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Background: Dementia affects over 55 million people globally, projected to double by 2050. In the UK, non-registered staff, including healthcare assistants (HCAs) and clinical support workers, provide a significant portion of dementia care, yet receive limited training. This study explores the knowledge, training, and attitudes of support workers towards dementia., Methods: A cross-sectional web-based survey was conducted from February 1 to April 1, 2024, targeting support workers in England. The survey included demographic information, dementia knowledge (using the Dementia Knowledge Assessment Scale, DKAS), and attitudes (using the Dementia Attitudes Scale, DAS). Data were analysed using descriptive statistics, ANOVA, t-tests, and Pearson's correlation., Results: One hundred and nine support workers responded, predominantly female (90%) and white British (76.4%), from various NHS settings and occupational groups. The majority (79.8%) had received dementia training, primarily from their organisations. Challenges included managing behavioural and psychological symptoms and communication difficulties. There was no significant correlation between years of experience and dementia knowledge (r = -0.019) or attitudes (r = -0.057). However, higher occupational grades were associated with greater dementia knowledge (p = <0.01). A moderate positive correlation was found between dementia knowledge and attitudes (r = 0.35, p = <0.01).Despite high levels of knowledge, support workers often feel inadequately prepared to provide optimal dementia care, indicating a need for more comprehensive training. Challenges in communication and managing symptoms highlight areas for improvement. The study suggests that better training can improve both knowledge and attitudes, enhancing care quality for people living with dementia., Conclusion: Support workers play a crucial role in dementia care but require more robust training programs to meet the growing demands. Enhanced training can improve their knowledge and attitudes, leading to better care outcomes for people with dementia., Competing Interests: No competing interests were disclosed., (Copyright: © 2024 Hall AJ et al.)

Background: AgeTech (technology for older people) offers digital solutions for older adults supporting aging in place, including digital health, assistive technology, Internet of Things, medical devices, robotics, wearables, and sensors. This study underscores the critical role of standards and guidelines in ensuring the safety and effectiveness of these technologies for the health of older adults. As the aging demographic expands, the focus on robust standards becomes vital, reflecting a collective commitment to improving the overall quality of life for older individuals through thoughtful and secure technology integration., Objective: This scoping review aims to investigate the current state of standards and guidelines applied in AgeTech design and development as reported in academic literature. We explore the existing knowledge of these standards and guidelines and identify key gaps in the design and development of AgeTech guidelines and standards in scholarly publications., Methods: The literature review adhered to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. Searches were carried out across multiple databases, including Scopus, IEEE, PubMed, Web of Science, EBSCO, CINAHL, Cochrane, and Google Scholar, using a search string incorporating concepts such as "older people," "technology," and "standards or guidelines." Alternative terms, Boolean operators, and truncation were used for comprehensive coverage in each database. The synthesis of results and data analysis involved both quantitative and qualitative methods., Results: Initially, 736 documents were identified across various databases. After applying specific inclusion and exclusion criteria and a screening process, 58 documents were selected for full-text review. The findings highlight that the most frequently addressed aspect of AgeTech standards or guidelines is related to "design and development," constituting 36% (21/58) of the literature; "usability and user experience" was the second most prevalent aspect, accounting for 19% (11/58) of the documents. In contrast, "privacy and security" (1/58, 2%) and "data quality" (1/58, 2%) were the least addressed aspects. Similarly, "ethics," "integration and interoperability," "accessibility," and "acceptance or adoption" each accounted for 3% (2/58) of the documents. In addition, a thematic analysis identified qualitative themes that warrant further exploration of variables., Conclusions: This study investigated the available knowledge regarding standards and guidelines in AgeTech design and development to evaluate their current status in academic literature. The substantial focus on assistive technologies and ambient assisted living technologies confirmed their vital role in AgeTech. The findings provide valuable insights for interested parties and point to prioritized areas for further development and research in the AgeTech domain., (©Shahabeddin Abhari, Josephine McMurray, Tanveer Randhawa, Gaya Bin Noon, Thokozani Hanjahanja-Phiri, Heather McNeil, Fiona Manning, Patricia Debergue, Jennifer Teague, Plinio Pelegrini Morita. Originally published in JMIR Aging (https://aging.jmir.org), 31.10.2024.)

Purpose: Hip fracture is common in older people - with prevalence even higher for people with dementia. Research often excludes people with dementia - especially those in the more advanced stages. Therefore, the most appropriate interventions remain unknown. The main aim of this study was to gain consensus about the core considerations needed to deliver a physical intervention for people with advanced dementia who fracture their hip. Materials and Methods: An expert consensus process was undertaken, using Nominal Group Technique, to explore the key considerations when delivering rehabilitation. Data collection was undertaken in January 2023 and involved an online group discussion followed by voting and off-line rating. Qualitative content analysis and quantitative analysis of consensus scoring was undertaken. An international group of seven highly specialised physiotherapists took part., Results: 59 statements were agreed following the process. Content analysis was used to categorise these statements according to the International Classification of Functioning, Disability and Health. Although consensus levels were high, there was disagreement in several areas., Conclusion: The statements provide an overarching understanding of the multidisciplinary expertise that is needed to effectively deliver rehabilitation interventions to this population. People with dementia require highly skilled and trained professionals, providing holistic and person-centred approaches to deliver rehabilitation interventions.IMPLICATIONS FOR REHABILITATIONThe expert consensus provides an overarching understanding of the multidisciplinary expertise that is needed to effectively deliver rehabilitation interventions to this population.Physiotherapy - or other interventions - cannot be used in isolation.People with dementia require highly skilled and trained professionals, providing holistic and person-centred approaches to deliver rehabilitation interventions.While our focus was on hip fracture, we suggest these statements can be used for people with advanced dementia with a variety of other conditions.

Interviews and focus groups with patients, FLS clinicians, and GPs identified challenges relating to clinical and shared decision-making about bone health and osteoporosis medicines. Findings will inform the development of the multicomponent iFraP intervention to address identified training needs and barriers to implementation to facilitate SDM about osteoporosis medicines., Purpose: The iFraP (improving uptake of Fracture Prevention treatments) study aimed to develop a multicomponent intervention, including an osteoporosis decision support tool (DST), to support shared decision-making (SDM) about osteoporosis medicines. To inform iFraP intervention development, this qualitative study explored current practice in relation to communication about bone health and osteoporosis medicines, anticipated barriers to, and facilitators of, an osteoporosis DST, and perceived training needs., Methods: Patients attending an FLS consultation (n = 8), FLS clinicians (n = 9), and general practitioners (GPs; n = 7) were purposively sampled to participate in a focus group and/or telephone interview. Data were transcribed, inductively coded, and then mapped to the Theoretical Domains Framework (TDF) as a deductive framework to systematically identify possible barriers to, and facilitators of, implementing a DST., Results: Inductive codes were deductively mapped to 12 TDF domains. FLS clinicians were perceived to have specialist expertise (knowledge). However, clinicians described aspects of clinical decision-making and risk communication as difficult (cognitive skills). Patients reflected on decisional uncertainty about medicines (decision processes). Discussions about current practice and the proposed DST indicated opportunities to facilitate SDM, if identified training needs are met. Potential individual and system-level barriers to implementation were identified, such as differences in FLS configuration and a move to remote consulting (environmental context and resources)., Conclusions: Understanding of current practice revealed unmet training needs, indicating that using a DST in isolation would be unlikely to produce a sustained shift to SDM. Findings will shape iFraP intervention development to address unmet needs., (© 2024. The Author(s).)

