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Colin J Ireland,1 Andrea L Gordon,2 Sarah K Thompson,3 David I Watson,4 David C Whiteman,5 Richard L Reed,6 Adrian Esterman1,7 1School of Nursing and Midwifery, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia; 2School of Pharmacy and Medical Science, Division of Health Sciences, University of South Australia, Adelaide, SA, Australia; 3Discipline of Surgery, University of Adelaide, Adelaide, SA, Australia; 4Department of Surgery, Flinders University, Bedford Park, SA, Australia; 5Population Health Department, QIMR Berghofer Medical Research Institute, Herston, QLD, Australia; 6Discipline of General Practice, Flinders University, Bedford Park, SA, Australia; 7Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD, Australia Background: Esophageal adenocarcinoma is a disease that has a high mortality rate, the only known precursor being Barrett’s esophagus (BE). While screening for BE is not cost-effective at the population level, targeted screening might be beneficial. We have developed a risk prediction model to identify people with BE, and here we present the external validation of this model. Materials and methods: A cohort study was undertaken to validate a risk prediction model for BE. Individuals with endoscopy and histopathology proven BE completed a questionnaire containing variables previously identified as risk factors for this condition. Their responses were combined with data from a population sample for analysis. Risk scores were derived for each participant. Overall performance of the risk prediction model in terms of calibration and discrimination was assessed. Results: Scores from 95 individuals with BE and 636 individuals from the general population were analyzed. The Brier score was 0.118, suggesting reasonable overall performance. The area under the receiver operating characteristic was 0.83 (95% CI 0.78–0.87). The Hosmer–Lemeshow statistic was p=0.14. Minimizing false positives and false negatives, the model achieved a sensitivity of 74% and a specificity of 73%. Conclusion: This study has validated a risk prediction model for BE that has a higher sensitivity than previous models. Keywords: Barrett’s esophagus, risk prediction model, screening, validation

Introduction: Sustaining effective interventions that improve quality and safety of care is a key challenge in improving the outcomes of healthcare. In recent years in the UK, there have been innovations to improve healthcare in care homes. They were led by dedicated project teams and had time-limited funding. This study aims to determine whether and how any improvements brought about by these innovations were sustained. Methods and analysis: This study will examine three care home healthcare improvement projects: Enhanced Health in Care Homes; Proactive Healthcare of Older People in Care Homes (PEACH); and Safer Salford Care Homes. Each of these projects sought to improve the quality of care in care homes. The study will collate administrative documentation from each project, and carry out approximately 32 semi-structured interviews with project managers, health and social care professionals, support staff, quality improvement experts, and clinical/care home experts. Data will be used to create a description of the three interventions, applying the Template for Intervention Description and Replication (TIDieR) framework. Interview data will be analysed thematically by two independent researchers using the Consolidated Framework for Sustainability (CFS) to examine which factors impact on sustainability in the care home setting, and explore why and how these factors influence sustainability. The findings will be used to develop guidance and practical strategies for future teams working on quality improvement in care homes.

Introduction: This protocol describes a study of a quality improvement collaborative (QIC) to support implementation and delivery of comprehensive geriatric assessment (CGA) in UK care homes. The QIC will be formed of health and social care professionals working in and with care homes and will be supported by clinical, quality improvement and research specialists. QIC participants will receive quality improvement training using the Model for Improvement. An appreciative approach to working with care homes will be encouraged through facilitated shared learning events, quality improvement coaching and assistance with project evaluation. Methods and analysis: The QIC will be delivered across a range of partnering organisations which plan, deliver and evaluate health services for care home residents in four local areas of one geographical region. A realist evaluation framework will be used to develop a programme theory informing how QICs are thought to work, for whom and in what ways when used to implement and deliver CGA in care homes. Data collection will involve participant observations of the QIC over 18 months, and interviews/focus groups with QIC participants to iteratively define, refine, test or refute the programme theory. Two researchers will analyse field notes, and interview/focus group transcripts, coding data using inductive and deductive analysis. The key findings and linked programme theory will be summarised as context-mechanism-outcome configurations describing what needs to be in place to use QICs to implement service improvements in care homes. Ethics and dissemination: The study protocol was reviewed by the National Health Service Health Research Authority (London Bromley research ethics committee reference: 205840) and the University of Nottingham (reference: LT07092016) ethics committees. Both determined that the Proactive HEAlthcare of Older People in Care Homes study was a service and quality improvement initiative. Findings will be shared nationally and internationally through conference presentations, publication in peer-reviewed journals, a graphical illustration and a dissemination video.

