reductions in pain scores and improvements in structural parameters assessed radiographically and by magnetic resonance imaging. KJD is not associated with decreased knee flexion, but is associated with a high risk of pin site infection. In patients aged 65 years or under at 1 year, no differences in WOMAC or pain scores was detected between patients managed with KJD compared with high tibial osteotomy or total knee arthroplasty. KJD may represent a potential treatment for knee arthritis, though further trials with longer term follow-up are required to establish its efficacy compared with contemporary treatments. This is a Level I (systematic review and meta-analysis) study.

Access to mental health in primary care: A qualitative meta-synthesis of evidence from the experience of people from ‘hard to reach’ groups

Knowledge about depression, access and help-seeking has increasingly been influenced from a range of disciplines including clinical and applied social science. A range of interventions can improve outcomes of depression and anxiety. However, many in need do not seek help, or their interaction with care-givers does not address their needs. We carried out a systematic search for qualitative articles focusing on the experiences of eight exemplar groups with exceptional problems in access (the homeless, long-term unemployed, adolescents with eating disorders, depressed elderly people, advanced cancer sufferers, patients with medically unexplained symptoms, asylum seekers and people from black and minority ethnic groups). Twenty articles representing these groups were selected, findings were then developed using qualitative meta-synthesis, this suggested a range of mechanisms accounting for poor access among these groups. Many regarded their mental health problems as rooted in social problems and employed a variety of self-management strategies to maintain function. These strategies could involve social withdrawal, focusing available resources on close family relationships and work roles. Over-investment in these roles could result in a sense of insecurity as wider networks were neglected. Material disadvantage affected both the resources people could bring to performing social roles and influenced help-seeking. A tacit understanding of the material, psychological and social ‘costs’ of engagement by patients and health professionals could influence decisions to seek and offer help. These costs were felt to be proportionally higher in deprived, marginalized and minority communities, where individual resources are limited and the stigma attached to mental ill-health is high.

A placebo-controlled trial of a proprietary lipid-lowering nutraceutical supplement in the management of dyslipidemia

There is an ever growing emergence in the popularity of patient-driven care. As this health and wellness model grows, inquiries into diet, lifestyle, and supplemental approaches will continue to become a focal point for the healthcare consumer. Because of this, the aim of this study is to determine the tolerability, and overall effectiveness of a proprietary multi-ingredient lipid-lowering supplement in subjects with dyslipidemia. Forty participants were recruited for a single-center, double-blind randomized, placebocontrolled trial. Study participants were recruited between December 2014 and March 2015. Initial screening included a physical examination, renal and hepatic function, serum lipid, serum electrolytes, complete blood counts, and urine analysis. The 40 participants were randomly assigned to receive either the proprietary multi-ingredient lipid-lowering supplement (PMILLS) n= 20 or placebo n= 20. The trial consisted of a screening visit, a two-week run-in, and a four-month treatment period. Samples were taken at baseline, one month and four months of treatment. Results from the trial showed that the PMILLS significantly reduced total cholesterol (TC), low density lipoprotein (LDL-C), very low density lipoprotein (VLDL-C), oxidized LDL (oxLDL), Apo-lipoprotein B, triglycerides (TG), LDL particle number (LDL-P), heart rate, and diastolic blood pressure compared to placebo at one month and four months. The PMILLS significantly increased high density lipoprotein (HDL) particle number (HDL-P), and low density lipoprotein (LDL) particle size from dense type III and IV to larger type I and II LDL particle, compared to placebo at one month and four months. In addition, the PMILLS significantly reduced high sensitivity C-reactive protein (hs-CRP), tumor necrosis alpha (TNF-α), and interleukin 6 (IL-6) within the treatment group from baseline. There were no adverse effects noted in the treatment group after four months of supplementation. The present study demonstrates this PMILLS improves all relevant lipid parameters, such as particle numbers and particles sizes, as well as showing a significant reduction in inflammatory markers linked to cardiovascular health. With such combined changes in lipids, lipid sub-fractions, and inflammation, which are considered among the most effective means of reducing coronary heart disease (CHD), this PMILLS represents a new addition to safe and effective lipid-modifying strategies.

Evaluating a complex model designed to increase access to high quality primary mental health care for under-served groups: a multi-method study

BACKGROUND

Many people with mental distress are disadvantaged because care is not available or does not address their needs. In order to increase access to high quality primary mental health care for under-served groups, we created a model of care with three discrete elements: community engagement, primary care training and tailored wellbeing interventions. We have previously demonstrated the individual impact of each element of the model. Here we assess the effectiveness of the combined model in increasing access to and improving the quality of primary mental health care. We test the assumptions that access to the wellbeing interventions is increased by the presence of community engagement and primary care training; and that quality of primary mental health care is increased by the presence of community engagement and the wellbeing interventions.