Objective: The corrected left ventricular ejection time (cLVET) comprises the phase from aortic valve opening to aortic valve closure corrected for heart rate. As a surrogate measure for cLVET, the corrected carotid flow time (ccFT) has been proposed in previous research. The aim of this study was to assess the clinical agreement between cLVET and ccFT in a dynamic clinical setting., Methods: Twenty-five patients with severe aortic valve stenosis (AS) were selected for transcatheter aortic valve replacement (TAVR). The cLVET and ccFT were derived from the left ventricular outflow tract (LVOT) and the common carotid artery (CCA), respectively, using pulsed wave Doppler ultrasound. Bazett's (B) and Wodey's (W) equations were used to calculate cLVET and ccFT. Measurements were performed directly before (T1) and after (T2) TAVR. Correlation, Bland-Altman and concordance analyses were performed., Results: Corrected LVET decreased from T1 to T2 (p < 0.001), with relative reductions of 11% (B) and 9% (W). Corrected carotid flow time decreased (p < 0.001), with relative reductions of 12% (B) and 10% (W). The correlation between cLVET and ccFT was strong for B (ρ = 0.74, p < 0.001) and W (ρ = 0.81, p < 0.001). The bias was -39 ms (B) and -37 ms (W), and the upper and lower levels of agreement were 19 and -98 ms (B) and 5 and -78 ms (W), respectively. Trending ability between cLVET and ccFT was good (concordance 96%) for both B and W., Conclusion: In TAVR patients, the clinical agreement between cLVET and ccFT was acceptable, indicating that ccFT could serve as a surrogate measure for cLVET., Competing Interests: Conflict of interest J.v.H., R.E., F.M., M.t.P., S.H., I.W. and P.T. declare they have no conflicts of interests. L.M. and A.B. act as clinical consultants for Philips Research in Eindhoven, The Netherlands, for which they receive consultant honoraria., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Osteoporosis and associated fractures are an increasingly prevalent concern with an ageing population. This study reports testing of IBEX Bone Health (IBEX BH) software, applied following acquisition of forearm radiographs. IBEX Bone Health analyses the radiograph to measure areal bone mineral density (aBMD) at the examination site. A non-randomized cross-sectional study design was performed involving 261 (254 after exclusions) participants (112/142 m/f; mean age 70.8 years (SD+/-9.0); 53 with osteoporosis). They underwent posterior-anterior distal forearm radiographs; dual X-ray absorptiometry (DXA) of the wrists, hips, and lumbar spine; and questionnaires exploring clinical risk factors. IBEX Bone Health automatically identifies regions of interest (ROI) at the ultra-distal (UD) and distal third (TD) regions of the radius. Analysis investigated area under the receiver operating characteristics curve performance of IBEX BH for prediction of (i) osteoporosis (based on clinical reporting of the hip and spine DXA) and (ii) treatment recommendations by Fracture Risk Assessment Tool (FRAX) inclusive of neck of femur (NoF) areal bone mineral density (aBMD) results following National Osteoporosis Guideline Group (NOGG) guidelines. Area under the receiver operating characteristics curve for osteoporosis prediction at the UD and TD ROIs were 0.86 (99% confidence interval (CI) [0.80, 0.91]) and 0.81 (99% CI [0.75, 0.88]), respectively. Area under the receiver operating characteristics curve for treatment recommendation using FRAX inclusive of NoF aBMD at the UD and TD ROIs were 0.95 (99% CI [0.91, 1.00]) and 0.97 (99% CI [0.93,1.00]), respectively. With a matched sensitivity to FRAX (without NoF aBMD) 0.93 (99% CI [0.78, 0.99]), IBEX BH predicted at the UD and TD ROIs recommended treatment outcomes by NOGG guidelines using FRAX (with NoF aBMD) with specificity 0.89 (99% CI 0.83, 0.94]) and 0.93 (99% CI [0.87, 0.97]), respectively. This is compared with 0.60 (99% CI [0.51, 0.69]) for FRAX (without NoF aBMD). Results demonstrate the potential clinical utility of IBEX BH as an opportunistic screening tool., Competing Interests: The co-authors on this paper from IBEX Innovations hold the intellectual property rights over the IBEX BH technology and have a vested interest in the adoption of this technology into clinical practice. There are no other conflicts of interest to declare., (© The Author(s) 2024. Published by Oxford University Press on behalf of the American Society for Bone and Mineral Research.)

Introduction: Research into patient and public views on predictive software and its use in healthcare is relatively new. This study aimed to understand older adults' acceptability of an opportunistic bone density assessment for osteoporosis diagnosis (IBEX BH), views on its integration into healthcare, and views on predictive software and AI in healthcare., Methods: Focus groups were conducted with participants aged over 50 years, based in South West England. Data were analysed using thematic analysis. Analysis was informed by the theoretical framework of acceptability., Results: Two focus groups were undertaken with a total of 14 participants. Overall, the participants were generally positive about the IBEX BH software, and predictive software's in general stating 'it sounds like a brilliant idea'. Although participants did not understand the intricacies of the software, they did not feel they needed to. Concerns about IBEX BH focussed more on the clinical indications of the software (e.g. more scans or medications), with participants expressing less trust in results if they indicated medication. Questions were also raised about how and who would receive the results of this software. Individual choice was evident in these discussions, however most indicated the preferences for spoken communication 'But I would expect that these results would be given by a human to another human.', Conclusions: Focus group participants were generally accepting of the use of predictive software in healthcare., Implications for Practice: Thought and care needs to be taken when integrating predictive software into practice. Focusses on empowering patients, providing information on processes and results are key., Competing Interests: Conflict of interest statement Authors FM and RM have worked on the clinical trial initial clinical trial of the IBEX BH Software. This study received no funding from, nor had any involvement from IBEX Innovations or any of their employees. No other competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: The aim of this study was to explore healthcare professionals' principles for providing and delivering rehabilitation interventions for people with advanced dementia., Design: This was a qualitative study with three focus groups undertaken virtually. The data were analysed using a process of reflexive thematic analysis in order to gain an in-depth understanding of rehabilitation principles for this population., Setting and Participants: 20 healthcare professionals who were specialists in treating and rehabilitating people with advanced dementia were recruited. These healthcare professionals had a wide range of experience in a variety of different settings including primary care, secondary care as well as specialist mental health teams. Purposive sampling focused on the requirement for participants to have significant experience of treating people with dementia. Participants were from the UK and Denmark. Data collection was undertaken during August and September 2022., Results: Three overarching themes were developed following analysis-organisational culture, knowledge and personal values of the healthcare professional. The first explored how the culture of an organisation affects a person with advanced dementia as well as the healthcare professional. The organisation needed to promote positive approaches to person-centred care and provide effective situational leadership to embed such approaches. Knowledge was a key consideration and was closely linked to the personal values of the healthcare professional, which formed the final theme. This study suggests that the interrelationship of these three factors influences the outcomes for the person with dementia and effective outcomes required consideration of all domains., Conclusions: Effective interventions for people with advanced dementia require the healthcare professional to have the knowledge about dementia and positive personal values, but the culture of the organisation is also key to ensure that the healthcare professional is able to deliver successful interventions., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objective: To assess the longer term impact of the COVID-19 pandemic on the self-reported physical and mental health of people with inflammatory rheumatic diseases (IRDs)., Methods: Two thousand twenty-four patients with IRDs were randomly selected from electronic health records. Survey invitations were sent (August 2021 coinciding with relaxation of UK COVID-19 restrictions) using SMS and postal approaches. Self-reported data included demographics, shielding status and physical (MSK-HQ) and mental health (PHQ8 and GAD7)., Results: Six hundred thirty-nine people completed the survey (mean (SD) age 64.5 (13.1) years, 384 (60%) female). Moderate/severe impact of the pandemic on physical and mental health was reported by 250 (41%) and 241 (39%) respectively. One hundred seventy-two (29%) reported moderate/severe depression (PHQ8 ≥ 10) and 135 (22%) moderate/severe anxiety (GAD7 ≥ 10). Females reported greater impacts of the pandemic on physical health (44% vs 34%), mental health (44% vs 34%), arthritis symptoms (49% vs 36%) and lifestyle factors (weight gain and reduced exercise and physical activity) than males. The physical and mental impacts were less in people with RA compared with other IRDs. Physical health impacts did not differ between age groups, but younger patients reported greater impacts on mental health., Conclusion: The COVID-19 pandemic has had a significant impact on the physical and mental health of people with IRDs. These effects were greatest in females. Recovery needs to address the negative impact of the pandemic on lifestyle factors to minimise the long-term impacts for people with IRDs. Key Points • The pandemic had a significant impact on long term physical and mental health in almost 40% of people with IRDs. • The impact of the pandemic was greater in women for physical health, mental health and arthritis symptoms. • Many people reported negative pandemic impacts on lifestyle factors including weight and physical activity., (© 2023. The Author(s).)

Objectives: People with RA taking DMARDs require safety monitoring to identify potential side effects. The aim of this study was to explore the perspectives of patients and family members on DMARD monitoring and how the associated treatment burden could be minimized to optimize concordance and safety., Methods: Thirteen adults with RA on DMARDs and three family members participated in semi-structured telephone interviews between July 2021 and January 2022. Data were analysed using a framework method. Findings were discussed with a group of stakeholders to develop implications for practice., Results: Two main themes were identified: (i) making sense of drug monitoring; and (ii) work involved in drug monitoring. Participants perceived DMARDs as necessary to reduce symptoms, with drug monitoring providing an opportunity for a holistic assessment of wellbeing. Participants expressed a preference for face-to-face consultations, which allowed them to share their concerns, rather than remote, often transactional, care. The limited availability of convenient appointment times, travel requirements and parking increased the work involved for patients and family members., Conclusion: Drug monitoring was accepted as a necessity of DMARD treatment, but increased the work for people with RA related to organizing and attending appointments. The potential for treatment burden needs to be assessed proactively by clinicians when a DMARD is commenced. Where identified, strategies for minimizing the treatment burden can form part of a shared management plan, including the offer of regular contact with health professionals, with an emphasis on person-centred care., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Dementia is a growing global challenge with numbers set to increase rapidly in the coming years. Evidence suggests that exercise can be effective in improving cognitive functioning, but the evidence does not yet support improvements in other key domains such as quality of life or physical ability. The aim of this study was to explore the key components that needed to be considered when providing physical rehabilitation to people with advanced dementia. The study used a qualitative approach involving semi-structured focus groups with health care professionals who are experts in delivering interventions to people with advanced dementia. As a pragmatic study seeking to inform the development of interventions, a thematic coding approach was used to make sense of the data. We collected data from 20 healthcare professionals who reported that key considerations needed to be considered from both an assessment and an intervention perspective. The assessment needed to be person centred and, with the right people engaged and using outcome measures that were meaningful to the patient. The actual intervention also needed to follow the principles of person-centred care, with emphasis placed on the importance of taking time to build a rapport with the person, but also reducing any of the barriers that would prevent effective engagement, such as unsuitable environments. Our study suggests that while there are barriers and challenges to providing interventions and rehabilitation to people with advanced dementia, appropriate person-centred, tailored interventions can be effective and therefore should be offered.