Background: Risk prediction tools are widely used for the early identification of disease and expediting referrals to medical specialists for further assessment. This study provides an understanding of general practitioners preferences for using some prediction tools over others. The recent development of a risk prediction model for Barrett’s oesophagus prompted our investigation of General Practitioners perspectives of the barriers and enablers to its use and screening tools per se. \ud \ud Method: Individual semi-structured interviews explored the use of risk prediction tools in the general practice setting. A case scenario was used to create a schema that described the risk assessment process for Barrett’s oesophagus. A content analysis of verbatim transcripts was coded for barriers and enablers to tool use and linked to explanatory themes. \ud \ud \ud Results: Data was collected from five general practitioners and one gastroenterologist. Barriers to regular use of risk prediction tools were identified and grouped using five themes; time poverty, tool format style, remembering to use, relevance of questions, and reduced autonomy in clinical decision making. Five key reasons for regular use were also identified; simple to use, memory prompt, provides a clear guide, aids in keeping me focused, and easy to access. All participants acknowledged the need for identifying Barrett’s oesophagus, the precursor to oesophageal adenocarcinoma, and viewed our tool as a significant contribution to risk assessment of this condition. \ud \ud \ud Conclusion: Identifying barriers and enablers is essential to wide implementation of risk prediction tools. Participants provided information crucial to the translation of our risk prediction model for Barrett’s oesophagus into clinical practice. They also confirmed that the developed model would be useful in the clinical setting.

This thesis reflects on the perceptions of resilience of more than fifty early career secondary teachers and is intended as the initial stage of a longitudinal research inquiry. It focuses on how the resilience of new entrants to the teaching profession is challenged and eroded, but also sustained and nurtured, in the initial year of teacher training and as a newly qualified teacher. Drawing on bricolage, the inquiry is qualitative in approach, using a range of methods, including a resilience test, questionnaires, interviews and a range of creative writing approaches, to explore deeper insights into the experiences and perspectives of early career teachers. This thesis complements important work in the field, including Gu and Day (2013) and Johnson et al., (2015), by adopting a wide-ranging and creative approach to gathering evidence from a group of early career teachers. The honesty and vulnerability of the participants has inspired me to consider ways in which resilience may be fostered at the beginning of a career in teaching. Clear implications for a more holistic view of the individual teacher at the heart of initial teacher education are highlighted as a result. Recommendations are made for changes to provision in initial teacher education, including a stronger focus on the emotional aspects of the teacher’s role, and a re-thinking of reflective practice and mentoring as part of transformational learning in the teaching profession.

Background The effect that the route of maternal fentanyl administration has on placental transfer of drug to the neonate is not well studied. Plasma concentration ratios are an indicator of fetal exposure, relative to the mother. Method A cohort study (n=30) was conducted to measure fentanyl concentrations in maternal plasma, and arterial and venous cord blood, among women administered with either intranasal or subcutaneous fentanyl for labour pain relief. Maternal and cord blood samples were collected within 30 min of birth to determine the fentanyl plasma concentration and to assess relative neonatal exposure. Neonatal outcomes were assessed by Apgar scores, need for resuscitation and nursery admission. The study was registered as ACTRN12618001012268. Results Thirty paired samples were obtained from healthy parturients with uncomplicated term pregnancies. Highest observed umbilical venous and arterial concentrations were 0.71 ng/mL and 0.56 ng/mL, respectively, and fetal to maternal fentanyl plasma concentration ratios ranged between 0.23 and 0.73, indicating low fetal exposure. While the total intranasal fentanyl dose administered was significantly higher than the subcutaneous fentanyl dose, this did not result in a higher fetal to maternal ratio. All neonates in both groups had 5-min Apgar scores >7, two neonates required short term stimulation and oxygen (unrelated to fentanyl) and no neonate was admitted to the nursery. Conclusion This study is the first to examine fetal and maternal fentanyl concentrations after subcutaneous administration. This research supports the safe use of fentanyl for labour analgesia for women.