METHODS

We implemented the model in four under-served localities in North-West England, focusing on older people and minority ethnic populations. Using a quasi-experimental design with no-intervention comparators, we gathered a combination of quantitative and qualitative information. Quantitative information, including referral and recruitment rates for the wellbeing interventions, and practice referrals to mental health services, was analysed descriptively. Qualitative information derived from interview and focus group responses to topic guides from more than 110 participants. Framework analysis was used to generate findings from the qualitative data.

RESULTS

Access to the wellbeing interventions was associated with the presence of the community engagement and the primary care training elements. Referrals to the wellbeing interventions were associated with community engagement, while recruitment was associated with primary care training. Qualitative data suggested that the mechanisms underlying these associations were increased awareness and sense of agency. The quality of primary mental health care was enhanced by information gained from our community mapping activities, and by the offer of access to the wellbeing interventions. There were variable benefits from health practitioner participation in community consultative groups. We also found that participation in the wellbeing interventions led to increased community engagement.

CONCLUSIONS

We explored the interactions between elements of a multilevel intervention and identified important associations and underlying mechanisms. Further research is needed to test the generalisability of the model.

TRIAL REGISTRATION

Current Controlled Trials, reference ISRCTN68572159 . Registered 25 February 2013.

The use of shoulder scoring systems and outcome measures in the UK

INTRODUCTION

In future, outcomes following shoulder surgery may be subject to public survey. Many outcome measures exist but we do not know whether there is a consensus between shoulder surgeons in the UK. The aim of this study was to survey the preferred outcome measures used by National Health Service (NHS) shoulder surgeons operating in the UK.

METHODS

A total of 350 shoulder surgeons working in NHS hospitals were asked to complete a short written questionnaire regarding their use of scoring systems and outcome measures. Questionnaires were sent and responses were received by post.

RESULTS

Overall, 217 responses were received (62%). Of the respondents, 171 (79%) use an outcome measure in their shoulder practice while 46 (21%) do not. There were 118 surgeons (69%) who use more than one outcome measure. The Oxford shoulder score was most commonly used by 150 surgeons (69%), followed by the Constant score with 106 (49%), the Oxford shoulder instability score with 82 (38%), and the Disabilities of the Arm, Shoulder and Hand score with 54 (25%). The less commonly used outcome measures were the SF-36® and SF-12® health questionnaires with 19 (9%), the University of California at Los Angeles activity score with 8 (4%), the American Shoulder and Elbow Surgeons shoulder assessment form with 8 (4%) and the EQ-5D™ with 10 (3%). Conclusions Validated outcome measures should be adopted by all practising surgeons in all specialties. This will allow better assessment of treatments in addition to assessment of surgical performance in a transparent way.

Community Engagement in a complex intervention to improve access to primary mental health care for hard-to-reach groups

BACKGROUND

Despite the availability of effective evidence-based treatments for depression and anxiety, many 'harder-to-reach' social and patient groups experience difficulties accessing treatment. We developed a complex intervention, the AMP (Improving Access to Mental Health in Primary Care) programme, which combined community engagement (CE), tailored (individual and group) psychosocial interventions and primary care involvement.

OBJECTIVES

To develop and evaluate a model for community engagement component of the complex intervention. This paper focuses on the development of relationships between stakeholders, their engagement with the issue of access to mental health and with the programme through the CE model.

DESIGN

Our evaluation draws on process data, qualitative interviews and focus groups, brought together through framework analysis to evaluate the issues and challenges encountered.

SETTING & PARTICIPANTS

A case study of the South Asian community project carried out in Longsight in Greater Manchester, United Kingdom.

KEY FINDINGS

Complex problems require multiple local stakeholders to work in concert. Assets based approaches implicitly make demands on scarce time and resources. Community development approaches have many benefits, but perceptions of open-ended investment are a barrier. The time-limited nature of a CE intervention provides an impetus to 'do it now', allowing stakeholders to negotiate their investment over time and accommodating their wider commitments. Both tangible outcomes and recognition of process benefits were vital in maintaining involvement.

CONCLUSIONS

CE interventions can play a key role in improving accessibility and acceptability by engaging patients, the public and practitioners in research and in the local service ecology.

Development and evaluation of culturally sensitive psychosocial interventions for under-served people in primary care

BACKGROUND

Psychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective.

METHODS

We developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial.

RESULTS

We recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery.

CONCLUSIONS

This exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs.

TRIAL REGISTRATION

Current controlled trials ISRCTN68572159.