Objectives: COVID-19 led to rapid uptake of digital health care. We sought to examine digital access, health and digital literacy, and impact on confidence and satisfaction with remote consultations in people with inflammatory rheumatic diseases (IRDs)., Methods: People with IRDs ( n  = 2024) were identified from their electronic health record and invited to participate in a cross-sectional survey, using short message service (SMS) and postal approaches. Data were collected on demographics, self-reported diagnosis, access to and use of internet-enabled devices, health and digital literacy, together with confidence and satisfaction with remote consultations. Ethical approval was obtained (Ref 21/PR/0867)., Results: Six hundred and thirty-nine (639) people completed the survey [mean (s.d.) age 64.5 (13.1) years, 384 (60.1%) female]. Two hundred and eighty-seven (44.9%) completed it online. One hundred and twenty-six (19.7%) people reported not having access to an internet-enabled device. Ninety-three (14.6%) reported never accessing the internet; this proportion was highest (23%) in people with RA. One hundred and seventeen (18%) reported limited health literacy. Even in those reporting internet use, digital literacy was only moderate. People with limited health or digital literacy or without internet access were less likely to report confidence or satisfaction with remote consultations., Conclusion: Limited health and digital literacy, lack of digital access and low reported internet use were common, especially in older people with RA. People with limited health literacy or limited digital access reported lower confidence and satisfaction with remote consultations. Digital implementation roll-out needs to take account of people requiring extra support to enable them to access care digitally or risks exacerbating health inequalities., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Purpose: To evaluate compliance with the precaution to sleep in a supine position following total hip arthroplasty (THA) and its impact on the other precautions., Materials and Methods: Single-center, parallel-group, stratified, randomized trial. Patients were allocated to a Restricted Group or an Unrestricted Group. This study focuses on compliance with the precaution to sleep in a supine position, compliance with the remaining set of precautions and the burden of restricted sleeping. Measurements were made using a self-administered diary and questionnaires. Trial registration number: NCT02107248., Results: During the first 2 weeks, 81% of the patients in the restricted group were compliant with sleeping in a supine position.Patients in the Unrestricted Group significantly kept sleeping fewer days per week in a supine position than patients in the Restricted Group ( p  = 0.000). No significant differences between the two groups were found regarding compliance with the remaining set of precautions. The burden of the sleeping restriction is significantly lowered in the Unrestricted Group ( p  = 0.000)., Conclusions: Compliance with restricting patients to sleep in a supine position is high. Removing this precaution has a significant decrease in burden for patients without affecting compliance with the remaining set of precautions., Trial Registration Number: ClinicalTrials.gov NCT02107248 - https://clinicaltrials.gov/ct2/show/NCT02107248?term=anil+peters&draw=2&rank=1IMPLICATIONS FOR REHABILITATIONSleeping precautions cause a high rate of burden to patients, whereas movement precautions do not.By removing sleeping precautions, the burden is significantly reduced without affecting the remaining set of precautions.Compliance with movement precautions is high compared to other more functional precautions.

High-dose vitamin C therapy has gained increased interest as an adjunctive treatment of septic shock, although convincing evidence is still lacking. High blood levels of vitamin C may interfere with several point-of-care blood glucose meters. We describe the case of a 67-year-old septic patient known with chronic renal failure who developed truly severe hypoglycemia, which was masked by spuriously high glucose values measured on a capillary blood glucose meter. This initially led to the treatment of spurious hyperglycemia with high-dose insulin and a delayed correct diagnosis and treatment, rendering substantial risk for the patient. Awareness of this dangerous interference is warranted., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Ten Berge et al.)

Involving research users in setting priorities for research is essential to ensure the outcomes are patient-centred and maximise its value and impact. The Musculoskeletal Disorders Research Advisory Group Versus Arthritis led a research priority setting exercise across musculoskeletal disorders. The Child Health and Nutrition Research Initiative (CHNRI) method of setting research priorities with a range of stakeholders was used, involving four stages and two surveys, to: (1) gather research uncertainties, (2) consolidate these, (3) score uncertainties against importance and impact, and (4) analyse scoring for prioritisation. 213 people responded to the first survey and 285 people to the second, representing clinicians, researchers, and people with musculoskeletal disorders. Key priorities included developing and testing new treatments, better treatment targeting, early diagnosis, prevention, and better understanding and management of pain, with an emphasis on understanding underpinning mechanisms. We present a call to action to researchers and funders to target these priorities., Competing Interests: FEW reports grants from UK Research and Innovation (UKRI), National Institute for Health and Care Research (NIHR), Versus Arthritis, Medical Research Council (MRC); consulting fees from Pfizer; and committee role for MRC and NIHR. ZP reports grants from NIHR, Versus Arthritis, Royal Osteoporosis Society, General Council for Nursing, Haywood Foundation, Chartered Society for Physiotherapy, and British Society for Rheumatology; honoraria from the Royal College of General Practitioners; non-paid consultancy for UCB, and unpaid committee roles with Royal Osteoporosis Society and Haywood Foundation. CB reports grants from Versus Arthritis and University of Liverpool (Liverpool, UK). EMC reports grants from Royal Osteoporosis Society, Elizabeth Blackwell Institute (University of Bristol, Bristol, UK) MRC Confidence in Concept Award, NIHR, Southmead Hospital Charity Research Fund, Healthcare Quality Improvement Partnership; payment or honoraria from Danske Fysioterapeuter and Journal of Bone and Mineral Research Plus; and an unpaid committee role with the Royal Osteoporosis Society. MG reports grants from Versus Arthritis and Clarendon Fund. RKJ reports grants from the Ministry of Defence. CLLM reports grants from H2020 ITN, Disc4All, Flexion Plc (Contract Research Funding), Engineering and Physical Sciences Research Council (EPSRC), MRC, and Versus Arthritis; consultancy fees and royalties or licensing fees from Flexion; committee roles for JOR Spine, Discovering Innovative Solutions for Conditions of the Spine, and Society of Back Pain Research. JL reports grants from MRC, The John George William Patterson Foundation, and the Ruth & Lionel Jacobson Charitable Trust. DJM reports grants from Orphelion, Innovation for All, Welsh Government with Knoell, Versus Arthritis, KESS2 & Hospital Innovations, EPSRC, Wellcome Trust Collaborative Award, Petplan Charitable Trust, and British Veterinary Orthopaedic Association; payment or honorarium from Eli Lilly; receipt of drugs from Novartis; participation on a data safety oversight board for NIHR (paid) and Innovative Medicines Initiative (paid), unpaid leadership role within British Orthopaedic Research Society and Orthopaedics Research Society, and paid committee role in Science Foundation Ireland Early Career Panel. NLM reports grants from MRC and Chan Zuckerberg Initiative. HP reports grants from Knowledge Transfer Partnership–Innovate UK, Pacira Pharmaceuticals, Zimmer Biomet Healthcare, B Braun, and Wellcome Trust; consulting fees from Medacta International, Smith and Nephew, Depuy Synthes, JRI Orthopaedics, Janssen, Meril Life, Zimmer Biomet, and Paradigm Pharmaceuticals; payment or honoraria from Invibio; payment for expert testimony from Kennedy's Law; support for attending meetings from Medacta International; participation on data safety oversight board for GreenBric Study; unpaid committee role for NIHR and National Joint Registry Regional Clinical Coordinators; and receipt of drug from Pacira Pharmaceuticals. GP reports grants from NIHR, Nuffield Foundation, and Versus Arthritis, and consulting fees from Office Health Inequalities & Disparities; participation on data safety monitoring board and role as Lancet Osteoarthritis Commissioner. SMR reports grants from Versus Arthritis and Wellcome Trust, honoraria from Portugal grant review, and had a role as treasurer and committee member for the Tissue and Cell Engineering Society. EJS reports grants from NHSX and committee role on musculoskeletal reform. LT reports grants from Versus Arthritis, The Macular Society, MRC, Rosetrees Trust, University of East Anglia Faculty of Medicine and Health Sciences (Norwich, UK), and the Kennedy Institute of Rheumatology; support for attending meetings from Advanced Course–Matrix Pathobiology, Signalling and Molecular Targets, and OACON 2019. RKW reports grants from EPSRC, DePuy Synthes, and Versus Arthritis; unpaid committee role in Royal Academy of Engineering; and receipt of materials from DePuy synthesis. CW reports support for attending meetings from European Pain Federation; participation on advisory board for University of Swansea (Swansea, UK), Health Data Research UK, and National Institute for Health and Care Excellence; and committee role for Versus Arthritis and University of Bath (Bath, UK). CF is employed by Versus Arthritis. All other authors declare no competing interests., (© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.)

Objective: Rheumatoid arthritis (RA) is an autoimmune, inflammatory, systemic condition that requires specific drug treatment to suppress disease activity and prevent joint deformity. To manage the ongoing symptoms of joint pain and fatigue patients are encouraged to engage in self-management activities. People with RA have an increased incidence of serious illness and mortality, with the potential to impact on quality of life. This study explored patients' experiences of living with RA on physical, psychological and social well-being as well as their ability to employ self-management skills during the coronavirus pandemic., Design: Qualitative, longitudinal (baseline, 16 September to 23 November 2020 and after 2-4 months, 11 January to the 17 January 2021), semistructured telephone interviews., Setting: A rheumatology service based in a community hospital., Participants: 15 adults with RA., Main Outcomes: Data were analysed using interpretative phenomenological analysis., Results: Five themes were identified that related to impact on (1) fear: the dominant emotion, (2) social connections and work practices, (3) physical health, (4) identity and (5) self-management as a coping mechanism. The overriding emotion was one of fear, which remained high throughout both interviews. The negative impact on social well-being increased as the pandemic progressed. Conversely, physical health was not affected at either time point, although participants reported difficulty in interpreting whether physical symptoms were attributable to their RA or COVID-19. Recognition of increased vulnerability led to a reassessment of self-identity; however, respondents reported using previously learnt self-management techniques to cope in the context of the pandemic., Conclusions: The main impact was on emotional and social well-being. Levels of fear and vulnerability which affected self-identity remained high throughout the pandemic and the impact on social well-being increased over time. Physical health remained largely unaffected. Self-management skills were used to maintain a sense of well-being., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: People with inflammatory arthritis have an increased incidence of serious illness and mortality, placing them at risk of poor outcomes from coronavirus disease 2019 (COVID-19). This study explored patients' perceptions of risk from COVID-19 over a longitudinal period of the pandemic., Methods: Fifteen adults with inflammatory arthritis attending a National Health Service rheumatology service each took part in three semi-structured telephone interviews conducted between 16 September 2020 and 29 July 2021. Interpretive phenomenological analysis was undertaken by two researchers and two public contributors., Results: Four main themes relating to perceptions of risk from COVID-19 were identified: inflammatory arthritis; medications and co-morbidities; immediate social environment; health policy communication; and media influence. Participants recognized that having inflammatory arthritis increased their individual risk. Perceptions of risk and associated fear increased during the pandemic, influenced by family/friends who had had COVID-19 and health policy communications. The perceived constant use of negative messages led to many participants disengaging with the media. At the final interviews, when the vaccination programme was well established, participants continued to assess the risk and benefits of engaging in activities., Conclusion: This study demonstrates the breadth of factors that influenced perceptions of risk in people with an inflammatory arthritis. As health professionals, we have only a small sphere of influence over some of these factors, namely health-care communications. People with inflammatory arthritis appropriately knew that their condition increased their infection risk, but more could be done to consider how and to what extent we involve patients in explaining risk at times of crisis., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Background: Guidance for choosing face-to-face vs remote consultations (RCs) encourages clinicians to consider patient preferences, however, little is known about acceptability of, and preferences for RCs, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, RC among patients with osteoporosis and rheumatoid arthritis., Methods: Three UK qualitative studies, exploring patient experiences of accessing and receiving healthcare, undertaken during the pandemic, with people with osteoporosis and rheumatoid arthritis. Study team members agreed a consistent approach to conduct rapid deductive analysis using the Theoretical Framework of Acceptability (TFA) on transcripts from each data set relating to RC, facilitated by group meetings to discuss interpretations. Findings from the three studies were pooled., Results: Findings from 1 focus group and 64 interviews with 35 people were included in the analysis. Participants' attitudes to RC, views on fairness (ethicality) and sense-making (intervention coherence) varied according to their needs within the consultation and views of the pandemic. Some participants valued the reduced burden associated with RC, while others highly valued non-verbal communication and physical examination associated with face-to-face consults (opportunity costs). Some participants described low confidence (self-efficacy) in being able to communicate in RCs and others perceived RCs as ineffective, in part due to suboptimal communication., Conclusions: Acceptability of, and preferences for RC appear to be influenced by societal, healthcare provider and personal factors and in this study, were not condition-dependant. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation., (© 2022. The Author(s).)

What Is Known on the Subject: ●Expert by Experience participation in mental health services is embedded in mental health policy in many countries. The negative attitudes of nurses and other health professionals to consumer participation poses a significant obstacle to this policy goal. ●Involving mental health Experts by Experience in the education of nursing students demonstrates positive attitudinal change., What the Paper Adds to Existing Knowledge: ●The paper presents perspectives from Experts by Experience about the unique knowledge and expertise they derive from their lived experience of mental distress and mental health service use. As a result, they can make a unique and essential contribution to mental health nursing education. They utilize this knowledge to create an interactive learning environment and encourage critical thinking. ●The international focus of this research enriches understandings about how Experts by Experience might be perceived in a broader range of countries., What Are the Implications for Practice: ●Mental health policy articulates the importance of service user involvement in all aspects of mental health service delivery. This goal will not be fully achieved without nurses having positive attitudes towards experts by experience as colleagues. ●Positive attitudes are more likely to develop when nurses understand and value the contribution experts by experience bring by virtue of their unique knowledge and expertise. This paper provides some important insights to achieving this end., Abstract: Introduction Embedding lived experience in mental health nursing education is increasing, with research findings suggesting the impact is positive. To date, research has primarily targeted the perspectives of nursing students and academics from the health professions. Aim To enhance understanding of the unique knowledge and expertise experts by experience contribute to mental health nursing education. Methods Qualitative exploratory research methods were employed. In-depth individual interviews were conducted with experts by experience who delivered a coproduced learning module to nursing students in Europe and Australia. Results Participants described their unique and essential contribution to mental health nursing education under four main themes: critical thinking, beyond textbooks; interactive and open communication; understanding personal recovery; and mental health is health. Conclusions These findings present an understanding of the unique knowledge and expertise Experts by Experience contribute to mental health education not previously addressed in the literature. Appreciating and respecting this, unique contribute is necessary as Expert by Experience contributions continue to develop. Implications for Practice Mental health services purport to value service user involvement. Identifying and respecting and valuing the unique contribution they bring to services is essential. Without this understanding, tokenistic involvement may become a major barrier., (© 2021 John Wiley & Sons Ltd.)

Expert by Experience involvement in mental health nursing education is increasing in popularity as a teaching technique. The emerging literature attests to its benefits in enriching the educational experience for students. Much less attention has been devoted to the experience from the perspective of the Experts themselves. To address this gap and ensure this important perspective is captured and considered, the aim of this paper is to present the perceptions and experiences of Experts by Experience in delivering an educational module to mental health nursing students. A qualitative exploratory approach was adopted, involving in-depth individual interviews with Experts by Experience who delivered a learning module to nursing students in Australia and Europe. Data were analysed thematically. Analysis produced two overarching themes: Empowerment, and Challenges. Challenges included six sub-themes: Being constructive, not just critical; Time to unpack and reflect; Need for co-production and support from nursing academics; Emotional and practical support; maintaining personal boundaries; and adapting to the audience. These findings make a significant contribution to a broader understanding of Expert by Experience involvement in mental health education. The use of standards to maintain integrity and avoid tokenism is recommended.

Background: Mental health nursing skills and knowledge are vital for the provision of high-quality healthcare across all settings. Negative attitudes of nurses, towards both mental illness and mental health nursing as a profession, limit recognition of the value of these skills and knowledge. Experts by Experience have a significant role in enhancing mental health nursing education. The impact of this involvement on attitudes to mental health nursing has not been well researched., Aim: To explore the impact of Expert by Experience-led teaching on students' perceptions of mental health nursing., Methods: Qualitative exploratory study involving focus groups with nursing students from five European countries and Australia., Results: Following Expert by Experience-led teaching, participants described more positive views towards mental health nursing skills and knowledge in three main ways: learning that mental health is everywhere, becoming better practitioners, and better appreciation of mental health nursing., Conclusions: Experts by experience contribute to promoting positive attitudinal change in nursing students towards mental health nursing skills and knowledge. Attitudinal change is essential for the provision of high-quality mental health care in specialist mental health services and throughout the healthcare sector.

Background: The prevention of self-harm is an international public health priority. It is vital to identify at-risk populations, particularly as self-harm is a risk factor for suicide. This study aims to examine the risk of self-harm in people with vertebral fractures., Methods: Retrospective cohort study. Patients with vertebral fracture were identified within the Clinical Practice Research Datalink and matched to patients without fracture by sex and age. Incident self-harm was defined by primary care record codes following vertebral fracture. Overall incidence rates (per 10,000 person-years (PY)) were reported. Cox regression analysis determined risk (hazard ratios (HR), 95 % confidence interval (CI)) of self-harm compared to the matched unexposed cohort. Initial crude analysis was subsequently adjusted and stratified by median age and sex., Results: The number of cases of vertebral fracture was 16,293, with a matched unexposed cohort of the same size. Patients were predominantly female (70.1 %), median age was 76.3 years. Overall incidence of self-harm in the cohort with vertebral fracture was 12.2 (10.1, 14.8) /10,000 PY. There was an initial crude association between vertebral fracture and self-harm, which remained after adjustment (HR 2.4 (95 %CI 1.5, 3.6). Greatest risk of self-harm was found in those with vertebral fractures who were aged below 76.3 years (3.2(1.8, 5.7)) and male (3.9(1.8, 8.5))., Conclusions: Primary care patients with vertebral fracture are at increased risk of self-harm compared to people without these fractures. Male patients aged below 76 years of age appear to be at greatest risk of self-harm. Clinicians need to be aware of the potential for self-harm in this patient group., (© 2021. The Author(s).)

Introduction: Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The I mproving uptake of Fra cture P revention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP D evelopment (iFraP-D) work., Methods and Analysis: The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial., Ethics and Dissemination: Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations., Trial Registration Number: researchregistry5041., Competing Interests: Competing interests: ZP reports grants from the NIHR Clinician Scientist Award (CS-2018-18-ST2-010), Royal Osteoporosis Society and the Haywood Rheumatology Research and Development Foundation to conduct this study. CJ reports funding from the NIHR Applied Research Collaboration (ARC) West Midlands; CM reports grants from the NIHR Research Professorship in General Practice (NIHR-RP-2014-04-026), the NIHR School for Primary Care Research and NIHR Applied Research Collaborations (West Midlands), Wellcome, Medical Research Council, Dunhill, Versus Arthritis and Bristol Myer-Squibb, outside the submitted work; FC-M reports grants from NIHR Clinical Research Network Scholar Programme; ST and SRC report receiving funds from National Institute for Health Research (NIHR) (Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy) and the Royal Osteoporosis Society via Prescribing Decision Support Ltd to support the development of the iFraP decision support tool; TWO’N reports grants and non-financial support from AMGEN and the NIHR Manchester Biomedical Research Centre outside the submitted work; CI reports grants from NIHR during the conduct of the study and disclosed being a member of NICE’s Medical Technologies Advisory Committee outside the submitted work; JJE reports grants as a NIHR Academic Clinical Lecturer in Primary Care (CL-2016-10-003). ECo reports grants from Versus Arthritis, NIHR RfPB, HQIP and the Royal Osteoporosis Society., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Patient information is important to help patients fully participate in their healthcare. Commonly accessed osteoporosis patient information resources were identified and assessed for readability, quality, accuracy and consistency. Resources contained inconsistencies and scored low when assessed for quality and readability. We recommend optimal language and identify information gaps to address., Introduction: The purpose of this paper is to identify commonly accessed patient information resources about osteoporosis and osteoporosis drug treatment, appraise the quality and make recommendations for improvement., Methods: Patient information resources were purposively sampled and text extracted. Data extracts underwent assessment of readability (Flesch Reading Ease and Flesch-Kincaid Grade Level) and quality (modified International Patient Decision Aid Standards (m-IPDAS)). A thematic analysis was conducted, and keywords and phrases were used to describe osteoporosis and its treatment identified. Findings were presented to a stakeholder group who identified inaccuracies and contradictions and discussed optimal language., Results: Nine patient information resources were selected, including webpages, a video and booklets (available online), from government, charity and private healthcare providers. No resource met acceptable readability scores for both measures of osteoporosis information and drug information. Quality scores from the modified IPDAS ranged from 21 to 64% (7-21/33). Thematic analysis was informed by Leventhal's Common-Sense Model of Disease. Thirteen subthemes relating to the identity, causes, timeline, consequences and controllability of osteoporosis were identified. Phrases and words from 9 subthemes were presented to the stakeholder group who identified a predominance of medical technical language, misleading terms about osteoporotic bone and treatment benefits, and contradictions about symptoms. They recommended key descriptors for providers to use to describe osteoporosis and treatment benefits., Conclusions: This study found that commonly accessed patient information resources about osteoporosis have highly variable quality, scored poorly on readability assessments and contained inconsistencies and inaccuracies. We produced practical recommendations for information providers to support improvements in understanding, relevance, balance and bias, and to address information gaps., (© 2021. Crown.)

The interface between the intervertebral disc and the vertebral body is important to the discs' biomechanics and physiology, and is widely implicated in its pathology. This study aimed to explore biochemically and structurally the bony endplate, cartilage endplate and intervertebral disc, below the nucleus and below the annulus in healthy bovine tails. Multiphoton imaging and spontaneous Raman spectroscopy were employed. Raman spectroscopy provided relative quantification of mineral and matrix components across the vertebral endplate and its adjacent areas with microscopic spatial resolution. Microscopy utilising second-harmonic generation (SHG) and two-photon fluorescence (TPF) allowed for the structural identification of distinct endplate regions. The cartilage endplate was revealed as structurally distinct from both the bone and disc, supporting its biomechanical function as a transition zone between the soft and hard tissue components. The collagen fibres were continuous across the tidemark which defines the interface between the mineralised and non-mineralised regions of the endplate. Raman spectroscopy revealed gradients in phosphate and carbonate content through the depth of the endplate and also differences beneath the nucleus and annulus consistent with a higher rate of remodelling under the annulus.

Fracture Liaison Services are recommended to deliver best practice in secondary fracture prevention. This modified Delphi survey, as part of the iFraP (Improving uptake of Fracture Prevention drug Treatments) study, provides consensus regarding tasks for clinicians in a model Fracture Liaison Service consultation., Purpose: The clinical consultation is of pivotal importance in addressing barriers to treatment adherence. The aim of this study was to agree to the content of the 'model Fracture Liaison Service (FLS) consultation' within the iFraP (Improving uptake of Fracture Prevention drug Treatments) study., Methods: A Delphi survey was co-designed with patients and clinical stakeholders using an evidence synthesis of current guidelines and content from frameworks and theories of shared decision-making, communication and medicine adherence. Patients with osteoporosis and/or fragility fractures, their carers, FLS clinicians and osteoporosis specialists were sent three rounds of the Delphi survey. Participants were presented with potential consultation content and asked to rate their perception of the importance of each statement on a 5-point Likert scale and to suggest new statements (Round 1). Lowest rated statements were removed or amended after Rounds 1 and 2. In Round 3, participants were asked whether each statement was 'essential' and percentage agreement calculated; the study team subsequently determined the threshold for essential content., Results: Seventy-two, 49 and 52 patients, carers and clinicians responded to Rounds 1, 2 and 3 respectively. One hundred twenty-two statements were considered. By Round 3, consensus was reached, with 81 statements deemed essential within FLS consultations, relating to greeting/introductions; gathering information; considering therapeutic options; eliciting patient perceptions; establishing shared decision-making preferences; sharing information about osteoporosis and treatments; checking understanding/summarising; and signposting next steps., Conclusions: This Delphi consensus exercise has summarised for the first time patient/carer and clinician consensus regarding clearly defined tasks for clinicians in a model FLS consultation.

Nurses play a central role in the delivery of quality mental health services. Desired qualities of a mental health nurse, in particular therapeutic relationships, have been described in the literature, primarily reflecting the nursing paradigm. Service users' perspectives must be more fully understood to reflect contemporary mental health policy and to recognize their position at the centre of mental health service delivery and to directly influence and contribute their perspectives and experiences to mental health nursing education. A qualitative exploratory research project was undertaken to inform and enhance understanding of what service users see as the desired qualities of a mental health nurse. The project was co-produced by service users as experts by experience, and mental health nurse academics to ensure the service user perspective was privileged. This international project conducted in Europe and Australia included a series of focus groups with service users (n = 50). Data were analysed thematically. Being with me was a major theme identified and reflected the sub-themes: respect towards service users as persons; empathy, compassion and effective communication; understanding service users; knowledge of services; and fostering hope and believing that recovery is possible. These qualities specifically reflecting the service user perspective must be central to mental health nursing curricula to facilitate the development of holistic care and recovery-oriented practice. These findings were utilized to directly inform development of a co-produced mental health nursing learning module, to maximize genuine service user involvement, and to fully realize the benefits of service user led education for undergraduate nursing students., (© 2020 Australian College of Mental Health Nurses Inc.)

Objective: To explore the acceptability of different bisphosphonate regimens for the treatment of osteoporosis among patients, clinicians and managers, payers and academics., Design: A systematic review of primary qualitative studies. Seven databases were searched from inception to July 2019. Screening, data extraction and quality assessment of full-articles selected for inclusion were performed independently by two authors. A framework synthesis was applied to extracted data based on the theoretical framework of acceptability (TFA). The TFA includes seven domains relating to sense-making, emotions, opportunity costs, burden, perceived effectiveness, ethicality and self-efficacy. Confidence in synthesis findings was assessed., Setting: Any developed country healthcare setting., Participants: Patients, healthcare professionals, managers, payers and academics., Intervention: Experiences and views of oral and intravenous bisphosphonates., Results: Twenty-five studies were included, mostly describing perceptions of oral bisphosphonates. We identified, with high confidence, how patients and healthcare professionals make sense (coherence) of bisphosphonates by balancing perceptions of need against concerns, how uncertainty prevails about bisphosphonate perceived effectiveness and a number of individual and service factors that have potential to increase self-efficacy in recommending and adhering to bisphosphonates. We identified, with moderate confidence, that bisphosphonate taking induces concern, but has the potential to engender reassurance, and that both side effects and special instructions for taking oral bisphosphonates can result in treatment burden. Finally, we identified with low confidence that multimorbidity plays a role in people's perception of bisphosphonate acceptability., Conclusion: By using the lens of acceptability, our findings demonstrate with high confidence that a theoretically informed, whole-system approach is necessary to both understand and improve adherence. Clinicians and patients need supporting to understand the need for bisphosphonates, and clinicians need to clarify to patients what constitutes bisphosphonate treatment success. Further research is needed to explore perspectives of male patients and those with multimorbidity receiving bisphosphonates, and patients receiving intravenous treatment., Prospero Registration Number: CRD42019143526., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

What Is Known on the Subject: Expert by Experience (EBE) involvement in mental health nursing education has demonstrated benefits, including enhancing understanding of holistic and recovery-focused practice and enhanced application of interpersonal skills. Structure and support for EBE involvement is lacking; often resulting in inadequate preparation and debriefing and tokenistic involvement. Service user involvement in mental health nursing education should be underpinned by lived experience perspectives., What the Paper Adds to Existing Knowledge: An exploration of EBE involvement in nursing education from the perspective of those with lived experience. The development of standards designed to provide structure to better support future EBEs involved in higher education. An exemplar for co-production of standards between EBE and nurse academics which has applicability for other contexts. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The standards could potentially strengthen EBE involvement in mental health nursing education, enhance their confidence and increase the retention of EBEs by creating an inclusive working culture. By increasing support for EBEs, the benefits to mental health nursing practice are likely to be maximized., Abstract: Introduction Involving people with lived experience of mental distress in mental health nursing education has gained considerable traction yet broader implementation remains ad hoc and tokenistic. Effective involvement requires curricula be informed by lived experience of service use. Aim To develop standards to underpin expert by experience involvement in mental health nursing education based on lived experience of service use. Methods Phase one used qualitative descriptive methods, involving focus groups with service users (n = 50) from six countries to explore perceptions of service user involvement in mental health nursing education. Phase two utilized these findings through consensus building to co-produce standards to support Experts by Experience involvement in mental health nursing education. Results Three themes emerged in Phase one: enablers and barriers, practical and informational support, and emotional and appraisal support. These themes underpinned development of the standards, which reflect nine processes: induction and orientation, external supervision, supportive teamwork, preparation for teaching and assessing, "intervision," mutual mentorship, pre- and post-debriefing, role clarity and equitable payment. Conclusions These standards form the framework entitled; Standards for Co-production of Education (Mental Health Nursing) (SCo-PE [MHN]). Implications for Practice The standards aim to support implementation of Expert by Experience roles in mental health nursing education., (© 2020 John Wiley & Sons Ltd.)

Purpose: To examine nursing students' perceptions of Experts by Experience impact on theoretical and practical learning., Design and Methods: Qualitative exploratory study involving focus groups with undergraduate nursing students from five European countries and Australia. Data were analyzed thematically., Findings: Participants described positive impacts as: bridging the theory and practice gap through first-hand experience, including sub-themes: bringing theory to life; can't be taught any other way, and innovative teaching methods fueling curiosity., Relevance to Clinical Practice: Integrating theory and practice is key for quality mental health nursing practice. Experts by experience can potentially contribute to reducing this enduring gap., (© 2020 Wiley Periodicals, Inc.)

The COVID-19 pandemic is influencing methods of healthcare delivery. In this short review, we discuss the evidence for remote healthcare delivery in the context of osteoporosis., Introduction: The COVID-19 pandemic has undoubtedly had, and will continue to have, a significant impact on the lives of people living with, and at risk of, osteoporosis and those caring for them. With osteoporosis outpatient and Fracture Liaison Services on pause, healthcare organisations have already moved to delivering new and follow-up consultations remotely, where staffing permits, by telephone or video., Methods: In this review, we consider different models of remote care delivery, the evidence for their use, and the possible implications of COVID-19 on osteoporosis services., Results: Telemedicine is a global term used to describe any use of telecommunication systems to deliver healthcare from a distance and encompasses a range of different scenarios from remote clinical data transfer to remote clinician-patient interactions. Across a range of conditions and contexts, there remains unclear evidence on the acceptability of telemedicine and the effect on healthcare costs. Within the context of osteoporosis management, there is some limited evidence to suggest telemedicine approaches are acceptable to patients but unclear evidence on whether telemedicine approaches support informed drug adherence. Gaps in the evidence pertain to the acceptability and benefits of using telemedicine in populations with hearing, cognitive, or visual impairments and in those with limited health literacy., Conclusion: There is an urgent need for further health service evaluation and research to address the impact of remote healthcare delivery during COVID-19 outbreak on patient care, and in the longer term, to identify acceptability and cost- and clinical-effectiveness of remote care delivery on outcomes of relevance to people living with osteoporosis.

Interlocked challenges of climate change, biodiversity loss, and land degradation require transformative interventions in the land management and food production sectors to reduce carbon emissions, strengthen adaptive capacity, and increase food security. However, deciding which interventions to pursue and understanding their relative co-benefits with and trade-offs against different social and environmental goals have been difficult without comparisons across a range of possible actions. This study examined 40 different options, implemented through land management, value chains, or risk management, for their relative impacts across 18 Nature's Contributions to People (NCPs) and the 17 Sustainable Development Goals (SDGs). We find that a relatively small number of interventions show positive synergies with both SDGs and NCPs with no significant adverse trade-offs; these include improved cropland management, improved grazing land management, improved livestock management, agroforestry, integrated water management, increased soil organic carbon content, reduced soil erosion, salinization, and compaction, fire management, reduced landslides and hazards, reduced pollution, reduced post-harvest losses, improved energy use in food systems, and disaster risk management. Several interventions show potentially significant negative impacts on both SDGs and NCPs; these include bioenergy and bioenergy with carbon capture and storage, afforestation, and some risk sharing measures, like commercial crop insurance. Our results demonstrate that a better understanding of co-benefits and trade-offs of different policy approaches can help decision-makers choose the more effective, or at the very minimum, more benign interventions for implementation., (© 2020 John Wiley & Sons Ltd.)

Expert by experience involvement in mental health education for health professional programmes has increased in recent decades. The related literature has articulated the benefits, and changes in attitudes have been measured in some studies. Less attention has been devoted to ways this learning approach could be improved. The aim of this paper is to present the nursing students perspectives on how Expert by Experience input into nursing curricula could be enhanced. Qualitative exploratory research was undertaken, involving focus groups with students who had completed a mental health learning module co-produced by Experts by Experience and nurse academics. Results show two main themes: getting the structure right, and changes to content and approach. Some student responses could directly influence changes to the learning module. In other instances, responses indicate the need to better prepare students of the value of lived experience knowledge in its own right, rather than adjunct to more traditional methods of education. These findings are important in encouraging reflection on how future learning modules co-produced by Experts by Experience and Mental Health Nursing academics can be refined and better articulated.

Consumer participation is a clear expectation of contemporary mental health policy. Most activity has concentrated in direct service delivery, and academic roles for mental health consumers have been slow to establish. An international project was undertaken to implement and evaluate meaningful consumer involvement in mental health nursing education. A learning module was co-produced between 'Experts by Experience' (drawing on experience of mental distress and service use) and Mental Health Nurse Academics. This qualitative exploratory study aimed to capture how Experts by Experience perceive their contribution. Interviews were undertaken with Experts by Experience who delivered the learning module. Data were analysed thematically and subsequently interpreted with Critical Social Theory. Two main themes emerged from the findings: 'there wasn't a barrier' described how personal narratives enhanced relationships between Experts by Experience and students; and 'made the human being visible', described their experiences of allowing students to see the person behind a diagnosis. These findings suggest Experts by Experience teaching is valuable and potentially a tool in redressing stigma. Addressing poor public perceptions could attract higher numbers of quality practitioners to mental health and meet identified workforce shortages. The findings presented here strengthen the evidence base for Expert by Experience roles in mental health professional education. These findings can be considered in international curricula reviews and aid progress towards a more socio-political, humanistic focus in mental health nursing, congruent with rights-based reform agendas., (© 2019 Australian College of Mental Health Nurses Inc.)

Background: Patient restrictions are prescribed after total hip arthroplasty (THA) to ensure proper healing and prevent early dislocation. It has been suggested that less or nonrestrictive protocols following THA do not lead to higher dislocation rates. Nonetheless, restrictions are still widely used. The aim of this study is to evaluate the rate of early dislocations when patients were restricted to supine sleeping or unrestricted sleeping in the first 8 weeks after THA using a posterolateral approach., Methods: The study design was a single-center, parallel-group, stratified, randomized, noninferiority trial in which primary THA patients were allocated to either a restricted group or a nonrestricted group. The primary outcome was early (<8 weeks) dislocation rate. Secondary outcomes include pain (visual analog scale [VAS]), function in activities of daily living (Hip Disability and Osteoarthritis Outcome Score [HOOS]), and quality of life (EuroQoL 5 Dimension [EQ-5D])., Results: A total of 408 patients were randomized into 2 groups: those who were restricted in their sleeping position (n = 203) and those who received no restrictions in sleeping position (n = 205). Three patients (1.48%) from the restricted group and 3 patients (1.46%) from the unrestricted group had a dislocation. The noninferiority of the restricted group compared to the nonrestricted group was established for early dislocation. In addition, no statistically significant differences were found for VAS, HOOS, and QoL-5D between both groups. Both groups showed a significant improvement in VAS, HOOS, and QoL-5D., Conclusion: Early dislocation rates in patients who were advised to comply to an unrestricted sleeping position following THA were not inferior to the dislocation rates in patients who were advised to sleep in a supine position following THA. The results of the present study strengthen the discussion regarding the relevance of providing patients with restrictions following THA., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Evaluate the validity of the Opening Minds Scale (OMS) for nursing students via Rasch models and confirmatory factor analysis (CFA)., Design and Methods: Undergraduate nursing student responses to OMS (n = 423). Validity was evaluated via CFA and Rasch analysis., Findings: CFA results were strongest for a three-factor 13-item version of OMS. Rasch modeling supported sound properties for two of three scales. Internal reliabilities ranged between 0.6 and 0.7., Practice Implications: OMS has potential as a valid measure for stigma research and antistigma program evaluation. Rasch analysis suggest it is inappropriate to use a total OMS score for nursing student populations., (© 2019 Wiley Periodicals, Inc.)

WHAT IS KNOWN ON THE SUBJECT?: Consumer participation in mental health services is embedded in mental health policy in many countries. The negative attitudes of nurses and other health professionals to consumer participation poses a significant obstacle to this policy goal Involving mental health "Experts by Experience" in the education of nursing students demonstrates positive attitudinal change WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: More detailed understanding of nursing students' experiences and perspectives about being taught mental health nursing by "Experts by Experience" An international focus, extending understandings about how Experts by Experience might be perceived in a broader range of countries WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Positive attitudes towards people labelled with mental illness are essential for quality nursing practice Nurses have an important leadership role in facilitating consumer participation within health services. It is critical that their attitudes are professional and optimistic. ABSTRACT: Introduction Consumer participation is central to mental health policy. Negative attitudes of health professionals are barriers to realizing policy goals. Evidence suggests consumers (Experts by Experience) can influence positive attitudes in nursing students. Research in this area to date is limited and primarily from Australia and New Zealand. Aim To enhance understanding of nursing students' perspectives and experiences of being taught mental health by an Expert by Experience. Method A qualitative exploratory approach was used. Focus groups were conducted with nursing students from seven universities in Australia and Europe. Data were analysed thematically. Results Student participants described how exposure to Experts by Experience challenged their views and attitudes and provided a mechanism for reflection, critique and change. The main theme "changing mindset" includes two subthemes: exposing stereotypes and reflection. Discussion This unique international study demonstrates the capacity for Experts by Experience to contribute to positive attitudinal change towards mental illness in nursing students. This changed mindset must occur for policy goals to be realized. Implications for practice Nurses in all areas of practice will work with people labelled with mental illness and experiencing mental distress. Overcoming stereotypes and adopting more positive attitudes is essential to deliver quality mental health care., (© 2019 John Wiley & Sons Ltd.)

Holistic and person-centred nursing care is commonly regarded as fundamental to nursing practice. These approaches are complementary to recovery which is rapidly becoming the preferred mode of practice within mental health. The willingness and ability of nurses to adopt recovery-oriented practice is essential to services realizing recovery goals. Involving consumers (referred herein as Experts by Experience) in mental health nursing education has demonstrated positive impact on the skills and attitudes of nursing students. A qualitative exploratory research project was undertaken to examine the perspectives of undergraduate nursing students to Expert by Experience-led teaching as part of a co-produced learning module developed through an international study. Focus groups were held with students at each site. Data were analysed thematically. Understanding the person behind the diagnosis was a major theme, including subthemes: person-centred care/seeing the whole person; getting to know the person, understanding, listening; and challenging the medical model, embracing recovery. Participants described recognizing consumers as far more than their psychiatric diagnoses, and the importance of person-centred care and recovery-oriented practice. Understanding the individuality of consumers, their needs and goals, is crucial in mental health and all areas of nursing practice. These findings suggest that recovery, taught by Experts by Experience, is effective and impactful on students' approach to practice. Further research addressing the impact of Experts by Experience is crucial to enhance our understanding of ways to facilitate the development of recovery-oriented practice in mental health and holistic and person-centred practice in all areas of health care., (© 2019 Australian College of Mental Health Nurses Inc.)

Background: Understanding student attitudes towards people diagnosed with mental illness is central to realising evidence-based nursing education and policy at an international level. Redressing stigmatised views can assist in preparing nursing students to work in mental health settings and support the active involvement of consumers in all aspects of mental health service delivery (known as: consumer participation) at individual and systemic levels. Accurate research on nursing student attitudes is dependent on the availability of valid and reliable measures., Objectives: Using data from and international study, this research sought to: (1) evaluate two measures of nurse student attitudes, and (2) explore whether attitudes to people labelled with a diagnosis of mental illness and who use mental health services is associated with more positive attitudes to consumer participation in mental health services., Design: Self-report quantitative data gained via the Consumer Participation Questionnaire (CPQ) and Mental Health Nurse Education Survey (MHNES)., Setting and Participants: University nursing students in Australia and Western Europe., Data: Pooled CPQ and MHNES data from Australia, Ireland, Finland, Norway and the Netherlands., Methods: The MHNES and CPQ were evaluated via exploratory factor analysis and Rasch modelling. Hierarchical regression was applied to see whether attitudes to mental illness and mental health practice relate to attitudes to consumer participation after addressing demographic differences., Results: Refined MHNES scales demonstrated overall fit on Rasch models. Reliabilities for MHNES ranged from 0.82 to 0.73. Perceived value of mental health nursing to consumers and lower negative stereotypes were associated with positive attitudes to consumer participation independent of age, gender and country [F (9, 381) = 15.78, p < .001]. Students who considered mental health nursing made a valuable contribution represented the strongest association with a positive attitude towards consumer participation., Conclusions: Differences in openness to consumer participation are partly attributable to views about people diagnosed with mental illness and the perception that mental health practice makes a positive difference to these people within health service contexts., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Reform to nursing education is essential to ensure future generations of nurses are strongly positioned to value, know, and deliver strength-based, recovery-oriented mental health practice. A promising pathway to effectively drive reform is the coproduction of curricula by nursing academics and people with lived experience of recovery from mental distress referred to as Experts by Experience. The Co-production in Mental Health Nursing Education (COMMUNE) project is an international collaboration for development and implementation of consumer coproduced curricula. This study evaluated the inclusion of Expert by Experience-led mental health nursing education on nursing students' attitudes to people labelled with mental illness, mental health nursing, and consumer participation. A repeated self-report measures design was implemented in Australia, Ireland, and Finland to ascertain level of generalizability of consumer involvement within undergraduate nursing programmes. Data were collected from nursing students (n = 194) immediately before and after the education module, using three self-report instruments on attitudes (Mental Health Nurse Education Survey, Consumer Participation Questionnaire, and Opening Minds Scale). Data were analysed using descriptive and inferential statistics. Eighty-nine per cent of the 27 points of change reflected more favourable and accepting attitudinal change. Of these, 41% were significant at Bonferroni adjusted alpha of 0.0025. There was a statistically significant increase in preparedness for practice in the mental health field in each of the three countries. The most pronounced change is related to the social and systemic inclusion of people with a diagnostic label and recovery-oriented care more broadly., (© 2018 Australian College of Mental Health Nurses Inc.)

Understanding the effects of captivity-induced stress on wild-caught animals after their release back into the wild is critical for the long-term success of relocation and reintroduction programs. To date, most of the research on captivity stress has focused on vertebrates, with far less attention paid to invertebrates. Here, we examine the effect of short-term captivity (i.e., up to four days) on self-righting, aggregation, and predator-escape behaviours in wild-caught red sea urchins, Mesocentrotus franciscanus , after their release back into the wild. Aggregation behaviour, which has been linked to feeding in sea urchins, was not affected by handling or captivity. In contrast, the sea urchins that had been handled and released immediately, as well as those that were handled and held captive, took longer to right themselves and were poorer at fleeing from predators than wild, unhandled sea urchins. These results indicate that handling rather than captivity impaired these behaviours in the short term. The duration of captivity did not influence the sea urchin behaviours examined. Longer-term monitoring is needed to establish what the fitness consequences of these short-term behavioural changes might be. Our study nevertheless highlights the importance of considering a suite of responses when examining the effects of capture and captivity. Our findings, which are based on a locally abundant species, can inform translocation efforts aimed at bolstering populations of ecologically similar but depleted invertebrate species to retain or restore important ecosystem functions., Competing Interests: The authors declare there are no competing interests.

The stigma associated with a diagnosis of mental illness is well known yet has not reduced significantly in recent years. Health professionals, including nurses, have been found to share similar negative attitudes towards people with labelled with mental illness as the general public. The low uptake of mental health nursing as a career option reflects these stigmatised views and is generally regarded as one of the least popular areas of in which to establish a nursing career. The aim of the current project was to examine nursing students' attitudes towards the concept of mental illness and mental health nursing across four European countries (Ireland, Finland, Norway and the Netherlands), and Australia, using the Opening Minds Scale and the Mental Health Nurse Education survey. The surveys were distributed to students prior to the commencement of the mental health theory component. Attitudes towards mental health nursing were generally favourable. Differences in opinion were evident in attitudes towards mental illness as a construct; with students from Australia and Ireland tending to have more positive attitudes than students from Finland, Norway and the Netherlands. The future quality of mental health services is dependent on attracting sufficient nurses with the desire, knowledge and attitudes to work in mental health settings. Understanding attitudes towards mental illness and mental health nursing is essential to achieving this aim.

Increasingly, experts as deemed by personal experience or mental health service use, are involved in the education of nurses; however, accompanying research is limited and focuses primarily on opinions of nurse educators and students. The aim of this study was to develop an understanding of the potential contribution to mental health nursing education by those with experience of mental health service use. The research was part of the international COMMUNE (Co-production of Mental Health Nursing Education) project, established to develop and evaluate co-produced mental health content for undergraduate nursing students. A qualitative descriptive design was adopted with data collected through focus group interviews in seven sites across Europe and Australia. Experts by experience (people with experience of distress, service use, and recovery) co-produced the project in partnership with nursing academics. Co-production enriched the process of data collection and facilitated the analysis of data from multiple perspectives. Two themes are presented in this paper. The first focuses on how experts by experience can enhance students' understanding of recovery by seeing the strengths inherent in the 'human' behind the diagnostic label. The second highlights the importance of communication and self-reflection on personal values, where students can explore their own thoughts and feelings about mental distress alongside those with lived experience. Interacting with experts by experience in the classroom can assist in challenging stigmatizing attitudes prior to nursing placements. These findings can be used to inform international nursing curricula by increasing the focus on nursing skills valued by those who use the services., (© 2018 Australian College of Mental Health Nurses Inc.)

Unlabelled: Our aims were to study the effect of birthweight growth discordance (≥20%) on neuro-developmental outcome of monochorionic and dichorionic twins and to compare the relative effects of foetal growth discordance and prematurity on cognitive outcome. We performed a cross-sectional multicentre prospective follow-up study from a cohort of 948 twin pregnancies. One hundred nineteen birthweight-discordant twin pairs were examined (24 monochorionic pairs) and were matched for gestational age at delivery with 111 concordant control pairs. Participants were assessed with the Bayley Scales between 24 and 42 months of age. Analysis was by paired t test for intra-twin pair differences and by multiple linear regression. Compared to the larger twin of a discordant pair, the smaller twin performed significantly worse in cognition (mean composite cognitive score difference = -1.7, 95% confidence interval (CI) = 0.3-3.1, p = 0.01) and also in language and motor skills. Prematurity prior to 33 weeks' gestation, however, had a far greater impact on cognitive outcomes (mean cognitive composite score difference = -5.8, 95% CI = 1.2-10.5, p = 0.008)., Conclusion: Birthweight growth discordance of ≥20% confers an independent adverse effect on long-term neuro-development of the smaller twin. However, prior to 33 weeks' gestation, gestational age at birth adversely affects cognitive development to a greater extent than foetal growth discordance.

There is a paucity of literature about the nutritional status and energy and protein intakes of Meals on Wheels (MOW) clients. The current study aimed to determine the nutritional status and the adequacy of energy and protein intakes of MOW clients. Forty-two clients were recruited from two MOW services in the Illawarra region of Australia for assessment of their nutritional status, using the Mini Nutritional Assessment (MNA(®)). Estimated energy and protein intakes for a MOW day were compared to a non-MOW day and average daily energy and protein intakes were assessed against estimated daily requirements. A single dietitian performed all assessments and home based interviews to explore the client's perception of the service. Mean daily energy intake (7593 (±2012) kJ) was not significantly different to estimated requirements (7720 (±975) kJ) (P = 0.480), while mean daily protein intake was higher (78.7 (±23.4) g) than calculated requirements (68.4 (±10.8) g; P = 0.009). However 16 clients were identified as at risk of malnutrition and 2 were malnourished; consuming 2072 kJ (P = 0.000) less energy and 20.4 g less protein (P = 0.004) per day compared to well-nourished clients. MOW clients are at risk of being poorly nourished and meals delivered by the service provide an important contribution to overall intakes. These findings support the need for regular nutrition screening and dietary monitoring in this high risk group, to identify those for whom additional strategies may be indicated., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: Sonographic estimated fetal weight (EFW) is important in the management of high-risk pregnancies. The possibility that increased maternal body mass index (BMI) adversely affects EFW assessments in twin pregnancies is controversial. The aim of this study was to investigate the effect of maternal BMI on the accuracy of EFW assessments in twin gestations prospectively recruited for the ESPRiT (Evaluation of Sonographic Predictors of Restricted growth in Twins) study., Study Design: One thousand one twin pair pregnancies were recruited. After exclusion, BMI, birthweights, and ultrasound determination of EFW (within 2 weeks of delivery) were available for 943 twin pairs. The accuracy of EFW determination was defined as the difference between EFW and actual birthweight for either twin (absolute difference and percent difference). Cells with less than 5% of the population were combined for analysis resulting in the following 3 maternal categories: (1) normal/underweight, (2) overweight, and (3) obese/extremely obese., Results: Analysis of the 3 categories revealed mean absolute variation values of 184 g (8.0%) in the normal/underweight group (n = 531), 196 g (8.5%) in the overweight group (n = 278), and 206 g (8.6%) in the obese/extremely obese group (n = 134) (P = .028, which was nonsignificant after adjustment for multiple testing). Regression analysis showed no linear or log-linear relationship between BMI and the accuracy of EFW (P value for absolute difference = .11, P value for percentage difference = .27)., Conclusion: Contrary to a commonly held clinical impression, increasing maternal BMI has no significant impact on the accuracy of EFW in twin pregnancy., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Here, we demonstrate that "moving to the beat" can improve the perception of timing, providing an intriguing explanation as to why we often move when listening to music. In the first experiment, participants heard a series of isochronous beats and identified whether the timing of a final tone after a short silence was consistent with the timing of the preceding sequence. On half of the trials, participants tapped along with the beat, and on half of the trials, they listened without moving. When the final tone occurred later than expected, performance in the movement condition was significantly better than performance in the no-movement condition. Two additional experiments illustrate that this improved performance is due to improved timekeeping, rather than to a shift in strategy. This work contributes to a growing literature on sensorimotor integration by demonstrating body movement's objective improvement in timekeeping, complementing previous explorations involving subjective tasks.